HECTOR Study Lead: Professor Graeme Currie & Dr Gareth Owen
Hector stands for Heartlands Elderly Care, Trauma and Ongoing Recovery Project. The aim of this project is to improve outcomes for elderly patients who sustain trauma injuries. At the moment, the evidences which shape trauma care are rooted in the experiences of military and general civilian personal. As such care practices do not adequately account for age related evidence. To improve Trauma services HECTOR delivers a holistic care package shaped by new evidence about elderly patients. Birmingham University is evaluating the outcomes of HECTOR. Warwick Business School is focusing on how the scientific evidence which drove HECTOR is translated into healthcare practice. In particular, we are looking at the roles, strategies and properties that support or hinder effective translation of evidence into clinical practice. With these insights, we will be able to help support the faster, more complete and effective translation of research into practice. It is the hope of the Hector team (Birmingham University, Heart of England Foundation Trust and Warwick Business School) that these improvements will then be rolled out to other hospitals.

BSOTS Study Lead: Professor Eivor Oborn & Dr Yaru Chen
The Birmingham Symptom-specific Obstetric Triage System (BSOTS) was developed in collaboration between University of Birmingham researchers and Birmingham Women’s Hospital health care professionals in response to an identified need for a standardised triage system to prioritise the clinical urgency of women who attended the maternity unit without a scheduled appointment. The triage system, similar to those utilised in Accident and Emergency departments, involves a standardised initial assessment within 15 minutes of arrival to determine the level of clinical urgency and then provide the appropriate standardised care and investigations. An initial pilot of BSOTS has suggested that it offers a reliable method of triaging women, and that midwives feel the safety of woman and baby had been improved. This initial success has prompted researchers to begin a wider rollout to a few additional sites in order to demonstrate and understand how BSOTS performs in other contexts beyond the initial pilot site. Getting research-based evidence into practice effectively is a recognised issue within health care, with practitioners and researchers alike bemoaning the inconsistency and variability in implementation initiatives. As a specific case study, the aim of this research is to identify the processes involved in getting BSOTS adopted into the regular routines of maternity departments. While clinical studies of the implementation will aim to show the clinical effectiveness of BSOTS as a means to improve patient care, this study seeks to understand the processes involved in taking such interventions from research contexts into operational environments. This involves, for example, identifying the barriers that constrain the adoption of BSOTS, how these barriers are overcome, avoided or may possibly prove insurmountable in getting novel research outputs embedded in practice. Key here is what it is that the various individuals and organisations do to get innovations implemented: for example, getting practitioners to understand how a new innovation such as BSOTS can meet their needs. By understanding what works well and what may be less effective in the implementation of BSOTS we can contribute to the wider understanding of implementation in general. This study is conducted by a research team within Warwick Business School. The research follows a social science approach, employing theories and concepts that may bring new perspectives to understanding the implementation of medical interventions. For example, we can consider the adoption of innovations to follow a process of searching and acquiring new knowledge, an attempt to adapt and change that knowledge to suit a local context and the ultimate embedding of that knowledge into routine practices. This flow of knowledge can be supported by systems (such as information technologies), relationships (such as professional networks) and means of coordinating the various elements (such as leadership). Such a view of how new knowledge can be taken from one context, such as university-based research, and shifted into another, such as a hospital maternity department, can enable researchers to highlight what may prove effective in supporting such shifts and how this could be exploited in the practice of implementation. This is a qualitative research study where data is gathered through interviews, observations of, for example, meetings, and texts such as project documents. The aim is to understand through the own words of those involved in the implementation as well as the artefacts generated during implementation what it is that is done to get research embedded into operational environments.

