Co-production within integrated care: a study protocol for multi-case study using Participatory Action Research within an Integrated Care System in England

Co-production within integrated care: a study protocol for multi-case study using Participatory Action Research within an Integrated Care System in England | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Co-production within integrated care: a study protocol for multi-case study using Participatory Action Research within an Integrated Care System in England Susan Conquer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2795837/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Globally, integrated health and care services are encouraged to work in collaboration with people who draw on their lived experience of health and care; co-producing change. Integrated Care Systems in England are recent structures, mandated in 2022, required to involve their service users, carers and citizens in strategic planning, service development, implementation and improvement. This multi-case study will use participatory action research to explore the impact of co-production on the design and transformation of services within integrated care. Methods Case studies of different examples of ongoing co-production within one Integrated Care System will be conducted simultaneously. Participatory action research will allow the researcher to partner with the participants as co-researchers, frame the research questions, and tailor the mixed methods. Co-researcher groups within each case study will consist of service leads, co-production project leads, service users, unpaid family carers, members of staff, and the researcher. Group meeting transcripts, co-researcher reflections, and other case study data collected will be continuously analysed and compared, developing a multi-case analysis. Discussion The knowledge built in each case will allow for interpretations of the data. The findings will contribute to the development of co-produced guidance for Integrated Care Systems. The co-researchers may be enabled to use the knowledge built during the case study as learning for their practice of co-production. The multi-case study findings will be submitted to a peer-reviewed international journal, and for conference presentation. co-production integrated health and care integrated care system case study multi-case study participatory action research Figures Figure 1 Lay-summary This study explores ongoing co-production within integrated care across one Integrated Care System (ICS) in England. Co-production is people working together to improve health and care services. It is a process whereby people, including service users and/or unpaid carers, become actively involved and influence decisions. Integrated care is when health and care services work together to coordinate and collaborate to better meet the needs of service users (patients and their carers). ICSs are partnerships that bring together National Health Service (NHS) organisations, local councils, the voluntary sector and others to work together to improve health and reduce inequalities. In England, ICSs became statutory on July 1st 2022 upon the introduction of the Health and Care Act 2022. ICSs will include members of staff, citizens, service users and carers to improve services by using co-production as a way to more actively involve people in decisions and design processes. This study will explore the co-production processes within three case studies over six months. This study will use a multi-case study and participatory action research (PAR) methodology. PAR means the participants will become ‘co-researchers’ working together with the researcher. Each case study will aim to recruit six co-researchers; two service /co-production leads, three service users /carers, and one member of staff. After six months of co-researcher meetings and data collection, the researcher will perform a multi-case analysis, presenting and publishing the findings collectively. The findings will contribute to the co-production of guidance for ICSs to support people to co-produce service changes and improvements. 1. Background The context of this study is set in the changes of England’s health and care legislation, the formation and formalisation of ICSs. The Health and Care Act ( 2022 ) enacted ICSs as legal entities with statutory powers and responsibilities. ICSs have two components; integrated care boards: statutory bodies responsible for planning and funding most NHS services in the area, and integrated care partnerships: statutory committees bringing system partners (e.g. local authorities, the voluntary and community sectors, NHS organisations) to develop a health and care strategy for the area (Charles 2022). These integrative system restructures will be including service users, patients, carers and citizens to improve service design, quality and accountability and will be assessed on whether they improve patient and service user outcomes (Patel 2021 ). There is a statutory requirement to view geographical areas holistically (Health and Care Act 2022 ), in partnership with residents and communities (NHS England 2022 ). The study is set within the context of one ICS in England. Co-production moves culture and practice away from more traditional and less person-centred methods of ‘doing to’ people, towards a ‘doing with’ in the context of public service provision (Batalden et al. 2016 ). Within health and care, it has been developed from the concepts and practice of the personalisation of care (Fox et al. 2018 ). On an individual level, being involved in co-productive programmes has been seen to improve health, wellbeing and recovery from long-term conditions (Boyle et al. 2006; Palumbo 2016 ), diminish health inequalities (Marshall and Bamber 2022 ), empower operational healthcare staff (Needham and Carr 2009 ), and improve the service user-service provider relationship (Realpe and Wallace 2017 ). However, there is a lack of tangible evidence about co-production within integrated health and care, a review (Lowe et al. 2021 ) that compares health services’ planning, delivery and evaluation when consumers and professionals work in partnership, find that no studies investigate the extent that changes to health services have reflected service users’ priorities. Questions remain regarding the contexts in which co-production within integrated care is successful, the influence that co-production has on the wider health and care system, the operation, evolution, evaluation, learning and recommendations from co-production in practice (Conquer and Bacon 2021 ). A pragmatic model of co-production for integrated care allows organisations to be flexible in their approach but more evidence is needed for what effective co-production entails within different contexts (Kaehne et al. 2018 ). This study aims to contribute to the depth of understanding of the approach of co-production within integrated health and care and minimise gaps in research by collecting and interpreting information, discussing, and reflecting upon how co-production impacts integrated care services within an important legislative change. This study aims to explore if co-production can be an approach to service integration within an ICS context, ensuring design and transformation processes are made alongside the population for whom they are intended, by focusing on local context and the use of co-production. The multi-case study design will be itself co-produced and will focus on design and transformation of services from the perspective of the service leads, co-production leads, service users, unpaid carers and staff involved. The study will use of the Standards for Reporting Qualitative Research (O’Brien et al. 2014 ). 2. Methodology This research will use a combination of case study and PAR methodologies. As we move through the process the overarching theoretical framework will be understood and developed. Although there are a number of methodological paradigms the study may move through during data collection and analysis, this study may fit within a relativist ontology (Stake 1995) and constructivist epistemology (Lincoln and Guba 2013). The PAR approach is an attempt to democratise research giving it potential to be transformational, addressing common issues relating to hierarchy and power-sharing. Case studies explore real-life cases over time through detailed data collection involving multiple sources of information (Creswell 2013). Multi-case studies have the benefits of creating convincing theories, understanding the differences and similarities between the cases (Gustafsson 2017), and the ability to analyse data within each situation and across different situations (Yin 2018). Case studies use a variety of methods, whilst PAR allows the participants to use the most appropriate methods of data collection for the context (Koch and Kralik 2006). Using mixed methods through PAR and a multi-case study has the potential to enhance the transferability of the study findings across contexts. Action research is a collaborative, democratic, process concerned with developing practical knowledge (Lewin 1946; Adelman 1993). It brings together action and reflection to deliver practical solutions (Reason and Bradbury 2001). As an interactive research approach, PAR encourages joint learning and decision-making between the participants and the researcher throughout the process (Kjellström et al. 2019). Koch and Kralik (2006) outline the five characteristics of PAR: Involves participation by the people involved in the research at all stages of the process, a partnership between the researcher and participants. Theory is generated from the experiences and understandings of participants which can create opportunities for change and lead to wider-scale social transformation. Focuses on empowerment, seeks to take action to address inequity in the researcher-participant relationship. Educative for researchers and participants, together generating data and becoming committed learners together. Aims to create social change, to affect the lives of those who participate. Farr et al. (2020) state that co-production builds upon PAR, as the research leads to action and beneficial outcomes for people involved, often those who have the least power in decision-making. PAR has been linked with feminist and emancipatory theory of ‘consciousness raising’ (Henderson 1995), enabling people to view the world in a different way based on the knowledge gained through participating. This study aims to eliminate the hierarchy between the different roles of co-researchers within each case study (service leads, service users/carers, members of staff, and the researcher) by creating a prepared space for honest and reciprocal dialogue (Freire 2005) and reflexivity on the part of the co-researchers and researcher. 2.1 Patient and Public Involvement (PPI) A Co-production Advisory Group (CAG) of six members equally representing service users, unpaid carers and members of staff who provide and draw upon services in one ICS has supported the understanding and choice of methodologies and methods for this study. The group meet with the researcher every three months with communication and tasks between meetings. PAR methodology was selected following group discussions and suggestions from members. Members have designed and agreed on the research questions, case study materials including the participation information sheets, easy-read formats, recruitment materials, and a case study selection process. The group will deliberate on the decisions about which three case studies will be selected. Meetings and communication will continue with the group throughout the case studies. During the data collection and analysis, the researcher will draw guidance from the CAG to gain their reflection on the process and resonance of the developing findings. 