Post on 24-Apr-2018
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SYMPOSIUM
An organizational behaviour perspective upon CLAHRCs (Collaboratives for Leadership in Health Research and Care): Mediating institutional
challenges through change agency
Graeme Currie*, Louise Fitzgerald***, Justin Keen**, Anne McBride***,
Graham Martin*****, Emma Rowley* Heather Waterman****
* Nottingham University Business School **Leeds Institute of Health Sciences, University of Leeds
*** Manchester Business School, University of Manchester ****School of Nursing, Midwifery and Social Work, University of Manchester
*****Department of Health Sciences, University of Leicester
Contact: Graeme.currie@nottingham.ac.uk
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An organizational behaviour perspective upon CLAHRCs (Collaboratives for Leadership in Health Research and Care): Mediating institutional
challenges through change agency
Abstract
Our paper conceptualizes CLAHRCs from an OB perspective. We represent the case of CLAHRCs as one where change agency and knowledge brokering at the local level need to mediate powerful macro-level institutional forces that potentially drive research and practice apart. This paper draws upon illustrations from four CLAHRCs over the first 18 months of their operations to provide some early analysis of the practical challenges CLAHRCs face in enacting their conceptual models. Our early analysis of CLAHRCs is revealing. CLAHRCs vary in the specific ways they organize for change agency and knowledge brokering. However, they face a similar institutional landscape. The institutional challenge is both professional and policy orientated. Professional hierarchy means that some change agents or knowledge brokers are accorded greater legitimacy than others, but we note that change agent or knowledge broker roles may be so novel that their enactment is slow to realize (Reay et al., 2006). If embedded in pre-existing professional, supported by managerial, hierarchy, then change agency and knowledge brokering may prove more successful (Currie et al., 2008). Meanwhile the policy institution itself may be inconsistent in its support for CLAHRCs, more so when focused upon productivity gains (Newman, 2001). The health and social care system is complex, with considerable variation across organizations regarding the extent to which R&D is institutionalized. To make the necessary impact, CLAHRCs are moving beyond the single clinical champion to drive change. More or less in the various CLAHRCs, the need to engage a wide range of stakeholders to engender a critical mass for change efforts is explicit (Greenhalgh et al., 2004). In summary, structural arrangements for change agency and knowledge brokering within the various CLAHRCs offer considerable promise. The challenge remains one to operationalize the CLAHRC model in a way that mediates institutional boundaries to, „move from what we know to what we do‟ in accelerating the translation of evidence-based innovation into healthcare practice. Introduction
Current research and development (R&D) policies for the NHS are based on the
belief that there is a „translation gap‟ between researchers and the NHS. In some
versions of these policies, it is assumed that there is plenty of good evidence that
is not being acted upon, and the challenge is to improve uptake. This infers that
we need to move, „from what we know to what we do‟. There is, however, a
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substantial literature which shows that the problem is more complicated (Nutley
et al., 2007). In particular, translation of evidence-based innovation is a non-
linear process that is characterized by political and cultural challenges that are
linked to a need to cross professional and organizational boundaries
(Greenhalgh et al., 2004)
To address the translation gap, the National Institute of Health Research in
England has funded 9 CLAHRCs, for a total of £100mn., with NHS partners
contributing matched funding 2008-2013. CLAHRCs are collaborations between
NHS organizations and Higher Education Institutions that accelerate the
translation of evidence-based innovation into healthcare practice, following the
Cooksey Report that identified the application of research into routine clinical
care as the „second gap‟ in such translation (HM Treasury, 2006). CLAHRCs are
charged with addressing a number of major challenges including: negotiating
novel partnership working arrangements; undertaking R&D which generates
usable knowledge; and, finding ways of diffusing both explicit and tacit
knowledge across professional and organizational boundaries. Internationally, we
highlight that Canada has proved an early mover in translational initiatives, upon
which NHS R&D policy in England and Wales draws (Canadian Health Research
Foundation, 2003; Lomas, 2007).
