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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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