RESEARCH Open Access

Flipping the paradigm: a qualitativeexploration of research translation centresin the United Kingdom and AustraliaTracy Robinson1,2,3* , Helen Skouteris1,3, Prue Burns1,4, Angela Melder1,3,5, Cate Bailey1, Charlotte Croft1,6,Dmitrios Spyridonidis1,6 and Helena Teede1,3,5*

Abstract

Background: Over the past decade, Research Translation Centres (RTCs) have been established in many countries.These centres (sometimes referred to as Academic Health Science Centres) are designed to bring universities andhealthcare providers together in order to accelerate the generation and translation of new evidence that isresponsive to health service and community priorities. This has the potential to effectively ‘flip’ the traditionalresearch and education paradigms because it requires active participation and continuous engagement withstakeholders (especially service users, the community and frontline clinicians). Although investment andexpectations of RTCs are high, the literature confirms a need to better understand the processes that RTCs use tomobilise knowledge, build workforce capacity, and co-produce research with patients and the public to ensurepopulation impact and drive healthcare improvement.

Methods: Semi-structured interviews were conducted with selected leaders and members from select RTCs inEngland and Australia. Convenience sampling was utilised to identify RTCs, based on their geography, accessibilityand availability. Purposive sampling and a snowballing approach were employed to recruit individual participantsfor interviews, which were conducted face to face or via videoconferencing. Interviews were recorded, transcribedverbatim and analysed using a reflexive and inductive approach. This involved two researchers comparing codesand interrogating themes that were analysed inductively against the study aims and through meetings with theresearch team.

Results: A total of 41 participants, 22 from England and 19 from Australia were interviewed. Five major themesemerged, including (1) dissonant metrics, (2) different models of leadership, (3) public and patient involvement andresearch co-production, (4) workforce development and (5) barriers to collaboration.

Conclusions: Participants identified the need for performance measures that capture community impact. Betteraligned success metrics, enhanced leadership, strategies to partner with patients and the public, enhancedworkforce development and strategies to enhance collaboration were all identified as crucial for RTCs to succeed.

Keywords: Research Translation Centres, collaborations, metrics, workforce development

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: trobinson@csu.edu.au; helena.teede@monash.edu.au1Monash Centre for Health Research and Implementation, School of PublicHealth and Preventive Medicine, Monash University, Level 1, 43-51 KanookaGrove, Clayton, Victoria 3168, AustraliaFull list of author information is available at the end of the article

Robinson et al. Health Research Policy and Systems (2020) 18:111 https://doi.org/10.1186/s12961-020-00622-9

BackgroundThe gap and time delays between evidence generationfrom research and translation into healthcare practicehas been widely acknowledged [1, 2]. Despite consider-able research investment, opportunities to translate newevidence across health systems are stymied when re-search is not embedded in clinical practice [3]. To date,a failure to engage relevant stakeholders as well as re-search and discipline ‘silos’ have contributed to barriersfor knowledge translation and for the integration of re-search and education within healthcare [4, 5]. This frag-mentation is highly evident in the divergent drivers andmetrics employed across academic and clinical sectors tomeasure success. These and other factors hinder theachievement of a high quality, research-informed, sus-tainable and community-centred health system.Over the past decade or more, Research Translation

Centres (RTCs) have been established internationally inthe United States, Canada, the United Kingdom andAustralia. These centres aim to improve the integrationof research, education and healthcare [5] and to over-come fragmentation. RTCs share a common purpose toaccelerate the generation and translation of new evi-dence by fostering meaningful collaboration and integra-tion between universities, health services and educationproviders [5] and to generate research and educationthat is responsive to health service and community pri-orities [3]. This approach extends the concept of ‘know-ledge’ to include the experience of frontline cliniciansand community members and has the potential to ‘flip’traditional paradigms of education and research as theprimary domain of ‘experts’, who, in the past, were seenas ‘sages on the stage’ [6, 7]. In contrast, RTCs aim todevelop a paradigm of active participation and ‘commu-nity centric’ integrated healthcare, education and re-search. This is characterised by continuous engagementwith stakeholders (especially service users, the commu-nity and frontline clinicians) to better understand prior-ities and health risks and to collectively generate priorityknowledge to improve health outcomes [8, 9]. WhileRTCs offer a unique opportunity to drive an integrated,evidence-informed healthcare system, this endeavour re-quires a shift from traditional siloed research and poortranslation, to a system where continuous collaborativelearning and implementation become the focus.Australia and the United Kingdom have world leading,

universally accessible public healthcare systems. Bothcountries have actively invested in RTCs. In England,Collaborations for Leadership in Applied Health Re-search Centres (CLAHRCs) and Academic Health Sci-ence Centres and Academic Health Science Networks(AHSNs) have emerged. In Australia, similar entitieshave been established, with the National Health andMedical Research Council (NHMRC) accrediting seven

Advanced Health Research Translation Centres (AHRTCs) (2015–2017) and three Centres for Innovation inRural Health (CIRHs) [10]. RTCs in England have vari-able funding sources but, in Australia, they now receivesubstantive Federal Government funding via the MedicalResearch Future Fund (MRFF) (2018–2028) [11].Although investment and expectations for RTCs are

high, important evidence on how best to meet the visionand purpose of the RTCs and to translate and apply highquality research and evidence into practice is still needed[12]. The United Kingdom has a decade of experiencewith this new type of partnership. The Australian cen-tres closely resemble the collaborative model adopted bythe English CLAHRCs, with the third iteration of CLAHRCs funded in 2019 and re-branded as Applied ResearchCollaborations (ARCs). The ARCs have a focus on im-proving patient and public outcomes and undertakingclinical and applied research [9]. In Australia, RTCs areunique in that they are led by health services rather thanby academic institutions. They also have a second starteradvantage to learn from RTCs in England and inter-nationally. Importantly, with unprecedented nationalcollaboration through the Australian Health ResearchAlliance (AHRA) across all NHMRC-accredited centres,these RTCs also have the opportunity to learn from eachother and to collaborate for system level changes. This isconsistent with the literature that confirms a need tobetter understand the processes that RTCs use to mobil-ise knowledge, build workforce capacity and co-produceresearch with patients and the public to ensure popula-tion impact and to drive change and healthcare improve-ment [13, 14]. The primary aim of the current study wasto explore particular dimensions of select CLAHRCs inEngland and RTCs in Australia in order to inform theirongoing progress and evolution in Australia. The ques-tions that this research addressed included how ARCsand RTCs foster collaboration and how they addresshealthcare and community priorities. In addition, the re-search sought to understand the dimensions of RTCs,their leadership, strategies for collaborating with stake-holders (particularly communities and service users) andhow they develop workforce capacity. These operationaldimensions have been prioritised by the AHRA [15] andare explored here to inform the ongoing development ofthese promising new entities in Australia. Given thesimilarities between the ARCs in England and theAHRTCs and CIRHs in Australia, Academic Health Sci-ence Centres and AHSNs in the United Kingdom werenot included.

