Starting point

At the time of bid development, Ashgrove, Oakdown and Hazeldean each started at a different point in relation to the nature of the existing organisational relationships between the HEI(s) and local health services through which the collaborations needed to be established. This became an important issue in the context of the relatively short turn-around time between the call and the submission date for CLAHRC, and subsequently at the start of their funding and, therefore, action.

Within Oakdown it was reported that pre-existing relationships had been important at the time of bid development:

We had . . . a very sound framework for the CLAHRC before we started and those key folk contributed hugely to the writing of the application and we managed to put it together very swiftly and in terms of NHS partners because . . . key theme leads . . . were in the NHS and they were in academia so they weren’t full-time university professors . . . so this little group of people were very embedded in the NHS anyway.

Leadership role, CLAHRC core team, Oakdown, R1

Not only had these relationships facilitated the co-development of the bid but they had also created a starting point for the CLAHRC where individuals had not needed to ‘go out and create new relationships, there was already quite an intimate fabric there to build on and for people to engage with’ (leadership role, CLAHRC core team, Oakdown, R1).

In contrast, participants in both Hazeldean and Ashgrove reported a different sort of starting point, in which the relationships needed to be built on a project-by-project basis because these organisational connections had not been well established at bid development stage; for example:

I was told to go out and evaluate the service, first of all I had to find out about the service and this person [name] didn’t know anything about it. So suddenly to have this company called CLAHRC who was not heard of by anybody, because we were very new.

Implementation facilitator, Hazeldean, R1

Similarly, participants in Ashgrove reported that it had taken some time to develop relationships to be able to progress action on CLAHRC activities:

So it’s really taken 12 months, I think to build these clinical relationships with colleagues in primary care . . . get themselves known, to be accepted.

Clinical academic, Ashgrove, R1

The political landscape has changed and we didn’t have the links [with the NHS] there to begin with . . . there wasn’t time to develop the collaborations and although chief executives signed up that is not the same thing as collaboration.

Clinical academic, Ashgrove, R1

Interpretation of the Collaboration for Leadership in Applied Health Research and Care brief

The CLAHRC journey was also shaped by the way in which the call for proposals had been interpreted. The NIHR call set the establishment of the CLAHRC ‘pilots’ within the context of the ‘second gap in translation’ and of improving patient outcomes through the conduct and implementation of applied health research, including evaluating initiatives and strategies to increase the use of evidence in practice.¹⁰⁸ There was significant potential for flexible interpretation of the NIHR call and, therefore, inevitably those leading the bid writing for the CLAHRCs had interpreted the brief variously, particularly in relation to their role in the implementation and application of applied health research and the emphasis they placed on this in their plans.

There had been a trade-off in focus, and, therefore, resources, between conducting research and undertaking implementation-related activity. Overall, the balance tended to be weighted towards activity that focused on conducting, rather than implementing, research. Where the balance was weighted towards the generation of evidence, it was of course possible to conduct research in a more or less collaborative way, leading to the potential development of more or less implementable or implemented research. Oakdown, for example, explicitly set out to avoid the CLAHRC being perceived as ‘some sort of piglet [sic] research programme that has a limited life’ (NHS senior leadership role, Oakdown, R1). Given this, it espoused ‘coproduction’ as its preferred approach and ‘to provide a framework which will make it more systematic to think about how you scope evidence and apply it in practice when you are working on a particular issue’ (academic, Oakdown, R1).

There are also data to suggest that the interpretation of the CLAHRC’s remit may have been influenced by the background and knowledge of those involved in its development, including some political and philosophical tensions: ‘There are huge internal political divisions with the CLAHRC’ (clinical leadership role, Hazeldean, R1).

Some participants also acknowledged the need to learn more about implementation: ‘So this [implementation] is something we are trying to learn’ (clinical academic, Ashgrove, R1).

Once the teams had responded to the brief and received funding, it was perceived that there had been very little flexibility in their plans to make changes later on. One participant also reflected that there had been little dialogue with the funder about the funder’s expectations of the CLAHRC since the decision to fund was made:

The problem with that is that NIHR had done very little to clarify what they are looking for in a CLAHRC. So other than when we put in the original bid, the NIHR have been absolutely silent about what they expect from the CLAHRC.

Leadership role, CLAHRC core team, R1

Setting priorities

Although the broad parameters for CLAHRC activity were set within their proposals, the way in which CLAHRCs went about establishing and agreeing priorities differed. For example, participants in Hazeldean reported a level of pragmatism in their approach to trying to engage with local priorities in that a number of PCTs had funded the CLAHRC and therefore they had to have some work ‘done in them’ (academic, leadership role, Hazeldean, R1):

The minute we got the money and got started . . . you have partners paying, in our case NHS partners, and you have got to get on and do something. So it was much more – ‘we have got four clinical areas, who is interested in doing what?’

Leadership role, CLAHRC core team, R1

In contrast, a number of Ashgrove participants reported a potential disconnect between regional NHS priorities and CLAHRC activity (in the early stages mainly around research priorities):

the potential disconnect between the priorities of the NHS and the work that is being done, that is not to say our projects weren’t important, they were the priorities of some senior people in the NHS . . . but those things were defined possibly as much or even more by those people with their academic hat than the health priorities of the NHS they were serving.

Leadership role, CLAHRC core team, Ashgrove, R1

Over time, and in relation to their implementation remit, both these CLAHRCs shifted their approach to identifying priorities in a more service-orientated way, although still reliant on either party making an approach. It was reported that ‘alignment’ with a service’s priorities had made it easier to ‘implement things and achieve things’ (management role, Hazeldean, R1).

In contrast, participants in Oakdown reported that at bid development stage they had collaboratively identified priorities of relevance to the NHS. This, they stated, had facilitated continued engagement of the NHS ‘because of the implementation side that this wasn’t just about doing blue sky research, it was about embedding it in practice’ (leadership role, CLAHRC core team, Oakdown, R1). This CLAHRC had also developed a mechanism for identifying the ongoing prioritisation of projects through consensus development events/meetings.

However, participants in all three of these CLAHRCs reported the challenges of working to develop priorities with NHS partners in a continually changing landscape, including in their resources and boundaries.

Summary

At the conception of the CLAHRCs these antecedents established some of the conditions that played out in various ways in the subsequent life of the CLAHRCs we studied. The starting position for each CLARHC is mapped in Figure 8. For example, it was evident that the initial position of those developing the CLAHRC proposal on issues, such as the balance between implementation and research, determined the relative attention that was paid to these agendas in their plans. Additionally, a divide between higher education and service, and therefore the potential for different agendas and competing priorities, emerged early on in the life of the CLAHRC depending on the nature and quality of historical and existing organisational relationships. This set the tone for people’s motivation to engage with the CLAHRC and its activities. These starting points or positions set the direction of travel in an enduring way.

FIGURE 8

Starting positions of CLAHRCs.

Engineered architecture: structure and space

As a distributed model for the conduct and application of applied health research across a health community and wide geographical area, the structures, roles and lines of accountability that were established within a CLAHRC provided a more or less supportive scaffold for communication, collaboration and implementation activity within and across its functions.

The activity within the CLAHRCs had been organised into themes. It was reported that this had been as a result of responding to the way the call had been constructed. The call for proposals had asked for detail about the specific research and implementation themes that would be pursued, including an overview of how they would relate to each other. The allocation of finances within the proposals was also distributed to themes and therefore, on balance, the majority of the financial allocation within CLAHRCs was to the generation of research, rather than its implementation.

Setting up the CLAHRCs as a collection of themes had resulted in the creation of boundaries between them as they operated in parallel and with limited connection between them and their functions:

it doesn’t work in parallel because the implementation teams started at the same time as the researchers and they had to get on implementing something and so they . . . went off and did their own thing . . . but it meant the strands went in different directions. I think that bridge [between research and implementation] has been difficult to properly bridge if people are honest with you.

Researcher, Hazeldean, R1

The consequences of the way in which the CLAHRCs had been engineered included challenges with communication, knowledge flow and sharing.

There were definitely problems with interaction, sometimes information did not flow easily.

Academic, Hazeldean, R1

There is not a shared understanding of what we are all working for because we do have these very separate applied themes who are lost in their research.

