Knowledge exchange and integrated services: experiences from an integrated community intellectual (learning) disability service for adults.

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Journal of Intellectual Disability Research 238

doi: 10.1111/jir.12131

volume 59 part 3 pp 238–247 march 2015

Knowledge exchange and integrated services: experiences from an integrated community intellectual (learning) disability service for adults C. Farrington,1 I. C. H. Clare,2,3,4 A. J. Holland,2,3,4 M. Barrett5 & E. Oborn6 1 Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK 2 NIHR CLAHRC East of England, Cambridge, UK 3 Cambridge Intellectual & Developmental Disabilities Research Group, Department of Psychiatry, University of Cambridge,

Cambridge, UK 4 Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK 5 Judge Business School, University of Cambridge, Cambridge, UK 6 Warwick Business School, University of Warwick, Coventry, UK

Abstract Background This paper examines knowledge exchange dynamics in a specialist integrated intellectual (learning) disability service, comprising specialist healthcare provision with social care commissioning and management, and considers their significance in terms of integrated service delivery. Methods A qualitative study focusing on knowledge exchange and integrated services. Semi-structured interviews (n = 25) were conducted with members of an integrated intellectual disability service in England regarding their perceptions of knowledge exchange within the service and the way in which knowledge exchange impinges on the operation of the integrated service.

Correspondence: Dr Conor Farrington, Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK (e-mail: [email protected]).

Results Exchange of ‘explicit’ (codifiable) knowledge between health and care management components of the service is problematic because of a lack of integrated clinical governance and related factors such as IT and care record systems and office arrangements. Team meetings and workplace interactions allowed for informal exchange of explicit and ‘tacit’ (non-codifiable) knowledge, but presented challenges in terms of knowledge exchange completeness and sustainability. Conclusions Knowledge exchange processes play an important role in the functioning of integrated services incorporating health and care management components. Managers need to ensure that knowledge exchange processes facilitate both explicit and tacit knowledge exchange and do not rely excessively on informal, ‘ad hoc’ interactions. Research on integrated services should take account of micro-scale knowledge exchange dynamics and relationships between social dynamics and physical factors.

© 2014 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd

volume 59 part 3 march 2015

Journal of Intellectual Disability Research 239 C. Farrington et al. • Knowledge exchange and integrated services

Keywords community-based intellectual (learning) disability teams, integrated services, knowledge exchange

Introduction Integrated service delivery has become increasingly prominent as a model for health and social care policy and practice over the past two decades, partly in response to challenges such as the growing burden of long-term non-communicable conditions, rising health and social care costs, and widespread recognition of ‘fault lines’ in care provision and commissioning (Lewis et al. 2010). Over the same period, researchers have recognised the significance of knowledge exchange processes within and across healthcare organisations, and the ways in which such processes may be hindered by these fault lines (Bate & Robert 2002). Given that a key driver behind service integration in intellectual disabilities (ID) is to bring the knowledge, care expertise and care arrangements from distinct occupational groups and service contexts together, knowledge exchange between the multiple actors is a key focus. However, while the success of integration often depends on successful knowledge exchange (see e.g. Currie et al. 2008; Nolte 2012), few researchers have explicitly foregrounded this insight or explored the relationship(s) between knowledge exchange and integrated services. In this paper we present findings from a study of community-based teams within an integrated (healthcare/care management) ID service, focusing on issues of knowledge exchange in order to consider their influence upon service integration. By highlighting difficulties in the formal exchange of explicit knowledge and the prevalence of informal tacit and explicit knowledge exchange, we explore some of the ways in which processes of knowledge exchange can both support and undermine the operation of integrated services. While our principal focus is on a specific ID service, our findings are of wider relevance to services for people with ID.

Integrated services Fault lines between primary and secondary care or between health and social care can generate

