CLAHRCs in practice: combined knowledge transfer and exchange strategies,cultural change,and experimentation

Establishing the CLAHRC

The primary emphasis was on the translation of research evidence into improved mental health, social care services, and patient care. CLAHRC-CP's goals included informing public health policy, collaborating with national partners, and embedding research-led innovation into the NHS and social care more broadly. ¹⁵ This was to be achieved through establishing and nurturing learning and exchange linkages between diverse stakeholders in the mental health services pathway, including academic researchers, clinicians, NHS managers, local authorities, general practitioner (GP) practices, commissioners, and service users. There was an understanding that the translation gap between research and services was not unidirectional and indeed that it suggested a degree of experimentation. The CLAHRC intended to involve stakeholders throughout different stages of the research and implementation processes: ‘It’s not like there is one gap between the researcher and the user of knowledge. There is a lot of information exchange along the whole process … It is an iterative process in the system.’ (Interviewee 1) (Figure 1, Supplemental Data online).

CLAHRC-CP evolved out of previous collaborations to secure funding for applied mental health research. There was growing interest in collaborating on applied research and implementation agendas and developing relationships between university and NHS organizations. The call for proposals presented an opportunity to harness support for collaborative efforts to improve evidence-based mental health and social care practice.

CLHARC-CP's approach was to improve understanding of service design and delivery and gradually improve services on the basis of existing and new evidence about best practice. The focus was on established strengths in approaches to mental health and on addressing challenges arising from the existing transitions in care, from adolescent to adult to old-age and end-of-life care, as well as developing new ones (such as mapping mental health pathways). To this end, the CLAHRC exploited existing local capacity, such as the East of England Evidence Adoption Centre ¹⁶ which undertakes systematic reviews, and the Institute of Public Health at Cambridge University; and strengthened links with groups with expertise in implementation and service design at the Engineering Design Centre and in service change and evidence-based innovation at the Judge Business School. ¹⁵

The local context was therefore seen to be crucial for driving the design of the CLAHRC projects, in terms both of their geographical and methodological scope. Many relationships (such as links with social care, the NHS, and individual commissioners) pre-dated the CLAHRC; however, the collaboration gave these relationships direction and focus, and provided a steer to implement projects. As they had only one clinical focus (mental health) and one primary NHS institution as a core partner, CLAHRC-CP was well-positioned to maintain oversight of the activities. Although this was seen to be advantageous, it was also more likely to (over) burden NHS colleagues (‘we’ve kind of saturated our NHS colleagues with research and evaluation …’ (Interviewee 3)) while also creating uncertainties for the CLAHRC when there were ‘major structural reorganisations’ (Interviewee 2) and changes in senior NHS staff in this one institution, which was a ‘huge challenge’ (Interviewee 2).

Working as a CLAHRC

While the overarching vision remained unchanged throughout, the approach used to realize this vision evolved over time. For example, there was consensus that the research agenda was initially driven by senior academics. However, the intrinsic mixture of disciplines within the collaboration required multi-disciplinary input to the design of individual projects. Clinical themes, initially designed as a set of projects as part of their funding application (psychiatry), benefited from the existence of implementation disciplines (management and engineering design) which fostered a more experimental and reactive approach to project design by looking for opportunities and knowledge gaps relevant to their respective NHS partners. The evolution and progression of projects was a feature common to most projects, and the extent to which they drew inspiration from the NHS increased in tandem with levels of NHS engagement.

This growing awareness of the importance of NHS involvement in research design was reflected in the comment that the ‘most successful projects have been co-produced’ (Interviewee 2) as a result of NHS or social care partner steering. Contributors reported that their understanding of how to deliver their mission changed during the first year as a result of what they learned in that time. The CLAHRC iterated between its framework (based on the life course approach) and its array of relationships, yielding exchanges in multiple settings that allowed for adaptation and change, and developed initiatives such as fellowships, studentships, training, and projects. Interviewees emphasized the need to engage with NHS and social care staff to generate research questions, be opportunistic in identifying new project ideas, and focus on interventions which might lead to sustainable legacies.