Implementation facilitator/boundary spanner, Ashgrove, R1

It was also reported that the issue of sharing across themes was compounded by an element of competition within the CLAHRC:

there was competition there so very often people were not keen to discuss things. They wouldn’t tell you what they were doing because there was some level of competition.

Academic, Hazeldean, R1

Participants suggested that the structural divides served to emphasise existing epistemic and professional differences:

I think the structures . . . have extenuated maybe ideological differences or philosophical differences in how research is done and how the research is gotten into practice. There has been a very big divide on that.

Clinical leadership role, Hazeldean, R1

Given the distributed nature of the CLAHRCs – ‘CLAHRC isn’t an organisation’, as one participant observed – and the challenges that had arisen from compartmentalised structures, their approach to governance became more important. There was evidence within Oakdown that, although the overall themed structure of the CLAHRC had created separation, its approach to governance, including reporting structures and processes, had facilitated some integration and knowledge sharing:

a lot of things around the governance and reporting structures actually helps to build that culture of what is expected and to consolidate that transfer . . . Individual projects without that organisation would be lost.

Leadership role, CLAHRC core team, Oakdown, R1

Although each CLAHRC had taken a similar approach to how it was engineered, there had been a recognition relatively early on that perhaps theme-type structures were not helpful; however, leaders in all three CLAHRCs perceived that there were limited possibilities to make changes partway through. The perception of inflexibility was particularly linked to the way that funding had been structured at the outset:

This CLAHRC as with most of the others, as it was putting itself together obviously came up with a budgetary split across the five themes . . . and that was allocated at that stage and pretty much committed . . . there was relatively little flexibility in the budget to make changes later on.

Leadership role, CLAHRC core team, Ashgrove, R1

Physical proximity between health services and higher education within the CLAHRC entity was a further feature of its engineered architecture. Relative closeness or distance to each other was determined by those setting the original course, related to existing relationships, position and view of a CLAHRC’s mission (e.g. the balance of research and implementation) and approach to doing business (e.g. more or less collaborative versus outreach/consultancy). Oakdown had deliberately decided at the outset to locate ‘CLAHRC central’ within a health service setting; the other two’s main centres remained in higher education settings, although NHS staff employed through CLAHRCs tended to be sited within NHS premises. The concept of colocation was important to Oakdown, as it was perceived to facilitate the development of productive partnerships:

[CLAHRC] brings a lot of likeminded people together in similar kind of areas and bridging that university and service provider divide. A lot of themes have got people from the universities working with service providers all working together and often colocated as well, which is quite important.

Leadership role, CLAHRC core team, Oakdown, R1

. . . so we had a kind of, if I can say, a very sound framework for the CLAHRC before we started and those key folk contributed hugely to the writing of the application . . . in terms of NHS partners because interestingly a lot of those key theme leads . . . they were in the NHS and academia so they weren’t whole-time university professors, so they were gynaecologists who ran clinics, a clinical psychologist who ran clinics, a speech and language therapist who was very involved with the trust speech and language department, myself, who always had a trust appointment as well as a university appointment, so it was this little group of people who were very embedded in the NHS anyway.

Leadership role, CLAHRC core team, Oakdown, R1

In Ashgrove and Hazeldean, those involved in project-level or boundary-spanning activity also recognised the value of sharing physical space as a way of providing opportunities for facilitating local buy-in to projects, building relationships, collaborative working, cross-fertilisation, sharing of ideas and an understanding about what a CLAHRC did; for example:

We are based in a hospital and some of the other themes are not . . . they are scattered and I think the fact that we are sitting together as a theme in one hospital with links with the clinicians and the managers . . . I think that is why actually we have got local enhanced knowledge of what CLAHRC does.

Management role, Ashgrove, R4

Aesthetic architecture: building an identity

Participants described CLAHRCs in various ways, including using the terms ‘consortium’, ‘network’, ‘movement’, ‘confederation’, ‘virtual’, ‘research organisation’, ‘consultancy’ and ‘umbrella organisation’. ‘CLAHRC’ was not a well-understood concept and the acronym itself was felt to be a barrier because it lacked meaning; this was particularly the case for service providers and those not closely aligned to a CLAHRC:

Ha ha, it is obscure . . . no one knows what CLAHRC stands for and those who are engaged with particular parts of CLAHRC do, they know about those parts of CLAHRC but I’m not sure anybody really, outside of the close CLAHRC community, knows what the purpose of a CLAHRC is.

Academic, Oakdown, R1

Both those in the CLAHRC executive and those working more locally in projects and/or in facilitation and boundary-spanning roles described ways in which they had either obscured or explained CLAHRC:

Well . . . number 1, you don’t really mention CLAHRC because nobody understands it.

Implementation facilitator/boundary spanner, Oakdown, R3

. . . also my job is about translation so . . . you know it’s important that our board and our executive team understand what CLAHRC is . . . it’s our job to translate that, make it meaningful to people who are at the bedside or in the clinic or in people’s homes . . . you might say it’s under this heading called CLAHRC but you can see people glaze over sometimes . . . if you use acronyms . . . we have a great role in translation, so they [practitioners] would know it was a project . . . they might not use the term ‘CLAHRC’.

NHS senior leadership role, Oakdown, R2

The challenges with the branding of CLAHRC were recognised as participants reflected on the need for a more active approach to marketing and publicity to raise their profile:

I don’t think a lot of people are aware . . . I think the CLAHRC themselves need to . . . advertise . . . some people have heard of it but they were very much in the minority.

Implementation facilitator/boundary spanner, Oakdown, R3

There was also evidence of an effort to sell CLAHRC to get buy-in and involvement through promoting its potential benefits including those for individuals and for services. The individual benefits of accessing education and training opportunities were made evident by, for example, ensuring certification for professional development portfolios and producing practical tools for practitioners to use. For services, useful ‘carrots that you can dangle in front of them’ (boundary spanner, Ashgrove, R3) had proved to be the potential benefits and incentives of engaging with projects and initiatives that would help them meet targets and gain points in the QOF and/or CQUIN Framework. It was also recognised that the benefits of being involved in CLAHRC activity needed to be realised quickly and obviously by both individuals and organisations.

The perception of ‘CLAHRC as other’ was exacerbated by a view that the partnership was aligned with academia rather than service. Within Ashgrove and Hazeldean, CLAHRC was perceived as academic input or an ‘organisation’ that was based in the universities, with the service side being described separately. There was also a pervasive theme in the data about CLAHRCs being a research funding body, a large programme grant. Given that there was more resource (finance) and attention (themes) on research, and NIHR reporting requirements focused on academic-related metrics, this is perhaps an unsurprising perception and is reflected in the data through scepticism, particularly from service providers, about what a CLAHRC was and what it was there to do:

There was a lengthy discussion about CLAHRC 2 and it was felt that it was going to be important to demonstrate strong partnerships and that ‘money won’t be forthcoming just to do interesting projects, like in CLAHRC 1’. The discussion continued with various academics suggesting that they didn’t do enough as researchers to find out what the priorities of the NHS were, with others feeling that they need to be talking to the NHS now [2011] to find out what their priorities are. This brought a mixed response from others, with the opinion expressed that the NHS changes its priorities so it was pointless asking them. There was concern expressed that by involving the NHS, that they would be seen by others, such as the local AHSC as doing ‘dustbin category’ research rather than pure academic research.

Hazeldean fieldnotes, board meeting 2 December 2011

The perception of CLAHRC as an ‘academic machine’ was perpetuated in cases where there was a higher proportion of ‘pure academics’, who, it was reported, were:

pretty much untouched by the implementation agenda and not that interested and didn’t want to have a dialogue with that half of the CLAHRC.

Clinical leadership role, Hazeldean, R1

The separateness or isolation of the CLAHRC from service providers was also evident in the discourse of participants describing both the design and the execution of project work:

I think we [CLAHRC name] have just been completely in the driving seat as project managers and I guess in an ideal world we would have liked to have someone in the trust . . . on the project management side.

Management role, Hazeldean, R2

Given this, in this example the CLAHRC had taken on more of a consultancy or supplier of services role in supporting trusts to deliver on their priorities. The cofunding arrangements set up an expectation that NHS bodies were going to get a free service. Although that term was used to describe their approach, it was also acknowledged that this approach needed to be balanced by joint working:

it is different with this kind of consultancy with the CLAHRC and it is certainly a balancing act to make sure that you not only have the buy-in but you have people commit to you and work jointly together.

