The focus of this research is NHS and university-based staff in knowledge brokering roles, how they link with knowledge and innovation, and how they transfer this to the health-care practitioner community. The transfer and mobilisation of knowledge from research into health-care delivery is a long-standing international challenge.1–6 Sebba7 highlights the economic, moral and academic imperatives for investing resources in improving research use. Alongside the need to base decisions on evidence (moral imperative) and the increasing need to demonstrate impact of academic research (academic imperative), the economic imperative to ensure the best use of limited resources and minimise waste is a timely concern. In a time of unprecedented financial restrictions,8 health-care managers face the enormous challenge of purchasing and providing health care to an ageing population with increasing expectations. Management decisions about planning, commissioning and service delivery affect large populations and require large amounts of public money. Failure to inform practice with evidence limits the improvement of the effectiveness of health services, wastes money and potentially adds to the scale of preventable morbidity and mortality.
It is in this context that our study sought to find out how to get the best out of knowledge and innovation transfer (KIT) ‘agents’, that is, NHS practitioners in knowledge brokering or mobilisation roles.
Knowledge mobilisation
Gainforth et al.9 defined knowledge mobilisation as ‘putting research in the hands of research users’, but the use of evidence is a complex, social and dynamic process.10 To inform decision-making in practice, research evidence needs to be ‘available to those who may best use it, at the time it is needed . . . in a format that facilitates its uptake’ as well as ‘comprehensible to potential users and . . . relevant and usable in local contexts’.11 In health care, this process and associated organisational change is widely recognised as complicated, messy, evolving and fraught with challenge.12–14 For example, practitioners are alleged to lack the time, motivation and capacity to use evidence15,16 or are purported to be overwhelmed by the quantity of diverse evidence.17–19 Research reports may lack relevance, can be opaque and verbose20 and it can be a long time before they are released.21 Some argue that research output is dominated by a biomedical focus on drugs, tests and devices. Instead, Walshe and Davies22 suggest that the current ‘predominant concerns’ relate to ‘pathway and process redesign, safety and quality; organizational issues like coordination, integration and networking; workforce issues like training and skill mix; and patient issues like experience, education and empowerment’. Addressing these concerns may require alternative models of knowledge creation in order to close the knowledge–practice gap.23,24
The policy context
There have been a number of efforts to build bridges between researchers, policy-makers and service providers, and there is growing interest in using collaborations to address the research–practice gap.25,26 Some of these are institutional partnerships involving colocation of teams, shared resources and so forth, whereas others rely on key individuals to bridge. All aim to link knowledge and innovation producers and users through various means that may or may not include a formal knowledge broker or KIT agent. Our understanding of the work of these KIT agents remains poor, and examples of collaborations can provide insight into potential modes of and mechanisms for engagement.
Linking trusts and health boards to research teams through managers can help organisations to use research findings in their own settings, and enable them to set up service improvement projects to improve health and health-care outcomes. The review led by Sir Ian Carruthers, ‘Innovation, Health and Wealth: Accelerating Adoption and Diffusion in the NHS’,27 placed innovation at the top of the service agenda, setting out ambitious recommendations to encourage quicker transfer of new practice, ranging from infrastructure change to realignment of system incentives and promotion of high-impact initiatives. Central to the Carruthers report27 is the argument for ‘a more systematic delivery mechanism for diffusion and collaboration within the NHS by building strong cross boundary networks’. Although the proposals of the Carruthers report27 are clear – productive regional collaborations between academia, industry and the health sector to identify and spread innovation and so drive service improvement – its recommendations accommodate regional conditions. Capacity to access, understand and use research knowledge is emphasised to ‘bring about a major shift in culture within the NHS, and develop our people by “hard wiring” innovation into training and education for managers and clinicians’. The contents of this report complement these key policy themes.
