The original evaluation

Briefly, we found that whether the mechanisms were active or not in the individual projects reflected subtle but important differences in the ways in which the partners collaborated on the projects. Through these mechanisms, the partners on the more successful projects took advantage of the opportunities afforded by the programme within the different contexts of their work, some of which were more conducive and sensitive to their efforts than others. Based on these findings, we suggested that the style of closer collaboration that best enabled the partners to seize opportunities and overcome barriers to achieving knowledge translation could be construed as a form of ‘co-production’ of knowledge.

Aims of the illustrative case study

In this paper, we develop and elaborate our thesis, addressing the question: what does the theory of co-production add to our understanding of the processes of knowledge creation and translation in PenCLAHRC? We begin by describing the theory and the core principles that underpin it. Using data from one of the projects where knowledge translation was readily achieved, we show how elements of co-production were encapsulated in the mechanisms of closer collaboration that were at play throughout the design, conduct and implementation of the project. We consider how the theory helps to explain why knowledge translation was achieved and how it might inform the future development and evaluation of collaborations in AHR more generally.

The theory of co-production

Ostrom and colleagues propounded the idea of ‘co-production’ in the late 1970s [14]. She defined it as ‘a process through which inputs used to produce a good or service are contributed by individuals who are not “in” the same organisation’ (p. 1073) [14]. Subsequently, the concept has simply been used to describe people who ‘contribute to’ (p. 4) or ‘collaborate in’ (p. 16) the production of the public services that they use [14]. As we explain below, this means more than involving and engaging service users.

The notion of co-production is founded on a number of elements or principles. These have been variously defined in the literature, but we discerned five core elements. First, in the process of co-production, users are regarded as active agents and not merely passive subjects or recipients of services [14, 15]. Second, there is greater equality in the relations between users and professionals, with services becoming more user driven and users’ knowledge and experience being valued on a par with that of professionals [16–18]. Third, service users and professionals recognise that they can achieve more by working together than they can apart; both also find their relationship to be reciprocal and mutually beneficial [16, 18]. Fourth, users’ increased participation transforms the ways in which public services are designed and delivered, developing capacity for users’ present and emerging needs to be met [15, 16]. Fifth, the participation of users in the co-production of services is encouraged and facilitated by networks and organisations that support their involvement (although it is recognised that it is people, not systems, who create change) [15, 16].

As the above implies, the theory of co-production was originally developed to conceptualise a particular type of relations between the providers of goods or services (such as public officials) and users of them (citizens). However, in recent years, it has also been used to describe the growing engagement of policy makers and practitioners in applied research [19–21]. For example, Martin [20] outlined five types of practitioner engagement in research, which he described as ranging from relatively weak (‘practitioners as informants’) to strong examples (‘practitioners as co-researchers’) of co-production. This, in turn, prompted Nutley [21] to highlight issues for future debate and research on the topic, such as the appropriateness of the breadth of Martin’s typology, and whether the boundaries between the two communities of researchers and practitioners are maintained or collapsed in the course of the co-production of research.

To date, there has been only limited discussion of the relevance of the theory of co-production to the work of the CLAHRCs [13, 22]. In an interim report of their evaluation of the Birmingham and Black Country CLAHRC, Hewison et al. observed that although the programme was not formally conceived in terms of co-production at the outset, its approach to partnership working could be so characterised. They also noted that this way of working was taking longer than traditional approaches to AHR and that it remained to be seen if the desired outcomes would be achieved or not [22].

In contrast, the findings we report below are based on analysis that was carried out using data from the evaluation of the entire pilot of PenCLAHRC, when the initial outcomes of many of its projects were discernable. Through a case study of one of the projects where knowledge translation was readily achieved, we describe how the style of collaboration exemplified by the project can be interpreted as a form of co-production. We suggest that the theory of co-production provides a useful existing social theory for expounding the nature of the mechanisms that were characteristic of successful knowledge generation and translation projects in PenCLAHRC.