Implementation facilitator, Hazeldean, R1

The identity, role and visibility of CLAHRCs remained a challenge, and participants continued to make observations about this across rounds of data collection, particularly in the context of other, related, policy initiatives such as Academic Health Science Networks. However, as one participant stated and as our data show, the perception of the CLAHRC brand or identity is completely context dependent and therefore patchy. For an academic and/or senior person in the organisation it was more likely that the CLAHRC was visible and that one could have been a beneficiary (e.g. in receipt of financial resources to undertake a project). In contrast ‘in the clinical front line it depends on if the experience was good and the relationships were good and sometimes they weren’t’ (clinical leadership role, Hazeldean, R4). Thus, some people felt part of something called CLAHRC, while others were on the periphery or not involved. These findings probably reflect the distributed nature of a CLAHRC and that it was separate from existing structures in the NHS landscape:

The fact is that although we are a co-operative, a collaborative, in many ways we are not . . . I think it is likely that CLAHRC will be seen as an external organisation in which the trust and CCG deal. It won’t be ‘this is an organisation we are part of’, it won’t be ‘this is a club I am part of’, it will be ‘this is an organisation I am aware of who does things for us because we give them money’.

Leadership role, CLAHRC core team, Ashgrove, R4

In contrast to some of the more negatively framed challenges of ‘CLAHRC’ described above, the CLAHRC label/brand also had the potential to be a boundary object. Organically and over time, which included opportunities for sense making and increasing familiarity, CLAHRCs’ capability in bringing people together to work on common goals developed: ‘well I think it’s the name of the CLAHRC that has enabled this to happen’ (facilitator, Oakdown, R2).

Social architecture: leadership, collaboration and boundaries

Although there were mixed views about what a CLAHRC was, and describing it as an ‘organisation’ in a traditional sense is potentially misleading given its distributed nature, CLAHRCs did directly employ people to deliver work and created environments and spaces for activity and action. Each CLAHRC was strategically and operationally led by some form of executive team, who by virtue of their role and function were the social architects of their CLAHRC, in that they were responsible for creating the milieu to encourage desired action and behaviour. There were a number of features of the social environment that created the conditions in which CLAHRCs approached collaboration and therefore the context through which any implementation activity was mediated.

Boundaries

Multiple types of boundaries were evident in our data (Table 7). The way in which CLAHRCs had engineered their architectures resulted in the construction of boundaries between research and practice, between higher education and health services and between communities. The different perspectives individuals and groups brought to the issue were a function of, and perpetuated, professional and epistemic boundaries. These professional and epistemic boundaries resulted in semantic ones. The geographic delineation of the CLAHRC resulted in physical and spatial boundaries.

TABLE 7

Types of boundaries

From an implementation perspective, boundaries could be conceptualised as barriers because they have to be overcome, permeated, spanned or eliminated for some form of productive action to take place. Therefore, the resilience of boundaries to be crossed and the effort required to find some shared space resulted in challenges with engagement and getting implementation work done. In this context, credible individuals in boundary-spanning roles were a key resource in facilitating the CLAHRC and its implementation agenda (described further in Boxes 1–3):

And so establishing and doing these sort of teaching sessions at first, we did quite a lot of study days where staff came from the trust. And [name of facilitator] was the biggest help in getting over any sort of barriers and boundaries because she was there, she knew the trust, she could sort of go and . . . work with the staff at a ward level . . . and constantly reinforce the message.

Implementation facilitator/boundary spanner, Oakdown, R3

There was also evidence that CLAHRCs had had a role in breaking down boundaries, in resourcing and creating a shared space for different groups of people, primarily academics and practitioners, to meet and network:

certainly strengthened by CLAHRC, it’s almost provided a hub for us to get to know each other a lot better. It has created links between people who mainly work in academia and people who work mainly in the health service so I think it’s made things perhaps slightly more relevant to people who are purely academically focused.

Implementation facilitator, Ashgrove, R2

Summary

The CLAHRCs’ engineered, aesthetic and social architectures shaped the conditions and space for collective action around implementation whereby their governance arrangements prompted varying opportunities for connectivity and engagement. Furthermore, organising activities in themes, which all CLAHRCs had done, emphasised the epistemic and professional differences within and between higher education and practice. The architectures were a consequence of the interpretation of the CLAHRC call, in particular the positioning of implementation and associated resources relative to other functions such as research. Leaders and executives were the social architects of CLAHRCs in that they set the course and the tone for their particular CLAHRC and for delivering the plan. More distributed leadership within a CLAHRC was associated with the social architects being ‘open’ and ‘collaborative’. There were dominant perceptions across all three CLAHRCs, particularly earlier on in their life cycle, that they were academic entities; as a consequence the nature and quality of interaction varied along a co-operation–collaboration continuum. The CLAHRC identity was constructed over time through activities (e.g. project meetings, training sessions) and roles that brought researchers and practitioners together, and thus started to become a known ‘brand’. As each CLAHRC was a distributed and mainly virtual entity, and as a result of the way it had been engineered, multiple types of boundaries were evident. These boundaries then hindered the potential for productive interaction and engagement, and required extra work to overcome them. The negotiation of these boundaries was entrusted to those in boundary-spanning roles, which, as described below, were a CLAHRC’s main investment in knowledge mobilisation.

Motivation to engage with implementation

Motivations to engage emerged over time in the narrative of participants. The motivation or incentive to engage with the implementation function of CLAHRCs was dependent on constituency – the ‘what’s in it for me’ factor. Those that did engage were incentivised by seeing something in it for them. For health services this was expressed in terms of some form of pay-back on their financial investment:

NHS side that we have invested a good deal of money and we want to see ourselves getting something out of it . . . something that will benefit patients and so we should really try very hard to make sure that we hold the CLAHRC to that.

Leadership role, core team, Ashgrove, R4

Services also saw CLAHRCs as an opportunity for support with service priorities and in the improvement of patient care, with the benefit of doing that based on an academic evidence base:

I think the project management support elements of it . . . the academic input side of things, so thinking that they are actually going to get some academic input in how to manage change in their organisation or change a particular culture or context or whatever it might be so that was a big motivator.

Leadership role, Hazeldean, R4

What the CLAHRC did really well was pick up on real service priorities. So it wasn’t a piece of research that was sort of sitting on its own in glorious isolation, it was picking up on real priorities . . . and to have an evidence-based approach to addressing them and getting them into practice was a real motivation for clinical staff . . . we could use CLAHRC as a vehicle to carry out work that enabled us to address those real tricky, wicked problems.

NHS senior leadership role, Oakdown, R4

As described earlier, and reinforced throughout the rounds of data collection, responding and improving on service priorities also had a knock-on effect of meeting targets such as QOF and CQUIN:

The nutrition project and the VTE project were identified by the organisation because they were CQUINs targets and if they didn’t meet the CQUINs targets they would lose a percentage of their income.

Leadership role, Oakdown, R2

For academics, the motivation and incentive to engage presented opposing stances. On the one hand the idea of having the opportunity to be more closely aligned with services and other providers was viewed positively:

From a university’s point of view what we do is public service and public health research . . . so the CLAHRC is just a vehicle for doing the sort of research that we do with the added bonus of close engagement with other providers, the NHS and indeed some industry groups as well so it enabled a much clearer model of coproduction.

Academic, Oakdown, R4

However, for some, the applied research and implementation focus of CLAHRCs did not meet the perceived academic standards that the Research Excellence Framework (REF) demands.

The differences of opinion between the communities explained why there were differences in whether or not they engaged in collective action. This serves to highlight the importance of mutual benefit. It was observed that that benefit tends to arise from the quality of relationships, which, as described earlier, were in varying stages of development even later on in the life cycle of CLAHRC 1:

I think that getting people engaged in it is about them seeing there’s some mutual benefit and where there wasn’t seen as any mutual benefit it doesn’t happen. But seeing there’s mutual benefit has come from relationship building, and there are plenty of times, and I know other CLAHRC directors feel a bit the same, that you feel like you’re a salesperson going round trying to sell things.

Leadership role, core team, Hazeldean, R4

Theory and its application

Both Oakdown and Hazeldean had articulated the use of a particular framework to guide their implementation activity. Hazeldean had framed its bid around the use of the PARIHS framework, and Oakdown had based its on the K2A framework. At the outset, Ashgrove had not articulated a particular theoretical position or starting point, but later ‘talked about our approach, which is the K2A cycle’ (leadership role, core team, Ashgrove, R1). How the use of these frameworks played out in practice varied, particularly at the level of the CLAHRC as a whole; however, their use was more easily described at project level.