3. Methods PAR allows the co-researchers to select the most appropriate methods to inform their case study. The co-researcher meeting discussions will be a consistent data collection method across the case studies. Research questions have been developed to focus each case study and the multi-case analysis (see Table 1 ). The co-researchers will explore the most suitable methods to answer the questions iteratively. Within each case, four foci will steer the PAR process as outlined by Koch and Kralik ( 2006 ). As data collection and analysis are taking place in each case study, the researcher will be guided by research questions for a multi-case analysis. As well as being guided by the co-researchers and CAG members, the multi-case analysis will consider methods of thematic coding, drawing upon reflexive journals, triangulation, and cross-case analysis techniques (Stake 2006 ). Table 1 Research questions Multi-case study overarching research question What is the impact of co-production on the design and transformation of integrated health and care services? Case study guide research questions and focus What is happening here? Gathering information, defining and describing the situation Why are things as they are? Exploring, analysing, interpreting and explaining How can we do things differently? Acting on the information and changing behaviours for improvement How will we know things have changed?’ Evaluating Multi-case study guide research questions What enables co-production within integrated care, and what are the barriers? How can integrated care systems use co-production to impact the design and transformation of services? What are the recommendations and solutions for the co-production of integrated health and care services? 3.1. Recruitment Health and care organisations employing a co-production process within their service design and/or transformation will be invited to become cases to study and take part in the multi-case study. Three cases representing across all geographical areas of the ICS will aim to be sought. Organisations will be identified through existing networks of the ICS of which the researcher and CAG members are aware. Written invitations will be sent in the form of emails and online newsletters. Attached to this will be an invitation poster, detailed visual summary and participation information sheet. Following this, if suitable cases have not been sought, the researcher and CAG members will disseminate within their networks and contacts. Within the participant information sheet, there is a link to an online survey for organisation representatives to submit an expression of interest. The researcher and CAG will use a selection pro-forma to ensure potential case studies are suitable for the purpose of the study and multi-case analysis to ensure a variety of service types, provisions and geography across the three cases. A decision will be made within two weeks of the expression of interest. Organisations taking part will view the Organisation Information Documents and perform appropriate internal ethical approval processes. Once an organisation has been recruited and the study has been approved by that organisation, an initial meeting will be held between the service and co-production leads and the researcher. The remaining service user, carer and member of staff co-researcher participants will then be recruited. Potential cohorts of participants will be identified by the organisation. Organisational representatives will use existing records of service users, unpaid carers and members of staff who are involved in their co-production processes. They will already have consent to contact these individuals. The service and co-production leads will send potential participants the cover letter summary, invitation poster and participation information sheet. Additional consent from these individuals to become participant co-researchers will need to be gained via the researcher directly, so potential participants will be asked to express interest with the researcher directly by email or telephone. Participating organisations will not be required to collect, use or store participant data for the study. Written consent will be gained by email or post. Easy-read formats of the participation information sheet and consent form have been produced. 3.2. Inclusion and exclusion criteria The inclusion criteria for organisations and co-researchers participating in the case study are based upon the agreed concept definitions for the research, as agreed with the CAG (see Table 2 ). The inclusion and exclusion criteria for organisations and participants of the case studies are detailed in Table 3 . Table 2 Study concept definitions as agreed with the CAG Concept Definition Co-production A process whereby people, including service users and/or unpaid carers, become actively involved and influence the decisions that design and transform health and care services. People Stakeholders (citizens, service users, patients, unpaid carers or representatives of organisations) who are part of, or impacted in any way by, the decisions made. Integrated care systems Defined and coordinated networks of partnerships and associations between organisations providing services that meet people’s health and care needs across a geographical area (adapted from NHS England, 2021 ). Service user Unpaid carer Member of staff A person who is, or has experience of, using and/or requiring access to health and/or care services. A person, usually a family member or friend, who takes a role in the care of a service user without payment for their time and expertise. A person who has a paid or voluntary job role, representing any organisation within an integrated care system, to provide health and/or care services. Health and care services Integrated care Provisions available to service users provided or commissioned by statutory organisations, charity and other third sector providers. Health provides clinical services, whilst care provides longer-term, preventative and educational services, supportive of independence. Some services provide aspects of both (adapted from Leutz, 1999 ). When health and care services work together to coordinate and collaborate for service users to receive more efficient and effective provision for their health and care needs. This may take place between providers operating at the same level (horizontal integration) and between providers at different levels (vertical integration) (adapted from Kodner and Spreeuwenberg, 2002 , and Ham and Curry, 2011 ). Design Transformation Design and transformation The act of developing new service processes within an integrated care system. The implementation and outcome of that change. Service design can contribute toward transformation by providing a person-centred, holistic and iterative approach to the creation of new services. Service users, unpaid carers and members of staff are actively engaged in transformation processes through participatory design approaches (adapted from Patricio et al., 2020). Table 3 Study inclusion and exclusion criteria Organisation Inclusion • There is an existing ongoing approach and process of co-production within an integrated health and care service within the ICS. • For the existing co-production, consent for the involvement of, and communication with, service users, carers and members of staff have been gained. Exclusion • An integrated care organisation or service's co-production which is defined by the organisation differently to the research's definitions. Case study representation • Case studies spanning the ICS will be sought, representing the geographical area. • Ensuring a variety of service types, provisions and geography across the cases. Participant co-researchers Inclusion • Currently involved in a process of co-production with the organisation/service taking part in the case study. • Service leads and co-production leads are members of staff who play an active role in the organisation’s co-production. Exclusion • Children under 18 years old Single case-study co-researcher group make up Six participants plus the researcher: • 2 x service/co-production leads • 3 x service users/carers involved in the co-production • 1 x member of staff involved in the co-production • 1 x researcher The co-researcher sample size provides each case study with an equal number of professional and service user participants, to ensure equal representation and equity within co-researcher meetings. Whilst always based on this principle, the actual sample size may change by one or two members as required and appropriate in each case study. The number of six participants in each study will allow in-depth group discussions where each participant can elaborate and be heard in decision-making. Co-researchers will be arranging group meetings and a smaller number will allow these to be organised with more ease than a larger number. 3.3. Accessibility Easy-read formats of the participation information sheet and consent form have been produced. The accessibility and communication requirements of the service users, unpaid carers and members of staff being invited may be known by the service and co-production leads. For example, if a carer they work with in co-production requires large print and a language other than English, all recruitment materials will be provided to them in a suitable format. This information will be obtained in the initial meeting with the researcher. Otherwise, the general cover letter summary, invitation poster, participation information sheet, and consent form will be provided in plain English and easy read. Reasonable adjustments will be made throughout the process, with consideration to the study time and budget restraints. The researcher will require participants to share their communication and accessibility requirements by returning a form. Each service user and unpaid carer who participates as a co-researcher will be offered a refund of any travel expenses for in-person meetings. £50 per person will also be available to support any other costs involved and as a thank you for taking part. This will be provided in two halves, £25 as data collection begins, and £25 after the final meeting provided as shopping vouchers or via bank transfer. Service and co-production leads and members of staff will not be offered expenses or payments. 3.4. The PAR process Table 4 outlines the seven steps from the recruitment of the case studies to the final co-researcher meeting. Table 4 Seven steps of PAR within each case study Step Step name Description Time commitment per co-researcher (hours) 1 Recruitment Potential participant organisations are sent the information sheet and express their interest in participating. A selection process takes place. Consents signed and returned within two weeks. 0.5 2 Initial meeting An online meeting is held to discuss the organisation’s co-production progress and processes. Selection/invitation methods of further co-researchers (known service users, carers and members of staff) are decided. 1 3 Further recruitment Potential co-researchers are sent the information sheet by the service and co-production leads. Individuals will need to make contact and meet with the researcher to discuss suitability. Consents are signed and returned within two weeks. 1 4 Second meeting All co-researchers (service/co-production leads, service users, carers, staff and researcher) meet at the organisation's premises or online to discuss communication preferences, group agreement, roles, methods, actions, and plan further meetings. 2 5 Data collection Over six months information will be gathered (as decided by the group), transcribed and themed by the researcher. For example, the researcher interviews co-researchers, focus groups, collate existing documentation, observe co-production in action. 0–3 6 Monthly meetings All co-researchers discuss progress, processes, share experiences, methods, and reflect on research questions. Meetings may include data collection, and meeting discussions form data collection. 6 7 Final meeting The researcher meets with all co-researchers after data collection and analysis are complete to get input into the case study write-up and multi-case analysis. 2 Meetings will be conducted online using Microsoft Teams or in person at the services premises. Online meetings will be audio and visually recorded and transcribed using the Microsoft Teams software. In-person meetings will be audio recorded and transcribed using the Microsoft Word online software. These files will be automatically saved and stored using Microsoft OneDrive. All Microsoft software used for the meetings and storage is encrypted. The researcher will complete the transcription and change the names of the participants (pseudonymise) as soon as possible and within two months, after which the recordings will be deleted. The transcriptions will be retained until the completion of the PhD study (estimated to be January 2025). 