Frequently asked questions


How do I get involved?

Whether you are looking to find out more about the framework and how you can apply it to reduce unwarranted variation or if you have a great example how you have led change, we want to hear from you. Find out how you can get involved and to hear how nursing, midwifery and care staff across the country are leading change across a variety of care settings

What does the framework do?

Leading Change, Adding Value is the national framework for all nursing, midwifery and care staff. It can be used by everyone, wherever you work and whatever your role. It has been developed with a wide range of national organisations, staff representatives, people we care for, carers and the public.

Nursing, midwifery and care staff have a crucial role to play in closing the three gaps identified in the Five Year Forward View – the health and wellbeing gap, the care and quality gap, and the funding and efficiency gap, by ensuring the activities we undertake are of high value. The 6Cs remain the value base in all that they do.

The framework highlights the need to focus on unwarranted variation – variations in health and care outcomes, patients’ experience and use of resources that cannot be justified by reasons of geography, demography, or infrastructure.

Nursing, midwifery and care staff form the largest proportion of the health and care workforce, they have a key, leadership role in delivering a positive impact on outcomes, experience and better use of resources – the Triple Aim outcome measures.

Find out more about the framework.

Who is the framework for?

The framework is for all nursing, midwifery and care staff, wherever you work and whatever your role.

What does unwarranted variation mean?

Variations in health and care outcomes, patients’ and staff experience and use of resources that cannot be justified by reasons of geography, demography, or infrastructure. Unwarranted variation can be identified and addressed in a number of ways.

For example, two large NHS care homes in the same neighbourhood, with exactly the same number of beds, the same staffing and the same client group; but, one care home may have a greater incidence of pressure ulcers. This suggests that there is unwarranted variation which may be due to a number of factors, including poor clinical practice, lack of training, poor leadership or even human error.

Nursing, midwifery and care staff are ideally placed to identify unwarranted variation in practice and lead change however small or large to make improvements in care to reduce harm, improve outcomes and experiences for individuals and staff and make more efficient use of available resources.

What are the three gaps?

The three gaps were identified in the Five Year Forward View.

They are areas where action must be taken to ensure that people in England receive high quality care. The three gaps are:

  1. Health and wellbeing: Without a greater focus on prevention, health inequalities will widen and our capacity to pay for new treatments will be compromised by the need to spend billions of pounds on avoidable illness.
  2. Care and quality: Health needs will go unmet unless we reshape care, harness technology and address variations in quality and safety.
  3. Funding and efficiency: Without efficiencies, a shortage of resources will hinder care services and progress. Importantly, this is not just about finances.

How can Leading Change, Adding Value help to close the three gaps?

Nursing, midwifery and care staff have a crucial role to play in closing the three gaps, by making sure that the work we do is high value. How we can help to close each of these gaps:

  • Closing the health and well-being gap: practise in ways which prevent avoidable illness, protect health and promote well-being and resilience.
  • Closing the care and quality gap: practise in ways which provide safe evidence- based care which maximises choice for patients.
  • Closing the funding and efficiency gap: practise in ways which manage resources well including time, equipment and referrals.

What are the ‘triple aims’?

The overall objective of the triple aim is to develop a high quality, financially sustainable service to achieve:

  • Better outcomes
  • Better experiences for patients and staff
  • Better use of resources

What are the 10 commitments?

The commitments are 10 aspirational statements which can help you to focus on narrowing the three gaps, identifying and addressing unwarranted variation and demonstrating the triple aim outcomes. They can be used in any environment by all staff.

Find out more about the 10 commitments.