Kneale et al.

Implementation Science (2017) 12:53

DOI 10.1186/s13012-017-0577-9

SYSTEMATIC REVIEW Open Access

The use of evidence in English local public

health decision-making: a systematic
scoping review
Dylan Kneale1*† , Antonio Rojas-García2†, Rosalind Raine2 and James Thomas1

Abstract
Background: Public health decision-making structures in England have transformed since the implementation
of reforms in 2013, with responsibility for public health services and planning having shifted from the “health”
boundary to local authority (LA; local government) control. This transformation may have interrupted flows of
research evidence use in decision-making and introduced a new political element to public health decision-making.
For generators of research evidence, understanding and responding to this new landscape and decision-makers’
evidence needs is essential.
Methods: We conducted a systematic scoping review of the literature, drawing upon four databases and
undertaking manual searching and citation tracking. Included studies were English-based, published in 2010
onwards, and were focused on public health decision-making, including the utilisation or underutilisation of
research evidence use, in local (regional or sub-regional) areas. All studies presented empirical findings collected
through primary research methods or through the reanalysis of existing primary data.
Results: From a total of 903 records, 23 papers from 21 studies were deemed to be eligible and were included
for further data extraction. Three clear trends in evidence use were identified: (i) the primacy of local evidence, (ii)
the important role of local experts in providing evidence and knowledge, and (iii) the high value placed on local
evaluation evidence despite the varying methodological rigour. Barriers to the use of research evidence included
issues around access and availability of applicable research evidence, and indications that the use of evidence could
be perceived as a bureaucratic process. Two new factors resulting from reforms to public health structures were
identified that potentially changed existing patterns of research evidence use and decision-making requirements:
(i) greater emphasis among public health practitioners on the perceived uniqueness of LA areas and structures
following devolution of public health into LAs and (ii) challenges introduced in responding to higher levels of local
political accountability.
Conclusions: There is a need to better understand and respond to the evidence needs of decision-makers working
in public health and to work more collaboratively in developing solutions to the underutilisation of research evidence
in decision-making.

* Correspondence: [email protected]
†
Equal contributors
1
Evidence for Policy and Practice Information and Coordinating Centre, UCL
Institute of Education, University College London, 20 Bedford Way, London
WC1H 0AL, UK
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kneale et al. Implementation Science (2017) 12:53 Page 2 of 12

Introduction aspects of public health (see [12] for a full outline). LAs
Since 2013, the context in which local public health are also responsible for improving health determinants
strategy is developed and services are commissioned in and reducing health inequalities across nine key areas
England has shifted, and decisions previously made impacting on population health including early years, edu-
within National Health Service (NHS) structures are cation, planning, housing, leisure and communities [13].
now being taken by different organisations and stake- This was said to be emblematic of a “social model of
holders. The shifting culture and context of decision- health” [14], with LAs having an interest, and potentially
making means that as generators and synthesisers of an ability to influence, most local public health activities
research evidence we need to respond to these changes and many local determinants of health. Newly created
if we are to continue to support public health decision- health and wellbeing boards provide some strategic leader-
makers to make informed and judicious evidence-based ship, support, and coordination on the response of LAs to
choices [1]. local health challenges. Most other local health services
The improvement of public health outcomes through are commissioned through local clinical commissioning
evidence-based strategies is widely recommended, of- groups (CCGs; which replaced primary care trusts (PCTs);
fering greater access to information on what works, in- although some aspects of public health are retained here).
creased opportunities for the effective use of resources, Although Table 1 attempts to disentangle what is a
and improved certainty around the likelihood of success fiendishly complex public health delivery landscape,
implementing different intervention options [2]. There actual day-to-day practice means that the divisions in
is no shortage of examples where evidence assembled responsibilities displayed below may not necessarily be as
from different settings has been used to directly inform clear-cut in real-world settings. For instance, screening
and mobilise public health interventions, the imple- and immunisation programmes are commissioned by
mentation of which has led to substantial improve- the NHS England and its regional teams. Directors of
ments in health behaviours and health states on a large Public Health and LA public health teams have a re-
scale. For example, Ireland’s trailblazing workplace sponsibility to provide advice and information to in-
smoking ban [3] which led to attributable increases in form immunisation and screening plans, as well as to
smoking cessation [4] was developed on the basis of a scrutinise these [15]. Implicitly, this means that while
strong evidence base [5]. Conversely, the potential for the commissioning of immunisation and screening ser-
ineffective or detrimental public health interventions to vices is ostensibly an NHS endeavour, in practice, the
pose harm on a large scale provides further justification of delivery of immunisation and screening services is
the importance of effective use of evidence (see [6, 7]). contingent on both LA and NHS input and resources.
Indeed, some authors highlight that the use of “scientific Furthermore, the LA remit could extend much further
knowledge” is an integral dimension of the very definition in some cases (for example to include quality assur-
of public health, which involves the “process of mobilizing ance) when the delivery of such services is in turn reli-
and engaging local, state, national, and international ant on agencies that lie within other LA commissioning
resources to assure the conditions in which people can be areas. Therefore, while Table 1 provides an indication
healthy” ([8], p538). of the broad areas of responsibility across different
In the case of public health, the complexity in target- agencies, the descriptions provided cannot represent
ing populations, or communities, necessitates providing the full extent of dependencies between agencies.
evidence that is both comprehensive and sensitive to The transition to new health decision-making struc-
this challenge [9]. It follows that the complexity of this tures described above is marked by heterogeneity (e.g.
evidence may lead to challenges in its effective implemen- [16]), which is in part reflective of existing differences in
tation [10, 11].The shift in decision-making structures local authority needs and practices [17]. The impact of
means that not only do we need to understand the new this heterogeneity on public health decision-making
culture and practices of evidence use in decision-making practices and actions is difficult to quantify; although,
but we also need to examine critically whether our own there have been some tangible actions common to all
research outputs are fit for purpose. The systematic scop- areas. First, all local authorities were expected to
ing review presented here explores how research evidence appoint a Director of Public Health (DPH) responsible
is being used in public health. for the public health budget and creating a staff of pub-
lic health consultants. Second, local authorities
How has the structure of local public health decision-making were jointly tasked with producing/ updating Joint Stra-
changed? tegic Needs Assessments (JSNAs), whose purpose is to
Since 2013, local public health leadership has mainly describe the current and future health needs of the
transferred to local authorities (LAs), whose public health population. A third tangible action was the creation of
remit now includes commissioning services across most Health and Wellbeing Strategies (HWSs), produced by
Kneale et al. Implementation Science (2017) 12:53 Page 3 of 12

