Decision Making and Policy Setting in Healthcare System

1. Decision Making and Policy Setting in Healthcare System Dr. Shahram Yazdani

2. Definition of evidence-based policy • The advice and decisions of policy makers are based upon the best available evidence from a wide range of sources ; all key stakeholders are involved at an early stage and throughout the policy’s development. All relevant evidence, including that from specialists, is available in an accessible and meaningful form to policy makers.

3. General Consensus • Evidence-based policy is a meaningful concept (to both theorists and practitioners); • Evidence can and should be available to policy-makers, in a timely and appropriate format; • This evidence can be interpreted and used in such a way as to inform policy development; • That policies based on evidence are better than policies which are not based on evidence.

4. Why isn’t policy evidence-based? • Research is not perceived as useful in the real-politic of office life (Davies et al 2000) • Policy-makers are biased against using it (Leicester 2000) • Research is not good quality or accessible to policy-makers (Parry 1999) • Policy-makers prefer to be led by ideology and pragmatism (Brown 2001) • Discrepancies of timing; • The low status of researchers compared to those they are trying to influence; • Different ways of viewing the world (values, language, interests etc.)

5. ‘Enemies of evidence-based policy’ Leicester (1999) • Timing (lacking the luxury of being able to do things thoroughly), • Bureaucratic logic (doing things the way that they have always been done) • Civil service culture (in particular, a strong distrust of information generated from outside the system); • Politics (doing what one can, rather than what is rationally best). • Lack of relevant research • The need to weigh up the relative value of different forms of evidence

6. Difficulties • Evidence-based policy-making strongly predicated on the model of evidence based medicine (Solesbury 2001). • However, there is no easy ‘read across’ from medical research to social research. • This is because social research cannot rely on the gold-standard of the random-controlled trial (RCT); • The possible explanatory variables are much more complicated and the interpretation of the research may always be disputed. • In addition, “agreed criteria for evaluating evidential quality are as far away as ever” (Young et al 2002: 223).

7. Evidence as: • “Expert knowledge; published research; existing statistics; stakeholder consultations; previous policy evaluations; the Internet; outcomes from consultations; costings of policy options; output from economic and statistical modelling.”

8. Policies Public, Administrative, Clinical Impact Evaluation Health Research Operation Monitoring HIS MIS Intrasectoral Governance Intersectoral Leadership Intrasectoral Operations Intersectoral Operations Health Outcomes

9. Evidence Based Policy Making Policies Public, Administrative, Clinical Impact Evaluation Health Research Operation Monitoring HIS MIS Intrasectoral Governance Intersectoral Leadership Intrasectoral Operations Intersectoral Operations Health Outcomes

10. The rational decision model • At a more fundamental level, these narratives about evidence-based policy seems to imply a particular model or theory of policy-making: the rational decision model. • This is because they all imply that if only research were accessible, timely, relevant, comprehensive, reliable and replicable, and if only policy-makers could be converted to using it, then research could be rationally fed into the policy-making process and would make a discernible improvement to policy decisions and outcomes. • Janowitz (1972) describes this relationship between research and policy in the ‘engineering model’, where applied research has a direct and specific influence on policy-making, in that it supplies resources which are then used to solve practical problems.

11. The rational decision model • This model sees policy-making as coherent, scientific, objective, rational, within a controlled climate without interference from outside. In particular, the process obviously takes place within a climate of elegant consensus, in which the problem, objectives and potential policy solutions, even if initially unclear, are shared and agreed.

12. The rational decision model • Shared knowledge is an important creator of this consensus. • Research and information would be vital at several different stages: • Analysis of the problem (to allow objectives to be set), • Analysis of the solutions (to find and analyze the ‘best solution to the problem’) • Analysis of implementation (to follow through and evaluation progress after the policy recommendation has been made).

13. The rational decision model Platt (1972) • …all the work which I have placed within the ‘dominant’ tradition of policy-related research demonstrated faith in a [rather straightforward and] rationalist model of research input to policy, where empirical data can be fed in at appropriate stages to guide the course of policy-making: to document the existing state of affairs, to assess the feasibility of alternative outcomes, and to design the mechanisms for bringing about change.

14. The rational decision model Lane (1993) • This model lacks behavioral realism: “In certain choice situations it may be normatively relevant to policy-makers; however, it fails to offer guidance to the understanding of policy-making characterized by choice situations involving multiple imprecise goals and extensive uncertainty”. • It also does not take into account collective, rather than individual, decision-making. As an idealized model, it is virtually impossible to find examples of decisions which are made in this way.

