In recent years there has been a good deal of research into health care priority setting [19
]. Some findings are clear. Priority setting is more than a technical exercise; it needs to be understood as a management process [28
]. Economic approaches to priority setting should incorporate ethical principles and vice versa [16
]. Both researchers and decision-makers need to think broadly about what constitutes appropriate and relevant evidence [31
]. The literature suggests that there are several gaps in knowledge, such as the evaluation of priority setting frameworks relevant to health outcomes and other interim outputs (e.g., does formal priority setting help with setting useable priorities; are these priorities used to make decisions; does a formal framework increase the use of evidence?) and in terms of appropriate ways to engage the community in resource allocation decisions
Given this work and the myriad of challenges faced by decision-makers, we believe that future research in this area should be highly collaborative. The exact questions must be shaped as much by decision-maker input as researcher interest. The current project aimed to develop a set of research priorities in the field of health care priority setting. While it is not our intent to suggest that the priorities identified are all encompassing, nor necessarily apply in all jurisdictions, our experience in this field both within and outside of Canada would suggest that the issues that were raised should be relevant for most jurisdictions faced with allocating a finite set of resources.
The forum process resulted in a research agenda with the following characteristics: (1) The province-wide nature of the project allowed us to identify a comprehensive range of issues, including those most relevant for organizations at various stages of development in formal priority setting and resource allocation work, while recognizing different geographies, populations and health needs, organizational structures, service mixes, financial positions, etc; (2) There is considerable potential and desire for comparative work, which would allow health regions to share experiences and avoid 'reinventing the wheel'; (3) We have identified priorities that already have decision-maker buy-in, so it should be somewhat simpler and quicker to promote subsequent dissemination and uptake in British Columbia.
Several other general desirable outcomes were obtained from the very process of engaging in these forums. To begin with, they demonstrate one successful way of bridging academic and practice worlds. Principles identified in the knowledge transfer and exchange literature--such as two-way interaction among decision-makers and researchers working together to evolve priority setting practice-were demonstrated [2
]. We speculate that this will result over the longer-term in a vibrant and growing network of BC researchers focused on priority setting, as well as a more common understanding of formal priority setting approaches and application of key principles at the health authority level. Such embedded knowledge should then contribute to improvements in routine priority setting practice.
The process allowed for sharing and networking among the health authorities themselves. Health authority personnel who attended were informed during the course of the forums about current priority setting research and practice in BC - their attendance increased their awareness of frameworks in use and likely promoted more in-depth contemplation regarding priority setting in the province. This form of research, involving active and reflective engagement in priority setting exercises, is also conducive to organizational learning and creation of greater awareness and understanding among decision-makers about how choices affect the organization as a whole.
Our observations suggest that the challenges, ideas and research topics would not have arisen - at least in the form they did - without direct interaction between researchers and decision-makers. Even as applied health services researchers, working closely with decision-makers in health service organizations, we could not predict, nor would we presume to know, the intricacies of priority setting at the coal face. We also observed a high level of peer to peer interaction between decision-makers from different health authorities. This was mentioned in the participant evaluations as a valuable aspect of the project. Furthermore, the expenditure on this team planning exercise was relatively modest, amounting to $37,500 total.
Would we do anything differently? We offer two suggestions.
• First, asking decision-makers to give up three half days within 9 months was in hindsight asking too much. If we were to do this again, we would have one day-long workshop geared towards a facilitated group discussion to maximize peer-to-peer and researcher-to-decision-maker interaction. If more then 20 decision-makers were interested in attending, we would hold separate workshops but ensure that all health authorities were represented at each session.
• Second, in follow-up, we would suggest having a more formal process in place to engage decision-makers with transition from an idea to an actual research question and, in due course, to a full research proposal. With the BC geography this is perhaps difficult, but nonetheless, allocating the budget to ensure one-on-one meetings with each of the health authorities following a primary workshop would in our view result in greater likelihood of ongoing research collaboration.
A few other potential limitations are worth mentioning. Were the 'right' people involved in the forums? Moving research forward effectively in practice settings requires a good balance between people who can speak to the technical issues 'at the coal face' of priority setting and resource allocation - those who know the challenging issues and dilemmas firsthand -- and those who are senior leaders able to devote resources to research. In this regard, our participants represented a good balance. In terms of previous experience, some participants had much direct priority setting experience to cite, others had relatively less or none. Most participants seemed actively engaged, though not all and not consistently. The fact that many participants returned for subsequent forums speaks to their engagement and sustained interest in this work, especially given the many competing demands on decision-makers' time. A conscious choice was made not to include personnel from the Provincial Ministry of Health; the focus was squarely placed on regional decision making.
We did not seek consensus, where all participants necessarily agreed upon particular research priorities shared in all health regions. Rather, the directions reported here reflect the whole range of topics raised; some persons and regions may be more interested in some of these than others. We have not reported here every possible research question that was raised during forum discussions; instead we have tried to group them into broad theme areas, with the attendant risk of omitting details which might be potentially very important to individual participants. Finally, the health authorities in BC have different populations and geographies. We wanted to be sure that the final agenda reflects this range of interests. Thus, we must ask whether or not some participants dominated the discussion and the outcomes. In careful review of the forum notes, most individuals did contribute; less vocal participants were called out for their perspective. However, it is realistic to suggest that some participants had a deeper understanding and greater engagement with the matters being discussed and their specific views may have risen to the top more readily.
Participants had several opportunities to validate the findings of this research; thus we are confident that the priorities represent their immediate needs and interests. The depth of that interest, however, will be shown by whether or not successful research collaborations are subsequently pursued. Of course, research proposals will necessarily be fitted to or constrained by available funding streams. Finally, there is frequent turnover among decision makers in the health care sector (already including some of our partners in this project). If the priorities we have identified are truly those of the health delivery organizations, rather than of the particular participants, then they should survive such developments intact. Again, time will tell.