This observational mixed methods evaluation of the system-level scale-up of NROL, a group-based telerehabilitation innovation, demonstrated enhancement of our regional community neurorehabilitation services. Despite anticipated healthcare system pressures, NROL was widely adopted and successfully embedded within real-world practice at all intended organisations across the region, with growing participation supported by collaborative system-level working. Acceptability was evidenced by the programme being well-utilised and valued by patients and therapy staff, while safely supporting increased therapy provision. Successful adoption, acceptability, and model efficiencies indicate strong potential for sustained delivery, although continued stakeholder engagement and alignment remain essential for long-term sustainability.

A data-driven approach enabled real-time tailoring to optimise innovation-context fit, an important factor in scaling efforts (29, 51). NROL proved compatible at a system-level, with phased adoption across three additional organisations over six months. This led to growth, with increased referrals in the first year (59%) followed by annual growth (30%), whilst demonstrating improved staffing efficiency over time (staff:patient ratio 0.4 to 0.3). Despite this growth, referrals accounted for a relatively small proportion of the wider caseload (2–16%), indicating potential for further participation. However, with block capacity nearing maximum (84%) broader participation may require model adjustments.

Implementation was influenced by individual and healthcare setting factors, such as initial therapy staff reluctance, competing priorities and infrastructure challenges, consistent with reported barriers to scale-up, innovation implementation and sustained use in healthcare (52, 53). Nevertheless, key enablers facilitated success, in particular leadership from a dedicated operational team and innovation champions. The importance of highly committed individuals is well-recognised (52–56). The impetus to overcome barriers may have been influenced by staffs’ recognition of the potential long-term benefits for patients, including improved outcomes for many and peer-support. Consistent with staff perceptions and previous single-service NROL evaluation (19), quantitative results indicated positive shifts in activity performance and health-related quality of life, supporting the programme’s sustained appropriateness when delivered at a regional level. In line with the prior findings, clinically meaningful group-level differences were not detected, although meaningful gains were reported for some individuals (30-39%). This may not be surprising given the relatively short duration of the NROL programme (typically six-weeks). From October 2024 the EQ-5D-5L has been included within the national community stroke clinical audit (e.g. SSNAP, 47) which may enable longer-term, and comparative, patient outcome review within future evaluation. Notably, staff valued NROL for increasing therapy and practice. Quantitative data supported their views, showing patients with stroke who participated in NROL received over than four times as many therapy minutes as non-NROL patients and were supported by community services for longer, marking significant steps toward meeting therapy targets.

Workforce limitations remain a major barrier to implementation and sustainability in healthcare systems (52, 57). We employed collective use of the regional rehabilitation therapy workforce, as a shared care approach, to help mitigate this challenge. This approach yielded several advantages. Firstly, it allowed a critical mass of patients to receive group therapy where impairment incidence was lower (e.g. speech-related groups). The cross-organisational structure (69% of sessions run cross-organisationally) reduced the need for multiple therapy staff from any one service per session, while providing opportunity for shared learning and networking. It also offered redundancy, allowing staff shortages in one service to be temporarily covered by another, minimising regional inequity. Although a concern regarding workload balance across organisations was voiced, staffing distribution aligned relatively well with referral patterns (variation –6% to 7%) suggesting a natural equilibrium or effective management. The collaborative system-level approach was enabled by the online format, which had the additional advantages of travel time, cost and emissions avoidance. Further, overall therapy staff resource use was minimised through the group-based model. Together, these advantages may help alleviate pressure on the healthcare system.

Wide stakeholder engagement fostered buy-in and short-term sustainment of the regional NROL innovation. Therapy staff and patients were integral to successful development and implementation as shown here and seen previously (19, 27). However, regular communication with decision-makers was also crucial for scale-up, though this perspective is yet to be formally captured as it was beyond the resource of this evaluation. Alignment (i.e. creating fit between elements of the inner and outer setting of an organisation or system) plays an important role for implementation success (58, 59). Anecdotally, decision-makers found NROL appealing due to its strategic alignment with community-based care priorities, its low operational resource use, and its contribution to broader healthcare goals, including workforce planning, performance benchmarks (e.g. SSNAP), environmental targets and addressing health inequalities. However, sustained funding is essential to prevent “pilotitis” and ensure long-term viability.

Some limitations should be considered when interpreting the findings. First, the therapy provision review was small-scale and limited to patients with a diagnosis of stroke, as clinical audit data were unavailable for other neurological conditions. Also, we only acquired access to stroke clinical audit datasets from two organisations. Further, interpretation should consider that the patients with stroke who participated in NROL may have been those who needed, could manage, or were motivated for therapy, potentially affecting therapy amount and duration. Second, the staff survey had a 36% estimated response rate (55% respondents had delivered NROL), introducing potential nonresponse bias. This is not unexpected, as subject familiarity increases survey participation likelihood. However, it is important to note that those with less positive experience may be underrepresented. However, a strength of a mixed-methods approach is that the use of qualitative and quantitative data can help illustrate converging or diverging factors, providing a more comprehensive view. Finally, it was difficult to capture what was not done (e.g. who was not referred). Whilst overall NROL had sustained appropriateness for mixed demographics, we found patients referred to NROL and went on to participate were younger. Factors could be gate-keeping from therapists or patient access to technology; this requires further exploration. Going forward these perspectives will be sought, as well as the aforementioned perspective of decision-makers.