The mutual influences between the NHS and CLAHRC developed as the projects progressed. Initially, there was variation in the timing and level of engagement between NHS staff and the CLAHRC: clinicians in the mental health trust were brought into the CLAHRC from the start, whereas managers and GPs were more difficult to engage. However, over time there was a clear change in attitude by some NHS management staff, one of whom was described as initially ‘aggressive and quite cynical’…[and then]… ‘completely turned around’ (Interviewee 2) and saw the value of the work for local services. Indeed, engagement with the NHS was seen to offer value beyond promoting research that responded to the needs of the service.

Most projects faced challenges as a result of changes in NHS policy, staff turnover in positions of authority and decision-making, and the disappearance of institutions and organizations. In order to respond adequately, resilience, flexibility, and responsiveness were required on the part of those delivering and researching services. ‘Questions emerge, new partners emerge, new researchers, new partners on the knowledge production side emerge, new techniques, new ideas. We need to be able to contain all those emergent issues.’ (Interviewee 4) Learning to adapt and be flexible in this way helped people and organizations develop resilience, and imbued the CLAHRC with the potential to become what one workshop participant described as ‘a beacon of stability’ within its local context.

CLAHRC-CP's focus on mental health meant that local authority and third sector involvement was crucial, with reports that this was successfully achieved:

‘The greatest impact of the CLAHRC to date has been, and continues to be, the gradual enlightenment on the part of our local authority, voluntary sector and clinical colleagues of the potential value of high quality research to their work.’ (Interviewee 1).

In one project, a senior academic who had worked closely with the local authorities to explore how research could inform decision-making in their area, noted how:

‘[i]t’s more apparent and it’s more impressive in the way in which we’ve changed our working relationship with Cambridgeshire Social Services … It’s us now co-producing a programme of evaluation which is funded by social services and will be supported by our infrastructure and I think we could say without hesitation that this would not be happening if it wasn’t for the CLAHRC. I think it’s the biggest multiagency success of my career …’ (Interviewee 3)

This perception was echoed by social care staff:

‘I’m grateful to the relationships that we had in the CLAHRC that just made us begin to think a little bit differently otherwise we wouldn’t be investing the money that we are doing in trying to create an evidence base for social work … we do feel as if we’re breaking new ground so it’s exciting.’ (Interviewee 5)

Lessons were learned about how research can influence thinking about practice as well as provide new ways to approach research. For example, discussion at the workshop highlighted how the notion of complexity can help commissioners facing complex decisions, and how CLAHRCs can provide valuable learning from their own experience:

‘The type 2 [translation] gap involves a great many players and an understanding of how to move ideas around a system. In fact, it’s a sophisticated systems engineering and management problem … What we’ve learned is that there are principles to short-circuiting having an idea and getting it into the hands of people who can use it.’ ¹⁷

In terms of shaping research approaches, one senior member of the CLAHRC noted that research success was initially conceptualized as performing longitudinal studies and randomized controlled trials (RCTs), as suggested in their original proposal. However, as the CLAHRC evolved, this shifted to demonstrating NHS staff engagement as another example of a marker of success. ¹⁸ Academics also reported that they had had opportunities to be introduced to real world research, to experiment with methods from other disciplines (for example, design and systems engineering for use in mental health), and that there was a general appreciation of the value and satisfaction of engaging with clinicians.

Perceptions of the balance between a focus on implementation and on applied research varied. There was some consensus among workshop participants that the focus had been largely on applied research, while also taking account of the contribution of implementation science. However, others expressed more mixed views and a lack of clarity regarding focus, although this may be because distinctions between research and implementation were not clear-cut in some projects, and because individual views were influenced by factors such as people’s academic and methodological expertise and working identity. Views may also have been influenced by what individuals thought the funder expected and would reward. Thus, one interviewee noted a shift to research rather than implementation, given that impacts from research (e.g. publications) are more easily understood by a funder compared to ‘NHS executives saying ‘I think about things differently’ (Interviewee 2).

Emerging impacts and legacies

Overall, CLAHRC-CP strengthened networks and relationships, built capacity in both academic and the NHS communities, and strengthened existing research and implementation methodologies. It established and nurtured relationships with individual commissioners, and set up strong collaborative projects with social care. Interviewees also reported that NHS stakeholders better appreciate health services research and academic support. Important factors have been the development of trust and good will, learning each other’s language and styles of working and understanding each other’s incentives and constraints.

