Figure 1 - uploaded by Trisha Greenhalgh
Content may be subject to copyright.
Source publication
This chapter describes a study undertaken as part of the UCL Evidence programme to explore how policymakers talk about and reason with evidence. Specifically, researchers were interested in the micro-processes of deliberation and meaning-making practices of a group of people charged with prioritising health care in an NHS Primary Care Trust in the...
Citations
... A constructive view of policy-making is needed, where evidence and action content lead to constructive negotiation. 8 What is needed to inform policy-making is a better understanding of the mechanisms for change from the perspective of all stakeholders-the government, the industry, and individuals. ...
... In the U.K., see Solesbury (2001). See also Russell and Greenhalgh (2011), and Cartwright and Stegenga (2011). 50 See above note 22. 51 Another ladder of abstraction illustrates the point: questions about rationality, reasoning in general (logic in a broad sense), and practical reasoning in general are principally philosophical questions; questions about reasoning in legal contexts, reasoning at all stages of litigation, and reasoning about questions of law in appellate courts are abstract jurisprudential questions that require both philosophical and legal knowledge (including some knowledge of different legal traditions at this level of generality); questions about reasoning in hard cases in common law jurisdictions or in American appellate courts in a specified period or the U.S. Supreme Court in a specified period, down to analysis of the reasoning in a single judicial opinion in the United States or elsewhere, all need significant amounts of local legal knowledge. ...
This is the first of two volumes announcing the emergence of the new legal realism as a field of study. At a time when the legal academy is turning to social science for new approaches, these volumes chart a new course for interdisciplinary research by synthesizing law on the ground, empirical research, and theory. Volume 1 lays the groundwork for this novel and comprehensive approach with an innovative mix of theoretical, historical, pedagogical, and empirical perspectives. Their empirical work covers such wide-ranging topics as the financial crisis, intellectual property battles, the legal disenfranchisement of African-American landowners, and gender and racial prejudice on law school faculties. The methodological blueprint offered here will be essential for anyone interested in the future of law-and-society.
... We had already begun to examine the language that think tanks use in their work, informed by our theoretical interest in rhetoric and argument (Russell and Greenhalgh 2011;Shaw 2010). Interviews allowed us to extend this work, examining the language and arguments that think tank actors employ to account for the work they do. ...
These data extracts are drawn from an interview and a research diary that form part of the data set for a study on the role of think tanks in shaping health policy and planning. Think tanks are civil society organisations that specialise in producing and disseminating knowledge that is relevant to public policy (Medvetz, 2008; Pautz, 2011). These ‘two different stories’ relate to different accounts of the planning process that were present in think tanks’ work: one focusing on the production and use of evidence to feed into policy and the other on political work involving people, values, ideas and interactions in shaping policy. Such stories (or narratives) work to shape policy problems and practices (Yanow, 1996; Rydin and Ockwell, 2005; Hajer, 2006). Identifying and unpacking them (for instance, examining who is involved, and the main arguments in play) proved vital to our analysis and understanding of think tanks’ role in shaping health policy. Our findings revealed how think tanks publicly (‘front-stage’) present a storyline to position themselves as ‘independent research organisations’, drawing on the language of technocratic health planning to define their role as producing evidence and feeding this into policy. This confers legitimacy in the eyes of decision-makers and the public. Away from public view (‘back-stage’), the storyline shifts with think tanks talking about how they link with particular actors and interests (e.g. via private dinners with decision-makers) as they seek to influence health policy and healthcare delivery.
... Deliberative processes are underpinned by the theory that an appropriately informed sample of the population can deliberate productively with a view to offering contributions to policy development that are reflective of broader values. Used productively in other contexts to canvass community and stakeholder perspectives on health-related priority setting [15][16][17], deliberative methods are held to both improve and legitimate policy directives [18]. In the context of disinvestment decisionmaking where, it may be argued, there is a particular imperative for "health services to be accountable to users as taxpayers, voters and consumers" [19], deliberative methods represent a more transparent means of addressing the complex, ethical nature of resource allocation and policymaking. ...