3.5. Analysis Co-researcher meeting notes, transcripts and other data collection will be thematically analysed within each case study by the researcher. The researcher will thematically analyse the cases together to produce a multi-case analysis. Within each case, data collection and analysis phases happen simultaneously. New findings and outcomes will be developed and tested with the co-researchers during meetings. There will be comparisons until data saturation occurs, if possible. The analyses will identify and explore the patterns, themes and stories (Koch and Kralik 2006 ). There will be a final meeting with the co-researchers to gain insights and resonance with the findings and gain their input into the case study write-up and multi-case analysis (Stake 2006 ). Using the knowledge built in each case and collectively, the researcher will create comparisons and interpretations to produce overall findings representing the co-production within the ICS. The findings will be displayed in written form and using imagery/graphs if appropriate. After data collection, the researcher will perform the analysis, present the findings from case studies together, and form a discussion building on context from existing theory. These findings will be shared widely using the networks of the ICS, the CAG members, reports, online publications, and within the PhD thesis. There is an aim to publish within a peer-reviewed journal and conference presentation. The findings will contribute to the next stage of the PhD research: the co-production of guidance for ICSs to support processes of co-production. All participants will have the opportunity to be part of this next stage. 3.6. Information confidentiality, security and storage All data collected from participants will remain confidential, and discussions in the co-researcher group meetings will be bound by a confidentiality agreement of the group. Electronic data will be stored and encrypted electronically only accessed by the researcher on one laptop. This laptop is password protected with the necessary anti-virus protections and access to technical support. All files containing personal identifiable information of participants and the recordings of data collection will be stored and accessed solely on encrypted Microsoft web-services namely OneDrive, Teams, and Outlook. Participating organisations will not be required to collect, use or store participant data for the study. All data will be collected and stored electronically with the exception of any document that includes both participant name and their study ID (for example the pseudonymisation key) which will be stored in a locked cabinet which will only be accessed by the researcher, and destroyed at end of the study. Any paper consent forms received will be transferred to electronic format and the paper copy destroyed immediately. Participants' names, contact details, accessibility requirements, details of an emergency contact and any emergency medical information they wish to provide will be the only personal information requested for the purpose of the case studies and will be stored separately to pseudonymised data. All data collected will be transcribed and stored by the researcher. Data such as transcripts of meetings and the co-production documents will be pseudonymised within two months of collection and then destroyed immediately. The data will be destroyed on completion of the PhD, estimated to be by January 2025. 3.7. Risks, mitigations and ethical considerations PAR alleviates study risks due to the co-researchers working together to shape the research process and decision-making regarding data collection. The process is designed to support already ongoing co-production processes. Risks and burdens within this study include time capacity, power imbalances, researcher bias and pace of the process which are summarised below. Mitigations have also been planned for (see Table 5 ). Time capacity: Service and co-production leads and members of staff participating may be undertaking co-production as an 'add on' to their everyday role. For service users and unpaid carers, participation in the research may be a commitment on top of the co-production activities they are part of within the organisation, as well as any health or caring-related constraints that they face. Power imbalance: The environment in which co-production conversations take place should be a safe space in which individuals can share their opinions. However, people can have conflicting views which cause debate, and at times there can seem to be a power imbalance, particularly if this happens between a service user/carer and a professional. Researcher bias: The researcher will become a co-researcher alongside the participants. There is a risk of subjectivity in data collection and the interpretation of findings. There will be difficulty building relationships as equals with the study group members whilst also acting as researcher, and there is risk of the study’s rigour upon publication. Pace: Co-production in health and care practice benefits from honest, open and transparent conversations. The PAR process may allow for discussion about decisions relating to the service co-production process at a faster or more detailed rate than may have happened without participating in the case study. This may make the organisation and co-researchers feel uneasy. Table 5 Study risk mitigations Risks Planned mitigations Time capacity • A minimum commitment for co-researchers after recruitment is one-hour meeting per month. Other data collection is optional for co-researchers to perform. • The research methodology, by design, ensures it is beneficial to the organisation, the progress of existing co-production plans, and each co-researcher individually. Power imbalances • The researcher is experienced in the co-production approach and facilitation. The group will follow six locally co-produced principles of co-production. • The co-researchers of each case study will create a group agreement and terms of reference. For example: - jargon will be avoided - the group will communicate using plain and simple language, - the environment in which co-production conversations take place is considered a safe space for individuals to share. • The researcher and service/co-production leads will ensure that information and the process as a whole are in accessible formats for each member’s individual needs. Researcher bias • Varying the role and influence of the researcher in the group during data collection, and challenging assumptions that are made in group discussions. • The researcher will keep a reflective journal and make notes on any possible bias, power sharing, group dynamics and perceived ‘insider’ or ‘outsider’ identity. • The researcher will examine their positionality personally and professionally. This process will both aid the data analysis and improve the awareness of subjectivity and objectivity. Pace • The researcher will work with the service and co-production leads of each case study closely to discuss how influential they feel research can and should be in their existing process, addressing this in the initial meeting. • This risk has been described as a ‘sliding scale’ by members of the CAG. This will be assessed on a case-by-case basis and may change over the course of the process. • The co-researcher group agreement and terms of reference which will include the pace and influence of the study on the existing co-production process in practice. 3.8. Ethical considerations The study received a favourable ethical opinion from the researcher’s university, the South East Scotland NHS Research Ethics Committee and the Health Research Authority. The university holds indemnity cover against any injury or damage sustained by a participant in this study. Principles of the General Data Protection Regulations 2018 will be followed with respect to data storage, processing, and destruction. The following arrangements are in place to prevent ethical dilemmas during the PAR process (see summary in Fig. 1 ). The nature of PAR empowers participants to be involved in all decision-making, data collection methods and discussion agendas. Co-researchers will together support the researcher to design, manage, undertake, analyse and disseminate the findings of the research. The ethos and approach of co-production have a commitment to equality and diversity (Social Care Institute for Excellence 2022 ). The recruitment and facilitation will be guided by locally co-produced principles of co-production. At the first meeting, the service/co-production leads and the researcher will discuss and draft a risk assessment template. This will consider equality, diversity, and inclusion, covering the risk of discrimination and exclusion, the roles and responsibilities of all stakeholders in the process, and monitoring. The assessment will be reviewed throughout the research process. Participants can withdraw at any time; however, they will understand and consent to the data collected from them in group discussions, up until that point, may still be used in the study. The co-researcher meetings will be bound by terms of reference and confidentiality agreement of the group, although, confidentiality may be broken if safeguarding concerns arise. If participants speak about harming themselves or others and/or speak about poor care being delivered, a referral to a support organisation and/or safeguarding referral may be made on their behalf (a support information leaflet is available to all participants). Although personal information and data collected by the researcher will be kept confidential, pseudonymised and secure, and the co-researchers will create their group agreement, complete anonymity and confidentially will be a challenge to maintain. This is because in-depth discussions about an ongoing project will take place within a group setting over a period of time and group members may unintentionally share identifiable details in relation to the study progress. Information sheets and consent forms reflect this. When describing details of the case studies within analysis and publication, consideration will be taken when combining incidental details about individuals. Identification is likely to only be possible to those directly related to that particular case study, every effort will be made to remove identifying context and details. The researcher will provide information sheets in plain English and easy-read formats. Other formats or languages will be provided where required, in consideration with service/co-production leads and the resources for the study, to ensure service users, carers and staff can consent and participate fully. 3.9. Researcher bias The researcher will, through the research process, discover the underpinning theoretical perspective of a multi-case study and PAR. The researcher will keep a reflective journal and make notes on any possible bias, power sharing, group dynamics and perceived ‘insider’ or ‘outsider’ identity, examining the researcher's position within the research (Chavez 2008 ; Hamdan 2009 ). This process will aid the data analysis and improve the awareness of subjectivity and objectivity throughout. Reflexivity is an important part of PAR, as the researcher becomes both the researched and the researcher simultaneously (Stake 1995 ; Baum et al. 2006 ). The researcher will examine their positionality personally and professionally, as well as support the co-researchers to understand and document their positionality as part of the study if they wish. The consideration of the ontology and epistemology behind the research processes will aid the data analysis, improve the awareness of subjectivity and objectivity within each case study context, promote validity, and the aim of transferability of the findings. 4. Discussion The multi-case analysis, performed as part of the PAR process with the co-researchers, will form the study’s interpretive findings. Existing published study findings and theories within the field of integrated care service design and transformation, including PAR and case studies, will be comparatively drawn upon to enhance the evidence in the field to support working practice. 