Within clinical sciences, the study of methods to promote knowledge
translation coheres around the idea of „behavioural medicine‟, with a Society for
Behavioural Medicine and a house journal, Implementation Science. This
represents work in progress, with limited conceptualizations, descriptions or
contextual data of interventions and little being known „about how best to
integrate disease and case management interventions into existing healthcare at
the system level‟ (Department of Health, 2007: 15). Nevertheless, it is an
emerging field that has driven much of the development of the CLAHRCs. To a
greater or lesser extent in all the CLAHRCs, social sciences, specifically
organizational behaviour (OB), is integrated with clinical sciences, as a means to
understand how translation of evidence-based innovation can be accelerated into
practice.
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In line with the need to build a social science platform to support the
translation of clinical research int0 practice, our paper conceptualizes CLAHRCs
from an OB perspective. We represent the case of CLAHRCs as one where
change agency and knowledge brokering at the local level need to mediate
powerful macro-level institutional forces that potentially drive research and
practice apart. This paper draws upon illustrations from four CLAHRCs over the
first 18 months of their operations to provide some early analysis of the practical
challenges CLAHRCs face in enacting their conceptual models.
The CLAHRC OB Challenge
In organizational behavior terms, the translation gap can be conceptualized as an
institutional challenge, where local level agency (either meso-level or micro-level)
mediates the macro-level structures that generate professional and
organizational boundaries to the translation of evidence-based innovation into
healthcare practice. We note the interaction of structure and agency in the
reproduction or mediation of institutions is now a well developed area of concern
within the organizational behavior discipline (Lawrence and Suddaby, 2006;
Scott, 2008) and consideration of translation of innovation in healthcare (Ferlie et
al., 2005; Fitzgerald and Ferlie, 2002; Greenhalgh et al., 2004); i.e. our specific
concerns about CLAHRCs are likely to make a more generic contribution to
organizational theory and healthcare innovation.
In the context of CLAHRCs, the following institutionalized boundaries are
particularly pertinent: clinical and social science academic - clinical and
management practice; clinical science academic - social science academic;
healthcare professional and academic - service user; healthcare provider -
healthcare commissioner. The agency of CLAHRCs and staff within them is
expected to enhance knowledge exchange across these institutionalized
boundaries and so accelerate the translation of evidence-based innovation into
healthcare practice. In essence CLAHRCs and staff within CLAHRCs are
expected as agents of institutional change, with a specific remit to broker
knowledge across professional and organizational boundaries in pursuit of
accelerated translation of innovation.
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The CLAHRC OB Solution
Change agents or knowledge brokers can take on a variety of roles. Ottaway‟s
(1983) taxonomy makes a useful starting place for analysis of the role of change
agents. He identifies ten change agency roles in three broad categories; change
generators (key agents, demonstrators, patrons and defenders), change
implementers (external and internal), and change adopters (early adopters,
maintainers and users). This categorization has resonance with the work of
Rogers (1995) on the diffusion of innovation in which he identifies early and late
adopters, with differing characteristics. Crucial seems to be the idea presented
by Stjernberg and Philips (1993), that change relies on a small number of
committed individuals called souls-of-fire, from the Swedish „eldsjälar‟ meaning
„driven by burning enthusiasm‟.
Meanwhile, Fernandez and Gould (2005) identify five roles for knowledge
brokers that reflect the change agent roles above: „liaison‟, where they broker
knowledge across different groups, neither of which they are members of;
„representative‟, where a senior member of a group delegates the brokering role
of external knowledge to someone else in the group; „gatekeeper‟, where the
broker screens external knowledge to distribute within their own group (a slight
variation of representation, but which Fernandez and Gould suggest is more
prone to filtering of knowledge by the broker aligned with self-interest) ; „co-
ordinator‟, where all the actors, including the broker and the source of
knowledge, are in the same group; „itinerant broker‟, where the broker mediates
between actors in the same group, but where the broker is not part of this group
(Fernandez and Gould, 1994).
