Russell Jill, Swinglehurst Deborah, Greenhalgh Trisha
Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK.
BMC Health Serv Res. 2014 Sep 20;14:413. doi: 10.1186/1472-6963-14-413.
In England the National Health Service (NHS) is not allowed to impose 'blanket bans' on treatments, but local commissioners produce lists of 'low value' procedures that they will normally not fund. Breast surgery is one example. However, evidence suggests that some breast surgery is clinically effective, with significant health gain. National guidelines indicate the circumstances under which breast surgery should be made available on the NHS, but there is widespread variation in their implementation.The purpose of this study was to explore the work practices of 'individual funding request' (IFR) panels, as they considered 'one-off' funding requests for breast surgery; examine how the notion of 'value' is dialogically constructed, and how decisions about who is deserving of NHS funding and who is not are accomplished in practice.
We undertook ethnographic exploration of three IFR panels. We extracted all (22) breast surgery cases considered by these panels from our data set and progressively focused on three case discussions, one from each panel, covering the three main breast procedures.We undertook a microanalysis of the talk and texts arising from these cases, within a conceptual framework of interpretive policy analysis.
Through an exploration of the symbolic artefacts (language, objects and acts) that are significant carriers of policy meaning, we identified the ways in which IFR panels create their own 'interpretive communities', within which deliberations about the funding of breast surgery are differently framed, and local decisions come to be justified. In particular, we demonstrated how each decision was contingent on [a] the evaluative accent given to certain words, [b] the work that documentary objects achieve in foregrounding particular concerns, and [c] the act of categorising. Meaning was constructed dialogically through local interaction and broader socio-cultural discourses about breasts and 'cosmetic' surgery.
Despite the appeal of calls to tackle 'unwarranted variation' in access to low priority treatments by ensuring uniformity of local guidelines and policies, our findings suggest that ultimately, given the contingent nature of practice, this is likely to remain an illusory policy goal. Our findings challenge the scientistic thinking underpinning mainstream health policy discourse.
在英国，国民医疗服务体系（NHS）不允许对治疗方法实施“全面禁令”，但地方医疗服务专员会列出他们通常不会资助的“低价值”程序清单。乳房手术就是一个例子。然而，有证据表明，一些乳房手术在临床上是有效的，能带来显著的健康益处。国家指南指出了在何种情况下NHS应提供乳房手术，但在实施过程中存在广泛差异。本研究的目的是探讨“个人资助申请”（IFR）小组的工作实践，因为他们会考虑乳房手术的“一次性”资助申请；研究“价值”概念是如何通过对话构建的，以及在实际操作中，关于谁应获得NHS资助以及谁不应获得资助的决定是如何达成的。
我们对三个IFR小组进行了人种志研究。我们从数据集中提取了这些小组审议的所有（22个）乳房手术案例，并逐步聚焦于三个案例讨论，每个小组一个，涵盖三种主要的乳房手术程序。我们在解释性政策分析的概念框架内，对这些案例中产生的谈话和文本进行了微观分析。
通过探索作为政策意义重要载体的象征性人工制品（语言、物品和行为），我们确定了IFR小组创建自己的“解释性社区”的方式，在这个社区中，关于乳房手术资助的审议有不同的框架，地方决策也因此得到正当化。特别是，我们展示了每个决定如何取决于：[a] 对某些词语赋予的评价性侧重点；[b] 文献资料在突出特定关注点方面所起的作用；[c] 分类行为。意义是通过地方互动以及关于乳房和“整形”手术的更广泛社会文化话语进行对话构建的。
尽管呼吁通过确保地方指南和政策的一致性来解决低优先级治疗获取方面的“不合理差异”很有吸引力，但我们的研究结果表明，最终，鉴于实践的偶然性，这可能仍然是一个虚幻的政策目标。我们的研究结果挑战了主流卫生政策话语背后的科学主义思维。
