Delivering the aims of the Collaborations for Leadership in Applied Health Research and Care: understanding their strategies and contributions

Research diffusion and knowledge utilisation

Research diffusion and knowledge utilisation are concepts central to the working of CLAHRCs. Two key papers are discussed here. Estabrooks et al. suggest that research on knowledge utilisation has evolved through a series of paradigms in which certain disciplines seem to have dominated at different stages. 25 In contrast, Greenhalgh et al. suggest that many streams of research have explored research diffusion in parallel and attempt to identify the interactions and linkages between them, developing ‘a unifying conceptual model’ to consider the diffusion of innovations in health-care organisations. 26 Both groups of authors emphasise the wide range of research traditions involved and explain how an early emphasis on diffusion research (Greenhalgh et al. ) or knowledge utilisation (Estabrooks et al. ) broadened to cover other fields. Greenhalgh et al. cite the emergence of development studies (covering the different contexts and meaning or value of innovations) and health promotion;26 Estabrooks et al. note the emergence of diffusion of innovations and technology transfer. 25 Both comment on the emergence of evidence-based medicine in the mid-1980s, and Greenhalgh et al. also discuss the relevance of the organisation and management literature. 26

Greenhalgh et al. ’s attempt to provide an underlying framework was ambitious, and their suggestions for (and against) further research have been helpful. They highlight the importance of context and ‘confounders’, which ‘lie at the very heart of the diffusion, dissemination, and implementation of complex innovations’ and how these are ‘not extraneous to the object of study; they are an integral part of it’. 26 Therefore, future research should be multidisciplinary and multimethod, meticulously detailed and participatory, and should acknowledge the central importance of context. They further suggest that the next generation of research on the diffusion of health service innovations should be empirically driven but theory-guided so that consistent processes can emerge.

We were persuaded by the arguments brought forward by Greenhalgh et al. and informed by their recommendations on how research translation should be studied. For CLAHRCs, the important lesson is that when discussing research diffusion and knowledge utilisation there is no single, stable and agreed conceptual framework and this requires being sensitive to how terms are being used and recognising that the same concept may have different meanings. It also means that there is no off-the-shelf conceptual model that can be used without the potential for confusion.

Implementation and the use of theory

Eccles et al. also call for greater use of theory in promoting the uptake of research findings, and describe the current situation as ‘an expensive version of trial-and-error, with no a-priori reason to expect success or to have confidence of being able to replicate success if it is achieved’. 27 Following other work, they describe theory as ‘a coherent and non-contradictory set of statements, concepts or ideas that organises, predicts and explains phenomena, events, behaviour, etc.’ (p. 108), and, along with Ferlie and Shortell,28 note that interventions that seek to improve health care operate at four levels: the individual health professional, the health-care group or team, the organisation providing health care (e.g. NHS trusts) and the larger health-care system or environment in which individual organisations are embedded. In a comment that could have been tailored specifically for the CLAHRCs, Eccles et al. also note: ‘Because implementation research lives in a policy-relevant context where clinicians, managers, and policy makers may erroneously believe that they already know what is best to do, it will always be prey to the demands for a quick fix and the political solution’ (p. 111). 27

In a similar vein, Grol et al. refer to the need for a ‘better understanding of the black box of change in health care’ and also call for a more systematic use of theories in planning and evaluating improvement interventions in clinical practice. 29 Following other work, they describe ‘theory’ as ‘a system of ideas or statements held as an explanation or account of a group of facts or phenomena’, and distinguish two types:

• impact theories: hypotheses about how specific interventions will facilitate a desired change, as well as the causes, effects and factors determining success (or the lack of it) in improving health care

• process theories: how implementation activities should be planned, organised and scheduled in order to be effective (the organisational plan) and how a target group will utilise and be influenced by the activities (the utilisation plan).

According to Grol et al. ,29 the ideal model for change in health care would encompass both types of theory. They summarise and recommend a set of 16 theories about change in health care, and, in a taxonomy that closely reflects that used by Eccles et al. ,27 differentiate these by ecological level (individual professional, social setting, organisational context, political and economic context). Cognisant of the limited empirical evidence of the effectiveness and feasibility of theoretical approaches to produce the intended change, they emphasise the need to draw on different theoretical perspectives simultaneously to inform change plans.

Building on Greenhalgh et al. ’s26 work, Damschroder et al. developed a consolidated, metatheoretical framework for implementation research that is based on 19 published theories. 30 This again is a very broad approach (the authors use the term ‘theory’ to refer to published models, theories and frameworks) that encompasses five major, interactive domains:

• intervention characteristics: source, evidence base, relative advantage, adaptability, trialability, complexity, design quality and packaging, and cost

• outer setting: economic, social and political context in which organisation resides

• inner setting: structural, political and cultural contexts through which the implementation will proceed

• characteristics of the individuals involved: knowledge and beliefs about implementation, belief in own capabilities, identification with organisation and other personal attributes such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, innovativeness, tenure and learning style

• process of implementation: planning, engaging, executing, reflecting and learning.

The aim was to provide a pragmatic structure for identifying potential influences on implementation and organising findings across studies.

Knowledge mobilisation and research utilisation: the potential contribution of the management literature

The relevance of the organisation and management literature is explored more fully by Crilly et al. ,31 who note that there is a well-established literature on the utilisation of clinical evidence in health care but that there has been less consideration of the utilisation of management evidence and research by health-care organisations. Crilly et al. 31 identify 10 thematic categories from the management literature: the nature of knowledge and knowing; information systems and technology; communities of practice; organisational form; organisational learning; resource-based view of the firm; critical theory; knowledge transfer and performance; barriers and facilitators; and culture. A review of the health and social science literature identified two further domains: the evidence-based movement and ‘super structures’, which they define as ‘the infrastructure of institutions and funding that commission healthcare research’ (p. 45). 31

Based on their review, the authors provide a series of propositions, including the general thesis that productivity and efficiency will become increasingly important in the context of spending restrictions in England, and that, as a result, knowledge transfer and the diffusion of innovations will be crucial to the sustainability of NHS organisations. Overall, they argue, the NHS would need to consider how knowledge and information can be used to improve productivity, innovation and performance. These arguments have been adopted in the establishment of Academic Health Science Networks (AHSNs) in England in 2013,32 to which we return later in this report.

Crilly et al. 31 also put forward propositions that are more specific to entities such as the CLAHRCs. They highlight the lack of consensus on what constitutes evidence-based management and suggest that ‘all management knowledge is contested’ (p. 216). 31 They draw on evidence about barriers to, and facilitators of, transfer, and propose that knowledge mobilisation is not just a mere technical activity, arguing that it is also cultural and political. A further proposition that Crilly et al. 31 put forward is extremely germane to the CLAHRCs: they suggest that partnership and network-based organisational forms are more effective at knowledge-sharing than markets or hierarchies and they emphasise the value of collaboration. This last proposition was also identified as important in studies of organisational culture, which we discuss further below. 33

Crilly et al. 31 observe that learning processes and their relationship with organisational design emerged as an important theme in their review. However, it is their further observation that is particularly telling, especially in relation to the CLAHRCs. Crilly et al. 31 note that the question of organisational form has received little attention in the health-care literature despite major reorganisations designed to promote bench to bedside research translation and organisational learning.

Knowledge transfer and exchange

A closely related field is the ongoing work on knowledge transfer and exchange (KTE), which Mitton et al. define as ‘an interactive process involving the interchange of knowledge between research users and researcher producers’ (p. 729). 34 In a wide-ranging review that examined the evidence base for KTE, the authors note that knowledge transfer emerged in the 1990s as a process by which research messages were pushed by the producers of research to the users of research but that, more recently, knowledge exchange emerged as a result of growing evidence that the successful uptake of knowledge requires more than one-way communication, calling instead for genuine interaction among researchers, decision-makers and other stakeholders. They also note a growing emphasis on generating knowledge that can have a practical impact on the health system, which has been a key driver of the CLAHRC scheme.

Mitton et al. list the key KTE strategies mentioned in the literature, including:34

• face-to-face exchange (consultation, regular meetings) between decision-makers and researchers

• education sessions for decision-makers

• networks and communities of practice

• facilitated meetings between decision-makers and researchers

• interactive, multidisciplinary workshops

• capacity building within health services and health delivery organisations

• web-based information, electronic communications

• steering committees (to integrate views of local experts into design, conduct and interpretation of research).

They also identify a variety of mechanisms to facilitate KTE, such as joint researcher–decision-maker workshops, the inclusion of decision-makers in the research process as part of interdisciplinary research teams, a collaborative definition of research questions and the use of intermediaries who understand both roles, known as ‘knowledge brokers’.

These lists suggest that a possible blueprint might be emerging for subsequent programmes (such as the CLAHRCs) to follow. However, Mitton et al. reiterate the concern about the lack of empirical evidence raised by others, noting that ‘despite the rhetoric and growing perception in health services research circles of the “value” of KTE, there is actually very little evidence that can adequately inform what KTE strategies work in what contexts’ (p. 756). 34

Research dissemination

There is some overlap between Mitton et al. ’s34 work on knowledge transfer and exchange and a review undertaken by Wilson et al. on the conceptual or organising frameworks relating to research dissemination. 35

While their focus is on dissemination, Wilson et al. 35 reiterate the debate about terminology mentioned earlier and note that the terms ‘diffusion’, ‘dissemination’, ‘implementation’, ‘knowledge transfer’, ‘knowledge mobilisation’, ‘linkage and exchange’ and ‘research into practice’ are all used to describe overlapping and interrelated concepts and practices. The authors define ‘dissemination’ broadly as ‘a planned process that involves consideration of target audiences and the settings in which research findings are to be received and, where appropriate, communicating and interacting with wider policy and health service audiences in ways that will facilitate research uptake in decision-making processes and practice’ (p. 2)(a formula that resonates with CLAHRC objectives). They note that there are currently a number of theoretically informed frameworks available to researchers that could be used to help guide their dissemination planning and activity, and identify 33, of which 28 are underpinned at least in part by one or more of three theoretical approaches: persuasive communication, diffusion of innovations theory and social marketing.

The authors do not provide a blueprint, although they caution against over-reliance on linear models of health communication. They also reiterate the need to use theoretically informed strategies and, specifically, suggest that funding agencies could consider encouraging grant applicants to develop theoretically informed plans for research dissemination.

Knowledge translation

The call for applications to establish the CLAHRCs stressed their role in addressing the second translation gap. 3 However, the terms ‘translation’ and ‘translation gap’ can be variously interpreted. Moreover, additional gaps have subsequently been identified to complement (and complicate) the two identified by the US Institute of Medicine 8 and the Cooksey Report. 16 Thus Westfall et al. propose a third translational step involving research in ambulatory clinical practices. 36 This proposal is based on the observation that much of clinical research is undertaken in an academic clinical setting whereas the majority of patients receive medical care in a primary care setting. It is at this interface, Westfall et al. 36 argue, that practice-based primary research is required to support primary care physicians to incorporate new discoveries into daily clinical practice, with the third translational step involving dissemination and implementation research. Khoury et al. add a fourth step that, beyond implementation, considers the impact of a given ‘discovery’ on population health outcomes. 37

However, it is increasingly recognised that this terminology may be unhelpful, and that a linear, basic-to-applied model which assumes that ‘gaps’ can somehow be ‘bridged’ does not fully capture the complexities of moving knowledge into action. 38 The translation and implementation of research in practice depends, in part, on the relevance, quality and usefulness of the research itself to service needs. That, in turn, depends on the ways in which research agendas are set, research processes implemented and research knowledge communicated and exchanged. Generating, translating and adopting knowledge is likely to involve iteration and feedback between multiple actors involved to varying degrees in different phases; therefore, implementation activity cannot be studied in isolation from research generation activity.

Research impact assessment

There is growing interest in understanding and measuring the return on investment in medical research. In a systematic review of the associated literature, Hanney et al. identified 200 papers, but relatively few were empirical studies. 39 One approach has been the descriptive categorisation of payback and the payback analytical framework developed by Buxton and Hanney,40 which originally assessed the impact or payback from health services research funded by the health department in England but is now applied more widely. The categorisation covers a wide range of measures of impact, including knowledge, benefits to future research and research use, informing policy and product development, health sector benefits and broader economic benefits. The payback framework focuses attention on the whole process including research production and use. Of specific relevance to the CLAHRCs and their potential influence in local health economies is another study identified in the review. This assessed the impact of the NHS South and West Region’s Development and Evaluation Committee’s technology appraisal reports and compared the impact in the south-west with that elsewhere in England. 41 It found considerable impact in the south-west but less elsewhere, suggesting that having local authors known to local decision-makers was influential in encouraging translation, a finding of interest given the local remit of the CLAHRCs.

Capacity building: collaborative research and absorptive capacity

The main purpose of the CLAHRCs was to develop collaborations that are a ‘mutually beneficial, forward-looking partnership between a university and the surrounding NHS organisations, focused on improving patient outcomes through the conduct and application of applied health research’ (p. 2). 3 Denis and Lomas traced the development of a collaborative approach to research in which researchers and potential users work together to identify research agendas, commission research and so on. 4 They identified the 1983 study by Kogan and Henkel of the R&D system of the health department in England42 as an important early contribution. According to Kogan and Henkel, a critical feature of the collaborative approach, as applied to research and policy-making, is that researchers and policy-makers should join forces ‘to identify research needs against policy relevance and feasibility’ (p. 143). 42 Work to analyse and operationalise this collaborative approach was subsequently undertaken by the Canadian Health Services Research Foundation, led by Lomas, whose concept of ‘linkage and exchange’ between users and researchers has been particularly influential. 43,44 Collaborative approaches to research somewhat mirror the concept of ‘Mode 2′ research: research that is context-driven, problem-focused and interdisciplinary. 14,45–47

The CLAHRCs were also required to increase ‘the capacity of NHS organisations to engage with and apply research’ (p. 4). 2 The concept of absorptive capacity was first described by Cohen and Levinthal in the context of industrial research;48 they suggested that conducting R&D within a firm helps that firm to develop and maintain its broader capabilities to assimilate and exploit externally available information from research. 49,50 The original theory could apply at different levels, including individual and organisational levels, and it can be argued that, when clinicians and managers in a health-care system are seen as stakeholders in the research system, their engagement in research is a way of enhancing their ability and willingness to use research from wherever it might originate. For example, Buxton and Hanney51 include increased capacity to use research as one of the benefits identified in their multidimensional categorisation of benefits from health research,40,51–53 and this approach is replicated in other health research impact assessment frameworks that build on the payback framework. 54–56 Part of the theoretical underpinning that research engagement contributes to building absorptive capacity is the notion that, in practice at least, knowledge is not a pure public good but instead requires a level of understanding of research before it can be absorbed. 57 Such understanding can be built up by undertaking research.

Cultural change

Another requirement of the CLAHRCs was to ‘embed a critical culture [in the NHS] that is more receptive to change’ (p. 14). 17 Shortell et al. 58 explored the relationship of organisational culture, quality improvement and selected outcomes in hospitals in the USA, showing that an organisational culture characterised as participative, flexible and risk-taking was significantly related to quality improvement implementation. More recently, Mannion et al. classified the extant cultures in NHS organisations into four types – clan, hierarchical, developmental and rational – and explored how these cultures change over time. 33 In general they identified ‘developmental’ culture, characterised by innovation, dynamism, growth and entrepreneurship with an external, relational focus, as one in which change was viewed as a ‘positive organisational attribute . . . [and there was a] . . . willingness of senior management to embrace innovative approaches to delivering services’ (p. 209). 33 It is this developmental culture that most closely matches the culture the CLAHRCs are seeking to instil. This is a considerable challenge; Mannion et al. found that this development culture was dominant in only a small percentage of NHS hospital trusts and general practitioner (GP) practices. 33 However, they also suggest that cultural change can happen when it is triggered by a perception of crisis, initiated and shaped by strong leaders, consolidated by perceived success and mediated by relearning or re-education.

Organisational change and system shift

Some health-care organisations have paid particular attention to the role of research in their overall approach to improve performance. 59 For example, the Veterans Administration in the USA sought to promote research engagement throughout its health-care delivery system as part of a comprehensive re-engineering exercise designed to improve the quality of the health care provided. 60 Veterans Administration investigators are nested in a fully integrated health-care delivery system with a stable patient population with a high prevalence of chronic conditions, which provides them ‘with unparalleled opportunities to translate research questions into studies and research findings into clinical action’ (p. I–10). 61 One way in which this integration has been achieved is through the aforementioned QUERI programme. Launched in 1998, it sought to accelerate the implementation of new research findings into clinical care by creating strong links between those performing research and those responsible for health systems operations: a remit that resonates strongly with that of the CLAHRCs. An evaluation of the QUERI programme described this approach as achieving a ‘paradigm shift to an action-oriented approach that meaningfully engages clinicians, managers, patients/clients, and researchers in research-driven initiatives to improve quality’ (p. 1). 62 In language that echoes that later used by the CLAHRCs, the authors concluded that this shift is towards coproduction of knowledge, or ‘Mode 2′ knowledge production.

Organising for quality

In the context of CLAHRCs, work on quality improvement also provides important insights. Bate et al. ,63 in a study of the quality of nine high-performing health-care organisations in the UK and the USA, took an approach that was grounded in the examination of actual processes at different organisational levels. Reflecting the observations of Grol et al. described earlier in this section,30 Bate et al. point to the underuse of theory in the quality improvement literature and note that much of the evidence that is available is descriptive rather than explanatory. 63 Furthermore, they contend that quality improvement has been dominated by a form of ‘menu mentality’,63 characterised by lists of factors seen as important, such as leadership support, team-based structures and composition, and information technologies (and their failings), instead of focusing on the processes that will bring these factors together to achieve change.

Emphasising that quality improvement has to be seen as a complex process, they suggest that the keys to quality improvement lie in the distinct characteristics and dynamics of organisational and human processes. In theoretical terms this is a shift from a variance or variables theory (e.g. more of X and more of Y produce more of Z) to a process theory (e.g. do A and then B to get to C). In empirical terms it is the shift from seeing quality improvement merely as a method, technique, discipline or set of skills to seeing it as a human and organisational achievement, that is a social process. Bate et al. identify six common challenges that all the organisations they studied faced, which they describe as structural (organising, planning and co-ordinating quality improvement), political, cultural, educational, emotional, and physical and technical. 63

Like others, Bate et al. 63 argue that there is no single best way to achieve service excellence. The case studies they report underscore the notion that quality improvement processes are interconnected and symbiotic. Organisational processes may form cycles or closed loops, which may be virtuous (upward improvement) or vicious (downward degrading) spirals. This step beyond the ‘menu mentality’ focuses on sequencing and transformation, and provides important insights for the CLAHRCs about the need to examine organisational processes and their interactions over time.

Normalisation process theory

Normalisation process theory (NPT) was developed by May et al. 64,65 and is concerned both with the implementation of new ways of thinking, acting and organising in health care and with the integration (‘routine embedding’) of new systems of practice into existing organisational and professional settings. NPT proposes what May and Finch refer to as a ‘working model of implementation, embedding and integration in conditions marked by complexity and emergence’ (p. 535). 66 It covers the relationships between a complex intervention and the context in which it is implemented. It is interested in the processes by which implementation proceeds – including interactions between people, technologies and organisational structures – and the work that proceeds from these. It proposes that (1) innovations become embedded in practice as a result of people working, individually and collectively, to implement them; (2) the work of implementation is operationalised through four generative mechanisms identified as coherence, cognitive participation, collective action and reflexive monitoring; and (3) organising structures and social norms specify the rules and roles that frame action. 66 The four mechanisms are described further as:64,67

• coherence or sense-making: how complex interventions are formed in ways that hold together and people make sense of, and specify, their involvement in it

• cognitive participation: how communities of practice are built and sustained, that is how actors enrol themselves and others into a complex intervention

• collective action: the collective work that people do to enact a set of practices

• reflexive monitoring: the appraisal that people make to understand the ways in which a new set of practices affects them and those around them.

May considers NPT a generic and middle-range theory of implementation that examines what people do and how they work. 64 This distinguishes it from theories of the cultural transmission of innovations (such as diffusion of innovations) that seek to explain how innovations spread, theories of collective and individual learning and expertise that seek to explain how innovations, are internalised, and theories of the relationships between individual attitudes and intentions, and behavioural outcomes. NPT emphasises the need to look for processes. It provides an important frame for CLAHRCs in that the outcomes of the CLAHRCs can be seen to result from the integration of a complex intervention into a complex system achieved by the accomplishments of its stakeholders.

Conclusions

This section has discussed theories of the diffusion of innovation, research use, quality improvement, collaboration and process theory that can inform CLAHRCs’ activities and their evaluation. The main observations are further summarised in Table 1. While we would not want to place too much weight on this brief overview, we believe that a number of key lessons can be learned:

1. There is no ‘industry standard’ to guide the CLAHRCs; CLAHRCs are involved in both developing their own solutions and delivering these.

2. The causes of problems are understood differently, and consequently solutions vary (although these are often at a high level of abstraction).

3. It is widely recognised that context is very important.

4. There is a general scepticism about overly rigid linear models (but in all there is a sense that processes can be managed to make progress over time).

5. It is likely that successful change will be multifaceted and therefore evaluations must be equally multifaceted if they are to understand the range of processes involved.

