Evidence-based policy-making in the NHS: exploring the interface between research and the commissioning process

The usage of data in NHS primary care commissioning: a realist review

BACKGROUND

Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data.

METHODS

We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory.

RESULTS

Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data.

CONCLUSIONS

There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.

EIDM training as a key intervention among researchers to enhance research uptake and policy engagement: an evaluation study

In the past decade, the field of Evidence Informed Decision Making (EIDM) has been evolving faster than before. This shows a need for capacity enhancement amongst evidence producers and evidence users in EIDM training. Through the Enhance DELTAS programme, led by the African Institute for Development Policy (AFIDEP), we provided research uptake and policy engagement training, mentorship and webinars to awardees of the Developing Excellence in Leadership, Training and Science (DELTAS) Africa initiative, led by the African Academy of Sciences (AAS). Two workshops were offered to individual early career DELTAS researchers in policy engagement and evidence uptake, referred to as ENHD101, and among research leaders to enhance institutional capacity on policy engagement and evidence uptake, (ENHD102). Overall, over the eight months’ period of training, mentorship and webinars, the programme attracted 31 early career researchers and 20 research leaders. Following the programme, the early career researchers understood the importance of EIDM for better health policies and programmes. In addition, the team appreciated the complexities of the policymaking processes as they developed the policy engagement strategy for their research. The utilisation of the EIDM knowledge was reflected during the mentorship with policy briefs as end product. For research leaders, they appreciated their role in strengthening capacity for EIDM in decision-making spaces. Although during the programme none of the research leaders participated in strengthening capacity for EIDM, the team anticipated improving in the area in the long run. In addition, the research leaders developed and implemented institutional strategies for policy engagement and research uptake through use of social media to influence policymakers. In conclusion, the project supported capacity building of African researchers in EIDM. It was evident that enhancing knowledge and skills on EIDM through an integrated approach to include training, mentorship, and webinars demonstrated enhanced capacity for policy engagement and evidence uptake.

Supporting the use of research evidence in decision-making in crisis zones in low- and middle-income countries: a critical interpretive synthesis

BACKGROUND

Decision-makers in crisis zones are faced with the challenge of having to make health-related decisions under limited time and resource constraints and in light of the many factors that can influence their decisions, of which research evidence is just one. To address a key gap in the research literature about how best to support the use of research evidence in such situations, we conducted a critical interpretive synthesis approach to develop a conceptual framework that outlines the strategies that leverage the facilitators and address the barriers to evidence use in crisis zones.

METHODS

We systematically reviewed both empirical and non-empirical literature and used an interpretive analytic approach to synthesise the results and develop the conceptual framework. We used a 'compass' question to create a detailed search strategy and conducted electronic searches in CINAHL, EMBASE, MEDLINE, SSCI and Web of Science. A second reviewer was assigned to a representative sample of articles. We purposively sampled additional papers to fill in conceptual gaps.

RESULTS

We identified 21 eligible papers to be analysed and purposively sampled an additional 6 to fill conceptual gaps. The synthesis resulted in a conceptual framework that focuses on evidence use in crisis zones examined through the lens of four systems - political, health, international humanitarian aid and health research. Within each of the four systems, the framework identifies the most actionable strategies that leverage the facilitators and address the barriers to evidence use.

CONCLUSIONS

This study presents a new conceptual framework that outlines strategies that leverage the facilitators and address the barriers to evidence use in crisis zones within different systems. This study expands on the literature pertaining to evidence-informed decision-making.

Lessons learned from Evidence-Informed Decision-Making in Nutrition & Health (EVIDENT) in Africa: a project evaluation

Background

Evidence-informed Decision-making in Nutrition and Health (EVIDENT) is an international partnership that seeks to identify information needs in nutrition and health in Africa and build local capacity in knowledge management to help translate the best available evidence into context-appropriate recommendations aligned to the priorities of decision-makers. This study evaluates the extent to which EVIDENT achieved its intended activities, documents the lessons learned and draws on these lessons learned to inform future activities of EVIDENT, as well as in evidence-informed decision-making (EIDM) in nutrition overall.