Table 1 Main agencies involved in public health post-2013

Name Geographic remit Post-2013 broad responsibilitiesa
(in England)
Organisations with statutory duties
Local authorities (LAs) Local Responsible for planning and commissioning most local public health
services (see above)
Clinical commissioning groups (CCGs) Local Retain some related public health functions including provision of Child
and Adolescent Mental Health Services (CAMHS) and mental health
services, occupational health, maternity services and commissioning of
alcohol workers in various settings (although overall responsibility for
alcohol misuse services, prevention and treatment sits with LAs) [64].
(221 CCGs)
Health and wellbeing boards (HWBs) Local Coordinate activity of local health and care leaders to improve
population health, reduce health inequalities and introduce
democratic accountability [65].
National Institute for Health and Care Excellence National Issues guidance on the effectiveness of interventions that can improve
(NICE) population health and reduce health inequalities.
Public Health England (PHE) National Provide support, epidemiological guidance and research for LAs and
coordination of national public health initiatives and campaigns; includes
former Public Health Observatories
Greater London Authority (GLA); Greater Manchester Regional GLA issues guidance and collects and synthesises epidemiological and
Public Health Network (GMPH) (and other regional demographic research for London Boroughs and also issues various
organisations) toolkits for action.
GMPH is a collaborative network of ten directors of public health working
together to achieve goals that could not be realised individually.
Other regional organisations and networks exist.
NHS England/NHS Commissioning Board National Provides oversight of CCGs; specific functions around the commissioning
of primary care; retained some screening functions.
Department of Health National Retains stewardship over relevant agencies including Public Health England,
NHS England and the Health and Social Care Information Centre.
Other types of organisation
King’s Fund, Nuffield, Local Government Association, National These organisations produce influential information and guidance directly
and others for local public health decision-makers; they are an important component
of the new evidence and decision-making landscape
a
See explanatory text above for caveats around dependencies in commissioning services and potential co-commissioning

