Facilitating knowledge exchange between health-care sectors, organisations and professions: a longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality

A wide range of communication skills

Martin and Tipton55 compiled a typology of communication roles from a purposive sample of non-clinical, salaried patient advocates who, as boundary spanners, might review medical charts, facilitate selection of doctors for second opinions or socialise with waiting family members. The roles were liaison, feedback/remediation, counselling and support, system monitor, troubleshooter, investigator and group facilitator. Although this research suggested, theoretically, that as boundary spanners these advocates may serve as system change agents – particularly when responding to patient complaints – the descriptive nature of the research did not build empirical evidence for vertical integration. Similarly, Abbott56 found that to be effective, nurse consultants needed to be credible leaders, be familiar with relevant policies and organisational structures, build and maintain effective relationships and apply communication skills (including facilitation of conflict).

In another mixed-methods study,57 three structural variables (team informational diversity, team boundedness and extra team links) were used to understand how to increase interorganisational boundary spanning in health promotion teams. Three types of boundary spanning were reported as being associated with team effectiveness: scouting, ambassadorial and co-ordinating. The author suggests that the most effective teams should maintain an open team configuration, invite experts and change team composition over time (including part- and full-time members). In this way, increased scouting implied greater informational diversity, and greater interorganisational team effectiveness, even in less bounded teams with more part-time members.

Tools, and processes, can serve as boundary-spanning entities as well. Three studies58–60 examined how knowledge sharing was accomplished through boundary-spanning methods. Hara and Hew58 observed an online community of practice for advanced practice nurses, finding that the non-competitive and asynchronous nature of online communication facilitated the improvement of current knowledge and validated best practice. A study of health behaviour change explored the use of referral guides along with support people external to the organisation to implement linkages in the community. 59 Connecting strategies, such as paper or electronic databases were developed to bridge primary care and community resources, especially for patient referrals. However, hurdles were discovered in both resource availability and accessibility to patients, and affordable infrastructure to support boundary-spanning activities was needed. Often boundary-spanning individuals were needed to fill in the gaps, and marshal the use of technology, when paradigm shifts in practices had not yet occurred.

As translators and diplomats, boundary spanners may serve to communicate new ideas across a divide. How that knowledge is shared, and whether or not it is adopted, is a sign of its impact. In a study of health planning staff and board members it was found that effective performance as boundary spanners improved collaboration. 60 As a study of communication strategies, staff members and board members influenced each other by the extent to which they answered each other's questions; seeking information became a mark of a good board member. Open communication appeared to enable the ability to act on shared objectives. Knowing the staff views and agency routines increased the perception of board effectiveness.

Formal and informal role negotiation

The development of new professional roles to bridge treatment areas is a relatively recent innovation in the UK. With the development of these roles comes ambiguity in task definition and efforts to build professional credibility. Examining pilots that sought to train GPs in specialist genetics and cancer roles, it was found that recruiting for such hybrid roles was difficult because of the day-to-day work of GPs; sustainability of the project was a major concern. 61 GPs with special interests were described as defining their legitimacy through relations with experts and through the motivation to extend clinical competency. However, between geneticists and GPs, the power of knowledge and jurisdiction (‘turf’) remained disputed in the professional hierarchy. Consensual divisions of labour may be backed by institutional goals, but, at the micro level, how roles were negotiated was not entirely clear. For example, a mutually agreeable role for the boundary-spanner clinician was delimited (by the specialist) to be less clinical and oriented towards a more educational role (similarly, nurse consultants are described as struggling to negotiate their role as either autonomous expert or process supporter, with a common experience of having difficulty identifying priorities56). An awareness of stakeholders' different priorities, social capital and established relationships was key for developing collaborations across organisational and sectoral boundaries. Short-term economic incentives were difficult to address with long-term preventative cost-saving calculations. In this way, politics was identified as an important aspect of role definition for boundary spanners. In these examples, beneficial evidence from putting a clinician in a boundary-spanner role was difficult to collect, and the role was constantly renegotiated within the context. When considering intentional efforts to vertically integrate services, the authors noted that colocated specialists and practitioners in hospitals had not only a supervisory relationship but also a more dialogical and informal relationship. Practitioners not located in the tertiary setting but working in primary care appeared to have more clinical–governance relationships with the hospital-based specialists. This latter relationship was considered time-consuming for the geneticist who had to check the risk assessments carried out by practitioners who might have had ‘inadequate’ training. 62 Defining a boundary-spanning role by task orientation and job description does not fully reveal the negotiations that happen on a daily basis.

Negotiating disciplinary boundaries between specialists and generalists may be mediated by disciplinary values (which may be semantic, historical, practical and unrelated to patient need or disease trajectory). In a role study in palliative care – and despite policy guidelines to share care – covert and overt tensions between services were noted, particularly in the practice of referrals. 63 Personal commitment and local organisational goals appeared to highlight dilemmas posed by uncertainty of prognosis, particularly in patients with heart failure. In these ways, boundary-spanning managers and newly appointed link workers who were perceived to have less clinical knowledge had less ability to influence others in the vertical dimension, even if supported by policy initiatives, newly funded posts or intentional clinical or managerial placement. Vertical integration may be suggested by policy, but professionals make individual decisions to collaborate, or move patients across boundaries, based on many other factors.

French64 describes four contextual factors (physical, social, political and economic) that influence how work group participants use evidence to make policy decisions. Doctors, managers and nurses working in different settings may have varying perspectives of what is needed for patient care. For example, in the social context of care, respondents reported using independent action, involvement in teaching and direct challenge to influence the care decisions by medical staff. Subterfuge and adaptation were also described as covert strategies used to influence care patterns. In the wider context of care, researchers observed that influencing commissioners, adapting decisions and informally ‘trading’ equipment were other strategies used to manage economic constraints. 64 In these ways nurses used different strategies to close gaps in services.

Finding time to engage in vertical integration activities was also a challenge for clinicians. Nurse consultants working in boundary-spanning positions were described as needing additional time to negotiate priorities and relationships, which limited the time that they were available for patient care,56 whereas cardiac surgeons reported that time constraints may contribute to inaccurate medical stories that are reported to newspapers. 65

Boundary spanners have been placed as intentional links between programmes in an effort to create a more seamless service for clients. For example, expanding the roles of mental health workers to bridge the hand-offs between the courts and components of the mental health system was a solution explored in one case. 66 Attempts to build this innovative programme as a model were complicated by the varying engagement of different stakeholders and by a lack of client health insurance (in the USA). An assessment to gauge interagency co-ordination was mentioned but not reported in detail.

For mental health link workers it was found that, although there was potential for these liaisons to improve communications between secondary education services and child and adolescent mental health services, staff were concerned that some increase in workload might result in the short term. 67

Another study examined the changing roles of practice nurses in the primary health-care setting in terms of them taking greater responsibility for the management of chronic disease. 68 The realignment of boundaries demarcating work previously carried out by GPs motivated nurses to increase their technical knowledge base to a less routine level of practice and to an increased level of professionalism, but raised some tensions in role definition.

Trust and communication, and power and conflict, were explored in a case study of multisectoral collaboration in the domain of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) community. 69 Boundary spanners were recognised as being in ‘dual roles’ – both collaborative partner and organisational representative – causing tensions to arise. Juggling the conversations between constituencies required a chain of conversations, which was framed as a creative process central to organising; the tension was positive and necessary for seeking change. In this case study the tenuous space between collaborators is described as a source of potential energy.

Attempts to map out a mental health safety care pathway also met challenges, because of complex assumptions about work arrangements, and attempts to connect the expectations of clinicians, managers and service users. 70 Negotiating the use of a guideline as a tool was unworkable when it was conceived of as an ideal document of standardisation. To co-ordinate services, and accommodate to variation, the pathway needed to become more abstract in its scope. As a boundary object the author describes the imprecision and looseness of the resulting pathway as an effective alignment and compromise between stakeholders. Creative solutions can resolve such tensions, while balancing the needs of standardisation with diversity of purpose. 70

Two quantitative studies71,72 in the vertical dimension measured time spent (number of hours engaging) in boundary-spanning functions as a positive characteristic of a supervisory position. Substance abuse programme directors, who were also treatment counsellors, were found to spend more time making community presentations and liaising with monitoring organisations, which the authors assume (but did not measure) may have improved treatment practices and political leverage. 71 Front-line nurse managers with a larger number of direct report staff reported lower supervision satisfaction with highly transformational leadership, except when operational hours were extended. 72 These boundary-spanning managers found more satisfaction in the transformative behaviour of performing ‘citizenship’ activities within the organisation, than simply having more time with staff, although having more time was a factor. The leadership activities that characterise boundary spanning appear to mediate contextual pressures, but further studies would need to explore this issue more fully.

Two studies73,74 used quantitative methods to evaluate the impact of perceived uncertainty on boundary-spanning behaviours. In an early field study of work units in health and welfare organisations,73 positive relationships were found between three variables: an organic management structure, frequency of boundary-spanning activity (verbal and written interactions) and perceived environmental uncertainty. The study used a composite variable of ‘organicness’ in management structure by using six scored measures, including extent of participation in strategic decisions, participation in work decisions, division of labour (specialisation), impersonality, formalisation and hierarchy of authority. Perceived environmental uncertainty was measured by questionnaire items rating whether or not subjects knew what to expect of people in the organisation. Frequency of boundary-spanning activity appeared to mediate environmental uncertainty and organisational structure. Organicness was strongly associated with frequent boundary-spanning behaviour; environmental uncertainty was not. By examining the individual as the unit of analysis, this attempt to understand the different effects of organisational structure and uncertainty made strides in adding contextual factors to the analysis of boundary-spanning activities, but limitations remain in measuring such linkages in context. Similarly, in their study of service providers working as boundary spanners in primary care partnerships in Australia, Walker and colleagues74 suggest that such individuals function to interpret environmental context for decision-makers, mediating risk and uncertainty. Service providers perceived less risk and uncertainty in the collaborative work and, so, experienced unproblematic relationships based on trust. In contrast, organisational managers perceived more risks from breaches of trust, particularly as a result of political partnerships, which also might result in more consequences and harmful uncertainties. Competitive allocation of funds and established system practices impacted these experiences, placing an importance on an institutional environment that supports trust across professions.

Social and political contextual influences on sharing knowledge

Twelve15,55,61–64,75–77,86,89,91 of the 14 studies of vertical exchanges specifically addressed the social and political contexts in which different disciplines function, particularly the two studies by Currie and colleagues. 75,76 These studies found that role and status seem to determine research uptake in professional groups, as opposed to managerial behaviour. Social and political relations between team members were identified as the medium for sharing knowledge in organisational change efforts. 76 A case study of how knowledge was shared between two NHS teaching hospitals, district general hospitals, PCTs, a strategic health authority and a university medical school took a neo-institutional perspective. 15 This study suggested that knowledge sharing could be enabled within similar organisations but that this was much more problematic across different organisations and professional groups. In this study hospital doctors were found to focus their knowledge-sharing activity on relationships with their peers within the hospital boundary and they downplayed any contribution that GPs or commissioning managers might make to service development.

The hierarchy of professional exchanges across disciplinary boundaries, and the tendency of higher-status clinicians to withhold rather than share knowledge, was described in a study of the barriers to the spread of innovation in multiprofessional health-care organisations in the UK. 77 Specialists hold overt power in the hierarchy of organisations and strong professional identity is associated with more reluctance to share knowledge. These researchers found that strong uniprofessional communities of practice can block external input from other groups and retard innovation. A key theme in both the horizontal and the vertical integration of services is therefore how credibility is inextricably linked to professional competency and expert knowledge. 77,78,92

Five ethnographic case studies78–82 examined the role of boundary spanners in horizontal integration. The advantages of observing the sociocultural and knowledge context of group work allowed these researchers to explore the factors that impede or enhance collaboration, whether in the tertiary care hospital or in the community clinic. Recognising the need for someone who sits outside of the usual routines – albeit temporarily – was noted in these studies. MacIntosh-Murray and Choo78 suggest that nursing staff – busy with prosaic tasks – may find that meetings and other forms of communication appear to be time-consuming with little time for critical thinking to solve knowledge gaps. The rhetoric of accountability (and risk of consequences) can focus busy staff on tasks rather than quality improvement and, with managerialist discourses, doers may feel burdened or disempowered by a perceived need to put in extra effort to fix problems. A boundary-spanning ‘surrogate’ was able to identify the information needs of others and act as a knowledge translator, but could not fix routines or inherent competence problems in individuals. 78 In another study,79 high workload demands in a complex environment were addressed by staffing flexible and transient teams in operating theatres; however, shared knowledge was at risk as was having a predictable knowledge composition of the teams. In this way, flexibility in coping with care delivery demands was found to undermine the acquisition of knowledge; risks to safety were implied, but evidence was not gathered to support this. Ambiguity can affect people working in boundary areas (such as volunteers working in formal organisations), which may cause confusion for the paid staff working with them. ‘Lay’ workers may be asked to share knowledge and experience but not to give advice, which poses particular tensions and the potential for conflict. 80 Salhani and Coulter81 describe how nurses in a psychiatric hospital ‘went underground’ with ‘guerrilla action’ to use a primary therapeutic nursing model to address biopsychosocial factors with patients, despite rejection from ward psychiatrists. Micropolitics and strategies to organise among the nurses were key factors in the description of interprofessional relationships in this study, as the ‘elite nurses’ intentionally expanded their jurisdictional boundaries through loyalties, logos and celebrations to oppose the dominant medical culture. In another study,82 working as ‘boundary people’ at the interface between community and statutory organisations in itself was a prized end, suggesting that empowerment may have its place in system change. In this case study, building change through ‘small steps’ and ‘good enough’ solutions were strategies used to build partnerships.

An NHS primary care-based study used a survey to examine how boundary spanners' characteristics and behaviours related to the effectiveness with which different groups jointly work together. 83 The study found that the productivity of group collaboration was predicted by boundary spanners who had frequent intergroup contact and high organisational identification. The authors suggest managerial implications (e.g. promoting individual boundary spanners to boundary positions when strong ties to their organisation can be used to overcome ineffective intergroup relations) but no interventions were tested.

Boundary-spanning strategies are used by organisations as well as individuals and groups. For hospitals in the USA, membership in a larger organisational (multihospital) system increased the likelihood that bridging strategies would be used for outreach, likely because of corporate policies to reduce costs. 84 Freestanding hospitals were less likely to seek external service linkages through planning groups or consortia. Confirming the idea that the hospital system is fragmented, this research suggested that hospitals do not have a uniform response to environmental pressures and noted that regulatory pressure did not increase boundary-spanning activity as expected. Retrenchment at the administrative level might be more likely as a response to vertical integration pressures, by increasing the size of boundary-spanning governing boards rather than increasing technical capacity. In another study of hospitals in the US health-care system85 it was found that inpatient psychiatric departments increased the number of boundary-spanning and buffering structures as they increased in size. Organisational performance was inversely related to department size as assessed by discharge rate, cost of discharge and cost per patient-day. Public hospitals had more secure government funding and were more likely to increase the number of professional staff, whereas private hospitals were more likely to use non- or paraprofessional staff to reduce costs.

Callister and Wall,86 in a mixed-methods study from the USA, specifically used conflict incidents to explore the interactions between managed-care representatives and service providers. Organisational power and status differences were the independent variables, and behavioural responses of the managed-care representatives and expressed negative emotions of providers were the dependent variables. The researchers noted that the individual boundary spanners with the most power (e.g. representatives of the larger managed-care organisation) were less compromising and collaborative when negotiating with smaller organisations, and anger resulted when decisions were blocked by a lower-status representative. Describing a ‘double power asymmetry’ the researchers also noted that the organisation that is larger and controls revenue streams can exert power over the medical doctor as provider; however, this is reversed if the boundary spanner from the managed-care organisation has a lower status (a clerk or a nurse) than the medical expertise of the provider. It is interesting to note that the boundary-spanning post can be both problematic and a proposed solution; the boundary-spanning representative in the middle of a conflict can experience stress and potential job turnover, which might be addressed by putting more doctors in boundary-spanning positions.

In a case study of successful local health partnerships,87 boundary spanning was accomplished both ‘downwards’ and ‘across and upwards’, meaning that community advisors had the responsibility for engaging multiple stakeholders, including programme recipients. Momentum was maintained for ongoing dialogue because of the trust engendered through the enthusiasm and optimistic personality of the boundary spanner. Positive results were reported as ‘100% uptake of energy efficiency measures’ and ‘high levels of satisfaction’, which were attributed to the increase in detailed local knowledge. Being a ‘community-led’ project was also held to be a positive aspect of the success of the strategic planning partnerships. The movement of knowledge across boundaries appears to be inextricable from the communicators of the process.

In another example of community partnerships, public health and faith collaborations were designed in an effort to address health disparities. 88 Boundary leaders were trained in methods of community system change at an educational institute and pre/post assessments of knowledge and skills were gathered from each participant. Despite reporting success on leadership measures of renewed sense of faith and team accomplishments in planning programmes, no impact on health disparities could be reported. Inducing plans for change can be an indicator of the effect of boundary-spanning interventions but does not provide clear and direct evidence of an impact on health outcomes, as is often demanded by stakeholders and funders.