In Hazeldean the use of PARIHS alongside a Plan, Do, Study, Act approach was mentioned, although more than one participant agreed that their knowledge, experience and application of both had been limited:

looking at the PARIHS framework was something I think we all adhered to but I don’t think it was something which we made an effort towards working with . . . so all the elements regarding evidence, context and facilitation, we knew they were key parts . . . But perhaps we didn’t actually do a formal context assessment of each practice or situation, it would perhaps be more ad hoc and more observational.

Implementation facilitator, Hazeldean, R1

However, in one of the improvement projects conducted within this CLAHRC, an assessment based on the context element of PARIHS had been undertaken. This discrepancy serves to highlight a disconnect between the expectations of the CLAHRC as a whole and what was happening at project level. That is, there was not a consistency of expectation about the use of PARIHS as the framework of choice for implementation activity. This became more visible in the reporting from a different participant, who was using normalisation process theory in her project activity (although it was not clear how this theory was being used either):

We have used the normalisation process model a lot in our interventions and working with clinicians to change their practice as they go along and I suppose it is a bit arrogant but I thought that that model worked and wasn’t prepared really to engage with a different model.

Researcher, Hazeldean, R1

A lack of consistency in expectation about the use of the PARIHS framework meant that:

across the four teams there are four completely different models of implementation that have been enacted.

Implementation facilitator, Hazeldean, R1

Within Oakdown, it was reported that it used the K2A framework to guide its implementation efforts. Although it was not always articulated how the framework was being used at either CLAHRC or project level, it seemed that different stages/phases within this planned action theory were being operationalised. For example, there was evidence that baseline audits had been conducted within projects, and there were reports that action arising from them had been undertaken. This activity corresponds with stages of the cyclical approach of K2A. For example:

We go through exercises based on literature reviews we did around the evidence of what influences the effectiveness of teams . . . then from that day we have actions that we take forward and we have half a day kind of action learning sets . . . there’s quite a lot of evidence gathering that goes on around it as well . . . all make sure we are not doing any harm but also see areas that we might improve as a result of the changes we are making and we can start to feed that back as well to various patients and staff and indicators.

Leadership role, core team, Oakdown, R1

Clear and explicit links between theory and action, that is theoretical fidelity, were difficult to find in Oakdown and Hazeldean and were absent from the data we collected from Ashgrove.

Type of knowledge mobilisation

The different views, values, interpretations and visions come together to result in a mixed picture, with varying amounts of implementation taking place within each of the CLAHRCs in this study. Over time we identified six types of activity that capture how knowledge was, or had the potential to be, mobilised and actively used, each with the possibility of being approached in interactive and coproductive ways:

1. Service improvement – the implementation of quality improvement methods within and across sites to improve specific service and/or clinical issues, for example in CKD, helping GP practices to diagnose patients with CKD earlier and helping to raise awareness on how to manage the condition more effectively.
2. Making evidence accessible – taking National Institute for Health and Care Excellence guidance and translating it into easily digestible, practical and potentially useable resources/packages, for example taking blood pressure targets and developing aides-memoire for clinical staff to use in practice.
3. Taking national evidence and getting it into practice – typically evident through a focus on prioritising the implementation of guidance (local or national) in local services, for example in improving care for people with VTE based on national guidance and quality standards through helping local implementation of a VTE assessment tool.
4. Mobilising local evidence – examples of intelligence gathering around implementation projects and potential sharing of local evidence about effective practice within and across CLAHRCs, for example using knowledge from one service improvement project to inform a different initiative, and as a result tinkering with the model/approach.
5. Using home-grown research – there was an aspiration, linked to funder expectations, that CLAHRCs should be implementing the research they generate within the 3- to 5-year period of funding. This aspiration was achieved in Ashgrove, which implemented its own research from CKD and COPD projects and an online cardiac rehabilitation tool.
6. Paying attention to implementation in the conduct of research – breaking down the divide between research and its use by considering implementation at the beginning of the research process, and/or adopting an approach to conducting research that could be described as coproductive.

In reality we observed a mixture of these different types of implementation within and across CLAHRCs. However, each CLAHRC tended to coalesce around certain types; for example, Hazeldean’s approach focused on service improvement and Oakdown’s on implementing guidance. Across the three CLAHRCs there was a greater balance towards knowledge transfer approaches than towards those that were more coproduced.

Additionally, each CLAHRC came from a different starting point with respect to both its view and its experience of knowledge mobilisation, and all were going through some form of journey in figuring it out. For example, participants from Oakdown were very clear that at the outset their approach would be one of ‘coproduction’. This then played out in their approach to working with partners in the way they conducted their research, and their implementation work was led by a practitioner-researcher experienced in evidence-based practice. Individuals in Ashgrove gave a very honest account of their contrasting starting point with respect to their implementation remit:

I think where I have found it difficult is understanding this second part of the CLAHRC, this implementation translation, and I think it has come across, we just don’t know how to do this.

Leadership role, core team, Ashgrove, R1

In this case, it was recognised that this issue was not helped by the fact that ‘the lines of communication between academics and the health trust are not well formed and so there isn’t an obvious route for implementation’ (leadership role, Ashgrove, core team, R1), and that implementation had not been clearly articulated in early plans because ‘a lot of us . . . weren’t up to speed with this agenda and how that would work’ (leadership role, core team, Ashgrove, R1).

Privileging of evidence

Different types of implementation privileged different types of evidence from different sources of knowledge. Perhaps unsurprisingly, in contexts where the research function of a CLAHRC was more prominent, research and academic knowledge tended to be privileged. In contexts where there was a broader appreciation of the CLAHRC remit, and evidence of implementation, such as service improvement activity, the value of incorporating different sources of knowledge was recognised; for example:

I think in our CLAHRC there is quite a lot of service improvement going on and service evaluation where different knowledge is used to inform and measure it over time . . . there is a move towards knowledge as practice or research as practice . . . if you don’t adopt all the different knowledges including research knowledge . . . practitioner knowledge, policy knowledge, user knowledge, if you don’t use those to interpret it [research] and put it into practice you are into a losing game really.

Leadership role, Oakdown, R1

Types of patient and public involvement

Even where research themes within CLAHRCs had a history of PPI, and some infrastructure to support it, they found it difficult to augment the focus of PPI in research to include implementation. The data demonstrate a lack of conceptual clarity about PPI, with cited examples including:

• patients as research study participants
• consultation activity across all CLAHRCs, but including qualitative research into the patient experience in Ashgrove
• using PPI as a focus for learning at improvement events, either directly or through patient stories
• using PPI as a source of knowledge/expertise to be represented in improvement work
• collaborating in product and service development
• dissemination, including the design and content of websites.

Hazeldean’s work on the development of a framework for assessment at 6 months after stroke was held up as an example of coproduction, and specifically its focus groups with patients ‘looking at what they considered to be the problems they had after their stroke’ (implementation facilitator, Hazeldean, R1). Indeed, in other CLAHRCs, although coproduction was usually couched in terms of ‘events’, there was a desire for future CLAHRCs to pay more attention to coproduction as an approach to meaningful PPI. Although participants across all CLAHRCs felt that progress had been made in embedding PPI in implementation projects, and clear instances of impact on activity and products were evident, PPI was viewed as a work in progress requiring sustained and strategic action in subsequent CLAHRC-type initiatives.

Influences and mediators of patient and public involvement

How the CLAHRCs had organised their research and implementation functions inevitably influenced how PPI was conceptualised. For example, where an initial approach to implementation focused predominantly on the (future) use of home-grown evidence in Ashgrove, then participants reported difficulty in contemplating the interplay between evidence from research and the patient voice: ‘asking patients what they want from services isn’t the same as injecting research evidence into those services’ (leadership role, core team, Ashgrove, R1). Further on, the development of ‘project groups’, with PPI representatives adopting an advisory role, was reported by both Hazeldean and Oakdown as helpful in providing a structure for melding different types of information for implementation.