We have identified a body of literature reflecting an area of research characterised by conceptual pluralism, alternative ways of framing the evidence and competing causal explanations. The conceptual terrain might be described as dynamic, pluralistic and competitive. With terminologies that evolve over time and compete one with another we need to define our terms with care. Given the wide range of theories and metatheories it is not always clear how to translate research into practice, although three general messages do emerge. The first is that context is increasingly identified as crucial to shaping outcome. If practitioners do not understand the context within which they operate, and evaluators fail to assess this accurately, then it is unlikely that we will develop a good understanding of why the CLAHRCs work in some contexts and not in others. Secondly, while there is a flow of knowledge it is not always clear that this is simply from research to practice and, even when this is largely the case, there will be a variety of ways in which information flows ‘back’ the other way. In the language of economists, there will be supply push as well as demand pull. Thirdly, and following from the first two, the metaphor of a single bridge, linking research to practice and with a steady flow of traffic moving one way, is unhelpful. Competing metaphors might include an ecosystem or a marketplace. 68

Structure of this report

This introductory chapter briefly set out the aims of and the policy context within which the CLAHRCs were established, as a means to illustrate the complexities involved and the innovative nature of the initiative. It also summarised the conceptual background against which the CLAHRCs were developed. Chapter 2 describes the methods used, setting out our approach and the phased nature of the work undertaken. Chapters 3 and 4 present the core findings of the work, with Chapter 3 presenting the observations from phase 1 of our evaluation while Chapter 4 focuses on findings emerging from phase 2 and is structured according to major themes that were identified in phase 1 of the study. Chapter 5 discusses our overall findings, seeking to relate them to the wider literature on research use and impact. We also review current developments in the NHS, in particular the new AHSNs, and explore how they, and the CLAHRCs in their second round of funding, have been tasked to work together in an integrated and synergistic way. Finally, we draw some general conclusions, highlight some practical implications and make recommendations for further research in an area that is continuing to evolve.

In-depth interviews

Interviews in the first phase of the evaluation sought to provide background information on the details of CLAHRC implementation strategies, approaches and activities, motivations for the selection of specific strategies and activities to achieve the CLAHRC goals, processes and structures in place for managing and delivering the activities, expected milestones and targets for outputs, and the nature and role of local and national factors as enablers or potential barriers to success.

We purposely sampled senior individuals who were likely to play a key role in implementing CLAHRC interventions across all nine CLAHRCs. We sought to interview three or four senior people per CLAHRC, covering clinicians, academics, managers and commissioners. Potential interviewees were identified in consultation with individual CLAHRCs. As indicated above, the final number of individuals agreeing to be interviewed varied across CLAHRCs, from two participants in South Yorkshire CLAHRC to eight participants representing Cambridgeshire and Peterborough (CP) CLAHRC and eight representing Leicestershire, Northamptonshire and Rutland CLAHRC (Table 2); roles and functions covered CLAHRC directors, clinical leads and theme leads. Interviews were conducted face to face or as telephone interviews, lasting an average of 60 minutes (the interview protocol is presented in Appendix 2). Interviews were recorded and transcribed following prior permission by the participant. Transcripts were analysed according to the themes guiding the interviews.

Workshops

The workshops sought to develop the themes identified in interviews with senior CLAHRC individuals. Specifically, the workshops aimed to explore innovative ways of delivering CLAHRC activities as well as the facilitators and challenges/barriers to their success, expected or intended outcomes, early and future impacts, and views on how to improve each CLAHRC’s performance. Participants were also asked to suggest issues on which the evaluation might focus in the succeeding period. An outline of the workshop agenda is presented in Appendix 3.

Our aim was to hold one workshop with each CLAHRC, which was to take place at the lead institution and involve five or six representatives of different stakeholder groups and organisations within the CLAHRC. However, as indicated in Table 2, the number and format of workshops varied, with two CLAHRCs limiting their participation in our evaluation to interviews only. Following the workshops, the evaluation team prepared a workshop report which summarised the issues discussed and the findings. These were shared with workshop participants to validate the evaluation team’s report.

Synthesis

Drawing on the primary and secondary data collected, we sought to identify and make explicit the theories of change and intervention logic of each CLAHRC. Specifically we explored:

• the types of intervention being used to identify problems and promote evidence-generation and evidence-based improvement in health-service practice

• the mechanisms through which these interventions operated (interactions, social influence, facilitation, etc.)

• the diversity of stakeholders involved in the intervention approaches

• the various levels at which these interventions operated:

  • the micro level, that is interventions that promoted improvements in the identification, conduct, application and integration of research by individual researchers, managers, practitioners and patients within a single organisation

  • the meso level, namely interventions that promoted improvements in the identification, conduct, application and integration of research by researchers, managers, practitioners and patients across different organisations

  • the macro level, interventions that promoted improvements in the identification, conduct, application and integration of research from organisation to organisation and across research and health-care sectors.

Guided by this information we developed logic models for each of the nine CLAHRCs, to illustrate and explore the theories of change underlying each CLAHRC.

In keeping with the formative emphasis of the evaluation, we fed early findings back to all the CLAHRCs, NIHR HSDR and other key stakeholders at a dedicated learning event in early 2011. We also provided a detailed report to the NIHR and others on progress achieved in the first year of the evaluation. 24

In addition to identifying and make explicit the diversity of strategic approaches adopted by individual CLAHRCs, phase 1 of our study also sought to identify the most pertinent research questions for detailed exploration in phase 2 of the evaluation. Informed by work undertaken in phase 1 and guided by the overarching question of how, and how effectively, CLAHRCs address the second translation gap, we identified a set of priority areas for further exploration. These priority areas were further informed through consultation with the advisory board to our study, and by consideration of the focus of the three other NIHR HSDR-commissioned evaluation teams. 71 Following this process, we identified three core areas for further analysis in phase 2 of the project, which we described in the introduction to this chapter:

1. How does the NHS influence CLAHRCs’ evolution, outcomes and impact (and indeed how does having a CLAHRC influence NHS behaviour)?

2. How are effective multistakeholder and multidisciplinary research and implementation teams for service improvement built: what can we learn from the CLAHRCs model and what mechanisms are being used to enable it?

3. What can we learn from the CLAHRCs that can cast new understanding on how to use research knowledge and evidence to change commissioning and clinical behaviour for patient benefit?

Stakeholder survey

To better understand the inter-relations between the NHS and the CLAHRCs, the (perceived) effectiveness of multistakeholder and multidisciplinary research for service improvement, and how research knowledge and evidence can be used to inform commissioning and clinical behaviour for patient benefit, we carried out a survey of CLAHRCs (see Appendix 4).

Against the background of the CLAHRCs as a complex intervention, and the interest in learning about how this model might be used in future, the design of the survey instrument was informed by the theory of the normalisation of complex interventions (NPT),54,65,72 which we discussed in Chapter 1 of this report. In developing the survey instrument, we drew on the four components of the NPT and mapped these against the core research questions guiding phase 2 of the evaluation:67

• coherence and sense-making: why people believe CLAHRCs to be distinctive and have value

• cognitive participation: how individuals and groups participating in CLAHRCs come to see the role they can play to achieve the value on offer

• collective action: how individuals and groups participating in CLAHRCs are able in practice to collaborate in pursuit of the goals of the CLAHRC

• reflexive monitoring: how improvement achieved by CLAHRCs can be sustained by learning and adapting a multifaceted and evolving approach.

Informed by the NPT, our survey examined the diversity of interventions taking place in CLAHRCs as they related to our three core areas of interest, alongside practical insights into how people work, and perspectives on effectiveness and impact. Using this approach, we identified five cross-cutting themes: building awareness of the intervention; creating buy-in and mobilisation; sustaining engagement with the intervention; learning from the experience of the intervention; and acting on learning. These themes were adapted to the CLAHRC-specific context, with additional questions included on issues that needed to be explored in more depth.

Each of the nine CLAHRCs was invited to participate in the survey, with six agreeing to do so: CP; Leeds, York and Bradford; North West London; South West Peninsula (PenCLAHRC); Nottinghamshire, Derbyshire and Lincolnshire; and Leicestershire, Northamptonshire and Rutland.

The survey was conducted online, using SelectSurvey (SelectSurvey.NETv4.126.000, ClassApps.com, Overland Park, KS, USA), a survey software that provides a web interface for creating, administering, deploying and monitoring the uptake of the survey, and analysing results. Prior to roll-out, the survey instrument was piloted with two members of CLAHRC-CP. The participating CLAHRCs were then asked to circulate a link to the survey, together with an explanatory section, to prospective respondents from a number of stakeholder groups involved with their respective CLAHRC. Data were collected over a 4-month period from October 2011 to January 2012.

Key characteristics of survey respondents

The number of potential respondents invited by the six CLAHRCs ranged from 43 to 145 individuals; of the approximately 500 people who were invited to participate in the survey, a total of 242 across the six CLAHRCs responded.

The number of respondents varied across CLAHRCs, from 22 to 79, with response rates ranging from 28% to 51%. There was an average of 40 respondents per CLAHRC (see Appendix 5). Of the 242 respondents, almost half reported spending most of their time working in the NHS (n = 103), with the remainder working predominantly in academia (n = 113) (the remaining 26 respondents did not respond to this question) (Figure 3). This proportion of respondents from the NHS and academia was also reflected across the majority of individual CLAHRCs (data not shown).

FIGURE 3.

Number of respondents across NHS and academia.

Figure 4 shows the nature of respondent involvement in the CLAHRCs where respondents reported this information (n = 163). A diverse range of job titles were cited, with the highest number being project team members, followed by theme leads, members of the CLAHRC board and research fellows.

FIGURE 4.

Respondent’s nature of involvement in the CLAHRC. PhD, doctor of philosophy; PPI, patient and public involvement.

Case studies

In order to develop a richer and more nuanced understanding of our areas of enquiry, we conducted case studies of two CLAHRCS. As noted earlier, the NIHR HSDR commissioned four teams to evaluate aspects of CLAHRCs. 71 HSDR’s key objectives throughout were to spread the evaluative effort evenly across the CLAHRCs, and to encourage the four HSDR-funded research teams to collaborate with each other so that the different parts of the evaluation were well co-ordinated and there was minimal duplication. All four research teams planned to undertake case studies with selected CLAHRCs. The selection of case study CLAHRCs was discussed by HSDR representatives and the four external evaluation teams at a start-up meeting in October 2009, and took into account the need to ensure an appropriate spread across all nine CLAHRCs and to ensure manageability for CLAHRCs and for researchers. Considerations about the nature and scope of individual CLAHRCs and more pragmatic reasons, such as geographical location, all played a role. As a result we agreed with HSDR that our evaluation should cover two case studies, CLAHRC-CP and PenCLAHRC.

Case studies comprised reviews of documentation relating to the two CLAHRCs, interviews with staff and a 1-day workshop with each CLAHRC to refine and validate emerging insights.

Validation interviews

Informed by the survey and the case studies, we developed a number of deductive propositions which we sought to test and validate through a final set of interviews with representatives from all nine CLAHRCs. Eighteen interviews were conducted as part of the validation stage during September and October 2012. Interviewees included the directors from each of the nine CLAHRCs; senior members of the CLAHRCs affiliated to the NHS (in seven of the nine CLAHRCs); and representatives from the funder (NIHR). The interview protocol was structured to elicit the views of respondents on four emerging propositions relating to the CLAHRCs that had emerged from the case studies:

• The task of the CLAHRCs is not just improving health-care research and not just improving patient outcomes, but a combination of both.

• CLAHRCs are rooted in local relationships (some in place prior to the CLAHRC, providing a platform on which to build, others created during the CLAHRC) and build on local capacities, with implications for critical size and remit.

• The collaborations CLAHRCs are building are ones that seek to promote integration and culture change, and are not designed simply to develop arrangements for brokerage (including knowledge brokerage) and linkage and exchange.

• CLAHRCs legitimise a degree of experimentation in finding new ways of identifying and addressing NHS research needs, encouraging the emergence of research questions from the service and from its patients, which can then be funded by the CLAHRC but also by others.

The interviews also aimed to gain insights into how the CLAHRCs had evolved over time, including establishing the collaboration (e.g. the extent to which the original model for the CLAHRC persisted over time); leadership and developing the collaboration (including the scope of the individual CLAHRC and perceived risks surrounding the collaboration); and sustainability (e.g. did interviewees regard CLAHRCs as a persisting entity that would continue to broker the collaboration between the NHS and academia, or as a shorter-term catalyst to encourage a collaboration that could eventually stand on their own?). The full interview protocol is presented in Appendix 8.

Interviews were semistructured in nature and conducted by phone. The majority of interviews were conducted by one researcher from the evaluation team, and lasted an average of 60 minutes. All interviews were recorded and transcribed with prior permission. Interviews were analysed separately by two evaluation team members, using qualitative data analysis software (NVivo version 9, QSR International, Burlington, MA, USA), in order to identify content relating to our research questions and emerging propositions, and to capture any new themes arising from the data. The resulting analyses were cross-checked by the second team member.

Document review

Also as part of phase 2, we conducted two separate document reviews. The first of these aimed to review the wider landscape in which the CLAHRCs were operating, in order to place them in context and provide insights on the future role and potential of the CLAHRCs. To inform the review of the wider landscape throughout the period of the project, we regularly monitored the websites of the Department of Health and the NIHR and the most relevant programmes within them, and, using snowballing, identified documents produced by both the NIHR and the NHS, especially those related to the translation of research. We also conducted web searches to identify, and then review, proposals made in response to the call in 2012 for proposals to establish AHSNs. 73 Key findings from this review are presented in Chapter 5 and Appendix 9 of this report.

In addition, we conducted a document review to complement the validation stage of the study. This was intended to test our emerging propositions by cross-referencing with the documents produced by each of the nine CLAHRCs. We included documents available on the websites of all individual CLAHRCs and also contacted CLAHRC managers to obtain further documents, including publication lists and annual reports. This component of the study did not seek to provide an exhaustive assessment of all documentation produced by CLAHRCs. Its main purpose was to provide additional contextual information to inform our results further.

A shared vision, but contrasting interpretations

The CLAHRCs involved collaboration between different stakeholders in health research and the NHS. They were intended to be vehicles for improving patient care through efficient and effective services built on improved generation, translation and adoption of knowledge. In this spirit we were interested not simply in the CLAHRCs as emerging forms of collaboration but also in how, through all their diverse impacts and activities, we could learn more about how a closer engagement between communities of researchers, health practitioners, health managers and others might lead to improved patient outcomes. From the detailed summaries (see Appendix 10) it was clear that all the CLAHRCs shared a vision and a vocabulary about the long-lasting change in the NHS that could be achieved by establishing new relationships between applied researchers and NHS decision-makers and new behaviours within each of these groups. There was shared optimism about the new pathways that could be forged, linking applied health-care research and medical research to patient outcomes and experiences. However, along with the similarities there were also more nuanced differences. Table 3 presents the broadly shared story of the CLAHRCs, using the data we obtained from all nine CLAHRCs. In Appendix 11 we show some of the ways in which individual CLAHRCs compare and contrast with others. The structure that we use to organise these summary tables draws upon a conceptualisation widely used to understand ‘improvement journeys’ in the health sector, reminding us that the ultimate aim of the CLAHRCs is to improve health care. See, for example, Bate et al. , who argue that there are six core challenges to organising for quality, and that these are structural, political, cultural, educational, emotional, and physical and technological. 63

Governance, accountability and organisational structure

Governance and management arrangements involve the formal structures through which resources are allocated, decisions taken and disputes resolved. They also establish who should be accountable to whom and on what basis. From the outset, all the CLAHRCs involved leading figures with experience in establishing and running such arrangements across academic and service–delivery boundaries. All the CLAHRCs also shared the governance and management challenges that are unavoidable consequences of working in this terrain. These include navigating and managing dual R&D governance systems (NHS and academia) within a single structure and developing capacity, systems, provisions and contingency plans to adapt and respond to changing health-system landscapes (such as changes in the nature of commissioning and uncertainty about long-term funding availability). There were, however, differences in the way in which the fundamental governance principles of transparency, accountability and responsibility were operationalised. Some CLAHRCs had centralised ownership, control and management arrangements, while others devolved significant amounts of responsibility and provided substantial autonomy to constituent partner organisations or to differentiated functional committees. The administrative support in each CLAHRC was, therefore, diverse both in nature and in levels of centralisation.

Table 3 identifies the set of widely shared activities. There was a concern with effective leadership, a need to balance central direction with professional autonomy and experimentation, a need to align with local and national priorities (which may not always sit comfortably together) and a need to allocate responsibilities and rights within a system of accountability. Organisationally, the CLAHRCs opted to ‘chunk’ their workload into particular themes, building upon pre-existing relationships linked to clinical areas or to implementation themes. They then established mechanisms for learning and sharing insights among these themes. Within this broadly shared set of parameters, Appendix 11 illustrates how specific CLAHRCs have addressed the issues, some favouring more experimentation and variation and others more concerned with aligning and steering.

The focus of some CLAHRCs was on specific health areas (e.g. mental health across the life course) while others tackled a broad range of regional priorities (e.g. chronic diseases or chronic and acute care). Some CLAHRCs had common implementation frameworks across different thematic groupings, while others were tailored to specific projects and themes. All were trying to integrate activities that emphasised applied health research projects with those that had an explicit focus on implementation, and to do so by creating environments that enabled joint working and knowledge exchange. The ways in which such environments were brought to life and organised differed. For example, fellowships and studentships in applied health research and implementation science were one of the more common approaches (e.g. postdoctorates, research degrees, medical degrees). Short training courses for researchers and practitioners were also established, and these varied in nature across the CLAHRCs depending on their thematic focus. Dedicated funding to buy out time from the NHS to enable research activity by clinicians and nurses was another common approach. Some CLAHRCs relied on mixed project teams of clinicians and academics from diverse disciplines (including those that are non-traditional for health services research, such as systems engineering), and sometimes also including patients, as the primary means of bringing about cultural change, while others emphasised the roles of ‘boundary spanners’, ‘knowledge transfer associates’ or ‘diffusion fellows’ embedded in trusts. All the CLAHRCs supported meetings to encourage knowledge exchange and bridge professional and disciplinary gaps. Emphasis on evaluation activities designed to create self-improving, reflexive systems varied substantially, as did the stage of development and maturation of evaluation frameworks.

Changing individual and group attitudes and behaviours

We know from the discussion of the literature presented in Chapter 1 that developing shared norms and embedding behaviour change are central to improving the quality of health services. Common to all the CLAHRCs were efforts to change or modify the behaviours and attitudes of researchers and practitioners (or, at an organisational level, academia, service providers and commissioners) towards a more common vision of the role of research in improving services. This required building a shared language and understanding of the functions and working methods of different academic and clinical professions and disciplines, as well as of respective responsibilities along the pathway from research production and implementation to improvement in patient care. It also required an understanding of the constructive roles that patients can play. In particular, all the CLAHRCs tried to raise the profile of research in the NHS, as well as awareness in academia of the importance of doing research that is driven first and foremost by the needs of service providers and users. Prioritisation processes for projects within the CLAHRCs tended to be driven by a combination of population needs and the availability of skills, experience and resources to address them in the local research and innovation communities.

Changing the attitudes of individuals depends not only on those individuals but also on the flexibility and responsiveness of existing organisational-level attitudes and behaviours. High levels of NHS involvement underpinned the CLAHRCs’ ethos and theories of change. The CLAHRCs also sought to encourage public and patient engagement, and worked to communicate the value of their involvement in research to them and, more generally, to NHS decision-makers and the research community. They disseminated information on CLAHRCs’ activities, outputs and impacts widely.

However, the ways through which the public were involved, as well as the intensity of their involvement in different stages of the research cycle, varied. Some CLAHRCs tried to engage service users throughout, encouraging them to identify research questions and get involved in research design, and to remain involved during the production of research and the adoption of research findings. They developed research training and induction programmes for service users, and supported formal patient or public representative posts within the CLAHRC. Other CLAHRCs placed less emphasis on active public involvement in research design and implementation, and engaged the public mostly through the dissemination of public information about CLAHRC activities as part of an awareness-raising strategy.

Across the CLAHRCs there were conscious efforts to change the language and culture of those engaged in research and practice. This was pursued through active leadership, and by developing compelling narratives of successful projects, providing training and creating opportunities to meet and discuss. Evidence from the interviews and workshops in phase 1 suggested that some of the individuals most closely involved may indeed have changed their relationship to research and/or health care. All the CLAHRCs sought to create environments that encouraged knowledge exchange, communication and learning within and between different communities of practice. They created opportunities for new groups to join existing networks, and raised expectations that behaviours within and across organisations would change. However, realising such expectations required some degree of direction, and an ability to align, lead and shape groups and behaviours. The CLAHRCs did not necessarily have the resources or the authority to direct and control groups of researchers explicitly, or to micro-manage NHS clinicians and managers. Consequently, we would argue that the CLAHRCs should be seen less as unified and homogeneous organisations and more as terrains upon which compromises, trade-offs and tensions are played out.

Infrastructure and use of resources

All the CLAHRCs pursued their activities through a combination of funding from the NIHR and matched funding from local organisations (predominantly NHS trusts). The sustainability of the CLAHRC approach depends in part upon being able to demonstrate the benefits and manage the costs so that the approach is absorbed into the mainstream of provision and research. The physical infrastructure available to participants in the CLAHRCs was in some cases geographically dispersed across a region, and in others more centralised with the colocation of different research and implementation teams in shared spaces. Many reported on the benefits of colocation.

Online resources are a way of reaching out to, and engaging, external stakeholders. All the CLAHRCs used resources to improve information and communication systems in order to promote more timely and efficient sharing of knowledge and data across stakeholders. This led to changes in the ways in which the skills, expertise, influence and authority of diverse stakeholders were mobilised in research and implementation agendas, from commissioners and NHS managers to patients and the public.

System shifts

In their initial proposals all the CLAHRCs reported that they were hoping to achieve a system shift through their activities. Their aspiration was to create a new generation of researchers and clinicians with changed professional identities and motivations who were supported by a different set of incentives and drivers, both national and local, and a commissioning approach that was committed to reinforcing the aims of the CLAHRC. Table 3 suggests the system-level changes required if the implementation of research findings is to happen more efficiently and with shorter time lags, and if research is to match real-world service needs continuously.

For example, clearer and stronger incentive structures for NHS and academic staff across academic and health service sectors are needed to sustain cultural change, but these cultural changes also need to become normalised within a new system of health care and research. Creating opportunities for the participation of NHS staff across different stages of research is another area meriting system-level attention. A more explicit policy position and a better-co-ordinated national strategy for engaging patients and the public in research and implementation activities would help to ensure and sustain their meaningful contributions to service improvement, and central to any such strategy is active communication and demonstration of the benefits of research implementation for the quality of care that individuals and communities receive.

