Following the pilot case study phase and the first national survey, the focus of research work shifted to the six main case studies. The selection of these core cases was informed, as planned, by the results from the first national survey and was also shaped by our knowledge of activity across potential case sites. We wanted geographical coverage so we ensured that the cases included CCGs in London, the Midlands and the North, and we also ensured coverage of urban and rural settings. Of special importance was our knowledge of the degree of service redesign activity occurring in these settings. A random selection of cases might easily have resulted in six CCGs characterised by relatively little activity. In order for us to be able to tease out the elemental processes of clinical engagement and leadership in service redesign, it was important to ensure that some of the cases had strong prima facie indications that they would be able to
TABLE 1 The comparative distribution of survey respondents and the NHSE ratings profile 2015–16
CCGs sampled
NHSE ratings profile 2015–16 (%)
Inadequate Requires improvement Good Outstanding
All NHSE CCGs 12 44 39 5
offer opportunities for detailed study of substantial activity, but we avoided over-reliance on the feted cases that may have enjoyed unusual and exceptional support.
Within each CCG we selected for detailed study one, or in some cases two, specific service innovations in particular areas. These focused on care of the frail elderly (usually involving cross-boundary working
designed to‘integrate’ health and social care); innovations in urgent care (usually involving cross-boundary
working with GPs, acute hospitals, the ambulance service and paramedics); and/or mental health.
Within these cases there were also many research choices to be made. We used both purposeful sampling and theoretical sampling to access the most appropriate informants.
Guidelines from Lincoln and Guba82were followed regarding‘purposeful sampling when selecting
informants within the case studies’. First, we selected informants whom we expected would have the
most relevant knowledge of the background issues affecting the CCG as a whole. This cluster was broadly common across the cases (accountable officer, CCG chairperson, clinical leads, and so on). However, in addition we were sensitive to the particularities of each service redesign attempt studied. Here we used
onward referral– a snowball research technique – in order to include informed and diverse perspectives
appropriate to the situation. For each service redesign attempt researched, a set of interviewees was agreed with a senior sponsor of the research collaboration within the CCG. The selection of each sample was guided by the need to include the actors who had played a key role in initiating, shaping and evaluating the course of the service redesign event. This typically meant that clinical leads, programme managers and project managers, as well as some of the clinicians, were involved. In several cases we were also able to include patient representatives who had been involved in the service innovation (e.g. through sitting on the relevant programme board). In recognition of the multilayered nature of health-care reform, it was necessary to look upwards and outwards to the wider context, including area, regional and national policies and institutions which had an impact on the service areas under focal scrutiny. Thus the institutional settings usually had fuzzy boundaries which extended across primary, secondary, administrative, regulatory, professional and educational institutions.
Theoretical sampling allows the clarification of the relationships among multiple constructs.75It allows the
revelation of unusual phenomena of diverse kinds. We used this approach in order to identify further
interviewees in each case, to ensure exposure to data from informants who could add to an accumulative and iterative body of knowledge about relevant issues. The range of informants evolved with the emergent theory.
Themes were pursued until little additional insight (what has been termed‘theoretical saturation’) was gained.83
We used three main methods within the cases. First, we conducted pre-entry documentary analysis drawing on a wide range of sources. Second, we conducted face-to-face semistructured interviews. Third, we used non-participant observation. Although interviews can be a highly efficient and effective research tool, it is recognised that they also present the challenge that bias may arise because of the efforts of image-conscious informants. This challenge was mitigated through the use of multiple interviews among
diverse informants who were likely to view the issues and events from different standpoints.84
The mode of operation was for each case study to be conducted by two members of the research team, with one of them acting as the lead investigator and contact person for that site. Some of the interviews were conducted with both researchers present, other interviews with just one researcher. In the main, interviews were recorded and transcribed. The researchers drew on a semistandard interview schedule comprising semistructured interview questions. These had to be adapted to the varying situations including, for example, the subject of the service redesign under scrutiny and the role and vantage point of the interviewee. The semistructured interview schedule was adapted accordingly. Appendix 4 shows a typical example of one such interview guideline.