In a context where there was a lack of early strategic intent around PPI, projects relied on efforts to engage patients in feedback on ‘redesign rather than design’ (secondee to CLAHRC, Hazeldean, R1) implementation initiatives. This led to a perception that PPI efforts were mostly around ‘catch-up’ (implementation facilitator, Hazeldean, R1), even in the context of a strong push from leadership around PPI. This was particularly evident in Ashgrove, where, after an external review, the appointment of a PPI champion led to the development of a PPI forum to cover both research and implementation CLAHRC functions. This led to input into all applied research projects. Attention to leadership was also mirrored by investment of resources in the training PPI. These changes led to the construction of a framework for PPI across the knowledge production and utilisation cycle, which aimed to enhance the implementability of research: ‘if everybody is being consulted at the right points throughout the process, you’re not going to have those barriers to implementation’ (implementation facilitator/boundary spanner, Ashgrove, R3).

Within the context of a programme of work to improve CKD services, there was a disconnect between research and implementation which meant that PPI fed into implementation/service improvement activity rather than the research upon which products were produced.

The data demonstrate that participants were persuaded of the importance of PPI: ‘everyone knows they should be doing it and most of them do it, and some of them do it outstandingly well. Others need to be monitored and encouraged’ (leadership role, core team, Hazeldean, R1). This view was mirrored in Ashgrove, where gaps between intention and action were crystallised: ‘no one seems to be very sure about how to set it up’ and there was ‘a problem in understanding what it is and what it consists of’ (implementation facilitator/boundary spanner, Ashgrove, R1). Intentions to engage patients in service improvement activities were sometimes thwarted through limited capacity for patient engagement within the service side: ‘most practices have underdeveloped systems for consulting their patients’ (leadership role, core team, Hazeldean, R1). However, there was a contrary perspective around positive intention in the data, where PPI was not always seen as essential, for example where ‘you are spreading proven innovation’ (leadership role, core team, Hazeldean, R1). PPI was often perceived as a NHS responsibility, although there was a recognition that capacity and capability were limited (leadership role, core team, Hazeldean, R1). Where the focus of implementation activities was principally conceived as generating a change in clinician behaviour, there also appeared to be little interest in PPI, other than in the production of patient information resources as in the case of HF work in Hazeldean. However, a sense of a moral dimension to PPI emerged in the narratives, specifically about PPI being the ‘right thing to do’. This was echoed by leaders, who reported that staff should ‘feel at least guilty for not doing it’ (leadership role, core team, Hazeldean, R1).

Patient and public involvement seemed to work well where there was a clear clinical focus around which patients and professionals could collaborate, as in the case of Oakdown’s work on diabetes research, as this provided a ‘shared interest’ to motivate engagement (NHS senior leadership role, Oakdown, R1). However, where there was a lack of agreement on the feasibility or appropriateness of the implementation activity, as appears to be the case for Hazeldean’s work around CKD management in primary care, there was little appetite for early patient engagement. The absence of a clear PPI strategy in the early stages of CLAHRC development probably reflects a predominant narrative in the data around PPI being something to be done when projects were up and running. There was no evidence in our data of PPI informing the selection of implementation projects to be conducted at CLAHRC level.

There was a general reliance on tapping into patient groups and networks that were already in existence, and serendipity about whether or not there was the right mix of resources. In Hazeldean, projects tended to ‘work with whoever just happens to be there and not if they aren’t’ (leadership role, core team, Hazeldean, R1). This appeared to reflect concerns about the significant costs associated with the development of infrastructure to support PPI. Oakdown also reported that its PPI activity was mostly through voluntary organisations and advocacy groups. However, Hazeldean’s work around HF, and the associated networking of professional groups and stakeholders, was successful in creating access to a ‘lot of patient of patient groups that existed, but nobody actually knew where they were’ (implementation facilitator, Hazeldean, R1). Data show that the further formation of service user groups or networks in this CLAHRC had been useful in informing the design of aspects of implementation projects, for example in establishing ‘what success would look like’ (management role, Hazeldean, R2), and was considered a key PPI success for the CLAHRC. Sustaining these was highlighted by both Hazeldean and Oakdown as a strategic challenge for the next round of CLAHRCs, given the considerable amounts of time and resources associated with group or network development. Continuing investment in PPI leadership was seen as key to the future in Ashgrove.

The strongest perspective in the data that emerged around PPI was the view of patients as holding a knowledge resource which could be tapped. The use of this resource appeared to be the most significant early impact of PPI, specifically in the capture and use of this knowledge to design patient information materials. Within Ashgrove, for example, concerns about the uptake of cardiac rehabilitation services, which were described as ‘really poor’ (implementation facilitator, Ashgrove, R2), were addressed through the coconstruction of a web-based support programme. Other more obvious impacts reported were around increasing access to hard-to-reach or ‘marginalised’ (leadership role, core team, Hazeldean, R1) groups such as ‘men with coronary heart disease in isolated circumstances’ (researcher, Hazeldean, R1).

Reflecting on their approaches to patient and public involvement

Strategic uncertainty about PPI within the CLAHRC appeared to be associated with reported challenges about scaling up, or learning about PPI, which both Hazeldean and Ashgrove recognised as requiring improvement, although progress with this appeared slow. This was also reinforced during the interpretive forum in which participants reiterated their challenges with operationalising PPI, particularly in the absence of an evidence base for PPI within implementation. Despite a learning event to reflect on PPI, Hazeldean had not developed any guidance on PPI. This left feelings of tokenism, with ‘little visibility’ (leadership role, Hazeldean, R4) of any achievement of PPI, and a concern that future efforts might not be ‘progressive and meaningful’ (clinical leadership role, Hazeldean, R4). In this CLAHRC, and despite processes for reporting progress with PPI, the board was reported to lack any ‘systematic view of how integral PPI is across the research theme or implementation theme. They get snapshots . . . they don’t get any real feeling of actual engagement’ (leadership role, Hazeldean, core team, R1). It appears that, in this case, board lay members were particularly exercised about this.

As time went on, there was evidence of a recognition that there was a lack of guidance around PPI. As a result, Ashgrove undertook a review of the literature on PPI in implementation, and engaged in other networking activity across CLAHRCs to further this aspect of their mission.

Although most CLAHRCs had made progress in the establishment or consolidation of PPI networks around projects, concerns emerged in later data collection rounds around the democratic nature of representation. Specifically, concerns were addressed around what agenda PPI representatives were bringing to programmes, and that the ‘same people were popping up all the time’ (management role, Hazeldean, R4). Despite these concerns, the development of more infrastructure for PPI was associated with a ‘less reactive’ (management role, Hazeldean, R4) approach, reflecting greater knowledge and confidence of PPI issues.

Perspectives from a different Collaboration for Leadership in Applied Health Research and Care

The configuration and range of experiences were checked out in one additional CLAHRC, which had adopted a more embedded approach to PPI from the outset. As with Ashgrove, leadership was key to driving PPI forward, although in this CLAHRC the leadership was part of a long-standing programme of public engagement around health issues within the CLAHRC footprint, including a ’10-year programme of doing user-led research’ (leadership role, PPI CLAHRC, R4). Additionally, leadership was sustained through dedicated funding for PPI staffing and related activities such as patient costs. The embedded approach to PPI was made explicit with a clear strategy for PPI at the inception of the CLAHRC, defined as ‘Engagement by Design’, and covered research priority setting and design issues such as the selection of outcome domains and measures. This reflected a recognition of the need to attend to implementation issues in the earliest phases of the knowledge production cycle. There was an assumption that, in this way, ‘the knowledge we’ve produced is actually much more likely to be taken up into practice’ (leadership role, PPI CLAHRC, R4). Whereas in our partner CLAHRCs PPI had been associated with surfacing patients’ experiential knowledge as a resource for improvement, and was ‘the right thing to do’, the ambitions of PPI in this CLAHRC were broader. Here there was an emphasis on changing the discourse of health through involvement at a regional level, increasing collaborative and collective capacity for implementation as ‘patients and professionals are learning about the evidence base together’ (PPI lead). Extending PPI beyond CLAHRC projects in this way appeared to reflect a regional tradition of activism around health, which provided the foundation for this CLAHRC’s approach to PPI. While other CLAHRCs worried about the professionalisation of PPI through the ‘usual suspects’ (PPI lead), this CLAHRC paid less attention to representation and more to the ‘authenticity of the experiences round the table’ (leadership role, PPI CLAHRC, R4) being brought to bear through PPI.

