Evans et al. (2013) [17] Mixed methods; national email survey of health service commissioners in Local Health Boards (n=22) and interviews (n=5). To understand the role of research evidence at the local level in relation to the implementation of a national chronic conditions management policy. According to one senior manager, preference for approach to care ‘informed by professional contacts’ over other forms of evidence. Tension between resources required to appraise research to inform commissioning decisions and that required to implement changes to services. Government policy, initiatives, and targets influenced commissioning context and drove decision making. Evidence-based policy valued but its use in practice constrained by budgetary pressures. Gallego (2008) [7] Qualitative study of perceptions; interviews (n=12) with senior managers, clinical service (medical), middle managers, medical clinicians, and nurse managers. To aid the design of a new process of technology assessment and decision making. Some decision-makers lack knowledge and understanding of economic evaluation; its credibility and accuracy, especially at a local system level, questioned. Decision-makers’ narrow view of economic evidence - based on costs and budgetary constraints – influenced potentially by need for rationing in health care system (budgetary impact and costs main deciding factor). Harden and Fulop (2015) [61] Qualitative study of seven Cancer networks, responsible for enhancing multi-disciplinary cancer care. Data collected through video-recordings of fifty-three network meetings. To explore how decision-making can be improved in healthcare contexts, such as cancer care networks, by adopting ‘relational’ leadership practices. Committee chairs’ moderate use of different types of evidence (leadership) (what the authors term the difference between ‘single ontology’ and sense making). Institutional or management issues in the organisation of care steered conversations toward scientific and technical themes at the expense of narrative perspectives, representing ‘single ontology’ sense-making. - Hendy and Barlow (2013) [53] Ethnography; five comparative, longitudinal case studies of remote care (telecare) services using formal interviews (115 hours), informal discussions and To explore how managers' use evidence to inform decisions about innovation adoption. - Evidence adapted to benefit managers and local staff based on managers’ agendas (e.g. alignment with existing practices and needs, moderating - Innovation spread mediated by its alignment with recipient organisation (non-alignment of organisation's values and expectations and managers' - committee
telehealth aligns with health service policies, and 3) achieving clinician acceptance through providing evidence of benefit and developing new models of clinical care. Change enabled by marketing telehealth to patients, clinicians and and building a community of practice. Williams and Bryan 2007 [8] Mixed-methods study. Qualitative case studies of four committees including documentary analysis, observation of committee meetings (n=11), and interviews with committee members (n=31). Survey in primary and secondary care to collate information proformas used by committees when considering proposed new technologies. To explore how local committees operate when making technology coverage decisions, the information they use and the extent to which economic evaluation featured in this. Other factors influenced the committees, such as the perspectives of committee members, especially clinicians. Some respondents felt that the committees were susceptible to powerful personalities on, or attending, the committee. In order to be useful, cost effectiveness analysis needs to better reflect the constraints of the local environment. Decision-making environment appeared to militate against emphasis on cost-effectiveness analysis, including unclear relationships with resource allocators, an explicitly political decision-making process, and poorly specified decision-making criteria. - Wye et al (2015) [48] Qualitative study of four commissioning organisations in England, using interviews (n=52), meeting observation (n=14), and documentary analysis. To identify the reasons that prompted commissioners to seek information, to clarify which sources and types of knowledge commissioners commonly consulted, and to describe the use of research evidence in decision-making. Commissioners acquired information through conversations, stories (clinical and patient) and documentation (especially bulleted summaries to capture attention) -Competing proposals for funding (persuasion needed). -Organisational processes change the original information. Decisions need to stand up to external scrutiny (locally and nationally)