Academic Health Science Collaborations, Partnerships and Networks
Following the Carruthers report,27 Academic Health Science Networks (AHSNs) have brought most NHS organisations in England into collaboration with universities. In England, 15 AHSNs were licensed in March 2013. AHSNs are tasked with aligning ‘education, clinical research, informatics, training and education and healthcare delivery’ and improving ‘patient and population health outcomes by translating research into practice and developing and implementing integrated health care systems’.28 Like their predecessors, Academic Health Science Collaborations (AHSCs), the central aim of these collaborations is ‘knowledge mobilisation, rather than research production’.22 As designated in ‘Innovation Health and Wealth’27 and the ‘Strategy for UK Life Sciences’,29 AHSNs are a systematic delivery mechanism for the adoption and spread of innovation at pace and scale through the NHS. The networks are designed to foster collaborations between academia, industry and health service, and shared aims include diffusing innovation, putting research into practice, and promoting economic growth.30 They are expected to work closely with industry and funders to bring together researchers, managers, patient groups, planners and policy-makers.
Compared with England, infrastructure targeting knowledge mobilisation and innovation is not well funded in Wales. However, the sole AHSC in Wales has identified knowledge transfer as a priority. The AHSC formed three regional hubs – in the north, south-west and south-east of Wales. In their initial period, these hubs attracted small-scale funding from Health and Care Research Wales [formerly the National Institute for Social Care and Health Research (NISCHR)], but this ceased in 2014. The South East Wales Academic Health Science Partnership (SEWAHSP) became independent and continued to operate. SEWAHSP has two key objectives: (1) to increase the speed and quality of ‘translational’ research; and (2) to promote and support innovation in south-east Wales.31 A national Task and Finish Group also made recommendations to Health and Care Research Wales on knowledge transfer policy.32
Collaborations for Leadership in Applied Health Research and Care
Descriptive studies focused on how research does make it into practice point to the importance of close interpersonal relationships between researcher and user.33–35 This has been built into interventions that seek to develop opportunities for both parties to link and engage. In England, these include programmes such as the National Institute for Health Research (NIHR)’s Collaborations for Leadership in Applied Health Research and Care (CLAHRCs), which were designed to address what Cooksey1 termed the ‘second gap in translation’, related to the failure of new ideas and tools to reach practice. CLAHRCs are serviced-led partnerships that aim to contract high-quality applied health research, implement findings and increase NHS capacity to engage in research.36–39 In 2008, nine CLAHRCs were established and a second wave extended the CLAHRCs reach with tapered funding (from NIHR) for 13 CLAHRCs. This is an indicator of the perceived success of the programme.
The CLAHRCs are the most established and evaluated programmes in the UK.39–46 The reports to date highlight similarities and differences between structural and content features of the CLAHRCs and point to early successes and challenges. For example, successes include strengthened networks and relationships;39,44,47 new organisational roles that ‘make sense to professionals’; collective action to improve practices;48 and creating a culture of reflection and learning.47 More specific successes have also been reported. For example, the CLAHRC for Greater Manchester achieved success in improving patient services in chronic kidney disease.41,49 Although such results demonstrate the impact of CLAHRCs and how the collaborations can change the approach of organisations for the better,39,50 it is very difficult to demonstrate a causal effect given the complexity of what they are and what they are trying to achieve. Walshe and Davies22 are more circumspect and conclude that ‘promising lessons’ can be distilled from the collaborations in England, which, among others, include ‘the development of organizational capacity in knowledge mobilisation’. Currie et al.43 usefully summarise key areas of uncertainty for CLAHRCs, which include the problem of metrics. They note the following uncertainties:
The balance of activity between research and implementation; whether research should be clinically or implementation focused; appropriate metrics for CLAHRCs; whether CLAHRCs should orientate towards their academic or NHS partners; and whether CLAHRCs should focus upon individual behavioural or organizational/system level change.