HWBs, which present a response outlining strategies interpretations [21]. Furthermore, reflective of the na-
and services that would be commissioned to address ture of LAs, final decision-making responsibility ultim-
the needs identified within JSNAs [18]. ately now falls with the elected members, not with
officers [22, 23]. Consequently, public health is now ex-
Implications for evidence use posed to a culture that is more likely to be shaped by
The transition to a new landscape of decision-making is political and legal constraints [24] and from an
perceived to have progressed reasonably smoothly in evidence-use perspective, an increased political element
some quarters [19], even if future challenges have been to local decision-making may have implications in terms
identified including anticipated further squeezing of of the type and format of evidence needed. A political
public health budgets. However, this standpoint is not dimension can also make public health priorities vulner-
universal across professionals and academics working able to rapid changes due to transitions in power, and
in public health, and more recent evidence highlights sub- producers of evidence will need to respond quickly to
stantial levels of concern about ongoing risks and severe support new directions or provide evidence to justify
challenges to the local delivery of public health [20]. existing activities. Reductions in public health grants
Structural changes have implications for the way in supporting the extensive public health remit of LAs [14]
which research evidence is used in public health and the different interpretations around how ring-fenced
decision-making. For example, the appointment of DPH public health monies should be spent [25] are also likely
exposed differing levels of commitment between those to influence the evidence required.
LAs who followed DH guidance and created new senior Within the extensive literature on evidence-informed
directorship posts for DPH and those with different public health policy-making more broadly, a pattern of
Kneale et al. Implementation Science (2017) 12:53 Page 4 of 12

underutilisation of research evidence persists despite its find potentially relevant studies. A bibliographic database
abundance [26, 27] and despite the recurring cycles of was created in EPPI-Reviewer 4 to store and manage
prioritisation by policy-makers [28]. Common barriers to the references [33], and data were extracted into
evidence use include perceived limitations in the rele- Microsoft Excel.
vance, importance and credibility of evidence [24, 29],
including concerns around the application of evidence Assessment of eligibility
generated in other settings [24, 30]. A previous review Titles and abstracts of the documents retrieved in the
concluded that few studies actually reveal the process searches were independently screened by two reviewers to
through which research evidence is used in public determine eligibility (full inclusion criteria provided in the
health decision-making [31], and how this sits within Additional file 2). Included studies were England-based
broader knowledge-utilisation frameworks. In addition, studies published from 2010 onwards that were focused
the use of the word “evidence” is not necessarily syn- on public health decision-making in local (regional or
onymous with drawing upon a robust body of research sub-regional) areas. The search strategy was limited to
evidence [32]. Where researchers have started to examine studies that included “public health” (or “health promo-
these issues in the post-2013 English landscape, they have tion”) in their title, abstract or keywords. Public health
indicated continued difficulties in using research evidence. decision-making was defined broadly as that which aims
In Beenstock and colleagues’ [18] analysis of 47 HWSs, to promote and protect the health and wellbeing of
they found that very few (5) referred to research evi- groups, communities and populations, mirroring broad
dence published in academic journals, just three refer- definitions employed in previous reviews [31]. We did not
enced NICE guidance, and none directly referenced a extend this definition to explore decision-making around
Cochrane systematic review. Furthermore, research the social determinants of health (e.g. education or em-
evidence was used more commonly to demonstrate ployment inequalities) except when this was described as
evidence of need than to demonstrate evidence of taking place specifically within the context of public health
effectiveness. (see [34] for an example where this took place). Included
The aim of the review presented here is to offer fur- studies focussed on decision-making involving (i) local
ther insight on these issues through mapping the use of public health services or (ii) local public health priori-
research evidence in public health decision-making at a tisation (using LA’s commissioning responsibilities [12]
sub-national level, and where possible to compare pat- as a guide where there was any ambiguity), or (iii) ex-
terns of evidence utilisation before the reconfiguration plored local decision-making among professionals
of public health services (2010–2012/13) and after- working in public health. Studies should have directly
wards (2013/14–2016). Unlike previous reviews, this re- included decision-makers and a focus on the process of
view adopts a broad set of inclusion criteria around evidence use in decision-making. Studies published
study design, with both observational and experimental during 2010 and onwards were selected for inclusion.
studies included, but a narrow scope in terms of geog- This date range was selected to provide evidence of re-
raphy and date range. Nevertheless, the patterns of evi- search use practice immediately before and after the
dence use and the obstacles that decision-makers in enactment of reform to decision-making structures in
local areas face when sourcing and using evidence are England (and where possible to contrast these); 2010
expected to have a much broader resonance and be of also coincides with the publication of the first system-
interest to readers outside England. This study was atic review by the Cochrane Public Health group, a rec-
conducted by a team of systematic reviewers who are ognition of the need for greater applicable evidence on
interested in the contribution of systematic reviews to specialist complex community-based interventions to
public health decision-making in England, and how this contribute to the evidence-based policy movement.
evidence contributes alongside other sources of re- Where other systematic reviews were encountered,
search evidence and public health intelligence more these were examined primarily as a further source of
broadly. studies. We also excluded studies that did not directly in-
volve observations of decision-makers (including [18]).
Studies fulfilling the inclusion criteria were selected for
Methods full-text assessment, after which a new independent as-
Search strategy sessment was performed. Disagreements were resolved
Four databases were searched for studies published through discussion between the reviewers.
between 2010 and 2016 (June) (PubMed, HMIC,
EconLit and Scopus) and specific search strategies were Data extraction and synthesis of the results
designed for each (see Additional file 1). In addition, a After piloting, we extracted information from all included
manual search of databases was carried out in order to studies. We did not undertake formal quality assessment
Kneale et al. Implementation Science (2017) 12:53 Page 5 of 12