Evidence of impact on the quality of patient care

Of the 14 studies15,55,56,61–65,75–77,86,89,91 that examined the impact on health-care quality of some form of vertical boundary-spanning intervention, only one examined patient outcomes as a result of a boundary-spanning initiative. Thompson and colleagues89 used key indicators (through retrospective chart audit) to determine the quality of peritoneal dialysis before and after a collaborative mapping project. Inpatient and ambulatory nursing representatives met to identify and change process flow charting for equipment utilisation (by patients and clinicians) across a service boundary. As an intentional quality improvement effort, patients who received care after the new jointly developed guidelines were implemented showed a decrease in transfer time between units, faster diagnosis and faster treatment of complications; plans for interdisciplinary collaboration for changing practice responses for hypovolaemia were also being monitored. In this study, how different professionals were brought together for discussions was not qualitatively examined, but the impact of the effort was well illustrated.

A postal survey and interviews90 identified five perspectives relating to the role of boundary spanners – networker, innovator, ‘cultural broker’, collaborator and leader – and explored how the factors of otherness and trust contributed to whether or not such individuals are ‘born and not bred’. The author concluded that research evidence was ‘weak on processes and effectiveness’ and failed to explain the link between individual and team behaviour and outcomes. The study confirmed the image of individual boundary spanners as being able to work in non-hierarchical decision environments by brokering resources and connecting problems to solutions; however, the link between competency and performance effectiveness was not explored.

Summary

Boundary spanning as a concept is well described in the organisational studies literature and many insights from our literature review confirm previous findings in other industries (i.e. broader insights do seem relevant to contemporary challenges relating to the vertical and horizontal integration of health-care services). However, although it is accepted that boundary spanning contributes to knowledge transfer in the technology industry, sectoral, organisational and professional boundaries in health-care systems can present significant barriers to the exchange of knowledge. 15 These can undermine attempts to integrate health-care systems and ultimately efforts to improve quality and efficiency.

Our review of the literature shows that boundary spanning is often regarded as a potential solution to the challenge of service integration. Although the 38 studies that we reviewed differed in terms of whether they took a quantitative or a qualitative stance, whether they studied boundary spanning as an informal or a formal activity and whether they focused on the co-ordination of teams within or between organisations, overall we found a quite strong normative emphasis in the literature. ‘Boundary spanning’ appeals as an ‘obvious’ solution and also tends to be quite reified through individuals being identified as ‘boundary spanners’ who extend collaboration and integration in health-care services. What is less clear, however, is how boundary spanners perform their role – or should perform their role – to improve the quality of care. But we would also note that some commentators45,46,50,51 perceive boundary-spanning processes as problematic, not just failing in implementation but also hindering and even jeopardising intended facilitation and change.

A recent review of current policy frameworks for supporting evidence-based health care93 specifically argues for greater attention to be paid to fostering ‘new boundary-spanning mechanisms to encourage knowledge flow across professional boundaries’ (p. 847) and to the means by which different professions can share and debate their ‘knowledge’ and then embed it into local practice. Our review found that, although the characteristics and experiences of individuals in formal or informal boundary-spanning roles have been studied in the health-care context, relatively little attention has been paid to date to the core focus of our study: the processes by which ‘boundary spanning’ can support horizontal and vertical health-care integration. Importantly, our review also demonstrated a lack of evidence of change in practice.

The study setting

Our study took place in an area within an inner-city borough that is dominated by the Asian, particularly Punjabi, community. Although there are many Muslim and Hindu residents, the largest portion of the borough's population is Sikh (23.2%). The borough has a population of approximately 300,000 residents, > 40% of residents were born outside the UK and about 25% of adults have no academic qualifications. In the borough as a whole, many children do not speak English as a first language.

Overall, the area in which our study was conducted ranks high on all deprivation scores and is impacted by many chronic diseases, reflected in higher than expected mortality rates. The Index of Multiple Deprivation (IMD) for the study area – a summary score measuring deprivation in relation to employment, income, education, skills and training, health and disability, barriers to housing and services, and living environment and crime – was the highest in the borough. A high proportion of housing in the area is overcrowded and the area has the highest scores in the borough for child poverty and deprivation affecting older people. One particular ward within our study area had the highest percentage of low-birthweight babies (10%) born between 2002 and 2004. The area also has four wards with the highest admission rates for depression in the borough and there are also high rates of admission for psychosis. The area as a whole has the highest prevalence rate for diabetes in the borough (12.6% in males), which is also more common in people of South Asian origin.

The boundary-spanning intervention that we studied was one local project designed to build connections between community services to improve local health and well-being. Clearly the wider local context was, on one hand, a challenging one in which to implement this intervention. On the other hand there was an extensive and vibrant network of community groups active in the locality and keen to engage in projects such as the WI.

Knowledge about available local services relating to the four topic areas

In Coxford respondents felt much more confident that they could find information that they needed to help diabetic patients than they could find information that they needed to help dementia patients. In Westpark respondents were similarly confident about diabetic patients but, on average, slightly less confident about BME patients with anxiety and depression (Table 7).

Attitudes towards local services relating to the four topic areas

Tables 8 and 9 report respondents' attitudes towards local services relating to each of the four topic areas in terms of, first, the degree of practical help when there is a crisis relating to a patient and, second, the degree of co-ordination between different services. In relation to both questions dementia services were rated as relatively less helpful and co-ordinated by respondents in both Coxford and Westpark, whereas diabetes services were consistently the highest rated on both aspects in both localities. With regard to the former question (degree of practical help) ratings increased over time for all four topic areas among Westpark respondents but decreased in Coxford in three of the four topic areas. However, small numbers of respondents make drawing firm comparative conclusions between the two areas problematic.

Table 10 reports how highly respondents rated their working relationships with a range of other health-care and non-health-care professionals. Relationships with school nurses were rated the lowest by respondents in both localities (range 2.48–3.00); dementia care teams also rated poorly (range 2.88–3.43). Relationships with community matrons were commonly rated highly (range 3.91–4.14) as were those with palliative care nurses (range 3.94–4.18) and pharmacists (range 4.23–4.56). Pharmacists were included in the time 2 survey only as was the ‘volunteer sector’, with whom working relationships were rated much lower (range 2.92–2.93).

Practices pertaining to local services relating to the four topic areas

Tables 11 and 12 present findings on, first, how respondents rated their working relationships with local services specifically relating to the four topic areas and, second, the extent to which they felt that their practice made a difference to the quality of life of patients in the four topic groups. In both cases respondents typically rated dementia lowest and diabetes highest.

Overall, dementia rated lowest of the four topic areas for all five questions relating to the KAP of survey respondents, whereas diabetes was consistently rated the highest of the four topic areas. In addition, working relationships with dementia care teams were rated poorly (only school nurses rated lower), whereas working relationships with diabetes specialists were rated reasonably highly. Across the five questions the responses in relation to the two other topic areas – anxiety and depression in BME populations and child and family health services – fell somewhere between these two extremes (dementia and diabetes) with no clear pattern emerging.

Black and minority ethnic patients with anxiety and depression

A focus group was held in March 2012 with two patients. One participant (FG1MH01) had been seen at the women's centre in Westpark 10 years previously and she had begun to work with the Coxford women's centre as a volunteer 4 years previously. The other participant (FG1MH02) had received CBT for depression when referred by her GP a year before.

Both talked about the importance of being quickly referred and the uncertainty of the time when they were suffering with anxiety and depression but had not yet begun to receive care. Having a ‘real’ person to talk to was a particular priority too. It took the second participant 3 weeks to be seen by the well-being service after her GP told her that she might have depression. Like many patients, she was seen by her GP for another complaint (shoulder pain) and happened to mention having trouble sleeping and feeling worried and distressed. At the time she was told that it would be 10 days before she would be contacted for some type of ‘psychological help’, which ‘felt like a long time’, but when she was called in 5 days she was quite relieved:

Yes, I was given a number to call, and I was very reluctant to call that number because they have so much box ticking going on in many of these organisations, and I really was not up for anything like that, because it was at a very serious point in my life, and I really did not want to have to sit in front of anyone just checking off things and stuff. So it took me a good week before I called. Then when I called, they told me it was going to be another 10 days for someone to call me. I said, ‘Here we go.’ That’s the way I felt, ‘Here we go.’ But I think they called me within 5 days. Within 5 days really I got a phone call. I thought they were very professional on the phone, which was surprising. She told me she would be calling back, and we’ll be going through a kind of interview on the phone. All of that went exactly as she said. Then I was referred to here, immediately I was referred to here.

FG1MH02

The first participant had called a hotline, but really wanted to meet with someone immediately:

I personally was very lucky that I’d got people around me that were able to step outside of the box – because I was not a very easy patient – step outside of the box and deal with me on a really serious one-to-one level, and not what was written here, because it was not going to work in my case. I was very fortunate where that was concerned. At the beginning, in addition to the counsellor I had an advocate.

FG1MH01

Patients often have a need for advocates outside of the mental health system, perhaps through the informal support provided by family members, as well as needing more formal legal advice and links to local agencies. Both participants needed support to address issues with the local council, for instance. The first patient needed help to work out issues with her pension, with having to go to court, with harassment where she lived and with housing difficulties. As well as psychological distress, she experienced language barriers and pressing concerns in her daily life. Connections to different services were crucial for both participants:

Yeah, I myself did a lot of research on this thing. But my case probably was a very unique case, I’ve got to say. It probably was a very unique case, and that’s what my counsellor told me too. But the big thing there is that they were able to split the . . . she was able to say, ‘You know what? I’m going to deal with her mental situation . . . .’ Yeah, I think the big thing there is . . . and I remember even feeling some relief, just on the very first meeting with her, that, ‘Okay, we’re going to remove that part, don’t worry about that right now, we’re just going to look after you.’

FG1MH02

In August 2011 the WI anxiety and depression in BME populations team began recruiting former patients for a patient forum to inform its work. Given their past experiences both patients were eager to help improve mental health services for people who may struggle as they had:

My counsellor told me that they want to start this group, and she thinks I would be a good candidate if I was interested in helping them set the group up. With my experience and everything I said, ‘Yeah, why not?’ Because I think it’s important.

FG1MH01

One of the reasons I joined the [forum] and being part of helping set it up is listening to other people and their situation. I think expediency is very important, that they react right away to a call. I think I was very lucky. I’ve heard of some people who have not been that lucky. I think if I did not get that immediate intervention, it wouldn’t have been so nice . . .  . Shorten time from the time you call to getting you in to see someone. When I called the very first time, I got a recording. When I called the first time, I got a recording, and the recording asked me to leave my name and number and that someone is going to call me back in 5 to 10 days, okay. Now, dependent on the urgency of that person, that 5 to 10 days is a very critical time.

FG1MH02

Having a hotline to call was an important aspect of swift services according to these two patients, and having to leave a recorded message was less of a concern if a quick response was forthcoming. They discussed together the importance of a free central number for help, but also recognised the cost barriers to implementation. As the second participant explained:

. . . to get an 0800 number available, and we were told today an 0800 number is free to the caller, but the organisation said the 0800 number has to pay for that, and they don’t know if they have those kinds of funds. This is very important, I know from working with the [refugee agency], sometimes people don’t have a phone, they don’t have money, or they have a phone and money, they need to get out of the house.

FG1MH02

Both acknowledged that their involvement in the patient forum was helping others as well as being therapeutic for them in terms of building their own confidence, something that the CBT therapist encouraged and acknowledged.

Diabetes

A focus group of diabetic patients from Westpark was held in February 2012. Seven people participated. The study information sheet was reviewed, questions regarding ethics were discussed and participants were given the opportunity to ask questions before signing the consent form. The session was recorded, transcribed and analysed for themes. The participants sat in a circle and introduced themselves, saying how long they had had diabetes, and most explained that they also cared for family members with diabetes. Six had type 2 diabetes and one had type 1 diabetes, five were women and all were of Asian descent.

Getting care all in one place and increasing their own understanding of the disease were important themes early in the group discussion:

Say 6, 7 years back, everybody was called for an annual check-up at Coxford Hospital. And then they discharged everybody and said, ‘You’ll have to go back to your local GP. They will be taking up your case, and then call you in for your check-up.’ Then any blood tests that need to be done, it was done there. In one way it’s convenient, rather than going to the hospital and waiting long. Here they give you an appointment, and then you do your tests, and you get your results. I think it’s the way forward. But what they’ve added is diabetic retinopathy, so that helps.

FG1DM05

They’ve given us little leaflets to look after ourselves now with all the results of all our bloods, which is really good because you can see where you are, which before I didn’t know what anything was.

FG1DM01

This same individual had had diabetes for 12 years and she talked about taking a short course at the Coxford Hospital 2 years previously (before the WI). Learning about food and diabetes had been helpful for her. She went on to describe the importance of quick access to the specialist nurses and how that helped with coping with the stigma of the disease:

But it was really, really good. I learnt so much information, we were able to share experiences, like this doesn’t happen. And I think initially when I was diagnosed, Indian society, being diabetic, being type 1 diabetic, oh, God forbid. God forbid you ever tell anyone. So it was absolutely disgusting . . . . Yeah. So it’s completely taboo, and it’s a shame, because now in current society people still don’t talk about it, especially because in Indian culture it’s a happening thing, it’s happening more and more. So it’s a shame. So I wasn’t able to speak to really my family other than my immediate family when I was first diagnosed. But the diabetic nurses at Coxford Hospital were absolutely amazing. I could ring them whenever I wanted, I could go and visit them any day of the week. Their offices were always open. I couldn’t see the doctor necessarily . . . . It’s stayed consistent. If I want to go and see them, if I want to make an appointment, they're always at the end of the phone. I think that's really, really nice.

FG1DM01

However, as the group continued to talk, it became clear that the care was felt to be more responsive through the hospital for the patient with type 1 diabetes than for the type 2 diabetics in the group, who found the care to be less timely:

Type 2, it’s probably a bit different, because it was the hospital, they saw you annually, and that’s it . . . . And if there’s any changes, for example, you know when they did the blood test for you, ‘Oh, your cholesterol has gone up. Oh, well, we’ll recommend you tablets, and then refer you back to your GP.’ And they would say . . . They would get the message, but not immediately. They would call you after about a month or two and say . . .

FG1DM05

Others in the group agreed that the connections between the hospital and the GPs seem to work at different speeds. When medication was being changed then time to contact was appropriately swift, but unfortunately not always informative:

Almost immediately. They always call me up, and it is almost immediate. They’ll call you in, get you a prescription. But the thing is, they don’t explain it. When I go to my NHS consultant, when he’s looking up my blood test, I like to be informed of what the changes are, even if it is every 3 months. I like to know. Just like you say, there is no support. When I got diagnosed, I had a really bad experience as well 6 years ago. And I had all the symptoms, all the symptoms that a diabetic could have had, and it was crystal clear. But I wasn’t able to get diagnosed by my GP however many times I came in. It was over a 3-month period that I was having these symptoms. So it was at a time when they didn’t really have all these monitors. I think it was about a year back when they started to introduce them, there was a big hype about all these local afternoon clinics, and they were saying, well, okay, a lot of them had free testing monitors being given out to them before these budget cuts.

FG1DM02

The participants had heard that diabetes rates were increasing in the local area and remembered that free testing monitors were frequently offered in the time period before the budget cuts, but their view was that education and support were now harder to find:

But nobody has got any information or support anywhere. Like she said, when she was first diagnosed, there’s not anywhere that . . . I had to literally do all of my reading on the internet. Diabetes . . . I got more information off the internet than I did from any of the medical professionals . . . I go to diabetes.co.uk.

FG1DM02

As the type 2 diabetics noted the shift in their services back to the GP surgery, they also began to describe their lack of confidence in the GP surgery nurse (as opposed to the diabetic specialist nurses based at the hospital). Five of the participants discussed recognising the lack of competence and continuity in their care provided at the surgery:

She hasn’t got a clue.

FG1DM02

Oh, I don’t come to see the nurse at the GP. I refuse to. I would much rather go to the hospital . . . I wouldn’t come here. But they don’t give you your prescription unless you have been to see them. So you are actually forced to come.

FG1DM06

Go to the hospital. She will do the basics, get your weight, see your feet, check your blood pressure, check your weight, and that’s about it, and everything on the system.

FG1DM05

She actually turned round to me once and said, ‘I don’t know why you’re coming here if you’re under hospital care.’ She’s not very informative. She doesn’t know, she hasn’t got much knowledge in the field of diabetes. You need specialist care.

FG1DM02

It’s very hard to get hold of her, she doesn’t do evenings. So my husband’s work, he has to take a lot of time off.

FG1DM01

In this manner, patients appear to be able to discern the difference between attentive service at a convenient location and self-selecting their care, if able, at the place where they perceive care to be the best. They also verbalised being able to recognise, and preferring, specialty-trained practitioners:

Yeah. See, they were really, really good, and you could ask questions and they actually knew, and there was a bit of banter going. It was all right. But I think with the nurse that they currently have, with me, I’ve got a running joke with the receptionist because I refuse to see her. She doesn’t even ask for me any more because I won’t. But there are some really good nurses out there who actually do know about these conditions.

