The World Health Organization has outlined ethical principles for resource allocation. The application of these principles can be facilitated by the use of decision-making frameworks (Guindo, 2012). This paper describes a case study of the use of integrated decision-making frameworks (iDMFs) in the scale-up of maternity continuity of carer models. A detailed description of a carefully staged process to design a model, engage stakeholders, create a set of resources including a leadership programme, and reach a collaborative set of recommendations to increase maternity continuity of carer models is provided. Thirteen of the 15 Hospital and Health Services in Queensland were introduced to iDMF and 11 worked through a set of questions designed to assist services to determine readiness for maternity service redesign. The paper triggers wider consideration about iDMF's use for strategic planning in healthcare and how this is evaluated.
iDMFs are often used because the issues being considered are complex and the framework approach provides a tool to manage these complexities. This complexity of variables can be a real challenge for process evaluation of iDMFs (Bartlett, 2003). Equally challenging can be the evaluation of the qualitative aspects of the process, for example development of trust, the use of ‘experts’, financial controls/restraints and underlying inter-personnel relationships.
Angelis et al. (2017) argue that focus should be placed on the process of decision-making in order to assess the efficiency and fairness of decision outcomes. Often cited in this context is the Accountability for Reasonableness Ethical Framework (Daniels and Sabin, 1998). Angelis et al. (2017) summarise this framework and state that: “For decisions to be fair and legitimate their processes should meet a number of conditions: they should be publicly available, based on relevant reasoning, and revisable in light of new evidence, all three conditions of which could be assured through enforcement mechanisms (i.e. regulation)” (Angelis et al., 2017: 77).
At government level there have been some moves from hierarchical governance towards collective decision-making and increased stakeholder engagement. One definition of iDMF is: “a way of making decisions in which a government involves citizens, societal organizations, private parties and/or other governments into the decision-making-process as soon as possible, in order to interact and/or to co-operate with them to establish the preparation, the determination, the implementation and/or the evaluation of policy” (Pröpper and Steenbeek, 1998: 293). Healthcare decision-making is also becoming more ‘democratised’, reflecting wider societal drivers for user involvement. An example of this is their use in clinical decision-making (Trevena and Barratt, 2003). Angelis et al. (2017) make the point that as resource allocation decisions are political, the application of an ethical framework to assess the decision-making process should be a priority.
The increasing use of iDMFs raises the question – is it a tool, the use of which needs to be systematically taught and transparently implemented, reviewed and reported, or is this an addition to research methods, and if so how can it be critiqued as such? If iDMF is more than a tool and is a new form of research methodology, and that is a big ‘if’, the method itself requires further critiquing, specifically in relation to nursing research and its relationship to policy and practice.
Biography
Elizabeth Young is a Visiting Fellow at University of South Wales. Her work experience is in the voluntary sector at senior executive level with responsibilities for strategic development, in the NHS with research development and governance roles and in academia. Her professional background is in nursing and medical sociology, and she has an interest in researching sensitive topics including death and dying, focus group methodology and, more recently, in evaluation and organisational development.
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