negative outcomes such as preventable use of services, service duplication and inefficiency, and inadequate care provision. In response, in England as in many other developed countries, the notion of integrated service delivery has become increasingly prominent in healthcare policy and practice over the past two decades, as exemplified by the Health and Social Care Act 2012 and current government policy calling for greater integration of primary and secondary care via general practitioner-led commissioning in England ( Lewis et al. 2010; Shaw et al. 2011; Department of Health 2012). Integrated service delivery can be defined as ‘(inter-sectoral) co-operation (co-ordination/networking) between care providers from both the health (medical) and social care sector in order to deliver seamless/ continuous care to . . . people with multiple needs, as a remedy to fragmentation and discontinuity’ (Mur-Veeman et al. 2003, cited Jansen et al. 2005, p. 215). Integration initiatives typically aim to improve service user outcomes and experience alongside greater efficiency and cost-effectiveness, but assume a wide variety of organisational forms according to the scope, purpose and character of particular initiatives in specific institutional contexts (Lewis et al. 2010; Shaw et al. 2011). While there is some evidence that integrated services can generate better clinical outcomes (Nolte 2012), researchers increasingly recognise that structural integration does not necessarily lead to desired outcomes, with barriers to effective integration including organisational divides, system complexity, entrenched roles and identities (especially those associated with professions), and resource limitations (Hardy et al. 1999). Consequently, the ‘managerialist’ tendency to regard integration as achievable through structural reorganisation alone is frequently problematic in practice (Kodner & Spreeuwenberg 2002; Currie et al. 2008). Moreover, the role of knowledge exchange in the success of integration initiatives is rarely discussed, leading to a tendency to regard knowledge as ‘information’ located in ‘information systems’ (see e.g. Shaw et al. 2011). Consequently, in addition to a general need for more research focused on the impacts of integrated care (Jansen et al. 2005), there is room for more nuanced accounts of knowledge exchange within integrated services.




Knowledge exchange Knowledge exchange research focuses on the processes through which members of organisations share knowledge in the course of their everyday work. Organisational scholars increasingly advocate a ‘situated’ understanding of knowledge that draws on the work of Polanyi (1968), who suggested that almost all knowledge contains elements of both explicit knowledge – codifiable, ‘know that’ knowledge such as facts, policies and protocols – and tacit knowledge, which is understood as ‘know how’ rather than ‘know that’, and as situated in a specific context with particular individuals and groups. While explicit knowledge is, typically, relatively easy to exchange within and between organisations, tacit knowledge, which ‘exists subjectively and intersubjectively through people’s interactions’, is often seen as ‘sticky’ and harder to articulate and exchange (Bate & Robert 2002, p. 649). The situated approach to knowledge emphasises the social construction of knowledge in particular contexts, with knowledge understood as ‘more than [just] information’ and as ‘anchored in beliefs, embedded in human action and institutional structures’ (Oborn & Dawson 2010, 1837), as opposed to ‘cognitivist’ understandings of knowledge as unproblematic, objective information (Tagliaventi & Mattarelli 2006). This approach embodies a shift away from a dominant focus on macro-level organisational processes and phenomena towards a more nuanced approach that also takes account of knowledge exchange dynamics at the levels of suborganisational units (e.g. teams), occupational groups and individuals. In line with ‘practice’ approaches in organisational studies (Orlikowski 2000), the situated approach also recognises that knowledge exchange is bound up with interactions between social processes and physical entities and factors (e.g. technology and micro-geographies such as office arrangements), which are embedded within, and interact with, wider social relationships and processes. Thus, a situated approach to knowledge exchange calls for greater attention to microscale dynamics and interactions between physical factors and social dynamics. In this paper, we adopt a situated approach to knowledge in an integrated ID partnership to examine knowledge exchange dynamics within

multi-disciplinary community-based teams, guided by the following research question: ‘What is the character of knowledge exchange in the intellectual disability partnership, and how does it relate to the attempt to provide an integrated service in the field of intellectual disability?’ In doing so, we develop a fuller understanding of how knowledge exchange processes and associated micro-level factors (including physical factors such as IT systems and office arrangements) impact on the dynamics of integrated service delivery.

Study context This study was carried out in the context of an integrated county-wide community service for men and women with ID, comprising specialist healthcare provision and social care commissioning, in an English county with a population of approximately 500 000 people. The service, referred to henceforth as the IDP (ID partnership), was established in 2001 by the local authority in conjunction with the local National Health Service (NHS) mental health trust. The IDP is led by the local authority with a pooled health and social care budget, enabled by the 2001 Health and Social Care Act (Department of Health 2001). At the time the study was carried out, no formal governance agreement had yet been established between the local authority and the relevant NHS trust (from which the authority commissions specialist ID-related healthcare), with day-to-day operations conducted according to informal agreements at the organisational level. The service includes a number of multidisciplinary community-based teams, which combine commissioning (care management) and provision (healthcare) functions. In terms of management, the Head of Operations manages two service managers, each of whom oversees the work of between two and three team managers. A number of occupations are represented within the teams, including administrative support workers and office managers, care managers/social workers, speech and language therapists, art or music therapists, nurses, clinical and trainee clinical psychologists, and psychiatrists. Each team has a distinctive organisational history, team skill-mix and office arrangements. For the purposes of this study, two teams were chosen to




provide a range of knowledge exchange experiences, with one team serving a primarily urban district (here referred to as the ‘Urban’ team) and the other serving a primarily rural district (referred to as the ‘Rural’ team). The Urban team (26 members) occupies rooms in two blocks of a community hospital on the outskirts of the county town, while the Rural team (19 members) occupies rooms in a county council building in a rural market-town some distance from the county town.

