The qualitative research project aims to explore commissioning of long-term conditions care in the NHS during a time of rapid healthcare reform. Using an action research model, the researchers are working with three commissioning communities to balance research with action. This approach helps address challenges of keeping the research relevant as organizations evolve and dissolve during the reforms. By engaging stakeholders, identifying local issues, and providing targeted support, the action research model enables the researchers to adapt to changes while still addressing their research aims. However, maintaining relationships and engagement is time-intensive as contacts and structures change. The researchers must also balance facilitation with maintaining independence. Overall, the flexible action research approach supports both observation and facilitating improvements, with the goal of informing policy recommendations

1. Undertaking high quality and
relevant qualitative research
at a time of rapid healthcare reform
Sara E Shaw
Alison Porter, Judith Smith
Rebecca Rosen and Elizabeth Eastmure

2. The qualitative research
Explore the ways in which NHS commissioning
can be enacted to assure high quality care for
people living with long-term conditions
– Focus on the practice of commissioning
– Working with three ‘commissioning communities’
– Funded by NIHR Service Delivery & Organisation

3. The bigger context
Project started in March 2010
White Paper published in July 2010
Entire landscape changing:
– Clustering of PCTs in June 2011
– Abolition of PCTs by 2013
– Formation of new GP-led commissioning consortia
Combined with drive for £20million ‘efficiency savings’
Little detailed guidance on how to transition
And from April 2011.... The Pause

4. Two key challenges
1) keeping qualitative
research relevant
2) engaging and
working with
evolving/dissolving
organisations

5. How has an action research
model enabled us to address
these challenges?

6. Our action research approach
In line with an action
research approach, specific
objectives within case
studies will be negotiated
with local stakeholders. We
anticipate that these will
focus on the research team
assessing and supporting
local commissioners at key
stages in the 'cycle of
commissioning’.
Quote from
funding application

7. Observations
and documents
1. Wirral
Stakeholder
SAMPLING AND ACTION
• Diabetes
interviews
DATA COLLECTION
• Dementia
3x 2. Calderdale
commissioning • Diabetes
communities • Dementia
Social 3. Somerset
network • Diabetes
analysis • Stroke
Impact and
outcomes
(inc quant)
TEAM INTERVIEWS AND REFLECTIONS

8. What does action approach involve
1. Engage with - and Co-organise workshops and
work alongside – negotiating project focus
each of the Feed in emerging findings
commissioning Run ‘next steps’ events
communities Facilitate stakeholder
workshops (e.g. dementia
services)
2. Offer targeted
Advise on e.g. service
support and advice specifications/care pathways
Act as ‘critical friend’ (e.g. on
3. Balance research emerging information
with action infrastructure)
Support data analysis (e.g re
service utilisation of new
model of diabetes care)

9. How has our approach helped
to address the two key
challenges?
1) keeping qualitative research relevant
2) engaging and working with evolving/dissolving
organisations

10. CHALLENGE 1
keeping qualitative research relevant
Working with a senior research team
Engaging with policy and practice
Identifying action

11. Senior team
Conscious decision from the outset to:
– Bring together senior team
– With strong background in action research
– Good knowledge/skills in support and facilitation
– Expertise of research in/on commissioning
– And experience of contextually aware frameworks
Supported by dedicated project management
Seek high level of funding
Two years, transfer findings asap

12. Engaging policy and practice
Engage with Familiar with
policy local contexts,
environment people &
priorities
Understand
policy Identify local
deliberations issues and
contribute to
Provide commiss’ing
advice and
support on Share local
reforms learning
Study team as ‘boundary spanners’

13. Identifying ‘action’
On-going discussion and negotiation
Action element negotiated with senior execs
Much of the detail enacted with middle managers
Balancing challenge and facilitation
Enabling local ownership of initiatives/change

14. ...people like the idea of having us involved
but of course then if we don’t then do what
they want us to do or don’t agree with what
they want to do or we’re suggesting there’s
another way of doing it or its not evidence
based...you know, that’s a challenge for us
and for them, and particularly at a vulnerable
time when people are worried about their jobs
Quote from member of the research team

15. CHALLENGE 2
engaging and working with
evolving/dissolving organisations
Reorient sampling and data collection
Dedicate time to relationship-building
Develop a ‘Chinese Wall’

16. Reorient sampling/data collection
Begin to engage with Continue to address
emerging GP-led research aims
commissioning consortia Regular review of
Undertake ‘strategic ‘scope creep’
interviews’ Adapt methods
Set up additional
‘tracking interviews’

17. Building relationships
Time intensive
Early recognition & extended engagement phases
2 of 3 lead contacts changed
More time-consuming to organise events (e.g.
workshops)
Less embedded than planned
Observations combined with more interviews
Links with individuals rather than organisations

18. I do have a little worry about the action
across the three sites that, if it’s all filtered
through the PCT lead, we’re doing what the
PCT think they want us to do which isn’t
necessarily what might be needed by the
broader commissioning community.
Quote from member of the research team

19. Develop a ‘Chinese wall’
Researchers Actioners
Listener, observer, Planner, catalyser,
synthesiser facilitator
Facilitate action Enable action
Provide periodic Facilitate dialogue
reports Nurture ownership
Facilitate relationship and local leaders
building

20. Early conclusions
The current programme of NHS reforms is impacting
on the people and structures allied to commissioning
Flexibility and adaptation are essential, more so
than usual
Action research approach enables engagement and
support, as well as observation and analysis
The link between policy and practice should help to
convert the research conclusions into relevant policy
recommendations

21. Five key questions
1. What approaches work ‘best’ in building effective
relationships at a time of rapid and intensive reform?
2. How can we shift from engaging with individuals to
engaging with ‘commissioning communities’?
3. Flexibility and adaptability are fine in the face of rapid
reform, but is the quid pro quo a lack of clarity?
4. Is there scope for more challenge, even in sensitive
times?
5. Is this simply a ‘ticket of entry’ or will our action
research approach lead to actionable policy
recommendations?

22. E: sara.shaw@nuffieldtrust.org.uk
T: +44 (0)20 7631 8450
W: www.nuffieldtrust.org.uk