Methods

Purposive and snowball sampling were used to identify participants that were either directly or indirectly involved with EVIDENT. An analytical framework of five key elements was developed to guide data collection from EVIDENT’s documentation, in-depth interviews (n = 20), online surveys (n = 26) and a participatory discussion. Interviews were transcribed verbatim and coded in NVivo 11, using deductive thematic content analysis and a phenomenological approach. Online surveys were analysed using Stata 14. Data were triangulated to address both objectives under each element of the analytical framework.

Results

EVIDENT succeeded in establishing a collaborative partnership, within which it delivered four short courses in EIDM. This capacity complemented case study activities in four partner African countries where EIDM processes were implemented and assessed. Identified barriers to these processes included little experience in EIDM, difficulties in engaging stakeholders, challenging local environments (e.g. donor influence, bureaucracy, inaccessibility to scientific research, poor internet connectivity), and limited time and funding. However, EVIDENT activities were driven by a local need for EIDM, a sheer interest and commitment to the cause, and the opportunity for the Global North and South to work together and build relationships. Future activities of EVIDENT, and EIDM in nutrition overall, should focus on sustained capacity-building in EIDM processes, leadership and functional skills across the Global South, investment in stakeholder engagement, context-specific EIDM, enhanced communication and linking, and strengthening relationships with existing stakeholder organisations.

Conclusions

In its first 3 years, EVIDENT developed and strengthened partnership, capacity and visibility on EIDM in Africa. Innovative and long-term capacity-building, dedicated leadership, further stakeholder engagement and sustainable financing, are needed for future activities of EVIDENT and EIDM in nutrition.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0413-6) contains supplementary material, which is available to authorized users.

Institutional capacity to generate and use evidence in LMICs: current state and opportunities for HPSR

BACKGROUND

Evidence-informed decision-making for health is far from the norm, particularly in many low- and middle-income countries (LMICs). Health policy and systems research (HPSR) has an important role in providing the context-sensitive and -relevant evidence that is needed. However, there remain significant challenges both on the supply side, in terms of capacity for generation of policy-relevant knowledge such as HPSR, and on the demand side in terms of the demand for and use of evidence for policy decisions. This paper brings together elements from both sides to analyse institutional capacity for the generation of HPSR and the use of evidence (including HPSR) more broadly in LMICs.

METHODS

The paper uses literature review methods and two survey instruments (directed at research institutions and Ministries of Health, respectively) to explore the types of institutional support required to enhance the generation and use of evidence.

RESULTS

Findings from the survey of research institutions identified the absence of core funding, the lack of definitional clarity and academic incentive structures for HPSR as significant constraints. On the other hand, the survey of Ministries of Health identified a lack of locally relevant evidence, poor presentation of research findings and low institutional prioritisation of evidence use as significant constraints to evidence uptake. In contrast, improved communication between researchers and decision-makers and increased availability of relevant evidence were identified as facilitators of evidence uptake.

CONCLUSION

The findings make a case for institutional arrangements in research that provide support for career development, collaboration and cross-learning for researchers, as well as the setting up of institutional arrangements and processes to incentivise the use of evidence among Ministries of Health and other decision-making institutions. The paper ends with a series of recommendations to build institutional capacity in HPSR through engaging multiple stakeholders in identifying and maintaining incentive structures, improving research (including HPSR) training, and developing stronger tools for synthesising non-traditional forms of local, policy-relevant evidence such as grey literature. Addressing challenges on both the supply and demand side can build institutional capacity in the research and policy worlds and support the enhanced uptake of high quality evidence in policy decisions.

Incorporating research evidence into decision-making processes: researcher and decision-maker perceptions from five low- and middle-income countries

BACKGROUND

The 'Sponsoring National Processes for Evidence-Informed Policy Making in the Health Sector of Developing Countries' program was launched by the Alliance for Health Policy and Systems Research, WHO, in July 2008. The program aimed to catalyse the use of evidence generated through health policy and systems research in policymaking processes through (1) promoting researchers and policy advocates to present their evidence in a manner that is easy for policymakers to understand and use, (2) creating mechanisms to spur the demand for and application of research evidence in policymaking, and (3) increased interaction between researchers, policy advocates, and policymakers. Grants ran for three years and five projects were supported in Argentina, Bangladesh, Cameroon, Nigeria and Zambia. This paper seeks to understand why projects in some settings were perceived by the key stakeholders involved to have made progress towards their goals, whereas others were perceived to have not done so well. Additionally, by comparing experiences across five countries, we seek to illustrate general learnings to inform future evidence-to-policy efforts in low- and middle-income countries.

