Ethical Decision-Making Processes Used In Funding Tailored Health Services

1. Ethical Decision-Making Processes Used In Funding Tailored Health Services Brian Evoy, MSW, PhD Candidate University of British Columbia Canadian Public Health Association Annual Conference June 3, 2008

2. Acknowledgements • Institute of Population and Public Health, Canadian Public Health Association, Canadian Public Health Initiative and Public Health Agency of Canada Population and Public Health Doctoral Student Award 2007 & 2008 • Canadian Institutes of Health Research Doctoral Research Award Recipient 2005

3. Research focus and motivations • Social Worker living through social & health service cuts • Why is it okay to fund a service at one point in time and okay to cut it at another point in time? • General reaction by my peers: “You’re assuming it’s ethical” [insert chuckle here]

5. Research objectives • Gain a better understanding of how health authority administrators make sense of their own funding-related decision-making processes • Look at participant descriptions of how decisions are made align with existing normative and descriptive decision-making frameworks and add to this area of knowledge

6. Research objectives • Examine how participants perceive themselves to be making “good” decisions related to funding, reducing, or eliminating funding to community-based tailored health care services on behalf of the public • Explore what the research participants think about tailored population-specific services as a way to address the health inequities gap

7. Methodology • Narrative Inquiry • Narrative structural unit analysis (Riessman, 1993) • Located story line(s) • Produced brief description of stories • Highlighted general impressions and unusual features (Bottorff et al., 2000) • Asked “who, what, when and where” questions • Documented narrative complications • Asked evaluation questions “what finally happened?” (Coffey & Atkinson, 1996)

8. Establishing research truth-value • Member-checking • Committee involvement • Audit trail: field notes, methodological, analytic and reflexive memos

9. Table 3.1: Select participant characteristics (N=24) Select participant characteristics (N=24)

10. Dataset • Interview transcripts • Internal documents, reports and emails • Meeting minutes • Terms of Reference • Question and Answer documents • Briefing notes • Proposal scoring templates

12. Justice as fairness “It’s incredible when [you] typically do the scoring etcetera [of proposed funding options] and that list goes up, even though people have been passionate about their own priorities, the consensus is typically quite strong. But then we give some other folks that aren’t typically part of that process, because I’m talking about integrated health services now, service planning etcetera, to take a look at that again and form recommendations. So there’s a number of processes for people to have that considerate second thought, if you will. It’s not perfect, but so far it’s the best process that I’ve been able to find.”

13. Justice as fairness & appropriateness “So what they did was they looked at the needs of the population, and where the services matched – Who was getting what? What were the wait lists? And whatever, and then presented it [to the management team, health authority] wide, so then it became crystal clear you could see, you couldn’t stand away and say, hmm. So everybody in the [one part of the region] could just, kind of had to do that, look away, because you know, it’s black and white now. You can kind of see it. There’s a disproportion of waiting for services. So, can you live that way? When we’re all on one team working together? Well no, not really. So how do we start to move it along?”

14. Appropriateness “We need to be constantly evaluating [whether] our service are meeting the needs of our population now. Let me take in a population that we wouldn’t typically discuss. A middle-aged white cardiac victim who has no experience with disclosing what’s going on in his personal life, with managing stress or anything related. Setting up a program where you just talk at somebody like that is not going to be useful. There will be no impact. We know health education does not deliver on its promise. There has to be an experiential and participatory opportunity for people to make the shift and integrate learning. So health education, which is talking at you, often a talking head process, has limited return.”

15. Collaboration “I’ve been able to challenge people to step to a potentially more inclusive place, a more cooperative and collaborative place…As soon as people get into defensive models, I know I’m missing something. And I’m really referring to community process here. But for example within my own shop, I have asked each manager to contribute something of their budget to a common good…If they’re going to be collaborative, they have got to be truly collaborative…And I think this is really important. I can find the money, but I think it’s more important for us to find the money. And it’s that moving people out of silos into a connected and supportive environment, where priorities are shared. Burdens are shared, struggles are shared. And so, we then move forward in common, towards our goals.”

16. Factors that influence decision-style

17. Factors that influence decision-style

18. Key findings • Administrators care about the funding decisions they make • Administrators understand that their decisions are value driven • Significant increase in formally structured decision-making process requiring senior executive sponsorship, risk management, communications and decision-making process documentation for transparency, and accountability and legitimacy purposes

19. Key findings • Formal decision-analysis, informed intuitive decision-making (established through long-standing expertise) and political pressures characterize the current BC health region planning, funding and service delivery landscape • Tensions emerge through formal planning thwarted by political interference, over reliance on bureaucratic procedures and concerns related to making legitimate decisions on the public’s behalf

20. Key findings • Following formal decision-making processes does not guarantee decisions will be implemented • Minimal evidence that decision processes or most projects presented during interviews are formally evaluated

21. References Bottorff, J. L., Johnson, J. L., Irwin, L. G., & Ratner, P. A. 2000, "Narratives of smoking relapse: The stories of postpartum women", Research in Nursing & Health, vol. 23, pp. 126-134. Coffey, A. & Atkinson, P. 1996, Making sense of qualitative data: Complementary research strategies Sage, Thousand Oaks. Commission on Social Determinants of Health 2007, A conceptual framework for action on the social determinants of health, World Health Organization, Geneva. Herzog, H. 2005, "On home turf: Interview location and its social meaning", Qualitative Sociology, vol. 28, no. 1, pp. 25-47. Riessman, C. K. 1993, Narrative analysis Sage, Newbury Park, CA. Sandelowski, M. 1995, "Focus on qualitative methods. Triangles and crystals: On the geometry of qualitative research", Research in Nursing & Health, vol. 18, pp. 569-574. Smythe, W. E. & Murray, M. J. 2000, "Owning the story: Ethical considerations in narrative research", Ethics & Behavior, vol. 10, no. 4, pp. 311-336. Strauss, A. & Corbin, J. 1998, Basics of qualitative research: Techniques and procedures for developing grounded theory Sage, Thousand Oaks.