5. Conclusion This multi-case study, taking place over the year 2023, is a unique study combining multi-case study and PAR methodologies to explore the impact of co-production on the design and transformation of integrated care services. Set within one ICS in England, the study has the potential to explore design and transformation operations involving service users, unpaid carers and members of staff of differing integrated care contexts within one system. The multi-case analysis aims to explore; facilitators and barriers of co-production within integrated care, how systems use co-production for design and transformation, and recommendations for co-production within integrated care. Findings will be driven and interpreted from the lenses of those participating, who have lived experience of integrated care system working practice. Abbreviations CAG - Co-production Advisory Group ICS - Integrated Care System NHS - National Health Service PAR - Participatory Action Research PhD - Doctor of Philosophy Statements And Declarations The author has no competing funding, employment or financial interests to declare. This study will form the requirements for PhD research. The PhD was funded through the Ipswich and East Clinical Commissioning Group through the Integrated Care Academy and is independent of this study. Acknowledgements Acknowledgement to the six members of the research Co-production Advisory Group (patient and public involvement) who guided each aspect of the study protocol. This study forms a PhD research project of the author, supervised by Dr Paul Driscoll-Evans, Dr Rachel Heathershaw (University of Suffolk) and Professor Karen Windle (University of Bradford). References Adelman, C.: Kurt Lewin and the Origins of Action Research, Educational Action Research. Educ. Action Res. 1:1 , 7–24 (1993). https://doi.org/10.1080/0965079930010102 Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., et al.: Coproduction of healthcare service. BMJ Qual. Saf. 25 , 509–517 (2016). http://dx.doi.org/10.1136/bmjqs-2015-004315 Baum, F., MacDougall, C., Smith, D.: Participatory action research. J. Epidemiol. Community Health. 60 (10), 854–857 (2006). https://doi.org/10.1136/jech.2004.028662 Boyle, D., Harris, M.: The Challenge of Co-production. (2009). https://media.nesta.org.uk/documents/the_challenge_of_co-production.pdf Accessed 20 March 2023 Charles, A.: Integrated care systems explained: making sense of systems, places and neighbourhoods. The King’s Fund. https://www.kingsfund.org.uk/publications/integrated-care-systems-explained Accessed: 20 March (2023) Chavez, C.: Conceptualizing from the inside: Advantages, complications, and demands on insider positionality. Qual. Rep. 13 (3), 474–494 (2008). https://doi.org/10.46743/2160-3715/2008.1589 Conquer, S., Bacon, L.: The value of co-production within health and social care: A literature review.Healthwatch Suffolk. (2021). Accessed 20 March 2023 Creswell, J.W.: Qualitative inquiry and research design: Choosing among five approaches. Sage, Thousand Oaks, CA (2013) Farr, M., Davies, R., Davies, P., Bagnall, D., Brangan, E., Andrews, H.: A map of resources for co-producing research in health and social care. National Institute for Health Research (NIHR) ARC West and People in Health West of England. University of Bristol and University of West of England. Version 1.1 https:// (2020). arc-w.nihr.ac.uk/Wordpress/wp-content/uploads/2020/02/Map-of-resources-Web-version-v1.1.pdf Accessed 19 March 2023 Fox, C., Smith, A., Traynor, P., Harrison, J.: Co-creation and Co-production in the United Kingdom - A rapid evidence assessment. Policy Evaluation and Research Unit Manchester, Metropolitan University. (2018). https://mmuperu.co.uk/wp-content/uploads/2020/09/Co-Creation_and_Co-Production_in_the_United_Kingdom_-_A_Rapid_Evidence_Assessment_-_March_2018.pdf Accessed 19 March 2023 Freire, P.: Pedagogy of the oppressed. The Continuum International Publishing Group Inc, New York (2005) Gustafsson, J.: Single case studies vs. multiple case studies: A comparative study. (2017). https://www.diva-portal.org/smash/get/diva2: 1064378/FULLTEXT01.pdf%20(10 (2017) Accessed 20 March 2023 Ham, C., Curry, N.: Integrated care: What is it? Does it work? What does it mean for the NHS? The King’s Fund. (2011). https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/integrated-care-summary-chris-ham-sep11.pdf Accessed 20 March 2023 Hamdan, A.K.: Reflexivity of discomfort in insider–outsider educational research. McGill J. Educ. 44 (3), 377–404 (2009). https://doi.org/10.7202/039946ar Health and Care Act:. (2022). https://www.legislation.gov.uk/ukpga/2022/31/contents/enacted Accessed 19 March 2023 Henderson, D.: Consciousness raising in participatory research: method and methodology for emancipatory nursing inquiry. Adv. Nurs. Sci. 17 (3), 58–69 (1995). https://doi.org/10.1097/00012272-199503000-00007 Kaehne, A., Beacham, A., Feather, J.: Co-production in integrated health and social care programmes: a pragmatic model. J. Integr. Care. 26 (1), 87–96 (2018). https://doi.org/10.1108/JICA-11-2017-0044 Kjellström, S., Areskoug-Josefsson, K., Andersson Gäre, B.: Exploring, measuring and enhancing the coproduction of health and well-being at the national, regional and local levels through comparative case studies in Sweden and England: the ‘Samskapa’ research programme protocol. BMJ Open. (2019). https://doi.org/10.1136/bmjopen-2019-029723 Koch, T., Kralik, D.: Participatory Action Research in Health Care. Blackwell Publishing, Oxford (2006) Kodner, D.L., Spreeuwenberg, C.: Integrated care: meaning, logic, applications, and implications – a discussion paper. Int J Integr Care. 14; 2(4) (2002). https://doi.org/10.1111/1468-0009.00125 Leutz, W.N.: Five Laws for Integrating Medical and Social Services: Lessons from the United States and the United Kingdom. Milbank Q. 77 (1), 77–110 (1999). https://doi.org/10.1111/1468-0009.00125 Lewin, K.: Action Research and Minority Problems. In: Lewin, G.W. (ed.) Resolving Social Conflicts, Selected Papers on Group Dynamic, pp. 143–152. American Psychological Association, Washington DC (1946) Lincoln, Y.S., Guba, E.G.: The Constructivist Credo. Left Coast Press, Walnut Creek, CA (2013) Lowe, D., Ryan, R., Schonfeld, L., Merner, B., Walsh, L., Graham-Wisener, L., Hill, S.: ‘Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation’,Cochrane Database of Systematic Reviews. 9 (2021) Marshall, K., Bamber, H.: Using co-production in the implementation of community integrated care: a scoping review. Prim. Health Care. 32 (4), 36–42 (2022). https://doi.org/https://doi.org/10.7748/phc.2022.e1753 Needham, C., Carr, S.: Co-production: an emerging evidence base for adult social care transformation. SCIE Research briefing 31. (2009). https://www.scie.org.uk/publications/briefings/briefing31/ Accessed 19 March 2023 NHS England:. : What is Integrated Care? (2021). https://www.england.nhs.uk/integratedcare/what-is-integrated-care / Accessed 20 March 2023 NHS England:. : Working in partnership with people and communities: Statutory guidance. (2022). https://www.england.nhs.uk/long-read/working-in-partnership-with-people-and-communities-statutory-guidance/ Accessed 20 March 2023 O’Brien, B.C., Harris, I.B., Beckman, T.J., Reed, D.A., Cook, D.A.: Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad. Med. 89 (9), 1245–1251 (2014). https://doi.org/10.1097/ACM.0000000000000388 Palumbo, R.: Contextualizing co-production of health care: a systematic literature review. Int. J. Public. Sect. Manag. 29 (1), 72–90 (2016). https://doi.org/https://doi.org/10.1108/IJPSM-07-2015-0125 Patel, P.: Solving the puzzle. Delivering on the promise of integration in health and care. Institute for Public Policy Research. (2021). https://www.ippr.org/research/publications/solving-the-integration-puzzle Accessed 20 March 2023 Patrício, L., Sangiorgi, D., Mahr, D., Čaić, M., Kalantari, S., Sundar, S.: Leveraging service design for healthcare transformation: toward people-centred, integrated, and technology-enabled healthcare systems. J. Serv. Manag. 31 (5), 889–909 (2020). https://doi.org/10.1108/JOSM-11-2019-0332 Realpe, A., Wallace, L.M.: What is co-production? The Health Foundation Inspiring Improvement. (2017). https://qi.elft.nhs.uk/wp-content/uploads/2017/01/what_is_co-production.pdf] Accessed 20 March 2023 Reason, P., Bradbury, H.: Handbook of Action Research: participatory Inquiry and Practice. Sage Publications, London (2001) Social Care Institute for Excellence:. Co-production: what it is and how to do it. (2022). https://www.scie.org.uk/co-production/what-how Accessed 19 March 2023 Stake, R.E.: The art of case study research. Sage Publications, Thousand Oaks, CA (1995) Stake, R.E.: Multiple Case Study Analysis. The Guilford Press, New York (2006) Yin, R.K.: Case Study Research and Applications: Design and Methods, 6th edn. Sage, Thousand Oaks, CA (2018) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2795837","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":190886494,"identity":"77b7840d-ae2f-40a8-8cf3-3c0b180556d2","order_by":0,"name":"Susan Conquer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBAC+QbmBxAWewNMjA2/FoMDbAYQFs8BYrUw8AhAWBIJxGthfFxQdljOfOYbw4c/GOzkGSTSEvBqkW/gYTaece6wscztHGNjHoZkwwaJtAN4tTAc4GGT5m07nDhDOsdMmoGBOYFBIr2BKC31MyTPmEn+YKgnSosYSEuChASPmQQPw2GgFgIOMzjMBvTCuXTDGTxpxcY8BscN23ieJeDVIt/e/PAxT5m1vAT74Y0Pf1RUy/OzpxngdxgziIDHhAHBWIEBIpWNglEwCkbBCAUAtjI3Z/2WBpAAAAAASUVORK5CYII=","orcid":"","institution":"University of Suffolk","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Susan","middleName":"","lastName":"Conquer","suffix":""}],"badges":[],"createdAt":"2023-04-09 17:59:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2795837/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2795837/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":35715833,"identity":"4dafb602-fd8d-4324-a8df-527999cc5307","added_by":"auto","created_at":"2023-04-13 14:28:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48388,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of the arrangements in place to maintain an ethical study\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-2795837/v1/073f161d0d3b4533820c0e67.png"},{"id":35971924,"identity":"d17a7aeb-eff7-4ab8-99ba-81014aa582bd","added_by":"auto","created_at":"2023-04-19 02:29:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":485898,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2795837/v1/446035eb-9f7b-4001-a3e6-7fd24a21e5ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-production within integrated care: a study protocol for multi-case study using Participatory Action Research within an Integrated Care System in England","fulltext":[{"header":"Lay-summary","content":"\u003cp\u003eThis study explores ongoing co-production within integrated care across one Integrated Care System (ICS) in England.\u003cbr\u003eCo-production is people working together to improve health and care services. It is a process whereby people, including service users and/or unpaid carers, become actively involved and influence decisions. Integrated care is when health and care services work together to coordinate and collaborate to better meet the needs of service users (patients and their carers).\u003cbr\u003eICSs are partnerships that bring together National Health Service (NHS) organisations, local councils, the voluntary sector and others to work together to improve health and reduce inequalities. In England, ICSs became statutory on July 1st 2022 upon the introduction of the Health and Care Act 2022. ICSs will include members of staff, citizens, service users and carers to improve services by using co-production as a way to more actively involve people in decisions and design processes.\u003cbr\u003eThis study will explore the co-production processes within three case studies over six months. This study will use a multi-case study and participatory action research (PAR) methodology. PAR means the participants will become \u0026lsquo;co-researchers\u0026rsquo; working together with the researcher. Each case study will aim to recruit six co-researchers; two service /co-production leads, three service users /carers, and one member of staff.\u003cbr\u003eAfter six months of co-researcher meetings and data collection, the researcher will perform a multi-case analysis, presenting and publishing the findings collectively. The findings will contribute to the co-production of guidance for ICSs to support people to co-produce service changes and improvements.\u003c/p\u003e"},{"header":"1. Background","content":"\u003cp\u003eThe context of this study is set in the changes of England\u0026rsquo;s health and care legislation, the formation and formalisation of ICSs. The Health and Care Act (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) enacted ICSs as legal entities with statutory powers and responsibilities. ICSs have two components; integrated care boards: statutory bodies responsible for planning and funding most NHS services in the area, and integrated care partnerships: statutory committees bringing system partners (e.g. local authorities, the voluntary and community sectors, NHS organisations) to develop a health and care strategy for the area (Charles 2022). These integrative system restructures will be including service users, patients, carers and citizens to improve service design, quality and accountability and will be assessed on whether they improve patient and service user outcomes (Patel \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). There is a statutory requirement to view geographical areas holistically (Health and Care Act \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), in partnership with residents and communities (NHS England \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The study is set within the context of one ICS in England.