Table 4 Thematic Analysis of Community Referral data

1. Adoption: engagement of providers

1a) Coherence: consensus, agreement and congruence around shared purpose

“[The CCG – Clinical Commissioning Group] I think are really supportive of community based interventions. They appreciate that it brings something different to the table.” 0I9 (Community Service Lead)

“The intervention we’re being asked to signpost into is an intervention that’s based in secondary care services at the hospital, and yet these people aren’t ill...So the whole fundamental way they think about it is to treat people in a clinical way, and it goes against the ethos and the way that we would work” 0030 (Community referral provider focus group)

“It’s really frustrating for our staff and demotivating when they’re seeing budget cuts continually in this service and then they’re seeing another service being commissioned to do what they were doing” 0030 (Community referral provider focus group)

Buy-in to the need for community referrals at all levels. Both Community agencies referred to similar benefits in comparison to clinical referrals (proactive, raising awareness, being more approachable) and similar requirements (flexibility, the importance of local knowledge)

Tensions between the community and clinical services regarding their different approaches, and tensions between the two community services in the context of limited funding, Unclear on value of both community services working together, what this added.

There was coherence from all participants (frontline workers, managers, and commissioners) for the need for community referral as a different way of working and the likely benefits. However, there was a lack of coherence regarding how this would be achieved and the value of the two community services working together.

1b) Cognitive participation: roles and relationships

“I think communication and an understanding of peoples roles, and a understanding of how people fit in, into the whole process, I think that was our kind of key. And some people maybe had a misunderstanding of what the role was … I would of liked … the expectations in place and then start, … getting expectations drawn up between the different parties” 033 (Community referral provider co-ordinator)

“I didn’t get...personally didn’t get my head round Care Call until much later into the pilot. How does it work? How does that link up with the case finding?” 019 (Community referral provider service lead)

Lack of clarity about how the collaboration would work in practice and how the different services were expected to work together.

Cognitive participation was problematic. The services involved did not share understanding about the work to be done (both the collaboration between the community services and the interaction between the community services and Care Call) and the processes required, and in the early stage of the pilot had not been brought together to collectively resolve the issues

2. Implementation and barriers to implementation

2a) Collective action: relationships and confidence in each other

“It’s really fragmented and broken down. There’s loads of different people involved in it and nobody knows what anybody else is doing.” 0030 (Community referral provider leads focus group)

“One of the problems has been communication …. I think sometimes when you’ve got a service like [Care Call]that’s very clinical and it’s almost quite a closed system and they know the referrals they’re getting through is very clean, I don’t think they understand how difficult it is for us to actually case find in the community.” 0030 (Community referral provider leads focus group)

“After speaking to [leads] they just said to me get out as much as you can and get as many people as you can … the fact of working with [the other service] and them referring in, I don’t really get where all that’s working together.” (042 Community referral provider frontline worker)

“While we are trying to target sometimes you don’t try to target too much. You’ve got to hit the numbers.” (028 Community referral provider frontline worker)

The lack of agreement on how to work together meant that provision was fragmented rather than collaborative, and divisions between the services were maintained.

This had 2 impacts on the referral process itself

1. Care Call were unprepared for the different referrals received from the community services. The community services felt that Care Call did not understand the work they were doing and had unrealistic expectations about what could be provided (for example, NHS Numbers) which led to delays in referrals being processed.

2. The focus on targeting was obscured by a focus on each service trying to “make up the numbers” rather than working effectively to co-ordinate the work required.

Collective action was not achieved – the division of labour and mechanisms for working together were unclear. The services did not have confidence in each other which led to delays and meant that the focus on targeting high-risk areas was partly abandoned.

2b) Reflexive monitoring: extent to which there is a shared understanding about the intervention.

“What’s been useful is the meetings that we’re having with [clinical service] around this project because we’ve relayed that information and we’ve actually had people from there attend and we’ve been able to put those to them and say, you know, we want the feedback.”

(Community referral provider frontline focus group)

“When we’re [community agencies] working together it’s really important that we know what they want but it’s also very important for them to tell us what they want... So communication is, we’ve learnt a lot from this about how different we work together” (Community referral provider frontline focus group)

Over the course of the pilot, the services all made efforts to improve their communication and understand each others’ roles. This led to an appreciation of the need to collectively understand the issues from each others perspective in order to resolve them.

Reflexive monitoring emerged as key over the course of the pilot, with services needing to come together directly to share their experiences and preferred ways of working, and revise processes where required, including establishing mechanisms for further feedback. The learning in terms of understanding each service and how to work together was highly valued but took time to develop.