To build a critical mass of NHS and academic staff thinking in the CLAHRC way takes time, but proactive efforts to share and exchange insights between the CLAHRCs, and with the broader health-care landscape nationally and internationally, are important for learning and feedback, for ensuring that best practice is implemented, spread and sustained, and for future resource allocation. Related to this is the need to share information better about the link between different translational research and implementation initiatives in the overall health-system landscape. We return to these issues below and in Chapter 4.

Phase 1: conclusions

We know from the literature that there is a need for more theory-based, context-sensitive, embedded evaluation in this area. The CLAHRCs offer an important opportunity to understand further both the theory and the practice of reshaping the activities of research producers and research users (and the boundaries between them) with the intention of improving health care and health outcomes. Phase 1 of our evaluation provided us with a detailed understanding of the activities involved in achieving this, the context of these activities and some of the criteria seen to be associated with success. Creativity and effort had been applied to develop different models of change.

Two conclusions emerge. First, the CLAHRCs will not resolve the lack of consensus raised by the literature about the ‘best’ approach to mobilising knowledge to improve health care, but they do provide an opportunity to look carefully at specific dimensions of the problems and develop a scientific basis for addressing them. Second, the CLAHRCs cannot, on their own and once and for all, bridge what has been called (however inappropriately) the second translation gap, but they can help to bring about system shifts that bring the health and health-research systems closer together.

Emerging questions: shaping phase 2 of the evaluation

In phase 1 of our evaluation we sought to provide an overview of the background, development and future plans and aspirations of each of the nine CLAHRCs. We could not explore in detail every dimension of the improvement journeys being pursued. However, we identified a number of key questions which we thought would cast further light on that wider picture and which were:

• relatively under-researched (as identified through our literature review)

• potentially high-impact with transferable lessons

• relevant to the success of the CLAHRCs

• not being covered by one of the three other evaluations

• capable of being researched across the CLAHRCs to support comparisons and contrasts.

These questions are listed in Box 1 starting with more macro-level questions about the relationships between the CLAHRCs and, on the one hand, the broader translational landscape and, on the other hand, the NHS. More meso-level questions concern issues such as governance and operational flexibility, and towards the end there are more micro-level questions about engagement and participation. This ordering is not intended to suggest any order of importance; there were macro-, meso- and micro-level dimensions to each of these questions.

As indicated in Chapter 2, we discussed phase 1 findings at a learning event with the CLAHRC directors and the NIHR. Our aim was, with their help, to identify three questions for more detailed investigation in phase 2. We describe these in detail in Chapter 4.

Perspectives of NHS and academic staff across six CLAHRCs

The survey sought to explore how NHS and academic staff perceived the aims of their CLAHRC. It showed that NHS and academic respondents strongly supported CLAHRC aims of increasing the capacity to carry out and use applied health research in the NHS, and to foster a culture of collaboration between the academic and service delivery sectors (Figure 5). However, a smaller number of respondents (around 40%) also saw the involvement of commissioners and NHS managers in the formulation of research questions and the implementation of findings as a core aim of CLAHRCs. The majority of respondents (76%) were in full agreement with the formal aims articulated by their CLAHRC (see Appendix 5, Figure 27).

FIGURE 5.

Perceived aims in relation to integrating NHS staff with research activities.

When asked about their motivations for engaging in the CLAHRCs initiative, over 60% of NHS respondents cited a desire to improve clinical effectiveness by applying existing research better (Figure 6). NHS respondents also expressed an interest in the production of research and in encouraging the pursuit of research relevant to practice. These motivations were also commonly cited by academics, in addition to the desire to spend more time on applied research.

FIGURE 6.

Motivation for getting involved in CLAHRC.

Respondents across all six CLAHRCs attributed NHS influence on their CLAHRC to a number of factors, including the involvement of clinicians in research design and in research implementation, and the existence of long-standing relationships between academic and NHS members of the CLAHRC (Figure 7). A relatively small number (10%) reported that this question was not applicable. It is difficult to assess, from these data, whether or not this implies that, in the view of these respondents, the NHS had not been influential in shaping CLAHRC activity. We explore this question further below.

FIGURE 7.

Reported reasons for the NHS being considered currently influential in shaping CLAHRC’s activities.

A key determinant of NHS influence on the CLAHRCs was the nature of the groups that shaped CLAHRC decision-making (Figure 8). Respondents suggested that seniority was important, including senior academic staff, senior NHS clinicians and senior NHS management. Conversely, junior NHS clinicians were judged to be the group with least strategic influence.

FIGURE 8.

Perceived extent to which different groups within local NHS and university are influential in shaping CLAHRC’s strategy, decisions, activities and choice of outputs.

As indicated in Figure 7, a minority of respondents believed that the NHS had not been influential in shaping the activities of their CLAHRC. Where this was the case, respondents were asked to identify whether this was because of a predominance of academic staff in the CLAHRC or a lack of buy-in from senior NHS leadership. Most respondents attributed this lack of influence to the former (Figure 9). Similar concerns were reported by NHS respondents as a significant barrier to the success of the CLAHRC in meeting its objectives (see Appendix 5, Figure 57).

FIGURE 9.

Stated reasons why the NHS may not be influential in CLAHRC activities.

On the issue of how having a CLAHRC might influence NHS behaviour, over 80% of respondents across all six CLAHRCs were confident that their CLAHRC would lead to changes in NHS behaviour over time (Figure 10). However, when disaggregated by individual CLAHRC the levels of confidence expressed by NHS staff and academics were more varied (between 45% and 90%; data not shown).

FIGURE 10.

The CLAHRC will lead to changes in practice/will influence NHS behaviour.

A majority of respondents also thought that, at the time of the survey, some change had already happened, with 65% of NHS respondents and 57% of academics believing that CLAHRC’s activities and projects had influenced the way they worked outside the CLAHRC. Where this was felt to be the case, nearly 60% of NHS staff attributed it to easy applicability of the research undertaken by the CLAHRC (Figure 11).

FIGURE 11.

Stated reasons why information received about CLAHRC’s activities and projects did influence behaviour and ways of working.

In line with the aims of the CLAHRCs, a majority of NHS respondents reported that they had developed new research skills as a result of working within the CLAHRC (Figure 12). There was also a sense that the innovative ways of working fostered by the CLAHRCs were engendering new skills in both groups, and over 40% of academic respondents reported that they had developed new communication skills. The findings also suggest that NHS respondents were starting to develop new ways of thinking about service provision and the use of evidence in practice, with a majority stating that working within the CLAHRC was enabling them to think about challenges in their work from different perspectives.

FIGURE 12.

Perceived difference in working within CLAHRCs from working outside it.

Experiences in CLAHRC-CP and PenCLAHRC

Our two case studies explored the influence of the NHS and the CLAHRCs on each other further. We identified four overarching themes: the local remit, the role of matched funding, the integrating nature of the collaboration and system change. In the following section we explore these issues, drawing on the experiences of CLAHRC-CP and PenCLAHRC. We also consider how the findings from the case studies are confirmed by the wider CLAHRC experience. We conclude each subsection with a short summary of key points observed.

Conclusions

In this section we have explored how the NHS has influenced the evolution of CLAHRCs and how the presence of a CLAHRC has affected the practice and culture of the NHS. We have identified four themes that characterise the nature of this mutual influence. First, we noted the importance of a local remit for the scope and work of the CLAHRCs. The CLAHRCs are rooted in local relationships, build on local capacity and expertise, and have relied on local relationships and capacity to shape their research projects. This has also meant that they have focused the outcomes of their projects across the widest possible local area through engagement with the local NHS providers and commissioners. Second, we noted how the requirement to attract matched funding provided opportunities (e.g. by creating NHS resources for projects through ‘in kind’ funding) and challenges (e.g. caused by health sector restructuring, which affected commitment). Third, the CLAHRCs have demonstrated a clear drive to promote integration through the creation of ‘integrating roles’ such as locality leads or diffusion fellows, as well as encouraging those not directly involved in the CLAHRC to engage with their activities as, for example, CLAHRC Associates. Finally, we explored the nature, and potential, of the CLAHRCs as complex interventions operating within highly complex health-care and health-research systems.

Perspectives of NHS and academic staff across six CLAHRCs

The findings of the CLARHC-wide survey (Figure 13) show that both academic and NHS respondents believed that they were working towards the same long-term goal: to improve health services and patient outcomes. Both groups also regarded capacity building and developing new skills as important aims of their CLAHRC. More NHS respondents than academics thought that the creation of a sustainable research infrastructure focused on the needs of the service and patients was important, but both groups supported the aim of increasing NHS responsiveness to individual patients’ needs.

FIGURE 13.

Perceived aims in relation to longer-term outcomes and impacts.

One important concern among respondents was how effective the CLAHRCs were in taking the views of all their stakeholders into account in the day-to-day delivery of their activities (Figure 14). We found a high level of agreement among NHS and academic respondents that the views and concerns of clinicians, commissioners and patients involved in CLAHRC activities were taken into account. However, the findings also suggest that there was scope for improvement in responding to the wider public and patients.

FIGURE 14.

Perceived effectiveness of the CLAHRC taking into account the views and concerns of its stakeholders in the day-to-day delivery of its activities.

When asked about the level of participation of different groups in the CLAHRC, there was consensus among respondents that senior and junior academic staff and senior NHS clinicians had had high levels of involvement (Figure 15). There appeared to be less agreement among academic and NHS respondents about the involvement of junior clinicians and NHS middle management, with academics tending to ascribe these groups a higher level of involvement. Although respondents thought that NHS senior management and public and patient representatives had had some level of engagement, there appeared to be scope for closer involvement.

FIGURE 15.

Perceived extent to which relevant people within CLAHRC’s local NHS/university actively involved in CLAHRC.

Respondents reported that people from the local NHS were actively involved in their CLAHRC primarily through the following three activities: working with academics on project teams; attending CLAHRC meetings and seminars; and having a place on the CLAHRC board (Figure 16). The availability of formal training courses and opportunities to solicit research projects based on NHS needs and consult academics also played a role in encouraging involvement.

FIGURE 16.

Reported reasons why relevant people within CLAHRC’s local NHS are actively involved in CLAHRC. MSc, Master of Science; PhD, doctor of philosophy.

We also sought to understand why people in the local NHS had not become involved in the CLAHRC, with a number of respondents citing an enduring focus on traditional research, at the expense of applied research (data not shown). This sentiment was particularly pronounced among academic respondents, and complements the finding that one of the ways that CLAHRCs were able to influence behaviour was by undertaking research that is easily applied [see Chapter 4, How does the NHS influence CLAHRCs’ evolution, outcomes and impact (and indeed how does having a CLAHRC influence NHS behaviour)?, Perspectives of NHS and academic staff across six CLAHRCs]. In combination, these findings imply that when CLAHRCs focused on research that can be applied (as was consistent with their aims) they were perceived to have facilitated engagement, and that the reverse is also true.

When asked what had enabled the CLAHRCs to meet their objectives, respondents emphasised the skills, expertise, motivation and commitment of people involved with the CLAHRC (see Appendix 5, Figure 54). Funding availability, good buy-in from key individuals and good pre-existing networks were commonly cited, in keeping with the nature of CLAHRCs as collaborations rooted in local relationships.

In this context we also sought to understand the perceived barriers to meeting the CLAHRCs’ objectives. The most commonly cited by both NHS and academic respondents were existing incentive structures, such as the focus on the Research Excellence Framework (REF) criteria for university researchers and the lack of recognition of research involvement in career progression for NHS staff (Figure 17). There was also a perception that insufficient NHS involvement in identifying research topics was a barrier. There was a difference of opinion regarding the extent to which the lack of commitment of key individuals was a problem, with over 30% of NHS respondents regarding poor buy-in as a barrier compared with 15% of academics.

FIGURE 17.

Perceived elements of CLAHRC and wider landscape that provide a barrier to meeting its objectives. IT, information technology.

Experiences in CLAHRC-CP and PenCLAHRC

We explored the development of effective multistakeholder and multidisciplinary teams further through our case studies and identified three overarching themes: getting people involved and changing attitudes; the CLAHRC ethos of experimentation and learning; and the time required for change.

Conclusions

In this section we investigated how multistakeholder and multidisciplinary teams for service improvement have been built by the CLAHRCs. We showed how, despite initial challenges, CLAHRCs succeeded in engaging different stakeholder groups including clinicians, managers, commissioners, academics and others, such as people from social services and the public, although the pattern of that engagement varied across the CLAHRCs. There was recognition that getting the different stakeholders on board was an incremental process, with partnership working and the coproduction of research at the core of promoting and sustaining engagement. We noted how responsiveness was an essential component of effective multistakeholder and multidisciplinary working, in particular against a background of a changing health and social care system, and that the need (and ability) to experiment was a crucial pre-condition for the CLAHRCs. We also saw that responsive partnership working needs to be based on trusting relationships, and that these take time to build and foster.

Perspectives of NHS and academic staff across six CLAHRCs

A key aspect of influencing practice is to make evidence available in a format that potential users find helpful. 35 The stakeholder survey therefore assessed how well information about CLAHRC activities and projects was communicated, the impact of what was communicated and the intended target audience. Views on whether or not information on CLAHRC activities was communicated well outside the CLAHRCs varied among respondents, with about a third of respondents from the NHS and academia not able to say (Figure 18). While it was not possible to explore the underlying reasons from the survey data, this finding suggests that a considerable proportion of NHS and academic staff were not effectively reached by the communication strategies of the CLAHRCs at the time of the survey.

FIGURE 18.

Information related to CLAHRC activities and projects is well communicated outside CLAHRC.

However, although respondents had different views about whether or not their CLAHRC communicated well with external audiences, there was consensus about the purpose of this communication. The primary aim of communicating information externally was identified as raising awareness of CLAHRC activities. Such communication was also thought to have helped to support the development of the collaboration and enhanced implementation of CLAHRC findings (Figure 19). Primary means of communicating this information were identified as the CLAHRC website and presentations from CLAHRC representatives (see Appendix 5, Figure 45).

FIGURE 19.

Perceived impact of disseminating the information outside CLAHRC.

Both NHS staff and academics saw clinicians and commissioners as the key target audiences for information communicated outside the CLAHRC (Figure 20).

FIGURE 20.

Reported target audiences for information related to CLAHRC activities and projects outside CLAHRC.

Experiences in CLAHRC-CP and PenCLAHRC

Building on the findings from the stakeholder survey, we explored how the CLAHRCs sought to encourage the use of research knowledge to change behaviour and influence practice, describing the approaches taken and some of mechanisms used in the two case studies. We identified three overarching themes: shifting academic paradigms; communicating with commissioning; and informing clinical practice. In the following section we analyse these further. We also consider how the findings from the case studies were supported by the wider CLAHRC experience.

Conclusions

In this section we explored the extent to which research knowledge and evidence is being used to change behaviour and influence practice. The survey findings focused primarily on communication and dissemination of CLAHRC activities, including the evidence generated through CLAHRC projects. However, in our case studies and validation interviews, we investigated other ways in which research knowledge and evidence were shared to support changes in practice. Three processes were observed: shifting academic paradigms, communicating with commissioners and influencing clinical practice. Academics within the CLAHRCs were exposed to people from other disciplines and other backgrounds, and this helped to broaden their understanding of ‘implementation’ and of other research fields and methodologies. Communication with commissioners was supported by the development of a CLAHRC ‘brand’, which helped to identify CLAHRC products and give them credence. The projects described in this section illustrate how the CLAHRC way of working was helping to improve clinical practice, and how these improvements were being spread across the service.

NHS influence on the CLAHRCs

The CLAHRCs were encouraged to develop innovative models for the conduct and application of applied health research, building on existing local research strengths. 3 Our analysis of the CLAHRCs’ early plans (see Chapter 3 and Appendix 10) demonstrated that the research strengths that the CLAHRCs identified when they made their original applications were largely strengths in clinical research, and that they intended to build on existing programmes of work on long-term conditions such as diabetes or chronic kidney disease. They also drew on their understanding of, and expertise in, fields such as implementation, quality improvement and innovation.

However, the CLAHRCs were intended to be more than just clinical/academic partnerships; they were also required to meet local research needs and involve a wide range of stakeholders, including NHS managers, commissioners, GPs and patients, and to seek matched funding from local NHS organisations. These arrangements potentially gave NHS organisations and their staff significant influence over the CLAHRCs’ emerging programmes. To identify and meet the research needs of all these groups, the CLAHRCs needed to address organisational and managerial concerns as well as clinical concerns, and, therefore, to draw on research approaches from a wide range of academic disciplines. In response, the CLAHRCs established links with business schools and with other groups with expertise in implementation and service design, and in operational research. Some CLAHRCs, such as CLAHRC-CP, did this at the outset in order to challenge their own thinking. Others did so over time as NHS staff (including managers) began to realise what the CLAHRCs had to offer and started to exercise more influence over the research topics that were selected and the way in which that research was undertaken and disseminated. Their involvement revealed gaps, such as the lack of sufficient research expertise to address the problems facing NHS managers, a challenge to which the CLAHRCs needed to respond: PenCLAHRC, for example, established a modelling and operational research facility (PenCHORD) in 2010. 85

It also became clear that something other than peer-reviewed publications was needed to bring the findings from CLAHRC projects to the attention of NHS decision-makers, and the CLAHRCs developed short evidence briefings and two-page summaries of successful projects (the CLAHRC BITEs). 89

In summary: the CLAHRCs were established to respond to NHS needs. They could do this effectively only if they were open to the influence of the service and tailored their research agendas and their research and implementation practices accordingly. They needed to be responsive and flexible.

CLAHRC influence on the NHS: capacity building and culture change

We saw in Chapter 3 how CLAHRC-CP and PenCLAHRC had changed the attitudes, and sometimes the behaviour, of those who had been directly involved in CLAHRC activities and projects. However, while this showed that the CLAHRCs could achieve positive change among those most directly involved, the broader question was if the CLAHRCs could influence others in and across the NHS. On this question, and after only 5 years of CLAHRC activity, we can provide no definite answer. The CLAHRCs themselves felt that 5 years was too short a time in which to embed their approach and change the norms of the service, and NIHR has provided further funding for a second round of CLAHRCs (see also Future developments). 93

The time it takes to achieve this sort of change is a common theme in the literature. 94,95 As we note earlier in this report, a recent study of change in management culture and organisational performance by Mannion et al. identified four distinct cultures within NHS organisations. 33 One of these, the development culture, is characterised by innovation, dynamism, growth and entrepreneurship with an external, relational focus in which ‘change was viewed as a positive organisational attribute . . . [and a] willingness of senior management to embrace innovative approaches to delivering services’. 33 The development culture has, in other words, all the hallmarks of the culture the CLAHRCs were seeking to instil across the NHS. However, the difficulties of doing so can be judged from other findings reported by Mannion et al. 33 During the time covered by their study (2001–8), the development culture was dominant in approximately 20% of NHS trusts, and, tellingly, this proportion remained largely unchanged during that period. If there was no movement towards a development culture in the NHS between 2001 and 2008, how could the CLAHRCs hope to make that change happen?

Mannion et al. suggest that culture change is triggered by a perception of crisis, initiated and shaped by strong leaders, consolidated by perceived success, and mediated by relearning or re-education. 33 As we saw from our case studies, and also from the wider CLAHRC experience, the CLAHRCs had strong, focused leadership, they relatively rapidly produced a portfolio of ‘quick wins’ that helped to convince sceptical NHS managers and commissioners, and they used their internal reviews and evaluations as a basis for learning and adaptation. Moreover, the NHS at this time faced a large-scale reorganisation and accompanying budget constraints which created significant uncertainty across the service. To this extent Mannion et al. ’s33 conditions for triggers of change were fulfilled. However, the time it takes to achieve change is not the only or even the main issue. The question of CLAHRC influence over the NHS is part of a wider debate about the role of CLAHRCs within the health research system generally, and the role of that system within the NHS.

Overall, this discussion suggests that the CLAHRCs’ goal of culture change is achievable (as the early evidence from our evaluation also confirmed), but after only 5 years the long-term aim of a NHS-wide change in attitudes towards research and its use in decision-making has not yet been achieved. The CLAHRCs’ experience therefore reinforces previous messages about the need to allow sufficient time for system change.

The relevance and importance of the local remit

The CLAHRCs were partnerships between local universities and local NHS organisations across a clearly defined geographic area. This local remit enabled the CLAHRCs to build on existing local relationships to get people in the NHS interested in how they could work with researchers to address knowledge gaps, since the CLAHRCs could become known across their local ‘patch’ in a way that would not have been possible if they had been more centralised and more distant. It was local clinicians, patients and managers who were spreading the word about the CLAHRC and its potential (see next section). It was local needs that were being identified and addressed, and matched funding from the local NHS that supported those activities; and even those who were not involved in specific CLAHRC projects had access to local evidence-based courses and to local learning events. All these were powerful influences.

Overall, the local remit was a defining characteristic of the CLAHRC initiative. It supported the development of collaboration, encouraged responsiveness to local research needs and shaped the separate character of each individual CLAHRC. However, what was equally important was that all this took place within the wider framework of the CLAHRC initiative as a whole, with the opportunities this provided for dialogue with other CLAHRCs, and the requirements this imposed to produce generalisable research and scale up successful projects. The CLAHRCs also needed to work beyond their own boundaries.

The practical implications of these findings are complex. The local remit was an important factor in the initial success of the CLAHRCs in meeting their goals and was, therefore, a helpful approach. However, and as we discuss further below, there can be tensions between addressing local research needs and producing generalisable findings that are useful to others. Attention also needs to be paid to the requirements of the research and health systems within which the CLAHRCs operate.

