The nature of the community partner’s context was found to influence the pre-implementation work required. Buckingham’s [
27] typology was a useful starting point for better understanding the range of contexts of operation. The partners were categorised from the information they had provided in the interviews and from documents gathered. What was found is that the community partners did not fall discreetly into a typology. Rather, what was found to exist was a continuum of contexts blending more smoothly from being more comfortable into more compliant, into more cautious contractors and into more community-based non-contractors. Few partners fell wholly into a typology, and where this did occur, it was often at the extreme ends: comfortable contractors (i.e. statutory service providers) and community-based non-contractors (i.e. places of worship). Many partner contexts displayed elements of two typologies, and so to reflect this continuum, three categories have been defined to reflect the clusters of partners falling on the continuum of typologies, as well as being useful to account for the complexities in settings. Table
2 describes the partners, places them on the continuum and illustrates where the three new categories overlap with Buckingham’s typology.
Table 2Community partner continuum
Comfortable contractors | 1 2 3 4 5 6 7 8 | Statutory service provider Statutory service provider Collection of GP practices Statutory service provider Health centre Community interest company Research centre Housing association | Fully Professionalised Organisations |
Compliant contractors | 9 10 11 12 13 14 15 | International charity—local branch Group of charitable social enterprises Group of charitable projects Charity—city-based National charity—local branch National charity—local branch Charity—city-based | Aspirational Community, Voluntary Social Enterprise |
Cautious contractors | 16 17 18 19 20 | Charity—city-based Charity (formed from merger) Charity (formally faith-based organisation) Community association Community centre |
Community-based non-contractors | 21 22 | Place of worship—church Place of worship—mosque | Non-professionalised Community-Based Groups |
To unpick what contributes towards the optimal pre-implementation context, and the nature of pre-implementation work, the findings take the newly formed categories as the basis of structuring the discussion: Fully Professionalised Organisations, Aspirational CVSEs and Non-Professionalised Community-Based Groups. The letters I, O and D are used to label the data excerpts from interviews, observations and documents, respectively, and the partner (P) numbered in correspondence to Table
2.
Fully Professionalised Organisations
Fully Professionalised Organisations (FPOs) are very business-minded; these highly professionalised settings often deliver services over a large geographical area and may even operate nationally with localised hubs. Importantly, in FPOs, there is a formal hierarchical structure and bureaucracy. Characteristically, they have secure contracts with local authorities and are competitive and entrepreneurial in nature.
These partners were heavily influenced by the political landscape because they were entangled with, embedded within and reliant upon government contracts. They themselves acknowledge they are ‘very politically swayed’ in the design of their ‘corporate strategy’ (IP8). As such, where there was close alignment between the intervention and the political agenda, captured by the CFIR sub-concept ‘external policies’, this was influential in securing buy-in from the leadership of these partners. In this example, loneliness had recently been declared a public health risk [
28]; nationally, the NHS Long-Term Plan [
14] outlined the importance of social prescribing and community assets in delivering universal personal care. Thus, for managers of FPOs, the political climate was heavily influential in securing buy-in, and therefore, the sub-concept ‘external policies’ becomes important in creating the optimal pre-implementation context. This was seen in the example of an early engagement meeting with representatives from several GP practices.
We were introduced to the room with some level of enthusiasm saying we were there to talk about linked to the new commissioning brief and the push for increased social prescribing that the navigators were to do (OP3)
In instances where the policy context and intervention aligned, managers saw the ‘relative advantage’ of the opportunity to trial the intervention that could help fulfil a strategic objective. The sub-concept ‘leadership engagement’ was also relevant in this context across all partner contexts. By securing ‘leadership engagement’ and with the intervention offering ‘relative advantage’ (i.e. fulfilling a strategic objective), these partners were more willing and able to allocate resources to aid implementation. This was particularly so in terms of human resources; in instances, this was clear ‘PALS was written into our job specifications, it is an objective for us’ (IP8), and in other instances, there was a clear commitment ‘we’ll find ways for this to work because it does overlap with what we do normally’ (IP3). This commitment helped to create a climate encouraging of implementation and one with sustainability potential due to the ‘resources available’. The ability to replace intervention facilitators easily to ensure implementation continued is an example.
[Female] going on MAT [maternity] leave in June, but as we were leaving the office we were introduced to [Male] who will replace [Female] as the facilitator. PALS had already been written into his objectives for the next quarter. (OP8)
With the potential to create a climate encouraging of implementation, the pre-implementation context was also contingent on factors beyond ‘political landscape’ and ‘leadership engagement’.
One factor relates to the sub-concept ‘patient needs’. In many instances, FPOs deliver services to individuals who are ‘in crisis’ (OP3) and who are ‘dealing with the immediate’ and often very complex issues (OP8). Where individuals are dealing with profound problems, partners also reported the individual can become ‘easily overwhelmed’ (IP4). This speaks to the suitability and timing of the intervention being implemented. In this example, some of the ‘patient needs’ were perceived to be too severe and complex, which led some partners to view Genie as being unsuitable for participants.
