Journal of Community Health Vol. 2, No. 2, Winter 1976

H E A L T H SERVICES RESEARCH AND H E A L T H POLICY H. David Banta, M.D., M.P.H., and Patricia Bauman, M.S.

A B S T R A C T : H e a l t h services r e s e a r c h (HSR) has t h e p o t e n t i a l to i n f l u e n c e the d e c i s i o n - m a k i n g process in a h e a l t h services s y s t e m t h a t is a c u t e l y aware o f its resource l i m i t a t i o n s . N o n e t h e l e s s , h e a l t h services researchers feel, w i t h . s o m e t r u t h , t h a t t h e i r r e s e a r c h has h a d o n l y a l i m i t e d e f f e c t o n h e a l t h policy. S o m e reasons f o r this are described, i n c l u d i n g t h e p r i m a c y o f political, r a t h e r t h a n t e c h n i c a l , c o n s i d e r a t i o n s in p o l i c y m a k i n g , t h e lack o f a c o m p r e h e n s i v e h e a l t h policy, a n d t h e p o o r q u a l i t y a n d irrelevance o f m u c h HSR. T h e role o f f u n d i n g for H S R b y the F e d e r a l g o v e r n m e n t is d e s c r i b e d ; it is s h o w n t h a t t h e Federal e f f o r t is f r a g m e n t e d , despite t h e c o n s o l i d a t i o n efforts m a d e in 1968. I n c r e a s e d s u p p o r t f o r specific t a r g e t e d , p r o b l e m - s o l v i n g h e a l t h services r e s e a r c h is p r o p o s e d , a n d s o m e possible m e t h o d s to achieve this arc described.

Our thesis is that impediments to the contributions made by HSR to decision making exist within the health services research community and within the policy process itself. On the one hand, researchers who are steeped in a particular discipline do not develop hypotheses in a timely fashion with respect to multicausal problems that policy decision makers address. Consequently, the findings of this research often do not suggest useful action for program or legislative development. On the other hand, the consumers of health services research in government fail to think through and articulate the problems for which they seek assistance, nor do they specify the uses to which they wish to put such research findings. Therefore, it is important for all who participate in the policy-making process to understand what health services research can and cannot be expected to yield. This paper will define health services research (HSR); it will describe the consumers and funders of research, largely in the public sector, and the policy process into which research must be integrated; lastly, it will consider the HSR community's problems and opportunities. Dr. Banta is a Professional Staff Member with the Office of Technology Assessment, Congress of the United States, Washington, D.C. 20510, and Associate Clinical Professor, Mount Sinai School of Medicine of the City University of New York. Ms. Bauman is a Professional Staff Member, Committee on Labor and Public Welfare, Senate of the United States, Washington, D.C. 20510. The authors would like to thank Carl Taylor of the Office of Technology Assessment, Arthur Viseltear of Yale University, and Richard Seggel of the Institute of Medicine for their helpful comments. Dr. Banta is grateful to the Robert Wood Johnson Foundation for its support of the Robert Wood Johnson Health Policy Fellowship and to the Institute of Medicine, which developed the Fellowship. A version of this paper was presented at the Medical Care Section, American Public Health Association meetings, Chicago, Illinois, November 19, 1975. 121

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Definition of Health Services Research and Development Health services research and development has been described as an iterative process whose purpose is to influence the delivery of health care. 1 Its responsibilities may be divided into four major components: (1) the collection and the diffusion of information and statistics, (2) the development and the evaluation of new health services systems and processes, (3) research and training, and (4) policy analysis. As White and Murnaghan note, decisions must be m a d e - w i t h or without data. 2 Accordingly, "the test of data utility is whether their limits of generalizability are such that their analysis will raise the level of empiricism and improve the climate of decision making for those who must decide." Although this definition fuses research with development, the latter is often absent in practice. In short, health services research is pragmatic, has no easily defined boundaries, and is not disciplinary. It encompasses m a n y bodies of knowledge, including epidemiology, biomedical sciences, economics, sociology, engineering, systems analysis, and management science. 1 HSR and biomedical research complement each other, although there are areas of overlap. Biomedical research seeks the fundamental information necessary to prevent, treat, and control disease and to restore function and minimize disability; health services research strives to improve the availability of that information and to define and evaluate the systems in which it can be applied. Because HSR and biomedical research often address similar problems and are often funded together, it is worthwhile to note their differences, as illustrated by the example of the coronary care unit. 1 Biomedical research lays the groundwork for treatment, and biomedical engineering designs the diagnostic and therapeutic equipment. Health services research follows with these functions: (1) determines the need and the demand for such a service; (2) conducts controlled clinical trials to determine its efficacy, in conjunction with biomedical researchers, with HSR primarily considering costs, staffing, and the problems of acceptability; and (3) plans the location of such units, evaluates their effectiveness, develops methods of quality control, and compares the performances of different units. This is, of course, an idealized schema, because neither the timing nor the problems are discrete. The Effects of Health Services Research on Health Policy Policy has been defined by Anderson as "any set of values, opinions and actions which moves d e c i s i o n - m a k i n g . . , in certain directions". 3 Titmuss expanded on this formulation: policy can be taken to refer to the principles that govern action directed towards given ends. The concept denotes action about means as well as ends, and it, therefore, implies change: changing situations,