MethodsQualitative, single semi-structured interviews (meantime of 1 hour) occurred with selected leaders and mem-bers from RTCs in England and Australia between April

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and August 2018. Convenience sampling was utilised toidentify and recruit RTCs in England based on their geo-graphic accessibility and availability at the time the inter-views were conducted. Although not representative of allRTCs in England, the sample included one metropolitanand two regional centres in an effort to capture their di-versity. In Australia, all RTCs that have been accreditedby the NHMRC were available and recruited. More de-tail about participating RTCs appears in Table 1. Interms of individual participants, a purposive and snow-balling approach was employed, whereby potential par-ticipants were identified by RTC leaders, early and mid-career researchers and, in the case of England, advisorsfrom public and patient involvement (PPI) initiatives.Sampling was also influenced by thematic saturation.The rationale for this approach was based on identifyingdiverse participants who had both the knowledge andexperience to describe the dimensions of interest ex-plored in the interviews. At least two experienced

qualitative researchers were present at each interviewand interviewees were sent questions prior to the inter-views. Researchers from the Monash Centre for HealthResearch and Implementation (Monash University) andthe School of Business and Management (Warwick Uni-versity) conducted the interviews. Collectively, they in-cluded PhD academics from diverse disciplines,including medicine, nursing, psychology and business.Interviewers had no prior relationships with participantsbut all were engaged in a wider programme of researchdesigned to support the development of policy and prac-tice to support the ongoing evolution of RTCs.Potential participants were contacted via email or

phone by members of the research team who were at‘arms-length’ from participants. After receiving writtenconsent from participants, interviews were conductedface to face or via videoconferencing between May andSeptember 2018. All interviews were de-identified priorto broad thematic analysis. An interview guide was

Table 1 Characteristics and foci of participating research translation centres

Research TranslationCentre

Catchment characteristics and focus of Research Translation Centre

ARC 1 UK ARC serving a socio-economically and inter-generationally diverse region that includes a mix of urban and rural regionswith substantial health inequalities.

ARC 2 UK ARC advantaged by a local agglomeration of biotech and health science organisations. Focal ambitions include clinicalinnovation and new technologies and therapeutics. Partners with local AHSN to facilitate spread of innovation and hasinterest in national as well as regional links and impact.

ARC 3 UK, ARC with focus on specific diseases and clinical conditions, together with cross-cutting enabling themes such asstrengthening patient and service user involvement.

CIRH 1 Australian CIRH striving to build locally led research capacity to address entrenched health inequalities in local populations.Corresponding focus on social determinants of health. Strong community presence and influence over governance of theCIRH.

CIRH 2 Australian CIRH servicing regional and remote communities in an area roughly the size of England. Strong focus oncommunity and patient voice, evident in co-design emphasis and education of researchers and clinicians in the process ofimplementation.

AHRTC 1 Urban-based, Australian AHRTC whose goals are less shaped by the specific needs of the local populace or by particulardiseases, and more by research and capacity building for the future of medicine and care.

AHRTC 2 Urban-based, Australian AHRTC also without specific focus on the needs of the local catchment area. Core research streamsare focused on specific diseases and health conditions, with effort also invested in mobilising expertise across organisationalboundaries to advance research in these streams.

AHRTC 3 Australian AHRTC that is the single AHRTC in its region and therefore covers urban, regional and remote catchment areas. Itsfoci are informed by the health needs of its populaces and are on specific diseases and conditions.

AHRTC 4 Australian, urban-based AHRTC covering socio-economically diverse populations with strong focus on understanding and im-proving implementation, and developing enabling sciences (e.g. informatics) that cut across diseases and clinical conditions.

AHRTC 5 Australian, urban based AHRTC with significant reach in the greater region, and diverse communities. Strong focus on cross-cutting issues, rather than specific diseases, such as addressing health inequality and systems improvement.

AHRTC 6 Australian, urban based AHRTC with socio economically and culturally diverse populations in catchment area. Focus ondissolving boundaries to facilitate creativity and innovation; local impact is first priority, with clinical priorities determined bylocal need.

AHRTC 7 Australian, urban based AHRTC with strong heritage in precision health and data linkage, leading to global outlook andformation of global partnerships.

Total: 12

Key:ARC Applied Research CollaborationCIRH Centre for Innovation in Rural HealthAHRTC Advanced Health and Research Translation Centre

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developed and included questions about how RTCs fostercollaboration, address healthcare and community priorities,and seek to embed research and translation into healthcareat scale. In addition, participants were asked to identify themetrics they use to assess impact, their leadership,strategies for collaborating with stakeholders (consumerand community involvement), workforce development, andbarriers to collaboration, as these areas have beenprioritised in the literature [13, 16] and by the AHRA [17].These questions extend the knowledge gleaned from oursystematic and grey literature reviews on United Kingdomand Australian RTCs (Robinson T, Bailey C, Morris H,Burns P, Melder A, Croft C, et al. Bridging the research –practice gap in healthcare: a rapid review of research trans-lation centres in the UK and Australia. Under Rev. 2020)and seek to address key knowledge gaps. Qualitativeinterviews were deemed the most suitable method forcapturing and providing detailed insights into the complexoperations of the RTCs. All interviews were audio-recorded, transcribed verbatim and analysed using a reflex-ive and inductive approach, described by Braun and Clarke[18] as the most appropriate for exploring a diversity ofexperiences.Transcripts were read, re-read and coded. The coded

data was reviewed to identify similarities and overlapsand the codes subsequently informed the generation ofinitial themes. A reflexive approach was adopted that in-volved two researchers comparing codes and interrogat-ing themes that were reviewed and analysed inductivelyagainst the specific study aims and through meetingswith the research team. In addition, notes taken duringinterviews were reviewed, which enabled further reflec-tion on codes and themes. This study met the NHMRCpriority for a healthcare improvement initiative and wastherefore registered with the ethics committee but didnot require ethics approval (H - #12480).