15. Alternatives‘Science of muddling through’ • One of the earliest challenges to the rational decision model came from Lindblom, who is perhaps most famous for his description of the ‘science of muddling through’ (or incrementalism). • Lindblom describes an irrational and complex model of policy-making, going beyond the actions of individuals and groups. • He suggests that policy-making is when “somehow a complex set of forces together produces effects called ‘policies’ “

16. ‘Garbage-can’ • A similar model is set out by Cohen, March and Olsen (1979), who describe the ‘garbage-can’ model. • Outcomes are separated from the intentions of the actors and no individual actor or group of actors can guide the process through to the desired result. • This is a much more anarchic process, in which decisions are less “made” than “come about”.

17. Mulgan, who suggests that civil servants tend to “muddle through” in order to “get by”. • Parry and Morriss ask ‘When is a decision not a decision?’. • They describe “decisionless decisions” as situations of drift where a series of smaller decisions commits each actor towards a bigger decision which he would not have independently contemplated.

18. Dependence of decision-making on power-bargaining Minogue (1993: 16) • Choices… are made: but they are made through political processes in which groups representing different policy areas bargain, and construct trade-offs; or, alternatively, where some groups, or one group, succeed in imposing their political power (however based) to the extent of winning a larger share of resources than other groups. • Moreover similar competitive struggles take place not only between policy arenas but within specific policy areas. The outcomes of such struggles are not determined by rational techniques of decision-making.

19. Heroic model of policy-making Edwards (2000) • Policy makers are who know what they want and set out to get it without recourse to supporting or opposing evidence... And the nuisance from the researchers’ point of view is that this is a legitimate point of view in a democracy: election legitimizes the weakest and craziest of policy beliefs. They derive from value preferences that can, but need not be, affected by knowledge. • The heroic model is guided by ideological conviction, and the policies are very often intended to be vote-winners.

20. The indirect effect of research • Rein (1976) stated that social science did influence public policy; but the link was rarely consensual, elegant or self-evident. The link is not elegant or self-evident, because the policy- making process is too complex to point to particular pieces of data as ‘leading to’ policy decisions. • The research does in fact find its way into the politico-administrative decision-making process in a “roundabout and murky” way . • “Scientifically generated knowledge constitutes an important, but on the whole unquantifiable part of the enormous store of knowledge which participants in the politico-administrative decision-making process apply to their practical tasks” (1995).

21. Sibeon (1996) • Policy outcomes may to some extent be affected by social science knowledge, but even when this happens, outcomes involve a great deal more than the straightforward application of social science knowledge. • The operation of values, judgments, resource limits, organizational and professional interests, changes in the conditions of action, shifting configurations of power in actor networks, etc, are all factors that combine in complex and sometimes unpredictable ways to influence policy decisions and outcomes.

22. Here, research is part of this complex, pressured and shifting policy process, not merely an input into it (Bulmer 1982).

23. The rational decision model assumes that facts are the most essential arguments in any case, and that decision-making can be made more rational if the facts are clearer. • However, as Parsons argues against positivism, “it is important to note … that there are no ‘facts’ out there. • Data is not neutral, but is the result of an exercise of values, beliefs and assumptions. (Parsons 1995)

24. “The crucial issues in a policy debate are not so much matters of fact as questions of interpretation.” • “Policy analysis is really about persuasion and argument rather than neutral expert advice” (Parsons 1995).

25. Marshall (2001) • Politicians may prefer to ignore evidence in preference for ideological or politically popular choices about ways to tackle problems • “it was a politically motivated decision” • “This is what the government was doing and who cares about research? That’s the government’s attitude.” • “Intuition beats proven causality every time”.

26. Four different models of situations in which groups of policy makers act and use information, • Poker players (where competitive policy makers keep control of valuable information, especially that which would bolster their own position) • Chess players (where professional policy analysts value and share formal data, according to tightly defined rules, within their own unit or department) • Snap! players (where policy makers make essentially opportunistic use of unstructured information and evidence, in order to enhance their own influence) • Football players (where faction members use evidence opportunistically, particularly evidence which supports their ideology and will help to bind them together as a team).