The complex challenges of knowledge mobilisation

[T]he inner workings, implicit rules, cultures, and realities that dominate the day to day lives of people working in the health system and those doing research on that system remain, for the most part, mysteries to people on the other side. 80

Complex health-care challenges require complex, multilevel solutions that are tailored to specific settings. 83 A key message that emerged from both phases of our evaluation was that a linear, basic-to-applied model which assumes that ‘gaps’ can somehow be ‘bridged’ does not fully capture the complexities of moving knowledge into action. The idea of building a single fixed bridge between two otherwise unchanging sides had little resonance with the CLAHRCs from the outset, and as they developed and the challenges they faced became clearer, there was an increased understanding of the complexities involved. All the CLAHRCs adopted relationship models that focused on interactions between people through which knowledge from multiple sources could be exchanged and adapted to local circumstances through a collaborative production–synthesis–integration cycle,43 and recruited people who could bring understanding of research to the service and vice versa. In one sense all CLAHRC staff acted as research champions, but many CLAHRCs also specifically recruited knowledge brokers (locality leads, diffusion fellows, CLAHRC associates and so on) to fulfil this function.

However, while a focus on multidisciplinary relationships was necessary, it was not, on its own, sufficient (see Chapter 4, How are effective multistakeholder and multidisciplinary research and implementation teams for service improvement built: what can we learn from the CLAHRC mode and what mechanisms are being used to enable it?). As the CLAHRCs were aware from the start, attention also needed to be paid to the systems within and through which these relationships operated, and to how system shift could be achieved.

This insight is reflected in recent literature. Using similar language to that used by the CLAHRCs, Best and Holmes describe a systems approach to getting evidence into policy in which knowledge is generated, assessed and used within specific contexts and cultures dominated by different priorities. 96 This knowledge cycle is mediated throughout by relationships and must be understood from a perspective that takes account of the organisation and its strategic purposes. Glasgow and Chambers38 also argue that if health-research results are to become more usable and timely, what is needed is a systems perspective that recognises that context is critical, that most problems and interventions are multilevel and complex, and that more emphasis needs to be placed on inter-relationships among system elements and system rules. They spell out what, in their view, needs to be done to make implementation science more rapid, rigorous and relevant. Their list could read as a list of CLAHRC objectives: more research needs to be undertaken that is pragmatic or practical, that evaluates participation and representativeness, that makes comparisons between real alternatives, and that collects cost and economic data; it needs to assess multiple outcomes, often using mixed methods; the research design should fit the question; and reporting should be transparent.

In summary, we note that when the CLAHRCs were established in 2008 there was no single roadmap to guide them. This is still the case, and what the experience of the CLAHRCs, taken as a whole, suggests is that the search for a single approach is probably a chimera. However, since 2008 thinking has moved on. As the two papers cited above indicate, there is now more understanding of the complexities of knowledge mobilisation and what these entail for practical programmes. In practical terms, the CLAHRCs have begun to make a contribution to these debates. They have demonstrated what it takes to identify, produce and implement research that is pragmatic and practical and which fits the question; they have assessed multiple outcomes and used mixed methods, and they have sought to produce clear, accessible reports; and they have shown how all this can be done in different ways in different contexts. Above all, they have brought the concept of linkage and exchange to life,43 and shown how individuals and organisations can build effective collaborations to address health-care research needs.

‘What constitutes evidence and when do we have enough evidence to translate?’97

As we saw above, the CLAHRCs were rooted in local relationships and had a focus on what is relevant and what works locally. But it was also a requirement of NIHR funding that the research they supported be generalisable. There has been much discussion in the literature and among the CLAHRCs about the tension between producing ‘quick wins’, research that is in some sense ‘good enough’ to support health service decision-making (relevance), and the longer time scales of generalisable, peer-reviewed research (rigour). Rigour is typically thought of as a focus on experimental control and internal validity. Relevance is commonly associated with studies that have external validity; that is, they identify causal relationships that can be generalised to different measures, persons, settings and times. 98 These two qualities are often seen to conflict.

However, there is some evidence that improving attention to external validity need not be at the expense of internal validity. The Veterans Administration in the USA, for example, faced the problem of the balance between rigour and relevance in its QUERI programme, and found that ‘both are possible and that benefits can be translated in a timely manner when there is active dialogue among clinicians, researchers and policy-makers’ (p. 69). 99 Other commentators go further and reject the dichotomy between rigour and relevance altogether. Glasgow and Emmons97 suggest that one of the reasons that research fails to get translated into practice is that the programmes and methods used fail to address contextual factors. They argue that there is a need ‘to address context and to utilize research, review, and reporting practices that address external validity issues – such as designs that focus on replication, and practical clinical and behavioural trials’ (p. 413). 97 In other words, what is needed is more consideration of external validity in the funding, reporting, synthesis and application of research to create a better balance of research that is both credible and relevant to decision-makers in the health service. In the USA some journal editors have already responded and made recommendations about how to improve attention to external validity (or applicability) in the research reports that they publish. 98,100

Some of the CLAHRCs changed their views about the relations between applied research and implementation as their understanding of their remit developed. These CLAHRCs had initially seen these two activities as separate phases in which research first produces findings and these are then implemented, but they came to understand (as some of their colleagues had understood from the start) that these two activities need to be closely integrated within one overall iterative process if research findings are to be used effectively in a timely fashion. Where necessary, the CLAHRCs adjusted their programmes accordingly. Moreover, as NHS staff from clinical, managerial and commissioning backgrounds became more involved in the CLAHRCs, the diversity of the concerns they raised required a rethink about the types of research and research methodologies that were needed to produce the evidence required.

Overall, we find that the debate about the nature of evidence continues. The challenges identified above, and the richness of the various responses across the CLAHRCs, warrant more detailed investigation.

Communicating with commissioners

In 2010, a large-scale reorganisation of the NHS that would include a complete overhaul of the commissioning function from 2013 was announced. 101 At the same time, the health service was required to make substantial efficiency savings. This created a difficult environment in which to get people’s attention and explain ideas that would not obviously help them to handle immediate pressures. The fact that the CLAHRCs did manage to communicate with, and involve, commissioners (albeit with difficulty and as the result of much perseverance) is an important justification of their local remit and their local role. In Chapter 3 we described how in the two case studies the CLAHRCs built on existing local collaborations with commissioners, and across the CLAHRCs we heard how they were able to maintain relations with local commissioning staff even as the organisations for which those people worked were reshaped.

We also found that the scale of the changes created opportunities as entrenched practices were disrupted and people looked for new ideas. Here the flexibility of the CLAHRCs, their commitment to learning and adaptation, the matched funding model and the CLAHRCs’ understanding of the need for short-term as well as long-term research and implementation projects were all crucial. The CLAHRCs were able to be opportunistic and provide support when it was needed, not 6 months down the line. The CLAHRCs exploited early ‘quick wins’ and developed simple user-friendly research briefs to spread the word about their activities and their potential. Over time they developed a strong local brand that enabled local NHS staff to recognise CLAHRC products even if they had not been involved in generating them. At the same time, the matched funding model of co-investment began to force NHS organisations to think prospectively about the business case for investing in research and knowledge mobilisation and become more active and discerning partners in the CLAHRCs. 102 Overall, what the CLAHRCs were seeking to achieve here was a shift not only in individual attitudes and behaviour but also in the workings of the commissioning function within the NHS, a system shift. The local and national contexts in which they operated played an important role, as did the CLAHRCs’ commitment to responsiveness and flexibility, their understanding of the complexities of their role, and all their various activities, taken as a whole.

Informing clinical practice

It was beyond the scope of our evaluation (even in the two case studies) to systematically assess the actual impacts of research undertaken within the CLAHRCs on clinical practice and population outcomes, largely because this was something the CLAHRCs were doing themselves through their own internal evaluations. However, we were able to explore how some of the successful projects achieved their results, and we described three of these in Chapter 4 (What can we learn from the CLAHRCs that can provide new understanding of how to use research knowledge and evidence to change commissioning and clinical behaviour for patient benefit?).

In each case the people involved in the projects stated what they thought had contributed to success. The CLAHRC-CP IAPT project showed how the CLAHRC-CP coproduction approach worked in practice: there was considerable interaction between those conducting the study and the CLAHRC team overseeing it with ongoing (and useful) discussions about what the study was finding and whether or not that was what the service wanted. Moreover, and reflecting the thoughts above about external validity, the large and diverse sample meant that the results were widely applicable, and therefore contributed to scale-up across the CLAHRC and nationally. 91 The PenCLAHRC stroke pathways project illustrated how modelling approaches using locally available data could assist service redesign and capture the interest of the trust involved. And the success of the PenCLAHRC project on the use of tranexamic acid [described in Chapter 4, How does the NHS influence CLAHRCs evolution, outcomes and impact (and indeed how does having a CLAHRC influence NHS behaviour)?, Experiences in CLAHRC-CP and PenCLAHRC] was attributed to, among other things, the fact that the staff involved already knew about PenCLAHRC and trusted its approach. Another important facilitator was an existing operational mandate: patient group directions were in place in the ambulance service that allowed ambulance personnel to use generic prescriptions.

The way in which the tranexamic acid project was facilitated by an existing operational mandate shows how improvement interventions can successfully exploit opportunities within the system. Equally, barriers within the system can impede change. One CLAHRC project on falls prevention among older people involved changes in the treatments delivered by numerous health-care professions in multiple settings, and it proved impossible to align the competing requirements of different service providers and different patient groups.

There is a growing literature on these issues. One study identified health-care organisations that found and used evidence at multiple levels and in an ongoing, integrated fashion, and compared them with those that did not. 103 Echoing the experience of the Veterans Administration we briefly reflected on in Chapter 1 (see The conceptual background, Organisational change and system shift; also Appendix 12), this study found that one determinant of success was the ‘integration of evidence-based practice into the routine fabric of the organization; also known as normalization’ (p. 3). 103 But exactly what this means in terms of tailoring interventions to fit into the existing fabric, the various NHS professional and organisational systems, is still something of a mystery. A review of studies of interventions tailored to overcome identified barriers to change found evidence that tailored interventions can change professional practice, but insufficient evidence about effective approaches to tailoring. 104

In summary, what the CLAHRCs were seeking to achieve here was a shift in the individual attitudes and behaviour of NHS clinicians and managers and, ultimately, their patients. As with the commissioners, what that also involved was an appreciation of the challenges and opportunities posed by the various systems (organisational, professional, economic and so on) within which people work and are treated. In the three CLAHRC projects described above, things aligned well and change followed. In other circumstances unforeseen barriers emerged and more complex changes in, for example, organisational or professional responsibilities and patterns of working (system shifts) were needed before improvements could be made.

An experimental approach: varieties of CLAHRC but a common ethos

The NIHR call for applications for the CLAHRCs was clear about what they were expected to do: the aims of the CLAHRCs were to increase the capacity to undertake and use applied health research in the NHS and to foster a culture of collaboration between the academic and service delivery sectors. 3 These aims were well understood by the CLAHRCs. However, although this vision was clear, there was considerable uncertainty about how to achieve it in practice. Programmes in other countries have attempted to do something similar (see Appendix 12). But the contexts in which these programmes operated and the remits to which they worked were very different. So, while lessons could be learned, these programmes could not provide definitive guidance. Moreover, and as we mentioned above (see Chapter 4, What can we learn from the CLAHRCs that can cast new understanding on how to use research knowledge and evidence to change commissioning and clinical behaviour for patient benefit?, Experiences in CLAHRC-CP and PenCLAHRC), the experience of the CLAHRCs support the view that there is no single ‘right’ model: ‘It is likely that there is no single or simple answer to the question, “how best to organise the implementation of large scale improvement programmes for health and social care”’ (p. 184). 105

This (inevitable) uncertainty was the rationale for the experimental approach that was adopted across the programme and by the CLAHRCs. NIHR did not prescribe how the individual CLAHRCs should achieve the goals they had been set. Instead, the CLAHRCs were encouraged to develop (and evaluate) innovative models for the conduct and application of applied health research. 3

The approaches adopted by individual CLAHRCs varied. The different principles that underpinned CLAHRC-CP and PenCLAHRC were described in Chapter 3: CLAHRC-CP was committed to the coproduction of research, and PenCLAHRC worked through the processes of ‘Engagement by Design’ to promote and support the explicit use of evidence as a norm among practitioners and organisations. The published protocols of other CLAHRCs describe their approaches (and where these were made explicit in their proposals as described in Appendix 10). Leicestershire, Northamptonshire and Rutland CLAHRC adopted an approach that was influenced by an organisational excellence model described by Nutley et al. 106 and by the experiences of the aforementioned US Veterans Health Administration’s QUERI. 107 The CLAHRC for Nottinghamshire, Derbyshire and Lincolnshire developed an approach that was based on organisational learning theory and used diffusion fellows and communities of practice as mechanisms to encourage change. 108 The CLAHRC for South Yorkshire incorporated implementation themes that built on the knowledge to action approach developed in Canada and on local work to develop evidence-based clinical effectiveness. 109 This diversity within the common CLAHRC programme should, over time, provide rich data about the advantages and disadvantages of different approaches.

In summary, notwithstanding their differences in approach, the CLAHRCs faced common challenges and shared a common ethos that included a willingness to negotiate and maintain a genuine dialogue between different partners, to listen and be responsive, and to adapt on the basis of ongoing evaluation and learning in the face of a constantly changing environment. The CLAHRC interviewees recognised these characteristics and valued them highly; they talked about the need to be flexible and nimble, and to respond serendipitously to unexpected opportunities and challenges. If the CLAHRCs’ achievements are to continue in the second round, an ongoing flexibility and a continuing openness to experimentation and learning are not only desirable but essential.

Flexible comprehensiveness

In Chapter 4, How are effective multi-stakeholder and multi-disciplinary research and implementation teams for service improvement built: what can we learn from the CLAHRC mode and what mechanisms are being used to enable it?, Experiences in CLAHRC-CP and PenCLAHRC, we suggested that the question of CLAHRC influence over the NHS was part of a wider debate about the role of CLAHRCs within the health research system generally, and the role of that system within the NHS. The experience of the QUERI, which was established by the US Veterans Administration to accelerate the implementation of new research findings into clinical care,6 suggests that, when the research function is fully integrated into the organisational structure of a health system, performance is improved. 62 The CLAHRC initiative was premised on the use of health-system resources (NHS matched funding) alongside research and development resources (NIHR funding), and in one sense this can be seen as a small move in that same direction. Throughout the CLAHRCs we saw this innovative funding arrangement beginning to work well. 102 Patients and NHS clinical and managerial staff were encouraged to become involved in research, their research needs were recognised and there was a move towards research-informed decision-making. However, as the Veterans Administration experience also demonstrates, many factors shape health-care performance, often in unknown and unintended ways. Like QUERI, the CLAHRCs were complex interventions that operated within complex systems. 38 In doing so, they pursued a strategy that can be categorised as one of flexible comprehensiveness; that is, their programmes were flexible and responsive and they used a range of approaches that sought to match the diverse aspects of the complex issues they faced. 110 Moreover, in future they will be expected to work with, and within, the AHSNs to produce a step change in the scale and pace of innovation in the NHS, adding opportunities for success but also further complexity.

Based on the discussion presented here, we conclude that what the CLAHRCs’ efforts to influence the NHS have achieved is ground-breaking. They have shown that it is possible to align research spending more closely with health-care spending and provide better support for health-care decision-making. 102 To date, the CLAHRCs have done this on a project-by-project basis. The challenge the second-round CLAHRCs, and the new AHSNs, now face is to convert that success into system-wide change.

Sustainability and scaling up

It was an NIHR requirement that effective improvement interventions that had been successfully implemented and evaluated locally should be sustainable, and should be spread, or ‘scaled up’, across the CLAHRC and the health service. 2 There is evidence from the CLAHRCs that they had some success in scaling up some projects, though it was generally too early to assess sustainability.

The CLAHRCs were new entities and initially their role in implementation was not necessarily well understood by their NHS colleagues, leading to some confusion and some disappointed expectations, although NIHR and the CLAHRC directors were clear from the start that making service improvements was a NHS responsibility and that the CLAHRCs were not funded to do this. The role of the CLAHRCs was to support implementation. This involved helping the service to identify, produce and disseminate the user-friendly evidence needed to support the development of effective improvement interventions. It also meant working with the service to evaluate new ways of implementing those interventions, and disseminating the findings from those studies. The CLAHRCs developed a substantial body of published projects in the peer-reviewed literature. They also developed evidence briefs and two-page publications aimed at decision makers (the CLAHRC BITEs, see Chapter 4, What can we learn from the CLAHRCs that can cast new understanding on how to use research knowledge and evidence to change commissioning and clinical behaviour for patient benefit?), which were made widely available through the CLAHRC websites. 89 They held large-scale CLAHRC-wide learning events. Through these efforts to communicate and disseminate information about their programmes and projects, the CLAHRCs sought to encourage NHS organisations and staff across their own locality (and sometimes beyond) to get engaged and to use interventions that had been successfully implemented elsewhere. 73,93

However, defining exactly what role the second-round CLAHRCs should play in sustainability and scale-up is still new territory. Glasgow et al. 111 describe sustainability and scaling up as areas where there are key opportunities to advance dissemination and implementation research, and suggest (in terms that would be familiar to any CLAHRC) that ‘further advances in the field will be achieved by focusing dissemination and implementation research on five core values: rigor and relevance, efficiency, collaboration, improved capacity, and cumulative knowledge’ (p. 1274). 111 More radically, Scheirer and Dearing suggest we should view ‘sustainability research as a further stage in the translation or dissemination of research-based interventions into practice’ (p. 2059). 112 A further issue is the sustainability and scale-up of the CLAHRC approach itself across the NHS. What the CLAHRCs were trying to promote was the explicit use of research evidence as a norm among NHS decision-makers, so that it is habitual for NHS staff to turn to research when they are seeking to improve services, and for academics to respond. The CLAHRCs have shown that it is possible to bring these two communities closer together. Through matched funding, the CLAHRCs have also demonstrated that it is possible to align research spending more closely with health-care spending and provide better support for health-care decision-making.

To summarise, the first-round CLAHRCs prepared the ground for closer integration of the research system and the health-care system. The challenge for the second-round CLAHRCs is to add scale and pace to CLAHRC activities within the context of the ASHNs. It is to these developments that we turn in the next section.

Implications for practice

In summary, the following factors, working together, are thought to have contributed to the CLAHRCs’ achievements:

• A focus on research relevant to the NHS and its patients.

• Strong leadership allied with a significant degree of devolved responsibility to people such as research theme leaders and knowledge brokers.

• A collaborative approach characterised by flexibility, responsiveness to the needs of partners and an ongoing ability to exploit foreseen and unforeseen opportunities. In practice this meant:

  • developing relationship models that focused on interactions between people through which knowledge from multiple sources could be exchanged and adapted to local circumstances through a collaborative production–synthesis–integration cycle43

  • recruiting people who could bring understanding of research to the service and vice versa: all CLAHRC staff acted as research champions; many CLAHRCs also recruited knowledge brokers to fulfil this function

  • developing research awareness and capacity through the coproduction of research and implementation projects, training and exchange programmes, regular cross-CLAHRC knowledge exchange meetings and user-friendly publications.

• Matched funding from the service, which helped to promote initial NHS buy-in, allowed scope for adaptability and responsiveness to the needs of the service, and encouraged NHS organisations to think prospectively about the business case for investing in research and knowledge mobilisation and become more active and discerning partners in the CLAHRCs. 102 However, the disadvantage of this funding model, that is the risks associated with involving NHS organisations of only one type in a NHS environment subject to ongoing change, needs to be considered from the outset.

• A continuing openness to experimentation and learning. The CLAHRCs had feedback from their own internal evaluations (including the evaluations of CLAHRC-funded projects), from the formative elements of the NIHR-funded external evaluations and, in some cases, from external interim reviews of progress.

Overall, the CLAHRCs’ experience suggests that programmes with similar goals need to adopt a systems perspective that recognises that context is critical, that most problems and interventions are multilevel and complex, and that more emphasis needs to be placed on inter-relationships among system elements and system rules and how system shift can be achieved. In practice this means developing programmes that can:

• produce and exploit research that is pragmatic and practical, encourages participation and representativeness, makes comparisons between real alternatives, collects cost data and assesses multiple outcomes, often using mixed methods

• identify and respond to the challenges and opportunities posed by the various systems (organisational, professional, economic and so on) within which NHS clinicians, managers and commissioners work

• include short-term as well as long-term research and implementation projects and adopt an early focus on ‘quick wins’

• consider external validity in the funding, reporting, synthesis and application of research as well as internal validity

• commit to the full and transparent reporting of research findings through effective communications, including user-friendly publications

• clarify, and strengthen, the roles of different players in research, implementation and service improvement.

Research recommendations

We have identified five overarching research areas and, within these, seven research questions from the evidence presented in this report that a future research programme could appropriately explore to further inform ongoing efforts within the health-research and health-service systems in England to promote the effective translation of evidence into practice.

1. Understanding the counterfactual. The second round of funding for the CLAHRCs provides an endorsement of their activities in the first round, and the development of the AHSNs helps to alleviate some of the concerns about the partial geographical coverage of the CLAHRCs. At the same time, the parallel development of the AHSNs and the second round of the CLAHRCs provides an important research opportunity to compare areas with both an AHSN and a CLAHRC, and areas with just an AHSN. Such a research programme would present an opportunity to explore the counterfactual, that is to understand the extent to which the CLAHRCs are making a contribution to furthering applied health research and its translation into patient benefit. Q: To what extent are the CLAHRCs furthering applied health research and its translation into patient benefit?

2. Understanding implementation. The role of the CLAHRCs was to support implementation and they were successful in helping the service to identify, produce and disseminate the user-friendly evidence needed to support the development of effective service improvement interventions, as well as evaluating new ways of implementing those interventions and subsequent dissemination of these evaluation findings.

   1. However, the requirement that evidence be generated that is relevant to local service needs while at the same time generalisable beyond the locality means that there is a need to consider internal and external validity when designing research projects. There is, therefore, a need to explore and evaluate different implementation theories to advance understanding of how to achieve a balance between rigour and relevance in order to improve the applicability of research findings.

      Q: What lessons can be learned from the CLAHRCs about how to balance rigour and relevance in research projects and improve the applicability of the findings?

