In the concept mapping, each mechanism of closer collaboration was found to correspond with the qualities of one or more of the core elements of co-production (see Fig. 1). In the rest of this section, we examine the relevance of the theory, drawing on examples of how closer collaboration was performed throughout the stroke thrombolysis project. Quotations used to illustrate the analysis have been anonymised and slightly edited for presentation.
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.
Another mechanism that made a difference to the success of the projects in general was the size and composition of the project teams (‘small strategic core’). In the case study project, a stroke consultant (who was also an active clinical academic) and a senior researcher jointly led the project. They had worked together before and trusted and valued each other. The team also included paramedics from a local ambulance trust who had not collaborated before with the other members prior to the establishment of PenCLAHRC. For one of them, an unexpected benefit of the project was the development of working relationships that went beyond it:
‘I think success is often dependent on good working relationships and networking and we’ve certainly done that you know I’ve almost got a friend in [operational researcher X] now and I know I can email [X] with any queries now whether it’s about this pathway or any other thing you know “I’ve got this idea and can I run it by you” and he is more than happy to help and support and [Y] is a fantastic lead … now I am on personal terms with [Y] before I may have been a little hesitant about emailing [them] but I think we’ve got quite a good relationship now.’ [ID5]
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.
Whether the various clinicians in the PenCLAHRC projects valued the researchers’ different knowledge and expertise (and vice versa), was also found to be a key mechanism (‘knowledge appetite’). In the stroke thrombolysis project, the lead clinician was initially unfamiliar with the operational research methods that the researchers proposed to use but quickly saw the relevance of the approach:
‘I had little understanding before I started on this about what operational research was or what it could do … the crucial thing about the collaboration, as soon as I was put in touch with people who knew how to do this, everything fell into place from my point of view very quickly, because I had a clear idea of what a clinician would want from that sort of project, and [operational researchers] had a very clear idea of what operational research had to offer that sort of work. So to me it clicked very quickly.’ [ID1]
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.
In the stroke thrombolysis project, this was evident in the researchers’ need for good-quality routine data for the modelling to be feasible. After being denied access to one potential source of data, the researchers were able to access another with the help of the lead clinician:
‘I think we never would have got it [data] as academics we never would have got hold of it, it was only through [clinician’s] influence that we were able to get access to the data. So [clinician] was fundamental’ [ID3]
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).
In reflecting on what they got out of the project, one of the stroke clinicians also observed that their involvement in this type of project provided a way of learning about each other’s part in the pathway:
‘It’s just been a really good positive project, it’s been a real interesting way to see process mapping applied to a clinical process incorporating very complex processes and organisations because we all are and we all work independently but looking at how we can pull them together with one common motorway if you like and it’s been very good I’ve enjoyed it’ [ID8]
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
As noted, a fundamental aim of the CLAHRCs was to transform the ways in which AHR was conducted. In PenCLAHRC, the researchers and clinicians in some of the projects found that their experience of working in collaboration on the projects was different to how they had carried out research before (‘game changers’) and opened up new possibilities and capacity. The operation of this mechanism was particularly evident in the case study project and found to fit with the ‘transformative’ principle of co-production. For example, the lead clinician reflected that
‘And what I find myself doing now, having had experience of the collaboration and the operational research, is when I look at other clinical problems that colleagues describe to me I end up looking at that and thinking, well, actually what you need is not do what the NHS has done before, which is muddle through on the strength of inadequate data through a process of trial and error … what you need to do is organise an operational research project … And, in fact, that’s the way we’ve done it with some of the spin-out projects’ [ID1]
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.
The size and composition of the project teams (‘small strategic core’) was also perceived by members of the stroke thrombolysis project team to have facilitated the research. The inclusive and participatory nature of the methods used by the researchers to build the computer model, and the extra modelling they carried out for some clinicians, also helped to engage the relevant clinicians in the process of the research through to the implementation stage (‘the end-user is King!’). As one of the operational researchers observed, this was a recognised aspect of how they worked:
‘..the general ethos of operational research is it’s important to involve stakeholders within the process of building a model if you’re going to sort of improve the chances of implementation’ [ID4]
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’).