FG1DM06

Can I just tell you, when [the previous doctor] was there, he had some very good nurses and staff. They were dedicated diabetic nurses.

FG1DM05

That had trained knowledge on it.

FG1DM02

As a group of diabetics with many years of experience, they were able to list the kinds of care that they knew that they should have, including blood pressure and weight monitoring and eye and kidney screening. They discussed how regular screening may have decreased recently, especially with the move of services back to primary care.

They used to do your weight . . . . Urine test they used to use, the little stick test thing for proteins. They used to do quite a bit, actually. It’s been a while now.

FG1DM02

The patients spoke about understanding the risk of hypoglycaemia and the way to treat it quickly with sugar, as well as the importance of having their eyes checked regularly. Two participants confirmed that their optician also checked their blood sugar and referred them back to their GP. The rest in the group were impressed and they began to share names of local opticians.

Making connections between services was recognised by the patients as important but not as efficient as it should be:

There was going to be a centralised database system, wasn’t there? I think that would be one step in the right direction. I know that there’s all these data protection laws and loads of negativity about it. But I think in respect of us getting the care that we deserve, everyone needs to have the same information. The last two times I’ve been to the hospital, they have written to me and cc’d in the GP. They’ve written a letter to tell them the results and what was discussed and stuff like that.

FG1DM06

The WI – and many other quality improvement efforts – have attempted to use IT solutions to co-ordinate care, but the patients in this focus group had not noticed more seamless services:

No, just about what was discussed and what my results were, because usually what used to happen was when I was going to come and see the nurse here, reluctantly, she would also send me for another blood test. And obviously I don’t have time to go out, I’m a teacher, I can’t go during term time. So there was no time. But if I’ve already had a blood test there the week before, then surely they should be able to have a look at the results here . . . . There’s not enough communication, and it’s an inconvenience against me. If something is wrong with you . . . I mean, because you could use any hospital A&E [accident and emergency]. Somebody needs to know. They could get into all of your medical records that way, knowing exactly what your past history is as well.

FG1DM06

When asked how to solve the problem of better integration of services, three of the patients suggested that they would prefer specialist care and that they believed that the hospital was where that had happened best in the past. They acknowledged recent national policy changes (e.g. GP commissioning) and the pressures of budget cuts, but they also knew how they would like care to be provided:

The step should be, like they say, like look, all the type 2s, they’re all coming to the GPs, but they’re all complaining. They’re not getting the care that they should do. So okay, you’re going to give it to the hospitals, get more consultants in there, people that know their job, know what they need, rather than have it shared here and them not know and still having to go back up to hospital to get it from the consultant. So take it off of the GPs and leave it with the hospitals where they can get their feet and their sugars and whatever they need done. I would never come to my GP. I would not be in care like they would be in care. No, they gave me the alternative, but I stayed at hospital.

FG1DM02

How you look at the doctors is generic. He is the first port of call, he has limited knowledge – I don’t know, I might be wrong. If he thinks, yes, you’ve said that, or you have some stomach problem, he’ll try to advise you and give you medication. But when it gets a bit complicated, he has to refer you to somebody specialist. That’s how they are taught. If your white blood cells are higher than normal, he can’t do anything.

FG1DM05

The participants were able to understand the difficulty in determining transitions in care between generalist and specialist services. They also discussed which health-care staff were the most informative and how to get more information about their own laboratory results. It was clear that there was no preferred discipline – whether consultant or pharmacist, doctor or nurse – but there was a consensus that they looked for practitioners who listened, explained and were readily available.

The participants also discussed the importance of receiving comprehensive care – and six of the group spoke excitedly about getting a full annual examination in India, with a body scan, a stool test and a full written report for £40–50. All agreed that this is desirable but that it is unfortunate that their UK physicians will not review the reports with them on return.

Good information is key for the patients. When discussing the use of the internet for finding information about their disease, the patients were glad to be able to find useful information, but they were not directed towards certain websites:

Pamphlets, leaflets, information sheets, somewhere to go, someone we can ring, someone who you can . . . . Not from people without having to do it myself . . . . You figure it out on your own. Yeah, who’s going to look and find for the older generation, toddling about on the internet?

FG1DM02

As the focus group wrapped up, the participants began to comment about the hour as if it was a support group and about how helpful such an experience can be.

It’s the first time I’ve been able to talk about it.

FG1DM02

This should happen more I think in the community, it should, because there are so many diabetics.

FG1DM06

The participants also asked about the study and some appeared to hope that that such discussions would continue, as they acknowledged the benefits of bringing patients together to share experiences.

Summary of focus groups

Participants in the two focus groups did not specifically identify ways in which the WI had impacted on their experiences or quality of care. However, participants were able to describe aspects of co-ordinated and timely service that they experienced as seamless care. In both focus groups quick response times through centralised telephone helplines were described as important, as was having access to a variety of services as and when necessary. Participants did not ascribe greater value to certain disciplines or professional roles but they did want more frequent access to knowledgeable practitioners who could co-ordinate their overall treatment over time, had access to their test results and could make changes to their care as needed. Where services were located was less important than oversight of patient care over time.

Anxiety and depression in black and minority ethnic populations

Team outcomes

The team had set three objectives in April 2010 at the start of the WI: to attach mental health link workers to Westpark GPs, to monitor changing patterns of referrals and to form a group to explore whole-system integration.

Pressure to provide evidence of the impact of the team's efforts came from the local trusts as well as from its involvement with research funded by this NIHR grant as well as CLAHRC (e.g. the latter expected weekly reports from team members, which ensured consistent activity and self-evaluation). Members of the team spoke of a sense of excitement over the impact that the link workers were felt to be having, as well as being overwhelmed by the need for data collection while also striving to provide clinical services. A coherent and specific goal of increasing referrals enabled this team to focus on appropriate methods for collecting useful data from the start of their work in 2010, and then to apply for more CLAHRC funding in 2011 to support this data collection process. Through 2011 and 2012 the team continued to be motivated, and partially funded by CLAHRC, to try to collect appropriate evidence, particularly around referral rates in the BME population.

Throughout the study period team members were clear about their goals but uncertain how to interpret and present data on the outcomes. They knew that referrals to the well-being service had increased but were hesitant to publish numbers for the first couple of years, partially because they were uncertain how to appropriately calculate the change over time, whether or not the ethnic distribution data were ‘clean’ and how to present the information with accuracy. They also felt that referrals from GPs were improving in quality, such that the right types of patients were being referred appropriately, although such information was not formally measured. When a previously reluctant GP began to ask for a mental health link worker in his practice, the team saw this as a success.

In February 2011, Vinoda described the outcomes at the time:

It’s not just the link workers, I think it’s everything to do with the stakeholder workshops where we’ve had practice nurses come, we’ve got health visitors that have come, we’ve got people from the voluntary sector that are making referrals. We’ve got a self-referral line which people can phone, and we’ve advertised it in different languages . . . . We’ve established links in the temples, the gurdwaras. We’re running a walk-in service in [a community centre] which is our older people service, where if someone wants to speak to one of my colleagues and wants a quick referral, we’re happy to do that. So it is a combination of stuff. But I think the GP referrals have gone up in those surgeries where there’s a link worker, and we’ve got stats to prove that.

WIL7G, BME therapy team leader

Vinoda further described signposting to the volunteer sector for domestic violence support and how waiting times for CBT had decreased from 18 months to 2–4 weeks. Persistently throughout the study period, Vinoda continued to relate how important the WI was to her own professional development, and the service:

Without the project, I don’t think we would have made such an impact, because we wouldn’t have had the time. Not just the time – especially the time, but the shared knowledge and experience and working with the other teams to do that.

WIL7G, BME therapy team leader

Informally, patient satisfaction was being catalogued as a list of small gestures (such as gifts of fruit) from thankful patients who were culturally comfortable with such exchanges. PHQ-9 data (Patient Health Questionnaire) were being collected at every patient visit for CBT counselling, but the data were sent to a distant university and were not always accessible to the staff and so changes in individual patient scores over time were not available at the time of care. In early 2012 the team drafted a report for CLAHRC, charting a 810% increase in referrals from the Westpark locality from 2008 to 2010 and a 939% increase in referrals from the Asian community in the same period. In 2007 there were < 50 referrals and in 2010 there were closer to 750 referrals. A creative variety of promotional activity was credited with impacting on professional and patient utilisation of services, as seen in increased referral rates, more appropriate referrals and perceived increases in awareness of the service among the BME population.

Our own analysis of trends in IAPT referrals is shown in Figure 5. The downward arrows indicate when the link worker started in each practice (note that for LW5 there was a link worker from April to August 2011 and then again from December 2012, and for LW1 the link worker started in January 2009). The mean profile for all other practices that did not have a link worker is shown by the dashed line (NLW). A link worker effect was not readily discernible from the figure; however, since October to December 2010 referrals have been generally higher (see Table 14 and Figure 6).

FIGURE 5.

Improving Access to Psychological Therapies referrals for individual practices with a link worker compared with all other Westpark practices. Downward arrows indicate when the link worker started.

Table 14 compares the mean number of referrals of BME patients with the IAPT service in each quarter by those practices with a link worker in post at the time and those practices without a link worker. In seven of the nine quarters practices with a link worker have, on average, referred more BME patients to the IAPT service than practices without a link worker. The results show that in four of the quarters there were > 200% more referrals from practices with a link worker than from practices without a link worker.

TABLE 14 - Mean number of referrals to the IAPT service by link worker and no link worker practices, January 2010–March 2012

Practice	January–March 2010	April–June 2010	July–September 2010	October–December 2010	January–March 2011	April–June 2011	July–September 2011	October–December 2011	January–March 2012
Link worker	1.00	6.00	3.00	12.00	12.50	18.00	10.13	16.50	8.83
No link worker	4.24	5.00	6.58	5.70	7.70	5.53	6.93	6.39	3.50

Figure 6 illustrates this table in graphical form.

FIGURE 6.

Graphical representation of mean number of referrals to the IAPT service by link worker and no link worker practices, January 2010 to March 2012.

In addition, we also explored whether or not there had been any significant changes in three relevant QOF scores by comparing performance over time in the 24 Westpark practices and the 55 Coxford practices for which data were available. Performance on the three QOF depression indicators by geographical area and across three successive QOF reporting periods is shown in Table 15.

TABLE 15 - Quality and Outcomes Framework depression indicators by geographical area and QOF reporting period

CHD, chronic heart disease.

QOF depression indicator		Coxford			Westpark
		2008/9	2009/10	2010/11	2008/9	2009/10	2010/11
DEP 1: % of patients on the diabetes/CHD registers for whom case finding for depression has been undertaken once in the previous 15 months	%	84.89	86.42	87.27	87.13	83.88	86.37
	n	12,923	13,271	14,216	7454	7773	8145
DEP 2: in patients with a new diagnosis of depression, recorded in the QOF year, % with assessment of severity at outset of treatment	%	9.57	79.50	81.71	11.70	79.93	74.79
	n	1397	1373	1126	295	243	181
DEP 3: in patients with a new diagnosis of depression and assessment of severity recorded in the QOF year, % who have had a further assessment of severity 5–12 weeks after the initial recording of the assessment of severity	%		46.58	53.82		61.57	72.99
	n		653	740		141	154

Area profiles did not differ significantly for any depression indicator. Most of the improvement in DEP 2 performance occurred between 2008/9 and 2009/10. Performance on DEP 2 dipped between 2009/10 and 2010/11 in Westpark but not in Coxford. For DEP 3 Coxford shows an increase of 7.2% and Westpark an increase of 11.4%, which is not statistically significant, and the number of patients contributing to DEP 3 is smaller than the numbers contributing to DEP 1 and DEP 2.

Dementia

Child and family health services

Diabetes

Team outcomes

At the outset of their involvement in the WI the diabetes team had set themselves two very broad objectives and three specific measures of impact (see Table 20), which we report on in this section. Chris reported to the forming commissioning group in September 2011 that the achievement of the WI diabetes team was that 14 GP practices had collaborated to improve diabetes care and participate in the YOC, as jointly led by the hospital and the Coxford PCT.

Performance on the QOF diabetes indicators by practice group and across three successive QOF reporting periods is shown in Table 21.

TABLE 21 - Quality and Outcomes Framework diabetes indicators by practice group and QOF reporting period

ACE, angiotensin-converting enzyme; BMI, body mass index.; eGFR, estimated glomerular filtration rate.

QOF diabetes indicator		Coxford			Diabetes cluster			Westpark remainder
		2008/9	2009/10	2010/11	2008/9	2009/10	2010/11	2008/9	2009/10	2010/11
DM 2: % with diabetes whose notes record BMI in the previous 15 months	%	91.18	89.70	90.52	92.42	96.18	94.16	90.53	86.73	88.35
	n	9526	9835	10,589	1244	1359	1404	4894	5163	5386
DM 5: % with diabetes with a record of HbA1c in the previous 15 months	%	92.91	92.80	93.54	91.53	92.29	91.95	91.25	86.91	91.24
	n	9707	10,175	10,942	1232	1304	1371	4933	5174	5562
DM 7: % with diabetes in whom the last HbA1c is ≤ 10% in the previous 15 months	%	84.41			77.41			80.02
	n	8819			1042			4326
DM 9: % with diabetes with record of presence/absence of peripheral pulses in the previous 15 months	%	86.10	84.92	85.59	86.70	90.87	89.20	87.00	83.62	86.37
	n	8996	9311	10,012	1167	1284	1330	4703	4978	5265
DM 10: % with diabetes with a record of neuropathy testing in the previous 15 months	%	85.91	84.76	85.46	86.70	90.87	89.40	86.77	83.02	86.27
	n	8976	9293	9997	1167	1284	1333	4691	4942	5259
DM 11: % with diabetes with a record of blood pressure in the previous 15 months	%	96.41	95.75	96.12	96.36	97.66	96.58	95.36	93.05	94.75
	n	10,073	10,498	11,244	1297	1380	1440	5155	5539	5776
DM 12: % with diabetes whose last blood pressure is ≤ 145/85 mmHg	%	76.05	76.13	76.51	72.21	75.80	74.98	71.79	70.82	73.28
	n	7946	8347	8950	972	1071	1118	3881	4216	4467
DM 13: % with diabetes with a record of microalbuminuria testing in the previous 15 months	%	77.51	82.21	83.31	75.78	82.40	80.80	68.35	76.07	78.25
	n	8098	8625	9348	1020	1114	1157	3695	4028	4250
DM 15: % with diabetes with a diagnosis of proteinuria or microalbuminuria treated with ACE inhibitors	%	9.37	85.05	81.04	8.31	84.44	81.94	13.80	79.91	80.53
	n	925	1217	1261	85	114	118	708	708	728
DM 16: % with diabetes who have a record of total cholesterol in the previous 15 months	%	92.87	92.50	93.20	92.12	93.91	92.76	91.38	87.32	91.58
	n	9703	10,142	10,903	1240	1327	1383	4940	5198	5583
DM 17: % with diabetes whose last measured total cholesterol within the previous 15 months is ≤ 5 mmol/l	%	74.45	76.30	75.47	70.06	70.70	70.02	68.55	68.79	71.56
	n	7779	8365	8829	943	999	1044	3706	4095	4362
DM 18: % with diabetes who have had influenza immunisation in the preceding 1 September to 31 March	%	73.78	73.87	73.06	78.23	79.12	79.07	76.32	77.24	75.26
	n	7709	8099	8546	1053	1118	1179	4126	4598	4588
DM 20: % with diabetes in whom the last HbA1c is ≤ 7.5% in the previous 15 months	%	56.24			41.23			47.26
	n	5876			555			2555
DM 21: % with diabetes with a record of retinal screening in the previous 15 months	%	88.75	85.77	87.03	90.71	87.54	89.47	81.89	76.90	85.50
	n	9273	9404	10,181	1221	1237	1334	4427	4578	5212
DM 22: % with diabetes with a record of eGFR/serum creatinine testing in the previous 15 months	%	93.40	92.69	93.47	91.90	93.42	93.29	91.40	87.33	91.45
	n	9758	10,163	10,934	1237	1320	1391	4941	5199	5575
DM 23: % with diabetes in whom the last HbA1c is ≤ 7% in the previous 15 months	%		42.89	42.43		30.50	32.41		33.85	33.25
	n		4702	4964		431	482		2015	2027
DM 24: % with diabetes in whom the last HbA1c is ≤ 8% in the previous 15 months	%		66.13	66.43		54.99	58.06		56.22	57.48
	n		7251	7771		777	864		3347	3504
DM 25: % with diabetes in whom the last HbA1c is ≤ 9% in the previous 15 months	%		77.86	78.40		72.26	72.23		69.31	71.88
	n		8537	9171		1021	1074		4126	4382

Profiles across the three QOF reporting periods varied significantly between practice groups for two indicators, DM 11 (% with diabetes with a record of blood pressure in the previous 15 months, χ² = 22.144, 4df, p < 0.001) and DM 15 (% with diabetes with a diagnosis of proteinuria or microalbuminuria treated with angiotensin-converting enzyme inhibitors, χ² = 11.195, 4 df, p = 0.024), and approached statistical significance for DM 21 (% patients with retinal screening in the previous 15 months, χ² = 8.935, 4 df, p = 0.063) and DM 24 [% with diabetes in whom the last HbA_1c (glycated haemoglobin) is ≤ 8% in the previous 15 months, χ² = 5.399, 2 df, p = 0.067].

