University of Sheffield, School of Health and Related Research (ScHARR), Section of Public Health, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
University of Warwick, Warwick Medical School, Population Evidence and Technologies, University of Warwick, Coventry, CV4 7AL, United Kingdom.
Soc Sci Med. 2017 Aug;186:122-129. doi: 10.1016/j.socscimed.2017.06.011. Epub 2017 Jun 12.
This paper explores how commissioners working in an English local government authority (LA) viewed a health economic decision tool for planning services in relation to diabetes. We conducted 15 interviews and 2 focus groups between July 2015 and February 2016, with commissioners (including public health managers, data analysts and council members). Two overlapping themes were identified explaining the obstacles and enablers of using such a tool in commissioning: a) evidence cultures, and b) system interdependency. The former highlighted the diverse evidence cultures present in the LA with politicians influenced by the 'soft' social care agendas affecting their local population and treating local opinion as evidence, whilst public health managers prioritised the scientific view of evidence informed by research. System interdependency further complicated the decision making process by recognizing interlinking with departments and other disease groups. To achieve legitimacy within the commissioning arena health economic modelling needs to function effectively in a highly politicised environment where decisions are made not only on the basis of research evidence, but on grounds of 'soft' data, personal opinion and intelligence. In this context decisions become politicised, with multiple opinions seeking a voice. The way that such decisions are negotiated and which ones establish authority is of importance. We analyse the data using Larson's (1990) discursive field concept to show how the tool becomes an object of research push and pull likely to be used instrumentally by stakeholders to advance specific agendas, not a means of informing complex decisions. In conclusion, LA decision making is underpinned by a transactional business ethic which is a further potential 'pull' mechanism for the incorporation of health economic modelling in local commissioning.
本文探讨了在英国地方政府机构（LA）工作的专员如何看待用于规划糖尿病服务的健康经济决策工具。我们在 2015 年 7 月至 2016 年 2 月期间进行了 15 次访谈和 2 次焦点小组讨论，受访者包括公共卫生经理、数据分析员和理事会成员。有两个重叠的主题解释了在委托中使用此类工具的障碍和促进因素：a）证据文化，和 b）系统相互依存关系。前者强调了 LA 中存在的不同证据文化，政治家受到影响“软”社会关怀议程影响他们的当地人口，并将当地意见视为证据，而公共卫生经理则优先考虑通过研究提供的科学证据观点。系统相互依存关系通过认识到与部门和其他疾病群体的相互联系，进一步使决策过程复杂化。为了在委托领域获得合法性，健康经济建模需要在高度政治化的环境中有效运作，在这种环境中，决策不仅基于研究证据，还基于“软”数据、个人意见和情报。在这种情况下，决策变得政治化，多种意见寻求发声。谈判这些决策的方式以及哪些决策确立权威非常重要。我们使用 Larson（1990）的话语领域概念分析数据，展示了该工具如何成为研究推动和拉动的对象，很可能被利益相关者用作工具来推进特定的议程，而不是告知复杂决策的手段。总之，LA 的决策是基于交易的商业伦理，这是将健康经济建模纳入地方委托的另一个潜在“拉动”机制。