The taxonomies of change agents and knowledge brokers resonate with the
emphasis upon „clinical champions‟ to enact change agency presented in the
healthcare innovation literature (Fairhurst & Huby 1998; Greenhalgh et al., 2004;
Locock et al 2001 Pettigrew et al., 1992). Within this literature, it is evident that
organizational change is always framed by context and therefore to be effective it
needs to be situationally specific (Denis, et al., 2002; Fitzgerald et al., 2007).
Healthcare can be perceived as a highly complex and professionalized context/s
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with some unusual characteristics which impact how improvement and change is
delivered (Buchanan et al., 2007). Organizationally, for example, the goals of
effective health care are difficult to define. Firstly, healthcare contains numerous
professional groups and it is important to understand the boundaries between
professions and competing professional ideologies as it relates to evidence
(Ferlie et al., 2005). Secondly, healthcare organizations and universities are
subject to centralized performance targets, which may cause change efforts to
fragment across research and practice (Currie and Suhomlinova, 2006). Finally,
healthcare researchers and practitioners hold divergent views of „success‟, and
the evidence that underpins change in practice (Currie & Suhomlinova, 2006). In
the context above, change agents take on a role of „boundary spanners‟,
individuals who move across evidence or knowledge domains (Ferlie et al.,
2009). Thus, we can locate change agency at the individual level, specifically as
those positioned to broker knowledge or evidence-based innovation across intra-
and inter-organizational and professional boundaries. However, individual
change agents are likely to prove relatively ineffective within a larger, complex
system, such as healthcare. Consequently, change agents will need to engage a
wider range of stakeholders (i.e. engender a critical mass of support for change)
if they are to accelerate the translation of evidence into practice in clinical
domains upon which they seek to impact (Greenhalgh et al., 2004)
In focusing upon change agency as knowledge brokerage in the case of
CLAHRCs, we highlight that CLAHRC staff facilitate knowledge exchange
through using their in-between vantage position (for example, between research
and practice, or between healthcare professionals/academics and service users)
to connect, recombine, and transfer to new contexts otherwise disconnected
pools of ideas: i.e. they get the right knowledge into the right hands, at the right
time (Hargadon and Sutton, 2000; Verona et al., 2006). Consistent with our view
that change agency needs to consider context, Shi et al. (2009) take a contingent
view of knowledge brokering. Particularly relevant is that the knowledge broker,
to have an effect upon translation of evidence-based innovation, may need to be
affiliated, or at least understand, the groups across which they seek to broker
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knowledge into; i.e. the question of who has the legitimacy for others to accept
their knowledge brokering role is a crucial one (Dobbins et al., 2009; Shi et al.,
2009). This appears more important where knowledge brokers seek to engender
community tendencies (Lave and Wenger, 1991), underpinned by social capital
(Nahapiet and Ghoshal, 1995), upon which change agency across the wider
healthcare system is likely to rest.
So, there are a number of ensuing issues and challenges we need to address
around change agency and knowledge brokering at the individual level of staff
within CLAHRCs. These include:
Understanding the institutional context that frames change agency and
knowledge brokering
Determining how change agency and knowledge brokering can be
developed and enacted in this institutional context
Understanding the basis of legitimacy for change agency and knowledge
brokering
The CLAHRC Structures
Whilst the underlying goals of the NIHR CLAHRC translational initiative are
shared, and each CLAHRC more or less explicitly adopts a change
agency/knowledge brokering model, the specific structures of each CLAHRC to
enact change agency/knowledge brokering vary. So, as a starting point for our
empirical section of the paper, it is necessary to outline the different CLAHRC
structures across our four examples as they relate to change agency and
knowledge brokering.