Performance dipped on DM 11 in the Coxford and Westpark practices in 2009/10, but not in the diabetes cluster, in which there was an increase in performance. There was a marked increase in performance on DM 15 for all practice groups between 2008/9 and 2009/10; performance then declined between 2009/10 and 2010/11 for Coxford (minus 4.0%) and the diabetes cluster (minus 2.5%), but not for the Westpark practices not in the diabetes cluster (plus 0.6%). Performance on DM 22 also dipped in the Coxford practices and the Westpark practices not in the diabetes cluster in 2009/10. There was greater improvement in DM 24 between 2009/10, when this indicator was first introduced, and 2010/11 in the diabetes cluster than in the other two practice groups.

Overall, therefore, those practices in Westpark that were part of the diabetes cluster performed better on three of the 17 QOF indicators (DM 11, DM 22 and DM 24) than practices in the remainder of Westpark and in the wider Coxford PCT. Practices in Westpark, but not in the diabetes cluster, performed better on DM 15, a counterintuitive finding. No statistically significant differences were found on the remaining 13 QOF indicators.

The time trends for elective admissions and bed-days and emergency admissions and bed-days based on the predicted rates (adjusting for IMD score) are shown in Figure 7.

FIGURE 7.

Admission and bed-day rates (per 10,000) by practice group over 19 NHS quarters. (a) Elective admissions; (b) elective bed-days; (c) emergency admissions; and (d) emergency bed-days.

The time profiles differed significantly (p < 0.001) between practice groups for elective admissions and bed-days and emergency admissions and bed-days. The rate of elective admissions (see Figure 7a) in the diabetes cluster diverged from the rates in the other practice groups around the third quarter of 2008/9 (October to December 2008), with some convergence with the Westpark practices not in the diabetes cluster in the second quarter of 2010/11. The two spikes in elective bed-days rate for the diabetes cluster make interpretation difficult (see Figure 7b); ignoring the two spikes the profiles are closer together than in Figure 7a. The emergency admissions profile (see Figure 7c) for the diabetes cluster was more erratic than for the other two practice groups, which perhaps was not unexpected because of its small size. There was some separation between the diabetes cluster and the other two practice group profiles from the second quarter of 2007/8 until the second quarter of 2009/10 followed by a short period of convergence and then divergence in the second and third quarters of 2010/11. Emergency bed-days (see Figure 7d) largely mirrored the profile for emergency admissions with perhaps less separation.

Summary results

As Table 22 shows, in terms of interactions in the past 2 weeks with other health-care professionals, representatives of the voluntary sector and patients/carers, interactions with primary health-care professionals were the most commonly reported by diary participants from each of the four topic areas (although the number of interactions was also high with patients/carers for the anxiety and depression in BME populations team and with social care for the child and family health services team). The 36 diaries recorded a total of 290 interactions and, overall, participants reported approximately eight interactions as a result of their efforts as part of the WI in each 2-week period for which they completed a diary; diabetes team members reported the highest number of interactions (10.6).

Table 23 shows that face-to-face meetings, e-mails and telephone calls made up similar proportions of the reported interactions as part of the WI. In 32 diaries, respondents also indicated that on 10 occasions (diabetes: three; dementia: one; anxiety and depression in BME populations: six) at least one of the interactions in the previous 2 weeks had been with individuals or organisations that they had not contacted or been contacted by before.

Table 24 reports, for 33 completed diaries, the number of times that different types of boundaries – sectoral, organisational, professional and geographical – were reported to have been crossed. Professional boundaries were most likely to have been crossed at least once in each 2-week period and such boundaries were generally the most likely to have been crossed multiple times.

Table 25 shows that, for 33 completed diaries, the types of boundaries crossed were similar for each of the four topic areas.

Table 26 shows how confident diary participants from each of the four teams were feeling that the work that they were involved in to improve care in Westpark would impact on:

• the quality of patient care

• levels of staff motivation

• their own personal satisfaction at work.

Respondents were generally less confident that the WI would impact on staff motivation and more confident that their work would improve the quality of patient care, with the anxiety and depression in BME populations and diabetes team members being the most confident.

Diary example 1: anxiety and depression in black and minority ethnic populations

In June 2011, Pam wrote about how important ‘instant’ interactions between primary care colleagues were, particularly in the form of telephone calls, e-mails and regular meetings between herself and her supervisor to discuss complex patient cases. Pam described improved sharing of knowledge relating to referral pathways, especially making connections with secondary care. However, she was frustrated at having to overcome last-minute cancellations and poor co-ordination by practice managers, as well as having to travel for supervision (which meant that she lost patient care time and missed targets). As Pam wrote in her first diary, her motivation increased after effective meetings to inform GPs about local services:

Really exciting that last week I was able to arrange a meeting with GP’s and dementia services from secondary care, which took place where I work. It was exciting as dementia services have been trying for many years to get a step in the door but have been unsuccessful due to time pressures and non-responsive practice managers . . . . We were successful in increasing dementia awareness to a total of eight GP’s. They found the presentation interesting, informative and as a result many questions from both sides were clarified and resolved. The meeting has also opened up a whole new dialogue on how dementia services can cross refer care for people diagnosed with dementia to mental health services for support. As a result we are now in the process of arranging workshops for both mental health and dementia services.

As part of the work of her WI team, Pam and others had systematically visited GPs in Westpark to talk about mental health. Through these interactions they were able to recognise how services could be made more seamless:

What would happen ordinarily is a client may be just referred for depression, we do the assessment and find out that actually it’s much more severe than actually meets the criteria for primary care setting. So we have now been working very closely with the secondary care partner to ensure that if we detect there is more severity to that case then we refer accordingly to secondary care services. It’s increased much more in the last year or year and a half now . . . I find the need to be talking to secondary care services much more than I would previously.

In July, Pam again wrote about making connections with dementia services for a patient, and reported increased exchanges across professional boundaries:

Contact with dementia services in [a different borough] due to the fact that the client I was seeing resided in that borough. As she did not fit the postcode criteria which would enable her to be seen by dementia services in Coxford, making contact with another borough’s dementia services meant I was able to find out their referral process, where they were located and then were able to do a referral on to their department. The client is now doing well and is under the correct medication for working age dementia and care. This has also allowed me to share this information with other colleagues within my team should they need to do a referral.

Unfortunately, her personal motivation was negatively impacted by a lack of follow-through by her clinical supervisor:

I have been trying to apply for accreditation and my clinical supervisor has still not completed her reference which has now taken a total of 7 months, something which could have been completed in 2–3 weeks. This makes me feel extremely frustrated and angry. I feel that as a team my personal development issues are being brushed aside and this can create a feeling of being demoralised and unappreciated.

In August, further new connections were made with child and family health services and with voluntary services. At this time Pam did not report many boundaries being crossed, and she did not report feeling very motivated, but she did have a new appreciation for issues related to safeguarding:

In particular I have spoken with [local child and family support organisation] to help a client deal with domestic violence which is having an impact on the children. This has now been successfully done and [they] are in the process of offering her an appointment next week. I feel knowing what agencies are out there and what they do is really crucial so that we are able to provide the correct intervention for our clients. This was the first time I have actually worked with [this organisation] which helps families with support and difficulties they may be experiencing.

Having written about how much she learned experientially about safeguarding, in her follow-up interview she further described the challenge of bridging gaps in services and her frustration at how inefficiencies impacted her own work targets:

I didn’t have the information to hand. I then had to rely upon other health professionals, but what I found wasn’t a seamless process. I phoned one person, they didn’t know. Phoned another person, they said, ‘Oh they're not in.’ Phoned another person who said, ‘Can you call back later?’ Phoned somebody else . . . It was that kind of attitude. There should be somebody there at the end of the line. Then I phoned safeguarding, they gave me information which was not coinciding with what information the police had given me around safeguarding issues and sexual abuse. So there’s miscommunication for clarity of what should be done and what is the right protocol to follow, and that causes a lot of frustration when you have time limits placed upon you . . . . A lot of time had been spent, wasted time, calling other health professionals who weren’t able to actually give me the kind of information I needed to be able to deal with it in an efficient, effective and fast manner.

In September, Pam reported making further new links with dementia services and contacts across sectoral boundaries, and reported confidence that her boundary-spanning efforts were making a difference, especially on quality of care. Spanning boundaries, however, was not easy:

I have been trying to speak with a consultant in secondary care regarding a client I am seeing but find the process of leaving messages, returning phone calls and missing each other due to client contact rather frustrating. This often means that there is either a delay in referring on or progressing with treatment.

Pam learned new skills through cross-boundary working as part of the WI, which became crucial. Pam is able to describe the kind of flexibility needed by a boundary spanner to use her skills but also notes how supervision can serve as a barrier instead of as support:

I would think that sometimes if we can use our judgment and make that decision ourselves rather than having to duplicate. Again, there was the waste of a whole afternoon when I know that this client was quite clearly not able to function and look after themselves, because all they could think of was about killing themselves, taking tablets, going to the park and drinking, and that’s it. So if I know that this person needs to looked after by secondary care as an inpatient, why then did I have to go to the local community mental health trust, go through all that rigmarole, go through all the assessment, and then find out they still ended up as an inpatient?

The frustration felt by individual boundary spanners attempting to close gaps in patient care can come at a cost to the health-care professional and risks undermining the quality of patient care, as Pam dramatically describes:

If you look at our targets, it’s more so now that we’re working so hard to meet deadlines, and if we don’t meet our deadlines at the end of the week then there’re questions asked, ‘What were you doing? Why weren’t you able to do it?’ They’re not going to see that as justified. They’re going to say, ‘Well, you’re supposed to be achieving twenty hours, the rest of it doesn’t matter’ . . . . Today I’ve been running around after a risk client. He sent me a text this morning saying, ‘I’m going to stab myself to death.’ When you hear that, everything else becomes irrelevant, so you want to make sure that a client is looked after. In total, in between clients, I’ve had to spend an hour and a half trying to locate the client, phoning the police, getting the police and ambulance services to her home address. All of that takes time, but when I report my schedules at the end of the week they’re going to say, ‘What were you doing for two hours of that day when you could have been seeing a client?’ Are they going to understand that I was trying to look after the welfare and safety of the client because they were threatening to stab themselves?

In noting how targets now drive her work, Pam explained that, as pressure to meet targets increased in January 2011, her work in making linkages happen has decreased, and the impact will be on referral rates:

One of the key things that came up was the fact that because now we’ve all been faced with targets, our promotional GP liaison work and promoting the service has gone rock bottom . . . . Actually if we don’t continue promoting the service and increasing awareness about what we’re doing that the referrals are going to start decreasing, which is evident, that’s what’s happened, the referral rates have gone down.

Diary example 2: diabetes

In early June 2011, in her first diary, Supriya writes about crossing many organisational and professional boundaries, and although none involved new contacts she reported feeling very confident about the impact of her boundary-spanning work on the quality of patient care. Involvement with Diabetes UK and the YOC pilot (with the Department of Health, the Health Foundation and the National Diabetes Support Team) was a part of her work during this time. Supriya reported that the recent training by YOC for GPs went well and that she ‘had some really good interactions with some GPs’. Supriya was also excited to have improved connections with individuals and community group representatives in the local area. Increasing disease awareness and motivating self-care for patients with diabetes are important aspects of evidence-based diabetes care and Supriya had become aware of the need to bring these concepts to both patients and practitioners:

Patients in the WI and through the LINk [Local Involvement Network] meeting I was presenting at, all said getting their [diabetes] results in advance and being involved in the decision-making is a really positive way forward and welcomed by the patients and carers. LINks were really happy to be involved in any way they can to support the diabetes work stream.

In her follow-up interview Supriya felt that her sense of confidence about impacting patient care was related to increasing her own knowledge through working with a diverse group of professionals across multiple organisations and as she provided training for local clinicians.

In her work as a commissioner of diabetes services, Supriya knew that efforts to link up services were an important way to improve care across the borough, as she outlines in one of her diaries:

I have had fantastic meetings with public health . . . 1) following from previous discussions, the new public health lead for LTCs [long-term conditions] and Active Lifestyles has arranged for a pilot on educating children at some local schools on diabetes, following the work done with asthma project. I pointed out the people that should be involved with this, including the paediatric diabetic specialist nurse and the public health lead identified school nurses, health visitors, etc. from social services; 2) the same public health lead has also agreed to put together a pack for each practice with information on different leaflets and how to get them, with recommendations on which leaflets are best for which type of patients; 3) I am also going to get the public health lead to talk to LINkS [Local Involvement Networks] to review the leaflets for YOC and simplify them and then translate them into other languages; 4) I have also met another public health lead who is working on putting a training package together for receptionists and health care assistants to do sign posting and deliver health promotion and prevention advice at GP practice.

Later in June, in the second diary, Supriya mentions an important need for collaboration with a diabetologist to bring services into the community. She also mentions frustrations with influential senior individuals who she perceived as being quite obstructive. However, she also writes about progress in making connections:

Two really exciting meetings have been with the consultant diabetologist at the Coxford Hospital and another meeting with a practice in [the north]. The diabetologist has been very indifferent to the commissioning direction for diabetes care for the last year but he has changed his approach. I hope he is being genuine and this is not just a way of getting what he wants . . . . There are frustrations in that the information governance team at the hospital are not willing to share the data. But the diabetologist is trying to get the green light himself. This data will help us determine how much money can be released from secondary care to reinvest back into primary care and community services.

At the spring residential retreat, Supriya was able to meet face-to-face with this diabetologist and her summer diaries confirm progress in sharing data between the primary care and acute trusts. Unfortunately, by the time that she was interviewed this interaction had not proved to be as productive as had been hoped.

In the third diary, Supriya also reported feeling pressurised by a pharmacist who did not think that she should be leading on a clinical topic (such sentiments had been verbalised before), frustrating her commitment to improving services.

Patient and public involvement is crucial for a commissioner working to policy guidelines, and Supriya is keenly aware of this perspective and its importance in serving local improvement efforts:

It’s given me the backing I needed. Because just very recently I was challenged on all the assumptions and the direction of travel that we’re taking with diabetes at the care committee and the clinical commissioning executive committee when I was asked, ‘What patient engagement have you done?’ And I was able to say, ‘We’ve done this huge event’, and I was able to follow that up with an e-mail with Diabetes UK and they came back immediately saying, ‘Yes, we know you've done a lot already.’

In the follow-up interview, Supriya described how she had gained an understanding of the patient perspective at a local WI event in the autumn of 2010:

We had a really multicultural group of patients attending, and carers, and they all knew exactly when was wrong with the system and what would help them manage themselves. What type of information they needed, what type . . . they even mentioned things that we hadn’t even thought of like – or we had thought of but didn’t think it was important to them – cooking for family members rather than for themselves . . . . And they knew exactly what they wanted. They knew what they wanted from GPs, they knew what they wanted from the hospital, they knew that they didn't want to go to hospital full stop, they preferred to just manage themselves.

Supriya gained that perspective through the initiative and it influenced her efforts to bridge gaps between services. This also enabled her to make a successful bid for involvement in the YOC and other funded pilots, outcomes that Supriya attributed to the WI:

And with the evidence that I had from the patient engagement and that I could ask we won the bid and we were able to launch Year of Care. So we’ve had 12 practices trained and this year we plan to get everybody else trained. So quite a significant amount of work has come from that patient engagement . . . . The patients that we invited were invited from the six groups of practices that were working specially on diabetes in the WI. And it was one of the outcomes that we wanted to achieve from the WI.

Gathering downstream evidence of the impact of PPI is rarely easy, but for Supriya it has had an important effect on enabling integration.

In her final diary, Supriya writes about overall progress on the topic of diabetes:

The practice nurses were already making good progress on YOC and knew all of their patients. I felt they were so good that they could be a leader and local trainer for YOC. One has agreed. I also had a meeting with the diabetes implementation team. The first of a series, looking to work in the same way as the WI. The focus will be to develop a practice pack with information on what services are available . . . . During one evening I was contacted by a GP in [a neighbouring borough] who was working on the integrated care pilot . . . to ask more about YOC. That felt good that I was being contacted about the project I was working on from another area.