Data collection Data were collected through semi-structured interviews with a total of 25 participants from the Urban and Rural teams and the IDP’s Head of Operations. Purposive sampling was utilised to capture, insofar as possible, the perspectives of members of both teams in a manner appropriate to the guiding research question (Bryman 2008). Following an initial visit to each team by the lead author to explain the purpose of the study and distribute study information sheets, members of each staff group were randomly selected from staff lists and subsequently received individual emails inviting them to participate. Table 1 shows that 24 participants worked in the Urban or Rural Teams; the remaining participant was the operational head of the IDP, who is not a member of any of the teams. The lead author conducted interviews lasting between 30 and 80 min with each participant, using a thematic guide incorporating theoretical ideas

concerning knowledge exchange and integrated services. In particular, topics included: the kinds of tacit and explicit knowledge involved in ID care, from both healthcare and care management perspectives; formal and informal exchange mechanisms for both tacit and explicit knowledge within the IDP; enablers and barriers to knowledge exchange, including geographical location/service population, and professional and disciplinary boundaries; and the wider significance of knowledge exchange for the operation of an integrated service. The interviews were audio-recorded and transcribed, and analysed utilising Atlas.ti software, with analysis guided by an overarching ‘thematic analysis’ approach (Braun & Clarke 2006) that entails six analytical steps: familiarisation with the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing a final analysis (summarised in Fig. 1). The trustworthiness and authenticity of the final analysis was addressed by consulting academic colleagues with a range of healthcare, care management and management roles in the ID field; this approach was taken to avoid placing further time burdens on participant by asking them to fulfil additional participant validation functions (Bryman 2008).

Results Our findings regarding knowledge exchange in the IDP are presented in two sections, both focusing on an overarching theme identified through thematic

Table 1 IDP team participants by occupation

Participants interviewed (n = 24) Healthcare occupations (n = 13)

Team Urban (n = 14) Rural (n = 10)

Nurse (n = 5)

Care management occupations (n = 11)

Therapist (n = 4)

Psychologist (n = 3)

Psychiatrist (n = 1)

Admin. support (n = 4)

Care manager (n = 4)*

Manager (team and service) (n = 3)

3

3

1

1

3

2

1

2*

1

2

0

1

2

2

* One of the nurses interviewed at Rural team also works at Urban team. IDP, intellectual disability partnership.




Figure 1 Themes arising from thematic analysis of interview data. NHS, National Health Service.

analysis and summarised in Fig. 1. These sections focus on, first, formal barriers to knowledge exchange within the Urban and Rural teams, especially those relating to care records and IT systems; and second, the informal solutions to these difficulties that have developed in these teams (although not unproblematically). To protect anonymity, participants are referred to according to their institutional location in either healthcare or care management rather than according to their precise role in the IDP.

Formal barriers to explicit knowledge exchange Analysis of interviews suggested that IDP staff view both NHS and local authority records (also referred to as care records, case-notes and files) as the most significant available source of explicit knowledge, and thus the source that they are most likely to try to access, especially when engaging with new service users. In this context, a care manager noted that ‘most people would go and look [at the records] . . . because otherwise you could be reinventing the wheel, you could be missing something that’s very important’. One healthcare practitioner indicated the wide range of useful information that could be gained from records:

[W]hat other work has been done . . ., if someone has . . . developed a formulation about what the problems are . . . if there’s any further information about their learning disability . . . any reports from other professions about speech and language . . . family systems, their living context and . . . risk issues. From this perspective, care records can be seen as a formal (i.e. systematic) mechanism for the exchange of explicit knowledge between different health and care management practitioners within IDP teams, and also (in cases where service users move into or out of the county) between IDP staff and professionals working in different regions. However, while participants acknowledged the importance of records as a source of explicit knowledge, they also highlighted limits to their knowledge exchange potential in the IDP (and hence optimum care delivery) – specifically, issues of reliability and accessibility. In terms of reliability, concerns were raised that records were often incomplete (e.g. lacking details of assessment or treatment) or out of date: [T]here are certainly parts of people’s notes are missing . . . And in some cases there’s very little