CLAHRC GM
The CLAHRC GM framework is informed by the “Model for Improvement” and the
“Promoting Action on Research Implementation in Health Services” (PARiHS)
framework (Kitson et al., 2008). This approach is based on an action research
paradigm, underpinned by the view that individuals are more likely to engage
with change if they can see a strong need for it, are in an environment that
supports it rather than hinders it, and they have the necessary human resource
for implementation of change (Waterman et al., 2001). Within this model, change
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agency and knowledge brokering largely relies upon “Knowledge Transfer
Associates” (KTAs). This rests on the prescription within the broader literature on
change agency outlined above, that organizational change can be facilitated and
supported by individuals whose specific focus and role is on supporting (and
enabling) the implementation process. Within each of the four clinical domains
upon which CLAHRC GM seeks to impact, there are two full time KTAs (i.e. eight
KTAs in total), who are supported by: part-time staff, a clinical lead (who is a
specialist in that field of care); an academic lead (with a background in
organizational change) and a project manager. These teams can also draw on
specialist support from an information analyst.
CLAHRC LNR
The CLAHRC LNR model for translation of innovation is a seven step process,
which moves from identification of a patient group and their need, to mediation of
barriers to change, and monitoring/evaluation of change implementation (Baker
et al., 2009). In CLAHRC LNR, change agency/knowledge brokering rests in
large part with “CLAHRC Co-ordinators”, who are located in all but one NHS
partner organizations. The seven CLAHRC Co-ordinator roles were introduced
to address various barriers between the local NHS and the university, by “(a)
facilitating the research and implementation work of the CLAHRC in [each] Trust,
(b) leading activities in the Trust to bring researchers and practitioners together
to translate evidence into practice, (c) co-ordinating training in applied research
and translation, and (d) identifying and co-ordinating the development of new
applied researchers” (original CLAHRC LNR application). Thus CLAHRC Co-
ordinators have a crucial role in the LNR approach to research translation, which
emphasises a research-minded organizational culture, partnerships across NHS
organizations and the university to facilitate the creation and use of knowledge,
and the responsibility of NHS organizations themselves for adopting, adapting
and applying research findings.
CLAHRC LYBRA
An underlying assumption of this CLAHRC is that there are different answers to
the question, what is the cause of the translation gap? First, it could relate to
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evidence being known but not being used. Second it could relate to evidence
being known but it not physically being possible for it to be incorporated into
practice. Third, it could relate to evidence not being known, and therefore new
research being required. For this group, the task is to create fora where the
different understandings can be discussed and mutually acceptable ways forward
negotiated. Put another way, the process of mediating the translation gap links to
organizational learning and has echoes of double loop learning (Argyris and
Schon 1974). CLAHRCs have to find accommodations between evidence and
practice, and in doing so, change institutional relationships between the various
parties involved.
To action the above, change agency/knowledge brokering arrangements are
more emergent than designed a priori, and also vary across the clinical domains
of CLAHRC LYBRA. One role involves local clinical effectiveness teams acting
as the change agents or knowledge brokers. They work between researchers
and clinicians, but are part of the NHS, and are accepted as part of the local
landscape; e.g. a PACE team. A second role, closer to the CLAHRC NDL
Diffusion Fellow role, focuses on stroke rehabilitation. Within this theme, the
service changes required are just too complex for any external change agency
role, so the only option is to have embedded staff leading local change; e.g.
clinical directors and directorate business managers, on the basis that CLAHRC
needs to mobilize both clinical and managerial support simultaneously.