METHODS

We adopted the theory of knowledge translation developed by Jacobson et al. (J Health Serv Res Policy 8(2):94-9, 2003) as a framing device to reflect on project experiences across the five cases. Using data from the projects' external evaluation reports, which included information from semi-structured interviews and quantitative evaluation surveys of those involved in projects, and supplemented by information from the projects' individual technical reports, we applied the theoretical framework with a partially grounded approach to analyse each of the cases and make comparisons.

RESULTS AND CONCLUSION

There was wide variation across projects in the type of activities carried out as well as their intensity. Based on our findings, we can conclude that projects perceived as having made progress towards their goals were characterized by the coming together of a number of domains identified by the theory. The domains of Jacobson's theoretical framework, initially developed for high-income settings, are of relevance to the low- and middle-income country context, but may need modification to be fully applicable to these settings. Specifically, the relative fragility of institutions and the concomitantly more significant role of individual leaders point to the need to look at leadership as an additional domain influencing the evidence-to-policy process.

Engagement in research: an innovative three-stage review of the benefits for health-care performance

Background

There is a widely held assumption that research engagement improves health-care performance at various levels, but little direct empirical evidence.

Objectives

To conduct a theoretically and empirically grounded synthesis to map and explore plausible mechanisms through which research engagement might improve health services performance. A review of the effects on patients of their health-care practitioner's or institution's participation in clinical trials was published after submission of the proposal for this review. It identified only 13 relevant papers and, overall, suggested that the evidence that research engagement improves health-care performance was less strong than some thought. We aimed to meet the need for a wider review.

Methods

An hourglass review was developed, consisting of three stages: (1) a planning and mapping stage; (2) a focused review concentrating on the core question of whether or not research engagement improves health care; and (3) a wider (but less systematic) review of papers identified during the two earlier stages. Studies were included inthe focused review if the concept of ‘engagementinresearch’ was an input and some measure of ‘performance’ an output. The search strategy covered the period 1990 to March 2012. MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and other relevant databases were searched. A total of 10,239 papers were identified through the database searches, and 159 from other sources. A further relevance and quality check on 473 papers was undertaken, and identified 33 papers for inclusion in the review. A standard meta-analysis was not possible on the heterogeneous mix of papers in the focused review. Therefore an explanatory matrix was developed to help characterise the circumstances in which research engagement might improve health-care performance and the mechanisms that might be at work, identifying two main dimensions along which to categorise the studies:the degree of intentionalityandthe scope of the impact.

Results

Of the 33 papers in the focused review, 28 were positive (of which six were positive/mixed) in relation to the question of whether or not research engagement improves health-care performance. Five papers were negative (of which two were negative/mixed). Seven out of 28 positive papers reported some improvement in health outcomes. For the rest, the improved care took the form of improved processes of care. Nine positive papers were at a clinician level and 19 at an institutional level. The wider review demonstrated, for example, how collaborative and action research can encourage some progress along the pathway from research engagement towards improved health-care performance. There is also evidence that organisations in which the research function is fully integrated into the organisational structure out-perform other organisations that pay less formal heed to research and its outputs. The focused and wider reviews identified the diversity in the mechanisms through which research engagement might improve health care: there are many circumstances and mechanisms at work, more than one mechanism is often operative, and the evidence available for each one is limited.

Limitations

To address the complexities of this evidence synthesis of research we needed to spend significant time mapping the literature, and narrowed the research question to make it feasible. We excluded many potentially relevant papers (though we partially addressed this by conducting a wider additional synthesis). Studies assessing the impact made on clinician behaviour by small, locally conducted pieces of research could be difficult to interpret without full knowledge of the context.

Conclusions

Drawing on the focused and wider reviews, it is suggested that when clinicians and health-care organisations engage in research there is the likelihood of a positive impact on health-care performance. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved health-care performance. Further explorations are required of research networks and schemes to promote the engagement of clinicians and managers in research. Detailed observational research focusing on research engagement within organisations would build up an understanding of mechanisms.