ResultsA total of 41 participants, 22 in England and 19 inAustralia from a total of 12 RTCs (3 ARCs in England, 7AHRTCs and 2 CIRHs in Australia) were interviewed.Given that the primary aim of the study was to informthe progress and ongoing evolution of RTCs inAustralia, all accredited RTCs in this country wereincluded.Five major themes emerged from the interview the-

matic analysis, namely (1) dissonant metrics and driversfor healthcare improvement and research; (2) differentmodels of leadership; (3) PPI and research co-production; (4) workforce development; and (5) barriersto collaboration. Quotes are presented as verbatim com-ments from participants and, where possible in terms ofconfidentiality, broad reference is made to their roles.

Theme 1: dissonant metrics and drivers for healthcareimprovement and researchParticipants from both countries identified significantchallenges in integrating applied healthcare and im-provement approaches with more rigorous discoveryand implementation research. Dissonant metrics be-tween academic and healthcare sectors underpin thistension. Academic organisations largely rely on the trad-itional research metrics of grants, publications and cita-tions, while healthcare measures focus more on serviceoutcomes (length of stay, occasions of service and pa-tient outcomes):

“Yes we need to publish papers, but the [health]trusts are much more interested in whether we areactually improving service delivery, contributing totraining, or whether we have actually implementeda quality improvement program that is of local rele-vance” (Participant 19, Executive, ARC, England)

This dissonance was echoed by Australian participants:

“…I think historically …we do basic science and thenyou look for a use for it and really it should be theother way around – we have got a clinical problemand how do we address that…” (Participant 27, Ex-ecutive, Australia)

This observation highlights how RTCs effectively needto have one foot in healthcare improvement and one inresearch, investing in healthcare improvement initiativesas well as traditional randomised studies. In the UnitedKingdom, local healthcare providers need service evalua-tions and rapid cycle improvement studies in their col-laborations with the ARCs, but these researchapproaches are not always privileged by funding bodiesor the academic sector, which often require probability-based research:

“…Innovation does not have an evidence base tosupport it. It is about trialling and taking risks withnew things. The academics need to have a whole ra-tionale for why something would work.” (Participant13, Business academic, England)

Participants from Australia also identified challenges inensuring health research is relevant to the needs offront-line staff:

“…we weren’t interested in somebody developing anApp or improving the specificity of a test. We wantedsome change to a model of care that could be imple-mented straight away if it was shown to be useful.”(Participant 37, Medical academic, Australia)

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Being subject to traditional research metrics meansthat academics continue to undertake discovery researchand clinical trials, which often comes at the expense ofimplementation and healthcare improvement studiesthat include processes for stakeholder engagement andco-production of research.Although they were established to build multi stake-

holder and co-produced research, in their first fundinground, ARCs were primarily measured against trad-itional academic metrics. Funding criteria have sincebroadened but meant that ARCs that initially focusedmore on co-creation and collaborations faced particularchallenges in demonstrating their impact with multiplestakeholders over the initial 5-year funding cycle:

“They didn’t get the findings that were appropriatebecause it takes time … for that less mainstreammodel.” (Participant 12, Business academic, England)

The use of traditional metrics was also a significantissue for the Australian RTCs:

“The NHMRC may talk of translation ...translationisn’t really funded … there is still no incentive to dothat.” (Participant 32, Nurse academic, Australia)

However, participants did refer to the national AHRAalliance between RTCs and described how it was enab-ling “…a clear framework that we can all be acceptingnationally about knowledge translation and impact sowe … don’t have a lot of duplicated effort or repetitionwhen we are trying to report these things” (Participant29, Executive, Australia). The MRFF was identified as apotential enabler of applied research and translation,were “…you could almost see the MRFF as an NIHR[National Institute for Health Research, the largestfunder of health research in the United Kingdom]equivalent for Australia … with NHMRC at the discoveryend and the MRFF in the middle, translation approach”(Participant 29, Executive, Australia).Participants from both countries identified difficulties

in trying to demonstrate clinical and community impactwhen constrained and measured by traditional academicmetrics. They also identified challenges demonstratingboth national and local impacts:

“For the national they need big studies, big papers,big impacts and yet their vision was that it [theARC] would have local relevance.” (Participant 21,Medical academic, England)

There is clearly a need to establish impact and successcriteria that capture participation, collaboration and co-production, and are relevant to and prioritised by

stakeholders and funders, but “…how do we show govern-ment – like how do we collect the data that’s needed toshow … we are being moved from the research front tothe practice front?” (Participant 20, Programme lead,United Kingdom). Ultimately, healthcare and academicmetrics need to integrate and align to achieve a moreholistic understanding and model of impact in both localhealthcare improvement (a priority for health services)and larger transformational programmes and rigoroustraditional evidence (favoured by researchers).

Theme 2: different models of leadershipParticipants from both countries concurred that thecomplex, cross-sector collaborations that RTCs seek toembed, and their mission to translate evidence into prac-tice, deems leadership a crucial determinant of their suc-cess. In the English centres involved in this study,directors had academic backgrounds with demonstratedexcellence in research that largely informed the centre’sstrategic themes. Here, academic metrics may contributeto now largely discredited ‘top-down’ leadership ap-proaches, where themes are developed and chosen ac-cording to a ‘push’ model, “…not because they naturallyhang together …but because the kind of CLAHRC periodwhich started four years ago, wanted each theme led byan internationally recognised sort of research leader”(Participant 17, Executive, England).Participants affirmed a need to re-align this ‘top-down’

leadership approach:

“It is very much top down and it’s quite interestingthey actually got…leadership development programsto try and create distributed leadership. But thenthere still seems to be quite a lot of control from thetop.” (Participant 14, Mid-career researcher, England)

Distributive and collective models of leadership wereidentified as an important alternative, especially inAustralia, where the RTCs are health service led:

“…there’s no question in my mind that the mostpowerful leadership in these kinds of organisationsare leaders who are able to work collaboratively withothers – who’d distribute leadership.” (Participant29, Executive, Australia).

Some of the key personal qualities that support thisleadership approach were identified:

“…I don’t assume that I have the answers, so I’mthere primarily as a facilitator and I respect theprocess and prioritised outcome and advocate for it,even if it’s not what I think is most important.” (Par-ticipant 39, Executive, Australia)

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Training needs to challenge the notion of leadership inhierarchies and instead focus on “…handling institu-tional complexity … because you’re bringing together somany different parties and interests and their job isabout being skilled as kind of like a conductor” (Partici-pant 29, Executive, Australia). The importance of leader-ship provided by middle managers was also emphasised:

“Often the middle management are the people thatset the strategy for the organisation and that actu-ally facilitate a lot of the new collaborations….theExecutives, are too busy … they’re away or they’rejust engaged with other things – I think we could dowith a middle [layer of leaders] … there isn’t reallya next level” (Participant 24, Executive, Australia).