CLAHRC NDL
The CLAHRC NDL model also applies ideas of organizational learning, but one
that is more sociologically informed. Their model is intended to highlight political
and cultural barriers to change (Easterby-Smith et al., 2000), to develop an
understanding of both the barriers to translation of evidence into practice, and to
develop prescriptions to overcome these; i.e. the emphasis of CLAHRC NDL lies
with a situated model of translation concerned to develop community tendencies
towards the implementation of change, which overcomes political and cultural
barriers to the translation of innovation into practice. Within CLAHRC NDL,
change agency/knowledge brokering rests with clinical and managerial staff from
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NHS partners, 30 of whom are seconded to work into research and translation
activity as “Diffusion Fellows”, linked into four clinical themes. Diffusion Fellows
contextualize the applied research, so that the evidence produced is relevant to
those commissioning care or applying it in their healthcare practice, and so
accelerates translation of evidence-based innovation into practice. Diffusion
Fellows attend CLAHRC NDL workshops and engage in learning sets with their
peers to enhance R&D capability in the NHS with a focus upon translation of
evidence-based innovation. They recruit others from NHS in the clinical domain
upon which they seek to impact, called “CLAHRC Associates” (who also go
through CLAHRC NDL workshops), to build an implementation „army‟, currently
numbering around 300, to push through the translation of evidence-based
innovation into practice.
The CLAHRCs in Action: Some Early Analysis
CLAHRC LYBRA
Thus far, our readers may have grasped the conceptual underpinnings of
CLAHRCs and their various structures, but remain unclear about what they look
like in action. The intentions of CLAHRC LYBRA provide an illustrative working
example.
One class of problems involves situations where there is an established
evidence base (e.g. NIHCE guidelines) and where local staff have not integrated
the evidence into their practices. This is just the sort of situation where a change
agent, or knowledge broker, model might be appropriate. Individuals with the
requisite organizational change skills, and with a proper understanding of the
evidence base, can make progress with clinicians and service managers.
A second class of problems focuses on situations where there is limited or no
evidence available to use to improve clinicians‟ common sense. A good example
here is vascular prevention services, which all commissioners are required to
provide, but for which there is limited evidence. The practical course of action, if
you are in a CLAHRC, is to undertake primary R&D in collaboration with
partners. The basic idea is to produce a virtuous cycle, starting with agreeing
what R&D might best inform resource allocation decisions, undertaking a
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research programme, discussing the implications of the findings with relevant
commissioners and service providers, and finally supporting implementation of
new models of care (e.g. by evaluating implementation). This outline description,
by itself, makes the point that change agents, however defined, will only be able
to help with elements of this process. A range of skills is required, including a
detailed understanding of research methods and the ability to interpret equivocal
evidence, and no single individual is likely to possess all of them.
The third class of problem is one that starts with policy imperatives. Stroke
care offers a useful illustration here. The 2007 Stroke Strategy, and NIHCE
stroke guidelines published in 2008, highlights the need for service re-designs in
most localities across the NHS. Too many stroke patients are not reaching
specialized stroke units early enough, or at all, even though there is clear
evidence of the effectiveness of such units. Practical challenges here include
finding ways of „routing‟ patients to appropriate services, and working out what
data clinicians need at different points along stroke pathways, such that the
quality of care and outcomes can be improved. The skills required here are more
diverse than in the first two examples. They will necessarily involve service
managers, planners, service design and informatics teams, and spanning
primary care, secondary care and commissioning. Again, the change agent role,
by itself, can only be part of any solution. Indeed, this last example highlights the
point that CLAHRCs are partnerships, and are thus pursuing a dual strategy, one
involving change agency roles in relatively contained settings, the other being
much broader, tackling larger scale institutional change.
However, we emphasize the above represents intention, and such is the
emergent nature of both the CLAHRC solution and the context in which they are
enacted, aspirations to drive change agency and knowledge brokering have been
faced with significant challenges. CLAHRC GM, CLAHRC LNR and CLAHRC
NDL provide some examples of the institutional nature of these challenges.
