On Being a Good Listener: Setting Priorities for Applied Health Services Research

In the last decade, explicit priority setting has become an integral part of health care systems. Indeed, there is even an International Society on Priorities in Health Care, created in 1997 (Ham 1997). Whether it is Oregon's priority ordering of symptom treatment pairs to maximize the impact of a limited Medicaid budget (Fox and Leichter 1991), England's National Institute for Clinical Excellence's assessing priorities for therapeutic innovations in the National Health Service (Rawlins 1999), or New Zealand's setting priorities for patients’ access to cardiovascular treatment (Hadorn and Holmes 1997), techniques for judging the relative worth of different health service investments abound. As these techniques are refined, the most common addition is the incorporation of public values as part of the assessment. Priority setting is increasingly seen as combining an objective assessment of costs and effects with a more subjective assessment of patient or public preferences (Lenaghan, New, and Mitchell 1996; Lomas 1997; National Institute for Clinical Excellence 2002; Stronks et al. 1997). The incorporation of the service users’ values has led some commentators to conclude that the process is more important than the science. For instance, Klein declared: Given conflicting values, the process of setting priorities for health care must inevitably be a process of debate. It is a debate, moreover, which cannot be resolved by an appeal to science and where the search for some formula or set of principles designed to provide decision-making rules will always prove elusive. Hence the crucial importance of getting the institutional setting of the debate right … the right process will produce socially acceptable answers—and this is the best we can hope for. (Klein and Williams 1999, 20–21) Our article is a response to Callahan's recent observation that “the effort to devise priorities for health care systems is far more advanced and sophisticated than for biomedical research. With the exception of the NIH, it is hard to discover much extended debate anywhere in the world on how best to prioritize research” (Callahan 1999, 116). We describe how the lessons learned from and the approaches to setting priorities for funding health services are translated into setting priorities for funding health services research, in which the paymasters want to use the finite human and financial resources for those areas most likely to improve health services delivery. We agree with Klein's and Callahan's views that getting the priority-setting process right—preventing domination by any particular interest, being transparent, and reflecting the values of all relevant users—is the most important consideration. Their approaches also reflect the emerging importance of involving users and their values in the process. In the case of research, however, the users include not only patients and providers but also managers and policymakers striving to make the best possible decisions in an evidence-based health service (Walshe and Rundall 2001). We begin with a review of previous approaches to setting priorities for health research and then state the case for the greater involvement of research users, at least for applied health services research. We use two case studies—one in England and one in Canada—to describe a “listening model” for setting user-driven health services research priorities. Finally, we draw lessons from the case studies before concluding that setting priorities for health services research is more an interpretive than a technical exercise.