This also applied to managers situated in healthservices:

“…there hasn’t been enough focus on building thecapacity of managers.” (Participant 26, Executive,Australia)

On the basis of equity, the dominance of women inthe healthcare workforce, and the preference of womenfor distributive leadership, participants identified an ur-gent need for “…training in leadership and developmentof leadership in women” (Participant 39, Executive,Australia), who are often operating in the middle levelmanagement of RTCs due to well-recognised barriers tocareer advancement and structural issues in medicineand healthcare that have yet to be overcome.

Theme 3: PPI and research co-productionParticipants were unanimous on the importance ofstakeholder engagement, yet they identified that pro-cesses for genuine PPI (in United Kingdom terminology)or consumer and community involvement (CCI; in Aus-tralian terminology), were often lacking in research andhealthcare improvement. There was consensus on theneed to improve understanding of what PPI or CCI ac-tually entail, what is most effective, and what processesare needed to guide meaningful and genuine co-production of research, translation and healthcare im-provement with communities.England has made significant advances at systems and

grassroots levels, in progressing meaningful PPI, whencompared with Australia, where system level changes arein their infancy and efforts remain fairly limited. InEngland, PPI advisors described wider health systemlevel changes, including that PPI is mandatory for allresearch grant applications funded by the NIHR. OtherEnglish system level strategies that participants describedfor advancing PPI included frameworks and a

collaboration with the NIHR to produce guides and con-duct reviews that support PPI endeavours. The JamesLind Alliance was cited as an example with a frameworkand toolkit for bringing together patients, carers andclinicians in priority-setting exercises to identify ‘treat-ment uncertainties’ and enable meaningful engagement.The James Lind Alliance is “…a very specific method formaking those joint priorities, but that’s only for a numberof different areas [treatment uncertainties]” (Participant5, Programme lead, England). Another NIHR initiativedescribed by participants was the Going the Extra Mile(Breaking Boundaries) Review [19], which identifies thecharacteristics of co-production and principles for PPI inhealthcare research:

“…we have very strong policy support at the highestlevels and so when we did our Breaking BoundariesReview …. which was about reviewing the landscapenationally and internationally… we worked with thewhole review panel to create recommendationswhich were very specific and are now being rolledout across the NIHR.” (Participant 6, England)

All the ARC participants reported having PPI as separateor cross-cutting themes:

“…the level of PPI within CLAHRCs is high …. Wemeet three times a year and we meet with the NIHRand we provide a report where we share what we’redoing.” (Participant 6, England)

In England, PPI advisor positions are publicly advertisedwith clear role descriptions [19] and come with financialsupport, “…which is 20 pounds per hour, 75 per half day,150 pounds for a day and we are very transparent aboutwhat’s involved” (Participant 6, England).CCI was identified as crucial in Australia for the on-

going evolution of the RTCs as “…consumers should beinvolved in every formal part of the structure” (Partici-pant 35, Executive, Australia). However, there were di-verse views about what PPI in research and healthcaremight actually look like or how consumers might have arole in the national research agenda:

“The consumers are very focused on the local experi-ence …our projects are often migrating into differentcontexts.” (Participant 25, Executive, Australia)

While consumers have had limited involvement inhealthcare planning and advocacy in Australia for the pastdecade, participants expressed a low awareness of how toco-produce research and no formal processes existed forrecruiting or training CCI members. The question of howto ensure representative consumer voices was also raised:

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“…The challenge, of course, with community engage-ment is who are the right representatives.” (Partici-pant 41, Medical academic and clinician, Australia)

Australia has had very limited policy or funding incen-tives for CCI as well as limited training and experience,but system-, organisational- and individual-level strat-egies are now being prioritised nationally, with the RTCsdesignated a significant role. Indeed, the RTCs havecome together nationally to create a CCI framework, es-tablish priorities, undertake a national scoping exerciseand co-design strategies, including training and a know-ledge hub that will accelerate and deliver culture changein this area. In this activity, the Australian RTCs havedrawn and learnt significantly from the experiences ofARCs in England.In England, participants reported progress in measuring

the impact of PPI. For example, the Guidelines for Report-ing the Impact of Patient and Public Involvement in Re-search (GRIPP2) have been developed in England toimprove the transparency and reporting of PPI impacts:

“…they’re [the NIHR] keen to create a consistency ofreporting.” (Participant 6, England)

Narratives and case studies were also utilised in theUnited Kingdom to improve understanding of how PPIaffects the experiences of patients, researchers and thepublic. The question of how to capture less formal im-pacts of PPI remains elusive:

“Sometimes someone will say to me that ‘I didn’t sayanything in that meeting’ and I said … but that’s finebecause the fact that you were there changed every-body’s way of thinking and so how you measure that…I don’t have the answers.” (Participant 6, England)

Another challenge for PPI advisors related to the time-frames needed to develop research proposals andprotocols:

“…it takes the academics two months to get theirheads around what they can do, what’s feasible”(Participant 6, England)

Feedback to PPI leads from ARC members was alsoreported to be inconsistent and potentially tokenistic,raising questions about the authenticity of PPI in someinstances:

“…I was really shocked at the statistic of 50% ofthem [PPI advisors] being asked to be involved andnever hearing anything again…” (Participant 7,England)

Of more concern is the fact that “…a lot of them hadnot even been told that the thing [proposal] they helpedwith had been funded” (Participant 7, England). Morework is needed to close the loop and establish true part-nerships with patients, public, consumers andcommunities.