CLAHRC GM
The individuals recruited to the KTA roles are all employed by the NHS, (hosted
by one Greater Manchester PCT). The eight staff recruited, hold varied
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backgrounds, ranging across ex-nurses with experience in clinical and
management roles; individuals with Masters qualifications in organizational
change and „bright‟ newly qualified degree students with limited prior work
experience. Thus „self‟ understanding of the role was the earliest issue facing the
incumbents. How should they envisage their role? How should they learn the
skills and explain it to others? How can they, as „new outsiders‟, persuade
professionals to listen to their arguments for change? How do they work with
many different disciplines, structures and cultures? Who should be approached
first? Linked to this, post-holders (and other staff) faced the challenge of
explaining their roles to NHS staff, that were mainly clinically, rather than
implementation, focused. So in the initiation period, most KTAs opted for „being
useful‟ in various ways to their project sponsors. As time progressed, and skills
and experience grow, the KTAs have recognized the variety of roles they
perform, from project management; group facilitator; analyst; „prodder‟ and co-
ordinator.
In enacting their roles, project work has to be carefully negotiated and
embedded in the health care system as it exists locally. This generates a
multiplicity of issues a concerning working inter-organizationally. For many of the
implementation teams, specifically KTAs, who are working across several
partners, the most basic task is to divide and manage their time and to cope with
the workload demands, which often include competing deadlines. Secondly,
there is the task of maintaining relationships with a wide range of individuals and
ensuring that communications are updated. Thirdly, the teams are moving
towards a new phase. Once projects are established and results are beginning to
become apparent, there is the issue of „spreading‟ this learning across and
between organizations. Clearly, interconnected to the tasks performed by KTAs
within projects, there is a need to consider and develop the knowledge base of all
our staff but especially, the capacity of KTAs.
Finally, there are considerable stresses on sharing between clinical and
academic leads, all of whom work part-time into CLAHRC NDL, and have
substantial other responsibilities. In addition, the backgrounds, training and
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expertise of the members of the two groups are dramatically different. This
generates problems of understanding and sharing of knowledge. So whilst the
academic leads meet together and the clinical leads meet together with the
Programme Directors, there exists a need to develop better sharing across
professional and academic boundaries.
CLAHRC LNR
The use of CLAHRC Co-ordinators has involved several challenges, many of
which might be understood in institutional terms. First of all, the job evaluation
and banding of the posts by NHS organizations‟ human resources departments
has been far from straightforward, with the posts ultimately banded one grade
lower than originally anticipated. This is indicative, perhaps, of the novelty of the
posts, and the difficulty of matching them to any existing roles within the NHS.
Moreover, it is also perhaps symptomatic of the unfamiliar nature of research-
oriented roles in general in the NHS, and the particular skills and competencies
these require, and this is reflected in the parallel process of banding NHS-
appointed research posts, which has been similarly prolonged.
Second, recruitment to the posts has been a lengthy process. At the first
recruitment round, only one NHS organisation appointed, and by the end of
2009, only two CLAHRC Co-ordinators were in post. This has required a number
of rounds of re-drafting of the job descriptions for the posts, and again, this
reflects the unusual nature of this boundary-spanning, facilitative role, which
does not fit readily into any established NHS (or university) career paths. The
initial round of job advertisements attracted small numbers of largely
inappropriate applicants; subsequent re-drafting of the advertisements and
person specifications placed less emphasis on existing knowledge of research,
and more on communication and „people‟ skills. Given the need to engage the
heterogeneous stakeholder groups that comprise an NHS organization in the
research and translation mission of the CLAHRC, an ability to work with
effectively with varied professionals and managers from all levels of seniority was
seen as fundamental to the role. Research literacy could then be built on this
initial foundation, for example through study for the Masters in Research in
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Applied Health Research that the CLAHRC has already established, and for
which one of the CLAHRC Co-ordinators has already enrolled. Thus the
capacity-building work of the CLAHRC may apply as much to its knowledge
brokers themselves as to the wider NHS community being engaged by these
knowledge brokers.
Finally, the CLAHRC Co-ordinators recruited to date have found themselves
extremely busy from day one. Their general mission, to bring researchers and
practitioners together, and facilitate research and implementation work in their
NHS organisations, has given rise to a great deal of work to do on the ground.
