Objectives To explore the process of public health decision-making, and the role of research evidence, taking cardiovascular disease (CVD) as a case study.
Design In-depth interview study.
Setting and Participants Over 30 public health policy-makers and planners in CVD, including: commissioners, public health consultants, data analysts, librarians and knowledge managers at Primary Care Trusts; public health academics; lead consultant cardiologists; local and national guideline developers; and third sector staff.
Methods In-depth semi-structured interviews were recorded and transcribed verbatim. Transcripts and field notes were analysed using the constant comparative method.
Findings Participants reported that previously there was relatively little change in health care investment year on year. Consequently, it was seldom necessary to seek research evidence. However, changes had occurred in recent times. National Health Service (NHS) cuts had led to a more systematic prioritisation process necessitating the explicit use of research evidence. There was a sense that decision-makers must now take stock of what they were doing and ascertain if it was evidence-based. Unfortunately, these cuts had also removed much of the opportunity for creative thinking and for trying out new and unproven innovations. Despite most participants wishing to address “upstream” issues, a focus on short-term national targets appeared to have constrained the adoption of population-level prevention initiatives in favour of “downstream” service development approaches. Furthermore, participants anticipated increased rationing of health care in the near future. Reliable research evidence was considered essential to inform rationing decisions. However, most academic research was perceived to be aimed at clinicians. Guidelines, particularly those produced by the National Institute for Health and Clinical Excellence (NICE), as well as local data (such as hospital statistics), were currently the main sources of evidence used by policy-makers and planners. In order to facilitate future decision-making, participants requested that researchers provide unequivocal evidence on the best approaches to service delivery.
Conclusions Most policy-makers and planners rely on NICE guidance and local data rather than directly accessing research evidence. Furthermore, public health decision-making in the NHS is constrained by organisational rigidity imposed by historic budgets and short-term national targets. Recent NHS cuts have led to increased systematisation and an emphasis on the evidence base. However, these cuts have also led to a focus on downstream interventions. In future, more effective health care rationing may require additional research on models of service delivery.
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