Theme 4: workforce developmentThere was wide agreement among participants that theability to implement and translate research evidence intopractice and to strengthen collaborations between re-search, policy and practice requires specific skills andcapabilities. Key themes for workforce development in-cluded a range of ‘global skills’ and the potential import-ance of dedicated roles – knowledge brokers (ordedicated translation roles).In England, knowledge brokers were deployed in several

ARCs or in partner organisations as intermediariesbetween academics and healthcare providers. Their rolesand titles varied across ‘diffusion fellows’, ‘improvementfellows’ and ‘boundary spanners’. One participantexplained that “improvement science fellows are thenavigators, while knowledge brokers facilitate diffusion”(Participant 11, Early career researcher, England). In thiscontext, knowledge brokers were seen as having a broaderremit than improvement fellows, but their exact roleswere somewhat blurred. Despite variation, knowledgebrokers largely operated outside the organisational hier-archy and were seen as making a valuable contribution –especially in working across professional boundaries:

“The people that emerged as being key in terms ofhaving a brokerage role were the ones that had a hy-brid background themselves.” (Participant 22, Execu-tive, England)

However, there was variation across ARCs in howthese roles operated:

“We had people from a range of quantitative andqualitative backgrounds, and a mix of clinicians andacademic backgrounds, so they could mix their skillsand projects and share their skills. These people arein demand.” (Participant 19, Executive, England)

However, diffusion fellows and knowledge brokers didnot always have clinical ‘credibility’:

“…they are relatively junior coming into the worldand a setting that is highly professional.” (Partici-pant 21, Executive, England)

The Fellows themselves acknowledged challenges withtheir bridging roles, especially the tension between the

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independence and isolation of the research-related di-mensions of their role, and the inherently interdepend-ent nature of knowledge brokering:

“…I deal with the clinicians and they ask meabout the research … but it’s my research not ourresearch …” (Participant 14, Mid-career researcher,England)

They also identified tension between the independenceand isolation that their role entails:

“You do have the independence of your time [but]you are quite isolated and it’s like doing the PhDwhich is very, you know, your project.” (Participant14, Mid-career researcher, England)

Another concern was a lack of clear career progres-sion/paths for knowledge brokers:

“…we need to be moving upwards and developingsort of middle grade faculty appointments becauseobviously we now have quite significant numbers ofthese people who have come through our CLAHRC.”(Participant 21, Executive, England)

Career progression was a particular issue for know-ledge brokers situated in clinical settings. The need for acritical mass or ‘army’ of knowledge brokers to ensuretheir work is sustained was identified, as was their roleas change agents:

“They need to want to change things. They need tobe in the boat and rock the boat, but they can’t fallout of the boat. They have got to do it from within,embedded in the community but disposed towardschange.” (Participant 14, Mid-career researcher,England)

In Australia, universities have traditionally developedacademic chair roles – positions funded by bothacademia and health services to provide leadership inresearch and clinical care and to drive integration.Participants identified a greater need for a “…hybridclinician that leads and owns the research, but has got astrong set of academic credentials that we’ve [the AHRTC] helped develop” (Participant 28, Executive, Australia).In Australia, there has been little to no funding forhealth services, implementation or applied researchers(<5% of NHMRC funding), with a major gap in theworkforce and skills. The funding models have alsofocused in the past on traditional research metrics,which make it difficult for active clinicians to competewith full time academics. Whilst this is changing,

participants expressed concerns about the challenges ex-perienced by clinical academics in this context:

“…I think we’ve lost a bit of ground…they are doingtwo impossible jobs, they are trying to be a good clin-ician and trying to be a good change agent and re-searcher … we are losing clinical academics.”(Participant 32, Nurse academic, Australia)

In terms of skills, English participants identifiedprogramme and service evaluation as crucial workforcecapabilities for RTCs. This includes more than traditionalprogramme logic approaches or the efficacy and effective-ness paradigms of implementation research. Participantsidentified implementation frameworks such as RE-AIMand the Consolidated Framework for Implementation Re-search (CFIR) but also reported a low awareness and skillsin these methods among both clinical and academic staff.Global skills such as digital health, communication,

team-work, priority-setting and leadership were alsodeemed important:

“You need the communication skills, you need theleadership skills to influence people, you need to lis-ten to the local authorities, and you need the tech-nical skills to get the evidence.” (Participant 15,Business academic, England)

Diplomacy skills, such as the ability to build and main-tain positive relationships, link and network with others,and deal with conflict effectively, were important formaintaining partnerships with local authorities, govern-ments, stakeholders and end-users. Additionally, qualitiessuch as “…emotional intelligence, the empathy, the interestin those around them” (Participant 11, Early career re-searcher, England) were identified as important, as wereteam based models of care and project management.Participants from one English ARC described their

programme of education and workforce development onimplementation, which includes both accredited aca-demic courses and more tailored workforce programmesfor clinicians. Implementation and improvement know-ledge were embedded in all their themes, with a discretecross-cutting theme in implementation science that en-abled them to develop a suite of tailored education pro-grammes. These programmes included a Master inImplementation and Improvement Science, a 3-dayMasterclass and whole day meetings with PPI represen-tatives to clarify processes for identifying gaps and re-search priorities. Flagship programmes, including mentalhealth, were identified and initiated:

“…we realised we needed to be offering a number ofthings.” (Participant 21, Executive, England)

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In Australia, with a more limited workforce in appliedresearch, participants tended to cite traditional researchskills as important:

“…we run a whole program of courses on cost-effectiveness, on implementation, on study design, onstatistics, meta-analysis…” (Participant 25, Execu-tive, Australia)

However, the need for workforce development pro-grammes to also address informal or global skills, suchas negotiating and communication, was recognised:

“…the intangibles, professionalism, patient safety, patientexperience – professionalism is a big topic …how doctorsinteract with themselves and their patients.” (Participant41, Medical academic and clinician, Australia)

Overall, there was consensus that workforce develop-ment programmes need to be tailored and that trad-itional unidirectional education alone is insufficient inthe absence of opportunities and motivation to applynew skills in clinical settings:

“What is the right approach to upskill people? It isnot just sitting in a lecture theatre and giving themknowledge. You need to help them absorb this know-ledge by taking it into their environment.” (Partici-pant 15, Business academic, CLAHRC, England)

This comment highlights the importance of integratingeducation and learning into healthcare:

“It is more than workshops. It is situated learning. Itis about them doing real life projects, leading them,and learning as they go along.” (Participant 14, Mid-career researcher, England)

The United Kingdom experience is instructive interms of recognising how partnerships between theARCs and health services have facilitated opportunitiesfor applied learning and the testing of new interventions:

“…most of them work as incubators, so early incuba-tors or later stage incubators.” (Participant 22, Ex-ecutive, England)

There is significant potential, therefore, for RTCs tooperate as ‘test beds’ for implementation and healthcareimprovement:

“It is about the ability to experiment, learn frommistakes, reflect, lead, and share collective responsi-bility.” (Participant 21, Executive, England)