This has varied from co-ordinating general awareness-raising campaigns, to
liaising with clinical research networks and GP practices to increase recruitment
to CLAHRC trials, to attempting to put specific individuals in touch with one
another. On the one hand, this is indicative of the previously unfilled need that
this role is addressing, and of the amount of new research and development
activity taking place in the organizations as a result of the inception of the
CLAHRC. On the other hand, there is a risk that these roles become
overburdened with the „nitty-gritty‟ of meetings and publicity, or become seen as
just another means of increasing trial recruitment in LNR. As the implementation
and translation-oriented activities of CLAHRC LNR increase in volume to match
the scale of its research activities, a key test of the efficacy of the CLAHRC Co-
ordinators will be the extent to which they are able to foster the kinds of networks
and partnerships that the LNR approach to translation calls for. Undoubtedly,
due to contextual factors as well as to their own capacities, some Co-ordinators
will be more successful in this mission than others, and comparative evaluation
of these roles will provide important information on how best to encourage and
support them. While they may not have the structural legitimacy afforded by, for
example, the Diffusion Fellows in CLAHRC NDL, who are seconded from existing
senior roles in the local NHS, the CLAHRC Co-ordinators do have the advantage
of being embedded within their NHS organizations, of the capacity-building
activities available to them via the CLAHRC, and of the developing infrastructure
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of CLAHR LNR as it seeks to create a research-minded NHS closely allied to the
university.
CLAHRC NDL
The intention within CLAHRC NDL is that Diffusion Fellows would be recruited
along multidisciplinary lines on the basis this is necessary to drive change across
professional boundaries and is consistent with other initiatives, such as
Healthcare Innovation and Education Clusters (HIECs), that aim to develop a
multidisciplinary workforce top deliver healthcare. However, medical consultants
dominate the ranks of Diffusion Fellows. On reflection this seems necessary
since such arrangements align with professional hierarchy with medical
consultants well positioned in legitimacy terms to drive change. This seems more
so when they also hold senior management positions, such as clinical
directorships, and align with the necessary managerial hierarchy to leverage
resources to support change.
The CLAHRC NDL Board, as with other CLAHRCs, consists of Chief
Executives or other senior executive directors. Combined with the appointment of
Diffusion Fellows from the apex of the professional hierarchy, CLAHRC NDL
appears top heavy. CLAHRC NDL, as with other CLAHRCs, faces a
considerable challenge to impact upon the middle levels of their organizational
partners, if it is to make its intended impact upon the translation of evidence into
practice. The recruitment of CLAHRC NDL Associates continues apace, with a
particular focus upon middle levels of constituent organizations. Included in
CLAHRC NDL‟s attempt to build an implementation army are service users and
carers, since their experiences of care in clinical domains can act as a focus
around which change can cohere.
The impact of CLAHRC NDL varies across its constituent organizations, yet to
drive system level change at the regional level requires that CLAHRC NDL
change agents and knowledge brokers influence all providers and
commissioners of healthcare. Primary Care Trusts (PCTs) in particular vary in
their understanding and support for the CLAHRC NDL translational initiative. For
some PCTs, they have been slow to identify and support suitable Diffusion
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Fellows in relevant areas. For system level change, one might expect General
Practitioners (GPs) to be recruited as Diffusion Fellows through PCTs. However,
PCTs have been reluctant to release funding of around £20,000 per year for this
to happen (only one of the PCTs has funded a GP). The local Primary Care
Research Network (PCRN) was willing to fund two GPs. However, that CLARHC
research is not portfolio adopted (on the basis that adoption would put too much
additional workload on Research Networks) meant they felt such funding no
longer supported their strategic priorities and so the offer was withdrawn despite
some interest from enthusiastic GPs. Meanwhile, outside the NHS, within local
authority partners, CLAHRC NDL has struggled in the face of limited appreciation
of the importance of R&D to engage stakeholders, including Diffusion Fellows,
yet such engagement is necessary in the case of long-term conditions, which all
CLAHRCs are designed to tackle.