Background
Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain.
Methods
Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis.
Results
Each forum demonstrated stakeholders’ capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around ‘equity’ and ‘patient responsibility’, culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access).
Conclusions
Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder ‘self-interest’ proved unfounded as each group sought to prioritise universal values (in particular, ‘equity’ and ‘responsibility’) over specific, within-group concerns. Our results - from an emotive case study in ART - highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.
... Thirdly, our epistemological perspective took on board mounting evidence from published research findings 13,14 and experiential reports from stakeholders, that local decision-making is as much a social practice of deliberation and judgement, involving tacit knowledge, 'common sense' and 'phronesis' ( practical reasoning), as a technical process of searching for and applying the relevant research evidence and correct ethical principles. For example, at the stakeholder workshop one participant commented that the most difficult aspect of the process was 'recognising the role of judgement -my bugbear is when everyone talks about evidence based practice and [the] reality is with IFRs [individual funding requests] that there isn't much evidence. ...
The NHS Constitution emphasizes patients’ rights to expect these decisions to be made ‘rationally’. The National Prescribing Centre (NPC), now the Medicines and Prescribing Centre at the National Institute for Health and Clinical Excellence, has directed considerable effort in recent years at defining the parameters of rational decisionmaking, and supporting PCTs in improving their approaches to prioritization and resource allocation. The NPC, commissioned by the Department of Health, embarked on a systematic process to develop a national ‘competency framework’ resource for those involved in making difficult prioritization decisions at a local level.This paper reports on how the NPC competency framework was developed, and presents a potentially transferable methodology for advancing a competency framework to support individual and organizational learning and improvement
... Debate around 'the fair and reasonable allocation of resources has become a prominent one in modern day discourses about healthcare' [9]. Health funding decisions, particularly those which relate to some level of reimbursement retraction (more effective redistribution notwithstanding) may carry significant moral implications, be highly contested (by a range of stakeholders) and historically have not been made in an explicit and transparent manner. ...
Governments and other payers are yet to determine optimal processes by which to review the safety, effectiveness, and cost-effectiveness of technologies and procedures that are in active use within health systems, and rescind funding (partially or fully) from those that display poor profiles against these parameters. To further progress a disinvestment agenda, a model is required to support payers in implementing disinvestment in a transparent manner that may withstand challenge from vested interests and concerned citizens. Combining approaches from health technology assessment and deliberative democratic theory, this project seeks to determine if and how wide stakeholder engagement can contribute to improved decision-making processes, wherein the views of both vested and non-vested stakeholders are seen to contribute to informing policy implementation within a disinvestment context.
Systematic reviews pertaining to illustrative case studies were developed and formed the evidence base for discussion. Review findings were presented at a series of deliberative, evidence-informed stakeholder engagements, including partisan (clinicians and consumers) and non-partisan (representative community members) stakeholders. Participants were actively facilitated towards identifying shared and dissenting perspectives regarding public funding policy for each of the case studies and developing their own funding models in response to the evidence presented. Policy advisors will subsequently be invited to evaluate disinvestment options based on the scientific and colloquial evidence presented to them, and to explore the value of this information to their decision-making processes with reference to disinvestment.
Analysis of the varied outputs of the deliberative engagements will contribute to the methodological development around how to best integrate scientific and colloquial evidence for consideration by policy advisors. It may contribute to the legitimization of broad and transparent stakeholder engagement in this context. It is anticipated that decision making will benefit from the knowledge delivered through informed deliberation with engaged stakeholders, and this will be explored through interviews with key decision makers.