STaRT Study Lead: Professor Eivor Oborn & Dr Yaru Chen
In a similar study to understanding the implementation of the maternity triage tool (BSOTS), we investigate the implementation of an intervention, STarT Back (stratified care for low back pain), developed at Keele University. STarT Back includes a screening tool, which assesses and stratifies patients with back pain according to their individual risk of developing persistent, long-term back pain, with matched treatment pathways which target those risks, and to which patients may be fast-tracked. In the research trial, Keele University researchers showed that the use of the STarT Back approach could both improve patient outcomes and reduce costs. An implementation study also demonstrated similar clinical and cost effectiveness outcomes to the research trial, in particular:

• physiotherapy services could be geared to providing targeted treatments according to patients’ individual levels of risk.
• the use of the STarT Back screening tool was feasible in General Practice.
• STarT Back was effective in targeting medium and high risk patients with more effective treatments while reducing referral rates for low risk patients.

The research was well received in health care contexts and gained the attention of wider society through positive media reporting. Keele University were particularly motivated to ensure that STarT Back prove as effective in practice as the research promised and, through a dedicated implementation team, have been driving the implementation in selected locations. Our study aims to review and in part follow the STarT Back implementation journey as it is adopted by practitioners, learning about the issues the implementation team and the practice locations face as they embed world class research into everyday practice. We follow a similar approach to our study of the implementation of the maternity triage by adopting a social science perspective of how knowledge and innovation can become embedded within organisations. The data analysis will be based on interviews, observations and documentation and guided by relevant theories enabling cross-case learning between studies.

Community mental health service Study Lead: Professor Graeme Currie & Dr Giovanni Radaelli
This project investigates the development and implementation of a new organizational role, i.e. Advanced Nurse Practitioners, in the Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT). The introduction of Advanced Nurse Practitioners is part of a broader project of ‘workforce development’ that is aimed to improve the integration of primary and secondary care in mental health services. Advanced Nurse Practitioners are nurses with broadened responsibilities of clinical leadership and supervision, e.g. in terms of diagnosing medical problems, independently prescribing medications for symptoms, and performing advanced treatment procedures. The reorganization in BSMHFT requires these Advanced Nurse Practitioners to take on roles previously carried out by Community Psychiatrists in secondary care; i.e. to liaise with primary care practitioners (mainly GPs, but also other healthcare professionals in GP practices) to triage patients presenting potential mental health conditions. The objectives of this reorganisation are thus to encourage primary care practitioners to deal with routine or lower risk cases in primary care, rather than refer these onwards to secondary care and, consequently, have them to refer to secondary care only the more complex or high risk cases. The main prospective impacts of this reorganisation are: (i) reducing the number of referrals to secondary care of low-risk patients, with consequent cost reduction and better caseload management for high-risk patients; (ii) developing competence for practitioners in primary care to improve the management of low-risk patients; (iii) developing the knowledge and competences of nursing professionals to support the clinical work multiprofessional and multidisciplinary teams. This reorganisation of primary and secondary care in mental health services is currently in the process of being rolled out into practice. The first phase of this rollout will involve the development of capability of Nurse Practitioners for their new, expanded, role; the development of criteria to triage patients with mental health problems with a particular need to identify those to be managed in primary care rather than secondary care. From the perspective of CLAHRC-WM Theme 5, this process provides an important opportunity to follow and acquire important insights on how an innovative role (such as the Advanced Nurse Practitioners, which are increasingly adopted in UK and US practice as a new standard of practice) are developed, adapted, and integrated in traditional practice. Methodologically, our research study adopts a longitudinal case study, in which researchers will retrospectively and prospectively investigate: the body of evidence (and other knowledge) used to develop the job description for Advanced Nurse Practitioners and, more generally, structure the reorganization of practice; how relationships and interactions among actors within secondary care (e.g. nurses, consultants, specialists) and primary care (e.g. GPs) shape the definition of the new role and the reorganization; how nurses experience the ‘role transition’ towards more extended clinical responsibilities; how managers and commissioners respond to the implementation of the new organization.