of the studies since the aim of the review is to map the robustness of individual studies, we did consider the
literature in this area and to lay the groundwork for pri- completeness and applicability of evidence, the robust-
mary research and more detailed synthesis (if supported ness of the synthesis methods and the quality of evi-
by the data). This means that we did not formally employ dence in terms of its relevance to the ambitions of the
existing taxonomies of implementation to structure or review, and this is presented in our discussion [37–39].
guide our synthesis; although, our aims align with an This process was carried out by two of the authors (DK
ambition of understanding the processes of translating and ARG), and any disagreement was also resolved by
research into practice (developing process models) and discussion.
understanding influencers on evidence use (developing
determinant frameworks) [35]. In this systematic scop-
ing review, our synthesis methods were confined to a Results
narrative, configurative approach [36] and we intended The search retrieved 903 references, 43 of which were
to provide a descriptive account of the main recurring identified as duplicates. After examining the abstracts
themes. We followed five stages: (a) initial coding the and titles of the retrieved studies, 108 potentially rele-
text by producing preliminary textual descriptions of vant papers were selected for full-text assessment. The
studies and their findings in a tabular format (see papers for these 108 studies were retrieved and were
Additional file 3); this also involved grouping the subject to a second round of full-text screening from
studies according to their characteristics (e.g. setting which we identified a total of 23 papers from 21 studies
and stakeholders) in order to understand the character- for synthesis (including two discovered through manual
istics of the body of literature and to observe emerging searching (see Fig. 1)). Their characteristics are sum-
patterns in the data; (b) further inductive coding of the marised in Table 2, and their main features in relation
textual summaries and identifying key preliminary to the use of evidence are summarised in the appendix
themes and their recurrence across studies; (c) develop- tables, with themes emanating from these discussed
ing a framework for arranging groupings and clusters below. Most studies were carried out in England (14); a
of studies according to the themes and exploration of surprisingly high number purported to cover the UK
these within and between the studies; (d) further gener- (7) despite public health policy being largely devolved.
ation of analytical themes through attempting to de- Few studies (8) were conducted during or after the
velop a common rubric to describe these findings; (e) implementation of the HSCA 2012 (in April 2013)
finally, although we did not formally quality assess the while almost three-quarters of the studies were

Fig. 1 Flow of studies through the review

Kneale et al. Implementation Science (2017) 12:53 Page 6 of 12

Table 2 Characteristics of studies In some studies, “local” denotes geographically bounded

