Our analysis highlighted that implementing ActEarly raised many challenges and the extent that the programme was able to navigate these successfully was varied. By exploring accounts of how the programme handled these challenges and reflecting on participants’ recommendations, we identified clarity, unity, feasibility and flexibility as the key mechanisms likely to support the implementation of a public health consortium like ActEarly (Fig. 1).
Enablers of running a public health consortium
Clarity
Having clarity around the programme’s aims and scope, governance and communication was seen to enable consortium members to manage their work.
Aims and scope
Participants were in the latter stages of developing the grant proposal at the time of the wave 1 interviews, and thus were relatively confident in describing and discussing the programme’s aims to reduce NCDs and health inequalities through building collaborations, knowledge and research capacity. However, the clarity and structure of ActEarly’s aims became less clear as time went on and as more people joined the programme. When asked to define ActEarly and its aims in the second and third waves of interviews, many people were uncertain of its ultimate purpose, even those who had been confident in their previous answers in 2018:
“I don’t think there is a complete clarity within the consortium about what ActEarly is about” (P1, wave 2).
The promotional materials and interviews with ECRs tended to focus more on the programme’s aim of improving child health in areas of deprivation through building the evidence base, while those who had been involved since the start placed greater emphasis on aims that built capacity for future research.
Acknowledging these conflicting perspectives, consortium members believed that ActEarly “could have defined the parameters much more” (staff workshop notes notes, May 2023) and believed more tangible objectives would have helped to avoid confusion:
“ActEarly is massive and it’s got very lofty aims but it would have been helpful to say you know, this is what we want to do and this is how we’re going to get there and then we sort of have steps that are actionable” (P41, wave 3).
A logic model outlining the programme aims was available to the team from the start and was updated in 2022 for clarity and to reflect the refined goals. However, the perceived breadth of scope, the “blurred line” of what (and who) counted as part of ActEarly and inconsistent terminology in materials created some confusion. Participants did recognize, however, that a certain amount of ambiguity is unavoidable when taking a whole-systems approach:
“from a sort of systems perspective, you don’t really have closed systems, so you can’t really say there’s a boundary around ActEarly and everything inside of that boundary is the project and everything outside is sort of straightforwardly not the project” (P27, wave 3).
Governance
Consortium members wanted more clarity about governance structure, roles and an overarching plan throughout the lifetime of ActEarly. During meetings and interviews, staff sought clarity on the responsibilities and expectations of job descriptions, and some queried the purpose of the cross-cutting themes (evaluation and co-production), uncertainty about how to access resources and how links between sites operate:
“the biggest issue that I find with ActEarly is understanding where the resources are and who ultimately is in charge of deciding how they should be best deployed” (P7, wave 2).
This was acknowledged throughout the programme, and ActEarly’s Scientific Advisory Group requested that the team simplify the governance structure 2 years into the grant. Responding to some of these criticisms and to make these structures clearer, organograms depicting the programme’s organizational structure were developed and shared, and any confusion was addressed in meetings as specific challenges arose. Despite these remedies, participants still expressed uncertainty about governance structures and processes towards the end of the project. It was recognized that the scale and design of the programme made this challenging, but one participant emphasized that the complexity of the programme made strong governance even more essential and a “necessary evil” to ensuring project success:
“a lot of it does come down to governance, right, and governance needs to include the forward planning, clarity about roles and responsibilities, where the decision-making points are, what the communication strategy is, a bit more oversight on how the money is being spent” (P26, wave 3).
Communication
Clear and consistent communication was considered important to maintain relationships, avoid duplication of work and support project management. ActEarly having dedicated programme managers at each site and roles linking with the local authorities was considered to have been very useful in tackling communication challenges, especially in LBTH where academics were spread out across multiple institutions. Making sure there was regular communication happening at all levels was considered an important facilitator of project success:
“it needs that constant dialogue and you know, it’s not enough to have it at the top or the bottom, it needs to be all the way through” (P37, wave 3).
Participants found regular communication challenging when senior researchers had limited availability, which could hinder ECRs having access to project support, whether it be to get plans approved or guidance: “something that might only be a 5-min conversation, it can actually take a week or so to arrange” (P11, wave 2).
A lack of clarity around the boundaries of ActEarly led to confusion about who should be involved in mailing lists, meetings and updates, leaving some consortium members unaware of what was happening outside of their focus of work:
“unless you’re kind of party to those governing spaces, you don’t necessarily know how other bits are working” (P38, wave 3).