Theme 5: barriers to collaborationAll participants identified that collaboration was fundamentalfor RTCs in both England and Australia. However, in Eng-land, participants were more likely to identify collaborationas a key endeavour. In Australia, where RTCs are health ser-vice led and governance includes both health services andacademic institutions, participants saw collaboration as inte-gral to their structure and had a stronger focus on a ‘transla-tion’ mission, consistent with policy and funders’ positioningof these entities. In England, “…it’s not about translation ofexisting research but about development of partnerships be-tween a variety of stakeholders in order to find ways to im-prove health…” (Participant 20, Programme lead, England).However, a number of barriers to collaboration were

identified. In England, ARCs have a 5-year cycle of fund-ing that presented some concerns as to whether collabo-rations could be sustained:

“…the funding cycle can disrupt relationships as theystart to get established.” (Participant 8, Executive,England)

Participants also described how ARCs are annuallyranked against each other often on traditional metrics:

“We are not supposed to be competing against eachother, but then when we submit the annual report …they rank us all, and everyone knows what theirnumber is.” (Participant 4, Medical academic,England)

The focus on traditional academic metrics and previ-ous funding models meant that, initially, genuine collab-oration was not always rewarded:

“Collaborating across CLAHRCs is not a priority be-cause you are all competing for the same pot offunding.” (Participant 8, Executive, England)

Even collaboration within ARCs is challenging:

“…the sheer practicalities of it. Someone’s got to getfrom A to B.” (Participant 9, Medical academic,England)

The need for more national collaboration betweenARCs was identified as crucial in any future iterations:

“…you could have your individual CLAHRCs butyou could have certain national themes like work-force … as priorities. And each CLAHRC would haveto commit a certain amount of funding to those na-tional priorities.” (Participant 10, Medical academic,CLAHRC, England)

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One participant commented on the irony that, “…insome ways it might be easier to have an internationalnetwork rather than UK based one, because one of thechallenges in the UK is they compete for the same fund-ing” (Participant 12, Business academic, England).In Australia, there was evidence of direct learnings from

England and attempts to avoid direct competition. Here,the accreditation by NHMRC (based on meeting criteriaand not on competition across RTCs), the strong nationalcollaboration afforded by the AHRA and the agreement toaward equal funding by the MRFF to all NHMRC-accre-dited RTCs, has created a system whereby RTCs cangenuinely collaborate and avoid competition. This has alsoallowed the centres to jointly establish a range of nationalpriorities, has facilitated collaboration across centres, re-duced competition and duplication, and accelerated shar-ing and the impact of the RTC work:

“…collaboration from the national alliance of thenine centres has been remarkable…when we got ourfunding this year every centre director just said wewill commit to continuing to implement these na-tional frameworks…” (Participant 28, Executive,Australia)

However, there was acknowledgement from some par-ticipants that a certain level of competition might con-tinue and that centres would need to identify wherethere was most value in collaboration. National system-level initiatives include “… setting up a national datarecord and sharing – agreeing on a set of privacy princi-ples … but at a state level there are things …where we’llcompete” (Participant 26, Executive, Australia).Participants in Australia expressed a strong commit-

ment to the AHRA and willingness to strengthen theirnational collaboration:

“…there is a mechanism to firstly find out what’s go-ing on across the other sites … we can be strategic.”(Participant 28, Executive, Australia)

In addition, the alliance was identified as a key factorin improving engagement with government:

“…when we are having those individual centre dis-cussions with governments and our own state govern-ments we actually have come together and sharedsome of the principles, difficulties and communica-tions so we can actually then go back with a sharedvoice.” (Participant 37, Executive, Australia)

Participants reported that the AHRA has convened na-tional steering committees (to address system-wide prior-ities) and different RTCs are working together to advance

shared knowledge around these priorities. These include(1) data-driven healthcare improvement, (2) CCI, (3) clin-ical research facilitation, (4) Indigenous capacity-building,and (5) health services research and workforce develop-ment [17]. Indeed, multiple participants maintained thatAHRA has been the most significant enabling factor forcollaboration and for the acceleration and sharing oflearning across centres in Australia:

“It’s open discussion, decision-making and the deliv-ery of the national frameworks …when we got ourfunding this year every Centre Director just said wewill commit to continuing to implement these na-tional frameworks…” (Participant 42, Executive,Australia)

In England, high staff turnover was a factor identified asa barrier to collaborative relationships. The NationalHealth Service (NHS) appears subject to political changes;attempts to significantly reform the NHS are commonand frequent. Even at a regional or organisation level, thiswas identified as a significant challenge. Participants de-scribed how the NHS has experienced a number of leader-ship changes in recent years and this creates significantdisruption, as researchers need to continually re-establishand re-strengthen their relationships:

“The NHS is constantly changing, and people moveon so quickly there. The four main NHS trusts withwhom we work now have different chief executivesand different people on their boards.” (Participant22, Executive, England)

Staff attrition also impacts on priority-settingprocesses:

“Although we have annual stakeholder meetings, wehardly ever get the same audience. It’s always a dif-ferent group of people.” (Participant 20, Programmelead, England)

The United Kingdom experience also highlightedstructural barriers to collaboration, whereby ARCthemes can reinforce internal silos:

“We are always trying to cross-refer and think abouthow all of the themes are working and whether as-pects of what one theme does can have an impact onanother. But often it doesn’t happen because theyare quite specialised.” (Participant 4, Medical aca-demic, England)

Relationships between leaders and their partners werecrucial factors that enabled collaboration. In England,

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“what makes the difference is that the leaders are willingto put in the time and agree to communicate with ourpartners, spending many hours at coffees, dinners, lunch,and breakfast meetings to slowly build those relationshipsso you can get to the stage of trusting each other and un-derstanding our visions” (Participant 8, Executive, Eng-land). The emphasis on the importance of relationshipshighlights the challenge but also the importance of cap-turing more informal types of communication as key en-abling factors for collaboration:

“We talk to our AHSN lead on a weekly basis, it isthe pick-up-the-phone-and-ask-a-question type of re-lationship that makes a huge difference.” (Participant10, Medical academic, England)

There is a need to ‘unpack’ what these collaborationsactually entail and how their impact and shape may becaptured:

“...what will these collaborative practices look like,how do we actually even, where do we begin …youknow to unfold that.” (Participant 13, Business aca-demic, England)

