From escalation to emergence: NHS Forth Valley and the quiet power of Transformative Simulation (31 January 2026)

Summary

In 2022, National Health Service (NHS) Forth Valley, Scotland was escalated to Level 4 under the NHS Scotland Support and Intervention Framework - triggering the highest level of oversight and engagement from the Scottish Government prior to statutory intervention. While many systems under such pressure default to compliance-driven responses, NHS Forth Valley took a different path: embracing a whole-system approach focused on leadership, culture, integration and governance. Within this, Transformative Simulation was embedded as a leadership method to support cultural and systemic renewal.

A multi-professional, multi-sector delegation from the Association for Simulated Practice in Healthcare (ASPiH) visited NHS Forth Valley in early 2025 to observe simulation in practice as a leadership tool. Over two immersive days, they witnessed how simulation was used not only for education and training but also for engaging with emotionally charged challenges, enabling system-wide reflection and co-designing new models of care.

Rather than retreating inward, the system opened up. One of the approaches was to progressively embed Transformative Simulation alongside a programme of culture change - not as an optional or remedial tool, but as a core leadership method for engaging with complexity, discomfort and relational repair.

Content

The framework draws on multiple fields, including human factors, patient safety science, quality improvement, implementation science, engagement theory, cultural studies and the social sciences. It is a living, practice-informed structure that honours complexity while supporting practical clarity. It enables reciprocal illumination - where multiple viewpoints surface, interact, and reshape understanding - and creates experiential foresight by allowing systems to experience change before enacting it. Over time, it builds relational infrastructure that supports trust, reflection, and sustained systems learning.

Weldon SM, Mardon J, Tallentire V, et al. BMJ Leader Published Online First: [please include Day Month Year]. doi:10.1136/ leader-2025-001408.