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Mental Health Link - a facilitated programme - aimed to develop systems within primary care and links with specialists to improve care for patients with long-term mental illness. A process evaluation based on Pawson and Tilley's Realistic Evaluation complemented a randomized controlled trial. This article describes the method developed for this 'realistic evaluation', the mechanisms behind the integration of linked specialist workers and discusses practical and theoretical issues arising from the use of the realistic evaluation framework as a way of explaining the results of trials and service development. Retrospective interviews identified the important outcomes and were used to construct 'Context-Mechanism-Outcome' configurations. The 12 case studies represented what had happened. A second-level analysis using analytic induction developed 'middle range theories' designed to be of value to those developing care elsewhere. The intervention was successful in stimulating productive joint working, through case discussions, but often failed to ensure a review of progress.

Background / aims / objectives
'Embedded' approaches to knowledge mobilisation are gaining currency, as health and social care services come under increasing pressure to redesign services now rather than wait for research. One such approach is the 'Researcher-in-Residence' (RiR) model which seeks to co-produce knowledge for action. The aim of this paper is to extend the evidence base regarding mechanisms of impact.


Methods
A two-year mixed-method case study of the experience and impact of two part-time RiRs, embedded within an Integrated Care Organisation to support the implementation of new models of care. Data included the results of an anonymous impact survey sent to 80 key stakeholders, field notes of meetings (n=112), and observations of naturally occurring events (n=68).


Findings
Impacts were identified in relation to use of co-produced evidence, capacity building, changes in ways of working, and to a lesser degree changes in operations or strategy. Impact involved learning which was mediated by three non-linear, non-predictable, positive and negative feedback cycles (expectations, access, learning/ improvement). A mixture of technical skills, personal attributes and behaviours were identified as key to this mediation.


Discussion/conclusion
The RiR model promises a timely, applied and transferable research model that contributes to the development, evaluation and adaptation of innovations that seek to integrate services where the evidence base is weak and uncertain. However, the model is not without challenges. These could be addressed by flexibility of research design and funding, and adequately supporting and developing key attributes of RiRs.

This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.

Medical Research Council guidelines recognise the need to optimise complex interventions prior to full trial through greater understanding of underlying theory and formative process evaluation, yet there are few examples. A realist approach to formative process evaluation makes a unique contribution through a focus on theory formalisation and abstraction. The success of an intervention is dependent on the extent to which it gels or jars with existing provision and can be successfully transferred to new contexts. Interventions with underlying programme theory about how they work, for whom, and under which circumstances will be better able to adapt to work with (rather than against) different services, individuals, and settings. In this methodological article, we describe and illustrate how a realist approach to formative process evaluation develops contextualised intervention theory that can underpin more adaptable and scalable interventions. We discuss challenges and benefits of this approach.

Medical Research Council guidelines recognise the need to optimise complex interventions prior to full trial through greater understanding of underlying theory and formative process evaluation, yet there are few examples. A realist approach to formative process evaluation makes a unique contribution through a focus on theory formalisation and abstraction. The success of an intervention is dependent on the extent to which it gels or jars with existing provision and can be successfully transferred to new contexts. Interventions with underlying programme theory about how they work, for whom, and under which circumstances will be better able to adapt to work with (rather than against) different services, individuals, and settings.In this methodological article, we describe and illustrate how a realist approach to formative process evaluation develops contextualised intervention theory that can underpin more adaptable and scalable interventions. We discuss challenges and benefits of this approach.

Judgemental rationality is infrequently referenced within discussions of Realist Evaluations. Judgemental rationality refers to researchers' capacity to assess which, potential, meanings provide the most credible explanations. In evaluation work, rationale for analysis is provided, though rarely do we see how an evaluator made judgements between competing theories, and which theories were discarded and why. We provide a worked example of the application of judgemental rationality. The Engager intervention offered support to prison leavers with common mental health problems. The data for 24, purposively sampled, participants from the intervention arm of the trial were integrated. Bhaskar's DREIC, a five-step analytical procedure, was used to transfactually theorise and interrogate the inferences made within, and across, cases. The findings demonstrated that the intervention was more effective when practitioners developed an in-depth understanding of the participant. We recommend that intervention developers look for ways to enhance therapeutic competencies and judgemental rationality in practitioner teams.

In this article, we present an exemplar of the initial theory-building phase of theory-driven evaluation for the PARTNERS2 project, a collaborative care intervention for people with experience of psychosis in England. Initial theory-building involved analysis of the literature, interviews with key leaders and focus groups with service users. The initial programme theory was developed from these sources in an iterative process between researchers and stakeholders (service users, practitioners, commissioners) involving four activities: articulation of 442 explanatory statements systematically developed using realist methods; debate and consensus; communication; and interrogation. We refute two criticisms of theory-driven evaluation of complex interventions. We demonstrate how the process of initial theory-building made a meaningful contribution to our complex intervention in five ways. Although time-consuming, it allowed us to develop an internally coherent and well-documented intervention. This study and the lessons learnt provide a detailed resource for other researchers wishing to build theory for theory-driven evaluation.

Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images), relationally (interpersonal interactions are altered), and clinically (patients are unique, some examinations require contact, and clinicians have deeply-held habits, dispositions and norms). Many of these challenges have an under-examined ethical dimension. In this paper, we present a novel framework, Planning and Evaluating Remote Consultation Services (PERCS), built from a literature review and ongoing research. PERCS has 7 domains—the reason for consulting, the patient, the clinical relationship, the home and family, technologies, staff, the healthcare organization, and the wider system—and considers how these domains interact and evolve over time as a complex system. It focuses attention on the organization's digital maturity and digital inclusion efforts. We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards. In contrast, our empirical data reveal that strategic decisions about establishing remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely are fraught with contradictions and tensions—for example, between demand management and patient choice—leading to both large- and small-scale ethical dilemmas for managers, support staff, and clinicians. These dilemmas cannot be resolved by standard operating procedures or algorithms. Rather, they must be managed by attending to here-and-now practicalities and emergent narratives, drawing ...