DiscussionIn Australia, the complex system of government andhealthcare funding both impedes change and protectsthe health system from political interference. BecauseState Governments fund and administer hospitals whilethe Federal Government is responsible for primary andambulatory care, political interference in healthcare canbe more difficult. A core aim of RTCs in both Australiaand the United Kingdom, as leading universal publichealth systems, is to drive better health outcomes for thepopulation by embedding research and education inhealthcare and accelerating the translation of new evi-dence into practice. This study sought to gain an indepth understanding of strategies to deliver on theseaims by examining metrics and drivers, leadership, PPI,research co-production, workforce development, andcollaboration. Key stakeholders, including RTC leaders,community and consumer representatives, and early-and mid-career researchers, participated in semi-structured interviews, revealing five broad themes foraddressing the evidence-practice gap and integrating re-search and education with healthcare – dissonant met-rics, different models of leadership, stakeholderengagement, workforce development, and barriers tocollaboration.Participants from RTCs in both England and Australia

identified dissonant metrics with a tension between trad-itional academic metrics of publications and citationswhile healthcare is measured by service outcomes such

as occasions of service and length of stay. In addition,they reported the challenge of trying to balance localhealthcare improvement studies with large-scale imple-mentation research. Not all clinical problems or gaps incare are amenable to sophisticated implementation stud-ies and healthcare providers may have a greater need forservice and programme evaluations (often within shorttime frames). Given that health services often requirepragmatic studies that produce rapid impacts on patientcare, there is arguably a need to ‘move’ researchers fromtraditional discovery research towards more serviceevaluation and healthcare improvement that has clinicalrelevance.However, there are also concerns that potentially less

rigorous healthcare improvement methods need to bestrengthened [20]. The scope of implementation re-search is broad and rigorous, with studies that seek tounderstand evidence-practice gaps, proof of conceptstudies, large scale implementation and effectiveness tri-als of complex interventions [21]. Participatory researchprocesses are necessary to ensure that research alignswith the needs of services and communities and thatprocesses for co-production are established. Such an ap-proach relies more on ‘lived experience’ than scienceand raises questions about how to increase the rigourand trustworthiness of participatory evaluations. Trad-itional rigorous clinical investigation, such as rando-mised controlled trails, focus on efficacy in highlyselected populations yet implementation research fo-cuses on broad population cohorts and contexts that en-compass implementation and effectiveness [21]. Bothapproaches are important to embed the translation ofevidence into practice. Hence, both healthcare improve-ment and implementation science need to better alignwith community needs in order to have more legitimacyand it is crucial that healthcare improvement acquires amore robust evidence base and becomes more of a col-lective endeavour [20].Leadership was a common theme reported by partici-

pants in RTCs. Two important aspects of translationidentified by participants were how to apply and how toscale up new evidence – both of which were reported tobe facilitated by distributed models of leadership. Des-pite evidence that effective leadership in healthcare cor-relates with quality care and improved patient outcomes[22], few participants in this study had received formaltraining in leadership. The concept of leadership as acollective and social process where employees areempowered to work collaboratively and take on leader-ship roles is likely to prove difficult in the healthcaresector, where hierarchical structures and political influ-ence combine to make effective change hard to achieve[23]. Despite these difficulties, clinicians need to driveimprovements and have greater accountability for

Robinson et al. Health Research Policy and Systems (2020) 18:111 Page 11 of 14

quality improvement if we are to respond effectively tothe growing complexity of healthcare [24]. The challengeof how to integrate research in healthcare is arguablynot amenable to hierarchical leadership. Distributedleadership offers a means of harnessing insights frommultiple stakeholders and improving the quality ofdecision-making [25]. Study findings accord with currentliterature on leadership and several participants identi-fied that distributed and collective leadership need to beembedded and evaluated in RTCs. Interestingly, leader-ship training has often become the bastion of businessand corporate endeavours, costs can be prohibitive, andco-design and evaluation limited [26]. In addition, agreater focus on leadership training for women inhealthcare improvement has been highlighted in theliterature [27].PPI, or CCI, emerged as an important theme and was

identified by participants from both the United Kingdomand Australia. There was wide agreement that CCI iscrucial at all stages of translational research and health-care improvement. Whilst the English RTCs appearmore advanced in terms of national strategies, systemlevel initiatives such as grant funding requirements andguides to processes, gaps were identified. Questions per-sist about the extent of PPI required for projects, the au-thenticity of PPI in some instances, and how to fund andembed it as core business. ARCs all identified PPI as animportant strategy but were still grappling with whetherand how to embed PPI in their structures and processes.In Australia, so called CCI is relatively under-developed,with some work emerging at a national level across theRTC Alliance (AHRA) and in funding body require-ments. Nevertheless, genuine PPI partnership in the re-search agenda of RTCs is a priority and appears to beprogressing in both countries, presenting an importantopportunity to study and further understand optimalprocesses and impact.In England, participants noted that the partnerships

that ARCs have with healthcare (the NHS) have enabledclinical settings to operate as ‘test beds’ for new innova-tions and implementation studies. This finding high-lights how stakeholder engagement needs to be multi-level with input from healthcare providers. When wethink of stakeholder engagement, we often immediatelythink of consumers/patients and the community. Here,we show that, in healthcare improvement, front-line cli-nicians and health service managers are key stakeholdersin building a culture of improvement. How services in-volve those who provide direct patient care in the plan-ning, delivery, improvement and evaluation of healthservices was identified as a significant determinant of theuptake of innovations. Information from the interviewsalso highlighted that health practitioners require datathat relates to the lived experience of patients as well as

access to training on basic improvement skills (these arenot widely taught in current undergraduate or workforcedevelopment programmes). Again, research and evi-dence translation on how to optimally engage with andbuild the capacity of clinicians remains a key gap.Workforce development was another core theme for

RTCs as an important enabling factor to support the in-tegration of research and education in healthcare. InEngland, a suite of tailored workforce development pro-grammes and accredited academic courses in implemen-tation have been developed in one ARC, but participantsstated that it is important to ‘marry’ these approacheswith healthcare and quality improvement methods toensure their clinical relevance. Global skills, includingstakeholder engagement, influencing skills, systemsthinking, negotiating and team work, have all been iden-tified as significant workforce capabilities for enabling aculture of learning and improvement [28]. Participantsin the current study confirmed the importance of ‘globalskills’, such as communication and active listening, butalso in relation to fostering collaborations between uni-versities and healthcare providers. In this context, partic-ipants identified healthcare leaders (and middlemanagers) as a key target group for workforce develop-ment. In England, new hybrid roles have been deployedto bridge the divide between universities and health ser-vices; this approach has also been trialled in Canada.However, in both countries, these roles are in their gen-esis and questions remain about career progression, pos-sible isolation and efficacy. The English participants alsonoted a need for a critical mass of ‘boundary spanners’and research savvy practitioners to engage and supportthis. In Australia, a dearth of skills in applied researchwas noted, with limited funding and a past focus ontraditional research skills. Development of this work-force is now a priority under the AHRA system-level ini-tiatives and is a focus of national collaboration withshared and freely accessible online programmes and in-ternal capacity-building activities now in place. RTCs inboth countries have the potential to harness the experi-ence and knowledge of frontline clinicians, the commu-nity and consumers, with researchers able to facilitatelearning on how to implement new knowledge acrossdifferent settings. Workforce development in applied re-search skills are a priority and extend beyond clinical orresearch skills to global skills.Regarding collaboration, whilst RTCs have significant

potential to integrate research, education, and healthcareand to overcome silos, barriers were identified. New ap-proaches are needed to enable collaboration and alignRTC processes and objectives. Participants noted systembarriers to collaboration, including competition, disson-ant metrics, and unclear measures of impact and suc-cess. These threaten to derail the collaboration and