ActEarly tackled some of these issues by splitting some of the consortium meetings into smaller groups (e.g. by location or theme); the inclusion of less senior staff and key local government members supported communication locally and provided more of an opportunity to be involved in decision-making. However, it is important to note that this cross-site division may have also contributed to a disconnect within the wider consortium:
“joining in the executive meetings at London level […] really helped me connect a lot more, understand what was going on…However this has really created a complete divide from where I’m sitting between Bradford and London” (P17, wave 3).
The introduction of e-bulletins in early 2022 was seen to mitigate some of the cross-site knowledge gap by providing a platform for consortium members to share their work and opportunities.
Unity
Creating a sense of unity and cohesion between partners was considered a key facilitator of delivering the work, but was also felt by many to be the most challenging aspect of the programme to manage. It required investing in building and maintaining relationships, creating a shared vision and ensuring shared access to resources.
Relationships
Bringing together people from a range of disciplines, backgrounds and organizations was seen as a highlight of the programme, and building these collaborative relationships was considered an essential part of creating change:
“you can get so far on your own sitting there observing ideas […] but it’s only when you start sharing them with other people that you get the other pieces of the jigsaw and what evolves is something that none of us could have done our own” (P1, wave 1)
Some people expressed that it was initially challenging to find the appropriate person to contact about a project. As well as being essential for supporting communication between existing partners, the development of roles linking the council and universities also made establishing new contacts in local authorities easier and in turn supported the development of new relationships:
“in ActEarly, the most important thing has been to have a dedicated person in the local authority who facilitates contacts with other people in the local authority” (P4, wave 2).
Having links to members of the public through partners such as voluntary and community sector organizations or schools also supported the building of researcher-community collaborations by being “a bridge between the academics and local community and trying to find different ways to bring people together and have meaningful conversations” (P30, wave 3). These partner organizations facilitated recruitment and held community events, which provided a platform for academics to connect with members of the public.
High staff turnover and the sprawling, cross-city nature of the programme made it challenging for many ECRs to feel part of the consortium. The addition of cross-site/cross-theme meetings, yearly week-long writing retreats and conference funding opportunities were considered to offer useful steps towards building these relationships: “The writing retreat was also really helpful, especially for connecting with the guys outside of London […] it’s just a lot more like natural and organic to talk about projects” (P39, wave 3).
Opportunities to connect with colleagues in person, such as workshops and conferences, also strengthened relationships across the consortium. At the same time, remote meetings allowed people to join meetings that they would never have been able to find time to attend, as well as keep in touch with colleagues across sites. Considerable investment in fostering a strong cross-site connection was needed, as the distance, competitive nature of academia and differences in working cultures made some feel like it was “two kind of sites collaborating rather than a team collaborating across two sites” (P16, wave 3).
Taking a systems approach was new to many, and participants acknowledged that it was challenging to find ways to collaborate effectively between so many different stakeholders who were used to working in a siloed way:
“this is like wild west stuff you know, this is frontier stuff, multiple institutions, multiple disciplines, […] working with a local authority that’s never really worked with academics before in an area that’s difficult enough to work in even if everybody was on the same page” (P12, wave 2).
As such, it was recognized that creating strong collaborative partnerships required a significant amount of work and commitment to build and maintain:
“you can’t overlook the investment of time required, the generosity of spirit required, the sharing of perspective, taking the time to build the relationships” (P26, wave 3).
Shared vision and priorities
Commitment from all parties was seen as necessary to make relationships work, and cultivating a team mindset required investment:
“you have to have good coordination. Keeping that synergy, keeping the sense that there’s a big prize here and we’re all in it” (P3, wave 1).
Consortium members reported being driven by their shared passion for improving health inequalities, and having a “unity of purpose” (P42, wave 3) was seen as a motivating factor for, and facilitator of, developing these cohesive cross-site relationships. The importance of creating a shared vision and mentality between local authorities and academics was also acknowledged, with staff at a 2021 workshop noting that “political mindset works on the idea we need to change something! Research is about finding out what the evidence tells us needs to change. This needs to come together and get a consensus” (staff workshop notes notes, November 2021).
Connected resources
Our participants acknowledged that making it simpler to share data, resources and finances across partner organizations would have supported better cross-institutional collaboration. Restricted or delayed access to data was a major barrier to projects which disrupted project timelines and diverted researcher capacity:
“a considerable amount of time and effort during these first two years of the project has gone into getting data sharing agreements in place” (Healthy Places theme summary, 2021).
