'A limpet on a ship': Spatio‐temporal dynamics of patient and public involvement in research

Abstract Objective To understand how current funding expectations that applied health research is undertaken in partnership with research institutions, health service providers and other stakeholders may impact on patient and public involvement (PPI). Background While there is considerable research on the potential impact of PPI in health research, the processes of embedding PPI in research teams remain understudied. We draw on anthropological research on meetings as sites of production and reproduction of institutional cultures and external contexts to investigate how these functions of meetings may affect the potential contributions of patients, carers and the public in research. Methods We present an ethnography of meetings that draws from a larger set of case studies of PPI in applied health research settings. The study draws on ethnographic observations, interviews with team members, analysis of documents and a presentation of preliminary findings through which feedback from informants was gathered. Results We identified four means by which the oversight meetings regulated research and constrained the possibilities for PPI: a logic of ‘deliverables’ and imagined interlocutors, the performance of inclusion, positioning PPI in an ‘elsewhere’ of research, and the use of meetings to embed apprenticeship for junior researchers. Conclusions PPI is essentially out of sync from the institutional logic of ‘deliverables’ constituting research partnerships. Embedding PPI in research requires challenging this logic.

it's like a jigsaw and you've got a missing piece, you haven't got the whole picture …' (Quotation 1, Interviewee E, Quality improvement manager, italics added) 1 Patient and public involvement (PPI) in health research positions patients and members of the public as actors undertaking or contributing to research rather than simply as its recipients or beneficiaries. 2 Yet, while there is considerable literature on PPI in research and quality improvement, 3-6 as well as on how different modalities of collaboration organize knowledge production, [7][8][9] little explicit attention has been paid to how the choreography and performance of collaborative research affects how PPI in particular is imagined and practised. 10, 11 Thompson, and subsequently Vermeulen, have deployed the term 'choreography' to demonstrate and understand how aspects of the world commonly thought to belong to 'different ontological orders' come together. 12,13 We use choreography to think through how collaborative projects involving PPI attempt to hold together different ways of doing research and envisaging expertise. They bring together heterogeneous people, infrastructures and technologies (such as meetings and minutes); the manner in which they do so -the kinds of sequences and spatial dynamics that unfold -end up centring certain people and priorities at the same time as pushing others to the margins. Understanding such temporal and spatial processes is particularly important at a moment in which PPI is being consolidated within highly regulated and governed collaborative settings, such as funded health research, beholden to numerous stakeholders and conditioned by tight timelines. 14 How PPI is practised -how choreographies unfold -may differ starkly from how PPI is commonly imagined by various stakeholders.
For example, we have been struck by how frequently the figure of the jigsaw puzzle appears in descriptions of research involving PPI.
Here, people with lived experience comprise the 'missing piece', which promises access to an epistemological and ontological 'whole picture'. In the first example, above, drawn from an interview with a clinical academic from the study discussed in this paper, health research is presented as a collaborative practice in which all kinds of expertise smoothly join together: knowledge from 'lived experience' sits snugly alongside statistical reasoning and clinical trial bureaucracy. Such an imaginary conjures a harmonious choreography -one where all actors have a part and move forward together. But this is not the imaginary that materialized through the ethnography we present here. In this paper, we depart from the figure of the jigsaw puzzle to arrive at the alternative figure of the 'limpet on the ship'.
In so doing, we address the disjuncture between common spatial and temporal imaginaries of PPI within research and practices of collaborative research which position PPI spatially and temporally out of synch with other parts of the research endeavour. 15 In our ethnographic analysis of meetings overseeing interlinked applied health research projects, we are concerned both with how those participating in PPI conceive of PPI and with how the logics that govern collaborative health research -logics that unfold through establishing an order that governs what needs to happen, when and in relation to whom -end up shaping practices of PPI. We explore how research involving PPI ends up framing where PPI belongs and how this has a significant effect on the epistemic contributions that PPI representatives (the term we use throughout) are able to make.
Data are drawn from a larger, comparative ethnographic study which investigated PPI in different applied health research projects, funded through a regionally awarded infrastructure grant from the UK's National Institute for Health Research (NIHR). Infrastructure grants provide a five-year funding cycle for research where the emphasis is on the development of partnerships between regional and national stakeholders -including NHS Trusts, local government, commissioners, industry, charities and service users and the public.
While PPI in research is now mandatory for NIHR and other major UK funders, its role is particularly important in the case of infrastructure grants, whose very objective is the development of sustainable collaborations. While all research environments are collaborative, in infrastructure grants, partnership is not a means to an end but rather it itself is the end, or outcome. Therefore, our examination of how PPI is enacted in these grants also opens up broader questions concerning the staging and performance of collaboration within applied health research, especially in an environment increasingly driven by consumerist, managerial and performance-focused logics, accountability requirements and practices. 16,17