They argue that the dominant approach is research focused, fixed on changing individual behaviour rather than ‘wider scale organizational and system level change’, as favoured by those from a social science tradition.43
Knowledge brokers
Embedded within the concept of knowledge mobilisation are the roles of knowledge broker and boundary spanner.51–53 Roles vary,42,54 but the essential feature is that they facilitate engagement between research and practice.55 With the aim of improving the transfer of knowledge and innovation, knowledge brokers seek to close knowledge gaps and foster knowledge-responsive capacity and culture.5,56–59
To facilitate knowledge mobilisation, many CLAHRCs used knowledge brokers, variously named.22,60 For example, in the first round of CLAHRCs funding, the Cambridgeshire and Peterborough CLAHRC had a fellowship programme for clinicians, health- and social-care practitioners and managers to work alongside researchers; the Nottinghamshire, Derbyshire and Lincolnshire CLAHRC funded35 ‘diffusion fellows’ attached to their research projects.61
The NIHR Service Delivery and Organisation (SDO) Management Fellowship programme provided another example, and one aimed exclusively at managers; an evaluation showed benefits from the interactions between the fellows, their NHS colleagues and research teams, but also revealed challenges in maximising those benefits for the workplace.62 The NIHR SDO scheme was later merged with the NIHR Health Services Research programme to create the NIHR Health Services and Delivery Research (HSDR) programme.
As knowledge broker roles grew in number and type across the UK, an interest group formed in 2014 looking at fellows in the system. Several organisations, including the Health Foundation, NHS Education for Scotland, NHS Improving Quality, NIHR, and Universities UK, were involved in early data-gathering exercises to understand the characteristics of the wide range of fellows and fellowship programmes that exists across the health and care system. This exercise culminated in a 1-day event, ‘Fellows Connect’, bringing together quality improvement (QI) fellows from across the UK to share experiences.63 At the same time, Berwick’s report on ‘Improving the safety of patients in England’ recommended a ‘national system of NHS Improvement Fellowships, to recognise the talent of staff and improvement capability and enable this to be available to other organisations’.64 This resulted in the creation of an initiative called ‘Q for Quality’, led by the Health Foundation and supported and cofunded by NHS England, connecting people skilled in improvement across the UK. The Q initiative aims to grow to be a community of thousands of people: patient-facing front-line staff, managers, researchers, ‘patient leaders’, policy-makers and others in order to accelerate improvements to the quality of care.65 Together, these recent developments illustrate the interest and also the investment by national organisations in the UK in maximising the potential of knowledge brokers to improve the quality and safety of health care for patients.
The aims and objectives of the study
The focus of this research is KIT ‘agents’ (NHS and university-based staff in knowledge brokering roles), how they link with evidence and innovation and how they transfer this to the health-care practitioner community. The study aimed to examine the work of KIT agents in practice in order to understand how the outcomes of their endeavours might be maximised. Our research questions are:
What are commonly shared expectations of the KIT agent role?
What, in practice, do KIT agents do?
What is their conception of KIT?
How do they see their role?
With whom do they link?
What are their principal activities?
How does the work of KIT agents impact on health-care practice?
How can KIT agents be best supported?
What measures can be used to assess the impact of KIT activity?
Our objectives were to:
map the innovation and knowledge transfer intentions of the new AHSNs and SEWAHSP
describe, and characterise, the roles of KIT agents and develop a typology of KIT agent roles
report the perceived impact of KIT agents on managers’ practice
investigate how KIT agents can be best supported
generate a set of impact measures for assessing innovation and knowledge transfer activities.
Concluding remarks
This chapter has established the importance of knowledge mobilisation in health care and provided the background policy context to the current position of initiatives designed to address the research–practice gap. We extend this in Chapter 2 by providing a summary of the literature on knowledge mobilisation.
Chapter 3 outlines the theoretical underpinnings, research study design and methods used. Chapter 4 explores the knowledge and innovation mobilisation intentions of the AHSNs in England and an Academic Health Science Partnership (AHSP) in Wales and introduces a suggested typology of the different forms that KIT roles may take.
The main reporting of the results begins in Chapter 5 with an overview of the case study KIT agents. They highlight content-specific knowledge transfer challenges, as well as generic mechanisms that support transfer. We commence the discussion of our findings in Chapter 6. We look across all the case studies to discuss common barriers and enablers reported by the KIT agents, and explore how they can be better supported in carrying out their role.
The focus of Chapter 7 is on assessing outcomes of knowledge brokering activity. It includes a report of the nominal group and also draws on the case study data and wider literature. In Chapter 8 we extend our discussion of outcomes by reviewing our findings through the lens of social marketing theory.
Last, Chapter 9 brings together the main conclusions and implications of the findings, positioning them within the wider literature and suggesting recommendations for future research.