The stroke thrombolysis project case study

We selected the stroke thrombolysis project for more detailed analysis of our preliminary theoretical claims for three main reasons. First, the project was an early product of the system that PenCLAHRC had set up for soliciting research questions on topics that were important to the local community in the south-west of England. It was based on a question submitted by a stroke consultant in 2009 about the scope for, and potential benefits of, making changes to the existing emergency pathway for acute ischaemic stroke with the aim of minimising the time between the onset and treatment of the condition. The question was prioritised by PenCLAHRC and taken forward by a dedicated project team who worked up the idea, carried out the research in 2010–2011 (episodically) and implemented the findings locally by early 2012. The team included various clinicians and managers (from the stroke unit and emergency department in a local hospital and from the regional stroke network), paramedics (from the local regional ambulance trust), researchers with expertise in operational research methods and a project facilitator (all from the local university and PenCLAHRC).

Second, in our evaluation, we found the stroke thrombolysis project was a particularly successful example of what PenCLAHRC, and the national CLAHRC programme in general, was intended to achieve: the publication and implementation of evidence from high-quality research and increased capacity for AHR. Specifically, the research was published in Stroke, a leading journal [23]. It led to the existing emergency pathway for acute ischaemic stroke being redesigned and a pre-alert system being introduced by the ambulance and hospital trusts. Once implemented, there was a fourfold increase in the number of patients treated, in half the time previously taken. The project also helped to increase interest in and capacity for operational research in the local health economy. A number of similar projects were subsequently undertaken by a growing team of operational researchers in PenCLAHRC in partnership with NHS Trusts in the region.

Third, all nine of the mechanisms of closer collaboration that were associated, to varying degrees, with the more successful projects were found to be present and active in the case of the stroke thrombolysis project.

Analysis

Further thematic analysis of qualitative data from the stroke thrombolysis project case study was carried out to enhance the original analysis. These data included semi-structured interviews, of 40–80-min duration, with nine participants involved in the project. They included five participants from the NHS Trusts and regional stroke network and four university and PenCLAHRC participants. The interviews were carried out between December 2012 and March 2013. Management briefings, conference papers and research publications from the project were also obtained and read for information about the conduct and impact of the work from its inception in 2009 to 2012. Over that period, the evaluation team was also engaged in wider observation of programme events and meetings that sometimes included a focus on the project.

We used a combination of concept mapping [24] and framework analysis [25] to examine if the mechanisms of closer collaboration discerned in the evaluation could potentially be explained in terms of the theory of co-production. Initially, we compared each of the mechanisms of closer collaboration (as specified in the evaluation) with the core elements of co-production (as defined in the existing literature on the topic) and identified potential links between these concepts. We then designed a matrix for cross-tabulating themes in the data relating to the five elements and their matching mechanisms (listed in rows), with the design, conduct and implementation phases of the stroke thrombolysis project (listed in columns). The resulting matrix captured evidence of the manifestation of the sorts of collaborative behaviour, actions or attitudes that were consistent (or not) with the principles of co-production at different stages in the research process.

JH led on this analysis. Entries in the matrix were independently checked by JD and NB against the data, who confirmed the initial entries and identified two additional examples of evidence supporting the links. The final versions of the matrix and conceptual map were agreed after review and discussion by all the authors.

Active agents

Central to ‘Engagement by Design’^© in PenCLAHRC was the idea that AHR should be primarily driven by the needs of end-users of the research, such as professionals in the NHS and service users, and not by researchers. This idea was explicit in the programme documents and in the stakeholders’ accounts of how PenCLAHRC was supposed to work. However, as our evaluation revealed, there was some variation in the extent to which the projects were perceived by members to be driven by end-users. Whether end-users drove the projects or not was found to be one of the nine mechanisms of closer collaboration that made a difference to the success of the projects (labelled ‘local end-user driven’ in Fig. 1). In the concept mapping, this and one other mechanism was found to be a good fit with the ways in which users were conceptualised to be ‘active agents’ in co-production, as we describe below.