on anyone at all . . . I don’t feel I can rely on those. Healthcare practitioner I think very often the information that you have on the [care record] might not be too brilliant, especially if it’s old information. Care Manager The reasons put forward by participants for the unreliability of notes included the sometimes untidy and chaotic nature of paper files – ‘the paper files are quite full of different [documents, and are] hit and miss in some ways because of that very nature’ (healthcare practitioner) – and the tendency for staff to fall behind in updating notes: ‘of course, people are sometimes behind with notes and things like that’ (care manager). Concerns were also raised regarding the accessibility of care records in the IDP, which participants saw as compromised by recording systems that reflect overarching differences between healthcare and care management. Reflecting issues surrounding patient confidentiality, NHS records are in principle only accessible to healthcare practitioners, a restriction which does not apply to care management records. In the IDP, NHS records are mostly paper rather than electronic records, and are quickly archived (making their retrieval costly), while care management records have been filed online since 2009, and are accessible to healthcare staff through an online password-protected portal. The combination of a mix of paper and electronic records, issues surrounding patient confidentiality in NHS records, and the lack of a single shared IT system has led to significant formal barriers to explicit knowledge exchange. The service manager for Rural team echoed several other participants in her remarks concerning the resultant knowledge divide: ‘Health files, the information is still on paper files, we’ve got . . . [an] electronic database with recording for [care management] . . . and ne’er the twain shall meet.’ The office arrangements of Rural and, particularly, Urban teams also generate barriers to explicit knowledge exchange. As the Rural team is based in a county council rather than NHS building, healthcare staff in the Rural team cannot access NHS electronic resources (including NHS email, e-learning modules and updates). Moreover, as

healthcare staff members are obliged to use care management email, they must ensure that they anonymise references to service users, sometimes leading to confusion when two service users have identical initials: I think it’s really hard because I think the systems don’t help us . . . the fact that you have to anonymise all your emails and stuff . . . [It] can sometimes be confusing, particularly if you’ve got [service users] in the same team with the same initials. Healthcare practitioner In the Urban context, by contrast, all health staff can access NHS email and online resources, which constitute a further source of explicit knowledge, albeit referring to issues such as appraisal and working arrangements rather than to particular service users. However, some healthcare staff in the Urban team have to walk between blocks to access NHS paper records: ‘[Some] health staff are now meant to be based in [one] building . . . but unfortunately the case files are still based in the other building so . . . there’s a lot of back and forth’ (healthcare practitioner). While these difficulties in both teams are annoyances rather than insurmountable barriers, they do nevertheless represent additional challenges in terms of explicit knowledge with regard to care records, and also (in the case of the Rural team) certain NHS online resources. One healthcare practitioner summed up her view of IDP explicit knowledge exchange as follows: ‘There’s a lot of stuff that should be explicit [but] . . . we’ve got very limited explicit knowledge formats.’

Formal and informal knowledge exchange solutions In response to the formal barriers to knowledge exchange presented by care records and IT systems, IDP staff members engage in alternative knowledge exchange processes, sharing both explicit and tacit knowledge through formal and informal mechanisms. This section of our findings will consider team meetings as a significant formal knowledge exchange mechanism before proceeding to consider more informal exchange mechanisms such as conversations, emails and phone calls, which play at




least as significant a role in knowledge exchange as any formal mechanisms. We then examine some of the negative aspects of this reliance on processes of informal exchange. Both Rural and Urban teams hold regular team meetings of various kinds and with varied frequency, focusing on particular service users (‘referral meetings’) or team administration (‘business meeting’ in Urban and ‘team meeting’ in Rural), and incorporating different staff groups or, in Rural team referral meetings, representatives of healthcare and care management practitioners. As these are pre-arranged meetings with set agendas, they can be considered as formal knowledge exchange mechanisms, and were considered by several participants as significant opportunities to exchange both explicit and tacit knowledge across disciplinary boundaries and to overcome some of the formal barriers to knowledge exchange discussed previously: [W]e do formally meet and have kind of multidisciplinary discussions about [service users] . . . I think it’s really important for the team to have a view of what someone’s problem is and how to help them . . . in a formal kind of way, get it in black and white. Healthcare practitioner Participants also felt that team meetings represented a significant mechanism for the exchange of tacit knowledge, which was valued by participants in terms of building up ‘a complete picture about a [service user] and knowing who that person is’ rather than merely ‘names and a fact and bits of [explicit] information’, as one healthcare practitioner put it. From this perspective, tacit knowledge not only possesses an instrumental value in terms of interpreting explicit (care-record based) knowledge about service users, but also an intrinsic and substantive value that stems from team members’ memories of service users’ histories and living conditions, the significance of particular episodes or treatments, and impressions gained from personal interactions: [H]opefully the notes have . . . something around dates and attendance and things like that . . . [but] when you’re talking to colleagues it’s more about whether they’ve got memory really [and]