| MEE TING S A S A SO CIAL FORM
Team meetings are indispensable elements of collaborative scientific and health research, and, in addition, the steering committee or advisory group remains arguably the most common site for PPI. 18 However, the dynamics of meetings and their role in embedding PPI remain understudied. While qualitative studies of PPI routinely include observations of meetings, 19 it is often interviews, and their retrospective discussion of meetings, which take centre stage. When studies do focus on meetings themselves, they often consider these as sites for decision making and borrow approaches from management studies and organizational psychology, which seek to optimize meeting effectiveness, transparency and accountability and explore barriers to equitable participation. 20 O'Shea and colleagues' ethnography takes a more sociological approach, considering how lay input to an NHS Clinical Commissioning Group was constrained by social and professional stratifications which defined the parameters of control over decision making. 21 Komporozos-Athanasiou and colleagues' ethnographic research uncovers the 'powerful ritual structures' of meetings that 'serve to legitimate policy-endorsed PPI aims and neutralize divergence from those aims'. 11 Martin and Finn, in-debted to the sociology of team work, consider meetings as sites of 'habitual immersion' through which 'team members' become acculturated to institutional culture which works to reproduce dominant power relations. 10  The approach to meetings we take here, while drawing on these literatures, is particularly indebted to Helen B. Schwartzman, whose foundational anthropological work has been extended by other anthropologists of meetings. 23

| S E T TING AND ME THODS
This paper discusses one aspect of a broader ethnography of PPI on a project we call Health in Mind (HiM) (a feasibility randomized controlled trial of a psychosocial intervention designed to encourage people with a psychiatric diagnosis to improve their physical health).
The case study involved the first author, SP, undertaking extensive

| FINDING S
We first summarize the general character of the meetings so that readers can orient themselves in relation to four overarching themes that comprise our findings: (i) the spatio-temporal logic of deliverables; (ii) maintaining the appearance of inclusion; (iii) installing PPI as a constitutive 'elsewhere'; and (iv) acculturating junior researchers: meetings as sites of apprenticeship.
The observed meetings were monthly, lasting 60-90 minutes.
Their stated purpose was to provide oversight on a workstream of inter-related, small-scale projects. These were of varying design and sought to align university-led research to local NHS Trust priorities and directives: integrating physical and mental health care and supporting mental health service users in managing physical health.
The oversight consisted in monitoring progress and advising on potential challenges to the running of studies. Initially, meetings were small, consisting in two senior clinical academics with roles in the partnered NHS Trust, who were lead investigators, and two early/ mid-career researchers on fixed-term contracts. After six months, meetings broadened to include the leads and research workers of five additional projects incorporated in the workstream, as well as an administrator. Yet, they remained small in-house affairs, typically involving approximately 8 people working in adjacent university buildings, although trust managers and clinicians were occasionally invited. Two PPI representatives, a service user and a carer, were invited to join the meetings at an early stage and on a quarterly basis (after mutual agreement concerning their availability). The two had an on-going relationship with the senior staff, familiarity with research processes, a declared interest in physical health management and had been specifically invited to provide advice and oversight on HiM. However, since in effect these meetings provided joint oversight, the representatives engaged with all eight projects.

| Conjuring absent interlocutors
Since the meetings' purpose was to ensure projects ran successfully to completion, meetings were constituted as a site for rehearsing responses to the demands of conjured interlocutors -that is, actors who were absent, but whose responses had to be anticipated

| Distancing oneself from conjured others
Researchers often performed a distancing from, or enacted a gentle mockery of, the demands placed upon them by various powerful agents. One senior clinician routinely baulked at the grant acronym, stating that the purpose and inner workings of the grant, and therefore funder intentions, were somewhat mystifying, a statement with which the assembled more junior researchers jokingly concurred.
Statements such as these performed impotence in relation to powerful, and absent, partners (eg funder, clinical directors) and served to create complicity between PPI representatives and other team members as both lacking executive authority and having a partial perspective rather than the imagined 'bird's-eye view' of the authoritative other. Furthermore, researchers often declared frustration over requirements for internal reports which, it was implied, detracted from the business at hand, that is, team projects. However, this distancing disavowed that the business at hand in all meetings, regardless of the timing of the reports, was in fact conjuring the demands of absent interlocutors, a process enacted through the circulated documents and their structuring of time and team orientation.