The ‘local end-user driven’ mechanism was manifest throughout the design, conduct and implementation of the stroke thrombolysis project. For example, it was a stroke consultant who jointly conceived the idea for the project and who submitted it to PenCLAHRC for prioritisation. The same clinician also jointly led the project team throughout. The team included other users from the NHS who were involved in the emergency pathway for acute ischaemic stroke, namely senior clinicians from the hospital’s stroke unit and emergency department (ED), and paramedics from the local ambulance trust. Other clinicians, who were not part of the project team but who were involved in delivering the pathway, also collected bespoke information for the project and participated in a workshop organised by the researchers where they helped to build a computer simulation model of the existing pathway. These clinicians were also involved in piloting the pre-alert system that was introduced on the basis of modelling potential consequences of proposed service changes.

The other mechanism that fitted the concept of ‘active agents’ was one that the members of the stroke thrombolysis project, more than any of the projects examined in the overall evaluation, had consciously initialised in the course of their work. This was where the members were cognisant of the role of the clinicians on the ground, whom they recognised were ultimately the users who would accept and adopt (or not) any proposed change in the design of the pathway. The operation of this mechanism (‘the end-user is King!’) was apparent in the lead clinician’s assertion that it was important that the research was relevant and meaningful to these clinicians and their daily practice: ‘Well, I think the crucial thing is to always relate it [research] to real life patients and real life clinical practice…’ [ID1]. The researchers accordingly carried out additional modelling in an attempt to engage and assuage these professionals and to demonstrate the ‘real-life’ problems that the research was addressing.

Although the team worked hard to involve various clinicians in the process of building the computer model of the pathway, the researchers realised during the project that they had not involved a wide enough range of clinicians from the ED early enough in the conduct of the research. This came to light during a meeting with the ED staff where the project team encountered some concerns about, and resistance to, some of the assumptions underpinning the model that they had constructed to date. The team were able to address these concerns but recognised that the scenario could have been avoided if they had involved a wider range of professionals earlier in the process. This experience only confirmed their view that it was important to include representatives of all the relevant professionals in the process of building a model, to make it sufficiently realistic and trustworthy, and to increase the chances of the results being accepted by them and acted upon.

Equality of partners

By seeking to enable clinicians, patients and the public to play a more active role in AHR, PenCLAHRC was also encouraging them to have a bigger and more equal role in the research process. Thus, the two aforementioned mechanisms (‘local end-user driven’ and ‘the end-user is King!’) were also found to fit with the ‘equality of partners’ principle of co-production.

The rest of the project team was small but stable throughout and inclusive of the key clinicians and researchers from the relevant partner organisations, each of whom were well positioned to progress the research. All the members were clear about their roles, which were distinct and vital to the success of the project. In these respects, we found the inclusiveness and even distribution of power in the project fitted with the general ‘equality of partners’ principle of co-production.

Likewise, the researchers were interested in finding out from the clinicians how the local emergency pathway for acute ischaemic stroke worked in practice, in order to be able to model it and estimate the effects of changing it. The clinicians who helped to build the model all reported that they felt that their contribution was valued by the researchers, and they very much enjoyed the process of taking part. In these respects, the knowledge and expertise of all the members were equally valued in the team.

Reciprocity and mutuality

Whether the different partners on the projects were open to and interested in learning from each other (‘knowledge appetite’) was also found to link to the ‘reciprocity and mutuality’ element of co-production. This was because the partners recognised that they needed each other’s knowledge and experience to meet the aims of the project and found that they each benefitted from being involved in the collaboration.

Through combining their knowledge and connections, the partners found that they achieved both their primary shared aim and other distinctive organisational goals. For example, the NHS Trusts and patients benefitted from implementation of the findings, which improved the emergency pathway for acute ischaemic stroke and reduced disability. The university benefitted from publishing the work in international journals and by achieving impact that was directly attributable to the research.

In addition, whereas in some of the projects in PenCLAHRC, the aims shifted over time or were never settled and agreed at all levels in their respective organisations, in the stroke thrombolysis project, the various clinicians and researchers all agreed about the aims of the research and the methods to be used (‘meeting of minds’). The project team members also had the full support of their respective organisations at a senior level and on the ground (after the concerns of some of the ED staff were addressed).