\u003c/p\u003e \u003cp\u003eCo-production moves culture and practice away from more traditional and less person-centred methods of \u0026lsquo;doing to\u0026rsquo; people, towards a \u0026lsquo;doing with\u0026rsquo; in the context of public service provision (Batalden et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Within health and care, it has been developed from the concepts and practice of the personalisation of care (Fox et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). On an individual level, being involved in co-productive programmes has been seen to improve health, wellbeing and recovery from long-term conditions (Boyle et al. 2006; Palumbo \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), diminish health inequalities (Marshall and Bamber \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), empower operational healthcare staff (Needham and Carr \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), and improve the service user-service provider relationship (Realpe and Wallace \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). However, there is a lack of tangible evidence about co-production within integrated health and care, a review (Lowe et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) that compares health services\u0026rsquo; planning, delivery and evaluation when consumers and professionals work in partnership, find that no studies investigate the extent that changes to health services have reflected service users\u0026rsquo; priorities. Questions remain regarding the contexts in which co-production within integrated care is successful, the influence that co-production has on the wider health and care system, the operation, evolution, evaluation, learning and recommendations from co-production in practice (Conquer and Bacon \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A pragmatic model of co-production for integrated care allows organisations to be flexible in their approach but more evidence is needed for what effective co-production entails within different contexts (Kaehne et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to contribute to the depth of understanding of the approach of co-production within integrated health and care and minimise gaps in research by collecting and interpreting information, discussing, and reflecting upon how co-production impacts integrated care services within an important legislative change. This study aims to explore if co-production can be an approach to service integration within an ICS context, ensuring design and transformation processes are made alongside the population for whom they are intended, by focusing on local context and the use of co-production. The multi-case study design will be itself co-produced and will focus on design and transformation of services from the perspective of the service leads, co-production leads, service users, unpaid carers and staff involved. The study will use of the Standards for Reporting Qualitative Research (O\u0026rsquo;Brien et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThis research will use a combination of case study and PAR methodologies. As we move through the process the overarching theoretical framework will be understood and developed. Although there are a number of methodological paradigms the study may move through during\u0026nbsp;data collection and analysis, this study may fit within a relativist ontology (Stake 1995) and constructivist epistemology (Lincoln and Guba 2013).\u0026nbsp;The PAR approach is an attempt to\u0026nbsp;democratise\u0026nbsp;research giving it potential to be transformational, addressing common issues relating to hierarchy and power-sharing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCase studies explore real-life cases over time through detailed data collection involving multiple sources of information (Creswell 2013).\u0026nbsp;Multi-case studies have the benefits of\u0026nbsp;creating convincing theories,\u0026nbsp;understanding the differences and similarities between the cases (Gustafsson 2017), and the ability to\u0026nbsp;analyse\u0026nbsp;data within each situation and across different situations (Yin 2018). Case studies use a variety of methods, whilst PAR allows the participants to use the most appropriate methods of data collection for the context (Koch and Kralik 2006). Using mixed methods through PAR\u0026nbsp;and a multi-case study has the potential to enhance the transferability of the study findings across contexts. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAction research is a collaborative, democratic, process concerned with developing practical knowledge (Lewin 1946; Adelman 1993). It brings together action and reflection to deliver practical solutions (Reason and Bradbury 2001). As an interactive research approach, PAR encourages joint learning and decision-making between the participants and the researcher throughout the process (Kjellstr\u0026ouml;m et al. 2019). Koch and Kralik (2006) outline the five characteristics of PAR:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eInvolves participation by the people involved in the research at all stages of the process, a partnership between the researcher and participants.\u003c/li\u003e\n \u003cli\u003eTheory is generated from the experiences and understandings of participants which can create opportunities for change and lead to wider-scale social transformation.\u003c/li\u003e\n \u003cli\u003eFocuses on empowerment, seeks to take action to address inequity in the researcher-participant relationship.\u003c/li\u003e\n \u003cli\u003eEducative for researchers and participants, together generating data and becoming committed learners together.\u003c/li\u003e\n \u003cli\u003eAims to create social change, to affect the lives of those who participate.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFarr et al. (2020) state that co-production builds upon PAR, as the research leads to action and beneficial outcomes for people involved, often those who have the least power in decision-making. PAR has been linked with feminist and emancipatory theory of \u0026lsquo;consciousness raising\u0026rsquo; (Henderson 1995), enabling people to view the world in a different way based on the knowledge gained through participating.\u0026nbsp;This study aims to eliminate the hierarchy between the different roles of co-researchers within each case study (service leads, service users/carers, members of staff, and the researcher) by creating a prepared space for honest and reciprocal dialogue (Freire 2005) and reflexivity on the part of the co-researchers and researcher.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Patient and Public Involvement (PPI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Co-production Advisory Group (CAG) of six members equally representing service users, unpaid carers and members of staff who provide and draw upon services in one ICS has supported the understanding and choice of methodologies and methods for this study. The group meet with the researcher every three months with communication and tasks between meetings. PAR methodology was selected following group discussions and suggestions from members. Members have designed and agreed on the research questions, case study materials including the participation information sheets, easy-read formats, recruitment materials, and a case study selection process. The group will deliberate on the decisions about which three case studies will be selected. Meetings and communication will continue with the group throughout the case studies. During the data collection and analysis, the researcher will draw guidance from the CAG to gain their reflection on the process and resonance of the developing findings.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003ePAR allows the co-researchers to select the most appropriate methods to inform their case study. The co-researcher meeting discussions will be a consistent data collection method across the case studies. Research questions have been developed to focus each case study and the multi-case analysis (see Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The co-researchers will explore the most suitable methods to answer the questions iteratively. Within each case, four foci will steer the PAR process as outlined by Koch and Kralik (\u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). As data collection and analysis are taking place in each case study, the researcher will be guided by research questions for a multi-case analysis. As well as being guided by the co-researchers and CAG members, the multi-case analysis will consider methods of thematic coding, drawing upon reflexive journals, triangulation, and cross-case analysis techniques (Stake \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eResearch questions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMulti-case study overarching research question\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWhat is the impact of co-production on the design and transformation of integrated health and care services?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase study guide research questions and focus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhat is happening here?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGathering information, defining and describing the situation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhy are things as they are?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExploring, analysing, interpreting and explaining\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow can we do things differently?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActing on the information and changing behaviours for improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHow will we know things have changed?\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEvaluating\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMulti-case study guide research questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWhat enables co-production within integrated care, and what are the barriers?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHow can integrated care systems use co-production to impact the design and transformation of services?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWhat are the recommendations and solutions for the co-production of integrated health and care services?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003e3.1. Recruitment\u003c/h2\u003e\n \u003cp\u003eHealth and care organisations employing a co-production process within their service design and/or transformation will be invited to become cases to study and take part in the multi-case study. Three cases representing across all geographical areas of the ICS will aim to be sought. Organisations will be identified through existing networks of the ICS of which the researcher and CAG members are aware. Written invitations will be sent in the form of emails and online newsletters. Attached to this will be an invitation poster, detailed visual summary and participation information sheet. Following this, if suitable cases have not been sought, the researcher and CAG members will disseminate within their networks and contacts.\u003c/p\u003e\n \u003cp\u003eWithin the participant information sheet, there is a link to an online survey for organisation representatives to submit an expression of interest. The researcher and CAG will use a selection pro-forma to ensure potential case studies are suitable for the purpose of the study and multi-case analysis to ensure a variety of service types, provisions and geography across the three cases. A decision will be made within two weeks of the expression of interest. Organisations taking part will view the Organisation Information Documents and perform appropriate internal ethical approval processes.