   2. There is also a need to identify the systemic barriers to, and facilitators of, implementation.

      Q: What lessons can be learned from the CLAHRCS about how to tailor the implementation of research findings to different settings while retaining fidelity?

3. Achieving sustainability and scale-up.

   1. We have shown how the CLAHRCs successfully influenced the culture in the NHS and in academia, and sought to ensure the explicit use of research evidence as a norm in the NHS. There is a need to understand the factors that support this normalisation better, and, in particular, the roles of communication and dissemination and of knowledge brokers.

      Q: What lessons can be learned from the CLAHRCs about the mechanisms through which the use of research evidence is promoted in the NHS?

   2. We have seen how the CLAHRCs were able to scale up some of their successful implementation projects across their own localities and across the NHS more generally. It has also been suggested that ‘sustainability research’ should be considered as a further stage in the translation or dissemination of research-based interventions into practice. 112 However, further work is required to advance our understanding of the processes and mechanisms that are needed to support the system-wide sustainability and scale-up of implementation projects.

      Q: What factors support, and what factors hinder, the sustainability and scale-up of successful implementation projects?

4. The role of patient and public involvement. In this report we present some, albeit limited, evidence that the involvement of patients and the public as partners in the CLAHRCs was uneven. We have not been able, in the context of this evaluation, to study approaches to and processes of engaging patients and the wider public in the CLAHRCs, as partners, users and/or coproducers of research and its implementation. There is a need to understand more about the key enablers and barriers of successful patient and public engagement in the processes of research production and implementation in collaborative partnerships such as the CLAHRCs. Such an understanding will require a more systematic assessment of the (expected) outcomes of involving patients and the wider public in the collaboration; the level of involvement (e.g. to inform priority setting, resource allocation, service delivery, etc.); their role (e.g. advisory, participatory, coproduction, etc.) and representation; and the extent to which involvement promotes equity. 119

   Q: What are the key enablers of, and barriers to, successful patient and public engagement in research production and implementation in collaborative partnerships such as the CLAHRCs?

5. The relation between CLAHRCs and NHS commissioners. We have seen that the CLAHRCs did not always find it easy to involve commissioners but that when they did so they found it, to use their own term, ‘exciting’. Given the recent changes in commissioning within the NHS and the opportunities these provide, it would be useful to explore how the developing relation between the CLAHRCs and local commissioners can be supported, how it operates and what it achieves.

   Q: Have NHS commissioners used CLAHRCs? If so, how and with what results? If not, why not?

Narrowing the second translation gap: evaluating CLAHRCs’ potential, strategies and contributions

Details of each phase

Each phase of the study is detailed below.

PHASE I

During the first phase, we will work collaboratively with all CLAHRCs to build a taxonomy of their approaches to the second translation gap (i.e. the gap in health research translation that refers to implementing research-informed product and service innovations into clinical practice). Each CLAHRC is likely to have more than one approach to the second translation gap, and each approach may be present in more than one CLAHRC. We will look at the approaches being adopted by CLAHRCs, identifying and exploring: (a) the types of interventions being used by CLAHRCs to promote practice change and the mechanisms through which they operate (e.g. interactions, social influence, facilitation, etc.) and (b) the various levels at which these interventions will be used to promote change in practice (e.g. individual, organisational, and system-wide), and c) the logic behind the intervention (i.e. why the CLAHRC believes that implementing certain interventions, in certain contexts and with specific inputs, should result in specific outcomes).

Our concern will be to capture initiatives to support improvements in clinical practice at:

• a micro-level, i.e. interventions that promote translation among individual practitioners within a single organisation (e.g. targeting research findings on doctors and nurses in a primary care practice setting, coupled with feedback opportunities),

• a meso-level, i.e. interventions that promote translation among researchers, managers and practitioners working in different organisations. Among these we include interventions that aim to enhance the roles service managers can play in supporting improvements in clinical care; and

• a macro-level, i.e. interventions that promote translation designed to facilitate organisation to organisation partnership, e.g. across research and health care sectors (such as the CLAHRCs themselves).

At the end of Phase I we will draft a First Interim Report, and feedback our early findings to all CLAHRCs, to the SDO, and the wider community of policy-makers and practitioners in and around the SDO.

The core methods to be used in phase I include literature review, document review and primary data collection through workshops/interviews with CLAHRCs. More details on different components and timelines for phase I are provided below:

Refining the evaluation design: it is important that the initial design and approach has been scrutinized by academics and practitioners within CLAHRCs (November–December 2009).

Reviewing key literature and assessing its significance for the evaluation project (November 2009–March 2010).

Kick-off meetings with SDO and CLAHRCs: The SDO organised kick off meetings with all the funded evaluation teams and with the CLAHRC Directors in October 2009 and February 2010 respectively. At these meetings, discussion and consensus building took place on issues of coordinating evaluation activities, minimising burden on CLAHRC time, and maximising learning.

Reviewing background information/CLAHRC documentation to assist in the scoping of CLAHRC ways of working and as inputs for data gathering at workshops/interviews (November 2009–end February 2010). Scoping the ways of working/logic models with each CLAHRC through meetings with each CLAHRC team and key informant interviews. These will be coordinated with other SDO-funded evaluation activities to minimize unnecessary burden. In terms of workshops, there will be 1 workshop at each CLAHRC to take place at the lead institution, and to involve approximately 5–6 representatives of different stakeholder groups and organisations within a CLAHRC (May 2010–September 2010).

Using meetings with CLAHRCs, their application forms, and CLAHRCs’ own developing documentation, we will model the logic(s) of intervention/ways of working for each CLAHRC. This will include describing the existing inputs, the processes (implementation plans) through which the second translation gap is to be addressed by the CLAHRC, and the expected outputs/outcomes from CLAHRC activity (September–November 2010).

We will then hold a national ‘learning’ event for CLAHRCs, SDO, other SDO-funded evaluation teams (involving also our Advisory group). We will disseminate and discuss our emerging findings, and identify questions which would benefit from further investigation (November 2010).

We will then meet with our Advisory group consider the significance of different intervention approaches and hold an initial discussion about which approaches to investigate further in phase two (November 2010).

Produce First Interim Report: identifying key models/ways of working, their significance, and the agenda for further evaluation in Phase Two (December 2010).

Quality Assurance on First Interim Report by two peer reviewers (December 2010).

PHASE II

In phase I, the RAND/HERG (Health Economics Research Group) team examined the CLAHRC landscape, and identified the various logics of intervention that different CLAHRCs are pursuing. CLAHRCs are each seeking to change the way research is done and the way the NHS uses research in commissioning, managing and delivering services. Our phase I work identified some similarities between the approaches of different CLAHRCs but also significant differences in areas such as operational approaches, disease focus, structures/governance approaches and stakeholder dynamics (as some examples). A range of interesting questions/themes around factors which are likely to influence CLAHRC evolution and performance emerged from our ‘landscape mapping’ in phase I.

In phase II we will explore some of these questions in more detail. The core questions to focus on were selected from the long list of questions, in consultation with our Advisory Board and some CLAHRCs (those who responded to our survey consultation). They were selected with the following criteria in mind:

• be relatively under-researched (as identified through our literature review)

• have a potentially high impact with transferable lessons

• be relevant to the success of the CLAHRCs

• not be covered by one of the three other evaluations (at least not as a central question)

• be capable of being researched across more than one CLAHRC to support comparisons and contrasts.

In light of the above, we will be examining three interrelated aspects of CLAHRCs processes in more detail.

1. Core question: How does the NHS influence CLAHRCs evolution, outcomes and impact (and indeed how does having a CLAHRC influence NHS behaviour)? This requires examining and specifying the nature and extent of NHS involvement, including to what extent rhetoric matches reality.

2. Complementary question A: How are effective multi-stakeholder and multidisciplinary research and implementation teams for service improvement built: what can we learn from the CLAHRCs model, and what mechanisms are being used to enable it?

3. Complementary question B: What can we learn from the CLAHRCs that can cast new understanding on how to use research knowledge and evidence to change commissioning and clinical behaviour for patient benefit?

A number of assumptions related to our phase I findings are driving the questions above. These assumptions include:

• High levels of NHS involvement underpin the CLAHRC ethos and theory of change.

• Collaboration between multiple stakeholders in academic research and service provision can lead to service improvements and a better healthcare system. Important stakeholders in this respect include: academics; NHS executives; clinicians; senior, middle and front-line managers; patient and public representation groups; commissioners etc.

• It is not enough to generate ‘good evidence’ for it to be adopted and lead to improved service. In addition to producing relevant and implementable research, a range of approaches and conducive infrastructures need to be in place for it to lead to service improvement.

Study design: we propose a four-step approach in phase II as illustrated in the figure below.

FIGURE 21.

Phase II study design.

The section below provides more detail about each of the tasks to be undertaken in Phase II. We have also included indicative timescales for when we expect these tasks to be undertaken. Given the range of methodologies being used in this phase of the work, some of the components of these tasks will be carried out in parallel as reflected in the overlapping timelines given for some of these tasks. Should these timescales be required to be readjusted significantly due to delays associated with undertaking the online survey, we would seek approval from our funder (the SDO) and would duly notify the research ethics committee of these delays in our next progress report.

TASK 1: stakeholder survey across CLAHRCs (from April 2011 to February 2012)

In this phase we would design and conduct an online survey across all CLAHRCs who agree to participate and with different stakeholders in each. This survey would help generate insights about core issues related to our three questions (NHS involvement, multi-stakeholder research and implementation teams, and evidence adoption) across the CLAHRC landscape. We will investigate the interventions CLAHRCs are implementing as associated with all three questions; the contexts and variables that influence their actions; and the effects of the various interventions. We will do so in a way that can capture the multiple perspectives of different actors that constitute CLAHRCs: researchers, clinicians, NHS managers, commissioners, academic leadership, Trust executive leadership and patient/public representatives. Based on the insights that emerge from this survey, we would select specific ‘sites’ to dig deeper into through a case-study approach.

The key steps in task 1 include:

• survey design

• survey pilot

• survey administration

• survey results analysis

• internal team analysis workshop

• advisory board meeting.

  In order to increase buy-in for the online survey, we envisage asking CLAHRC managers to send the link to the survey to relevant respondents. We would also seek to obtain an email/letter endorsed by the National Institute for Health Research to inform potential respondents about the importance of the survey for this research.

TASK 2: deep dives – interviews and workshop (from November 2011 to April 2012)

We will select 2 case-studies/sites exemplifying distinct types of interventions/combinations of interventions related to our research questions (likely to be two or maybe three sites). Site selection will be driven by the results of the CLAHRC survey and pragmatic concerns. Issues to consider include: focusing on sites which are addressing the questions we are researching in relatively novel, unexplored and/or promising ways; not overlapping with sites that other teams are researching (i.e. coordination).

The ‘deep dives’ would be implemented through a combination of document reviews (CLAHRCs own documents/grey literature); interviews (semi-structured, either face-to-face or telephone), and on-site workshops. The interviews will help refine the task 1 survey results by enriching earlier findings with more contextual data, and test the views/approaches of the selected CLAHRC against the perspectives of other CLAHRCs (based on survey results). The CLAHRCs documentation and interviews will set the scene for the workshops. The workshops would need to bring together representatives of multiple partners in a CLAHRC and attendants should come from different levels of the CLAHRC’s hierarchy. The workshops would focus on understanding the implicit assumptions and causal mechanisms at play in the CLAHRCs, as they relate to our research questions. They will focus not only on ‘the what’, but in depth on the how, why and ‘so what’/effects.

The key steps in task 2 include:

• Deep dive site document reviews.

• Interview template development.

• Interview conduct.

• Interview transcription.

• Workshop preparation.

• Workshop delivery.

• Administration related to workshop organisation.

• Analysis and synthesis of interview and workshop data.

• Internal reflection and learning workshop.

• A brief executive summary to use in soliciting validation interviews in task 3.

• Advisory Board meeting.

TASK 3: validation stage (from June 2012 to December 2012)

The findings from our deep dives would be further enriched by a validation interview round with all (willing participant) CLAHRCs to test what emerged for transferability and generalizability, and to refine our insights further. We may also interview external stakeholders to get their views on our findings. In addition to interviews, this stage of the work will also include a review of all CLAHRCs’ relevant documentation to supplement our interview findings.

The key steps in task 3 include:

• A review of relevant documents produced by all CLAHRCs.

• Interview administration (soliciting participants).

• Telephone validation interviews – template development.

• Interview conduct.

• Interview transcription.

• Analysis of interviews.

• Internal team workshop.

TASK 4 (led by HERG): the wider translational research and implementation landscape in the UK (and interpretation of phase II findings in this context)

In this task, we would produce a review of how CLAHRCs fit into the broader translational research and implementation landscape of the NIHR (and other funders) at present and how they relate to other initiatives. This is a complementary task and will actually be used in the final outputs of phase III. But if possible, we could explore whether and how phase II findings relate to the wider translational research landscape context, and what they imply for it. It may be possible to include some comparative analysis between CLAHRC and non-CLAHRC sites into this.

Outputs of phase II

The results of phase two would be communicated through:

• Participation at SDO learning events.

• Phase II interim report (submitted in May 2012).

PHASE III

The third phase will explore the implications of our findings for improving current policy and practice in the establishment of ‘beneficial forward-looking partnerships between universities and their surrounding NHS organisations’, including contributions to increase the capacity of NHS organisations to engage with and apply research (‘absorptive capacity’) and to encourage the effective involvement of patients and the public. We will demonstrate how this adds to, challenges, or reinforces existing international research. Throughout we will seek to work interactively with CLAHRCs to support learning. We will write a Final Report and a short Briefing Document, and will conduct a series of meetings to discuss our findings with policy-makers, relevant academics, NHS practitioners and managers, and representatives from patient and public associations. These interactions will be conducted in liaison with SDO. We will hold a final workshop with all CLAHRCs and the SDO to discuss our findings. We will also prepare papers and presentations for peer reviewed journals and conferences, and prepare and present policy-oriented briefings for the Department of Health and organisations such as the Nuffield Trust, funder-oriented material for the funders of medical research (such as NIHR, Wellcome, MRC, The Health Foundation, medical research charities), and management-oriented material for forums such as The NHS Confederation.

The core methods to be used in phase III include workshops and interviews with stakeholders, and triangulation of evidence from previous work packages and the literature. More details on different components and timelines for phase III are provided below. (These timelines are currently based on our original timelines for Phase II and could be subject to changes should the tasks in Phase II be delayed by the process of gaining further ethical approval for this study.)

Preparing and writing Final Report and Briefing Document (June–November 2012).

Quality Assurance on Final Report and Briefing Document by two peer reviewers (November 2012).

Final meeting with Advisory Group to discuss findings and dissemination strategy (October 2012).

Preparing and presenting articles for peer reviewed journals/conferences (June–December 2012).

Presenting findings to policy-makers and policy-researchers (DH, NHS Confederation, Nuffield Trust, Health research charities etc.) (May–July 2013).

Workshop with CLAHRCs and SDO to discuss findings (August–November 2012).

Presentation of final report and budget to SDO (December 2012).

Collaborating with SDO in overall presentation of findings from across the evaluation (August–December 2012).

Introduction

Thank you for agreeing to complete this survey, the survey will remain open until Tuesday, October 25th, 2011.

It is part of a wider evaluation of the CLAHRCs funded by the Department of Health’s Service Delivery Programme. Information resulting from this survey is likely to be beneficial in informing how your CLAHRC evolves looking forward. It will also help us understand the evolution of activities across all the CLAHRCs. The questions were arrived at as a result of our initial appraisal of the issues facing the CLAHRCs and also reflect our current evaluation focus.

Aggregate results and fully anonymised results for the initiative (i.e. findings across all of the CLAHRCs completing the survey) will be freely available to all participants. The responses of individuals completing this survey will not be accessed by anyone outside the RAND Europe/HERG research team.

The survey should take 15 to 20 minutes to complete. Many thanks in advance for your participation,

Tom Ling,

Chief investigator on behalf of the RAND Europe/HERG evaluation team.

Should you require any further information, please contact the evaluation team on clahrcevaluation@rand.org.

Survey questions

1. With which CLAHRC are you involved?

   • NIHR CLAHRC for Birmingham and the Black Country

   • NIHR CLAHRC for Cambridgeshire and Peterborough

   • NIHR CLAHRC for Greater Manchester

   • NIHR CLAHRC for Leeds, York and Bradford

   • NIHRC CLAHRC for Leicestershire, Northamptonshire and Rutland

   • NIHR CLAHRC for North West London

   • NIHR CLAHRC for Nottinghamshire

   • NIHR CLAHRC for South West Peninsula

   • NIHR CLAHRC for South Yorkshire

2. What is your job title within your CLAHRC?

   • Director of the CLAHRC

   • Manager of the CLAHRC

   • Member of the CLAHRC Board Theme lead

   • Project team member

   • Advisor

   • Other, please specify:

3. Where do you work most of the time?

   • In the NHS

   • In academia

   • Other, please specify:

4. What were your motivations for getting involved in your CLAHRC?

   Please select all that apply.

   • To encourage the pursuit of research relevant practice

   • To improve clinical effectiveness by better applying existing research

   • To access financial support for pursuing my research interests

   • To spend more time on applied research

   • To get a better understanding of health service needs

   • To get a better understanding of how academic research can improve service delivery

   • To better understand the needs and interests of individuals from other organisations and/or disciplines

   • I was looking for a post/job and this became available

   • Other, please specify:

Background

Through our CLAHRC-wide survey and two in-depth case studies (at CLAHRC-CP and PenCLAHRC) we have developed a number of broad propositions about the nature of the collaborations developed by the CLAHRCs, and what is special about them. It is these that we would like to explore through this interview, especially to see how far our emerging findings from the two in depth studies might be applicable more widely to CLAHRCs.

CLAHRCs (our emerging view)

1. Their task is not just improving health-care research and not just improving patient outcomes, but a combination of both.

2. They are rooted in local relationships (some in place prior to the CLAHRC providing a platform on which to build, others created during the CLAHRC) and build on local capacities, with implications for critical size and remit.

3. The collaborations CLAHRCs are building are ones that seek to promote integration and culture change, not only to develop arrangements for brokerage (including knowledge brokerage) and linkage and exchange.

4. CLAHRCs legitimise a degree of experimentation in finding new ways of identifying and addressing NHS research needs, encouraging the emergence of research questions from the service and from its patients, which can then be funded by the CLAHRC but also by others.

Interview questions

Partnership and governance structures

University Hospital Birmingham NHS Foundation Trust is the lead NHS organisation and the University of Birmingham is the lead higher education institution. This core partnership is complemented by the West Midlands Strategic Health Authority (SHA). The main PCTs and secondary care trusts from the region are also part of the initiative. CLAHRC-BBC partners have a long history of collaboration with the University of Birmingham and the West Midlands SHA.

There are three levels of management, overseen by the CLAHRC director and the programme manager.

• Nine theme management groups are responsible for the overall co-ordination and monitoring of each research theme. Each meets at least four times a year and reports to the programme management committee, outlined below, on a monthly basis. The administrators working for each theme are supported by a project management group co-ordinated by the programme manager.

• The programme management committee oversees the delivery of the whole programme and optimises integration and synergy between themes. As well as monitoring the finances of the programme, the programme management committee plays an important role in reviewing and appraising the research proposals that are developed within each theme. It convenes each month and comprises theme leaders, lead researchers and financial and operational personnel.

• The programme steering committee reports on the progress of the programme to the NIHR, provides strategic advice on the management of the research programmes, undertakes financial monitoring and is responsible for external relations and the dissemination of results.

Geographical context

Birmingham and Black Country CLAHRC covers all the Birmingham PCTs and extends into the area covered by two of the four Black Country PCTs. A highly diverse population is served.

High-level aims and key objectives

The main objective is to conduct needs-based applied health research to generate evidence that can be rapidly translated into routine practice to improve patient care. CLAHRC-BBC aims to reduce inequalities in and improve the quality of health-care provision, and to enhance safety and reinforce preventative services. Four core ideas build on each other:

• The NIHR funding and matched funding will support service interventions that will be evaluated prospectively.

• Complementary activities across themes and linked projects within themes will be conducted to help provide evaluations and an evidence base.

• Research programme and management of staff careers will aim to generate sustainable capacity over the area.

• The partnership will aim to capitalise on this capacity by developing further topics for research and by expanding its geographical reach further within the Birmingham and Black Country area.

CLAHRC-BBC approach

All the research and implementation themes focus on systems-level interventions intended to improve services. The CLAHRC has a strong commitment to evaluation, using a mixed-methods approach. The research studies are expected to identify factors that determine success or failure, and the various themes share findings and expertise in order to add value to each other and promote learning across the CLAHRC.

Research and implementation themes

Birmingham and Black Country CLAHRC comprises nine individual research or implementation themes addressing national health policy initiatives and reflecting local policies and priorities. Choice of the themes was driven by national and local priorities but was also opportunistic to the extent that it was seen as an opportunity to support local service development with research.

The research themes are, to that extent, based on service need, designed to promote relevance and information exchange.

Research themes:

• health-service redesign

• evaluation of paediatric outreach service

• early detection and intervention in psychosis

• assessment of the effects of new housing interventions

• redesigned maternity support services for multiethnic disadvantaged groups

• investment in prevention (evaluation of targeted prevention of cardiovascular disease in primary care)

• optimisation of the management of stroke and transient ischaemic attack.

Implementation themes:

• implementation of effective community care for diabetes

• study of an evolving information technology system to improve patient safety.

Expected outputs/outcomes

• Effective and appropriate service change: things that do not work are discontinued and things that do work are widely implemented.

• An entrenched system for identifying and evaluating prospective service changes.

• Good governance will allow a distributed leadership and will be supported by central administrative and management support. This will facilitate a culture of collaboration, stimulating closer ties between researchers and service delivery sectors, shorter time lags between research and application, and a base for securing further funding to support CLAHRC-like efforts.