Several interviewees commented on the capacity-building legacy. CLAHRC-CP has provided a fertile environment for NHS managers and local authorities to make use of research, for clinicians to do research (through the fellows scheme), and for academics to build flexibility and responsiveness into their way of working: ‘practitioner researchers, who are clinicians, feel more comfortable debating and contributing to academic research debates’ (Interviewee 6). The methodological legacies are in understanding and communicating how to address complexity, particularly to their commissioning community, and developing a measurement tool for their key performance indicators. Another important legacy is the range of successful projects that have been undertaken, especially those with a clear impact on health care delivery, such as the project on Improving Access to Psychological Therapies (Box 1).

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Box 1.

Improving access to psychological therapies programme legacy (CLAHRC-CP).

The Improving Access to Psychological Therapies (IAPT) programme aimed to provide quick access to cost-effective talking therapies to people who have common mental health problems. 19 As part of the programme, a low-intensity cognitive behavioural therapy delivered over the telephone was tested in order to enhance access to treatment for those who would otherwise be unable to attend because of transport problems, work commitments, physical disability or other reasons. The research, which was published in a peer-reviewed journal, 20 involved the development of a telephone training skills scheme, which was taken up swiftly across the locality and beyond: ‘I then developed a telephone training skills programme, and developed some core skills and developed a bespoke training programme, rolled it out to 150 therapists across the region, got amazing feedback from it that said everybody should go on this training, it’s improved our confidence and the way that we manage people on the telephone, and services have said [….] we can do three times as many contacts and all the rest of it. I’ve taken that to the Department of Health IAPT team, and rolled it out nationally …’(Interviewee 5)

Establishing the CLAHRC

An important inspiration was the 2007 Chief Medical Officer’s High Level Group on Clinical Effectiveness, ²¹ which highlighted the need to make better use of existing evidence to inform decision-making and so reduce variation in clinical practice. Against this background, the strategy was based around a process, ‘Engagement by Design’©, that seeks to build a partnership between the public, NHS clinicians and managers, policy makers, and academics to identify key research and implementation topics that directly address the needs of decision makers, accelerate the implementation of existing evidence, and produce new evidence where there are knowledge gaps. The underlying hypothesis was that working with people to find out what problems they face and what information they need to support rational decisions would make it more likely that providing that information will stimulate change.

‘If you talk … about why they do or don’t use an intervention, it’s because they have a specific set of outcomes that they are trying to achieve and that they value in one way or another … So what underlies it for us is keeping it grounded in the perspective of the person who is going to make the decision’ (Interviewee 1) (Figure 2, Supplemental Data online).

Within this framework, PenCLAHRC addressed four overlapping research themes: diabetes and cardiovascular health; mental health and neurology; development and ageing; and environment and human health. These themes reflect pre-existing research strengths and include many of the major problems that account for the bulk of NHS expenditure.

The overall goal was to change the culture and work towards explicit use of evidence as a norm among practitioners and organizations, with academics routinely working with the public and practitioners from the design phase to maximize the impact of their research. However, while there was clarity about the overall goals at the start, there was less clarity about how to achieve them. The initial stages were characterized by uncertainty about how to operationalize ‘Engagement by Design’© and make it real in a practical sense. Flexibility to try out various arrangements and learn from them was therefore important, and from the outset the CLAHRC recognized the value of a formative evaluation of progress. Crucially, ‘Engagement by Design’© was never seen as a simple linear model or as a constraint, but rather as a frame within which partners could think things through: ‘This looks like a terribly simple linear model. We know that this is an ideal-type model, but this is not the way it works. It is a frame that allows us to think about things.’ (Interviewee 1)