\u003c/p\u003e\n \u003cp\u003eOnce an organisation has been recruited and the study has been approved by that organisation, an initial meeting will be held between the service and co-production leads and the researcher. The remaining service user, carer and member of staff co-researcher participants will then be recruited. Potential cohorts of participants will be identified by the organisation. Organisational representatives will use existing records of service users, unpaid carers and members of staff who are involved in their co-production processes. They will already have consent to contact these individuals. The service and co-production leads will send potential participants the cover letter summary, invitation poster and participation information sheet. Additional consent from these individuals to become participant co-researchers will need to be gained via the researcher directly, so potential participants will be asked to express interest with the researcher directly by email or telephone. Participating organisations will not be required to collect, use or store participant data for the study. Written consent will be gained by email or post. Easy-read formats of the participation information sheet and consent form have been produced.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec6\"\u003e\n \u003ch2\u003e3.2. Inclusion and exclusion criteria\u003c/h2\u003e\n \u003cp\u003eThe inclusion criteria for organisations and co-researchers participating in the case study are based upon the agreed concept definitions for the research, as agreed with the CAG (see Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The inclusion and exclusion criteria for organisations and participants of the case studies are detailed in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudy concept definitions as agreed with the CAG\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eConcept\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDefinition\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCo-production\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA process whereby people, including service users and/or unpaid carers, become actively involved and influence the decisions that design and transform health and care services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeople\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStakeholders (citizens, service users, patients, unpaid carers or representatives of organisations) who are part of, or impacted in any way by, the decisions made.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntegrated care systems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDefined and coordinated networks of partnerships and associations between organisations providing services that meet people\u0026rsquo;s health and care needs across a geographical area (adapted from NHS England, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eService user\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnpaid carer\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMember of staff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA person who is, or has experience of, using and/or requiring access to health and/or care services.\u003c/p\u003e\n \u003cp\u003eA person, usually a family member or friend, who takes a role in the care of a service user without payment for their time and expertise.\u003c/p\u003e\n \u003cp\u003eA person who has a paid or voluntary job role, representing any organisation within an integrated care system, to provide health and/or care services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth and care services\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIntegrated care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProvisions available to service users provided or commissioned by statutory organisations, charity and other third sector providers. Health provides clinical services, whilst care provides longer-term, preventative and educational services, supportive of independence. Some services provide aspects of both (adapted from Leutz, \u003cspan class=\"CitationRef\"\u003e1999\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eWhen health and care services work together to coordinate and collaborate for service users to receive more efficient and effective provision for their health and care needs. This may take place between providers operating at the same level (horizontal integration) and between providers at different levels (vertical integration) (adapted from Kodner and Spreeuwenberg, \u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e, and Ham and Curry, \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTransformation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDesign and transformation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe act of developing new service processes within an integrated care system.\u003c/p\u003e\n \u003cp\u003eThe implementation and outcome of that change.\u003c/p\u003e\n \u003cp\u003eService design can contribute toward transformation by providing a person-centred, holistic and iterative approach to the creation of new services. Service users, unpaid carers and members of staff are actively engaged in transformation processes through participatory design approaches (adapted from Patricio et al., 2020).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudy inclusion and exclusion criteria\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOrganisation\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInclusion\u003c/p\u003e\n \u003cp\u003e\u0026bull; There is an existing ongoing approach and process of co-production within an integrated health and care service within the ICS.\u003c/p\u003e\n \u003cp\u003e\u0026bull; For the existing co-production, consent for the involvement of, and communication with, service users, carers and members of staff have been gained.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExclusion\u003c/p\u003e\n \u003cp\u003e\u0026bull; An integrated care organisation or service\u0026apos;s co-production which is defined by the organisation differently to the research\u0026apos;s definitions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase study representation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026bull; Case studies spanning the ICS will be sought, representing the geographical area.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Ensuring a variety of service types, provisions and geography across the cases.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant co-researchers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInclusion\u003c/p\u003e\n \u003cp\u003e\u0026bull; Currently involved in a process of co-production with the organisation/service taking part in the case study.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Service leads and co-production leads are members of staff who play an active role in the organisation\u0026rsquo;s co-production.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExclusion\u003c/p\u003e\n \u003cp\u003e\u0026bull; Children under 18 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSingle case-study co-researcher group make up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSix participants plus the researcher:\u003c/p\u003e\n \u003cp\u003e\u0026bull; 2 x service/co-production leads\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3 x service users/carers involved in the co-production\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1 x member of staff involved in the co-production\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1 x researcher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe co-researcher sample size provides each case study with an equal number of professional and service user participants, to ensure equal representation and equity within co-researcher meetings. Whilst always based on this principle, the actual sample size may change by one or two members as required and appropriate in each case study. The number of six participants in each study will allow in-depth group discussions where each participant can elaborate and be heard in decision-making. Co-researchers will be arranging group meetings and a smaller number will allow these to be organised with more ease than a larger number.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003e3.3. Accessibility\u003c/h2\u003e\n \u003cp\u003eEasy-read formats of the participation information sheet and consent form have been produced. The accessibility and communication requirements of the service users, unpaid carers and members of staff being invited may be known by the service and co-production leads. For example, if a carer they work with in co-production requires large print and a language other than English, all recruitment materials will be provided to them in a suitable format. This information will be obtained in the initial meeting with the researcher. Otherwise, the general cover letter summary, invitation poster, participation information sheet, and consent form will be provided in plain English and easy read. Reasonable adjustments will be made throughout the process, with consideration to the study time and budget restraints. The researcher will require participants to share their communication and accessibility requirements by returning a form.\u003c/p\u003e\n \u003cp\u003eEach service user and unpaid carer who participates as a co-researcher will be offered a refund of any travel expenses for in-person meetings. \u0026pound;50 per person will also be available to support any other costs involved and as a thank you for taking part. This will be provided in two halves, \u0026pound;25 as data collection begins, and \u0026pound;25 after the final meeting provided as shopping vouchers or via bank transfer. Service and co-production leads and members of staff will not be offered expenses or payments.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003e3.4. The PAR process\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e outlines the seven steps from the recruitment of the case studies to the final co-researcher meeting.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSeven steps of PAR within each case study\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStep\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStep name\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime commitment per\u003c/p\u003e\n \u003cp\u003eco-researcher (hours)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecruitment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePotential participant organisations are sent the information sheet and express their interest in participating. A selection process takes place. Consents signed and returned within two weeks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInitial meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAn online meeting is held to discuss the organisation\u0026rsquo;s co-production progress and processes. Selection/invitation methods of further co-researchers (known service users, carers and members of staff) are decided.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFurther recruitment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePotential co-researchers are sent the information sheet by the service and co-production leads. Individuals will need to make contact and meet with the researcher to discuss suitability. Consents are signed and returned within two weeks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecond meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll co-researchers (service/co-production leads, service users, carers, staff and researcher) meet at the organisation\u0026apos;s premises or online to discuss communication preferences, group agreement, roles, methods, actions, and plan further meetings.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eData collection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOver six months information will be gathered (as decided by the group), transcribed and themed by the researcher. For example, the researcher interviews co-researchers, focus groups, collate existing documentation, observe\u003c/p\u003e\n \u003cp\u003eco-production in action.