Although ‘leadership engagement’ was influential in the creation of the optimal pre-implementation climate and also ‘implementation readiness’, those responsible for delivering the intervention were in the beginning often excluded from engagement conversations, and yet were integral to implementation. In instances where there was ‘leadership engagement’, the pre-implementation context was still negatively affected where buy-in failed to be secured at all levels. As illustrated in this example, buy-in had been secured at the senior management level, but middle management and those identified as potential facilitators had not been consulted about the partnership.
This is benefiting the service, but they [the potential facilitators] see people with real difficult psychological problems who are in immediate threat, there’s safeguarding and real difficult stuff. Loneliness is important, and I’m not saying it isn’t, but is it of the same standard. Can I justify their time? (OP4)
Relating to the sub-concept ‘knowledge and belief about intervention’, failure to acquire the insights across the workforce hierarchy led to the need to troubleshoot further down the line, which also illustrates the need for pliability (as the intervention team worked flexibly within the protocol to tailor the division of labour to each partner). Through a process of monitoring and reflection, the need to secure multi-level buy-in (rather than assume organisations would internally secure this) became a priority and was solved by the introduction of two meetings. One meeting took place ahead of facilitator training, and one that took place after the facilitators had been trained. These meetings took place with everyone directly involved in the implementation process and often included a member of leadership, middle management (who tended to have direct oversight of the project) and individuals becoming intervention facilitators. These meetings were important for all contexts but especially so for the FPOs where the workforce tended to be larger, and there was more risk of a disconnect between top-level managers and those responsible for delivery. These meetings enabled troubleshooting to take place earlier and ensure that buy-in was secured from all involved. The meetings were a real contributor to the creation of coherence [
29] and thus the optimal pre-implementation context.
Where the necessary elements were in place to create the optimal pre-implementation climate, readiness for implementation was time-sensitive. Being business-like in operation, where there are objectives to deliver on within a time frame, often meant the organisations’ pace of work was the fastest of all categories. Thus, these partners reported that in their context, ‘it is a changing picture, when we say go you go or you’ve missed it’ (IP8), and any delay from the implementation team may mean the window of readiness closes. Whilst the experience here was that the window was never closed completely, some delays on the implementation team due to the research side of the project regarding ethical administration (vs intervention readiness) did mean moments of readiness for some partners were missed. As in the example where changes to the ethical approval process stalled implementation, and where facilitators had been trained, the delay meant that the facilitators required refresher training.
To be honest things are really busy leading up to Christmas so a refresher training for the team would have to happen in the new year (OP9)
This illuminates the different challenges posed by the intervention and by the research trial; in this example case, it was often the latter posing the challenges. However, it serves as a caution to readers that when working in open systems, but especially in FPOs, readiness is paramount on both the intervention and the research side. The optimal pre-implementation context has several contributing factors, and the window of implementation readiness may be fleeting.
Aspirational CVSE
Aspirational CVSEs are an amalgamation of the compliant and cautious contractors [
27]. It refers to those CVSEs who mainly operate at a regional to a local level and for whom voluntary income and volunteer involvement are important contributors. Aspirational CVSEs tend to try to stay as close to their values and ethos and have a small structured workforce.
Of all partners, these partners balance being influenced by ‘external policies’, particularly the local political agenda, and being authentic to the values on which they were founded. Aspirational CVSEs further along the professionalisation journey were more influenced by ‘external policies’, as ‘the local policy arena dictates some procedures, but it is not the only driver’ (IP10). Whilst for the less professionalised partners, staying close to founding values and ethos was more important.
There are some reservations I have about whether it [Genie]…we don’t want to become a clipboard organisation (IP18)
For Aspirational CVSEs, if the intervention aligned with their main influence, either ‘external policies’ or founding values, or the tension between the two had been reconciled, ‘leadership engagement’ was secured. Like FPOs, this was an important contributor towards creating the optimal pre-implementation context. Furthermore, ‘leadership engagement’ was also influenced by the ‘relative advantage’ of the intervention and the benefit to be gained. Here, it was the potential of receiving an evaluation of their services, especially so where alignment exists, and the intervention was considered to be ‘a formalised version of what we do with people who use our service’ (OP16).
I want to be able to measure the impact of the work, the service, I want evidence about what we do. (OP16)
The second ‘relative advantage’ was the potential participation had in ‘upskilling the team’ (IP10). This was of particular interest to the more professionalised partners, whereas the potential to offer evidence was more of interest to the less professionalised Aspirational CVSE partners. These ‘relative advantages’ were significant pulls because of the precarious tenure of partners. Thus, ‘leadership engagement’ was influenced by the potential evidence the research component could provide, enabling Aspirational CVSE partners to utilise this to support future funding applications.
The more precarious a partner’s tenure, the more this influenced ‘leadership engagement’. This was because leaders considered the scarcity of ‘resource availability’. Perceived ‘resource availability’ was in some ways the most significant contributor of the pre-implementation context. Part of the pre-implementation work when seeking to implement an intervention in Aspirational CVSEs concerned troubleshooting human, financial and physical resource availability, especially for the least professionalised partners, as in the example of partner 18 who outlined ‘at the moment we’re very short-staffed, I don’t think we have the capacity in our paid staff to do it [Genie] through them’ (IP18). This limited human resource availability meant there was less flexibility, specifically because the same workforce was required to do several jobs. This posed challenges for the research element of the partnership and required pliability. In response, the implementation team worked flexibly within the stated protocol to maintain methodological rigour but also accommodate the human resource limitation. This pliability was required in order to accommodate the context and promote alignment but ensure methodological rigour.