• Compared with other CLAHRCs, there is a particular emphasis on the importance of evaluation as a means of creating a self-improving and reflexive system. In time this will lead to improved services, a sustainable bridge between research and delivery sectors making both more responsive and timely. Meanwhile there will be spill-over effects on the local economy.

Challenges

• Tensions between academic and NHS cultures: between producing papers and developing a focus on work of more immediate practical value that leads to soundly based, sustainable change. There is a related issue of getting the right people in CLAHRC posts who can work across the academic/service divide.

• Differing interpretations of the CLAHRC remit.

• Getting (and retaining) NHS management buy-in.

• Communications, and specifically raising awareness in NHS trusts and engaging all trust staff.

• Policy and finance-driven changes in local and NHS bureaucracies, such as the disappearance of the PCTs. There is a risk of the CLAHRC itself becoming overly bureaucratic.

• Information sharing, governance problems and dealing with local bureaucracies

• Getting genuine and real user participation.

• The long time-scales to produce results.

Emerging lessons

• Need to research service interventions properly in a timely fashion and learn as you go. Keys are producing timely data and working to appropriate time scales.

• Need to help managers and commissioners to be more literate about research methods and appreciate the value of research, and to do this more systematically. Need to help managers, commissioners and clinicians understand the key levers of change.

• Developing communications and building awareness about what the research is for and the best way of doing it; using some extra funding to raise knowledge about research through fellowships, secondments, etc. This requires a change of culture and to engage all trust staff.

• Need for flexibility and working together, getting NHS people and researchers together to brainstorm possible service changes.

• Value in having multidisciplinary teams working on CLAHRC themes, but this is challenging. There was a perception that the CLAHRC did provide a platform that brought together different research paradigms, allowing debate, exchange and exploration of areas of shared interest. It also helps to develop stronger links with people in other sectors, such as social services.

• Means of getting and retaining NHS management buy-in, including:

  • matching funding

  • exploiting initiatives, such as the CQUIN (Commissioning for Quality and Innovation) framework and the new public health focus of local authorities

  • developing synergies with NHS bodies, such as SHAs.

• A secondary value in exploiting wider economic potential; for example, local jobs can be created to develop health technologies being trialled locally.

FIGURE 58.

Birmingham and Black Country CLAHRC logic model of the theory of change.

Partnership and governance structures

Cambridgeshire and Peterborough Mental Health Partnership NHS Trust, Cambridgeshire PCT, Peterborough PCT, NHS East of England Public Health Commissioning Network, University of Cambridge, Anglia Ruskin University, Cambridgeshire County Council and Cambridgeshire Community Services, supported by the UK Clinical Research Network (UKCRN) Mental Health Research Network East Anglia Hub, Eastern Region Public Health Observatory and the East Anglia Primary Care Research Network.

Many of the partners in CLAHRC-CP have a history of working together locally in research and care delivery initiatives. CLAHRC funding has enabled the consolidation of existing relationships, integration of fragmented efforts, bringing in additional expertise from new partners, and increasing regional participation and the coverage of diverse populations with varying needs. This included developing new partnerships with primary and social care providers and commissioners, and with organisations with expertise in change implementation.

The CLAHRC board is responsible for overall implementation and direction, and includes representatives from different academic disciplines, service providers, commissioners and local authorities. The CLAHRC executive group takes operational responsibility for the initiative and monitors the progress of the themes and implementation of research findings. Members include the theme leads, senior managers from the NHS, social care partners and the University of Cambridge. A governance group includes NHS R&D leads and ensures research governance, management and infrastructure support across the CLAHRC. Within a framework of central co-ordination and formal procedures for intertheme collaboration, there is also flexibility in terms of leadership, management and organisation within themes (distributed leadership).

Geographical context

The CLAHRC covers a population of over 1 million people living in both urban and rural environments across Cambridgeshire and Peterborough, with very diverse socioeconomic status and ethnicity.

High-level aim and key objectives

The mission of CLAHRC-CP is to improve the quality of community mental health and well-being, aiming to understand better the ways in which services are designed and delivered, examine them critically, and gradually improve services based on existing and new evidence on best practice. The CLAHRC’s focus is on people with mental illness, learning disability and acquired brain injury, and on end-of-life care. Within this broad field, CLAHRC-CP is building on established strengths of partners in life-course approaches to health and illness, focusing in particular on challenges at the points of transition. Specific objectives are to:

• Create an environment that encourages interactions within and between thematic programmes: those working in implementation themes are conducting implementation science research, and will work with the research themes to inform research agenda-setting based on service needs, and enable the translation of research outputs into improved mental-health service delivery.

• Facilitate knowledge exchange and build capacity to conduct, integrate and use health research to improve services and the quality of patient care.

• Develop collaborative projects involving multiple stakeholders in an iterative manner, from design to dissemination; this includes academic researchers, clinicians, managers, commissioners, users and local authorities.

• Mobilise individuals who can bridge disciplinary and professional boundaries between academic and service delivery sectors (e.g. as theme leads) and trying to empower future ‘boundary spanners’ and ‘knowledge exchange champions’ through its capacity in building and training activities. Related to this is a belief in the need to involve clinicians in research activities in a way that enables them to remain active in clinical practice (and teaching).

• Share and disseminate learning widely, including beyond local and regional levels. This is grounded in the understanding that, although the CLAHRC’s direct and immediate focus is on local service delivery improvement, this should not compromise an academic ethos of sharing and communicating lessons learnt and research findings.

CLAHRC-CP approach

Cambridgeshire and Peterborough CLAHRC’s theory of change is based on a number of inter-related assumptions:

• Effective mental-health services need to be designed in a way that considers the patient’s needs throughout their life. Improved practices in service provision are needed in particular at points of transition.

• Improvement in practices requires a detailed understanding of the mental-health system pathway from the perspectives of different actors in the system (across professional groups and disciplines), so that areas in need of research-, policy- and practice-related attention are made explicit, and research and change implementation activities are framed accordingly.

• Service improvement requires integrating doing research with translating and using applied health research.

• The effective translation of research into practice is an iterative process with feedback loops between different stages. This requires close collaboration and knowledge exchange throughout all stages of research generation, maturation and utilisation processes.

CLAHRC-CP aims to establish and nurture strong and sustainable learning and exchange linkages between diverse stakeholders in the mental-health services pathway, including academic researchers, clinicians, NHS managers, local authorities, GP practices, commissioners and service users. Senior staff from all PCTs and the county council sit on the CLAHRC board, and heads of service commissioning sit on the executive group. The CLAHRC is also bringing together new combinations of disciplines, professions and individuals in research and implementation teams (in engineering, business, public health, general practice and psychiatry). This plurality is expected to enable the process of generating, communicating, disseminating and adopting research findings to be better tuned to the health-care system, and increase the relevance, usefulness and adoptability of outputs. The translation gap is not seen to be unidirectional, and CLAHRC-CP intends to involve stakeholders throughout different stages of the research and implementation processes.

Research and implementation themes

The CLAHRC aims to harness local research strengths in life-course approaches to health and illness, and focus on ‘pinch-points’ in service provision (such as transition between adolescent and adult services, social care and health, and end-of-life care) for some of the most vulnerable members of society.

There are three research themes:

• adult disorders, focusing on learning disability and long-term outcome of head injury

• child and adolescent mental health, focusing on transitions between these services and adult systems, with some work on autism

• mental health and disability in old age, including end-of-life care and a development of clinical academic old age psychiatry.

There are two cross-cutting implementation themes:

• public health, focusing on population health and commissioning

• design, focusing on health systems analysis, education and training for managers, commissioners and clinicians, and investigation of the spread of innovation and ideas in health systems.

The expected outputs/outcomes are:

• A more collaborative culture with a capacity to address issues in new ways: health services will become more evidence based and will draw upon research more quickly. This will create a platform for securing further future funding.

• Outcomes including improved experiences and outcomes for service users, more appropriate applied research, more evidence-based services, a sustainable network of organisations to support this, and contributions to the national and international understanding of the theory and practice of how to bring research and practice together for the benefit of service users and society.

Challenges

• Cultural, administrative and practical differences between the main organisations: there is a need to manage and navigate dual governance systems (i.e. academia and NHS).

• Engaging the main players in the CLAHRC vision of integrated collaborative research, and sustaining partner enthusiasm and commitment to delivery on agreed objectives and responsibilities (including from senior levels in the NHS).

• PPI is not easy (there were recruitment challenges to get a lead for PPI in post).

• Getting buy-in at middle management and senior levels in universities and NHS trusts.

• Navigating and responding to changing socioeconomic, political and NHS landscapes – related to this is the need for flexibility from all CLAHRC stakeholders.

• Finding ways to balance and manage the academic ambitions of research groups with time commitments and emphasis on impact of research on services.

• Clarity and management of expectations about the timelines needed for demonstrable change and wide-scale service improvement.

• Continuation of the CLAHRC or CLAHRC-like funding beyond the first phase of initiative existence.

Emerging lessons

• Central management and co-ordination capacity for complicated collaborative initiatives such as the CLAHRC is important (e.g. ethics, financial management, communications, appointments).

• It is also important to develop leadership capacity through a commitment to distributed leadership.

• Key performance indicators may further support this and can be a way of building consensus on goals, commitments and expectations from all participants (across organisations and disciplines).

• Good public relations/website/communications are important if internal and external stakeholders are to engage effectively with the CLAHRC.

• It is important to engage diverse stakeholders from the onset of the research process, not only at the end: i.e. in research agenda setting, implementation and adoption (e.g. local authorities, service users). Creating formal and informal opportunities for interpersonal and interorganisational exchange is important.

• There is a need to identify and support champions of change: those who can use knowledge to affect service delivery and implement change (commissioners, managers, clinicians, social care practitioners, end users).

• Physical proximity and colocation are important facilitators of multidisciplinary and multistakeholder collaboration.

• There are practical organisational barriers for colleagues with split roles: it is difficult to work out how time is covered under each role. There is an associated issue of releasing time for people to be out of their normal team and in the CLAHRC (this is particularly relevant for applied health professionals). It is necessary to examine what types of support are needed to sustain split roles.

• Building and working in multidisciplinary teams (especially if they bring together groups that had previously not worked together) requires time and repeated interactions (formal and informal), an openness to learn from each other, and positive attitudes to plurality and different working styles.

FIGURE 59.

Cambridgeshire and Peterborough CLAHRC logic model of the theory of change.

Partnership and governance structures

Manchester University, 10 PCTs, six hospital trusts, three mental-health trusts and an ambulance service: it is led by the Salford Teaching PCT. There is a long history of collaboration between the University of Manchester and local NHS organisations, and all the local trusts have previously worked together to improve the quality, relevance and impact of NHS research for the public.

Greater Manchester CLAHRC has a central leadership and secretariat. It also includes studentships and 24 knowledge transfer associates. Its governance is made up of the following elements:

• A steering group that is chaired by the lead trust meets twice annually to approve the CLAHRC’s budget and programme. The lead trust is responsible for managing finances and subcontracts with partners and providing general administrative support.

• A research and implementation group meets quarterly to review progress across all themes and ensure integration of the work. It is composed of the theme leaders, the chief operating officer and the CLAHRC director as chair. The theme leaders meet monthly and manage day-to-day theme work.

• The CLAHRC director is accountable to the NIHR and steering group for overall management and performance, and chairs the research and implementation group.

• The chief operating officer is responsible for day-to-day management, including research governance and research protocols, and reports to the director.

Geographical and demographic context

Greater Manchester has more than 2.56 million residents and is the third largest metropolitan area in the UK. It is characterised by poverty (75% of wards in bottom fifth for England), ethnic diversity with a relatively high representation of Asian (approximately 6.5%) and black (1.7%) people, poor health (lowest life expectancy in England for men, 72.5 years; second lowest for women, 78.3 years; and a high incidence of cardiovascular disease) and inequalities in health/health-care provision.

High-level aims and key objectives

The overall goal is to improve the health of people in Greater Manchester by enhancing the quality of care in terms of safety, efficacy, efficiency, patient-centredness, timeliness and equality through the application of world-class research.

The overall objectives are to:

• develop and evaluate a series of interrelated interventions to support patient self-management and improve the quality of care for people with chronic vascular disease

• implement these and other evidence-based interventions in NHS trusts across Greater Manchester to improve patient health and reduce inequalities in healthcare provision

• build local NHS capacity to plan and implement evidence-based changes in care pathways for people with vascular disease through close working and knowledge transfer between university researchers and NHS providers and commissioners.

CLAHRC-GM approach

• Research approach: CLAHRC-GM notes that current approaches to chronic disease focus on developing evidence-based standards of care, as found in clinical guidelines. However, research that improves patient self-management may significantly reduce the burden of NHS service consumption. Recent research has shown that patient self-management can be improved by enhancing patient knowledge and coping strategies in a systems approach. This research approach can be implemented in six steps: agreeing what is to be accomplished; determining how the impact of change will be measured; identifying what changes should be made; implementing change using plan–do–study–act cycles; sustaining and spreading the changes; and evaluation of implementation.

• The strategy for the implementation theme rests on the recognition that successful implementation requires multifaceted interventions across whole systems and is not a linear or technical process.

• The research theme findings will feed into the implementation themes and knowledge transfer partnerships to facilitate change and build leadership capacity in implementation.

• The CLAHRC aims to develop existing systems of partnership working among NHS trusts and the University of Manchester through closer alignment of research with NHS needs and priorities, facilitating the uptake of research into practice.

• This approach involves both research and implementation themes and building capacity to generate and disseminate knowledge. The creation and application of knowledge is fundamental to the approach, and the knowledge transfer partnerships are an important aspect of this.

Research and implementation themes

There are four research themes and four implementation themes, focusing on patient self-management of chronic diseases.

Research themes:

• People with long-term conditions: To elicit the needs, social and health contexts, and receptivity (to information) of socially disadvantaged people with vascular conditions in order that information can be developed, integrated and evaluated within an existing evidenced-based approach to guide self-management support.

• Health-care practitioners: To promote better patient-centred care by practitioners through the development and testing of new approaches to the management of depression in patients with long-term conditions.

• Health-care services: To contribute to the promotion of self-management through the development of new patient-centred systems of access to specialist care and through the development of allied programmes of training for specialists. Combined with the self-care information resources from the first research theme, this will generate whole-systems intervention.

• Health information systems: Will develop the information systems needed to improve health-care planning by monitoring variations and inequalities in health-care provision for people with chronic vascular disease, and assessing the likely impacts of interventions to improve patient care and public health.

Implementation themes:

• Coronary heart disease: To enhance NHS capacity to translate research findings into improved outcomes for patients by the improvement of services for people with heart disease.

• Chronic kidney disease: To enhance NHS capacity to translate research findings into improved outcomes for patients by improving services for people with chronic kidney disease.

• Diabetes: To translate research findings into improved outcomes for patients with diabetes by developing and improving services for people.

• Stroke: To enhance NHS capacity to translate research findings into improved outcomes for patients by the improvement of services for people with stroke.

Expected outputs/outcomes

• Outputs are focused on the production and creative use of information sources, including cost–benefit information, simulation models (allowing commissioners to engage with the evidence base by simulating the likely impact on costs of changing pathways) and peer-reviewed publications. Alongside these, and closely related to them, is the production of workforce development plans to support redesigned pathways and improved ways to access care.

• Knowledge is therefore intended to play a key and transformative role in achieving ambitious impacts, more effective treatment, reduced (inappropriate) demand and improved access, improved patient self-management, a more responsive NHS, reduced inequalities and increased capacity in the NHS to plan and implement evidence-based changes.

• The intended outcomes are firmly focused on transforming NHS services.

Challenges

• Researchers and practitioners have different ways of working.

• Having many different kinds of people working together involves practicalities and logistics, including pragmatic issues such as planning meetings, the number of meetings, lengthy and uncertain recruitment processes, and increased bureaucracy and governance.

Lessons emerging

• There is an inherent tension between the research and service delivery worlds, one factor being that they work at different paces. CLAHRC-GM funded consecutive rounds of evidence-based innovation projects with a quick turn-round, allowing faster answers to be provided, while building on previous knowledge in future work. In other words, the research setting can be reorganised to respond to different time frames without losing the long-term accumulation of knowledge that lies at the heart of the scientific process.

• Funding that forces interaction between researchers and research users may sometimes be successful. The success of the CLAHRC may depend upon the transformative power of knowledge, but it also recognises the need to support this with incentives and guidance.

• Greater Manchester CLAHRC can synthesise information on how to bring research and practice into a more mutually beneficial relationship in a reliable and accessible way. In this sense CLAHRCs have a metafunction: supporting learning about learning.

• There are dangers in trying to link everything with everything, and there is a need to retain focus; otherwise there may be a series of unproductive meetings and little else. The issue here is how priorities can be identified, agreed and acted upon within a distributed leadership.

• Greater Manchester CLAHRC has had to emphasise that it is not about running services: it is about informing the way in which services are run and supporting evidence-based change.

FIGURE 60.

Greater Manchester CLAHRC logic model of the theory of change.

Partnership and governance structure

There are four core partners: the Universities of Leeds and York, and the Leeds and Bradford teaching hospital trusts. The core partnership was determined on the basis of the ambition to bid with the two strongest academic and NHS components in the region. These partners are also linked to the Leeds Partnerships NHS Foundation Trust, Bradford Metropolitan District Council, NHS Bradford and Airedale Teaching PCT, Leeds City Council, NHS Yorkshire and the Humber SHA, the NHS Innovation Hub for the Yorkshire and Humber region and the Yorkshire regional development agency (Yorkshire Forward).

Leeds, York and Bradford CLAHRC partners have worked together for many years in a variety of ways.

The governance of CLAHRC-LYB aims to provide central direction through a CLAHRC-LYB board (with input from public and patients) and a CLAHRC-LYB executive group (supported by an infrastructure group and a scientific steering committee) while giving the various themes freedom in running their work. Appointments to the various themes mainly come from the four core partners, but members also come from the other sectors on which the CLAHRC draws.

Geographical and demographic context

The CLAHRC covers a population of around 5 million people who have a range of socioeconomic, ethnic and cultural backgrounds.

High-level aims and key objectives

Leeds, York and Bradford CLAHRC aims to build capacity to innovate into NHS commissioning and service delivery in a cost-effective way. Specific objectives include:

• building the research capacity of the NHS

• building researchers’ ability to respond to front-line needs

• building commissioners’ and NHS staff’s ability to communicate front-line needs

• building the capacity of commissioners and those delivering health-care services to innovate – by tying research to outcomes, changing relationships and networks, and communicating on the topics of interest to commissioners

• evaluating the cost-effectiveness of work

• informing practice on the basis of rigorous evidence.

CLAHRC-LYB approach

The CLAHRC aims to respond to local and chronic health conditions distributed unequally in the population. It is driven by two key ideas:

• The research themes are the starting point for developing local NHS capacity to drive the research cycle, starting with identifying questions, reviewing the literature to find out whether they have been answered, designing studies, undertaking them and interpreting the results. There are plans to develop NHS staff to the point where they can drive these cycles, with appropriate support from academics.

• The implementation themes are concerned with the other aspect of innovation, with creating the capacity to incorporate new knowledge and practices safely and effectively into routine service delivery. NHS teams will seek to develop new ways of working and achieve cost reductions and improvements in quality and safety. CLAHRC-LYB will be responsible for ensuring that the teams have the tools/resources they need, and will work with NHS managers to remove barriers to change where necessary.

Leeds, York and Bradford CLAHRC builds change within the NHS by involving individuals who are in authority and in a position because of their place within networks to cascade the research and its outputs throughout the service. CLAHRC-LYB also seeks to involve commissioners, as well as clinicians, in order to build long-term capacity to integrate the clinicians and researchers’ knowledge into clinical research and practice: it sees commissioners as key to the sustainability of the CLAHRC legacy. PPI is also important to CLAHRC-LYB, as demonstrated through the board’s relationship with patients and the public and through the individual themes.

Research and implementation themes

Two research themes draw on local expertise and are intertwined:

• The physical health and addiction theme will explore cost-effective interventions which can be routinely implemented in the acute care setting.

• The vascular disease theme will investigate prevention, through a range of lifestyle-change advice programmes to at-risk communities; and treatment, exploring the reasons for poor medicines adherence.

There are three implementation themes: implementation-driven research (in maternal and child health and in stroke), and the Translating Research into Practice in Leeds and Bradford (TRiP-LaB) programme.

• The child and maternal health theme will develop and implement research-calibre information systems that will focus on addressing inequalities in antenatal health (exposures to risk factors in utero), infant and child feeding and obesity, maternal mental health, and access to health and social care services.

• The stroke care theme will seek to uncover the reasons for poor stroke care by routinely collecting data on hard-to-capture measures such as information on stroke care delivered, stroke care organisation and delivery structure, the unique characteristics of patients and the outcomes of care on patients, as described by them.

• The TRiP-LaB programme will explore the hypothesis that multifaceted and theoretically informed interventions targeting different barriers to change are more likely to be effective than single interventions for getting evidence into practice, examining questions such as: What should a change strategy look like? What sorts of barriers can be overcome and how? How will we know if what we can achieve is worth it?

Projects will apply a range of theories to underpin their rationale, which may allow TRiP-LaB to draw conclusions regarding the application of different theoretical approaches. The projects will all focus on making access to care more equitable across communities, in particular for chronic disease, and cost-effectiveness will be a strong element.

Expected outputs/outcomes

• The CLAHRC is expecting improved knowledge of the cost-effectiveness of certain interventions, better outcome measures and a better understanding of what the public wants. Capacity building includes embedding research and evaluation capacities in the NHS and embedding the needs of the NHS in researchers’ approaches. It also seeks to understand better what works in bridging the second translation gap.

• The intended outcome is a structural and cultural change in the NHS, in academia and in commissioning, resulting in a new and sustainable relationship between researchers and practitioners.

Challenges

• Providing clinicians with the time to engage in research through funding streams is not sufficient; it may be difficult to backfill their position.

• Relationships and networks need to be built amidst a changing health-service landscape. This may confuse the direction of effort as well as the willingness and commitment of health-service providers to engage.