N = 21
a
% evidence that would allow for service planning (evidence
Region of need) or benchmarking or drawing comparisons of ef-
UK 7 33%
fectiveness with neighbouring areas (based on evidence of
effectiveness) [34]; in other studies, “local” appeared not
England 14 67%
to be strictly geographically bounded but involved a
HSCA 2012 broader consideration of evidence that was contextually
Before implementation (pre-April 2013) 12 57% salient [42].
After implementation (post-April 2013) 6 29%
Before and after 2 10%
Unclear 1 5%
Decision-making and local contexts and local
conceptualisations of public health
Setting
Evidence that was aligned to the local political ideology
Various (NHS, LA, PCT, etc.) 15 71% [40, 47] and could support broader organisational aims
Local authorities only 5 24% (where benefits could be visible beyond public health
PCTs only 1 5% alone [43, 48]) was most useful to decision-makers.
Type of evidence Philips and Green’s study, for example, which aims to
Specific programmes/interventions 1 5%
understand the processes and practices of local public
health decision-making, highlights how decision-makers
Economic evidence 2 10%
construct unique identities for their organisations that
General research evidence 18 86% translated into specific processes for action, which in
a
Refers to studies not papers; 23 papers included turn led to perceived distinctiveness in terms of informa-
tion needs [40]. One study found that services and strat-
egies did not always need to be supported by evidence if
conducted with stakeholders based in different institu- these initiatives were congruent with the current direc-
tions (namely LAs, PCTs, CCGs). tion of the organisation [49]. This political ideology was
shaped by the strong affiliation with accountability to
local populations, and sometimes, this could lead to
Locality of evidence conflicting perspectives as to which public health issues
Many studies suggest that the research evidence base to prioritise. Marks and colleagues [14] provide a compel-
does not match the evidence needs of decision-makers ling example from a HWB board member highlighting the
with respect to the locality of evidence [34, 40–44]. tension between evidence and local accountability: “…it
This was identified as an underlying reason why was pointed out that lots more people die of smoking re-
decision-makers consult with sources other than re- lated conditions than they do of drug related conditions,
search evidence [34, 40, 41]. In one of the included alcohol and drug related conditions, but nobody com-
studies, having local evidence was said to “trump” plains to me about the next door neighbour smoking. But
other forms of evidence, even if this is of lower meth- they will complain about the drug dealers on the corner
odological quality [41]. For example, Wye and col- and the alcohol, noise and abuse and all that stuff, which
leagues [41] contrast the low impact that a briefing has a big effect on peoples’ lives. It ripples out on the
based on academic research evidence had among a community. But they’ve got a point, but we’ve got a point
committee considering commissioning telehealth, as well. (p1200)” Political considerations and public
when compared to experiential local evidence based perceptions directly shaped elected members’ decision-
on eight service users. Despite the methodological ro- making, even where there existed robust evidence to
bustness of the former, the latter evidence refuted the suggest an alternative course of action, as articulated in
findings of the former and was instrumental in in- one study where a DPH found challenges in “advocating
creased positivity towards telehealth among the com- something [in this case minimum alcohol pricing] at a
mittee [41]. A similar theme was shared among other population level that is just not palatable from a political”
studies where contextually relevant evidence was ([44], p32).
prioritised in decision-making [34, 45], including local One study, which took place after 2013, also found
public health intelligence [34, 42, 46]. Problematically, that the local political ideology and the type of case that
decision-makers may emphasise the uniqueness of was required to made around a given public health issue
their local areas and their public health challenges, as changed over a short duration [49], which may impact
opposed to highlighting commonalities with other on the type of evidence required to support, or in some
areas [40]. cases challenge this.
Kneale et al. Implementation Science (2017) 12:53 Page 7 of 12

The value of expert opinion The degree to which the demand for and usage of evalu-
The need for evidence that was transferable to the local ation evidence, evidence from experts, and locally embed-
political context may also be an underlying explanation ded evidence are linked trends is not clearly expressed in
as to why expert opinion, advice, and experience were the literature. Frequent deployment of local experts in
found to be highly utilised and valued in several studies public health decision-making may be as a result of their
[42, 46, 50, 51]. Expert opinion and advice was sometimes ability to blend inter/national sources research evidence
utilised more than other robust forms of evidence, includ- with knowledge gained from local evaluation/experience.
ing NICE and other national guidelines [41, 46] and sys- Oliver and DeVocht [42] identified a potentially broad
tematic reviews and meta-analyses [42]. Experts often knowledge translation role for reliable experts in public
included professional colleagues, suggesting that expertise health decision-making in explaining the importance of
may be again related to experiential knowledge [46]. findings, translating evidence into contextually “compre-
There were some indications of conflicting evidence-use hensible statements” and “providing clear direction for
patterns, with usage patterns not necessarily reflective of decision-makers”. This suggests that the remit of experts
importance. One study found that NICE guidelines were in this case could extend beyond the usual boundaries of
one of the most frequently used sources of evidence, but knowledge translation [57] to a much more directive role.
practice guidelines (including NICE guidelines) were not The data they collected in the study did not illuminate the
universally regarded as the most useful [42]. The sample characteristics or motivations of existing experts or pre-
composition and the range of roles and specialisms may cisely the type of evidence where a knowledge translation
have partially accounted for some of this discrepancy role was most desired. However, they did note that
between perceptions of usefulness and frequency of usage; decision-makers expressed a desire to utilise existing data
although, the study did not publish disaggregated results and evidence through improved interpretation, suggesting
that allow this to be interrogated further. This study also that further refinement of knowledge translation practice
suggested that expert opinion was one of the most fre- was desirable [42].
quently utilised sources of evidence, but one that was not
always highly valued [42]. Demand for economic evidence falls short of the mark
Social network analyses suggest that the most power- Several studies suggested that decision-makers would
ful influencers on public health decision-making were find evidence around the economic impacts of inter-
able to form a bridge between local authority and NHS ventions useful, but that this was not always available
organisations [51]. In contrast, academic bodies and [14, 45, 47, 49, 53, 55]. In some cases, an increased de-
individual academic experts were rarely considered to mand for evidence around cost and benefit implications
be influential in their own right [51], perhaps reinfor- was directly related to austerity and the prioritisation
cing the findings of other studies which emphasise the that local decision-makers would now have to undertake
disconnect between academics and policy-makers with as a result of reduced, and in some cases, unprotected
regards to what constitutes useful and robust know- budget [14]. However, not all methods of prioritisation
ledge [52] as well as the broader disconnect between based on economic methods are viewed as being sensitive
cultures of public health evidence generation and to local contexts and some are viewed as excessively
evidence use [53, 54]. technocratic [14].
Two studies provided further disaggregation around
Evaluation evidence, experts and localism the type of economic evidence that decision-makers
A number of studies suggested that some of the most valued the most [48, 58], which included evidence of
influential evidence on local public health decision- impact across the remits of local authorities beyond
making was generated through local evaluation activ- traditional departmental siloes [48] as well as evidence
ities [40, 41, 55]. Such data meet decision-makers’ of the way in which existing local services and structures
requirements around the locality of evidence and are were likely to influence cost effectiveness [58]. Marks and
generated within the local political context therefore colleagues [14] provide an outline of different potential
meeting requirements around the transferability of approaches and tools that can support decision-making
findings [40, 47]. One study reported that evaluation and prioritisation and map these onto different stages of
evidence, even if based largely on an anecdote or a very decision-making. For example, the first decision-making
small number of cases, could sway senior decision- stage involves reaching an agreement on public health ob-
makers’ views [41]. Despite the local evaluation evidence jectives; here, relevant information includes JSNAs and
being generally regarded as useful for decision-makers, other public health intelligence, while other decision-
some studies also identified that this form of evidence had support methods that may be employed include broad
limitations particularly around the timing and intended stakeholder consultation and involvement. Further stages
usage [45, 56]. of decision-making outlined include identifying options
Kneale et al. Implementation Science (2017) 12:53 Page 8 of 12