This also led to an improvement in the working relationships between the stroke and ED departments, with the stroke clinicians feeling that their role was valued more as a result of what the model showed.

Transformative

The clinician also reported finding it easier to ‘sell’ the project to clinical colleagues, and to make a case for the proposed redesign of the emergency pathway for acute ischaemic stroke, using the evidence from the researchers’ models rather than having to rely on ‘hunches’ or suppositions based on experience, as before. And as we mentioned earlier, the researchers claimed that without the help of the lead clinician, they would not have been able to obtain access to the data that they needed for the modelling. By working directly and immediately with the clinicians and their organisations to help them model the pathway and implement service changes, the researchers were also able to see the outcomes of the work, which they personally found more satisfying than not being involved in the implementation phase of the research.

As noted above, the researchers’ recognition that they needed to engage a full range of clinicians in future projects in order to enhance the credibility and acceptability of the modelling to those who would be involved in implementing any proposed changes (‘the end-user is King!’) also fitted with the ‘transformative’ element of co-production.

So, too, did the ways in which members of the team pooled and utilised each other’s local and specialised knowledge, resources and connections (‘creative assets’). For example, members were able to draw on existing data, specialist research methods, connections with colleagues and networks and the clinicians’ mundane knowledge of the day-to-day workings of the emergency pathway for acute ischaemic stroke, to effectively deliver the project. Paramedics from the ambulance trust subsequently became involved with other PenCLAHRC operational research projects after their positive experience of collaborating on the stroke thrombolysis project.

Members of the team were also subsequently enabled by PenCLAHRC to visit other centres in the region and demonstrate the potential of applying the approach to local variations of the emergency pathway for acute ischaemic stroke and configurations of services in these trusts. Through this mechanism (‘relational adaptive capacity’), the members endeavoured to promote the methodology and findings of the research to clinicians in other settings in the south-west of England.

Facilitated

Finally, several of the mechanisms of closer collaboration already mentioned above were also found to fit with the ‘facilitated’ principle of co-production. This was where PenCLAHRC and/or the individual projects had structures or procedures that supported this style of collaboration. The first of these concerned the ways in which some of the PenCLAHRC projects were led (‘facilitative leadership’). In the stroke thrombolysis project, the joint clinical and research leads were both perceived by the rest of the team to have the relevant qualities of being credible, enthusiastic and inclusive in their approach. They were also regarded as having good contacts within and outside their organisations and being well placed to progress the research. For example, the lead clinician had strong links with the local and national stroke research networks and organisations, and the researchers had established connections with colleagues in other universities who advised on some aspects of the modelling.

More generally, PenCLAHRC provided an infrastructure that enabled and supported the stroke thrombolysis and other projects. For example, it established the process by which the stroke consultant was able to submit a question for prioritisation; it also funded some of the lead clinician’s time for working on the project, enabling them to be involved in all stages of the research process (‘local end-user driven’). By bringing together clinicians, researchers, and project facilitators and support staff, PenCLAHRC also provided its partners with an opportunity to do AHR in a different way and to systemically generate new projects between partners (‘game changers’). Finally, as described above, PenCLAHRC also provided funding to enable the members of the stroke team to visit other centres in the south-west to promote the methodology and encourage clinicians in other centres to follow suit (‘relational adaptive capacity’).

Limitations

We deliberately focussed here on a case of successful knowledge translation identified from a wider evaluation [13] in order to examine and illustrate in more depth the style of collaboration it exemplified. Although the featured stroke thrombolysis project itself involved a small number of interviews, the analysis builds on related findings from a thematic examination of interviews with 28 members of four projects and documentary analysis that were carried out as part of the wider evaluation.

A limitation of this work is that it only examined the collaborative relations between clinicians and researchers in PenCLAHRC and not the contribution of patients and the public, who played a significant part in around half of the projects undertaken during the pilot programme. In the interviews with members of the four project teams, we did ask about the actual or potential contribution of patients and the public. The stroke thrombolysis team found it hard to see what patient or public members might have contributed to this particular project, but the researchers were open to the possibility of involving them in future operational research projects and have done so in subsequent work in PenCLAHRC [27].