Community mental health service (MUS) Study Lead: Professor Graeme Currie & Dr Giovanni Radaelli
This project investigates the development and implementation of a new system for detection and management of patients with Medically Unexplained Symptoms (MUS) in the Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT). According to the NHS, MUS represent situations in which people “suffer from persistent complaints, such as dizziness or pain that do not appear to have an obvious cause [and for which] doctors cannot find any disease or problem with the body that would otherwise account for the symptoms”. MUS represent a double threat for the NHS. First and foremost, MUS affect the well-being of patients, since they are characterised by conditions such as chronic fatigue and fibromyalgia, and they are associated with outcomes such as depression, anxiety and chronic fatigue. As remarked by the NHS, in fact, MUS are not “faked or are all in the head – they are real and can affect your ability to function properly. Not understanding the cause can make them all the more distressing and difficult to cope with”. Second, MUS affect service use and costs in healthcare organisations since its patients are frequent attenders in secondary care and are likely to undergo numerous consultations and tests before finding a viable solution. Previous research and implementation efforts are dedicating increasing attention to improving the assessment and management of MUS, without however reaching any substantive consensus on their early identification. To address this issue, BSMHFT is now working on the design and implementation of a whole-system management network for the early detection and management of MUS. The new system pursues three goals. First, it aims at developing across its clinical departments a common understanding and procedure to identify MUS patients. Second, it aims at improving the liaison between mental healthcare and physical healthcare services. Such liaison is important because the assessment and management of patients’ psychological condition would play a key role in addressing the physical symptoms. However, MUS patients typically access health services associated with their physical symptoms, and liaisons with mental health services might be neglected throughout the process. Third, it aims at improving liaison between primary and secondary care, to expand the capacity of GPs and community actors to identify and manage MUS patients and thus reduce the burden of care for secondary care. The development and implementation of this whole-system approach provides an important opportunity to follow the process of translation of evidence, and in particular how different interpretations and routines are reconciled and enhanced in a professional context. Methodologically, our research study adopts a longitudinal case study, in which researchers will retrospectively and prospectively investigate: which knowledge is used to generate a common understanding of MUS, develop the algorithm for the early detection of MUS and develop the whole-system approach; how relationships and interactions among actors within secondary care (e.g. nurses, consultants in physical and psychological departments) and primary care (e.g. GPs) shape the definition of MUS and the new system; how managers and commissioners respond to the implementation of the new organisation.

(PKB) electronic patient recordsStudy Lead: Professor Graeme Currie & Dr Giovanni Radaelli
This project investigates the implementation of Patients Knows Best (PKB) technology in Sandwell and West Birmingham Hospitals NHS trust (SWBH). PKB represents an electronic personal health record which differs from traditional medical records as it (i) gives control to patients over the access and use of clinical information and (ii) connects in an integrated system, health information that is currently fragmented and dispersed across different institutions. The effectiveness of personal health records is currently debated, since arguments for higher cost-effectiveness (especially ensued by the integration of data) and patient empowerment (especially ensued by increased patient control over their information) are balanced by professional concern related to loss of control and misuse of data and by several false starts in the past, such as the Google Health platform launched in 2008 and withdrawn in 2011. These failures have been attributed primarily to issues related to the implementation and acceptance of the new systems from providers and patients, rather than to technical limitations. Drawing upon this, we look with specific interest to the local experience of SWBH, which has already piloted PKB in the Clinical Immunology service and is now extending to other clinical areas based at Birmingham City Hospital. The PKB pilots in SWBH are currently pursuing multiple objectives, such as engaging with established patient groups and clinicians in these clinical areas to promote knowledge, engagement and uptake; facilitating e-communication with GPs and other specialists through the PKB system; enabling professional advice from e-access for patient in order to reduce inappropriate hospital follow up; defining and assessing the benefits of PKB uptake to scale-up its implementation to whole trust. Against this backdrop, our research study adopts a longitudinal case study to follow the implementation and the gradual scaling-up of the PKB platform in SWBH with a specific focus on: which knowledge on the patient and on service is embedded in the PKB system, and which (and how) is used to inform health care delivery; how the corporate PKB solution is adapted in local variations across the different departments, according to the different clinical needs, professional interests and patient requests; what factors facilitate or frustrate the “success” of the implementation and its continued use and how PKB affects the integration of health care delivery.