Study registration

PROSPERO: CRD42012001990.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Evaluation models and evaluation use

The use of evaluation results is at the core of evaluation theory and practice. Major debates in the field have emphasized the importance of both the evaluator's role and the evaluation process itself in fostering evaluation use. A recent systematic review of interventions aimed at influencing policy-making or organizational behavior through knowledge exchange offers a new perspective on evaluation use. We propose here a framework for better understanding the embedded relations between evaluation context, choice of an evaluation model and use of results. The article argues that the evaluation context presents conditions that affect both the appropriateness of the evaluation model implemented and the use of results.

The use of research evidence in public health decision making processes: systematic review

Background

The use of research evidence to underpin public health policy is strongly promoted. However, its implementation has not been straightforward. The objectives of this systematic review were to synthesise empirical evidence on the use of research evidence by public health decision makers in settings with universal health care systems.

Methods

To locate eligible studies, 13 bibliographic databases were screened, organisational websites were scanned, key informants were contacted and bibliographies of included studies were scrutinised. Two reviewers independently assessed studies for inclusion, extracted data and assessed methodological quality. Data were synthesised as a narrative review.

Findings

18 studies were included: 15 qualitative studies, and three surveys. Their methodological quality was mixed. They were set in a range of country and decision making settings. Study participants included 1063 public health decision makers, 72 researchers, and 174 with overlapping roles. Decision making processes varied widely between settings, and were viewed differently by key players. A range of research evidence was accessed. However, there was no reliable evidence on the extent of its use. Its impact was often indirect, competing with other influences. Barriers to the use of research evidence included: decision makers' perceptions of research evidence; the gulf between researchers and decision makers; the culture of decision making; competing influences on decision making; and practical constraints. Suggested (but largely untested) ways of overcoming these barriers included: research targeted at the needs of decision makers; research clearly highlighting key messages; and capacity building. There was little evidence on the role of research evidence in decision making to reduce inequalities.

Conclusions

To more effectively implement research informed public health policy, action is required by decision makers and researchers to address the barriers identified in this systematic review. There is an urgent need for evidence to support the use of research evidence to inform public health decision making to reduce inequalities.

Knowledge exchange processes in organizations and policy arenas: a narrative systematic review of the literature

CONTEXT

This article presents the main results from a large-scale analytical systematic review on knowledge exchange interventions at the organizational and policymaking levels. The review integrated two broad traditions, one roughly focused on the use of social science research results and the other focused on policymaking and lobbying processes.

METHODS

Data collection was done using systematic snowball sampling. First, we used prospective snowballing to identify all documents citing any of a set of thirty-three seminal papers. This process identified 4,102 documents, 102 of which were retained for in-depth analysis. The bibliographies of these 102 documents were merged and used to identify retrospectively all articles cited five times or more and all books cited seven times or more. All together, 205 documents were analyzed. To develop an integrated model, the data were synthesized using an analytical approach.

FINDINGS

This article developed integrated conceptualizations of the forms of collective knowledge exchange systems, the nature of the knowledge exchanged, and the definition of collective-level use. This literature synthesis is organized around three dimensions of context: level of polarization (politics), cost-sharing equilibrium (economics), and institutionalized structures of communication (social structuring).

CONCLUSIONS

The model developed here suggests that research is unlikely to provide context-independent evidence for the intrinsic efficacy of knowledge exchange strategies. To design a knowledge exchange intervention to maximize knowledge use, a detailed analysis of the context could use the kind of framework developed here.

Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making

Background

In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making.

Methods

Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified.

Results

Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established.

Conclusion

Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.

Asking the right questions: scoping studies in the commissioning of research on the organisation and delivery of health services

Scoping studies have been used across a range of disciplines for a wide variety of purposes. However, their value is increasingly limited by a lack of definition and clarity of purpose. The UK's Service Delivery and Organisation Research Programme (SDO) has extensive experience of commissioning and using such studies; twenty four have now been completed.