27. Types of research utilization 1. Instrumental use • Research feeds directly into decision-making for policy and practice. 2. Conceptual use • Even if policy makers or practitioners are blocked from using findings, research can change their understanding of a situation, provide new ways of thinking and offer insights into the strengths and weaknesses of particular courses of action. New conceptual understandings can then sometimes be used in instrumental ways. 3. Mobilisation of support • Here, research becomes an instrument of persuasion. Findings – or simply the act of research – can be used as a political tool and legitimate particular courses of action or inaction. 4. Wider influence • Research can have an influence beyond the institutions and events being studied. Evidence may be synthesised. It might come into currency through networks of practitioners and researchers, and alter policy paradigms or belief communities. This kind of influence is both rare and hard to achieve, but research adds to the accumulation of knowledge that ultimately contributes to large-scale shifts in thinking, and sometimes action.

28. Improving dissemination • Recommendations for research commissioners • Time research to deliver solutions at the right time to specific questions facing practitioners and policy-makers. • Ensure relevance to current policy agenda. • Allocate dedicated dissemination and development resources within research funding. • Include a clear dissemination strategy at the outset. • Involve professional researchers in the commissioning process. • Involve service users in the research process. • Commission research reviews to synthesize and evaluate research.

29. Improving dissemination • Recommendations for researchers • Provide accessible summaries of research. • Keep the research report brief and concise. • Publish in journals or publications that are user friendly. • Use language and styles of presentation that engage interest. • Target material to the needs of the audience. • Extract the policy and practice implications of research. • Tailor dissemination events to the target audience and evaluate them. • Use a combination of dissemination methods • Use the media. • Be proactive and contact relevant policy and delivery agencies • Understand the external factors likely to affect the uptake of research.

30. Encouraging better use of evidence in policy making • Increasing the pull for evidence • Require the publication of the evidence base for policy decisions • Require departmental spending bids to provide a supporting evidence base • Submit government analysis (such as forecasting models) to external expert scrutiny • Provide open access to information – leading to more informed citizens and pressure groups.

31. Encouraging better use of evidence in policy making • Facilitating better evidence use • Encourage better collaboration across internal analytical services (e.g. researchers, statisticians and economists) • Co-locate policy makers and internal analysts • Integrate analytical staff at all stages of the policy development process • Link R&D strategies to departmental business plans • Cast external researchers more as partners than as contractors • Second more university staff into government • Train staff in evidence use

32. Policy Makers Politicians Board Members Managers Institutional CEOs Program Managers Service Professionals Physicians Nurses Researchers Mission Oriented In-house Employees Management Consultants Applied Research Institutes Insulated Academics Discovery Driven Decision Makers Solutions Problems

33. Issues and Priorities Decision Makers Service Delivery Problems Policy Makers Managers Dx, Tx, Px Service Professionals Solutions Problems Incentives Researchers Mission Oriented Discovery Driven Researchable Questions Research Funders Applications Commercial R&D Grant Agencies Self-funding Discovery

34. Issues and Priorities Decision Makers Research Funders Applications Discovery Service Delivery Problems Policy Makers Managers Dx, Tx, Px Service Professionals Solutions Problems Incentives Researchers Mission Oriented Discovery Driven Researchable Questions Knowledge Purveyors Stories Public Relations Media Think Tank Conferences Journals Books Facts Ideas Best Practice Interventions Personal Experiences Anecdotes Interests Wants Values Myths Assumptions Evidences

35. Issues and Priorities Decision Makers Research Funders Applications Discovery Service Delivery Problems Policy Makers Managers Dx, Tx, Px Service Professionals Solutions Problems Incentives Researchers Mission Oriented Discovery Driven Researchable Questions Knowledge Purveyors Stories Facts Ideas Best Practice Interventions Anecdotes Interests Wants Values Myths Evidences

36. Decision Makers Policy Makers Managers Service Professionals Researchers Mission Oriented Discovery Driven Knowledge Purveyors Stories Facts Ideas Issues and Priorities Research Funders Applications Discovery Service Delivery Problems Best Practice Interventions Dx, Tx, Px Solutions Problems Knowledge Brokers Solutions Anecdotes Interests Wants Values Myths Incentives Researchable Questions Evidences

37. Questionable Quality Irrelevant 1-Knowledge Purveyor 2- Knowledge Creator 3-Knowledge Broker 1-Ethical Expert Evidence 1-Political Bargainer Ambiguous Loose Always Important ! Policies Ethics Politics Role of Gifted and Talented:

38. Thank You ! Any Question ?