and resources for reaching the objectives, identifying below, few studies provided descriptive accounts of the way
measurable criteria, deciding on preferences and making in which research evidence is used in practice, which pre-
choice. This study provides one of the few examples where cluded the development of process models representing the
authors have tried to understand decision-making as a way in which research evidence is translated into local pub-
series of sequential processes. However, they do not lic health practice [35]. Similarly, no studies directly con-
present explicit information on levels of awareness or trasted the use of research evidence before and after the
usage of the different decision-support tools, or how 2013 reorganisation of public health structures, although
much resonance the stages of decision-making hold across some did describe the changes in some of the influencers of
the three localities included in the study. evidence use, including the changing way in which prior-
ities were set and the influence of local accountability and
Solutions, facilitators and barriers identified in the politicisation [14, 41]. Therefore, with regards to meeting
literature our aims of exploring evidence-use processes and under-
One study identified evidence briefings based on sys- standing how these processes may have changed as a result
tematic reviews as a promising but currently underuti- of the reforms described earlier, the body of available
lised approach [40] while a further study suggested evidence did not allow us full insight.
methodologically robust case studies of local innovation Further caveats exist, particularly around the broad in-
as being a way of enhancing the usefulness of academic clusion criteria with regards to study design which pre-
research evidence for policy-makers [34]. Other studies cluded more formal synthesis and an assessment of
identified strengthening networks and communications individual study quality. However, all but three studies
between evidence producers and evidence users, includ- supported multiple themes (Table 3), providing some in-
ing recognising the role of interpersonal relationships in dication that the majority of the included studies were
determining evidence use and influence, as being import- relevant to the review. The narrow focus on local public
ant in working towards meeting the evidence needs of health decision-making in England could also mean that
public health decision-makers [42, 48, 51, 52]. None of the the results have limited applicability to other settings; al-
studies specifically mentioned “co-production” as a term; though, the findings have a degree of overlap with those
although, some recommended greater collaboration be- of previous reviews of evidence use in health settings
tween generators of evidence and evidence users [52, 56]. elsewhere [31, 60]. For example, Liverani and colleagues’
For example, one study suggested that different “cultures [60] conclusion that our understanding of the major influ-
of evidence” were not incommensurable in collaborative encers on evidence use in public health decision-making
work between evidence producers and users when the remains piecemeal also stand here. Additionally, two stud-
gains to be made from collaborative working were made ies were identified that took place in Scotland and Wales
clear to all parties involved [56]. where the public health challenges may be similar but the
Named barriers to evidence use included access [41], policy-making context differed. Nevertheless, both studies
capacity to analyse and interpret evidence [42], availabil- provided support for the key themes emanating from this
ity and relevance [58] and knowledge of different review, and particularly the importance of research evi-
sources and types [42]. In terms of economic evalua- dence that could be reinterpreted to become contextually
tions, another study also highlighted the difficulties to meaningful, including blending the findings from research
analyse the return on investment due to the organisa- evidence with findings from other sources [61, 62].
tional culture, capacity, the status of services, or admin- Consistent across the studies was a tendency to de-
istrative or political inertia [48]. A final study provided scribe research evidence as being underutilised in
indicative evidence that the use of evidence was per- decision-making but generally to be absent of sufficient
ceived as being tied to other decision-making processes detail around the type, process and context of the deci-
(such as strategic partnership working) that were per- sion being made that could illuminate a way forward.
ceived as “bureaucratic” [59]. Many of the suggestions being put forward in studies
tend to be from the perspective of researchers, and argu-
Discussion ably, this has led to a pre-occupation with identifying
Summary different forms of evidence, as opposed to different form
This systematic scoping review identified 21 studies (23 and stages of decision-making where evidence is needed
papers) that included a specific focus on the process of but is currently not, or under-, utilised.
English public health decision-making from 2010 on-
wards. These studies allowed us to identify some recur- Complexity and heterogeneity in decision-making and
ring themes around the role research evidence plays in public health
decision-making, as well as some of the major influen- Heterogeneity in process and structure is ostensibly a defin-
cers on the use of research evidence use. As we discuss ing characteristic of public health decision-making post-
Kneale et al. Implementation Science (2017) 12:53 Page 9 of 12

