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Using a complexity-informed approach, we aim to understand why introduction of a mobile service delivery model for osteoporosis across diverse organisational and country contexts in the UK National Health Service (NHS) met with variable success.

Six comparative case studies; three prospectively in Scotland using an action research-informed approach; and three retrospectively in England with variable degrees of success. The Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework explored interactions between multi-level contextual factors and their influence on efforts to introduce and sustain services.

Cross-boundary service development was a continuous process of adaptation and evolution in rapidly shifting healthcare context. Whilst the outer healthcare policy context differed significantly across cases, inner contextual features predominated in shaping the success or otherwise of service innovations. Technical and logistical issues, organisational resources, patient and staff actions combined in unpredictable ways to shape the lifecycle of service change. Patient and staff thoughts about place and access to services actively shaped service development. The use of tacit “soft intelligence” and a sense of “chronic unease” emerged as important in successfully navigating around awkward people and places.

“Chronic unease” and “soft intelligence” can be used to help individuals and organisations “tame” complexity, identify hidden threats and opportunities to achieving change in a particular context, and anticipate how these may change over time. Understanding how patients think and feel about where, when and how care is delivered provides unique insights into previously unseen aspects of context, and can usefully inform development and sustainability of patient-centred healthcare services.

This study has uniquely traced the fortunes of a single service innovation across diverse organisational and country contexts. Novel application of the NASSS framework enabled comparative analysis across real-time service change and historical failures. This study also adds to theories of context and complexity by surfacing the neglected role of patients in shaping healthcare context.

The purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings.

A qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n = 36) and observations (n = 46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis.

While each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process.

The paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them.

The paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.

Following publication of a new vision for the English National Health Service (NHS) in 2014, known as the NHS Five-Year Forward View, a Vanguard programme was introduced by NHS England charged with the task of designing and delivering a range of new care models (NCMs) aimed at tackling deep-seated problems of a type facing all health systems to a greater or lesser degree. Drawing upon recent theoretical developments on the multilevel nature of context, we explore factors shaping the implementation of five NCM initiatives in the North East of England.

Data collection was based on semi-structured interviews (66 in total) between December 2016 and May 2017 with key informants at each site and a detailed review of Trusts' internal documents and policies related to the implementation of each NCM. Our analysis explores factors shaping the implementation of five NCM pilot sites as they touched on the multiple levels of context ranging from the macro policy level to the micro-level setting of workforce redesign.

It is far too early to conclude with any confidence that a successful outcome for the NCM programme will be forthcoming although the NHS Long-Term Plan seeks to build on the earlier vision set out in the Five-Year Forward View. Early indications show some signs of promise, especially where there is evidence of the ground having been prepared and changes already being put in place prior to the official launch of NCM initiatives. At the same time our findings demonstrate that all five pilot sites experienced, and were subject to, unrealistic pressure placed upon them to deliver outcomes.

Our findings demonstrate the need for a deeper understanding of the multilevel nature of context by exploring factors shaping the implementation of five NCMs in the North East of England. Exploring the wider national policy context is desirable as well as understanding the perceptions of front-line staff and service users in order to establish the degree of alignment or, conversely, to identify where policy and practice are at risk of pushing and pulling against each other.

The field of implementation science has emerged as a response to the challenges experienced in translating evidence-based practice and research findings to healthcare settings. Whilst the field has grown considerably in recent years, comparatively, there is a conspicuous lack of attention paid to the work of pre-implementation, that is, how we effectively engage with organisations to support the translation of research into practice. Securing the engagement and commitment of healthcare organisations and staff is key in quality improvement and organisational research. In this paper the authors draw attention to the pre-implementation phase, that is, the development of an amenable context to support implementation research.

Drawing from examples across an interdisciplinary group of health systems researchers working across a range of healthcare organisations, the authors present a reflective narrative viewpoint. They identify the principal challenges experienced during the course of their work, describe strategies deployed to effectively mitigate these challenges and offer a series of recommendations to researchers based on their collective experiences of engaging in collaborations with healthcare organisations for research and implementation. This reflective piece will contribute to the narrative evidence base by documenting the challenges, experiences and learning emerging from the authors’ work as university researchers seeking to engage and collaborate with healthcare organisations.

The RELATE model is presented to guide researchers through six key steps and sample strategies in working to secure organisational buy-in and creating a context amenable to implementation and research. The six stages of the RELATE model are: (1) Recognising and navigating the organisation's complexity; (2) Enhancing understanding of organisational priorities and aligning intervention; (3) Leveraging common values and communicating to key individuals the value of implementation research; (4) Aligning and positioning intervention to illustrate synergies with other initiatives; (5) Building and maintaining credibility and trust in the research team; and (6) Evolving the intervention through listening and learning.