Aspirational CVSEs were more insecure than the FPOs. These partners also experienced high demand for their services with shrinking budgets; thus, capacity was stretched and the flexibility within these settings was limited compared to the FPOs settings. Take for example the pivotal role of volunteers. Where the intervention is an additional task for a setting already at capacity, the role of volunteers may be essential to the implementation, as in the case of partners 14 and 18. The additional difficulty of implementing an intervention that requires the use of technology placed further strain on resources and on budgets where there was no flexibility to accommodate this. Pliability was required to support the maximising of available resources, for example, finding volunteers as in the case of partner 18 or supplying physical resources to support intervention (i.e. laptops). Where the necessary resources can be mobilised, this makes for an encouraging pre-implementation context.
Overcoming the challenge of capacity that troubles many Aspirational CVSEs is important for implementation. It is also important for similar public health interventions that require self-directed change especially because there appeared to be close alignment between the ‘patient needs’ and the intervention.
We’ll use the information and support group, because the clients would be more able to go to the group (OP14)
Where FPOs provided support to people referred into the service due to being in crisis, Aspirational CVSE partners served a wider breadth of people often ‘picking up the people who fall through the gaps’ (IP18). These settings provide needed support to people in the community, and often, the people accessing the services were perceived as being suitable for the intervention. Individuals were not necessarily in crisis, and their needs tended to be less complex and multifaceted than those individuals accessing FPOs. This contributed towards an optimal pre-implementation context for there was a potential pool of participants for the research trial, but importantly, the Aspirational CVSE partners had access to people who were perceived to have potential to benefit from the intervention.
With the ability to access people with optimal needs (to the intervention), with ‘leadership engagement’ and with the challenge of ‘resource availability’ overcome, implementation readiness was achieved. For Aspirational CVSEs, the pace of achieving this readiness was slower than that of the FPOs; however, the potential for readiness stayed open for longer.
There were two Non-Professionalised Community-Based (NPCB) groups, which are those Buckingham [
27] describes as community-based non-contractors, usually faith-based groups as these case studies are. These informal groups are embedded within the local community in which they are based. They offer activities which are not eligible for funding and rely heavily on voluntary donations and volunteers. These groups emphasise acceptance, promote community cohesion and are a site of sociability and often solidarity [
27].
In both cases, the engagement with the project and the pre-implementation work was more relational than any of the other partners. In the first instance, access to the groups was negotiated by a network referral. Where in the more structured setting of Fully Professionalised and Aspirational partners initial contact was made with the managerial team, NPCB groups operate more informally and do not have such a formalised structure. Thus, the ‘way in’ to these settings may appear a little trickier, or even fortuitous, but it arose with a significant effort in relational work. That is, in-roads were made indirectly through a process of engagement with members of structured organisations such as local authorities, county councils and to a degree also with FPOs who often also have a high degree of cosmopolitanism. Through engaging with these highly networked members, access to NPCB groups was obtained via referral.
Hi [Name], I would like to introduce you to Becky who is leading on the PALS study. I will leave Becky to link with you to look at the opportunities… (OP21)
In these case studies of NPCB groups, this personal referral was to an individual who themselves were highly networked and embedded within the community. The role and importance of this individual in the pre-implementation work in championing the partnership were more integral than in any other setting. The champion negotiated between the implementation team and the group to achieve ‘leadership engagement’ (i.e. senior religious leaders).
I’ve now had the chance to talk with my colleagues at the church and they’re all very interested (OP21)
Unlike the other partners, the ‘outer setting’ of the CFIR was of less influence in securing buy-in. Of most importance was the sub-concept ‘culture’ of the ‘inner setting’, specifically of most influence was the values of the groups, that is, the values of promoting community cohesion and being a place of inclusion for all, including the congregation and members of the geographical community. Where the intervention was perceived to align with these values, i.e. was deemed to be beneficial to the community, this led to a commitment from the leadership and strengthened the champion’s resolve to implement Genie, as in partner 22 who considered PALS ‘an excellent project [that] could be very beneficial to our community therefore they were ‘at your disposal’ (IP22). The integral role of the champion in these settings cannot be overstated. However, the reliance on one individual, as in both cases here, due to limited ‘resources availability’ did contribute towards achieving readiness extremely slowly. Despite low resource availability and thus low absorptive capacity within groups, the commitment to support the community was the primary motivator, and even though the readiness for implementation was slower to achieve, the motivation remained, with the metaphor ‘I am like a tortoise…but hopefully we’ll get there in the end’ (IP21) being a fine example. NPCB groups were influenced and negatively impacted by limited resources. They were most influenced by the commitment to serve and support their local community, both the immediate congregation and the geographical community. Without such devotion of a champion, however, it is reasonable to question whether readiness for implementation would have ever be achieved.