PenCLAHRC was built on existing local relationships (such as the South West Peninsula Clinical Research Collaboration ²² ), on existing research strengths, and on the goodwill generated between the NHS and local universities during the establishment, in 2000, of the Peninsula College of Medicine and Dentistry. The Peninsula Technology Assessment Group already offered a growing body of work and brought close links with the national HTA programme, and an eight-year programme of work on patient involvement in the South West (through Folk-us ²³ ) provided the basis for the Peninsula patient involvement group. The national context was more challenging: for instance, the re-organization of the NHS led to disruption of some existing relationships as key staff sought new posts, while NHS organizations became increasingly focused on short-term priorities amid on-going budget constraints. PenCLAHRC sought matched funding from a variety of local NHS organizations, which helped reduce concerns that funding might disappear following structural re-organization and also brought in more NHS partners. Much matched funding was in the form of released time for NHS staff, allowing them to become actively involved in the collaboration. There were six locality leads who were respected clinicians from NHS trusts who also worked part-time for PenCLAHRC; ‘… the locality leads are all people who have got clinical background, that’s the idea behind that … because they’re health care professionals they’ll have that ability to influence people’ (Interviewee 3) Although these leads were encouraged to become involved and to involve others, in question generation, they were also crucial for relationship building and implementation.

Working as a CLAHRC

Sustained organizational commitment by the NHS depends on the CLAHRC being able to respond to the organizational and managerial agenda as well as to clinical questions and those generated by patients. PenCLAHRC encouraged NHS staff and patients to raise issues of concern, and to get engaged in setting the research agenda and in the production and implementation of research. However, it took time for those involved to understand what was required and different groups responded differently at different speeds.

For instance, clinicians in the NHS trusts tended to pose questions about the treatment of particular conditions or new forms of care that are familiar to clinical researchers, and in doing so they had support from the clinical locality leads. Both these factors helped to promote relatively early and productive engagement. It proved more challenging to engage GPs due, in part, to the way that the health care system was seen to encourage GPs to act as individuals who work in their own practices to address the problems of specific patients, rather than to think more strategically about services. This was also a time of considerable change in primary care and in commissioning. It proved impossible to commit GP time and establish GP locality leads, although there were two locality leads from PCTs.

NHS managers tended to ask operationally related questions about how to organize services effectively and efficiently, questions that are largely outside the scope of clinical research and require a different set of skills. One senior NHS-affiliated member recounted a talk given by one chief executive of a local trust, where he described ‘why I was originally very indifferent to PenCLAHRC and why I’m now persuaded of its importance’. Although it took time, this chief executive had been convinced by mainstream CLAHRC projects, some of which were not directly relevant to his/her own operations. However, middle managers, who face urgent day-to-day concerns and are often subject to pressures over which they have no direct control, were more difficult to involve systematically, rather than on a project-by-project basis. But there was also evidence that over time this group could be reached, albeit with difficulty: ‘In the … [local acute trust] we’ve really gone in quite deep with that group, middle management, and it’s been very, very, very helpful; but in other places not very far at all’ (Interviewee 1).

At the start also there were no managerial locality leads. The result of both factors was an initial lack of engagement among NHS managers. This situation has now changed, particularly for senior managers, but it has taken time (two to three years), an early focus on quick wins seen by managers as helpful to the service, and the development of initiatives that can address the managerial research and implementation agenda. The latter have included the Peninsula Collaboration for Health Operational Research and Development, ²⁴ launched in November 2010 to support local trusts in the use of modelling, simulation and other operational research techniques to improve patient care, and the provision of evidence-based summaries of completed CLAHRC projects to inform managerial decision-making.

It has also taken willingness on the part of CLAHRC partners to listen, adapt, and learn. These experiences also demonstrated that despite the support of NHS management and clinicians, other barriers within the system can impede change. For example, one project on falls prevention among older people ²⁵ involved changes in the treatments delivered by numerous health care professions in multiple settings, and it proved impossible to align the competing requirements of different service providers and different patient groups. In other cases, the system was more responsive. In a project on the use of tranexamic acid to reduce heavy bleeding in emergency care, the changes involved a single group of health professionals working in a single service (the local Ambulance Trust) with whom good relations had already been developed through CLAHRC evidence-based practice training courses ‘that opened up a space … they already knew about PenCLAHRC’ (Interviewee 1). Engagement was further facilitated by the existence of a helpful operational mandate: patient group directions were in place that allowed ambulance personnel to use generic prescriptions. ²⁶