| Having a place at the table
Following both representatives' suggestion, a 'PPI item' was included at the end of the agenda from the first meeting and remained there for all meetings, its presence legitimizing the representatives' place at the table even in their absence. Furthermore, the architecture of the meeting, as well as the performances within it, served to cement a logic and rhetoric of inclusion, which indicated meaningful dialogue with PPI representatives. Team members were particularly courteous with them, respectfully listening whenever they spoke.
Notably, since both representatives had existing relationships with team members, meetings acted as opportunities for transactions beyond the scope of the projects: in one meeting, the service user representative was reminded she needed to sign off on a group paper in which she was co-author, while the carer representative was invited to give a talk to a committee another clinician chaired.   [Researcher] also assured the team of her confidence in the design used as the most robust method available.

| The affordance of explanatory scaffolding
(Minutes of team meeting 12.12.2016) The researcher's assurance re-assured: it restored the integrity of the updates' retrospective narrative in which questions of design had already been settled, thus rendering W.'s challenges out of time.
The absence of W.'s further challenges from subsequent minutes reinforced and preserved the temporal logic of projects and agenda alike, proofing it against further disruptions.

| Installing PPI as a constitutive 'elsewhere'
The relationship between the PPI item, the representatives' talk in the meetings, and 'PPI' as something that needed to be part of the studies remained unclear -despite the explanatory scaffolding, extensive transactions with the two representatives, and the on-going presence of the PPI agenda item. In one meeting, SP observed the researchers trying to imagine how potential participants might react to being contacted by their mental health team -without turning to the PPI representatives. During a discussion on how service users use their mobile phones, a senior researcher turned to SP saying 'PPI can help us here' -even as the two representatives were present.
Presumably, this was in the expectation that SP, as a researcher paid to investigate PPI, would suggest possibilities. In those meetings not attended by the representatives, what was referred to as 'doing the PPI' item became an opportunity for ECRs to report back on any PPIrelated activities they may have participated in.
PPI, then, cohered precisely as a site of uncertainty -neither moored to particular aspects of the study nor securely associated with specific interlocutors or actions. At the same time, SP glimpsed a related phenomenon: team members would typically mention to SP that PPI had already taken place in earlier stages (prior to SP's observations) or was planned for a later stage (eg there would be userled evaluations on the feasibility of the physical health intervention; service users had worked with the team to evaluate an intervention on substance misuse). These sites for PPI were either temporally out of sync with the present project or contemporaneous, yet occurring in parts of studies for which SP had no ethics clearance.
After several occurrences of this, SP suspected they had not simply missed PPI by choosing to observe the wrong meetings, but that the location for PPI was a constitutive elsewhere. It was comparable to the 'other research project' which a senior team member had invoked when one representative challenged the premises of the health checklist. This suspicion was given credence by the visualization of PPI in a PowerPoint presentation on the workstream delivered to the grant governing body. One slide was a graph with the linked projects represented as individual columns. A double-headed arrow ran beneath them, separate from the columns and captioned 'PPI'.
The arrow's purpose was to indicate that PPI was present throughout all studies but it was not clear what that presence consisted in.
That lack of specificity in content and location thus manifested the 'everywhere' as nowhere: running across the projects but hard to locate and specify, a constitutive part yet spatially and temporally apart from the rest.