Table 3 Summary of the studies by analytic theme

Study no. Authors/year Analytic themes
Locality of Decision-making vs Expert Evaluation evidence, Economic Facilitator and
evidence local context opinion experts and localism evidence barriers
1 Blackman et al. (2011) [59] ●
2 Blackman et al. (2012) [43] ● ● ●
3 Clarke et al. (2013) [46] ● ●
4 Hunter et al. (2016) [47] ● ● ● ●
Marks et al. (2015) [14] ● ● ● ●
5 Jenkins et al. (2015) [66] ●
Peckham et al. (2015) [44] ● ●
6 King (2014) [48] ● ● ●
7 Lister and Merritt (2013) [58] ● ●
8 Marsh et al. (2012) [55] ● ● ●
9 Martin et al. (2011) [52] ● ●
10 McGill et al. (2015) [34] ● ●
11 Milton et al. (2014) [56] ● ●
12 Oliver et al. (2012) [51] ● ●
13 Oliver et al. (2013) [50] ●
14 Oliver and De Vocht (2015) [42] ● ● ●
15 Orton et al. (2011) [53] ● ●
16 Phillips and Green (2015) [40] ● ● ● ●
17 Rushmer et al. (2014) [54] ●
18 Salisbury et al. (2011) [45] ● ● ●
19 Skinner et al. (2015) [67] ●
20 Willmott et al. (2015) [49] ● ●
21 Wye et al. (2015) [41] ● ● ● ●
● = Study provided support to the theme

2013. Local decision-makers are keen to emphasise the Certainly, some studies suggested that political influence
uniqueness of their areas [40], as opposed to identifying had disrupted previously established flows of evidence into
commonalities. It is important that we acknowledge this different stages of decision-making [24, 40, 48, 49], which
heterogeneity in processes and structures as part of may impede on evidence-based policy-making. Some
the ecosystem in which public health services and in- studies suggested that a more politicised environment
terventions operate, and in which evidence is used. influenced priority setting [14, 47] and that the local polit-
However, it is also important that we attempt to under- ical ideology and the case required for a public health
stand and respond to this heterogeneity. Research has issue changed over a short duration [49]. This may sup-
not advanced to understanding the landscape in terms port the idea that more politicised environments could
of typologies and groupings of public health decision- foster cultures of “short-termism” in a priority setting [63]
making processes and structures. Developing such typ- and indicate the way in which a change in administration
ologies could facilitate understanding broad patterns of after an election may lead to rapid changes in priorities;
evidence use (and need) within these groupings and ultim- both of which present challenges to evidence production.
ately bridge a gap between evidence use and generation. The demand for economic evidence, a theme dis-
Similarly, the demand for local evidence uncovered cussed in this review, is likely to strengthen against the
[34, 40–42, 62] should be interrogated further. background of funding cuts to public health budgets
outlined in the introduction. Meanwhile, the role of
A changing balance of factors influencing decision-making local experts in a knowledge translation role is also
It is difficult to fully establish how the transition into local likely to be sustained if research evidence continues to
authorities has influenced the politics of decision-making. hold either low resonance or transferability or usability
Kneale et al. Implementation Science (2017) 12:53 Page 10 of 12