Role in knowledge mobilisation

Individuals in these roles generally said that they had vague job descriptions, particularly at the outset. However, in all three CLAHRCs those appointed to these roles were expected to engage in activity that ranged from training in research and evaluation to being focused on facilitating knowledge mobilisation. In contrast to the training and education function of individuals in Ashgrove, the implementation facilitators in Oakdown were more focused on knowledge mobilisation. Here, they were involved in the development of tools and procedures in three projects to support the use of knowledge in practice. This involved providing e-learning resources, training staff and working with steering groups to develop tools and procedures for implementing evidence. In addition, they had a supporting role for the ward-based champions, who had been identified as another means of knowledge mobilisation. In this sense there was the enactment of an external–internal facilitator-type approach:

One [approach] was to introduce ward-based nutritional champions so members of the ward team would help facilitate that change in practice with support of what we would call [implementation facilitators], who come from CLAHRC.

Leadership role, core team, Oakdown, R2

Oakdown facilitators were also expected to spread evidence-based improvements across the hospitals in which they were working:

there’s been spread through our [implementation facilitators] that we appointed to work across the wards and help disseminate so there’s been, I suppose, formal approaches like the workshops and the newsletter and there have been less formal ones where there’s been spread through people meeting informally.

Leadership role, core team, Oakdown, R3

There was also some clarity about the role of the facilitators in Hazeldean, where they were expected to implement evidence into practice:

I think it started off that they employed like seven [implementation facilitators] and our job was to facilitate the implementation of evidence, whatever evidence into practice.

Implementation facilitator, Hazeldean, R1

Boundary spanning

In all three CLAHRCs these individuals also served as boundary spanners; this was most obvious in Oakdown, where, in descriptions of the implementation facilitators and their role, ‘boundary spanning’ or ‘boundary spanners’ was the dominant discourse. Here, there was a recognition that it was necessary to have boundary spanners functioning at different levels within the health-care organisation:

I think what has become evident for us is the importance of boundary spanning at different levels . . . it is about the importance of boundary spanning at executive and board level going down to middle managers and steering committee members, key clinicians in the trust as well as middle managers and then importantly boundary spanning with frontline staff, the people whose practice we are trying to change.

Leadership role, core team, Oakdown, R2

Likewise in Ashgrove, the skills and qualities of the boundary spanner were identified in outlining their role:

we needed somebody in the trust to bring the organisations and the researchers together . . . a good [boundary spanner] is someone who is basically a great people person, brings people together, communicates, organises, networks, you know, speaks their minds . . . It’s not necessarily about the evidence, but it is about the people skills . . . we see them as sort of boundary spanners really, getting people across the boundaries and letting things happen that way.

Leadership role, core team, Ashgrove, R1

The critical feature of success for people in these roles was their credibility. Therefore, over time, Hazeldean augmented the work of its boundary spanners by employing clinical staff on secondment, because the people they had employed lacked clinical credibility, which had been a problem. In clinically embedded projects (CKD and HF), these roles were seen as important because the people had knowledge of the health-care context, including clinical knowledge:

So across the CLAHRC as a whole now we’ve got as least as many seconded people in knowledge transfer-type roles as we have people we originally recruited because that does bring that much more informal knowledge of people, networks and the clinical knowledge you know, and although there’s a few of those who we recruited who are good facilitators, in view of credibility and particularly the confidence that goes with those abilities are very important I think.

Leadership role, Hazeldean, R3

In contrast, Oakdown had employed only staff with a clinical background in its implementation facilitator roles, so they brought with them the clinical and contextual knowledge (i.e. local knowledge) that was seen as important for implementation success. In Ashgrove, boundary spanners were based in PCT R&D departments. In addition to the implementation facilitators in the PCTs, one of the research themes in Ashgrove had employed a full-time senior nurse as an implementation manager. This was seen as bringing clinical credibility to the role along with a sound knowledge of the health-care context, including barriers and enablers to implementation.

Overall, it was perceived that individuals in these roles were pivotal to knowledge mobilisation within CLAHRCs through facilitation and boundary spanning. They were also the most visible presence of the CLAHRC within health services. The focus of their function was allied to the particular position the CLAHRC had taken around research versus implementation, and in relation to the use of particular frameworks/models to underpin its activities. These individuals were perceived to be credible messengers – credible in the sense that they could interface with individuals at various levels of organisations and in that they brought clinical and contextual savvy to the implementation situation. The investment in them also provided the potential to build capability and capacity for implementation and research within health services.

General overview of the types of things that can be classified as boundary objects in theory

Those objects listed in the columns labelled ‘Standardised methods and forms’ and ‘Objects, models and maps’ suggest a considerable overlap between classes (many of these listed items can occupy both classes). However, multiple classification is a feature of many boundary objects, and a single boundary object may reside in several classes simultaneously.

During interviews with participants who were operating as boundary spanners, conceptual (e.g. CLAHRC concept) entities also emerged that appeared to operate as boundary objects, and it became evident that whether or not the boundary objects in theory operated as boundary objects, in practice was a function of the way in which they evolved and the meaning that was attached to them. Interviews with participants verified if and how boundary objects in theory (i.e. those that were evident in documents; Table 9) played out in practice as boundary objects in use.

TABLE 9

Types of boundary objects in theory

Concrete to conceptual boundary objects

A range of what could be described as concrete boundary objects was evident in the discourse of the boundary-spanner interviewees. The nature and properties of some of these are outlined in Table 10. These objects had the potential to share meaning and knowledge and to catalyse action among those who coalesced around them.

TABLE 10

Examples of concrete boundary objects

In addition to the tangible objects that were identified as potential boundary objects, less tangible entities, conceptual or symbolic, emerged that could also have boundary object properties attached. CLAHRCs as a concept served as a boundary object, in that they possessed some cohesive property (which varied across them) in catalysing the potential to cultivate collaboration. There were varying perceptions about what a CLAHRC is, which were related to the type of stakeholder expressing the opinion: those in CLAHRC leadership roles were clearer about it than those in the front line of the health service. Over time, and through a process of collective sense making, CLAHRCs as a concept became clearer for some:

we really sort of got our heads together about what CLAHRC was, and actually what we should be doing . . . yeah, we kind of just worked something out ourselves and just created a job and created work for ourselves, based on our interpretations of . . . of what it is . . . it’s a programme of work to promote collaborative . . . collaborative work between academia and health care to . . . ensure research evidence is used quickly, and it is . . . is . . . worthwhile, it’s wanted, and it’s used.

Implementation facilitator/boundary spanner, Ashgrove, R3

However, CLAHRCs’ catalytic potential to bring about collaboration was hindered by their architectures.

There were also examples of language being used to create a shared meaning around issues and topics, and thereby acting as a symbolic boundary object. In this example a facilitator had been using what she described as a slogan to engage practitioners’ attention:

I’m tending to use a slogan that I suppose is about patient safety . . . Everybody’s business. So those are sort of catchphrases that capture people’s interest.

Implementation facilitator/boundary spanner, Oakdown, R3

Clinical issues also had the potential to have cohesive properties. For example, in Oakdown shared clinical topics such as nutrition and dysphagia were boundary-spanning concepts, which were meaningful to a range of stakeholders including practitioners and patients.

I think the thing with nutrition is it’s not a hard sell . . . I really don’t think anybody thinks it’s not important . . . everybody thinks it is important . . . And most people, and I can’t think . . . as I say, most people believe nutrition is important . . . So it’s not a hard sell. What’s the hard sell is how to do it.

Implementation facilitator/boundary spanner, R3

In this example, nutrition was a useful symbolic boundary object that resonated across contexts and was perceived to be universally important, providing a focus around which to catalyse engagement and potential action for improvement.

The evolution of boundary objects: collective action

The potential of boundary objects to have cohesive properties appeared to be partly a function of the way in which they evolved. Those objects that transformed from objects in theory to object in use had similarities in terms of their collective generation. Collective generation occurred through discussion and collaborative activity in developing, amending and tailoring objects for use. There are a number of examples in the data where particular tools had emerged from collective endeavours, which had involved the engagement of relevant stakeholders and resulted in their use in practice [e.g. CKD audit tool at Ashgrove and Hazeldean, Malnutrition Universal Screening Tool (MUST)+ and VTE assessment tools at Oakdown and HF alert card at Hazeldean]. In this way they mobilised knowledge between communities because the process involved the integrating of local evidence and experience with external evidence from guidance and thereby became meaningful to stakeholders.