... The remit of the Priorities Forum was to make population-level resource allocation decisions, i.e. to decide whether the PCT should stop funding or invest less (or occasionally more) money in an existing service, or shift funding from one form of service provision to another for a particular patient group. Our findings on this aspect of resource allocation have been published elsewhere (Russell & Greenhalgh, 2010;. During this phase of our research IFRs were sometimes discussed by the Forum and emerged as an increasingly significant component of PCT activity, and we obtained funding (2009e2012) to undertake further research, focused on this specific aspect of local rationing practices. ...
Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs) - requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.
... A shift towards stakeholder involvement and deliberation in decision-making has also been identified as a feature of modern health policymaking (Abelson, Giacomini, Lehoux, & Gauvin, 2007), and has served to inform priority-setting decisions (Russell & Greenhalgh, 2009). In line with the contemporary evidence focus, incorporating community and stakeholder perspectives in decision-making processes has been seen as a means of improving and legitimating policy directives (Davies, Wetherell, & Barnett, 2006). ...
... Exactly how clinical evidence and stakeholder perspectives come together to inform policy directives, however, has increasingly been the focus of qualitative research. Informed by an understanding of 'policy as discourse', these studies have shed light on the social processes by which health policy 'problems' and 'evidence-based solutions' are constituted in deliberative contexts (Russell & Greenhalgh, 2009). Rather than seeing deliberative engagement as a means of enhancing a pre-existing (usually clinical) evidence base with additional 'contextual data', studies within this field treat the notion of evidence per se as a contestable domain. ...
... In line with this framework, we take a synthetic approach to the analysis of discourse (Wetherell, 1998), attending to the structure of physicians' accounts (how they are put together rhetorically so as to appear factual, credible, etc) as well as their function (how they serve to position certain kinds or orders of evidence as more or less compelling). This rhetorical, discursive perspective allows an analytic focus on the "language, arguments and discourses through which policy is constructed and enacted, and provides a conceptual framework for linking decision-making to processes of practical reasoning" (Russell & Greenhalgh, 2009). ...
Internationally, there is an increasing focus on quality and sustainability measures oriented to reducing inefficiencies in health provision. The use of assisted reproductive technologies (ART) for older women represents a case study in this area. This paper analyses the constructions of evidence brought to bear by ART physicians in the context of deliberative stakeholder engagements (held 2010) around options for restricting public subsidy of ART in Australia. Physicians participated in two deliberative engagements during which they were presented with results of a systematic review of ART effectiveness, as well as ethical and cost analyses. These sessions were part of a broader research program of engagements held with policymakers, community members and consumers. Physicians deliberated around the data presented with a view to formulating an informed contribution to policy. The ensuing discussions were transcribed and subject to discourse analysis. Physicians questioned the evidence presented on the grounds of 'currency', 'proximity', 'selectivity' and 'bias'. We outline physicians' accounts of what should count as evidence informing ART policy, and how this evidence should be counted. These accounts reflect implicit decisions around both the inclusion of evidence (selection) and the status it is accorded (evaluation). Our analysis suggests that participatory policy processes do not represent the simple task of assessing the quality/effectiveness of a given technology against self-evident criteria. Rather, these processes involve the negotiation of different orders of evidence (empirical, contextual and anecdotal), indicating a need for higher-level discussion around 'what counts and how to count it' when making disinvestment decisions.
Background
Primary care has been described as the ‘bedrock’ of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data.
Methods
We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory.
Results
Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners’ perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with ‘imperfect’ data.
Conclusions
There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government’s ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.
NORSK TIDSSKRIFT FOR LOGOPEDI, 4/2018: Nylig var jeg på konferansen Cultural crossings of care. Siden jeg selv setter stor pris på å lese det kollegaer skriver fra konferanser, så kom jeg på at notatene mine muligens kunne være av interesse for flere enn meg. Derfor et reisebrev. Selv om reisen var mer mental enn egentlig fysisk. Konferansen fant sted i Oslo, altså bare noen mil hjemmefra. Men faglig sett hadde jeg reist langt fra mitt faglige «hjem», logopedien. Eller hadde jeg egentlig det?