among end users. However, there is much left to learn decisions where insights and knowledge from evidence is
about the role that experts do indeed fulfil, given that needed, but where this need is unmet.
one study suggested that experts take a directive role.
Regarding our own concern around the role of systematic Additional files
reviews in public health decision-making, it is notable that
almost half of policy actors in one study viewed meta- Additional file 1: Scoping review on the use of evidence in local
analyses as useful; although, none reported using this authorities. Search strategy and results. (DOCX 17 kb)
evidence regularly [42]. Additional file 2: PRISMA 2009 Checklist. (DOC 64 kb)
Additional file 3: Preliminary textual descriptions of studies and their
findings. (DOCX 41 kb)
Conclusions
The body of available evidence did not allow for full
Abbreviations
insight on the way in which evidence is used in English CCG: Clinical commissioning group; HSCA: Health and Social Care Act;
public health decision-making; although, a number of HWS: Health and Wellbeing Strategy; LA: Local authority; PCT: Primary care trust
distinct processes and preferences were identified. Over-
Acknowledgements
all, these findings suggested that much of the research
We would like to acknowledge helpful input of Dr Helen Barratt (UCL) as
evidence being produced may not match the needs of well as the input from the steering group for this project and, in particular,
decision-makers due to its “global” nature and that Dr Karen Lock (LSHTM) and Jayne Taylor (Consultant in Public Health for the
London Boroughs of Hackney and City of London). We would also like to
decision-makers may instead look to other means and
thank the reviewers and editors for their input, who helped to strengthen
sources to bridge this need. A clear gap in the literature this manuscript greatly.
identified in this systematic review was an insight into
the process of decision-making in the new public health Funding
The research was supported by the National Institute for Health Research
landscape, and how evidence is used differentially at (NIHR) Collaboration for Leadership in Applied Health Research and Care
different stages; Phillips and Green [40] provided an North Thames at Barts Health NHS Trust. The views expressed are those
exception. of the authors and not necessarily those of the NHS, the NIHR or the
Department of Health.
Most of the literature encountered in this review
focus on attempting to establish “determinant frame- Availability of data and materials
works” of barriers and facilitators, without first estab- Data sharing is not applicable to this article as no datasets were generated
or analysed during the current study.
lishing “process models” of the use of evidence [35].
Constructing process models could establish an under- Authors’ contributions
standing of who “consumes” research evidence and DK and ARG are joint first authors. JT conceptualized this study and secured the
study funding from the NIHR, as part of a broader collaboration directed by RR.
distinguish between decision-influencers and decision- JT and RR provided methodological consultation. DK and ARG conducted all
makers, who may have very different evidence require- the stages of the review itself. All authors contributed to manuscript drafts,
ments. Some studies, conducted pre-2013, suggested approved and reviewed the final manuscript.
that influential actors in public health decision-making
Competing interests
were not necessarily the most senior; and several studies The authors declare that they have no competing interests.
have indicated that external experts also hold an high de-
gree of influence, if not holding decision-making powers Consent for publication
Not applicable.
themselves. Ascertaining the steps that should be taken to
enhance evidence use in public health decision-making is Ethics approval and consent to participate
challenging in the absence of detailed understandings of Not applicable.
current practice; process models which identify evidence
needs at different stages of decision-making for different Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
types of decisions being made could help to overcome this
published maps and institutional affiliations.
limitation.
The challenges raised in this review are clear. These in- Author details
1
Evidence for Policy and Practice Information and Coordinating Centre, UCL
clude the need for researchers to develop a much deeper
Institute of Education, University College London, 20 Bedford Way, London
understanding of evidence requirements from the perspec- WC1H 0AL, UK. 2NIHR CLAHRC North Thames, Department of Applied Health
tive of decision-makers. The current body of literature and, Research, University College London, 1-19 Torrington Place, London WC1E
7HB, UK.
in particular, the solutions and facilitators to increasing
research evidence use identified tend towards an under- Received: 17 August 2016 Accepted: 28 March 2017
standing of decision-makers needs from the researchers’
perspective. This means that we prioritise types of evidence
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