ActEarly worked to build this infrastructure and support data linkage through cross-site projects, supporting the development of “whole-systems data linkage accelerators” which participants hoped would make accessing data simpler in the future. Budgets were managed separately by independent finance departments at each institution, making accessing and keeping track of funds a time-consuming and complicated process. Having links to specific points of contact at each institution helped to manage this challenge.
Different institutions used different productivity and collaboration software (i.e. Google for Business versus Microsoft360) and had different data protection policies, which often made sharing research data or even internal documents a lengthy and complex process. One participant suggested that “having good policies and procedures and support or even just directions for how you access the same information” across institutions would support efficient cross-institutional working (P34, wave 3).
Flexibility
To have an impact in public health, consortium members believed that “researchers need to do research that is accessible, reactive and flexible for rapid implementation and responsive to change” (staff workshop notes notes, November 2021). Flexibility was seen to facilitate the management of the external influences outside of the team’s control.
Collaboration
Participants felt that being flexible to adjusting to different working cultures and expectations across different disciplines, roles and institutions was vital:
“you have to start to learn to adjust and to have ways of communicating and connecting people, that you recognize those cultural differences and different ways of working” (P10, wave 2).
Overcoming language barriers and working to “consider how to resolve conflict and conflicting agendas” between different stakeholders (London AEG minutes, April 2023) were considered important to keep everyone on the same page. Local authorities tended to work on shorter timescales than academics, making expectations of what was achievable in the time frame “difficult to manage” (P2, wave 3), while academics were “doing great things, but not necessarily what local authorities needed, or certainly not in the format that they needed it in” (P1, wave 3). Acknowledging this difference and being willing to adapt to each other’s communication styles was seen to be important when addressing this disconnect.
Collaborating with the public also required a more flexible approach than other research, as the iterative and reflexive nature of working with communities can mean that “you don’t know at the very start of the project exactly what you want to do” (P10, wave 3).
Wider system events
Events occurring outside of the direct ActEarly system affected programme implementation both directly [e.g. coronavirus disease 2019 (COVID-19)] and indirectly (e.g. shift in political priorities). ActEarly was willing to adapt its processes to meet the needs of various wider system events that affected the running of the programme:
“what we’ve learnt as we go along is how to make it work in practice, so where you have to be flexible and where you have to sort of fit with local politics or local resources” (P10, wave 2).
The COVID-19 pandemic and ensuing lockdowns were a major disruption that required consortium members to adapt their research priorities and approaches. One participant reflected that adjusting to these changes was about “having to compromise, having to be quite pragmatic” (P36, wave 3) about what could be achieved. Many quickly adapted to the disruptions by redirecting their research efforts towards pandemic-related research. This agility allowed them to provide timely evidence to support local initiatives, and in some cases acted as a springboard for the development of new research. For example, a study on the provision of food aid in Bradford during the pandemic provided rationale for a wider review of community food assets across both sites.
Consortium members had to consider the political acceptability of their work and dissemination to maximize the chance of it making an impact. Changes in political leadership meant some projects were disrupted or cancelled when they did not fit with the new political agenda. This was particularly challenging for work around street safety, as low traffic neighbourhoods became a highly divisive issue in LBTH. It was recognized that “politics can’t be planned for in advance” (staff workshop notes notes, May 2023), but meetings regularly addressed how researchers “mustn’t underestimate the political interface of their work” (London AEG minutes, April 2023) and should iteratively reflect on “where there might be linkages with the activities in the political cycle” (staff workshop notes notes, March 2022).
Working within a wider system did not just mean considering the impact external events had on the programme, but being prepared to adapt plans to accommodate the unpredictable impact the programme’s actions on the system: “I think it’s a big challenge because when we pull a lever here we don’t always know like how it reverberates throughout the whole system” (P13, wave 2).
Programme management
The large number of stakeholders in the consortium meant the programme frequently had to manage internal changes. Staff turnover and maternity leave commonly disrupted capacity and influenced the strength of interpersonal relationships over time. Leadership took a flexible approach to managing these challenges:
“there’s so many people involved it’s its own complex adaptive system. So there’s a bit about not trying to control it or trying to fix it too much, but let it happen” (P5, wave 3).
Participants felt that this more decentralized management structure had given them the freedom to respond to wider system changes:
“[ActEarly’s] philosophy is a lot more actually people should be self-organizing […].
That’s really exciting and it enables you to respond more agilely to Council agendas” (P32, wave 3).