Managing Patient Safety Evidence in Birmingham Children’s Hospital Study Lead: Professor Graeme Currie & Dr Brian Litchfield-Cant
The ability to learn from evidence is critical to keeping patients safe. However, the evidence is highly complex, increasingly diverse, and frequently distributed across multiple systems. As a result, whilst healthcare organisations have a lot of evidence, this evidence does not always shape what they do. Birmingham Children’s Hospital (BCH) is committed to being the sector leader in managing evidence to ensure that patients are kept safe. We have therefore established a group of research projects which supports BCH achieve this ambition, and also helps other hospitals learn from them. Due to the complexity and importance of this work, we are taking a multi-staged approach to investigate different dimensions of evidence management (acquisition, assimilation, transformation, and exploitation). The first stage of research seeks to capture insights at the corporate management and governance level of risk evidence. We will conduct non-participatory observations of hospital risk committees and interviews with staff. Our findings will help shape strategic-level practice, and they will also help identifying future stages of research. The second stage of our research will develop insights into how evidence flows around an origination. The specific projects we research will depend on our first stage findings but this will include, for example, looking at the perceived tension in using a hospital performance dashboard as management tool for control, and as an early warning system for safety. We may also look at how patient experience evidence is captured and exploited across the hospital. The final stage of research focuses on the contextual challenges of learning from evidence at the frontline of service provision. This stage of research includes a four-year PhD project focusing on patient safety in day-to-night handover. Across these three phases, researchers will undertake qualitative research to capture rich contextual details which are often missing in this kind of research. We will interview staff and other stakeholders (e.g. regulators), whose behaviours affect the translation of evidence into clinical practice. We will observe forums through which evidence is possessed, such as the various clinical governance committees.

Exploration of roles and experiences of PPI Study Lead: Dr Sophie Staniszewska & Dr Yaru Chen
A lot of work has looked at Patient and Public Involvement (PPI) in research, but there has been less looking at PPI in service delivery. In both areas, we know little about what PPI works, for whom, why, and where. There are also limited definitions of PPI and what it actually is. Few studies have looked at PPI reference groups and the experiences of the advisors who contribute to the groups. This study will look at some of those research gaps; it is part of the Collaborations for Leadership in Applied Health Research and Care West Midlands (CLAHRC WM) Implementation Science and Organisation Studies (ISOS) theme of work, based at Warwick Business School. The IOS work theme looks at ‘implementation’ - identifying how, where and why research findings can be turned into services for patients, which use the evidence-base of what works. So the proposed study will look at what PPI is in CLAHRC WM, and how it contributes to the work of the CLAHRC, including implementation

Evaluating a 0-25 Youth Mental Health Service Study Lead: Professor Graeme Currie & Dr Giovanni Radaelli
The project investigates the design and implementation of a community and inpatient mental health service for children and young adults aged 0-25. The new service has been commissioned by Birmingham South Central CCG and aims at improving the management of patients in the teenager-adult transition. Before its introduction, patients aged 16-25 experience three separate pathways (i.e. 0-16; 16-18 and adult pathway 18+ patients), each with a different approach and providers. Such segmentation has led to poor clinical outcomes and patient and carer experience. Research-based evidence has called for an integrated pathway, where 16-25 patients are managed with a single approach and set of providers, thus avoiding dramatic transitions in terms of service and settings of care. The partnership “Forward Thinking Birmingham” has been selected as the provider for the new community mental health service. This partnership is led by Birmingham Children's Hospital NHS Foundation Trust and also involves Worcestershire Health and Care NHS Trust, Priory Health Care, Beacon UK and The Children's Society. The new service will be segmented into 5 tiers – from activities in support of primary care and prevention up to specialist services for crisis management. The design and implementation of the 0-25 service is expected to produce significant consequences to patients and to be eventually scaled up at national level. From the perspective of CLAHRC-WM, the development and implementation of the 0-25 Service are extremely precious to investigate how a complex network of organisations acquires, negotiates and transforms knowledge (and, in particular, research-based evidence) to address macro-level demands from patients and commissioning groups as well as micro-level demands and requirements within organisations and professionals groups. In particular, it represents an important occasion to investigate how networks of healthcare providers are able to organize their professional frontline (typically careful to protect their autonomy and practices) for a radical change. Following this, we will investigate the ‘translation’ of knowledge as a complex and pluralist phenomenon, i.e. we will investigate how actors in the network use and transform a combination of research-based evidence about clinical and cost effectiveness, patient/carer experience, clinicians’ experiences and viewpoints – to address external and internal demands. Methodologically, our research follows the translation ‘journey’ through which preliminary ideas and templates of reinventing the service are translated into actual practice. Particularly, the process leading to the identification of Forward Thinking Birmingham as preferred provider will be investigated through a retrospective case study; while the implementation process will be investigated in real-time and prospectively. We will in particular investigate: (i) how different partners had developed their proposal (i.e. how they acquired, assimilated and transformed evidence to outline a 0-25 service that proved particularly successful in eliciting CCGs’ positive response); (ii) how CCGs have identified the preferred provider and managed the bidding process; (iii) how the knowledge/evidence embedded in service proposals are translated and possibly transformed during the actual implementation in real-life contexts (and thus: what is the fidelity between the original proposal and the implemented service, and what explain the differences); (iv) how evidence has been selected, used, interpreted, adopted and created throughout these processes; (v) what are the interactions between different personnel within a wide and heterogeneous network of healthcare, social care, and other organisations.