This review article has four objectives; to describe the nature of the scoping studies that have been commissioned by the SDO Programme; to consider the impact of and uses made of such studies; to provide definitions for the different elements that may constitute a scoping study; and to describe the lessons learnt by the SDO Programme in commissioning scoping studies.

Scoping studies are imprecisely defined but usually consist of one or more discrete components; most commonly they are non-systematic reviews of the literature, but other important elements are literature mapping, conceptual mapping and policy mapping. Some scoping studies also involve consultations with stakeholders including the end users of research.

Scoping studies have been used for a wide variety of purposes, although a common feature is to identify questions and topics for future research. The reports of scoping studies often have an impact that extends beyond informing research commissioners about future research areas; some have been published in peer reviewed journals, and others have been published in research summaries aimed at a broader audience of health service managers and policymakers.

Key lessons from the SDO experience are the need to relate scoping studies to a particular health service context; the need for scoping teams to be multi-disciplinary and to be given enough time to integrate diverse findings; and the need for the research commissioners to be explicit not only about the aims of scoping studies but also about their intended uses. This necessitates regular contact between researchers and commissioners.

Scoping studies are an essential element in the portfolio of approaches to research, particularly as a mechanism for helping research commissioners and policy makers to ask the right questions. Their utility will be further enhanced by greater recognition of the individual components, definitions for which are provided.

The Quality Improvement Demonstration Study: an example of evidence-based policy-making in practice

Background

Randomized trials have long been the gold-standard for evaluating clinical practice. There is growing recognition that rigorous studies are similarly needed to assess the effects of policy. However, these studies are rarely conducted. We report on the Quality Improvement Demonstration Study (QIDS), an example of a large randomized policy experiment, introduced and conducted in a scientific manner to evaluate the impact of large-scale governmental policy interventions.

Methods

In 1999 the Philippine government proposed sweeping reforms in the National Health Sector Reform Agenda. We recognized the unique opportunity to conduct a social experiment. Our ongoing goal has been to generate results that inform health policy. Early on we concentrated on developing a multi-institutional collaborative effort. The QIDS team then developed hypotheses that specifically evaluated the impact of two policy reforms on both the delivery of care and long-term health status in children. We formed an experimental design by randomizing matched blocks of three communities into one of the two policy interventions plus a control group. Based on the reform agenda, one arm of the experiment provided expanded insurance coverage for children; the other introduced performance-based payments to hospitals and physicians. Data were collected in household, hospital-based patient exit, and facility surveys, as well as clinical vignettes, which were used to assess physician practice. Delivery of services and health status were evaluated at baseline and after the interventions were put in place using difference-in-difference estimation.

Results

We found and addressed numerous challenges conducting this study, namely: formalizing the experimental design using the existing health infrastructure; securing funding to do research coincident with the policy reforms; recognizing biases and designing the study to account for these; putting in place a broad data collection effort to account for unanticipated findings; introducing sustainable policy interventions based on the reform agenda; and providing results in real-time to policy makers through a combination of venues.

Conclusion

QIDS demonstrates that a large, prospective, randomized controlled policy experiment can be successfully implemented at a national level as part of sectoral reform. While we believe policy experiments should be used to generate evidence-based health policy, to do this requires opportunity and trust, strong collaborative relationships, and timing. This study nurtures the growing attitude that translation of scientific findings from the bedside to the community can be done successfully and that we should raise the bar on project evaluation and the policy-making process.

Marginalized evidence: effective knowledge translation strategies for low awareness issues

There are particular knowledge translation (KT) challenges in communicating evidence on low awareness topics. Often considered peripheral to the main focus of health care provision, these issues may fail to "get on the agenda" of decision-makers, even when supported by strong evidence. This article describes the successful application of KT strategies to a specific low awareness issue (the importance of using trained health interpreters) within a large Canadian Regional Health Authority.

Towards systematic reviews that inform health care management and policy-making

OBJECTIVES

To identify ways to improve the usefulness of systematic reviews for health care managers and policy-makers that could then be evaluated prospectively.

METHODS

We systematically reviewed studies of decision-making by health care managers and policy-makers, conducted interviews with a purposive sample of them in Canada and the United Kingdom (n = 29), and reviewed the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences (n = 45).