Though not involved in the day-to-day of individual projects, leadership was still regularly updated and led the management of unexpected circumstances and challenges. The programme was open to hearing and adapting to staff concerns; interviews with consortium members halfway through the programme informed changes which aimed to support building relationships, improving communication and providing training opportunities.
Despite the challenges of managing ActEarly’s ‘fuzzy boundaries’, some also saw this versatility as one of the programme’s strengths, as it allowed for synergistic relationships with different programmes and opened up wider opportunities: “I think there is some benefit in it being loosely defined sometimes because then you’re not constrained” (P16, wave 3).
Feasibility
The breadth and scale of ActEarly’s aims were considered too ambitious by many, and a result of having to “promise the world to get the funding” (P2, wave 3). Participants emphasized that it would be important to consider the feasibility of achieving a programme’s aims within systemic limitations, available resources and existing infrastructure when developing similar programmes in the future.
Resources
Having sufficient funds and staff capacity were seen to contribute to the feasibility of achieving the programme’s aims. However, many participants believed that ActEarly had been undercosted for what it set out to achieve:
“a few million quid over five years, split between two areas in billion pound economies, you know, you’ve got to be realistic about what to expect in terms of outcomes” (P5, wave 3).
As a grant based on facilitating collaboration, it relied on members independently gaining funding for their projects. This meant that the cost of interventions was not covered, which disrupted the initial plan to focus on evaluating them.
Sufficient researcher capacity was highlighted as being vital to being able to deliver. The annual report in 2021 recognized that ActEarly’s interdisciplinary, whole-systems approach meant that it was important to have expertise across the “range of disciplines needed to cover the broad areas important to wider determinant NCD research”, but that doing so it “significantly spreads the resource thinly leaving many with very limited funded time” (annual report, 2021). Some themes only had one ECR working across both sites, often part time. Expectations around what ECRs could achieve with this limited capacity were not considered realistic:
“a singular research fellow on two days a week is not a realistic amount of work capacity for what the project aims to do” (P34, wave 3).
Participants commonly suggested that the work would have been more feasible if the programme had funded fewer co-investigators but with a higher time commitment, as well as more “on-the-ground” research staff:
“We funded the grant in a typical way, which is lots of co-apps at 5% and what we should have done is […] fund more research fellows, more research management capacity at the beginning and have a much more agile way of funding researcher input” (P32, wave 3).
Systemic limitations
Working within multiple overlapping systems (e.g. academic, governmental) meant delivering objectives within the limitations of regulations, culture, timelines and expectations. Participants recommended considering these wider constraints when determining whether an activity is feasible. Co-production was considered a priority for ActEarly; however, funder timelines, administrative barriers and a lack of researcher experience limited the extent that it could be incorporated. Including communities meaningfully in research required time and flexibility, and funders did not like unclear research questions. It was also believed that the current system made it challenging to receive ethical approvals and pay external partners/community groups:
“you need to design [the system] in a way which is going to make it easy for communities to get involved. Currently, it’s not.” (P12, wave 3).
Achieving true interdisciplinarity was felt to be hampered by systemic and academic boundaries. For example, participants found that it was difficult to be awarded grants outside of their primary academic discipline:
“if the funder is a funder with a very strong health focus then I do find that is a lot better that the lead is in fact a health researcher or academic” (P7, wave 2).
A period of 5 years was not considered to be long enough to achieve the building of sustainable infrastructure, networks, and a measurable impact on population health. It was noted that acknowledging that this was not feasible was important when measuring the programme’s success, and that smaller impacts should not be seen as failures, but as progress towards the wider high-level aims of public health research:
“This is societal stuff, it’s big stuff you know so you have to move boulders to do that and we’re moving stones at the moment you know so, but the stones add up to boulders eventually” (P12, wave 2).
Research infrastructure
The availability of research infrastructure affected the feasibility of the work. Bradford started the project with a stronger research infrastructure across data linkage, social networks, community links and research culture. LBTH faced more challenges in executing their plans as a result, and consortium members believed it was useful to consider that the difference in infrastructure could mean that different sites could need different timelines, funding and expectations. ActEarly was designed to build on the existing infrastructure in Bradford, and thus was prepared to manage this difference, though it still took more time and investment than many had originally thought. Workshops, projects to identify challenges, and regular engagement at all stages of the research process was believed to help to overcome these limitations. Several suggested that accounting for additional time to lay the foundations for future collaboration would increase the feasibility of similar work:
“I think in some ways you almost need a two-year lead time to develop relationships, to ascertain and get access to data and to data confidentiality agreement” (P8, wave 3).
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