Implementation of the NHS Health Check Programme in Coventry Study Lead: Professor Graeme Currie & Dr Brian Litchfield-Cant
This project investigates the implementation, uptake and effectiveness of the NHS Health Check programme across GPs and pharmacies in Coventry and Warwickshire. The Health Check programme is a national programme of primary prevention launched in 2009 by the Department of Health. The programme, now a mandatory Local Health service, targets people aged 40-74 without a previous cardiovascular diagnosis, and assesses the top seven causes of preventable deaths, i.e. high blood pressure, smoking, high cholesterol, obesity, poor diet, physical inactivity and alcohol consumption. Through the early identification and management of these risk factors, the programme aims to prevent diabetes, chronic kidney disease, dementia and cardiovascular disease and thus reduce morbidity, mortality and health inequalities. Currently, evidence on the effectiveness is still limited (one RCT and six cross-sectional or cohort studies) and provides contradictory results on increases in the detection of risk factors, in the prescription of statins and in the reduction of patients’ risk scores and risk factors. Furthermore, patients’ uptake of the programme is substantively lower than the expected 70% target. Qualitative studies have highlighted that one way to understand these contradictory results might be how the programme is implemented locally. These studies have in fact found important variations in multiple dimensions, such as the staff conducting health checks, training, risk score, communication of advices and access to internal and external services. Taken together, current evidence emphasizes the need for more research that could provide less contradictory evidence on the effectiveness of NHS Health Checks as well as diverse type of research that could link information about the local variations in the implementation of the programme with quantitative indicators of effectiveness and uptake. Drawing upon this concern, our project adopts a mixed methods approach with pursues two main objectives: (i) describe and assess the heterogeneity of Health Check programmes implemented within Local Authority areas and (ii) produce evidence on the link between these different local programmes and indicators of uptake, process outcomes and (where data permit) health outcomes. First, we investigate how the legal framework provided the “Regulations 2013” (which posited a unique implementation model) has been translated locally in different solutions. We seek to: identify the different implementation model that coexist in Coventry and Warwickshire; cluster these according to the nature of invitation (e.g. rate and type of invitation) and management (e.g. tests included; key players); explain why and how GP practices have developed their version of the programme (e.g. contingencies that motivated specific adaptations to the national model). Second, we develop statistical models to explain the predictors of uptake and process outcomes. The models will include predictors at multiple levels of analysis, such as properties of the eligible population (e.g. socio-demographics), of the provider (e.g. location, typology) and of the intervention. Differently from previous quantitative research, we will embed in the statistical model also predictors measuring variations in the local implementation of the programme, in order to highlight also if specific implementation model or organizational features are correlated with higher uptake or effectiveness.