RESULTS

Our systematic review identified that factors such as interactions between researchers and health care policy-makers and timing/timeliness appear to increase the prospects for research use among policy-makers. Our interviews with health care managers and policy-makers suggest that they would benefit from having information that is relevant for decisions highlighted for them (e.g. contextual factors that affect a review's local applicability and information about the benefits, harms/risks and costs of interventions) and having reviews presented in a way that allows for rapid scanning for relevance and then graded entry (such as one page of take-home messages, a three-page executive summary and a 25-page report). Managers and policy-makers have mixed views about the helpfulness of recommendations. Our analysis of websites found that contextual factors were rarely highlighted, recommendations were often provided and graded entry formats were rarely used.

CONCLUSIONS

Researchers could help to ensure that the future flow of systematic reviews will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions. Research funders could help to ensure that the global stock of systematic reviews will better inform health care management and policy-making by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly 'front ends' for potentially relevant systematic reviews.

Feeding back survey research findings within palliative care. Findings from qualitative research

The feedback of research findings to practitioners and policy makers is an important component of palliative care research. Little is, however, understood about professionals' views on the ways research findings should be fed back. This study used semi-structured telephone interviews with a vignette to understand professionals' views on the feedback of survey research findings within palliative care. Content analysis of data uncovered a range of issues professionals emphasised as important to consider. These issues are discussed within the context of existing literature in order to raise the profile of research feedback within palliative care.

The wound dressing supply chain within England's National Health Service: unravelling the context for users

AIM

To explore the representation of user needs (nurses and patients, both individuals and groups) at the industrial (wound dressing manufacture) and National Health Service interface.

MAIN ISSUES

The wound dressing supply chain is outlined, tracking organizational changes. The methods that are used to transfer user information between industries that produce dressings and those using the products are reviewed in terms of their ability to communicate what users need from dressings. Organizational policies and systems are outlined, with the focus on their role in facilitating the communication of user needs.

CONCLUSION

Methods for generating user information that can directly inform dressing design are needed together with interactive communication routes within the supply chain, specifically between users, manufacturers, purchasers and suppliers. This will facilitate dual benefits for nursing management through improvements in purchasing decisions and nurses' management of wound care.

Evidence-based health policy: context and utilisation

Evidence-based decision-making is centred on the justification of decisions. In the shift from an individual-clinical to a population-policy level, the decision-making context becomes more uncertain, variable and complex. To address this we have developed a conceptual framework for evidence-based decision-making, focusing on how context impacts on what constitutes evidence and how that evidence is utilised. We present two distinct orientations towards what constitutes evidence, representing different relationships between evidence and context. We also categorise the decision-making context based on the ways in which context impacts on evidence-based decision-making. Furthermore, we invoke the concept of axes of evidence-based decision-making to describe the relationship between evidence and context as we move from evidence-based medicine to evidence-based health policy. From this, we suggest that it may be more important how evidence is utilised than how it is defined. Based on the research and knowledge utilisation literature, we present a process model of evidence utilisation, which forms the basis for the conceptual framework for context-based evidence-based decision-making. The conceptual framework attempts to capture the role that context plays in the introduction, interpretation and application of evidence. We illustrate this framework with examples from policy development for colorectal cancer screening.

How are policy makers using evidence? Models of research utilisation and local NHS policy making

STUDY OBJECTIVE

This paper is based on a qualitative study that aimed to identify factors that facilitate or impede evidence-based policy making at a local level in the UK National Health Service (NHS). It considers how models of research utilisation drawn from the social sciences map onto empirical evidence from this study.

DESIGN

A literature review and case studies of social research projects that were initiated by NHS health authority managers or GP fundholders in one region of the NHS. In depth interviews and document analysis were used.

SETTING

One NHS region in England.

PARTICIPANTS

Policy makers, GPs and researchers working on each of the social research projects selected as case studies.

MAIN RESULTS

The direct influence of research evidence on decision making was tempered by factors such as financial constraints, shifting timescales and decision makers' own experiential knowledge. Research was more likely to impact on policy in indirect ways, including shaping policy debate and mediating dialogue between service providers and users.

CONCLUSIONS

The study highlights the role of sustained dialogue between researchers and the users of research in improving the utilisation of research-based evidence in the policy process.