From escalation to emergence: NHS Forth Valley and the quiet power of Transformative Simulation

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, we 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. Leadership behaviours observed during the visit were marked by humility, openness and courage. Senior leaders did not simply oversee change - they participated in simulations, listened deeply and responded actively. Simulation served as both a mirror and a mechanism: surfacing cultural dynamics, enabling cross-boundary collaboration and supporting healing after organisational trauma. Transformative Simulation emerged not as a short-term intervention but as a long-term leadership framework. NHS Forth Valley's response demonstrates that simulation, when embedded intentionally, can be a powerful lever for leadership, trust-building and transformation. Their story offers a hopeful vision of what becomes possible when leadership chooses connection over control. [Abstract copyright: © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.]