Learning from past efforts became incorporated into the method of moving forward, and despite many hurdles and hesitations the outcome of finally realising a community-based holistic diabetic clinic was accomplished in early 2012. GP commissioners, diabetologists and specialist nurses had begun to align ways to bring diabetic care out of the hospital and into a specific community setting, and to agree how to fund such efforts. Although details of how to incorporate dieticians, podiatry and other disciplines were still being negotiated, at this point in time Supriya noted that true multidisciplinary co-ordination was weak:

And I think there’s a big fundamental issue going on at the ICO [Integrated Care Organisation] at the moment, the hospitals see themselves as an acute trust still, not as part of an ICO. And the community services again feel frustrated because they feel like the hospital services have taken over the whole agenda and community services are just sidelined and expected to just deliver and it’s not important enough. But actually, the shift that needs to happen, that the commissioners are really pushing for, is more of a shift to make the community providers a stronger partner in all of this, because that’s where we need the services. And for the acute trust to acknowledge that and work with the community providers to provide a more streamlined pathway where patients go to one place for everything almost. You know, in the ideal world. And it’s not just diabetes this is happening I’m seeing it in other areas that we’re working on as well. And I think they’re starting to realise. I don’t think the hospital have realised it yet.

When asked whether or not she felt confident that she had made an impact during her time as part of the WI, Supriya said:

My motivation comes from knowing that I can impact on patients’ lives, individually and as a population . . . . Sometimes when a practice nurse will e-mail me and say, ‘You know what, I’ve just had some patients in on Year of Care and they’ve saying how delighted and how . . . .’ I think one called it, ‘bloody marvellous, and why hadn’t we done it years ago’. Sometimes it is when I’ve arranged a really important meeting and somebody, a couple of days later, says, ‘That was a really, really good meeting. It’s about time. It’s fantastic we’re moving forward with this.’ Sometimes it’s when you finally get a breakthrough, and we’ve got a clinic starting next week. All those little things give me the motivation to just keep on going until the next one, the next high . . . . And just being that person in the middle to sort of join these people up to start to influence the whole picture. That’s what gives me the motivation.

Impact

Given the adaptable nature of the WI, Chris formulated his own view of the successes of the initiative in ongoing and iterative ways. The expanding networks associated with the WI were seen by Chris as evidence of how professionals changed their behaviours because of the new connections being built:

So the very fact that [the diabetic specialist nurse] was there speaking with such seeming confidence and smiling a lot was a result of, I think, the work done in Westpark Initiative coupled with various prompting including my work of the last week.

WIL2B, WI founder

Although Chris pointed to improvements in gathering patient outcome data – ‘I think we're in an easier place now to produce quantitative data about that than we were a year ago or even 6 months ago’ – these have been more difficult to identify by our research team. For Chris, the focus was clearly on relationship building rather than any formal evaluation of impact on clinical or quality indicators. When a specialist agreed to share more data after the community-based diabetes clinic finally opened in the spring of 2012, Chris would point to these changes as strong evidence:

So I’m using that as another example of how there’s a legacy of people, a network of people who have been affected by it and kind of assume it is a given static long-term entity.

WIL2B, WI founder

When asked to describe the successes, Chris points to changes in the levels of engagement of GPs in Westpark:

Look at the numbers of Westpark people who are pitching up to meetings and with a smile on their face. They used to huddle in the corners looking very defensive, and they’re there talking and smiling. We’ve got all practices still engaged . . . I’m focused on what I think as the more, bigger, things which is the change in the hearts and minds and getting people on the front foot and feeling motivated and part of changing things. That has dramatically changed.

WIL2B, WI founder

Certainly, many participants noted the palpable enthusiasm at meetings, for example ‘the energy and commitment that was clearly visible’ at the 2011 retreat, as Phillipa described.

As a commissioner of dementia services in 2009, John was intrigued as to how the WI could be used to improve links between primary and secondary care. By mid-2011, John was able to describe how he felt aspects of the model could be implemented in many areas:

I mean, I wouldn’t adopt it as the main improvement approach. But what I would do, and what I have done, is I’ve taken what I thought was the most valuable stuff out of it. Certainly the idea of recurrent open-ended type workshops where you don’t necessarily go in with a preset agenda, but you do hope that certain outcomes will be achieved by the end of it, and you rely on the natural flow and the natural dynamics within that meeting to lead you to where the general group perceives to be the main issue, is certainly valuable. But there are caveats, as in any approach. And I think the value it gives to a manager or a commissioner is how you know the times and the extent to which you should use this tool.

WIA22V, commissioning manager

He further describes that, although there is no distinct – or preferred – quality improvement strategy in Coxford, and although neither dementia pathways nor clinical expectations had recently changed, he believes that the patients' journey experience theoretically may have improved ‘because things move slightly quicker’ because of better communication between providers (although no monitoring of this is carried out on a regular basis). With all the necessary tests for dementia that need to be co-ordinated, the care can improve through the personal interactions provided by the WI:

So you manage the expectation. You don’t change any of the service, but people know what to expect, and that’s different. It makes a world of difference.

WIL2B, WI founder

Despite these concerns about measuring impact, Phillipa reflected that aspects of what she terms ‘Chris's whole-systems model’ could be usefully combined with traditional aspects of management:

So we’ve constantly tried to bring those two things together . . . . And I think that’s the bit of this methodology, by being so pure in its . . . at the pure end of how you take the research around whole- system thinking, and not perhaps thinking a little bit more about how you contextualise this little bit to the systems that you’ve got, and how you also pay some regard to the other things that are going on so that you can better make it an integral part of everything, rather than this thing that's going on here, or the WI.

WIA23W, Director of Quality and Clinical Leadership

So when asked if the model is repeatable, Phillipa said:

One of the things I’m really pleased at a strategic level is that we really are trying to hang on to those sort of joint relationships at the top. So what we haven’t yet done, and we’re trying really hard not to do in a sense, is to retreat back into our specific agency corners and attempt to cross shift between each other So last week, as the executives, we all sat around from each of the agencies and had a very honest conversation about what was going on for us financially, what were we cutting, what impact might that have on somebody else, how do we try and do that. We even had a conversation about trying to create an integrated borough recovery plan and share that across each other. So we need these sorts of approaches even more. The question is: are there different ways of doing them?

WIA23W, Director of Quality and Clinical Leadership

‘Key success factors’

Key stakeholders identified four ‘key success factors’ relating to the WI; all of these were highlighted in terms of their absence from the initiative and offered as explanations for why it had not, in the views of senior interviewees, achieved as much as they had hoped.

The rhetorical tone at the end of the previous quotation is indicative of the first key success factor of the WI identified by key local stakeholders: senior leadership support. It was clear from our fieldwork that support for the WI was not forthcoming from all senior leaders. John felt that this was because its approach and appeal were problematic:

I do think it has suffered from lack of senior leadership support. And I’ve seen this on more occasions than one. And what I did notice, it’s all the pragmatic learners who didn’t see much value in it, because they can’t personally relate to that type of working, who thought it’s too fluffy, and it won’t lead to anything. And unfortunately, most of the people in this world are pragmatic learners.

WIA22V, commissioning manager

A second key success factor, measuring impact, was clearly identified by Phillipa, who was frustrated at the lack of progress in identifying ‘hard measurables’ for the WI:

The difficulties of data collection gathering and setting up data analysis systems . . . we seem to have been having some of those conversations for a very, very, very long time.

WIA23W, Director of Quality and Clinical Leadership

As she explains, the methodology of the WI means that it is difficult to define and monitor relevant metrics:

So I think the biggest challenge now is moving the overall equation towards, ‘Is it sufficiently effective, and is it sufficiently output-focused, to warrant us continuing to do it?’ We do know it delivers, but what I was saying earlier about the pace of change and this balance between consolidation and change may not necessarily work in its favour.

WIA23W, Director of Quality and Clinical Leadership

The scalability and sustainability of the WI was openly debated among senior management. Although John described the potential for increased sustainability of the changes implemented by the WI model, he also mentioned the lack of extended reach to GPs:

Aligning the work of the Trust with GPs goes beyond just the five to six GPs who are involved through the different stages of [the WI] . . . but not a lot beyond. And I would suggest that this is partly due to the leadership and the professional opinion that those GPs can leverage within their locality. Which in some cases isn't very much, or some of them may not necessarily be very highly regarded.

WIA22V, commissioning manager

A third key success factor relates to the perceived lack of structure in the WI. This was a frequent criticism by senior managers and one that became more acute as almost all jobs and titles in the PCT changed in early 2011 (anticipating restructuring changes related to national reforms and necessary cost reductions in the NHS).

A fourth key success factor was the importance of PPI:

I think in some of these whole-system methodologies can, particularly if you bring patients and carers into the centre, can bring the best way for communicating confidence in the system . . . . It’s when they aren’t confident about that because the system is fragmented, or they think they’ll have some horrific nightmare to get re-referred in, that they won’t get out in the first place.

WIA23W, Director of Quality and Clinical Leadership

The end of the Westpark Initiative or a new beginning?

Throughout the significant reorganisations in Coxford from early 2011 onwards, Chris continued as a clinical leader although his role changed to a slightly more educational position with no line authority. The trust chief executive left and had been replaced with Phillipa, now as the new borough director. John continued in an extended role in aligning service improvement with commissioning. All remained colocated at the main office of the PCT.

By February 2011, the anticipated annual cycle of the WI appeared to have come to an end, although Chris continued to envision ways that the principles of his model could be embedded in other settings. Through 2011 the diabetes team (supported by affiliation with Diabetes UK) and the anxiety and depression team (supported by affiliation with CLAHRC) continued to hold events and team meetings to address ongoing efforts in their topic areas. Triggered by financial concerns across the locality in spring 2011, discussions again took place about continuing with another iteration of the model, and internal debates on the ‘luxury’ of this sort of model ensued.

In spring 2011, roll-out of the model to other localities was widely debated but the nature of the support from the newly formed commissioning consortium was a major concern. Managers discussed whether or not the four teams should continue with the same topics and whether or not resources should be given to certain projects. Senior managers discussed how to empower staff with more direct authority, and how to determine outcomes and deliverables given the new and still emerging parameters for success in general practice.

By June 2011, John (involved since the beginning in 2009) felt that the WI was already ‘done’ and that the challenge was ‘rolling it out to the rest of the borough’. Trust and consortium leaders were discussing how to use the same infrastructure of the initiative to now engage clinical discussions among GP commissioners about the ongoing transitions in the commissioning group and to reach beyond service providers. Structuring future work around the same four teams was being debated, including the risk of continuing with only marginally involved participants attached to the WI, and ways to work differently (more effectively). As John explained, ‘So a lot of people are being carried along by virtue of inertia, or dynamics, depending whichever way you want to look at it.’ Attention to Quality, Innovation, Productivity and Prevention (QIPP) items at this point began to drive the agenda in terms of deciding where to apply attention, time and funds:

For example, BME, it will die a slow death unless it’s kept as part of a package with all the other initiatives, because it’s not on the QIPP list. Diabetes is. Mental health in general is, although not that one in particular. And dementia isn’t, but dementia has a different type of driver. Dementia has a national drive – it doesn’t sit on the QIPP agenda, but it’s very high profile for the government at the moment.

WIA22V, commissioning manager

Well aware of this complex policy environment, pragmatic aspects dominated discussions, in which Chris worked to influence this decision-making process, acting as a facilitator at commissioning meetings.

By September 2011, the WI was no longer receiving specific PCT support and had lost even part-time administrative support, and no stakeholder events were being held or planned. The conference reservation for the May 2012 retreat was cancelled. Phillipa had transitioned out of the area from her position as borough director. Chris continued to facilitate local GP and consortium meetings with a focus on integration and whole-systems thinking, and all were trying to cope with national and local policy changes. Opportunities to reinvigorate joined-up working, and new debates about geographical boundaries, were recognised by Chris as a potential opening for renewed effort. He reported:

As far as I can see, people are not ready to talk about the WI or the lessons but there seems to be an opportunity opening up in the next week or so for Westpark to readopt the processes of the WI.

WIL2B, WI founder

Although not the same as ‘political commitment’, Chris recognised some receptiveness to the idea of developing new leaders, particularly across four defined boundaries with primary care [a feature that was now being (re)attributed as the founding principle of the model]:

For example, the WI would say there are four major boundaries to cross: mental health, social care, community care and acute care from primary care, and each year you decide what you want to do in those kind of areas.

At the end of our fieldwork, Chris felt that the commissioning consortium was ready to ‘restart’ some aspects of the four streams of work, and he describes recent conversations about local changes attributed to the previous work of the WI. He thought such ‘echoes’ could be identified in recent accomplishments, and could possibly be seen as repeat patterns in the future.

Anxiety and depression in black and minority ethnic populations

This team, operating in a receptive context with national policy drivers indirectly supporting its efforts, was the most successful in terms of successfully transitioning between the four stages of the SECI model. Members of this team came to the early meetings of the WI in 2009 with previous skills in counselling individuals, interacting in multidisciplinary teams and professional recognition of patterns of individual and organisational behaviour change. Perhaps unsurprisingly, socialisation between individuals was therefore easily achieved, enhanced by the WI stakeholder meetings. For example, a community health worker was not formally assigned by her organisation to be involved with the WI but was casually invited to attend an informal team session. New to the locality this individual describes the initial experience of the WI as having been ‘inspiring’ and motivating:

That was so exciting for me, because I just . . . it seemed so small when you have those meetings with just a few people. But when you look at the huge amount of time, the huge amount of space, and the amount of people that are actually all involved, when you look at every single person, it was amazing. It was so exciting . . . the WI it was definitely . . . the range of people coming in and out and contributing, even if they left and they didn’t come back, you still had that contact with them if you wanted to follow it up yourself. So I think just the spider web of . . . and range of people was the key for me to be able to get things done.

WIP11K, community worker

Including GPs and other stakeholders as part of the WI was a technique that was then used by this team to externalise and share tacit and explicit knowledge about the existing provision of care with different sectors, teams and groups. As an example, the community worker, after socialisation, identified – through conversations at WI stakeholder meetings – opportunities to develop knowledge assets in the local area relating to mental health outreach services. This individual had the resourcefulness to then develop and deliver four information sessions that reached around 30 staff members of community-level programmes and which spanned three of the teams taking part in the WI:

I ended up doing lots of other things with the other kind of groups that were involved, particularly children and families, because we had a lot of issues with mental health and people with BME backgrounds, but they often hadn’t made any connections with other people or anything like that. So basically going and making connections with the family groups that are out there in Coxford and talking to them about mental health services and things like that was actually really productive, because they hadn’t really had any information about what is mental health. So I ended up developing this mental health information kind of session for volunteers or lots of the community groups that were in Coxford, so that they would have an understanding of what mental health is and how it’s identified . . . and then that leads to dementia, because people who are under a lot of stress have mental health issues because they’re caring for people with dementia or diabetes or whatever . . . . So I just put together something, and then from there I went and initiated that with lots of the other family groups that I knew from the WI as well.

WIP11K, community worker

Delivering information sessions for GPs in this way inspired many WI participants and was acknowledged as an early success by those leading the initiative. However, this community worker was made redundant and with a new supervisor in a different programme there was no support (in time or funding) to continue such sessions.

Positioning mental health workers in GP surgeries improved knowledge exchange between primary care and mental health services. The opportunity to place such professionals at strategic junctions of knowledge flows (both horizontally and vertically) resulted in demonstrably qualitative improvements in information sharing and an increase in appropriate referrals to different services along the acute to community spectrum of care. For example (see vignette in Diary example 1: anxiety and depression in black and minority ethnic populations), an office worker in a private health insurance company was inspired to train as a CBT therapist when national policy support for IAPT services offered funds for such training. This newly trained therapist was then employed in a local GP surgery to serve the population of Westpark, which has always been her home. Working in the context of nationally determined goals and alongside like-minded mental health colleagues, the therapist's intentional aim as part of the WI was to try to improve access to psychological therapies for people of BME backgrounds. As a link worker this CBT therapist made persistent efforts to get past the practice manager to meet directly with the GPs, and initiated a meeting with all GPs in the large surgery (including three members of the local mental health team) to describe locally available mental health services. The evidence of impact of this boundary-spanning (dialoguing) meeting was described by the therapist as being able to see increased awareness by the GPs, increased multidisciplinary utilisation and improved appropriateness of referrals, a year after the meeting:

I think them knowing that there’s somebody here who they can count on for support, who will tell them the right information is really great. The other impact is then they know what we’re doing, they know all the different anxieties they can refer for. Before we weren’t getting very much referrals for things like OCD [obsessive–compulsive disorder], for instance, which is very much a lack of understanding amongst the BME communities, they don’t recognise what OCD is. So if they go and see their GPs, if they can pick that up and they can refer, we can do some good work with them and they don’t have to suffer with it. So I think increased awareness is one of the key issues with GPs. They now know little by little how to differentiate between primary care and secondary care, although I think there's a lot of work to be done in that area.

WIP10J, CBT therapist

Fine-tuning of the referral process and timing of communications continues; improved local adaptation was evident in qualitative exchanges, not just in the number of referrals. In further exchanges, the same therapist talks about the positive impact of promotional work by the mental health team to increase awareness about the counselling services: radio shows in a local dialect to reach potential patients, disseminating pamphlets and posters, meetings with GPs at their surgeries and meeting with people at the gurdwaras, the temples, the colleges, the day centres and the town hall. In an intentional reflective practice this team met regularly to ask: ‘Are we getting into every nook and cranny that we could? . . . . Trying to break down the stigma so that more people are coming forward and saying, “Yes, I have a problem and I can get help for it”.’ In this manner, outreach became more than social exchanges, and more than articulating explicit knowledge; literal efforts to document and package explicit knowledge were systematically explored. These further initiatives to systemise integration (combination) have been moderately successful, but routine internalisation remained a challenge at the end of our fieldwork.