Robinson et al. Health Research Policy and Systems (2020) 18:111 Page 12 of 14

integration required for RTCs to succeed. In England,early funding schemes and traditional metrics exacer-bated the tension between sectors and sustained compe-tition, despite collaboration being central to RTCendeavours. Processes for demonstrating impact of theARCs have evolved since their inception but, despite anaspiration to strengthen national collaborations, there iscurrently no national structure or funding for this en-deavour in England. In Australia, system strengths in-clude health service leadership of the centres andindependent NHMRC accreditation of centres that isnot linked to funding. While accreditation is competitiveonce this is achieved, funding is equally shared acrossAustralian RTCs and facilitated through the national al-liance. Whilst, in many areas, Australia is less advancedand mature than England, the need to build a nationalalliance and avoid competition was recognised after ob-serving some competition across RTCs in England andis an example of a ‘second mover advantage’. As a result,AHRA has enabled collaboration and is able to focus onthe goal of integration of research and healthcare, andtranslation, rather than the removal of barriers to collab-oration. The national alliance of RTCs, for example, hasfacilitated the development of shared, high-level healthand system priorities in five areas: healthcare service re-search, data-driven healthcare improvement, Indigenoushealth, clinical research and workforce development.AHRA has also facilitated processes for collaborativelyidentifying and defining problems or gaps in carethrough multiple stakeholder lenses. There may be po-tential learnings applicable to the English setting fromthe systems developed in Australia that facilitate sharedlearnings, avoid duplication and competition, and facili-tate collaboration.Since RTCs have been established and funded for re-

search and translation, performance measures aroundimpact are needed. Little evidence emerged during theinterviews on optimal impact measurements and strat-egies. Narratives or case studies have been used [29],whilst the NHMRC in Australia is using reports basedon evidence of moving research along the ‘translationimpact pathway’ at the system, process and project level[29]. In England, the Research Excellence Frameworkhas focused and linked university funding to impact.Australia is yet to implement system-level changes thatgenerate success metrics that are aligned to funding. Op-timal strategies to measure impact are needed inter-nationally in the context of RTCs.The limitations of this study must be acknowledged,

including reliance on purposive and convenience sam-pling in England that was vulnerable to selection biaswith only a subgroup of English RTCs participating ininterviews. Future research should engage broader ARCsas they have continued to evolve. Nevertheless, this

study allowed for in-depth exploration and understand-ing of RTCs and a comparison across a more matureEnglish system and an emerging Australian system, bothof which operate in the context of leading public univer-sal health systems. RTCs have received significant invest-ment. Accordingly, expectations are high that they willintegrate research, education and healthcare, build col-laboration, and deliver health impact into the future.This finding highlights that, although there is a mandateor focus on ‘education’ across RTCs, it remains difficultto elucidate clearly who the target is and to what endand how this is differentiated from other education bod-ies. An area for future focus for the RTCs is to identifythe niche where gaps are identified, added value can beprovided and duplication avoided.Advances are occurring; however, further development

is needed, including better aligned success metrics, en-hanced leadership, more mature strategies to partnerwith patients and public, enhanced workforce develop-ment, and strategies to enhance collaboration such asthe AHRA and removal of direct competition inAustralia. Finally, there is a need to clarify the optimalapproaches for measuring the impact of RTCs.

AbbreviationsAHSC: Academic Health Science Centre; AHRA: Australian Heath ResearchAlliance; AHRTCs: Advanced Health Research Translation Centres;AHSNs: Academic Health Science Networks; ARCs: Applied ResearchCollaborations; CLAHRCs: Collaborations for Leadership in Applied HealthResearch Centres; CCI: consumer and community involvement;CIRHs: Centres for Innovation in Rural Health; MRFF: Medical Research FutureFund; NHMRC: National Health and Medical Research Council; NHS: NationalHealth Service; PPI: public and patient involvement; RTCs: ResearchTranslation Centres

DeclarationsThis study met the NHMRC priority for a healthcare improvement initiativeand was therefore registered with the ethics committee but did not requireethics approval (H - #12480). All authors have reviewed the final draft,consented to publication and declare no conflicts of interest.

Authors’ contributionsTR was the lead author, study investigator, conducted interviews, analyseddata and drafted manuscript. HS was an investigator on the study andconducted interviews, data analysis, and revision of the manuscript. PB wasan investigator on the study, conducted interviews and revised themanuscript. AM was an investigator on the study, conducted interviews, andrevised the manuscript. CB revised the manuscript and references. CC was aninvestigator on the study, conducted interviews and revised the manuscript.DS was an investigator on the study, conducted interviews and revised themanuscript. HT was a lead investigator and provided significantcontributions to the manuscript. The authors read and approved the finalmanuscript.

FundingThis work was supported by a small internal grant from the Monash WarwickAlliance (Monash University and Warwick University).

Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.

Competing interestsThe authors declare they have no competing interests.

Robinson et al. Health Research Policy and Systems (2020) 18:111 Page 13 of 14

Author details1Monash Centre for Health Research and Implementation, School of PublicHealth and Preventive Medicine, Monash University, Level 1, 43-51 KanookaGrove, Clayton, Victoria 3168, Australia. 2School of Nursing, Midwifery andIndigenous Health, Charles Sturt University, Bathurst, NSW 2795, Australia.3Monash Partners Academic Health Science Centre, Clayton, Victoria,Australia. 4School of Management, College of Business, RMIT University,Melbourne, Australia. 5Monash Health, Clayton, Victoria, Australia. 6WarwickBusiness School, Gibbet Hill Road, Coventry CV4 7AL, United Kingdom.

Received: 3 March 2020 Accepted: 27 August 2020

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