Box 5 provides an example of how collective action around a shared symbolic object was transformed into a concrete boundary object, something that was relevant and had resonance with its end-users, which was then used in practice.

BOX 5

Collective development of a boundary object in use Through a mapping exercise of HF services undertaken by members of Hazeldean’s implementation theme, poor communication between primary and secondary care was identified as a problem:

Within Oakdown there were also reports of collective tailoring of standardised generic objects that had originated externally from the CLAHRC organisations, including the MUST and VTE assessment tools. These tools underwent a process of tailoring and contextualisation, including the incorporation of local knowledge:

things like the MUST screening tool or the Department of Health VTE assessment form and the idea that those are then adapted to the local context so MUST was developed to what we called MUST+ because it had an extra question that we felt was appropriate.

Clinical academic, core team, Oakdown, R3

. . . without us . . . without doing enough tailoring . . . I think what we learnt was you have to do a lot more tailoring than you think.

Implementation facilitator/boundary spanner, Oakdown, R3

If there was not enough collective action involving relevant stakeholders in either development or tailoring, the result was that a concrete boundary object in theory potentially operated in an inhibitory rather than catalytic way in practice; for example:

they decided, because . . . South Asian communities have a higher incidence of diabetes at a lower BMI [body mass index] . . . this was a real . . . it was important, and obviously Ashgrove has a very high South Asian population; it was really important that this tool worked for that group . . . They’d done a literal translation, which was in places quite offensive . . . and the . . . the . . . as a visual aid, it’s like a traffic light . . . you know, red, two ambers and a green, and they couldn’t get why you would have two ambers. It really . . . you know, it stopped the purpose of the tool, it . . . you know, they were saying ‘Oh why . . .’ you know, ‘How do I know which amber I am?’ and things like this. So those discussions, if they hadn’t have taken place that tool would have gone out, I mean it is out, Diabetes UK host it, it is a really valuable tool . . . But it would not have worked for that group if they hadn’t had that conversation.

Leadership role, Ashgrove, R3

Our data show that meaningful collaboration provided a condition in which the potential of boundary objects may be released, because this provided a receptive context and opportunity for attaching meaning, resonance and value, which enabled knowledge mobilisation. Therefore it could be predicted that, in environments in which there is more and good-quality collaboration, the power and potential of boundary objects might be greater.

Summary: knowledge and its mobilisation

Different levels of attention were focused on CLAHRCs’ implementation function. These levels linked back to how the CLAHRC initially interpreted the brief (i.e. its position about what CLAHRC was for), and the positioning of resources to enact its plans. However, we identified a number of different types of activity that mobilised knowledge or had the potential to mobilise it, and around which each CLAHRC tended to coalesce. On balance these approaches were concerned more with knowledge transfer than with coproduction; that reflected an emphasis on CLARHCs as producers rather than users of applied health research. CLAHRCs were figuring out PPI within knowledge mobilisation and articulated their challenges with this remit. Generally, they had conflated PPI in research and PPI in implementation, which demonstrated a lack of conceptual clarity around this issue and their challenge in operationalising it in a CLAHRC context. Engaging with the CLAHRC agenda and around knowledge mobilisation was an enactment of ‘what’s in it for me’; different stakeholder motivations provided a loop of reinforcement for engagement. Motivations to engage also differed between health services and academia; those in practice perceived CLAHRCs to be dominated by an academic agenda.

The CLAHRCs positioned financial investment in implementation through the creation of boundary-spanning roles. Individuals who were credible and visible in these roles played a significant role in mobilising knowledge (and in making a CLAHRC real). They developed and had at their disposal a number of ‘things’ that were, or became, boundary objects. Potentially meaningful collaboration (e.g. in the creation of objects) provided the conditions in which the potential of boundary objects was released.

Direct, processual and conceptual impacts

Throughout the rounds of data collection there was a consistent narrative about needing to demonstrate impact. This was particularly acute in the early stages of the life cycle of the CLAHRCS: ‘high expectations from the trust and the funding, there is a lot we need to achieve in a quite short space of time and I think that is quite difficult or I personally found quite difficult, quite a lot of pressure in a sense to achieve results quickly’ (implementation facilitator, Hazeldean, R2). Given the time that it takes to generate impact, particularly in relation to changes in practice, service delivery and patient outcomes, it was perhaps unsurprising that evidence of more direct impacts accumulated over time and was, therefore, more obvious at the point of transition between CLAHRC 1 and CLAHRC 2, when data collection in this project was finishing. Appendix 8 provides a list of evidence extracted from a variety of documents about the direct impacts that CLAHRC’s had generated and reported. Some of these impacts are illustrated in Table 11. The most prominent source of these more direct types of impacts from implementation activity appears to be service/quality improvement-type projects. Discussions between CLAHRC participants at the interpretive forum acknowledged that the (regional) public health impacts expected in the original CLAHRC bid had not been realised as intended, and that perhaps this was partly a result of the types of metrics they were being asked to deliver and report on.

TABLE 11

Summary of some of the direct impacts evident in CLAHRC documentation

In addition to an increasing accumulation of direct impacts, we also heard about different sorts of impacts arising from the implementation of specific projects and from being involved in a CLAHRC. For example, respondents reported impacts on the processes of care through the implementation of particular tools, which, in the case of the illustration below, if assessment led to appropriate action, had the potential to impact on outcomes:

So it was huge . . . when we got that in [VTE assessment into documentation] I mean I did an audit when it had been in about 2 or 3 months and the . . . compliance you could see had just gone up. It’s not by any means perfectly completed, but they are risk-assessing and, you know, it’s much better.

Implementation facilitator/boundary spanner, Oakdown, R3

There were also other processual impacts on service delivery processes. For example, a care pathway to co-ordinate the physical health of people with enduring mental health problems between primary, community and inpatient services was implemented, and that had impacts on communication:

Communication had improved between GPs and the trust . . . but also communication within the trust had improved with greater numbers of referrals of patients to lifestyle services who were able to offer advice about smoking cessation and weight loss for service users.

NHS partner, Hazeldean, R2

Further, partly as a function of the closeness of relationships between a CLAHRC’s constituent services and HEIs, including joint appointment, there was also evidence that learning through a CLAHRC had an impact on curriculum development: ‘we can influence the curriculum and how the curriculum can respond more quickly to the learning from CLAHRC’ (implementation facilitator/boundary spanner, Oakdown, R3).

Additionally, there were numerous reports of changes to thinking, knowledge, skills and attitudes as a result of project-related activity. However, the gap between conceptual and direct impacts was also noted:

We did get some nice changes in attitude and knowledge using the questionnaire but . . . it was much more difficult to see what had actually changed . . . so it was more of a conceptual use of knowledge rather than the instrumental use of knowledge.

Implementation facilitator/boundary spanner, Oakdown, R2

The challenge of spreading impacts beyond the projects from which they originated and beyond the boundaries of the CLAHRC was an issue that was articulated consistently by those in leadership positions within CLAHRCs:

It has got to be about the impact and the scale of it and the spread of it so you know it is something that not just a handful of people are benefiting from because there is so many pockets of good practice and things being done well but then if you are the unfortunate person who doesn’t fit into that pocket then you don’t get the benefit and I think it has got to be the scale of it.

Management role, Hazeldean, R4

However, there were examples of particular tools developed through CLAHRCs (e.g. an online cardiac rehabilitation programme) that had proved to be popular (i.e. useful and relevant) and spread across the UK, and their translation/extension into other disease groups had been initiated. Tools such as these had been developed collaboratively and had been driven by a service-identified need.

Personal impacts

Data show that different sort of impacts were important for different stakeholders. Academics valued publications and the provision of opportunities to increase grant capture. CLAHRCs had concentrated or focused expertise and academic talent within England, which has resulted in increased activity around grant applications and awards. However, the applied nature of the CLAHRC work has caused a tension for some, particularly in relation to career framework expectations and REF 2014:

I think some of it [CLAHRC activity] is considered subscience and I think they like the fact that it is going on and I wonder if people are glad that it is happening but not them doing it . . . the so-called hard core scientists actually like to leave it to others and now I understand why, because these things, however good, and PPI and all that sort of stuff, it doesn’t impact on REF or is more difficult to impact on REF-type activities . . . I am not sure it is of hard core value in the world of academia, certainly not yet.