Dementia

The WI focused on socialisation through stakeholder meetings but was largely unable to engage large numbers of GPs in either the specific topic teams or at open meetings. A PCT administrator – working on diversity and public health issues – spoke of the need for face-to-face interactions in a locality like Coxford with significant challenges. A latecomer to the WI, this individual described with enthusiasm what needed to happen – what Nonaka terms ‘socialisation’ – while also noting that no actual changes had yet resulted from the stakeholder events:

If anything is going to break through, that sort of thing is going to help, because it’s about bringing people together. So for example, what you see in dementia with the debate between GPs and the Mental Health Trust, it’s instead of letting people stay in their silos and see the world in their way, it’s making them get out and see the world another way. And that can only be helpful.

WIP15O, head of partnerships and diversity

In an example of how the WI sometimes struggled to move beyond the stage of socialisation, a community pharmacist attended a local dementia meeting hoping to hear more about how to signpost the exhausted carers of elderly parents with signs of dementia (see Vignette 6). Frustrated by identifying patients at home with poorly managed medications, and combined with concerns about how to initiate access for families into primary care, the pharmacist felt motivated to attend a nearby educational event that was part of the WI. This pharmacist was therefore already aware of the gaps in service integration and was eager to contribute to finding interdisciplinary solutions. Unfortunately, these concerns were not addressed at the locally sponsored educational session; explicit knowledge (e.g. tools for signposting) was not available. The pharmacist was able to verbalise some ways to decrease inappropriate use of acute services, and to improve signposting in primary care, including the walk-in, impromptu opportunity to advise clients at pharmacies. Our field notes document how the pharmacist's suggestions went unnoticed by others at the meeting. Interviewed after the meeting, the pharmacist spoke of his disappointment at the missed opportunity to improve services for patients with dementia. The pharmacist recalled the meeting in terms of a sense of ongoing frustration. In this manner, a multidisciplinary, face-to-face meeting did provide an opportunity for socialisation but there was no transition to explicit knowledge assets (externalisation).

As described earlier in this report, those individuals working on the topic of dementia struggled to find coherence as a team. A lack of clear membership beyond the two leaders – one of whom retired at an early stage of the WI and the other who was relatively inexperienced – meant that objectives remained unclear and there was no local champion for the work. Individual professional development was noted, as was increased awareness of services by some individuals, but putative attempts to restructure outreach services and to disseminate explicit knowledge assets (externalisation) lacked traction. Ultimately, aspirations to widely promote available services, such as educational outreach (combination), went unrealised. To illustrate (see The stories of the four teams, Dementia), producing materials in different languages was a key objective (e.g. translating clinical tools for memory assessment and disseminating dementia information in local dialects) but, although such products were created (externalisation), they were not routinely disseminated:

The leaflets we have produced and the other tools I have produced with regards to that, our assessment process, I think they are more user friendly. The information we are giving on the GP surgeries, they would not be able to get that if that had not happened. Now, all the six GP surgeries in my cluster, they have got the information on the dementia in different languages. The people, they can choose and pick whatever they want. The carers, or the patient, or anybody, they can look into those leaflets and they can go back to GP then refer to us.

WIL3C, specialist practitioner nurse

In another local attempt to improve joined-up working through explicit knowledge exchange, plans to train receptionists how to signpost patients were pursued. Chris spoke with the health promotion lead and this prompted the design of a short module (externalisation) by the borough-wide training co-ordinator:

So we did three training sessions, the first one on 16 June was in the [Coxford 1] practice, and we had eight members from receptionists there, including one GP. On 29 June we went to [Westpark] practice, and it was just the practice manager and the business manager. And then on 20 July we went to [Coxford 2] practice, and there were eight members of reception and mid-team there . . . some people knew about some things, and other people didn’t. So you’ve got a mixed level of knowledge . . . . Because we were telling them about things that they weren’t aware about, all these things . . . the thing that came out to them was they wanted a general overview of the plethora of services available, because they knew about some, they didn’t know about others.

WIP38L, health training co-ordinator

This trainer spent considerable time trying to find out who to reach and how to develop an extranet as an area-wide resource, but IT support from the PCT was not forthcoming. As a result, the receptionist-training programme did not extend beyond the initial efforts described above. Practice managers blocked efforts to meet with receptionists in Westpark, stating time and space restrictions. Additional efforts floundered on mundane issues such as suitable meeting space, finding administrative support for invitations and flyers and logistical resourcing. Despite the creation and availability of local knowledge assets and support from WI leaders for disseminating health promotion information in the community, efforts continued to rely on passionate individuals and struggled to gain systemisation (combination). The training co-ordinator attempted to find funding and staff to build an intranet signposting resource, but with little success to date. When the team leader was made redundant, there was little momentum for the work and the PCT soon found other topics on which to focus.

Child and family health services

With a broad agenda, individuals working to improve services for children also struggled to form a cohesive team (socialisation), particularly as joined-up working could potentially involve a wide array of professionals from several sectors. In an effort to connect the WI to broader community involvement efforts, stakeholder meetings were held in local area centres and a wide range of patient and public representatives were invited by to attend. For example, an experienced paediatric social worker and commissioner of paediatric services describes the need to continually ‘show up’ at meetings to advocate for children's programmes, particularly for teenagers aged up to 18 years who can be missed by planning efforts that focus on younger teenagers.

If I know my job so well that I can recognise that there’s an inefficiency or a duplication, and I can get the people round the table who can actually say, ‘Yeah, you’re right’, and we can work together to put a pathway together that makes everything much more efficient, and again releases some capacity so someone can go off and do something else that’s needed, or some money that we can reinvest, that makes me happy . . . . Little things like I was in a substance misuse meeting yesterday, and we’ve worked really hard to integrate two services who 3 years ago were competitors, and both thought the other one was doing a crap job, and they could do it better, and, ‘Why don’t you just give me the money?’ And we’ve moved from they wouldn’t talk and they had no pathway between them, and kids bounced between them, and they duplicated and it was all horrible, to the fact that they now call themselves part of one service. They’ve got a joint service name. They’re colocated. They have a shared action plan.

WIP36J, commissioner of children's services

As a commissioner the need to connect resources is part of the job, but changing policies, redundancies, funding losses and local politics made the work more challenging.

A community co-ordinator (not in health care) talked of his early excitement but then quick disillusionment with what appeared to be a focus on ‘research’ rather than on local action:

Initially I went in with a very open attitude. I didn’t know what to expect. After a meeting or so I thought maybe this is going to be a practical project in the sense that there may be some attempt to resolve some of the things which patients from meetings we go to have been expressing as their concern . . . . That’s really what kept me interested at that stage. It was also the reason why I think I lost interest, quite frankly, afterwards because I think I came to feel it was a research project. I’d been maybe a bit naive, it was a bit too much a focus upon the academic side of things, and research, and research method, and so on. I was probably being a bit too impatient and I wanted the world to change in the space of 6 months or so . . . . I think I remember Chris asked for us to remain involved and lend a community presence to the whole thing but I did have the impression that this was something more for the professionals than it was for people from the community. That’s why after a while I think my interest waned.

WIP20T, co-ordinator, Westpark Community Alliance

The initial team leader left after 1 year (because of loss of funding) and the next leader, although personally committed to children through a nursing background, was professionally focused on adult services as a commissioner. Membership of the team also waned, with social care and community representatives tapping in to occasional meetings but feeling unable to align identified team priorities with their own organisation's or professional objectives. Lacking a clearly defined project that might have led to effective action, team member attrition happened fast. Solutions and potential innovations surfaced in many different areas, from a variety of stakeholders, but without the team leaders serving as ‘knowledge engineers’121 the ‘team’ was unable to move to externalisation; knowledge, ideas and plans fell through the gaps, particularly at strategic horizontal junctions. For example (see The stories of the four teams, Child and family health services), a local resource guide (a ‘dialoguing product’) was updated and made available to a small cluster of GP surgeries in the local area. The team leader met with GPs to encourage their use of the resource guide and one receptionist in particular became known for using the document to signpost patients to local services in the community:

While they haven’t fed back specific examples, what they have said is, at this particular practice, the GP, one of the lead GPs, he refers at least two clients per week back to the receptionist for using the services, one or other of the services in the booklet, and the practice, as a whole, as an entity, they have embraced the idea and they’ve got delegated responsibilities to this receptionist.

WIL1A, team leader

Unfortunately, this receptionist left her position, moving away from the area for personal reasons. Although the ‘receptionist’ example was widely cited and held up as an example of the impact of the WI, few similar examples were observed. In addition, the adoption of the resource guide was not widely replicated and no plans were ever made to disseminate it to a wider audience. In SECI terms, dialogue was demonstrated and externalised (i.e. tacit knowledge became an explicit knowledge asset in the form of the local resource guide) but was not combined or internalised beyond the initial cluster of GP practices. The efforts of this team continued to be characterised by a sense of fragmentation until the end of our fieldwork.

Diabetes

This team had the advantage of having an already clearly defined goal relating to a patient condition that is the focus of many evidence-based guidelines, including NICE guidelines, and well-established metrics (e.g. QOF indicators). However, local concerns about how to commission and fund services, in parallel with organisational reorganisations, complicated efforts to create and follow through on what might appear to have been a relatively straightforward project: opening a community-based clinic for diabetes. For example, a commissioning manager at the PCT (not a clinician or a GP) was asked to work with the WI as a member of the diabetes team. Through the series of stakeholder meetings, a broader perspective of the composition of primary care services was acquired by this individual (socialisation):

Through the WI, we were working with six practices. And what had happened, inadvertently, because I was a PBC manager as well, I happened to be working with just six GPs. And nobody else was invited to that GP commissioning meeting, it was just the GPs. And I was going round and round, and I was trying to deliver things and plan service provision with just the GPs. And every time I got close to getting anywhere near starting to implement something, I found that there was a drawback to it . . . . So eventually everybody in the group, everybody that worked in the practice, got involved at some level. So the practice nurses, health-care assistants, the practice managers, the GPs themselves, everyone. And that’s when I realised that it’s not a GP’s practice, it’s a multidisciplinary group practice.

WIL4D, PBC manager

The complexity of funding arrangements meant that few people who were working on improving diabetes services in the locality saw themselves as a member of an actual ‘team’. Personal, social and ‘political’ divisions stalled this team at the externalisation stage for a significant period of our fieldwork. In another effort to improve local joined-up working, there was an aspiration to establish and open a community-based clinic for diabetics, not least to facilitate patient access to relevant services. In the 5 years before the WI, occasional conversations had happened between primary, secondary and tertiary care professionals regarding funding, premises, personnel and a variety of other matters relating to the appropriate provision of diabetic patient care. Administrators, managers, practice nurses, specialist nurses, GPs and consultants had all, at some point, taken part in these discussions, offering their professional perspectives. A community-based nurse manager described one part of the ‘conversation’:

So we got the GPs involved, which is really important. Because the WI was being involved at the time last year it was felt that everything to do with diabetes seemed to be focused around Westpark. And we wanted to give another opportunity to another area and that’s why [neighbouring area] was chosen, because they’ve got GP’s in that area with special interest in diabetes and also the GPs were quite keen to see it happening.

WIP29C, community services

This vignette barely scrapes the surface of the deeply political stand-off between the hospital and the PCT – and the various professionals in between – as we observed at many different meetings. After more than a few years of wrangling, a clinic with a less than ideal location, and a less than ideal work plan (according to many), did finally open for half a day a week. It remains to be seen if, and how, successful this project will be, despite the very hard work of many. Despite efforts to encourage patient involvement at various stages in the planning process, the scheduled inclusion of patient representatives was particularly side-tracked because of the length of the negotiations. Therefore, after several attempts at facilitated dialogue, and continued inefficient use of resources across all services, a compromise goal was achieved. Systemising (combination) may now happen in the form of joined-up services in the community but it remains unclear whether or not routine measures of success and behaviour change (internalisation) have been embedded going forward.

Socialisation, externalisation, combination and internalisation analysis of the Westpark Initiative

The previous sections provide a sense of the process or journey of the four boundary-spanning teams through the four SECI stages and help to illustrate key differences between the teams. We conducted this cross-case analysis of our qualitative data relating to the four teams to reflect on – and try to explain – these differences. The examples cited show how knowledge exchange processes were facilitated (or not facilitated) by the work of the four WI boundary-spanning teams and the impact that they had in terms of service integration. Enablers and barriers identified by the participants are summarised in Figure 9.

FIGURE 9.

Boundary-spanning themes with regard to SECI.

Clearly, although the four teams were invited to the same annual cycle of facilitated learning events, they varied in their ability to exchange knowledge across boundaries and then implement improvements. When considering each team, these same themes help to identify the SECI stage to which each had progressed (Figure 10).

FIGURE 10.

Four cases: boundary-spanning themes with regard to SECI.

The dementia team was essentially ‘pinned’ at the socialisation stage. It was unable to establish an infrastructure for lasting knowledge exchange in explicit forms, despite translating the MMSE into a common Asian dialect and undertaking GP-led training sessions for GPs about dementia screening. The child and family services team was able to create a community resource guide to share with patients by way of receptionists but it was unable to move forward to create lasting products or receptionist training programmes; it was ‘stuck’ at the externalisation stage without formal leadership and a clear action plan. The diabetes team spent much time in the externalisation and combination stages, endeavouring to build the infrastructure for vertical integration of services through hospital specialists being based in the community. Combination goals were achieved through dialogue, and expert knowledge assets were put into place as hoped, but they had yet to be fully internalised at the time our study concluded. The anxiety and depression in BME populations team appeared to be the most successful overall, perhaps because it inherited a clearly defined goal and received structured support, despite persistent internal reorganisation. Indeed, some of the integrating efforts of this team were in place before the WI, but many innovative solutions were generated by the team as prompted and developed after interactions with the WI. This team had aspects of the internalisation stage in place but by early 2012 was struggling to keep the local infrastructure intact. None of the four teams – with this possible exception – could claim to have embedded routines within organisational culture and explicit skills in daily operations (internalisation).

Given a turbulent context (i.e. a lack of sustained leadership and inconsistent membership of three of the teams coupled with wider systemic changes), we might have predicted some of the unsuccessful boundary-spanning attempts and, based on the existing literature, it is not surprising that efforts to facilitate vertical integration in particular appear to be particularly challenging at the juncture between externalisation and combination (from dialoguing to systemising). Only one of the teams, anxiety and depression in BME populations, managed to galvanise itself in the face of a largely adverse context and ‘keep going’ through almost all of the SECI stages. As a positive outlier this one team appears to have successfully managed, in the face of the same external challenges faced by the other three teams, to blend the boundary-spanning activities enabled by the WI together with the rigour and structure demanded by CLAHRC, leading to the improved horizontal integration of primary and mental health-care services. When looking across the four teams, and at the examples from each of the four SECI stages provided earlier, four common themes emerge.

First, we would note that socialisation is only a start, and the enthusiasm of individual staff during this stage cannot be sustained without a successful transition to more explicit forms of knowledge that can be shared with groups (not least because professional satisfaction appeared to increase in situations in which explicit knowledge could be applied to directly impact outcomes). Socialisation can be successfully accomplished through the generation of enthusiasm and professional curiosity at stakeholder meetings, although even this may not be easy given time pressures and conflicting priorities, but the opportunity is brief and gaining sufficient traction to carry integration efforts forward can be challenging. Socialisation processes can also be time-consuming, particularly if boundary-spanning interventions require engagement with multiple professional groups at different times.

Second, although clinicians, staff and managers clearly recognised that socialisation is only a first step to empowering quality improvement efforts, the majority of the four teams we studied did not progress far beyond this stage. We observed instances of innovative solutions to health-care system problems emerging from the community but when they were not heard and acted on then community members quickly withdrew their commitment and interest. Administrators and managers in liaison roles can serve as boundary spanners between different professions but without successfully forming boundary-spanning teams such individuals can be left in a position of oversight of heterogeneous multidisciplinary groups that lack shared goals and clear working processes; subsequent efforts to make tacit knowledge explicit (externalisation) can then be undermined.

Third, we found that, for those teams or boundary-spanning individuals who did manage to externalise knowledge (and innovative solutions did surface in all of the four teams), horizontal and vertical integration efforts often appeared to ‘stick’ between the combination and internalisation stages of the SECI model. It was common for efforts to systemise combined forms of knowledge to hit political and logistical barriers. Despite explicit attention paid to packaging knowledge assets appropriately and tailoring delivery, systemising knowledge through, for example, training can be blocked by influential individuals at the local level (e.g. practice managers at GP surgeries in primary care). Boundary-spanning individuals may be in an ideal position to identify innovative and efficient solutions to combining sources of explicit knowledge, such as the use of an extranet to provide up-to-date information on a range of services specific to a particular patient condition, but can be undermined by their inability to secure system resources and support. Although individual boundary spanners could be well placed during each of the transitions between the four SECI stages, their success in helping to combine and internalise knowledge seemed largely dependent on their own individual capabilities and capacity, both within and external to the organisation in which they worked.