The authors hope this guidance will stimulate thinking and planning and indeed that it will encourage other research teams to reflect and share their experiences and strategies for successful engagement of organisations, thus developing a knowledge base to strengthen implementation efforts and increase efficacy in this important enterprise.

Researchers must relate to the world’s everyday reality of the healthcare managers and administrators and enable them to relate to the potential of the research world in enhancing practice if we are to succeed in bringing the evidence to practice in a timely and efficient manner. Climates receptive to implementation must be developed incrementally over time and require actors to navigate messy and potentially unfamiliar organisational contexts. In this paper, the often invisible and lamentably underreported work of how we begin to work with healthcare organisations has been addressed. The authors hope this guidance will stimulate thinking and planning and indeed that it will encourage other research teams to reflect and share their experiences and strategies for successful engagement of organisations, thus developing a knowledge base to strengthen implementation efforts and increase efficacy in this important enterprise.

Despite many calls to strengthen connections between health systems and communities as a way to improve primary healthcare, little is known about how new collaborations can effectively alter service provision. The purpose of this paper is to explore how a health authority, municipal leaders and physicians worked together in the process of transforming primary healthcare.

A longitudinal qualitative case study was conducted to explore the processes of change at the regional level and within seven communities across Northern British Columbia (BC), Canada. Over three years, 239 interviews were conducted with physicians, municipal leaders, health authority clinicians and leaders and other health and social service providers. Interviews and contextual documents were analyzed and interpreted to articulate how ongoing transformation has occurred.

Four overall strategies with nine approaches were apparent. The strategies were partnering for innovation, keeping the focus on people in communities, taking advantage of opportunities for change and encouraging experimentation while managing risk. The strategies have bumped the existing system out of the status quo and are achieving transformation. Key components have been a commitment to a clear end-in-view, a focus on patients, families, and communities, and acting together over time.

This study illuminates how partnering for primary healthcare transformation is messy and complicated but can create a foundation for whole system change.

The purpose of this paper is to review the establishment of Primary Health Network (PHN) in Australia and its utility in commissioning Primary Health Care (PHC) services.

This study is an analysis of management practice about the establishment and development of a PHN as a case study over the three-year period. The PHN is the Hunter New England and Central Coast PHN (HNECCPHN). The study is based on “insiders perspectives” drawing from documentation, reports and evaluations undertaken.

HNECCPHN demonstrates a unique inclusive organisation across a substantial diverse geographic area. It has taken an innovative and evidence-based approach to its creation, governance and operation. HNECCPHN addresses the health challenges of a substantial Aboriginal and/or Torres Strait Islander population. It contains significant and diverse urban, coastal and distinct rural, regional and remote populations. It can be described as a “virtual” organisation, using a distributed network of practice approach to engage clinicians, communities and providers. The authors describe progress and learning in the context of theories of complex organisations, innovation, networks of practice, knowledge translation and social innovation.

The study provides initial publication into the establishment phase of a PHN in Australia.

The study describes the implementation and progress in terms of relevant international practice and theoretical concepts. This paper demonstrates significant innovative practice in the short term.

The study describes significant engagement and the importance of that with and between communities, service providers and health professionals.

This is the first study of the results of the implementation of an important change in the funding and delivery of PHC in Australia.

The aim of this study is to explore and discuss key challenges associated with having stakeholders take part in co-designing a health care intervention to increase mobility in older medical patients admitted to two medical departments at two hospitals in Denmark.

The study used a qualitative design to investigate the challenges of co-designing an intervention in five workshops involving health professionals, patients and relatives. “Challenges” are understood as “situations of being faced with something that needs great mental or physical effort in order to be done successfully and therefore tests a person's ability” (Cambridge Dictionary). Thematic content analysis was conducted with a background in the analytical question: “What key challenges arise in the material in relation to the co-design process?”.

Two key challenges were identified: engagement and facilitation. These consisted of five sub-themes: recruiting patients and relatives, involving physicians, adjusting to a new researcher role, utilizing contextual knowledge and handling ethical dilemmas.

The population of patients and relatives participating in the workshops was small, which likely affected the co-design process.

Researchers who want to use co-design must be prepared for the extra time required and the need for skills concerning engagement, communication, facilitation, negotiation and resolution of conflict. Time is also required for ethical discussions and considerations concerning different types of knowledge creation.

Engaging stakeholders in co-design processes is increasingly encouraged. This study documents the key challenges in such processes and reports practical implications.