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systems, practices, behavior . . . . The concept of policy is only meaningful if w e . . . believe it can affect change.4 Thus, policy is generally thought of as rational, and as directed to specific goals and objectives that promote change. The question then becomes, to what extent does health services research currently contribute, or could better contribute, to the development of health policy. White and Murnaghan identify two levels of potential usefulness for health services research: the level of provider-consumer interaction and the level of governmental decision making. They note that the traditional models of the authoritarian medical professional and the care-seeking, naive patient are not conducive to change. Mechanic goes further, arguing that health services research poses a threat to professional a u t o n o m y , work priorities, and control over work that explains the failure of health services research to effect any changes in the organization of medical services. He concludes that recommendations for a fundamental restructuring of activities are unlikely to yield significant change, s A willingness to change, not a notable characteristic of health professionals, is a necessary precondition for change. For this reason, the results of health services research must be used primarily by government (especially Federal) employees or agents, if change is to occur. This is not to ignore policy analysis and policy planning at the State level but to recognize that the most important, far-reaching policies emanate from the Federal government. We are not surprised that periods of political conservatism recur, periods during which an emphasis is placed on State and local initiative. However, we believe that the "big" problems eventually return to the context of "big government" policy making for solutions. 6 White and Murnaghan are optimistic that the increasing body of sound research will affect Federal health policyfl Falcone and Jaeger believe that the health care field is generally not a highly politicized area and so should be relatively open to "rational" decision making. 7 In the real world of day-to-day government, the consumers of health services research are those who advise policy makers: that is, the staff of committees or members of Congress; the staff of the Secretary of the Department of Health, Education, and Welfare (HEW) and other HEW officials; the staff in the Office of Management and Budget (OMB); and the staff of White House officials. These staff members in the Executive Branch have a predominantly economic orientation presently, while physicians and lawyers are predominant in the Congress. a Thus there is a veritable tower of Babel arising from the diverse health services research consumers and producers. Health services research has been effective with and is valued by these staff members who must continually search for data to help in the decision-making process. Naturally, there is a vast difference between raw d a t a - w h i c h is difficult for the Executive and Congressional staff to interpret, because they have not been trained to do s o - a n d an analysis of that

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data to display the broad spectrum of possible policy opportunities. The search for data takes different forms in the two branches of government. In the Executive, the idea of options is institutionalized, and policy options are advocated that are based on the available data and their analysis. However, the Congress has become accustomed to reacting to Executive proposals, so that it tends to seek data that prove or disprove a particular policy approach or political position. In other words, in Congress research is often used after-the-fact to justify, not generate, policy. It should be noted, however, that the Congress is becoming more active in policy development, as is evidenced by legislation that seeks to effect policy changes with respect to health manpower and health care financing.

The Federal Health Policy Process

In American Government, public policies are determined by legislative enactment, except for those delegated to the Executive Branch and certain specialized functions that reside in the courts. 9 In practice, these distinctions are not so clear-cut. The Executive has enormous latitude in program administration and the formulation of program regulations. Furthermore, the President exercises important legislative functions. For the past several decades, most successful legislative initiatives have emanated from the Executive Branch. The President can propose, and may endorse or veto, legislation. His role is particularly strong when he can control the Congress, or when there is agreement between the executive and legislative approaches to problems. Developing a rational policy is difficult in itself, regardless of which branch of government assumes leadership. The overall goal of any policy is the "public good," a value-laden concept that is not fixed or specifically definable. 9 In a large, complex, and heterogeneous country that cherishes individual freedom, the greatest public good may very well be to protect individuals from someone else's idea of the public good. In health care, this concept is expressed in the "pluralistic health syst em " , s a concept espoused by most people, regardless of their political persuasions. Most important, the private sector dominates the health field, accounting for 60% of all health expenditures in 1974. l° Those who seek to influence policy in the health field represent a large and complex mix of public, nonprofit, and private industry interests. Even programs on the Federal level are not operated on the basis of a coherent policy. Congress both expresses and reflects the country's complexity and heterogeneity. The Legislative processes are slow, frustrating, and difficult to understand. The very structure of Congress probably precludes the development of an holistic policy. Congress is organized into an horizontal bureaucracy that decentralizes its operations, with 535 Representatives and Senators and multiple committees and subcommittees; it includes