Another hard-to-reach group was NHS commissioners, not least as primary care trusts (PCTs) were to be replaced by Clinical Commissioning Groups. But what did work well was a CLAHRC arrangement with a consortium of local PCTs that provided them with rapid local assessments of new drugs that could be used to inform commissioning decisions. This had a direct impact locally on the quality of specific commissioning. ²⁷ PenCLAHRC is also collaborating with NICE and with local clinicians, commissioners and patients on a pilot project to identify ineffective procedures which the NHS should stop supporting, prior to national roll-out. ²⁸

Overall, the confidence of NHS staff grew over time and they became more involved. The local remit of the CLAHRC and the additional, flexible resource they brought to the system were crucial, enabling them to build on and develop local relationships and local capacities.

PenCLAHRC's approach encourages academics to do research that relates directly to the needs of the service and its patients. However, this also means that research priorities and production are no longer their sole preserve and raises issues about how academics can best interact with patients and managers whose first language is not research, develop appropriate research methodologies to address the new and challenging questions they ask, and respond to their pressures and timescales. There is a need to balance relevance (seeking speedy answers to local problems) with rigour (the production of generalizable research), a struggle that surfaced in concerns among senior university staff that PenCLAHRC would not deliver research suitable for the Research Excellence Framework (REF) agenda. It took time, but with the help of external factors such as new ‘impact’ case studies in the REF, the push to get universities more ‘community involved’ and the CLAHRC’s demonstrable success in attracting external peer-reviewed funding, the research agenda has become increasingly acceptable to the local universities and of interest to more academics.

One of PenCLAHRC's successes has been to engage patients and the public; almost 15% of projects have been initiated by patients and carers who have also been involved throughout the projects and have attended meetings and training courses. One patient described all these possibilities as an ‘Aladdin’s Cave’ of opportunity. Three commitments underpinned this work: funding public and patient involvement adequately, building on what was already there, and getting patients to help develop the partnership. What also contributed was an on-going evaluation to assess levels and types of engagement which demonstrated that initial concerns about whether patients would make a valuable contribution have been completely overturned. There was recognition among academics and NHS staff that their CLAHRC has helped patients and the public become better informed about research and its benefits and has produced more patient-focused research.

PenCLAHRC sought to engage local authorities from the outset but found it hard to achieve this at organizational level because the latter lacked the necessary funds, personnel, and motivation. However, it did succeed in engaging with some groups, specifically in education, in a series of projects on behaviour and mental health problems in children (Box 2). They also developed a wide range of collaborations with industry and third sector organizations which they see as a key source of innovation. These include acting as a conduit to help partners from industry evaluate innovative ideas in the health sector, working with industry to use their platforms to better develop in-house research programmes, and acting as an explicit driver in the local wealth agenda. ²⁹

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Box 2.

Demonstrating the PenCLAHRC ethos: preventing obesity in schools.

Initial charitable funding to develop and pilot a complex intervention which attempts to affect children’s lifestyles by influencing them, their families and the school environment. A NIHR-funded pilot trial suggested that this low cost intervention has a substantial effect on reducing the risk of obesity in 12-year-old children two years after the intervention. Further NIHR funding (£1.35 M) for a definitive cluster randomized trial. The question came from local PCTs, which supported all phases of the development. PenCLAHRC worked with children, parents, and teachers to ensure that the intervention was enjoyable for children, acceptable to families, feasible to deliver within the normal school environment, and seen by teachers as adding value. Across three phases of piloting involving six schools and 400 children, only three families opted out. There was over 93% follow-up at 24 months. Within six weeks of funding being in place, all 32 schools needed for the definitive trial were recruited. Close working with the local authorities inspires confidence that, if the intervention proves cost-effective, implementation will be relatively straightforward.

Emerging impacts and legacies

The CLAHRC has delivered clear benefits in services, attracted over £17 million in external research grant funding between October 2008 to early 2013 (Personal communication – S. Logan), and published high-quality research. These successes have depended on building effective relationships between service providers, commissioners, service users, and academics, and having the right people and processes in place to deliver high quality research and service improvement. NHS capacities to understand and use health research have been strengthened, and the internal evaluation has provided useful lessons about how the CLAHRC and the processes on which it is based can be developed further.