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMonthly meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll co-researchers discuss progress, processes, share experiences, methods, and reflect on research questions. Meetings may include data collection, and meeting discussions form data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe researcher meets with all co-researchers after data collection and analysis are complete to get input into the case study write-up and multi-case analysis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eMeetings will be conducted online using Microsoft Teams or in person at the services premises. Online meetings will be audio and visually recorded and transcribed using the Microsoft Teams software. In-person meetings will be audio recorded and transcribed using the Microsoft Word online software. These files will be automatically saved and stored using Microsoft OneDrive. All Microsoft software used for the meetings and storage is encrypted. The researcher will complete the transcription and change the names of the participants (pseudonymise) as soon as possible and within two months, after which the recordings will be deleted. The transcriptions will be retained until the completion of the PhD study (estimated to be January 2025).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003e3.5. Analysis\u003c/h2\u003e\n \u003cp\u003eCo-researcher meeting notes, transcripts and other data collection will be thematically analysed within each case study by the researcher. The researcher will thematically analyse the cases together to produce a multi-case analysis. Within each case, data collection and analysis phases happen simultaneously. New findings and outcomes will be developed and tested with the co-researchers during meetings. There will be comparisons until data saturation occurs, if possible. The analyses will identify and explore the patterns, themes and stories (Koch and Kralik \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). There will be a final meeting with the co-researchers to gain insights and resonance with the findings and gain their input into the case study write-up and multi-case analysis (Stake \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). Using the knowledge built in each case and collectively, the researcher will create comparisons and interpretations to produce overall findings representing the co-production within the ICS. The findings will be displayed in written form and using imagery/graphs if appropriate.\u003c/p\u003e\n \u003cp\u003eAfter data collection, the researcher will perform the analysis, present the findings from case studies together, and form a discussion building on context from existing theory. These findings will be shared widely using the networks of the ICS, the CAG members, reports, online publications, and within the PhD thesis. There is an aim to publish within a peer-reviewed journal and conference presentation. The findings will contribute to the next stage of the PhD research: the co-production of guidance for ICSs to support processes of co-production. All participants will have the opportunity to be part of this next stage.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003e3.6. Information confidentiality, security and storage\u003c/h2\u003e\n \u003cp\u003eAll data collected from participants will remain confidential, and discussions in the co-researcher group meetings will be bound by a confidentiality agreement of the group. Electronic data will be stored and encrypted electronically only accessed by the researcher on one laptop. This laptop is password protected with the necessary anti-virus protections and access to technical support. All files containing personal identifiable information of participants and the recordings of data collection will be stored and accessed solely on encrypted Microsoft web-services namely OneDrive, Teams, and Outlook. Participating organisations will not be required to collect, use or store participant data for the study.\u003c/p\u003e\n \u003cp\u003eAll data will be collected and stored electronically with the exception of any document that includes both participant name and their study ID (for example the pseudonymisation key) which will be stored in a locked cabinet which will only be accessed by the researcher, and destroyed at end of the study. Any paper consent forms received will be transferred to electronic format and the paper copy destroyed immediately.\u003c/p\u003e\n \u003cp\u003eParticipants\u0026apos; names, contact details, accessibility requirements, details of an emergency contact and any emergency medical information they wish to provide will be the only personal information requested for the purpose of the case studies and will be stored separately to pseudonymised data. All data collected will be transcribed and stored by the researcher. Data such as transcripts of meetings and the co-production documents will be pseudonymised within two months of collection and then destroyed immediately. The data will be destroyed on completion of the PhD, estimated to be by January 2025.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003e3.7. Risks, mitigations and ethical considerations\u003c/h2\u003e\n \u003cp\u003ePAR alleviates study risks due to the co-researchers working together to shape the research process and decision-making regarding data collection. The process is designed to support already ongoing co-production processes. Risks and burdens within this study include time capacity, power imbalances, researcher bias and pace of the process which are summarised below. Mitigations have also been planned for (see Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eTime capacity: Service and co-production leads and members of staff participating may be undertaking co-production as an \u0026apos;add on\u0026apos; to their everyday role. For service users and unpaid carers, participation in the research may be a commitment on top of the co-production activities they are part of within the organisation, as well as any health or caring-related constraints that they face.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePower imbalance: The environment in which co-production conversations take place should be a safe space in which individuals can share their opinions. However, people can have conflicting views which cause debate, and at times there can seem to be a power imbalance, particularly if this happens between a service user/carer and a professional.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eResearcher bias: The researcher will become a co-researcher alongside the participants. There is a risk of subjectivity in data collection and the interpretation of findings. There will be difficulty building relationships as equals with the study group members whilst also acting as researcher, and there is risk of the study\u0026rsquo;s rigour upon publication.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePace: Co-production in health and care practice benefits from honest, open and transparent conversations. The PAR process may allow for discussion about decisions relating to the service co-production process at a faster or more detailed rate than may have happened without participating in the case study. This may make the organisation and co-researchers feel uneasy.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab5\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStudy risk mitigations\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRisks\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePlanned mitigations\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; A minimum commitment for co-researchers after recruitment is one-hour meeting per month. Other data collection is optional for co-researchers to perform.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The research methodology, by design, ensures it is beneficial to the organisation, the progress of existing co-production plans, and each co-researcher individually.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePower imbalances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; The researcher is experienced in the co-production approach and facilitation. The group will follow six locally co-produced principles of co-production.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The co-researchers of each case study will create a group agreement and terms of reference. For example:\u003c/p\u003e\n \u003cp\u003e- jargon will be avoided\u003c/p\u003e\n \u003cp\u003e- the group will communicate using plain and simple language,\u003c/p\u003e\n \u003cp\u003e- the environment in which co-production conversations take place is considered a safe space for individuals to share.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The researcher and service/co-production leads will ensure that information and the process as a whole are in accessible formats for each member\u0026rsquo;s individual needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResearcher bias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Varying the role and influence of the researcher in the group during data collection, and challenging assumptions that are made in group discussions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The researcher will keep a reflective journal and make notes on any possible bias, power sharing, group dynamics and perceived \u0026lsquo;insider\u0026rsquo; or \u0026lsquo;outsider\u0026rsquo; identity.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The researcher will examine their positionality personally and professionally. This process will both aid the data analysis and improve the awareness of subjectivity and objectivity.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; The researcher will work with the service and co-production leads of each case study closely to discuss how influential they feel research can and should be in their existing process, addressing this in the initial meeting.\u003c/p\u003e\n \u003cp\u003e\u0026bull; This risk has been described as a \u0026lsquo;sliding scale\u0026rsquo; by members of the CAG. This will be assessed on a case-by-case basis and may change over the course of the process.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The co-researcher group agreement and terms of reference which will include the pace and influence of the study on the existing co-production process in practice.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003e3.8. Ethical considerations\u003c/h2\u003e\n \u003cp\u003eThe study received a favourable ethical opinion from the researcher\u0026rsquo;s university, the South East Scotland NHS Research Ethics Committee and the Health Research Authority. The university holds indemnity cover against any injury or damage sustained by a participant in this study. Principles of the General Data Protection Regulations 2018 will be followed with respect to data storage, processing, and destruction.\u003c/p\u003e\n \u003cp\u003eThe following arrangements are in place to prevent ethical dilemmas during the PAR process (see summary in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The nature of PAR empowers participants to be involved in all decision-making, data collection methods and discussion agendas. Co-researchers will together support the researcher to design, manage, undertake, analyse and disseminate the findings of the research. The ethos and approach of co-production have a commitment to equality and diversity (Social Care Institute for Excellence \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). The recruitment and facilitation will be guided by locally co-produced principles of co-production. At the first meeting, the service/co-production leads and the researcher will discuss and draft a risk assessment template. This will consider equality, diversity, and inclusion, covering the risk of discrimination and exclusion, the roles and responsibilities of all stakeholders in the process, and monitoring. The assessment will be reviewed throughout the research process. Participants can withdraw at any time; however, they will understand and consent to the data collected from them in group discussions, up until that point, may still be used in the study. The co-researcher meetings will be bound by terms of reference and confidentiality agreement of the group, although, confidentiality may be broken if safeguarding concerns arise. If participants speak about harming themselves or others and/or speak about poor care being delivered, a referral to a support organisation and/or safeguarding referral may be made on their behalf (a support information leaflet is available to all participants). Although personal information and data collected by the researcher will be kept confidential, pseudonymised and secure, and the co-researchers will create their group agreement, complete anonymity and confidentially will be a challenge to maintain. This is because in-depth discussions about an ongoing project will take place within a group setting over a period of time and group members may unintentionally share identifiable details in relation to the study progress. Information sheets and consent forms reflect this. When describing details of the case studies within analysis and publication, consideration will be taken when combining incidental details about individuals. Identification is likely to only be possible to those directly related to that particular case study, every effort will be made to remove identifying context and details. The researcher will provide information sheets in plain English and easy-read formats. Other formats or languages will be provided where required, in consideration with service/co-production leads and the resources for the study, to ensure service users, carers and staff can consent and participate fully.