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The theory of change was developed through reviewing existing evidence and a substantial co-design process in Q’s development phase (2015). It was then revised in 2018 to integrate the evaluation findings so far (especially Ling et al, 2018) and a ‘stocktake’ process involving stakeholder consultation.

Fundamental to Q’s theory of change is the need for an effective infrastructure underpinned by a secure governance structure and a central staff team that attracts a diverse group of members through compelling communications. This infrastructure delivers a range of platforms that support improvement including online and face-to-face activities, resources and spaces that spread knowledge, skills and expertise.

The infrastructure and platforms support a connected community leading improvement across the health and care system where members are connecting (both within and beyond the community), collaborating (to undertake improvement activities), supporting (both each other and influencing improvement contexts) and developing (learning skills, knowledge and building capacity). These four processes can be seen as the key mechanisms of change that link the infrastructure and platforms to the resulting positive change that Q is aiming to achieve. Individual elements of Q don’t fit neatly in to one of these processes and, indeed, it is their interrelation that leads to greater impact from improvement.

This impact is seen in members being inspired and energised as well as possessing greater skills to work with others to deliver improvements to services and accelerate progress on key priorities. Ultimately, the hypothesis is that this will contribute to sustainable improvement in health and care across the UK through more visible and better-connected improvers, more effective across team working and a workforce that is more actively involved in embedding successful initiatives.

The nested boxes and arrows convey that influence is not linear and that Q operates at multiples levels that impact on each other. The extent to which Q is able to demonstrate a positive impact on the context for improvers, and the wider system will influence in turn the extent to which Q’s infrastructure, activities and community are motivated and supported to engage. While difficult to convey on paper, Q has the organic, dynamic characteristics of a large-scale community.

Q’s theory of change is dynamic and will be periodically reviewed based on emerging evidence and priorities including at the formal review stages in 2025 and 2030.