Finally, we note that none of the four teams, with the possible exception of the anxiety and depression in BME populations team, could claim to have embedded routines within organisational culture and explicit skills in daily operations (internalisation).

Enabling teams to exchange knowledge across boundaries: why context (and ba) matters

A central factor that shaped the outcomes of the WI as a boundary-spanning intervention, and one that we explicitly included in our overall evaluation framework, was the role of ‘context’, both local and national. The early descriptions of the SECI model take no account of ‘context’. Yet as Fischer and Ferlie129 argue, in interorganisational contexts, local ‘indigenous’ knowledge, often characterised by personal and emotional involvement, interacts with, and can be significantly shaped by, external social and political contexts, including formal knowledge systems. We reflect here on how later extensions to the SECI model incorporate the role of context as a factor in explaining knowledge exchange processes and the contribution that these can make to our understanding of the varied success of the four boundary-spanning teams that we studied.

The various conceptualisations of ‘context’ originate to a large extent in the variety of different perspectives that have been brought to bear on the question of its role (e.g. organisational studies, social psychology, knowledge management and innovation studies). These different perspectives have led to different methodological approaches to studying context: broadly, on one hand, researchers have viewed contextual factors as discrete variables that can be measured; on the other hand, others view ‘context’ as a set of processes that relate both to each other and to change/improvement. By adopting Pettigrew and colleagues'130 definition we fall firmly into the latter camp:

Context refers to the ‘why’ and ‘when’ of change and concerns itself both with influence from the outer context (such as the prevailing economic, social, political environment) and influences internal to the focal organisation under study (for example, its resources, capabilities, structure, culture and politics).

p. 91

A recent review by one of the authors of this report (GR)131 argues that contemporary psychological perspectives (focusing on staff commitment to change or other social dynamics) need to be considered alongside more ‘traditional’ structural perspectives (focusing on an organisation's policies, resources or systems) of how context shapes the outcomes of quality improvement interventions such as the WI. This review found that 338 of the 476 contextual factors previously studied related to structural as opposed to psychological factors. When psychological factors had been studied this was most commonly in terms of ‘a supportive organisational culture’ at the meso (organisational) level; very few psychological factors had been studied at the micro (front-line team) level.

By contrast, we emphasise the importance of micro as well as meso contextual factors. Similarly, for Nonaka and colleagues,95,97 key to the related questions of how teams transition between the four stages of SECI and move between different levels (individual, group and organisation) is the concept of ‘ba’. ba is the energy and place where a shared context happens and where resources are concentrated so that knowledge can be created and used (Figure 11).

FIGURE 11.

‘ba’ as shared context in motion. Reprinted from Long Range Planning, 33, Nonaka et al. , SECI, ba and leadership: a unified model of dynamic knowledge creation, pp. 5–34, © 2000, with permission from Elsevier. 97

Although the four SECI stages initially provided a useful analytical lens, the concept of ‘ba’ has been helpful in explaining the differences between the stories of the four boundary-spanning teams by highlighting the role of context. For knowledge to be created, interactions must happen, and boundaries are transcended in a complex and rather fluid motion of evolving possibility. 80 Knowledge itself is boundary-less and intangible, can be both explicit and tacit and can take different forms or ‘assets’ depending on the context. Knowledge is expressed and transmitted in different ways between individuals and groups, depending on context and specific time and place, and across interfaces in a dynamic manner97,131 (Figure 12).

FIGURE 12.

Four categories of knowledge assets. Reprinted from Long Range Planning, 33, Nonaka et al. , SECI, ba and leadership: a unified model of dynamic knowledge creation, pp. 5–34, © 2000, with permission from Elsevier. 97

The distinction between the role of structural and psychological contextual factors at different levels (macro, meso and micro) of a health-care system is therefore also reflected, to a degree, in later elaborations of the SECI model and, importantly for our study, explicitly linked to how knowledge exchange processes are enacted and to different types of knowledge assets. We say ‘to a degree’ because the familiar macro–meso–micro distinction blurs some of the micro-psychological interactions that take place between different system and organisational levels; hence, the importance of individual boundary spanners and boundary-spanning processes. Although boundary spanning should not be seen solely as an individual role or activity, we also question the implication that ‘micro’ personal–psychological interactions take place only at the organisational margins. Our cases suggest that such interactions do indeed create important (network-like) linkages within and between systems and organisations, and not solely in the shape of individual boundary spanners. Fischer's132 article similarly argues that interactions take place in liminal areas at the ‘interstices of social relations’ where experiences, emotions and ideas are exchanged across individual, group and organisational levels. These liminal areas may function as ‘formative space(s) in which authentic, mutual relations develop, useful for organizational productivity’ (p. 1155). Their interactions are not confined to micro-level (front-line) areas but may be generated and exchanged across different organisational levels, such as in conditions of organisational turbulence.

In complex, pluralist domains such as health care, much of what constitutes useful work takes place in the micro-practices between practitioners and in their interactions with service users. Often below the radar of official organisational scrutiny, a less visible aspect of collaboration takes place in these peripheral spaces, occupied by emotionally invested participants. 133 And unlike the strategic and political advantages that may occur in formal organisational relationships, a characteristic of informal collaboration is that it is a means not only of exchanging existing knowledge, but also of creating new knowledge and innovation. Relatedly, the distributed leadership literature reveals a similarly promising perspective: groups that are deeply interconnected across formal organisational boundaries have considerable potential to achieve concerted action. When leadership develops as a distributed property of a network of interacting individuals, the knowledge, initiative and creativity that emerges between them has distinct advantages over traditional, hierarchal forms of leadership, particularly when tackling complex, interdependent problems that require innovation,36,134 such as those faced on a routine basis by the health-care practitioners that we studied.

Key activities for knowledge creation and exchange across boundaries

Nonaka and colleagues97–99,122–124,135,136 have been writing about SECI as a model of knowledge creation since 1994 and suggest that leaders play a role in facilitating how knowledge assets are developed and redefined, by moderating the conversion process, supplying energy and invoking judgments of quality. More recently, von Krogh and colleagues99 have provided suggestions for key activities or processes to support knowledge creation and exchange across boundaries. They argue that the following activities need to take place in three ‘layers’ that span formal and informal organisations:

• core activity (the informal layer where knowledge is being created and exchanged through direct contact and collaboration between individuals):

  • look for common interests

  • emphasise and promote higher goals

  • mobilise and co-ordinate assets to convince participants of likely success

  • fix meetings and initiate discussions on priority issues

  • capture outcomes

• conditional (connecting the knowledge creation and exchange processes with the overlying formal structures):

  • form teams at the right time and draw on existing links between participants

  • build non-hierarchical peer groups

  • provide experiential assets and routines

  • judge suitability of existing assets

  • connect outcomes of knowledge exchange to vision

  • connect and integrate people formally and informally*

  • provide and steer flow of assets (e.g. IT systems and data sets)*

  • set incentives to engage in knowledge creation and exchange*

• structural (formal and structured processes):

  • formulate a knowledge vision that ties existing knowledge to new areas where knowledge should be sought*

  • formulate, decide on and help implement communication systems, rules and procedures*

  • balance goals for knowledge creation and exchange with economic efficiency*

  • co-ordinate access to knowledge assets across organisations and systems.*

The later activities marked with an asterisk are seen by von Krogh and colleagues99 as relating to ‘a formal position, process, or activity controlled by some central authority’, whereas the earlier activities in the list emerge from ‘cooperation between individuals that manifests itself in their shared direction, the alignment of their behaviour, and their mutual commitment to a particular practice’ (p. 249).

As Fischer and Ferlie129 also argue, balancing interactions between such layers (in their empirical study, particularly between core activity and structuring processes) can significantly shape the local conditions and ‘tone’ of knowledge exchange. Formal knowledge systems may provide an important background resource that can be worked with creatively and internalised; conversely, formal systems may readily proliferate, yet without their intended local effects of increasing knowledge exchange and learning.

Our empirical case suggests that ‘conditioning’ alignment between these layers may be especially important in interorganisational and intersectoral contexts. As described earlier in this report, many of the activities in the core activity layer were observed in our fieldwork and study of the four boundary-spanning teams in the WI. However, with the significant exception of the anxiety and depression in BME populations team, we would argue that the WI alone lacked many, if not all, of the key activities or processes to support knowledge creation and exchange both in the structural layer and in some of the conditional layer activities listed above. More importantly, though, ‘conditioning work’ aligning these layers appeared to be central to enabling transition beyond socialisation and externalisation to combination and internalisation.

Whereas external formal and structured processes were underdeveloped in the context of the child and family health services team, in the other three teams' contexts these structural activities developed and indeed proliferated. Notably, in the diabetes team we see a proliferation of metrics and guidelines combining external knowledge, particularly at the structural level. In the dementia team we similarly note how external knowledge was combined to produce tools and materials. As we have already noted, the anxiety and depression in BME populations team developed significant structural activities (importantly, these structural and some conditioning activities were largely provided and supported by CLAHRC). Yet combining formal knowledge in this structural layer is not sufficient, we argue, to allow teams to make the transition from the combination phase to the internalisation phase. In both the diabetes team and the dementia team, explicit and formal knowledge may have in theory been ‘combined’, but in practice it failed to move beyond a structural level to combine with local and more tacit knowledge. (In the diabetes team it was blocked by interorganisational tensions; in the dementia team it failed to move across organisational boundaries). By contrast, the anxiety and depression in BME populations team made significant progress in mobilising explicit knowledge across organisational boundaries through extensive dialogue meetings, bypassing potential barriers (such as general practice receptionists or practice administrators) to create opportunities for knowledge exchange and customisation to local contexts.

We suggest that this combination of external knowledge with more tacit knowledge is an essential aspect of the combination phase that has been overlooked in the original SECI model, yet which our interorganisational and intersectoral context reveals is highly significant. Our analysis indicates that, whereas explicit structural knowledge can readily proliferate in these contexts, considerable conditioning activities are needed to marshal resources and combine explicit knowledge with implicit knowledge – customising it for mobilisation within and between organisations. To enable the transition from the combination phase to the internalisation phase, notionally ‘combined’ explicit knowledge needs to undergo significant further elaboration and customisation.

According to our analysis, then, our teams were inhibited from progressing from socialisation to externalisation when there was insufficient shared context (ba) and lower structural processes (i.e. the child and family health services team). Conversely, when there were medium levels of shared context and higher structural processes, teams were enabled to move from implicit to explicit knowledge, combining it with formal knowledge (which tended to readily proliferate, especially in the wider context of the dementia and diabetes teams). To complete the combination phase, though, a significant activity was customising and transforming explicit knowledge – in other words, preparing it for the final stage of mobilising knowledge for internalisation. As our final example of the anxiety and depression in BME populations team indicates, the ‘combination’ phase may involve significantly more elaboration than the original SECI model suggests.

What does our case reveal about the SECI model? As a heuristic, we find that it has been helpful in allowing us to study in detail the progress of knowledge exchange in each of the teams; indeed, we advocate its further use and possible development in other interorganisational contexts. Yet our study also suggests an important limitation to the model. As originally conceptualised the combination phase suggests a quite linear (and perhaps cognitivist) progression from combined explicit knowledge to its internalisation; however, our empirical case reveals that a significant process of customisation is needed to transform explicit knowledge, developing it for potential internalisation. This activity suggests an addition to the combination phase: instead of socialisation → externalisation → combination → internalisation (SECI) we suggest socialisation → externalisation → combination and customisation → internalisation (SECCI).

In summary, although moderate to high levels of core activity in the WI initially appeared promising, knowledge creation and exchange appeared to be hampered by a general tendency for structural activities to proliferate, yet with relatively low conditional activities, and low alignment between all three levels.

Implications for leaders of ‘boundary-spanning’ interventions

In the literature review in Chapter 2 we identified four main themes relating to boundary spanning in health care: the need for a wide range of communication skills, negotiating formal and informal boundary-spanning roles, recognising and responding to social and political contextual influences on knowledge exchange processes, and demonstrating evidence of impact. The review therefore established a basic framework for considering boundary-spanning processes in dynamic health-care settings. In revisiting the notion of boundary spanning through analysis of our primary data, further insights have surfaced.

Reflecting on our empirical findings in the light of the existing literature, and particularly the later developments of the SECI model described in the previous section, suggests a framework that may help to further explain what we found, as well as contributing to the design of future boundary-spanning interventions in the health-care sector. We propose that there are three interacting elements:

• interventions such as the WI are successful at generating shared contexts for knowledge creation and exchange (ba) (i.e. they are well suited to enabling micro-boundary-spanning processes at the core activity layer) but in isolation are weaker at creating and embedding movement through the four stages of the SECI model

• in the WI case, the Coxford PCT and wider formal organisations in the health community could have potentially provided the necessary resources and structure to facilitate the movement of the teams through the SECI stages and embed improved integration of services but, alone, are unlikely to be able to provide ba (and in our cases sometimes undermined and competed with it)

• internal boundary-spanning team characteristics, which may enable selective drawing on external structuring ‘resources’ (e.g. CLAHRC in the case of the anxiety and depression in BME populations team) and have the potential for adapting to external constraints (similar to the activities outlined in the conditional layer).

In terms of applying this framework to our four boundary-spanning teams, then, the anxiety and depression in BME populations team was remarkably coherent with strong internal leadership; it integrated ba generation (through the WI) with sufficient ‘structuring’ (through its external CLAHRC funding) to enable it to move through the SECI stages. In contrast, in the child and family health services topic area there seemed to be a (potential) leader without a team, resulting in a much weaker shared context for knowledge exchange (ba) and very weak ‘structuring’. The dementia and diabetes teams had stronger ‘structuring’ (at least potentially) but weaker ba. The middle management roles of these two teams' leaders provided some strategic support to enable some new connections to be made; however, particularly in a time of system restructuring, the leaders were less able to create and sustain shared contexts for knowledge exchange to help their teams transition through the SECI stages.

Our overall finding, as discussed in the previous section, is therefore that, although moderate to high levels of knowledge creation and exchange through informal contact and collaboration between individuals in the WI initially appeared promising, these were generally hampered by relatively poor connections between such knowledge creation and exchange processes and the overlying formal structures present in the local Coxford and Westpark contexts. Nor is the WI atypical in NHS terms; similar initiatives and activities are being undertaken in many localities in England and so the lessons from this study are likely to have much wider applicability.

In terms of the implications for leaders of future ‘boundary-spanning’ interventions it would therefore seem crucial to recognise that, although it is relatively straightforward to enable knowledge exchange processes across professional, organisational and sectoral boundaries, it is much more challenging to align these with existing structures and systems. As highlighted by our review of the empirical literature, to do so requires a wide range of communication skills, negotiating formal and informal boundary-spanning roles, recognising and responding to social and political contextual influences on knowledge exchange processes and demonstrating evidence of impact. Beyond these, however, and as the lens of SECI helped clarify, socialisation and externalisation as forms of dialogue are just the beginning of the knowledge exchange process. Although charismatic leadership, thought leaders and empowering experiences can enable knowledge exchange in these stages, formal supervisors and managers elsewhere in the local systems act as gatekeepers and have key roles to play in enabling, or blocking, boundary-spanning initiatives during the combination and internalisation stages. Potential mechanisms to overcome the barriers encountered in the WI would, following von Krogh and colleagues,99 include:

• connecting and integrating people formally (as well as informally)

• providing and steering the flow of assets (e.g. IT systems and data sets)

• setting incentives to engage in knowledge creation and exchange.

Such ‘bridging’ activities between informal knowledge creation and exchange processes and formal and structured roles and processes appear to be a crucial part of a boundary-spanning intervention. In short, although informal boundary-spanning processes (as emphasised by Chris in the WI) created the ba for knowledge exchange, a more considered approach to aligning these processes with pre-existing structures and systems was needed to move the teams through the SECI stages. Strikingly, the one team that was enabled (through CLAHRC) to align its work in this way was significantly more successful than the other three teams that we studied.

Recommendations for future research

As a key to understanding how knowledge moves and how this impacts on the quality of health care, it will be increasingly important to study exactly how problematic professional, organisational and sectoral boundaries are negotiated. 99 Boundary spanners are embedded in, and constrained by, their group identity, their organisational membership and the larger health-care system. Future empirical research of boundary spanning will need a range of tools and approaches to address these complexities and, crucially, assess the impact of such processes on health-care quality. Therefore, in order of priority, our recommendations for future research are:

• Longitudinal studies evaluating the direct, measurable and sustained impact of boundary-spanning processes on patient care outcomes (and experiences). A variety of research designs can accomplish this task, but a move beyond purely descriptive studies of the roles and activities of individual ‘boundary spanners’ is now warranted; studying boundary spanning as a complex intervention (using the Medical Research Council framework) through a mixed-methods approach would be one potential design.

• Based on our initial findings, a further empirically based critique and reconceptualisation of the SECI model is required, both generally and of the concept of ba particularly, so that the implications can be translated into practical ideas developed in partnership with NHS managers.