about what they remember of what was offered before and how it worked . . . and what shall we try now? Healthcare practitioner Whether mediated by technology (telephone calls and personal emails) or not (conversations, impromptu meetings), informal mechanisms of exchange were seen as supplementing team meetings and as circumventing the restrictions placed on explicit knowledge exchange: [B]ecause there seems to be a lack of formal information sharing . . . we go around in person [instead] . . . I mean, our systems, being what they are, it’s very frustrating. Care manager I think people are always open to somebody just walking over and saying can I have a quick word with you about this. Healthcare practitioner Together with phone calls, email was seen as useful in certain contexts but also as a second-best option compared with face-to-face communication; one care manager noted that face to face communication, aided by paper records, was useful in terms of accessing individual practitioners’ memories of particular service users: ‘Sometimes . . . email and telephone . . . they’re not quite the same, . . . because obviously if you put a piece of paper in front of them . . . it jogs their memory a lot quicker.’ Our findings also highlighted potentially negative aspects of this predominantly informal knowledge exchange culture, principally relating to issues of arbitrariness and sustainability. Informal knowledge exchange was seen as often falling short of the ideal (i.e. of knowledge reaching those who require it) precisely because its informality leads to arbitrariness in terms of what knowledge reaches which members of the team. Thus one healthcare practitioner mentioned the potential for information to get lost: ‘I feel that if [the person who works next to me is] not there and maybe I miss the next meeting or whatever, somehow the information seems to get lost.’ Likewise, another healthcare practitioner stated that:




[s]ometimes there is information out there, which is not necessarily . . . made accessible to everybody who needs to know . . . [T]here is information with different people, [so] it’s very ad hoc as to who passes on . . . what to whom. Given the centrality of knowledge regarding specific service users and their particular circumstances in terms of understanding their clinical histories and present and future needs, the arbitrariness of knowledge exchange in the IDP is a potentially significant barrier to effective care delivery. Related to the issue of arbitrariness is the issue of sustainability, or the concern that as informal methods of knowledge exchange rely on the tacit knowledge of individual team members, the temporary absence or permanent departure of these team members represents a loss of ‘team knowledge’ – i.e. the stock of explicit and (especially) tacit knowledge collectively possessed by team members. Discussing this issue from the point of view of knowledge exchange and team culture, one care manager stated that the Urban team only functions from a positive perspective because of the personalities in it . . . you’ve only got to get somebody leave and somebody else come in . . . are they going to affect the culture? I do wonder sometimes whether there is sufficient attention paid to that. Clearly, limitations in terms of arbitrariness and/or sustainability of informal knowledge exchange present significant (and interrelated) challenges for service delivery. Acknowledging this, one care manager stated: ‘I don’t wish to give the impression that people don’t talk and share things, because people do . . . but I still think there is room to be more efficient and effective in how it’s all delivered.’ In a similar vein, the Urban team manager stated his policy of formalising informal relationships to ensure that departures from the team will not undermine joint working (and by extension, effective knowledge exchange): The benefit of people being together for twenty years . . . is actually they’ve come up with a lot of informal kind of relationships . . . that kind of cover the way things need covering. So I’ve come in to formalise them, because . . . well, if [they] all do move on, I want people to [work together]

not for favours but because it’s the culture of the place and it’s part of our policy . . .