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003e3.9. Researcher bias\u003c/h2\u003e\n \u003cp\u003eThe researcher will, through the research process, discover the underpinning theoretical perspective of a multi-case study and PAR. The researcher will keep a reflective journal and make notes on any possible bias, power sharing, group dynamics and perceived \u0026lsquo;insider\u0026rsquo; or \u0026lsquo;outsider\u0026rsquo; identity, examining the researcher\u0026apos;s position within the research (Chavez \u003cspan class=\"CitationRef\"\u003e2008\u003c/span\u003e; Hamdan \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e). This process will aid the data analysis and improve the awareness of subjectivity and objectivity throughout. Reflexivity is an important part of PAR, as the researcher becomes both the researched and the researcher simultaneously (Stake \u003cspan class=\"CitationRef\"\u003e1995\u003c/span\u003e; Baum et al. \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). The researcher will examine their positionality personally and professionally, as well as support the co-researchers to understand and document their positionality as part of the study if they wish. The consideration of the ontology and epistemology behind the research processes will aid the data analysis, improve the awareness of subjectivity and objectivity within each case study context, promote validity, and the aim of transferability of the findings.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe multi-case analysis, performed as part of the PAR process with the co-researchers, will form the study\u0026rsquo;s interpretive findings. Existing published study findings and theories within the field of integrated care service design and transformation, including PAR and case studies, will be comparatively drawn upon to enhance the evidence in the field to support working practice.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e This multi-case study, taking place over the year 2023, is a unique study combining multi-case study and PAR methodologies to explore the impact of co-production on the design and transformation of integrated care services. Set within one ICS in England, the study has the potential to explore design and transformation operations involving service users, unpaid carers and members of staff of differing integrated care contexts within one system. The multi-case analysis aims to explore; facilitators and barriers of co-production within integrated care, how systems use co-production for design and transformation, and recommendations for co-production within integrated care. Findings will be driven and interpreted from the lenses of those participating, who have lived experience of integrated care system working practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCAG - Co-production Advisory Group\u0026nbsp;\u003cbr\u003eICS - Integrated Care System\u003cbr\u003e\u0026nbsp;NHS - National Health Service\u003cbr\u003e\u0026nbsp;PAR - Participatory Action Research\u003cbr\u003e\u0026nbsp;PhD - Doctor of Philosophy\u003c/p\u003e"},{"header":"Statements And Declarations","content":"\u003cp\u003eThe author has no competing funding, employment or financial interests to declare. This study will form the requirements for PhD research. The PhD was funded through the Ipswich and East Clinical Commissioning Group through the Integrated Care Academy and is independent of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcknowledgement to the six members of the research Co-production Advisory Group (patient and public involvement) who guided each aspect of the study protocol. This study forms a PhD research project of the author, supervised by Dr Paul Driscoll-Evans, Dr Rachel Heathershaw (University of Suffolk) and Professor Karen Windle (University of Bradford).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdelman, C.: Kurt Lewin and the Origins of Action Research, Educational Action Research. Educ. Action Res. \u003cb\u003e1:1\u003c/b\u003e, 7\u0026ndash;24 (1993). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/0965079930010102\u003c/span\u003e\u003cspan address=\"10.1080/0965079930010102\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., et al.: Coproduction of healthcare service. BMJ Qual. Saf. \u003cb\u003e25\u003c/b\u003e, 509\u0026ndash;517 (2016). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1136/bmjqs-2015-004315\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2015-004315\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaum, F., MacDougall, C., Smith, D.: Participatory action research. J. Epidemiol. 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The King\u0026rsquo;s Fund. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kingsfund.org.uk/publications/integrated-care-systems-explained\u003c/span\u003e\u003cspan address=\"https://www.kingsfund.org.uk/publications/integrated-care-systems-explained\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAccessed: 20 March (2023)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChavez, C.: Conceptualizing from the inside: Advantages, complications, and demands on insider positionality. Qual. 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Health Care. \u003cb\u003e32\u003c/b\u003e(4), 36\u0026ndash;42 (2022). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.7748/phc.2022.e1753\u003c/span\u003e\u003cspan address=\"10.7748/phc.2022.e1753\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeedham, C., Carr, S.: Co-production: an emerging evidence base for adult social care transformation. SCIE Research briefing 31. (2009). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scie.org.uk/publications/briefings/briefing31/\u003c/span\u003e\u003cspan address=\"https://www.scie.org.uk/publications/briefings/briefing31/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 19 March 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS England:. : What is Integrated Care? 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Med. \u003cb\u003e89\u003c/b\u003e(9), 1245\u0026ndash;1251 (2014). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ACM.0000000000000388\u003c/span\u003e\u003cspan address=\"10.1097/ACM.0000000000000388\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalumbo, R.: Contextualizing co-production of health care: a systematic literature review. Int. J. Public. Sect. Manag. \u003cb\u003e29\u003c/b\u003e(1), 72\u0026ndash;90 (2016). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1108/IJPSM-07-2015-0125\u003c/span\u003e\u003cspan address=\"10.1108/IJPSM-07-2015-0125\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel, P.: Solving the puzzle. Delivering on the promise of integration in health and care. Institute for Public Policy Research. (2021). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ippr.org/research/publications/solving-the-integration-puzzle\u003c/span\u003e\u003cspan address=\"https://www.ippr.org/research/publications/solving-the-integration-puzzle\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 20 March 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatr\u0026iacute;cio, L., Sangiorgi, D., Mahr, D., Čaić, M., Kalantari, S., Sundar, S.: Leveraging service design for healthcare transformation: toward people-centred, integrated, and technology-enabled healthcare systems. J. Serv. Manag. \u003cb\u003e31\u003c/b\u003e(5), 889\u0026ndash;909 (2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/JOSM-11-2019-0332\u003c/span\u003e\u003cspan address=\"10.1108/JOSM-11-2019-0332\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRealpe, A., Wallace, L.M.: What is co-production? The Health Foundation Inspiring Improvement. (2017). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://qi.elft.nhs.uk/wp-content/uploads/2017/01/what_is_co-production.pdf]\u003c/span\u003e\u003cspan address=\"https://qi.elft.nhs.uk/wp-content/uploads/2017/01/what_is_co-production.pdf]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 20 March 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReason, P., Bradbury, H.: Handbook of Action Research: participatory Inquiry and Practice. Sage Publications, London (2001)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSocial Care Institute for Excellence:. Co-production: what it is and how to do it. (2022). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scie.org.uk/co-production/what-how\u003c/span\u003e\u003cspan address=\"https://www.scie.org.uk/co-production/what-how\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 19 March 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStake, R.E.: The art of case study research. Sage Publications, Thousand Oaks, CA (1995)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStake, R.E.: Multiple Case Study Analysis. The Guilford Press, New York (2006)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYin, R.K.: Case Study Research and Applications: Design and Methods, 6th edn. Sage, Thousand Oaks, CA (2018)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"co-production, integrated health and care, integrated care system, case study, multi-case study, participatory action research","lastPublishedDoi":"10.21203/rs.3.rs-2795837/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2795837/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nGlobally, integrated health and care services are encouraged to work in collaboration with people who draw on their lived experience of health and care; co-producing change. Integrated Care Systems in England are recent structures, mandated in 2022, required to involve their service users, carers and citizens in strategic planning, service development, implementation and improvement. This multi-case study will use participatory action research to explore the impact of co-production on the design and transformation of services within integrated care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCase studies of different examples of ongoing co-production within one Integrated Care System will be conducted simultaneously. Participatory action research will allow the researcher to partner with the participants as co-researchers, frame the research questions, and tailor the mixed methods. Co-researcher groups within each case study will consist of service leads, co-production project leads, service users, unpaid family carers, members of staff, and the researcher. Group meeting transcripts, co-researcher reflections, and other case study data collected will be continuously analysed and compared, developing a multi-case analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe knowledge built in each case will allow for interpretations of the data. The findings will contribute to the development of co-produced guidance for Integrated Care Systems. The co-researchers may be enabled to use the knowledge built during the case study as learning for their practice of co-production. The multi-case study findings will be submitted to a peer-reviewed international journal, and for conference presentation.\u003c/p\u003e","manuscriptTitle":"Co-production within integrated care: a study protocol for multi-case study using Participatory Action Research within an Integrated Care System in England","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-13 14:28:48","doi":"10.21203/rs.3.rs-2795837/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb28808c-9236-4e58-9a31-deeee133244b","owner":[],"postedDate":"April 13th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-04-19T02:29:24+00:00","versionOfRecord":[],"versionCreatedAt":"2023-04-13 14:28:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2795837","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2795837","identity":"rs-2795837","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}