Background and objective Ireland does not have a national strategy for diabetes management akin to policy frameworks developed in other European countries. In 2006, the Irish Health Service Executive (HSE) established an Expert Advisory Group for diabetes, to act ‘as the HSE’s primary source of operational policy and strategic advice'. The aim of this study is to examine the Diabetes Expert Advisory Group (EAG) process as an instrumental case study of policy formulation in the health service.

Methods A case description was built through interviews and documentary analysis. Fifteen in-depth interviews were conducted with a purposive sample of EAG members. The topic guide was informed by three theories of policy formulation; Rational Model of Decision Making (1), Advocacy Coalition Framework (ACF) (2) and Multiple Streams Theory (3). Thematic analysis was conducted using the theoretical assumptions as analytical tools. NVIVO software was used for data management.

Results Preliminary analysis suggests the EAG followed a sequential process; identifying priorities, developing recommendations and proposing a strategy for approval by the HSE. However the rational model of decision-making became less relevant as the process moved from approval to implementation. There was lack of clarity around what constituted a decision and who made decisions in the health system. ACF theory assumes ‘advocacy coalitions’ share ‘policy core beliefs’ although members may disagree about secondary beliefs. This fits with accounts of the EAG process; “I think we were all there with the same purpose but how we went about it, how the problem is going to be solved might be slightly different…” The economic recession could be considered an ‘external shock’ which constrained the resources available to the group and pushed implementation down the agenda. The Multiple Streams Theory identifies three streams in the policy arena (problem, policy, politics). By 2006 the problem of diabetes had been well established with an international evidence base informing the management of the illness (policy). However the political commitment (politics) to the EAG recommendations faded as the implications emerged; “in order to do it the way other countries do it, it is going to require investment. Our first report sketched out the sort of investment it might need and I think that just frightened them off.”

Conclusions Different aspects of the policy formulation process were highlighted and hidden by applying an ‘alternative lens’ perspective (4). The story of the Diabetes EAG illuminates broader policy issues including the role of evidence in health policy, the impact of external events on decision making and the gap between decision-making and implementation.