Discussion Taken together, our findings illustrate both the value of a situated approach to knowledge exchange processes in the IDP and, more widely, the significance of knowledge exchange in integrated service contexts in general. In terms of the former, our findings highlight how physical and organisational factors are ‘inextricably related’ (Orlikowski 2007, p. 1437) to social practices such as knowledge exchange, thus allowing for a deeper understanding of the particularities of knowledge exchange dynamics within the IDP context. Interpreting the use of care records as a form of explicit knowledge exchange, for example, our analysis illuminates how physical and organisational aspects of care records – i.e. their unreliability and/or inaccessibility respectively – often obstruct formal processes of explicit knowledge exchange within IDP teams and increase reliance on other forms of explicit and tacit knowledge exchange processes such as team meetings and conversations. Furthermore, the relative success of these knowledge exchange solutions highlights an important aspect of IDP specificity: while knowledge exchange literature typically highlights difficulties relating to the exchange of tacit knowledge (Bate & Robert 2002), our findings point instead to difficulties surrounding the exchange of explicit knowledge through formal systems and the relative ease of exchanging explicit and tacit knowledge through other means (and informal means in particular). Yet our findings also highlight the ambivalence of IDP knowledge exchange dynamics and the ways in which the interactions of physical and organisational factors generate mixed outcomes. For instance, the physical co-location of Rural team members in a local authority building aids informal explicit and tacit knowledge exchange between healthcare and care management colleagues, but also makes it difficult for healthcare staff to access NHS online resources and interact with NHS colleagues elsewhere. Moreover, while informal knowledge exchange solutions in the IDP appear to address knowledge deficits with relative success, their




impromptu nature and potential arbitrariness raise concerns in terms of the completeness and sustainability of knowledge exchange, thus highlighting a managerial need to capture the benefits of these processes in a more consistent manner. As such, our situated approach highlights the complexities of knowledge exchange and emphasises that ‘[n]either physical nor virtual connection [alone] is sufficient for knowledge sharing’ (Bate & Robert 2002, p. 6). The study has important limitations. First, we focused solely on knowledge exchange processes from the perspective of team members and the operational head of service; we did not attempt to examine their impact on the delivery of care to service users and caregivers, nor did we examine the perceptions of these important stakeholders. This is an important, but so far generally rather neglected, area of ID services research (but see Hempe et al. 2013); as such it would be a fruitful and important area for future research focused on knowledge exchange and integrated services. Second, the generalisability of our findings may be limited by the historical and geographical specificity of the IDP, which exhibits a number of features (e.g. healthcare staff sited within a local authority building) that impinge on knowledge exchange and integrated services but which may not be shared by other ID services elsewhere in England or in other developed countries. Limited generalisability is a particular concern given the numerous different models of ‘integrated services’ (see Lewis et al. 2010; Shaw et al. 2011). Nevertheless, we suggest that a situated approach to knowledge exchange highlights a general need for services to account for the influence of local physical and organisational factors upon the particularities of micro-scale knowledge exchange dynamics in specific contexts. Integration initiatives frequently approach knowledge as easily shared ‘information’, conceptualise knowledge exchange as taking place largely through systems designed and operated principally at the macro level, and overlook the ways in which tacit knowledge in particular is ‘created and shared within practitioner groups’ (Currie et al. 2008, p. 370; also Shaw et al. 2011). By contrast, situated approaches offer fuller accounts of the dynamics and complexities of integrated services and the inevitable knowledge exchange challenges that they are likely to encounter in practice,

suggesting that the ‘generic transfer of [knowledge exchange] models and ideas from the private sector [is likely to be] . . . ineffective’ (Currie et al. 2008, p. 381). Regarding the practical implications of our findings, it seems likely that the IDP, and similar integration initiatives more widely, would benefit from adopting a more structured approach to knowledge exchange in order to build upon and formalise informal knowledge exchange capacities. Moves towards this approach have already been initiated in the IDP in the form of a new integrated care record system intended to take account of the relevant governance issues relating to NHS and local authority records. There could also be scope for introducing dedicated knowledge management roles within the IDP – similar to communications management positions in private companies (Nothhaft 2010) – to oversee efforts to improve formal and informal knowledge exchange mechanisms. Such initiatives could help to formalise the powerful modes of informal exchange that already exist within the IDP, and address concerns regarding the completeness and sustainability of knowledge exchange within this integrated service.

Conflict of interest The authors declare that there is no conflict of interest.

Ethics An opinion regarding the ethical status of the research was sought from the appropriate National Research Ethics Service (NRES) committee, which confirmed that the study was service evaluation and so did not require formal ethical approval. Recruitment of participants followed approval by the Interim Head of Service and initial visits to each ID team in order to explain the purpose of the study and to distribute information sheets. The lead author preceded interviews by reiterating the purpose and character of the study and emphasising issues of confidence, anonymity and voluntariness.

Acknowledgements The authors would like to thank the management and staff of the IDP for their participation in the




research. The lead author would like to thank Mark Detre for information provided regarding communications management roles in private companies. This paper presents independent research funded by the National Institute for Health Research (NIHR), specifically Collaborations for Leadership in Applied Health Research and Care for Cambridgeshire and Peterborough (NIHR CLAHRCCP). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

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Accepted 21 March 2014


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