Purpose: In this paper, we explore how rational decision making is accomplished in practice in the context of individual funding reviews which involve decisions about whether to fund treatments in exceptional cases. In this context the groups involved overtly seek to arrive at rational and publically defensible decisions. We address the following important questions: What resources do actors rely on to perform their roles as ‘rational’ decision makers? What models of rational judgement do organisational actors draw upon in practice, and how? Our suggested answers to these questions advance understanding of rational decision making in healthcare.
Method: We conducted a focused ethnography of decision making in the English National Health Service (NHS). Our empirical setting was healthcare purchasing (commissioning) organisations, which consider individual funding requests (IFRs) made for medicines or other treatments that are not routinely purchased. We observed in real time the making of decisions for 118 IFR cases, which generally involved thorough evaluation of the available evidence and supporting documentation. We analysed our rich observational data iteratively and thematically.
Result: Our analysis revealed that, for rational decision making to be accomplished, organisational actors perform three kinds of interrelated activities: (i) addressing procedural requirements, (ii) interpreting and making sense of decision cases and (iii) deliberating the merits of cases on the basis of public reasons. Our data indicate that decision makers seek rationality, by, not only calculating the consequences of their decisions for individual patients, but also (and mainly) crafting a robust and rigorous justification on the basis of evidence as regards the funding merits of their decision. This form of decision making, we suggest, represents a distinct pursuit of rational judgement in practice.
Conclusion: Our study makes an important contribution to our understanding of how rationality is sought and performed in actual healthcare organisational situations. Our investigation of IFR decision making in the NHS suggests that the understanding of rationality may be significantly improved if we address and examine the pursuit of rational judgement as a situated empirical phenomenon. The results of our focused ethnography vividly demonstrate in fact that deciding rationally and appearing to do so is a complex and uncertain social process bounded by demands for rigorous justifications of a decision.
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