Such struggles to recruit Diffusion Fellows are exacerbated within the current
productive climate. Across both NHS and local authority organizations, the
CLAHRC Director and academic leads for the clinical themes have expended
considerable effort to ensure the CLAHRC NDL Diffusion Fellow role is not
merely added to existing workload, but that, if necessary, clinicians have their
clinics backfilled; i.e. the CLAHRC NDL Diffusion Fellow role equates to two
clinical sessions.
Finally, the integration of clinical and social science is challenging.
Implementation research is commonly driven into clinical research protocols by
CLAHRC NDL Scientific Committee. Even once embedded in the protocol,
clinical academics vary in the extent to which they privilege implementation
research, with some resorting to their traditional canon of research, which
emphasizes the production of more evidence about „what works‟, rather than how
we might drive existing evidence into practice.
Conclusion
Our early analysis of CLAHRCs is revealing. CLAHRCs face a similar institutional
landscape. The institutional challenge is both professional and policy orientated.
In response, CLAHRCs vary in the specific ways they organize for change
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agency and knowledge brokering, with key staff enacting a range of roles on the
ground, which appear consistent with existing taxonomies (Fernandez and
Gould, 2005; Ottoway, 1983). However, there is some concern that key staff are
pulled into more general activity that is decoupled from change agency or
knowledge brokering as they attempt to prove their value to external
stakeholders. This may prove an antecedent to later influence, but nevertheless
may compromise „early wins‟ for the CLAHRCs.
Professional hierarchy means that some change agents or knowledge brokers
are accorded greater legitimacy than others, but we note that change agent or
knowledge broker roles may be so novel that their enactment is slow to realize
(Reay et al., 2006). If embedded in pre-existing professional, supported by
managerial, hierarchy, then change agency and knowledge brokering may prove
more successful (Currie et al., 2008). Even then, there is a need for workforce
development. Staff recruited to change agent and knowledge broker roles
commonly require both their research and influence skills to be enhanced. So,
even where they are willing to embark upon novel roles within CLAHRCs, they
may lack the competence to enact these novel roles. In short, there is a need for
CLAHRCs, HEIs and NHS partners to offer considerable support to those taking
up change agent or knowledge broker roles.
Meanwhile the policy institution itself may be inconsistent in its support for
CLAHRCs, more so when focused upon productivity gains (Newman, 2001). The
health and social care system is complex, with considerable variation across
organizations regarding the extent to which R&D is institutionalized. To make the
necessary impact, CLAHRCs are moving beyond the single clinical champion to
drive change. More or less in the various CLAHRCs, the need to engage a wide
range of stakeholders to engender a critical mass for change efforts is explicit
(Greenhalgh et al., 2004).
Change agency and knowledge brokering arrangements within CLAHRCs
focus upon the research-practice boundary. More broadly, there is the question
of how CLAHRCs sit within the innovation landscape of the NHS. This includes
the integration of CLAHRCs with Research Networks, but also other translational
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initiatives, such as innovation hubs, HIECs, and Academic Health Science
Centres (AHSCs). There is a need for boundary spanning across translational
initiatives. This also extends to the social science and clinical science boundary,
where different epistemological worlds collide (Ferlie et al., 2005). Perhaps in this
case, ongoing interaction over the course of CLAHRCs, between social science
and clinical science academics will engender knowledge exchange and change
agency to bridge this boundary. In this respect, we should recognize CLAHRCs
are emergent, subject to contestation within and outside their boundaries, to the
extent they represent an institution in the making. Our challenge remains one to
operationalize the CLAHRC model in a way that mediates institutional
boundaries to, „move from what we know to what we do‟ in accelerating the
translation of evidence-based innovation into healthcare practice.
19
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