• The impending abolishment of the PCTs had substantial implications, with NHS Bradford PCT being one of CLAHRC-LYB’s primary partners.

• Funding has been delayed (allegedly because of the difficulty of fulfilling the novel CLAHRC human-resource funding approach) which has meant that certain outputs may not be achievable within the set time frame.

• As yet, CLAHRC-LYB partners do not have a fully shared view of what the CLAHRC identity is/should be.

• There are cultural barriers and differences between the NHS and academia to overcome, including:

  • Conceptual barriers – the sectors do not necessarily understand terminology and concepts in the same way;

  • Differences in ambition – practitioners are driven by different ambitions. These are not incompatible but they do imply different priorities; there need to be practical compromises;

  • Differences in work environment – clinicians and researchers do not generally grasp the day-to-day activities and the possibilities and constraints of each other’s work. This is an obstacle to successful collaboration.

  • Differences in time scales – researchers’ time scales are generally much longer than clinicians’, who have a fire-fighting capacity.

• In seeking to bridge the second translation gap, clinicians and other NHS practitioners are expected to ask questions that will still be relevant to them in the future, while researchers are expected to be flexible and pursue research that can start providing answers relatively quickly.

• The optimal way to achieve PPI is not clear.

• The CLAHRC rests on deep collaborations. These rely on an element of trust between partners. This trust can take time to build, as partners have their personal ambitions and reason for being protective of these. This suggests that collaborations will take time and may have uncertain consequences.

• Demonstrating impact: there are a number of tangible outcomes that may be measured, but much of the core of the CLAHRCs includes intangibles.

Emerging lessons

• Networking is key to achieving collaboration and an understanding of ‘the other’s’ work environment, ambitions, possibilities and constraints. It is one of the hardest and most time-consuming activities, but is crucial to success. It is important to use people who are already embedded in the organisation and understand the culture and where the leaders are.

• Buy-in from the chief executives is a key factor that can make the CLAHRC’s relationship brokering and pursuit of various activities more seamless.

• There is a need to exploit clinical leadership and build on existing strands of expertise; this helps to build credibility and interest.

• There is a need to develop a close relationship with commissioners, with mutual commitment to listening and integrating the other’s advice.

• The fact that the CLAHRC initiative did not provide support costs was a concern at first but has since been considered a positive element, forcing researchers to ensure the usefulness and feasibility of the research. Field diaries can be a useful way of capturing these intangible aspects of CLAHRC activities.

• It is important to engage, build and sustain a critical mass of change-capable agents.

FIGURE 61.

Leeds, York and Bradford CLAHRC logic model of the theory of change.

Partners and governance structure

University Hospitals of Leicester NHS Trust, Northampton General Hospital NHS Trust, Kettering General Hospital, Leicester City PCT, Leicestershire County and Rutland PCT, Northamptonshire Teaching PCT, Leicestershire Partnership Trust, Northamptonshire Healthcare NHS Trust, University of Leicester. The CLAHRC has access to a large number of GP practices and builds on previous networks. Relationships include the LNR Comprehensive Local Research Network, the South East Midlands Diabetes Network and the East Midlands and South Yorkshire Primary Care Research Network.

The CLAHRC board includes chief executives and senior people from the trusts including R&D leads. CLAHRC staff include a core team of director, deputy director, five theme leads, five deputy theme leads and five theme managers.

Geographical and demographic context

The counties of Leicestershire, Northamptonshire and Rutland cover a population of approximately 1.6 million. A large percentage of the population in some areas is from ethnic minorities (e.g. 34% in Leicester). Indicators of health are similar to the average for England and the East Midlands region, but there is wide variation, with significant levels of deprivation and poor health in some areas.

High-level aims and key objectives

To conduct applied health research (in long-term care) in new ways that can more rapidly inform practice, and to increase research capacity in the NHS. This means enabling partner NHS organisations to generate new research evidence, make use of existing research evidence and develop systems and structures for the application of knowledge and for the translation of research evidence into more effective and efficient health-care policy and practice. These high-level aims are underpinned by a set of nine objectives:

1. Secure a step change in the way that applied health research is conducted and health research evidence is put into practice.

2. Increase capacity to conduct and implement applied health research through education and collaboration.

3. Increase the involvement of stakeholders from the local health community, including the public, in the design, conduct and application of health research.

4. Link those who conduct applied health research with those who use it in practice.

5. Test new initiatives to encourage the use of applied health research findings in health-care practice.

6. Create and embed approaches to research that are specifically designed to take account of the changing ways in which healthcare is delivered.

7. Focus on the needs of patients.

8. Improve the health of the local population.

9. Make a significant positive impact on the health of the people of its region and contribute to a better understanding of the mechanisms for sustaining that improvement.

LNR-CLAHRC approach

The overall approach is influenced by the organisational excellence model described by Nutley et al. 106 and by the experiences of the Veterans Administration QUERI programme. 107

• Engage NHS partners in all CLAHRC activities and at all stages of the research cycle, so they are encouraged to see research as part of their day-to-day work, with useful outputs that can be practically implemented.

• Involve the public, patients and clinicians in research and CLAHRC activities so that the research the CLAHRC produces is directly relevant to them and has greater drive.

• Develop guidelines locally and involve local partners.

• Provide trusts with research that is tailored to their needs and those of their patients, using existing local knowledge where possible and ‘piggy backing’ on existing activities to make outputs relevant.

• Use CLAHRC co-ordinators embedded in the trusts and translational teams in decisions on research.

• Spread the relevance of the CLAHRC’s work by training people to deliver a model of education developed by the CLAHRC to support its aims.

• Achieve buy-in from clinicians and the support of NHS management. The CLAHRC board includes chief executives and senior people from the trusts including R&D leads, which makes it powerful and gives it legitimacy; some of the ideas driving the CLAHRC come from them and, overall, their involvement makes it possible to get things done in the trusts.

Research and implementation themes

Four applied research themes focus on different stages of treatment (early detection of chronic disease, self-management and education in long-term conditions, prevention of chronic disease and its associated comorbidity, rehabilitation).

One implementation theme aims to improve the uptake of evidence-based practice, promote the implementation of LNR-supported research and develop an evidence base for effective implementation through evaluation.

Expected outputs/outcomes

• Intended outputs include securing further funding, improving the availability of data to clinicians so they know when they are departing from evidence-based practice and guidelines. New and usable evidence is to be created along with an infrastructure to support the implementation of locally produced research.

• Outputs already achieved included the ‘Detect Tool’ and articles in peer-reviewed journals.

• Outcomes already achieved included raising awareness, bringing clinicians who were previously non-researchers into research activities and developing strengths in new areas of research. In the longer term, the CLAHRC hoped to achieve better health outcomes for patients, improved ways of working and sustainable behaviour change among NHS staff and researchers.

Challenges

• There are geographical variances in engagement with the CLAHRC: different trusts have different levels of interest as well as varying levels of previous experience and expertise in research. Different tailored approaches are needed to achieve buy-in from all partners involved.

• There are different incentives and time scales for researchers and for NHS staff: NHS staff often lack the time to stop and reflect on their practices, and NHS resources are seldom dedicated to evaluating current practice owing to the short time scales they operate on as well as frequent changes in management (if a research finding can make a difference but only in a few years, it is likely that the leadership of the trust will change and so will its priorities).

• The CLAHRC operates in an environment where it is competing for the attention of all sorts of people, and current changes in the NHS landscape mean that involving commissioners in research is increasingly complex; the people the CLAHRC needs to engage are changing, and their priorities are changing because of current pressures.

• There are staffing and recruitment problems: because of the bureaucratic processes involved and difficulty of defining some CLAHRC posts, such as CLAHRC co-ordinators.

• It is difficult to get ethics approval for some studies.

• There were unrealistic expectations of what the CLAHRC could achieve. A large grant was awarded to the CLAHRC, but it was relatively small compared with the region it covered and the changes it would like to bring about in the system. The CLAHRC cannot solve everyone’s problems and that was sometimes not well received. In addition, although the CLAHRC had been able to put together an infrastructure to make changes happen, these changes would be realised in the long term rather than straight away.

• The CLAHRC research studies did not have research portfolio status and are therefore not eligible for support from the local research networks; CLAHRC studies competing with other prospective research studies that do have this status are at a disadvantage.

• There is some concern that there is too much emphasis on applied research and too little on implementation, and concern that the applied themes are very close to traditional research.

FIGURE 62.

Leicestershire, Northamptonshire and Rutland CLAHRC logic model of the theory of change.

Partners and governance structure

The lead NHS organisation is Chelsea and Westminster NHS Foundation Trust; the lead higher education institution is Imperial College London, complemented by the main PCTs and social care trusts of the region, and supported by the London SHA and the West London Research Network. The CLAHRC partners have been jointly involved in similar work previously, targeting research and change management.

Governance is centralised with around 20 full-time staff for governance, management, administration and leadership of the themes funded. Twenty full-time research staff at the doctorate level are indirectly funded through research projects. The fully funded staff represent only a fraction of all those involved with the CLAHRC, estimated at around 500. A number of the key CLAHRC staff had/have appointments in both the clinical and research sector, and the CLAHRC’s core team come from a range of backgrounds including academic, NHS, PCT and frontline medical and nursing practice.

Geographical and demographic context

It covers a specific geographical area in London with 1.9 million individuals of whom 35% come from ethnic minorities (mainly Asian and black), 23% are under the age of 20 years and 12% are over the age of 65 years.

High-level aims and key objectives

Northwest London CLAHRC aims to devise and evaluate a systematic approach to the implementation of novel interventions. An action research programme will be used to facilitate rapid adoption and engage those directly involved in health-care delivery. Both the programme and research projects will be evaluated using quantitative and qualitative approaches as necessary to ensure outcomes are clear and hence help build a strong evidence base to deliver improvements in health care and patient experience. Specifically, the aim is to bring about institutional change in the NHS by building the capacity and knowledge of specific groups who in turn will be able to build the capacity and knowledge of their colleagues and bring about a comprehensive system change by enabling the principles, processes and skills to be transferred continuously and sustainably. As the system change being sought relates to the patient’s journey, the CLAHRC has put patients in the centre of its activities. The focus is on using projects to learn, feed back and build knowledge.

Specific objectives are:

• monitoring the cost-effectiveness of clinical interventions

• enhancing and speeding up uptake of clinical cost-effective interventions

• improving the patient journey across interfaces

• changing the culture and empowering individuals to design, influence and implement change programmes.

Northwest London CLAHRC approach

• Within this CLAHRC the funding of research projects is an activity in itself, rather than an input. Northwest London CLAHRC provides training to prospective applicants (who have passed the screening stage) in the key principles underpinning the CLAHRC. In so doing, they are building some capacity that will not be directly captured at output/outcome stage, since not all applicants will eventually be funded.

• The research projects selected are seen primarily as experiments to test new models for bridging the second translation gap. The CLAHRC’s core focus is on how the models fare, and it reflects and builds on the research project experiments through its implementation themes. There is a large number of committee, theme and CLAHRC-wide meetings (weekly and quarterly) to discuss experiences, successes and challenges, allowing for close monitoring. Data on outputs are collected on a weekly basis.

• The CLAHRC engages with key stakeholders such as health-care planners and policy-makers as well as industry in order to inform them about their results and implement improvements in service delivery and caution about directions that appear to be either unproductive or counterproductive. This includes building cross-organisational networks to encourage sustained collaboration and exchange.

Expected outputs/outcomes

• Northwest London CLAHRC sees these processes (training applicants, testing models through research projects, reflection and building on these research projects through collaboration, evaluation and engagement with stakeholders) as the means to gain insight into how to bridge the second translation gap, produce research-specific findings (i.e. the direct results of the research projects) and build capacity, especially in the NHS, to inform, conduct and integrate research into practice.

• The CLAHRC hopes to achieve a systematic approach to education, knowledge and transfer from its collaborations, and thereby continue and sustain improvements in patient care. The CLAHRC also hopes that through its collaborations it will generate a critical mass of researchers and clinicians who understand one another and can work together to achieve products of shared benefit.

Research and implementation themes

There are two research themes:

• chronic (human immunodeficiency virus testing in PCTs and the management of complex-needs patients)

• acute care (mostly focused on the issues of medicines management and care bundles in chronic obstructive pulmonary disease and pneumonia).

There are three implementation themes:

• collaboration, learning and delivery (develops and helps the application of a systematic approach to implementing and adopting new practice, providing educational and training programmes on improvement and research methodology, and on the value of public patient involvement; also provides tailored advice and support, and helps research teams collaborate and co-operate)

• PPI (looks into methods that can be used to understand patient needs and opinions; provides an induction and training programme to empower the public to become involved in research into service delivery: both activities underpinned by public open days to develop knowledge about these opportunities)

• evaluation (focuses on monitoring change programmes, assessing their outcomes and impacts, and drawing lessons from these to feed into future change programmes).

The research themes are, primarily, seen as the means to experiment and evaluate different systems to bridge the second translation gap, and the implementation themes support them through knowledge transfer and capacity building. The CLAHRC encourages larger teams than necessary to allow building a critical mass of skills, knowledge and interest, and it funds research projects in three rounds, thereby retaining flexibility over its activities. This provides the opportunity for the team to learn lessons from past experimental research projects and build on this in future projects, and for the implementation themes to continuously adapt the support they offer.

Challenges

• Research projects need to be according to plan.

• Staff turnover and retention: the CLAHRC places a large emphasis on people (notably through a large number of recruitments).

• Sustainability relies on two key elements: the CLAHRC developing a clear identity; and the funding environment, which can keep initiatives going, aligning with the user focus as the CLAHRC does.

• The CLAHRC aims to bring people out of their comfort zone, which means there can be misunderstandings and tensions between those involved, e.g. researchers, who may not grasp the importance of PPI.

• There are inherent tensions between the research and service delivery worlds, which work at different paces. The CLAHRC has sought to address this by funding consecutive rounds of evidence-based innovation projects with a quick turn-round. It allows provision of faster answers, while still building on previous knowledge in future work.

• The language barrier between different sectors means that there are different understandings of the same term.

Emerging lessons

• A sense of group achievement is key to maintaining momentum of effort.

• A useful aspect of the CLAHRC is its reliable and accessible synthesis of the large body of information on how to bridge the second translation gap.

• Bridging the second translation gap starts not at the findings stage of research, but at the proposal stage. This allows service delivery processes to be integrated into the research through, for example, action research methodology.

• Any effort at bridging the translation gap benefits strongly from being underpinned by strong collaboration/co-operation and evaluation. It allows learning and sharing from those lessons.

• Communication is most successful when it is between individuals who relate to and respect each other.

• Matched funding can usefully increase organisational involvement.

FIGURE 63.

Northwest London CLAHRC logic model of the theory of change.

Partnership and governance structure

University of Nottingham, Nottinghamshire University Hospitals NHS Trust, Nottingham County Council, Nottingham City Council, Derbyshire Mental Health NHS Trust, NHS Nottingham City, Lincolnshire Partnership Foundation NHS Trust, NHS East Midlands, Bassetlaw PCT, Derbyshire County PCT, Nottinghamshire University Hospital NHS Trust, Nottinghamshire Healthcare NHS Trust, NHS Nottingham County and NHS Derby City. The partners had working relationships before the formation of the CLAHRC, and had already been engaged in translational research.

Oversight is from a governing board called BOAST (Behavioural medicine, Organisation science and Applied research Synergy in the Trent region) made up of four elements:

• Operational executive: this meets monthly to supervise, co-ordinate and lead the detailed operation of BOAST themes and the wider relationship to the local health economy. It implements policies and project proposals agreed by the BOAST board and NIHR.

• Theme structures and management: this ensures that themes and projects run to agreed timetables and budgets, meet all regulatory ethical and clinical governance requirements and report in a timely way. Training and support are offered by a senior trials manager. Each theme has an quarterly executive committee meeting.

• Research support: trial management, administration, statistics, health economics and health psychology input into the studies constituting the research and implementation themes are centrally provided, sharing methodologies, protocol and procedures.

• Engagement of service in research and research in service: 1 day each week, 20 to 25 diffusion fellows encourage research-based innovations in clinical practice and work with clinical staff to stimulate research. Associate fellows receive monthly e-mail updates and can become involved in a variety of activities hosted by BOAST, including a road show to take lessons learnt from BOAST to other parts of the East Midlands.

There are three governance centres:

• Centre governance is to establish memoranda of understanding between partners, meet quarterly to set general strategy and plan updates, ensure clarity of roles, manage risk and outputs, oversee forward planning and sign off annual reports. Members are representatives from the SHA, local authorities and trusts.

• Research governance is undertaken by research leaders from outside and inside the region. There is also a scientific committee chaired by an external expert to oversee the scientific quality of research, ensuring projects are peer reviewed and conducted in accordance with prevailing ethics and research procedures.

• Partnership governance: two board subpanels, one looking at commissioners and one at health service users, carers and the public, ensure that the board is aware of priorities, issues and concerns identified by service users, the public and commissioners. Members are elected.

The CLAHRC has a chair, director, manager, two engagement fellows and 20 to 25 diffusion fellows.

Geographical and demographic context

The CLAHRC covers half of the population of the East Midlands SHA, which in total includes Leicestershire, Rutland and Northamptonshire as well as Nottinghamshire, Lincolnshire and Derbyshire. The SHA is responsible for around 4.3 million people.

High-level aims and key objectives

The overall goal of CLAHRC-NDL is to improve patient care by demonstrating the feasibility and usefulness of organisational learning in the NHS, and build capacity to apply organisational learning in the NHS. The overall strategy is to couple organisational learning and behavioural medicine (which combines behavioural, social and organisational science) to improve patient outcomes. Specific objectives include:

• addressing cross-cutting themes of universal relevance concerning access to health care and occupational engagement, as a means to promote engagement and diffusion in the NHS workforce, service users and other stakeholders such as local councils

• sustaining a coherent platform for future health gains in the East Midlands through developing capacity at the organisational and individual level in the local health economy, enabling the NHS to take the lead on future implementation research.

CLAHRC-NDL approach

The overall approach is based on organisational learning theory and uses diffusion fellows and communities of practice as mechanisms to encourage change:108

• Employ and develop diffusion fellows seconded by practice partners in BOAST.

• Engage health-care practitioners and managers as BOAST associates, and involve health professionals and other local stakeholders in research and implementation activity.

• Set up research themes focused on chronic illness in the areas of mental health, stroke rehabilitation, young people and primary care.

• Set up research-based implementation themes looking at implementation research and educational developments, and at engagement, synthesis and diffusion.

• Engage commissioners through governance procedures and support the development of commissioning competencies through organisational learning that drives system-wide change.

• Set up focused research projects to meet local research priorities.

Research, dissemination and engagement themes

The research theme focuses on four areas (primary care, mental health, children and young people, stroke rehabilitation) and has three aims:

• To improve clinical care to at least the best current national standard by studying issues identified as local priorities and open to change. Studies attempt to identify where patient care is failing because of unsatisfactory interventions or unsatisfactory service provision.

• To explore if organisational learning research is feasible, informative and of additional use to the process of commissioning and delivery of NHS services.

• To develop capacity in the NHS workforce so that NHS commissioners and providers can undertake organisational studies research with minimal academic supervision.

The implementation theme aims to:

• identify barriers and facilitators to implement innovations

• identify how barriers and facilitators might be mediated or leveraged

• provide local-level ‘situated’ educational support and national-level postgraduate programmes

• engage, develop and sustain capacity within the NHS to implement and evaluate innovation among those delivering services

• develop measures to evaluate the effectiveness of BOAST.

The engagement theme seeks stakeholder engagement in CLAHRC work and in the synthesis and dissemination of CLAHRC work, with a focus on access to care and occupational outcomes.

Expected outputs/outcomes

• The outputs will be publications in peer-reviewed journals, clear and relevant recommendations, ‘evidence to practice’ guides and a systematic approach to communication, engagement and diffusion. The outcomes will be changed practice in selected sites, a national contribution to guidelines and knowledge of good practice, a change to NHS services reflecting findings, and an enhanced training and education capacity.

• The approach depends (among other things) upon the quality and relevance of the research along with the innovative use of engagement and diffusion fellows. The BOAST synthesis and diffusion themes will therefore be especially important outputs. The quality and peer-reviewed nature of the research is seen as important both to reinforce local adoption and to contribute to national guidance and appraisal.

Challenges

• Collaboration tensions: researchers and practitioners have different ways of working; practitioners tend not to understand what researchers are thinking, and researchers tend not to appreciate the problems practitioners face.

• Community engagement: prompting users to define the problems they face is difficult and not always helpful.

Emerging lessons

• There are limits to the codification of knowledge, and some knowledge must be transferred in person; interpersonal contact is important.

• The CLAHRC can usefully bring together a range of activities: for example, RCTs can be a learning as well as an implementation effort.

• Not all users’ experience is useful. Distinguishing between experience that does not seem to contribute much and experience that is useful is difficult but necessary, otherwise user involvement risks becoming a tick-box exercise.

Translation seems to differ significantly by therapeutic area.

FIGURE 64.

Nottinghamshire, Derbyshire and Lincolnshire logic model of the theory of change.

Partnership and governance structures

Universities of Exeter and Plymouth and all the NHS trusts in the far south-west. The partnership has been facilitated by the local SHA (NHS South West) and is complemented by the NIHR CLRN in the south-west. Most of the CLAHRC partners have a history of recent and explicit collaboration, and PenCLAHRC builds on the strong joint research governance structures that were already in place across the Peninsula College of Medicine and Dentistry and its NHS partners.

The PenCLAHRC management board consists of 23 senior members with representatives from all the NHS trusts, the universities and patients. The director of PenCLAHRC chairs the executive group, which includes the PenCLAHRC project manager and the research and implementation theme leaders; the director oversees day-to-day management issues and ensures good communication and project integration. Each implementation theme has a theme lead and a separate theme management group.

Geographical context

The CLAHRC covers the south-west peninsula, with a population of 1.6 million people.