| Acculturating junior researchers: meetings as sites of apprenticeship
In installing the spatial and temporal logics of deliverables -in which PPI was a part, apart -meetings also served to acculturate junior members into organizational cultures. Through practices of steering as course correction, ECRs learned to hone and redirect their energies towards the 'correct' set of imagined interlocutors. In the observed projects, regular reports to both senior clinical academics and PPI representatives testified to ECRs' capacity to broker and mediate partnerships across managers, administrators, IT services and care workers. Initially tasked with the writing of agendas and minutes, R., the ECR managing several projects, had to adjudicate what was recordable and actionable, how a meeting was to be recast as signal and noise, recorded and forgotten. By the end, and as a result of such repeat performances, the ECR had internalized the narrative through which the research project will have been completed according to protocol and the constraints of various regulatory systems. The same ECR also wrote the updates to PPI representatives, their retrospective clarity and abstraction consolidating his identity as one belonging within an institutional space.
This ECR -a strong proponent of PPI -told SP, when interviewed in early months of the project, of his ambitious plans for how involvement could be folded into these studies. With HiM, for example, he discussed a process evaluation to be led by peer researchers, as well as the potential involvement of study participants themselves in a steering committee of a larger study: 'if the project is feasible, we'd like to do a bigger proj- In internalizing these coordinates, the ECR had also inadvertently internalized that constitutive elsewhere in which to locate PPI: it had been relocated to that 'other research project' -an anticipated future which might never arrive. Our research, in concert with existing studies, demonstrates how difficult it is for PPI representatives to make epistemic contributions within committees. But we go further, in arguing that principles commonly thought to optimize such epistemic contributions (eg clear feedback, respect, significant good will), 2,33 or indeed, the ability of PPI representatives to move within professional spaces as engaged actors, 22 might tend, in fact, to detract attention from structural barriers to substantive contributions within the architecture that the meetings themselves install. As Komporozos-Athanasiou and colleagues have argued, attempts to encourage 'active citizen spaces' of PPI allow those citizen participants 'little room for re-writing the rules of participation'. 11 Our findings also problematize current investments in operationalizing such 'active citizen spaces' through measuring instruments which seek to define good PPI practice in terms of levels or standards of participation. One unsettling implication of our study is that attempts to optimize or standardize PPI within health research projects might end up further displacing PPI both spatially and temporally from the very sphere of action where research takes place.

| CON CLUS ION
We contribute to the literature on epistemic politics in PPI 45,47,[52][53][54][55] by arguing that it is only by attending to the spatio-temporal logics through which PPI representatives are embedded within research projects that we can understand the epistemic challenges they face.
We recommend further research on the spatio-temporal logics of meetings to better understand how they might contribute to making PPI essentially supernumerary to the requirements that constitute research -its hull, as it were. We are left with what it might mean to conjure alternative means of choreographing collaborative research involving PPI. Such alternatives would demand ensuring that the potential for PPI to be an active agent within them is not evacuated. 56 Within a logic of deliverables and partners who matter, PPI is constitutively out of sync and out of place. Finding alternatives might mean envisaging ways of breaking apart and remaking the hull.

| LI M ITATI O N S
SP was the sole ethnographer. We attempted to increase validity of our findings through having both authors involved in data interpretation and running a workshop presenting preliminary findings, in which participants reflected back to SP their assessments of PPI in the study, which fed into our interpretations here. SP had further interactions with some researchers in the study, as they were employees of the same institution. These interactions added to the familiarization with and 'thickness' of the data but also potentially created blind-spots, as SP takes this organizational culture for granted in their own working lives. Anthropological studies of meetings often note the ethnographer's own acculturation through meetings can be a limitation but also a productive challenge which can give depth to observations. 57 Finally, we acknowledge our data relate to a particular instantiation of PPI: the PPI representatives had been invited to join a steering committee to consult on projects already in progress when they arrived. However, such late arrivals are the case in many enactments of PPI, while the steering of projects through 'delivering' and 'reporting' in relation to a funder is an integral part of applied health research in general.

| N OTE
We recognize that the term 'PPI representative' can be seen as a problematic choice. There are considerable debates attached to the use of the alternatives -'survivor', 'service user/carer', 'lived experience contributor' and 'lay advisor'. When asked, the two participants had different preferred terms; therefore, 'PPI representative' was used as a compromise.

ACK N OWLED G EM ENTS
SP is grateful for the supervision of Prof Diana Rose during this study. The authors are grateful to Dr Angela Sweeney whose suggestions and careful reading were essential to the final revi- Finally, SP especially wishes to thank R., one of the participants, whose insights, generosity and commitment to their work were invaluable in enabling a richer analysis of the data on which this study is based. This paper is dedicated to them.

CO N FLI C T O F I NTE R E S T
SP declares that while undertaking the study presented here, they had some institutional contact with some of the participants in the study. SP shared a funder and a grant with some of the participants during the study. FC declares no conflict of interest.

PATI E NT O R PU B LI C CO NTR I B UTI O N
Both authors contributed to the writing of the paper. Both authors are service user researchers, and so there was substantial patient involvement in the design, conduct, analysis and interpretation of the study. Additionally, the protocol for the study was presented and discussed at the Exchange Network, a mixed group of patients, carers, researchers and NHS workers set up through the Collaboration for

Leadership in Applied Health Research and Care [CLAHRC] North
West London, in June 2015. Preliminary findings from the study were presented to the team members who are the focus of the ethnography -and who include two PPI representatives (one a patient, the other a carer); their contributions fed back into the interpretation and analysis of findings presented here. Dr Angela Sweeney, a service user academic, read a complete draft of the manuscript and gave extensive comments and feedback.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.