• Following Kreindler and colleagues,137 studies of social identity dynamics during collaboration–integration efforts with a focus on identity mobilisation and context change (and how these relate to ba) may also offer valuable insights into mechanisms that explain the impact of boundary-spanning processes on the quality of health care.

• Employing social network analysis to systematically explore the nature and composition of the interpersonal networks that emerge in boundary-spanning interventions, and the impact of these on variables such as staff well-being and team performance.

a. Setting

Our case study is a project designed to improve services through collaboration between general practitioners, community services, voluntary groups and acute specialists. The project includes the development of a network of leaders across organisational and community boundaries to facilitate knowledge exchange, and is directly linked with a programme of ‘whole system’ stakeholder conferences to create organisational learning and change, together with community development. The project is being led in an area where there is sustained political support and understanding for this way of working from local statutory organisations, in partnership with voluntary sector agencies. Four topic areas will be covered by the project which will form our case study:

1. Dementia.

2. Child & Family Health.

3. Depression & anxiety in people from black and minority ethnic backgrounds.

4. Diabetes.

The WI project itself is bringing people from all parts of the health care system together at ‘stakeholder conferences’ on four occasions to share their experiences, consider data, exchange views and agree actions to be completed as they relate to each of the four topic areas. Preparation for the project began with focus groups to understand different perspectives and a stakeholder conference to set the scene; these events were attended and observed by a member of the research team (Robert). The next stakeholder conference will aim to shape the agreed priorities in each of the four topic areas (and will again be observed by the research team), with a final conference planned where the findings from the project will be disseminated.

b. Design

We will use an in-depth longitudinal, case study approach. Our extensive fieldwork will encompass the four specific topic areas in which boundary-spanning activities will be undertaken as part of the case study. Research methods will include ethnographic fieldwork through: non-participant observation, interviews centred on individuals in the boundary-spanning groups, participant (boundary-spanning individual) diaries, ongoing review of project documentation, and patient & carer focus groups. This qualitative fieldwork will be supplemented with a Knowledge, Attitude and Practice (KAP) questionnaire delivered at two time points 6–12 months apart and secondary analyses of routine datasets.

Organisational case studies are a preferred research method within complex and dynamic contexts where it is difficult to isolate variables or where there are strong interactions between variables. The case study can generate hypotheses from exploratory data which can then be tested in wider samples using different methods, and – particularly relevant to this proposal – they address questions of process as opposed to the input–output model of much quantitative research. Process research is characterised by the dynamic study of behaviour within organisations, focusing on organisational context, activity and actions which unfold over time. Making sense of processes will be especially useful for examining the role of boundary spanners in the dynamic context of cross-boundary working. Our case study research strategy is therefore particularly well suited for a detailed investigation of people in different organisations, in their local context, and over time.

The proposed study will explicitly set out to explore the theoretical framework (theories, assumptions, key concepts) for boundary-spanning that underpins the case study. For example, previous work involving the lead applicant (Robert) has presented different conceptual and theoretical bases for the spread of innovation in service organisations, ranging from unpredictable and emergent (bottom-up) processes, through negotiated and enabled facilitation, and onto the scientific and planned (top-down) interventions. Through our fieldwork we will seek to make the framework operating in the case study explicit and explore whether it is appropriate (based on our review of the research evidence and empirical data) to meet the agreed priorities in each of the topic areas. The rationale for highlighting the importance of these underlying frameworks is that – as a number of influential researchers have proposed – behaviour does not occur by chance but is guided by ‘mental models’ and intrinsic ‘theories of action’. A key part of our assessment of the boundary-spanning processes under study will therefore be to surface the mental models/theories in action that the participants are acting on. We will explore whether the models imparted during the case study have actually been translated into practice and are appropriate for facilitating knowledge exchange and leading, and spreading and sustaining high quality health care on the ground.

c. Data collection

(See flow diagram in Annex 1 for summary of six phases to the research.).

Our approach to data collection and analysis will be to use a preliminary theoretical framework drawn from the literature review; data analysis will be a combination of induction (data-driven generalisation) and deduction (theory-driven exploration of hypotheses). This approach has been used previously by organisational researchers in the NHS. Our fieldwork will seek to provide a ‘close-to’ record of what happens once the boundary-spanning groups are working in the four topic areas. In order to capture this we will (a) study the cohort of boundary-spanning groups throughout the project by means of a combination of all of the various qualitative data collection methods described below, and (b) assess the value of the constituent parts of the project (for example, the leadership training, opportunities for joint reflection on amalgamated data, cycles of inquiry and action, and work on identified quality improvement projects) from the perspective of the participants themselves by means of semi-structured interviews and participant diaries. We will pay equal attention to capturing instances of (a) knowledge creation and exchange between different sectors, organisations and professions and then prospectively track how these lead (or not) to the implementation of improvements in the quality of service provision, and (b) the barriers to such processes.

Phase 2: Induction, familiarisation and relationship building: firstly, we would make contact and meet with the formal leaders of the WI project and identify early ‘key informants’ associated with each of the four topic areas – including voluntary and community groups and service users – to help get an early ‘lie of the land’ and begin to develop relationships and clarify expectations and fruitful lines of inquiry. We would also conduct a contextual inquiry to gain an appreciation of the socio-organisational environment within which the boundary-spanning processes we will be studying are situated and embedded. This will include discussions with participants to recapitulate on the history, origins and rationales of the project and understand the contexts within which it has unfolded to date. It should be noted that we would anticipate that much of this familiarization and relationship building will have been completed before a research grant may be awarded through our ongoing attendance at the management team meetings for the project from November 2009 onwards. Secondly, we would undertake a content analysis of the documentation relating to the WI project to: a) identify aims and objectives, key terms, themes and methods being employed, and b) begin to surface, describe and make explicit the ‘espoused’ theories and models underlying the chosen approach to boundary spanning (assumptions, values, concepts). As argued earlier, making the (often) implicit explicit in this way will be crucial to the evaluation process. As part of this first phase we will be able to draw on secondary data provided, including routine data, business plans, previous related schemes and any evaluation reports.

Phase 3: Scoping Observation and Tool Design: to help inform our overall study of the impact of boundary-spanning processes we will begin our scoping observations as soon as ethics is approved. Individuals involved in the boundary-spanning intervention under study will be conducting focus groups with their own established patient reference groups to collect the perceptions of services provided for patients and their informal carers. As part of the intervention, focus groups will also be initiated with staff and practitioners in local GP surgeries to determine what service improvements may be worth developing and delivering. Discussions between team members at these focus groups, and at their team meetings, will be observed, and it is expected that this will be an iterative process throughout the intervention. Further, our research interviews (see Phase 4) with team members who conducted and participated in focus groups will deepen our understanding of how sectoral, organisational and professional boundaries impact upon the lived experiences of staff and practitioners, and how efforts to enable vertical and horizontal integration of services might improve those experiences; the findings from the focus groups that are undertaken as part of the boundary-spanning intervention under study will therefore help us both refine our overall research approach (including assisting with the design of several of our later research tools) and inform our final evaluation of the project. We will conduct a Knowledge, Attitudes and Practices (KAP) questionnaire survey relating to the four topic areas (and any additional topic areas) which will be sent to a stratified, random sample of named staff (including GPs, nurse practitioners and other staff groups) in (a) each of the general practices in Westpark, (b) the remaining practices elsewhere in the wider PCT, and (c) practices in neighbouring primary care trusts. KAP studies are highly focused and seek to measure changes in what is known, believed and done in relation to a particular topic. In this vein the questionnaire will be designed to assess: what respondents know about available local services relating to the four topic areas; what they think about these services; and the ways in which they demonstrate their knowledge and attitudes through their actions (in terms of, for example, making referrals, advice-seeking, collaboration and giving information to patients). The questionnaire will also directly explore respondents' views as to the nature and extent of the vertical and horizontal integration of services in relation to the four topic areas, the formal and informal networks of which they are part relating to each topic area, and any specific knowledge exchange activities in which they are already involved. The questionnaire will be designed by the core research team in conjunction with local stakeholders (ensuring a wide range of perspectives) and piloted with staff from 3 general practices in Coxford and a neighbouring PCT.

Phase 4: Programme engagement and immersion (‘deep dive’) and ‘thick/rich description’: following our initial assessment and the design of our research tools, our in-depth qualitative fieldwork will comprise: non-participant observation, participant interviews, participant diaries, and ongoing collation and analysis of project-related documentation. All of our qualitative research will be grounded in the real-life experiences and events of the boundary-spanning individuals and groups, and the participants in the wider project in each of the four topic areas; this ‘actor centred’ approach will allow us to focus on the interactive, pedagogic and political processes which shape the individual (and collective) development and impact of the boundary-spanning individuals and teams (thereby taking in the ‘facts on the ground’). Given that knowledge is mainly tacit knowledge and is shared face-to-face in real time as problems arise, it will be necessary to complement a standard interview-based approach with observation of knowledge exchange and creation within the case studies. This would involve observing the boundary-spanning individuals and groups in situ; two members of the research team would therefore attend the (a) action learning sets and (b) stakeholder conferences to observe them in action and to interact informally and get ‘live commentary’ from those who are participating in them. Contemporaneous field notes would be supplemented by the use of either an audio diary or written notes by the researchers immediately after each observation ‘event’. These field notes and audio diaries will be analysed (see section below) as part of the overall research evaluation. In parallel to the observational fieldwork we would undertake tape-recorded, semi-structured participant interviews in order to compare what was/is being provided in terms of support for cross-boundary knowledge exchange and creation (and the way it was/is provided) with what participants felt they needed and wanted. The specific questions to be asked at these interviews will be developed and refined as the data collection process unfolds and will, wherever possible, be ‘grounded’ in critical incidents and the real-life experiences and events of participants. Questions will however largely focus on the ‘how’ and ‘why’ to elicit rich information about boundary spanning and knowledge exchange processes targeted at the improvement priorities identified in each of the topic areas, and will include exploration of the interactions of stakeholders with each other, and highlight any barriers to knowledge sharing between stakeholders. Selecting participants to be interviewed will be via a ‘360-degree’ approach for systematic coverage of the whole system; the four leaders of the boundary-spanning groups in each of the topic areas would be the focus of the approach and the first to be interviewed. The ‘360-degree’ method for gathering feedback is often associated with annual performance appraisals of staff by seeking input from all members of an individual's work group, including those with both higher and lower levels of line authority and those serving in different roles. For the purposes of this research, we will apply the concept of ‘360-degree’ to identify participants to interview across the sectoral, professional and organisational boundaries represented within the project; in this way all participants being interviewed are considered key stakeholders in the boundary-spanning group work. This will mean that any individuals who come into contact with one or more of the four boundary spanner leaders as a direct consequence of the boundary-spanning group work during the case study would be invited to participate; this might include hospital consultants, GPs, nurses, managers and voluntary sector workers. Where relevant we would conduct repeat interviews with key individuals and members of the groups at various points in order to monitor any change of attitudes or experiences over time. The qualitative fieldwork will also include in-depth, embedded case studies of four individual boundary spanners (the leader and two other members) drawn from each of the four topic areas to enable an assessment of (a) the impact of the project on the individual development of the participants, as well as (b) the impact of the boundary-spanning activities on a sample of specific quality improvement priorities pertaining to their specific topic area. We will adopt an ‘autoethnography’/narrative autobiography approach that will draw largely on the self-completed diaries that members of the boundary-spanning groups will be asked to maintain as part of their training and activities throughout the project. Diaries as a research method are ideal for capturing details that exist in complex social structures, beyond so-called technical work or formal procedures. As an ethnographic method, diaries can provide scientific observations in situations where a researcher cannot be present and capture reflections upon interpersonal processes. Other than the nominated leaders of the four groups, at least two additional boundary spanners from each of the four topic areas who will be invited to complete a diary will be identified by their roles which cross across known organizational, sectoral and/or professional boundaries; each will be asked to record weekly to fortnightly diaries which address knowledge, attitudes and practices in their work and how they perceive these to be changing (or not) as a result of the project (with specific reference to improving the vertical and horizontal integration of services). Diaries will be brief and semi-structured, directing responses to a few specific questions about progress towards self-defined goals over time, reflection about knowledge exchange and creation processes within and across groups, and include an open-ended question allowing for subjective narrative. Professional time spent recording diaries will be kept brief to ensure on-going involvement of participants. Further, at the onset of the study, and in an effort to decrease attrition due to time burden, respondents will be invited to collaborate in formalizing the diary design to ensure the most convenient format and timing for diary recording. Finally, as part of the qualitative fieldwork we will collect and analyse relevant documentation such as the minutes of meetings and email discussion lists on an ongoing basis.

Phase 5: End of project evaluation: this will comprise a repeat of the earlier questionnaire survey, secondary analyses of routine datasets and our own patient & carer focus groups. We will repeat our questionnaire survey in (a) each of the general practices in Westpark, (b) the remaining practices elsewhere in Coxford, and (c) practices in neighbouring primary care trusts, and observe any differences in responses from each of – and between – these groups compared with the baseline assessment (see above). As an integral part of the WI project will be monitoring on a PCT-wide basis the following routine datasets with regard to patient contacts in each of the four topic areas: (a) EMIS/Vision (software systems used for practice management and patient records in primary health care), (b) RiO (a clinical information system for community staff which is being deployed throughout London as part of the National Programme for IT), (c) Adastra (a patient management system for unscheduled care across England that includes episodes of patient care in, for example, GP Out-of-Hours, Walk-in Centres, Minor Injuries Units, and Community Nurse Teams), and (d) Secondary Uses Service (SUS) including Hospital Episode Statistics (HES) which allows practices to see how the way they commission services and refer patients compares with other practices locally and nationally, and also enables them to see how they care and treat on patients with particular conditions compares to other practices. The data to be monitored by the PCT will be determined by the priorities for improvement identified by participants in the project once the work in the topic areas begins in spring 2010. We will conduct secondary analyses of these datasets which will focus specifically on indicators that we would hypothesise – as a result of the boundary-spanning processes that we observe during our fieldwork – should see improvements in the quality of patient care over the course of the project in the participating general practices in Westpark (compared with the PCT as a whole). However, whilst knowledge exchange can empower an individual to avoid costly referrals it can also potentially raise awareness of hidden problems and precipitate referrals; our secondary analyses of the datasets will examine both of these scenarios.

Finally, we will undertake focus groups at the end of the project with patients & carers from each of the topic areas. These focus groups will explore the perceptions of the patients & carers as to the real (or perceived to be likely) impact of the improvements made and reported as part of the project on their own experiences of care and treatment in Westpark (with particular regard to the impact on patients & carers of specific attempts to improve the vertical and horizontal integration of services).Their experiences and degree of integration of services will be explored through semi-structured questions.

d. Data analysis

As stated in the ‘aims and objectives’ above, our research hypothesis is that boundary-spanning processes will stimulate the exchange and creation of knowledge between sectors, organisations and professions and that this will lead to service improvements (as measured by a range of quality indicators including patient and carer experience). We will describe and assess the perceived value of boundary-spanning processes in each of the four topic areas by posing the following overall question: to what extent – and by what vertical and horizontal processes – has boundary spanning facilitated knowledge exchange and creation across sectoral, organisational and professional boundaries, and what impact has this had on the quality of patient care? In seeking to test our hypothesis we will undertake four specific and related activities (details of which are provided above): (i) provide a rich ethnographic account of all the boundary-spanning processes (horizontal and vertical) that occur within each of the four topic areas as we observe and follow them throughout the duration of the overall project; (ii) monitor a range of routine datasets and quality indicators pertaining to the four topic areas across the whole PCT, including making comparisons between (a) the general practices in Westpark and (b) practices from the remainder of the PCT; (iii) undertake a repeated project questionnaire survey of selected staff in (a) each of the general practices in Westpark, (b) practices elsewhere in Coxford, and (c) practices in neighbouring PCTs; and (iv) conduct focus groups with patients and carers in each of the four topic areas as to their experiences of care and treatment.

The research team will iteratively analyse the data from the four activities above and share our evolving interpretations as the research unfolds, jointly exploring the significance of the findings and building theory from our qualitative, quantitative and secondary data along the lines described by Eisenhardt. In terms of our final findings our intention is to generalize in a theoretical/analytical rather than statistical manner. The research team is experienced in the use of framework analysis as a means of managing and organizing complex qualitative datasets and we will use this approach in order to assist our development of key themes reflecting the perceptions of interviewees from the various sources described above, our observational data and issues evident in documentation. Transcripts, fieldnotes and document content analysis will be entered into ‘Framework’ software to assist data interpretation. In presenting our findings, temporal bracketing and narrative strategies will be utilized in a holistic analysis so that data remains contextualized. Our interpretation of the data will be checked through feeding back our initial findings to the leaders and participants in the project. Completion of this process is essential if the proposed combination of (largely) case study-based research is to result in more than interesting vignettes from each of the topic areas and boundary-spanning groups. Our overall aim is to make a wider contribution to the theory and practice of implementing quality improvements through the vertical and horizontal integration of services.