High-level aims and key objectives

The goal of PenCLAHRC is to improve health outcomes for patients and the public through the conduct and translation of patient-focused research. This goal embraces both clinical and cost-effectiveness in the use of evidence-based implementation, and PenCLAHRC strives for national as well as regional impact. More specifically, the objectives are:

• to support the identification of research questions that address clinical concerns (within the four key research themes)

• to support and undertake research that tests treatments, interventions and new ways of working in specific clinical areas, to see if they are effective and appropriate for everyday use in the health service

• where effective interventions are identified, to support research into how NHS staff can implement them into their everyday working practices, so that patients across the local community and beyond receive a better standard of health care

• through PenCLAHRC research and educational activity, to embed and fuel the partnership between the NHS and academia, building research capacity in applied health research and implementation

• to treble the partnership’s involvement in applied health research to enable it to become a major sustainable contributor to this field for the future

• to promote engagement and involvement in research that reflects real clinical concerns, contributing to the creation of a research-receptive culture in the local NHS.

PenCLAHRC’s priorities are aligned with the priorities of NHS South West.

Research and implementation themes

• The four formal research themes are diabetes and cardiovascular health, mental health and neurology, development and ageing, and environment and human health. These themes reflect the existing research strengths within the partnership and include many of the major problem areas for public health and chronic disease and the bulk of NHS expenditure.

• However, different projects take place at different stages of the research process so some of the projects are projects which could be characterised as implementation projects. A large component of funded work comes from the question generating and prioritisation, and there is a common system for the identification and structuring of research and implementation.

• By colocating multiple implementation initiatives from different areas of practice within a single overarching group, the implementation group seeks to derive generalisable evidence for the whole health-care community.

PenCLAHRC approach

The model adopted, ‘Engagement by Design’, builds on the previous experience of the academic leads of working closely with clinicians, service users, and NHS and social care organisations. All these stakeholders are involved at all stages of the research process, from the generation of research questions, through the design and conduct of research, to the design and evaluation of implementation strategies.

• Academics, clinicians and managers working in NHS organisations and the social care sector, and patients, the public and third-sector organisations work together to identify key research/implementation questions.

• A rapid review process identifies what is known about a potential research issue and where key information gaps exist.

• Depending on the results of the review, this may lead, if the evidence is clear, to the design of implementation strategies or, if evidence is not apparent, to primary or secondary research.

• The design of these research or implementation projects will continue to involve those who originally generated the research question to ensure that projects remain grounded in service requirements and that the need for effective implementation guides research design.

• PenCLAHRC is supported by a prospective, internal, formative evaluation.

Intended outputs and outcomes

• The CLAHRC aims to produce some movement in the culture so that collaborative working between different stakeholder groups (including patients and the public) becomes embedded.

• It seeks to delineate research questions, some of which will be taken up by other funders, some of which will lead to local studies.

• It will rapidly review evidence already available.

• It will help NHS partners to implement research findings from elsewhere

• It aims to develop specific tools for implementation based on implementation research.

• It will build capacity, which includes the development of skills among the public, clinicians, academics and managers.

• The CLAHRC will be valued as a priority resource for NHS commissioners and providers, and as a means of making sure that their priority research needs are addressed by the university. This advantage will be available to the whole south-west region.

Challenges

• Initial uncertainty about the CLAHRC’s remit.

• Tensions between academic and NHS cultures: between producing academic papers and developing a focus on work of real, practical and immediate value that produces soundly based, sustainable change.

• Keeping it real and staying relevant.

• Linking to local health properties.

• Integration with commissioning.

• Fast prioritisation of decisions about research.

• Getting (and retaining) NHS management buy-in, garnering organisational commitment.

• Developing the capacity to respond fast to the problems of the day.

• NHS trusts’ abilities to provide input into the PenCLAHRC question-generating model, and to get a perceived return on their matching funding.

• Adequately exploiting other NHS initiatives, such as Quality, Innovation, Productivity and Prevention.

• Debates with trusts about which outcomes should be measured.

• Weakness of research implementation in trusts.

• Raising expectations that PenCLAHRC cannot fulfil; for example, developing research questions through their model which they cannot use themselves.

• The new world of no PCTs.

• Special position of the district general hospitals, which tend to express little interest in research.

• Research bureaucracy; for example, research governance and ethics arrangements, not being able to get CLAHRC projects adopted under the clinical research network portfolio and the deeper issue of how the various government initiatives (clinical research networks, HIECs, etc.) work together with the CLAHRCs.

Emerging lessons

1. Addressing people’s actual concerns:

   1. Need to involve patients adequately: a very high proportion of interventions are never used; they are prescribed but they are not used by the end user if the patient is not convinced that the benefits will outweigh the costs. There is a need to involve patients to help develop the partnership, and fund this adequately.

   2. Clinicians and policy-makers: there is a perception that clinicians as well as policy-makers seek to achieve specific outcomes and there is a need to communicate them appropriately. PenCLAHRC has used clinical locality leads – clinicians who can spread the word about the CLAHRC and work with clinical teams to develop researchable questions.

   3. NHS management: the PenCLAHRC operational research facility (PenCHORD) is one response; it has recognised the need to work alongside NHS managers and clinicians to transform the ways in which care is organised and delivered.

2. The importance of marketing and of early dissemination of findings.

3. The need for flexibility when working together and the importance of having an emergent approach based on learning.

FIGURE 65.

South West Peninsular CLAHRC logic model of the theory of change.

Partners and governance structure

Higher education institutions – University of Sheffield, Sheffield Hallam University; NHS foundation trusts – Sheffield Teaching Hospitals, Barnsley Hospital, Rotherham NHS Foundation Trust, Sheffield Children’s Hospital, Doncaster and Bassetlaw Hospitals, Sheffield Health and Social Care; NHS PCTs – Barnsley, Doncaster, Rotherham, Sheffield. The partnership is supported by the South Yorkshire NIHR CLRN. There is a local history of strong collaboration, including the Sheffield Health and Social Research Consortium, which has been in existence since 2001.

The SY-CLAHRC Board is chaired by a senior NHS academic who is independent of the CLAHRC. An executive committee chaired by the clinical director reports to the board and is charged with overseeing progress with project milestones and deliverables within each theme; it is supported by a committee of theme leads. The CLAHRC director is supported by an operational team and an associate director. Each theme has a designated steering group.

Geographical context

The CLAHRC covers the whole of South Yorkshire. This area has a population of 1.3 million and covers 1559 km². This region experiences poorer health outcomes than other regions in England.

Aims and objectives

The CLAHRC focuses on enabling patients with long-term conditions to self-manage their care and aims to reduce health inequalities across South Yorkshire and to promote and support networks through which peer-review processes will be strengthened, international links developed, front-line staff and commissioners engaged, and academic and other partners secured to assist knowledge transfer and improved business development.

The mission of CLAHRC-SY is to undertake high-quality, strategic, applied research and related education in order to enable a step change in the way research is delivered and services are designed in South Yorkshire; and to foster knowledge transfer that will improve the quality and effectiveness of health-care delivery across South Yorkshire.

Specific objectives are:

• to improve the health and well-being of people with long-term conditions in South Yorkshire through a distributed model of health research

• to implement an innovative model for conducting applied research and translation which is embedded in the self-management and technology agenda for people with long-term conditions

• to provide leadership in the governance of applied research and operate according to rigorous principles

• to promote the transfer of knowledge from applied research into practice and facilitate the implementation of new knowledge into health service policy and practice

• to encourage commercial exploitation, where appropriate, for the benefit of the South Yorkshire economy

• to use existing advances in health technologies within the care pathways of South Yorkshire, enhancing self-management and improving access, choice and personalised care for people with long-term conditions

• to work together as an organisationally robust and creative collaboration of higher education institutions and NHS leaders who will foster capacity and innovation in applied and translational research

• to inform and respond to the needs for service commissioning within South Yorkshire

• to ensure that the modern NHS workforce fully embraces both the self-care and the technology agendas for long-term conditions.

CLAHRC-SY approach

The overall approach incorporated implementation themes that built on the knowledge to action approach developed in Canada and on local work to develop evidence-based clinical effectiveness. 109

• To integrate applied research into the business development and planning processes of health-service partners. By doing this, it is hoped that health service organisations will reduce the risks that are associated with the introduction of new initiatives by basing decisions on evidence-based planning and conducting rigorous evaluation of service changes and new interventions.

• To capitalise on the expertise of academic partners in knowledge transfer and research implementation to work in collaboration with health service partners. There is an expectation that such an approach might help promote the delivery of effective care along the patient pathway and lead to enhanced outcomes and better quality of care overall.

• To involve front-line clinical and managerial staff to improve the relevance of the research produced.

Research and implementation themes

South Yorkshire CLAHRC divides its activities into 12 themes that build on existing research strengths:

• eight research themes focusing on self-management and self-care of long-term conditions (depression, chronic obstructive pulmonary disease, diabetes, stroke, obesity, attention deficit hyperactivity disorder), the application of technologies and genetics

• four implementation themes focusing on research translation, particularly user-controlled health-care design, intelligent commissioning, knowledge into action and inequalities in health.

Expected outputs/outcomes

Research outputs include a screening tool, revised guidelines and other interactive tools for engaging individuals and organisations. Tangible outputs include a new website, newsletters and training. Other outputs concern a more effective business innovation and communication strategy, improved collaboration with partners and new ways of engaging individuals. The outcome is to integrate these programme outputs into the daily practice of NHS and research bodies in the partnership.

Challenges

• Recruitment, which took longer than expected.

• Changes in the NHS and in particular the restructuring of PCTs.

• Concerns that some of the research priorities set may be more in line with areas of research expertise of those leading than with the priorities and challenges faced by health service partners.

FIGURE 66.

South Yorkshire logic model of the theory of change.

Quebec Social Research Council (CQRS) Programme Grants

In 1992 the Quebec Social Research Council (CQRS) introduced a grant programme to encourage researchers, practitioners and policy-makers with the aim of delivering health benefits. The programme’s aims were to:

• introduce a culture of research within action settings, which are often isolated from social sciences

• introduce a culture of action into research settings, increasing the pertinence and usefulness of the research produced

• create an improved context for the training of young researchers and practitioners.

The 10-year programme offered infrastructure funding for research teams interested in developing programme-based partnerships between university researchers and the institutional sector. It introduced a range of requirements for the organisational structure of the partnerships (codirection from a researcher and practitioner, independent secretariat, etc.) to ensure effective integration, as well as offering long-term funding to ensure stability.

Antil et al. analysed the implementation of the CQRS (based on consultations with key informants from the programme). 5 Their analysis did not assess the impact of the CQRS on the quality, application and productivity of social research, but it noted that the teams supported by the CQRS were involved in the research and development of many innovative social programmes that were widely implemented across Quebec, that the principal stakeholders considered it to be a success and that the CQRS model had influenced other research foundations in Canada.

The following factors were thought to have explained the success of the CQRS programme:

• Leadership and coherence in implementation: all the partners found benefits in the programme, thus ensuring buy-in. The flexibility and long-term nature of the funding provided time and space to build partnerships. It provided effective and inspiring institutional leadership by presenting a well-designed programme and executing it effectively and efficiently.

• Favourable political and social conjuncture: it was linked to a broader strategic framework, and the partnerships were required to provide demonstrable proof of their results.

• Ability to respond to the needs of institutions providing services and formulating policy: it improved access to useful research for health-service providers and policy-makers through increased contact and interaction with researchers, and was also effective in bringing together the different cultures of action-based policy-makers and health-care practitioners and university-based researchers. Decision-makers’ receptive capacities for research results were improved.

• Responsive to the needs and expectations of universities: it gave universities leverage to obtain other funding, and made them more receptive to collaborative schemes.

Denis et al. explored the views and experiences of the researchers and practitioners involved in the CQRS programme, with similar findings. 125 The programme was viewed positively by participants and had significant outcomes in terms of building the skills and mind-sets to facilitate future collaborations, as well as building a culture of experimentation. There were positive changes in the attitudes and receptiveness of both researchers and practitioners, and a convergence of views about the importance and value of collaborative research.

NHS R&D Implementation Methods Programme

The NHS R&D Implementation Methods Programme (IMP) was set up in 1994. It was the last of a series of time-limited topic-specific R&D programmes that were otherwise developed largely with clinical research in mind, covering fields such as mental health and cancer. The IMP spanned a wider range of research fields, including social science, policy and management. With a budget of £4 million, the IMP funded 36 time-limited projects exploring issues of research implementation. It ended early because of external changes to the structure and remits of the NHS, and the full programme was never realised.

An evaluation carried out in 2002 regarded the programme as highly innovative. 126 Some of the projects funded had considerable impact but the IMP as a whole was hampered by not being well understood by the largely clinically based researchers who responded to the call for proposals. Specific difficulties (and insights of importance for initiatives such as CLAHRCs) were:

• tensions between the perceived need for immediate demonstrable relevance to practice and more academic methodological/conceptual issues

• the low quality of many applications

• the lack of a programme-wide tailor-made communication strategy to support interactions among stakeholders, including the potential users of research findings.

The last of these was a significant shortcoming; such a strategy was planned but not realised because the IMP ended earlier than planned. Many of the problems encountered by the IMP came about because the state of knowledge at that time could not fully support its ambitions. The evaluators suggested that it might have been better to build the programme more gradually, learning from experience as it developed.

Quality Enhancement Research Initiative programme

The Quality Enhancement Research Initiative programme was launched in 1998 as part of a restructuring of the US Veterans Health Administration. It continues to this day. QUERI seeks to accelerate the implementation of new research findings into clinical care by creating a bridge between those performing research and those responsible for health system operations. QUERI researchers collaborate with policy-makers and health-care professionals to implement evidence-based practices into routine use, working within disease- or condition-specific units. The model is based on six logical steps:127

1. Identify high-risk/high-volume diseases or problems.

2. Identify best practices.

3. Define existing practice patterns and outcomes and variation from best practice.

4. Identify and implement interventions to promote best practices.

5. Document that best practice improves outcomes.

6. Document that outcomes are associated with improved quality of life.

The implementation stage (step 4) is generally subdivided into four phases to ensure effective roll-out (the planned action model):

1. single-site pilot

2. small-scale multisite trial

3. large-scale, multiregion trial

4. system-wide roll-out.

An overall evaluation of the programme and the many papers it has produced has been published. 62 This found that the programme had represented a ‘paradigm shift to action-orientated research’ and had utilised and substantially contributed to the implementation literature. The QUERI programme demonstrated the extent to which change takes time and persistence; benefits in terms of health gain were starting to emerge only in 2009, when this evaluation was published. The evaluation also found that the QUERI approach had been a significant contribution to the field of implementation and had contributed to debates about the ethical issues relevant to implementation research, the need for economic evaluations and the need to sustain change. The overall conclusion of the evaluation was resoundingly positive.

The QUERI programme can be considered a national case study that reveals that changing a health-care and research system by reorienting efforts towards the implementation of best practices is a complex, long and never-ending process, but the potential gains in health outcomes make it worth it. The QUERI programme also illustrates the value of working top down and bottom up, if not simultaneously, then iteratively. In other words, clear vision and leadership, supported by frameworks and tools, as well as a responsive collaborative team-focused work force, is a winning combination for innovation within the health system.

Atkins notes that the QUERI programme and implementation research have both come of age, and discusses some of the challenges to come. 127 These are as follows:

• Tying implementation science to more effective implementation: going beyond basic discovery (i.e. listing lessons learned) and using and testing the increasing number of theoretical implementation models described in the literature.

• Methodological debate: ensuring that evidence is both valid and acceptable, and that all relevant methodologies are considered without prejudice in order to foster timely improvements in care while protecting against ineffective or even harmful change.

• Ensuring that implementation research becomes more relevant to the daily decisions of key stakeholders: aligning the priorities of research and the health-care system as early as possible.

• Developing adequate and useful economic evaluations of implementation interventions: Promoting economic analyses and aligning economic models more closely with the budgeting and decision-making processes.

• Developing capacity: Nurturing new implementers (front-line connectors) and new implementation researchers.

• Strengthening connections to other operational and research activities that influence change in the health-care system, such as quality improvement, continuing education and health informatics: aligning with existing priorities.

• Managing expectations: being realistic about what success looks like and transparent about goals and objectives.

• Demonstrating impacts on health and healthcare that are meaningful to key stakeholders: showing what difference implementation research makes.

Need to Know Project

In 2001 the Canadian Institutes of Health Research funded the Need to Know project in Manitoba. This project built on an existing relationship between the Manitoba Centre for Health Policy and the provincial health authority, Manitoba Health, and was designed to address the need for research to support the decision-making of rural/northern regional health authorities, to promote and develop models of collaborative research and, ultimately, to improve health outcomes.

An evaluation of the Need to Know project was published in 2005. 7 This concludes that much of what was discovered through this project about knowledge translation was not new and, after initial scepticism, turned out to be equally well understood by researchers and community partners. There were clear messages about:

• the importance of building trust between partners through formal and informal contacts

• the need to overcome institutional barriers (such as understanding the time and resource limitations of partners)

• the need to develop a common language and culture

• recognising that time is required to build relationships and generate useful outcomes.

Participants regarded the relationships created by the project as its most significant outcome, and their creation as one of its most difficult challenges. The emphasis on capacity building included helping practitioners to engage better with research, helping researchers to understand more fully the practicalities of health care and the needs of patients, and building organisational capacity in all the partner organisations to identify, develop and implement well-founded and useful research.

Key lessons from these programmes

• The aims of the CQRS programme were very similar to those of the CLAHRCs and its success factors were highly relevant to the latter. They included leadership and coherence in implementation; a favourable political and social conjuncture; an ability to respond to the needs of institutions providing services and formulating policy; and responsiveness to the needs and expectations of universities.

• The IMP was the first attempt in England to set up a programme of implementation research. It followed the applied, needs-based emphasis of the NHS R&D programme and concentrated largely on what was later identified as the second translation gap. What the experience of the IMP highlights is the danger of having insufficient time to develop capacity among all partners in the programme, to promote strong and productive interaction between different groups and to develop a robust communication strategy.

• The QUERI programme has generated a large literature and been very influential; its experiences were drawn on by the CLAHRCs, either explicitly in their published protocols107 or implicitly in their programmes. The experience of the QUERI programme confirms that a long time-scale is required to see systemic change, and, therefore, suggested from the start that the CLAHRCs were unlikely to produce measurable health gains over a 5-year period and that health impacts would become evident only later.

• The Need to Know project also reinforced the message about the time and effort it takes to build effective relationships between professional groups and stakeholders.

Diffusion of innovation

Arising out of their review of the literature on research diffusion, Greenhalgh et al. developed a multifaceted evidence-based model of the diffusion of innovations in health-service organisations. 26 The broad scope of this model can be seen from its main components (Box 7).

The links between these individual components form an important part of the model. They include linkage at the development stage between the developers and potential users of an innovation, a positive and supportive change agency and effective external change agents.

Research use

Nutley et al. identify three models of research use:106

1. Research-based practitioner model

   1. In this model, individual practitioners seek out and keep themselves informed about the latest research to inform their decision-making. The origins of this model lie in evidence-based medicine and its focus is on enabling the practitioner to access good-quality research and develop the skill to appraise this evidence critically.

2. Embedded research model

   1. In this model, relationships between the research and the clinician/manager are mediated by a number of organisational factors. Practitioners rarely engage directly with research findings, and the responsibility for developing and ensuring research-based practice lies with local and national policy-makers and service-delivery managers. The model’s approach depends on the widespread adoption of research-informed guidelines and tools, and it therefore tends to restrict rather than emphasise practitioner autonomy. The guideline movement to some extent reflects this model.

3. Organisational excellence model

   1. At the core of this approach is a recognition that actions undertaken by individual practitioners are influenced by organisational, procedural and cultural service structures and policies. The focus is on changing the culture and context of the organisation; initiatives to adapt research findings to this context will take place at the local level, relying on partnerships with universities and other bodies to facilitate cross-pollination and the effective use of knowledge. The model contains many parallels to the CLAHRC scheme, and was specifically identified as an important influence by CLAHRC-LNR.

Quality improvement

Quality improvement initiatives are another means through which research finds its way into routine practice. Powell et al. 128 describe five models of quality improvement (Total Quality Management/Chartered Quality Institute, Business Process Reengineering, IHI and rapid cycle change, lean thinking, Six Sigma) and five system-wide multimodel approaches (Jönköping County Sweden, Kaiser Permanente, QUERI, Organising for Quality case successes, IHI’s 100,000 Lives campaign). The models share a set of necessary, but not sufficient, conditions for the successful implementation of change. These are:

• active engagement of health professionals

• active participation of middle and senior managers and the support of board members

• use of different approaches to intervention and allowing sufficient time for prolonged action

• alignment of the process of implementation with the broader goals of the organisation

• embedding of implementation as a part of everyday work of all staff.

Information technology support and sufficient training and development also matter.

However, crucially, Powell et al. 128 conclude that there is no one ‘right’ approach. Models should be selected in relation to circumstance and applied flexibly over a sustained period in order to engage staff at all levels and achieve desired outcomes.

Collaboration

There are two key features of collaboration models,4 both of which underpin the work of the Canadian Health Services Research Foundation, which was established in 1997 to facilitate evidence-based decision-making in Canada’s health system:43

1. Linkage and exchange between researchers and decision-makers, ‘[Here] the primary motivation for collaboration comes from the demonstration that a major predictor for the application of research to practice is the extent of interaction throughout the research process between the researchers and the practitioners who could potentially use the results’ (p. 2). 4

   1. The collaborative, or interaction, model aims to increase the implementation of research by encouraging applied health research that is directly relevant to the health-care system.

2. Knowledge brokering – bridging the know–do gap (a component of the linkage and exchange model)

   1. Here research use is defined not just in terms of process change but also in terms of changes in understanding. In knowledge transfer there is a perceived need for frequent personal interactions; hence the importance of collaborative working, including the colocation of health-care professionals and researchers,129 and the use of knowledge brokers to bridge the know–do gap. 80