It would appear from the literature review that any interventions aimed at increasing the effectiveness of CCGs need to be focused on increasing RACAP. The ability to transform and exploit knowledge throughout the organisational network, and to implement innovations and recommendations, is a fundamental need for CCGs. Consequently, when considering critical review capacity in health care, there is a need for research into how organisational antecedents affect ACAP, which takes into account organisational context, the role of individuals and groups, and associated power and politics.8,9,12,13
This requires more focus on social mechanisms, as the CCG will need to develop the ability to share and transform information and knowledge to make critical decisions. The difficulties associated with knowledge sharing and transfer cannot be resolved through redesign of governance structure because of the socially embedded nature of tacit knowledge, which is a key element of critical decision-making in social contexts.50
Although existing research into ACAP has engendered deeper understanding of the organisational
conditions that have an impact on organisational knowledge processes, literature in this theoretical domain remains focused on knowledge acquisition, rather than its use,6and there is a lack of detailed understanding
of the antecedent capabilities for enhancing ACAP, and in particular of reducing the variance between PACAP and RACAP.8,11What is clear is that there are antecedents to ACAP, specifically known as
combinative capabilities.10,12As noted previously, health-care organisations represent a distinctive context
compared with private sector R&D contexts, in which much of the empirical work around ACAP has taken place, and, as such, combinative capabilities will influence the four ACAP mechanisms in health-care organisations in a particular way.5Van den Boschet al.11distinguish three types of combinative capabilities
that influence ACAP: socialisation capabilities, system capabilities and co-ordination capabilities. In the following section we discuss these capabilities in the context of CCGs.
Socialisation capabilities
Socialisation capabilities refer to an organisation’s ability to produce a shared ideology and develop a distinct group identity. The social processes associated with this capability are often seen as most influential in the development of ACAP within professional organisations.6,13Health-care organisations
exemplify the professional bureaucracy archetype,51within which professional organisation is likely to
represent a key influence on socialisation capability, limiting ACAP as described in the following paragraphs. External knowledge interacts with strong organisational cultures and structures, so that socialisation capability within health-care organisations restricts the development of ACAP.11Thus, power and status
linked to professional roles are likely to have an impact on health-care organisations’ability to exploit new knowledge.3,33For example, Bertaet al.4note the role of doctors in subverting an organisation’s learning
capacity in relation to the adoption of new clinical guidelines into practice, based on formal evidence. Similarly, Ferlieet al.49note that deeply ingrained organisational structures and social networks within
health-care organisations engender institutionalised epistemic communities of professional practice, which
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exist in silos, relatively decoupled from one another. This may have an impact on socialisation capabilities, as professional training and early career experience may engender a custodial role orientation whereby professionals orientate narrowly towards their peers, rather than across the health-care delivery system.52
This stymies the search for external knowledge that lies outside current ways of thinking among powerful professional groups. The shared culture or ideologies represented by socialisation capabilities enables the transformation and exploitation of new knowledge, but those same cultures may represent a‘mental prison’that limits the potential of absorption of external knowledge, particularly when that knowledge may contradict shared beliefs.10The implication is that employees need to be exposed to diverse
knowledge sources, but transformation and exploitation of this knowledge will be enhanced only when it complements existing knowledge sources.13
Further to this, knowledge is more likely to be transferred and shared within organisations, rather than with external stakeholders, as they have shared experiences in terms of expertise and training in addition to a shared collective identity.12Finally, there is considerable but variable agency for actors to influence
knowledge acquisition, assimilation, transformation and exploitation.4In particular, powerful groups of
actors may influence knowledge absorption processes to achieve their goals.5,10
Systems capabilities
System capabilities refer to formal knowledge exchange mechanisms such as written policies, procedures and manuals that are explicitly designed to facilitate the transfer of codified knowledge.11The primary
virtue of systems capabilities is that they provide a memory for staff handling routine situations in an organisation, with the result that staff can react quickly, increasing the efficiency of knowledge exploitation. For example, within health-care contexts, admissions data or other patient information may be collected and collated in certain ways to comply with the demands of external agencies and legal requirements regarding sharing of data. Such data may (or may not) prove useful for CCGs to monitor trends, such as the local patterns of GP referrals of older people into hospitals, potentially allowing CCGs to distinguish between necessary and avoidable admissions. Alternatively, systems capabilities may take the form of clinical guidelines, such as those set by NICE, or mandatory priority setting by top-down government initiatives, such as the continuing influence of the National Commissioning Board over CCGs. System capabilities such as pre-existing policy in the realm of organisational incentives, legislation and system-level dissemination mechanisms or initiatives, which afford access to external resources and influencers, formalise but narrow knowledge acquisition and assimilation and, at the same time, restrict exploratory learning, innovation and transformation.4
Health-care organisations are subject to New Public Management reform that frames performance through financial incentives and regulation. Encompassed within systems capabilities, such government policy affords access to external resources, and directs and formalises acquisition and assimilation of knowledge. However, it narrows the search for new external knowledge and the scope for processing of that knowledge, as managers in health-care organisations‘gameplay’to ensure compliance with policy requirements around their governance.31,53Pulling in external knowledge within health-care organisations towards quality
improvement appears to be particularly directed towards compliance with government regulation and performance management54in a way that is likely to limit the search and utilisation of external evidence,
limiting the level of ACAP.
Co-ordination capabilities
Co-ordination capabilities refer to lateral forms of communication or structures, such as education and training, job rotation, cross-functional interfaces and distinct liaison roles. In contrast to socialisation and systems capabilities, co-ordination capabilities increase the scope of external knowledge acquired and assimilated, and may also engender greater organisational flexibility regarding subsequent transformation and exploitation of knowledge (subsequently reducing the variance between PACAP and RACAP). Hence, to enhance ACAP, managers might attend to organisational mechanisms associated with co-ordination capability.8,11The aim for organisational managers, in developing co-ordination capabilities, is to establish
ties with external sources of new knowledge (enhancing acquisition and assimilation) and to support this through establishing dense networks of ties within the organisation (enhancing transformation and exploitation).8Thus, organisation managers might seek to enhance‘social integration mechanisms’, such as
boundary-spanning or liaison mechanisms and roles and communities of practice, and seek to decentralise authority and decision-making.2,9,12For example (as discussed inGeneral practitioner involvement), within
CCGs, the increased involvement of GPs within the commissioning structures might act as a co-ordination capability, as doctors have been noted as holding a mediating role in communication (or lack of) across jurisdictional boundaries.4
Co-ordination capabilities could be a mechanism that facilitates mediation between the effects of socialisation and systems capabilities. This is particularly evident in professionalised organisations, as co-ordination capabilities facilitate development and dissemination of internal knowledge, which is commonly tacit, as well as external, codified knowledge.33This enhances ACAP by ensuring that external knowledge is
effectively combined with prior knowledge held by front-line clinicians, informing the commissioning and delivery of health care.