Academic, Ashgrove, R4

Although it was noted by participants at the interpretive forum that, in the context of the (then) forthcoming outcome of REF 2014, impact stories, for which CLAHRC activity provides a natural pipeline, may contribute to the survival of the CLAHRC concept and a shift in thinking by academics to value engagement with more applied research and its implementation as a rewarding activity.

It is clear that CLAHRCs have provided opportunities for capability building and for individuals to develop personally and professionally. Involvement in activities and projects has provided job satisfaction to those who have felt that they have contributed to making a difference, and it has given others the chance to develop their curriculum vitae, while in parallel developing implementation capability within the system:

I think importantly what it has also done for a lot of people is develop their own knowledge and skills around implementation, so my core team had varying knowledge about implementation when they started but through projects that we have done, the reading that we have done through their engagement in KU [knowledge utilisation] events . . . people have been exposed to a different environment . . . in the NHS . . . working in partnership with academics in universities that often they don’t do that, so I think they have learnt more about the process of research of the process of rigorous evaluation through that process . . . they have developed their CV [curriculum vitae] so we had people promoted through readership to personal chairs . . . through the NHS from Band 6s to Band 7s and taking on more leadership responsibility.

Leadership role, core team, Oakdown, R4

Development and personal growth impacts were very particular to those individuals who took on boundary-spanning and facilitator-type roles. However, there was also evidence from others that being involved in a CLAHRC had provided a platform for career development and an opportunity for personal profiling:

I am the director of [NHS organisation] – how did that happen?! That was a direct result of [CLAHRC]; there is absolutely no way that I would have the kind of experience I needed . . . I wouldn’t have had that experience to go to the trust board if it hadn’t have been for [CLAHRC] . . . it would have taken me another 10 years to get where I am if it hadn’t been for [CLAHRC].

NHS partner, Oakdown, R4

You know they’ve [facilitators] all . . . you know, become experts in their fields over the years, and some of them did that very quickly and were then able to transfer knowledge very quickly. I think the lady who runs the . . . post-stroke assessment . . . dare I say probably . . . at a national level known quite well as an expert in stroke . . . she would be seen probably as an opinion leader in her own right.

Academic leadership role, Hazeldean, R3

Collaboration for Leadership in Applied Health Research and Care ‘footprint’

As the above examples begin to illustrate, there were many and varying types of impacts that could be attributed to the existence of a CLAHRC. However, one issue that was discussed within the interpretive forum and was thought to be either missing or not yet articulated was the ‘footprint’ left by CLAHRC. This means the impact that CLAHRC had had on an area and the NHS as a whole, and cultural change: the ‘way we do research’ or the ‘way we do implementation’. The ability to see the footprint was potentially impeded by changes to the NHS landscape, including frequent changes in relationships and health service boundaries. However, the ability to identify the footprint might also be linked to the absence or presence of mechanisms and processes for meta-learning within and across CLAHRCs.

Summary: impacts

We observed many different types of impact from CLAHRC activity. These could be considered to be positioned on a continuum, in that direct impacts (on practice and service delivery) took time to realise and were preceded by other types of impacts, which were less instrumental, including those that were more personal to individuals engaged in CLAHRC roles. Participants stressed their desire and need to make an impact, and the funder’s monitoring focused attention on particular metrics, for example number of publications and amount of research funding. External reporting requirements fuelled an emphasis on particular types of metrics and on a need to demonstrate volume of activity. Locally generated reports also included case studies and stories of impact. The impact of the CLAHRC was an accumulation of project-level impacts rather than a demonstration of cultural change in a region or in the NHS, and therefore the imprint left by the CLAHRC footprint as a whole was still faint when we stopped collecting data.

Information sharing

When asked to reflect on the processes and mechanisms for learning within CLAHRCs, most participants talked about sharing information between projects and themes through, for example, reports, meetings and knowledge-sharing events. However, a common perception that emerged from participants across all three CLAHRCs was that sharing of information tended to be focused on metrics, at the level of individual projects, and for the purpose of feeding into 6-monthly returns for the NIHR:

There was a process, there was some really dysfunctional research and implementation meetings but nothing got done. They tended to be focused around things like the 6-monthly NIHR reports and the annual report.

Leadership role, Hazeldean, R4

Information sharing within a CLAHRC was hindered by the structures that had been established (engineered architecture), the leadership approach and style (more or less transparent and open to critique and learning) and the communication mechanisms that had been developed and sustained. In contrast, where there were strong relationships and connections between individuals, teams and services, this created openness, which facilitated information sharing. However, most participants felt that sharing for learning within and across CLAHRCs could have been better. The prevalent reason for sharing was, as one participant put it, provision of information rather than sharing for learning by bringing challenges to the table and learning from each other. It was noted, however, that the potential to learn would require a different sort of forum from that which currently existed:

There is a difference between going to a meeting where there is an agenda, one to six different projects, and a meeting where we are beginning to think . . . about what is the same, what is different, what have we learned, is any of it generalisable, can it be used in theory. Those are different kinds of meetings. Most of the meetings have been A rather than B.

NHS partner, Ashgrove, R4

Scaling up

Given this, although there were information sharing and feedback mechanisms in place within CLAHRCs, it was unclear how this information was being used to learn or scale up from individual projects. This finding was corroborated at the interpretive forum, at which participants reflected that not formally evaluating the question ‘what have we learnt?’ was a missed opportunity. However, it was reported by CLAHRC directors that there had been some ‘organisational’ learning in CLAHRC 1 that was being taken forward in revisions to structures (fewer divisions between structures) and some processes (considering more opportunities for learning) for CLAHRC 2. Furthermore, it was felt that the externally funded evaluations were not universally helpful because in reality it had been a challenge for them to provide timely formative information, and because some of the projects had not been designed in an interactive way. These problems were not perceived positively by some CLAHRC directors.

Responses

The CLAHRCs within this study responded in different ways to different (mainly externally located) stimuli prompting changes to the way things were being done. There were considerable changes to the NHS landscape during the life cycle of CLAHRC 1; these significantly affected Hazeldean, which had set up a funding structure that was reliant on actual (rather than in-kind) resource from primary care partners. During this time, health service partners left the collaboration, withdrawing their money, which necessitated the CLAHRC’s cutting its cloth accordingly: prioritising activities with the resources they were left with and doing less. In the first 2 years of its existence, the board of Ashgrove (the body the CLAHRC was accountable to) instigated a formal external review, which in itself signalled a need and openness to receive feedback. The review team critiqued its approach, specifically the balance of activity, which was felt to be too weighted towards research and not enough towards its application, and building capacity and capability. The external review resulted in a course correction for this CLAHRC, through which it began to pay more attention to implementation:

Yes definitely, that it [implementation] had to be incorporated and I think it was a difficult concept really because we were doing clinical trials and we thought, actually you are doing this trial because you don’t know the answer, so it is difficult to think about implementation . . . but now [after the evaluation] if you are embarking on a clinical trial then we do appreciate that you have to talk to patients, you have to talk to commissioners and you have to think about implementation . . . so I think gradually you know the penny had dropped and so it has changed, will change our view over the longer term.

Management role, Ashgrove, R4

In contrast, Oakdown took an ongoing approach to reviewing its activity and approach through reflection and negotiation with internal and external stakeholders. This seemed to have insulated the CLAHRC from changes in the primary care landscape and enabled it to be responsive to partners without compromising its ongoing activity and future plans.

Summary: evaluation and learning

Learning within and across Ashgrove, Oakdown and Hazeldean was patchy, with varying levels of receptiveness and therefore varying levels of attention being given to evaluation and to structures and processes that could mediate feedback and sharing. Learning at a project level was more evident than learning from the CLAHRC as a whole; however, from our data it was not clear how project learning was being incorporated into doing things differently in the future. Equally, their potential to learn from the externally funded evaluations had been varied, with issues raised about the timing and format of the feedback provided. However, there had been different externally driven prompts in Ashgrove and Hazeldean that had necessitated review and resulted in adaption. Oakdown took a more ongoing approach to reflection and subsequent refinement. It was also evident that learning from CLAHRC 1, or the ‘pilot’, had been taken forward into proposals for CLAHRC 2.