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several centers for analytic activity, including the Congressional Research Service, the General Accounting Office, the Office of Technology Assessment, and the Congressional Budget Office. Most of the substantive legislative activity takes place in the subcommittees: indeed, more than ten committees in each chamber concern themselves with various types of health legislation. Most activity takes place in three committees in both the Senate and the House. In the Senate, health programs that fall within the purview of the Department of Health, Education, and Welfare are usually handled by two authorizing committees: Senate Finance-for the health care financing programs (Medicare and Medicaid)-and Labor and Public Welfare, for other programs such as biomedical research, the funding for the education of health professionals, disease control, and so forth. This jurisdictional split, in itself, makes the development of a rational, integrated policy for governmental health programs difficult. As an example, at present there is a regulatory program for clinical laboratories under the jurisdiction of the Social Security Administration and another program at the Center for Disease Control.* Thus, program activity is split at both the Executive level and the Congressional level. In addition, the Senate Appropriations Committee has overall responsibility for the Budget, which includes programs authorized by the two committees. In the House of Representatives, the situation is similar, except that in 1975, Medicaid and Part B (medical services) of Medicare were transferred from the Committee on Ways and Means to the Committee on Interstate and Foreign Commerce; this committee is responsible for all Public Health Service legislation. However, jurisdiction over national health insurance legislation is still an unsettled question in the House. The House also has its own Appropriations Committee that exercises responsibility for the Budget; all appropriations bills must originate in the House before going to the Senate. The split jurisdictional problems in Congress are mirrored in the organization of the Department of Health, Education, and Welfare, where major health programs are administered by three line organizations: the Social Security Administration for Medicare; the Social and Rehabilitation Service for Medicaid; and the Public Health Service, whose six health agencies are directed by the Assistant Secretary of Health. Thus, although the Assistant Secretary of Health is referred to as the highest ranking Federal officer in the health area, he actually has a limited role in the control of the major health financing programs. His programs comprise only about $5 billion a year, whereas Medicare and Medicaid account for more than $25 billion of Federal monies. 1° The Assistant Secretary's role in the financing programs is solely that of an advisor to the Secretary of HEW. The relationships between Congress and the Executive are much more complex than can adequately be described in this brief summary. In *Pending legislation would resolve this problem.

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addition to the formal relationships that have not been covered, there are innumerable informal contacts: Congressional staff may seek information on operating programs, or the HEW staff may make legislative proposals directly to Congressional staff; or either may even covertly criticize the formal policies of the Administration. Also, staff in both branches are in frequent, informal touch with academic-based policy researchers. The Department of HEW has other offices that use health services research effectively. The Office of the Assistant Secretary for Planning and Evaluation in HEW employs a staff of policy analysts whose training and experience enables them to be sophisticated consumers of research. The Office of Research and Statistics of the Social Security Administration produces fundamental policy research information for decision making. The Assistant Secretary of Health does not have such a resource group of high-caliber policy analysts; this helps to explain some of the essential weakness of his Office. This fragmentation of the program-making and decision-making processes in both Congress and the Executive Branch suggests that incrementalism, rather than the development of a coherent, rational health policy, will probably remain the predominant mode in government. The advantage of the incremental approach is that it may permit opportunities for the application of research data and for incorporating political and technical feedback. However, the passage of a national health insurance program would probably force consideration of a combination of policies, with respect to financing, organization, and resource allocations within personal health care services.

Financial Support for Health Services Research Given the complexity of the Federal policy-making processes and their organization, it is not surprising that Federal support for health services research comes from a variety of agencies and programs in the Executive Branch. The most obvious source is the National Center for Health Services Research, established in 1968 to serve as an organizational focus for investigations into the health care delivery system. Appropriations for the Center increased steadily until 1972, when they reached $56 million, and then began to decline, reaching $38 million in 1974.11 For 1976, the HEW appropriation was $26 million. This reduction is often interpreted as a reflection of a lack of interest in HSR in Congress and in the Administration. But, in reality, the sources for funding have been fragmented. Reduced appropriations for the National Center reflect, rather, the failure to project a strong image and to present a convincing case for the Center's successes in translating research into improved health care delivery systems. Actually, it is far from clear that the total amount of m o n e y spent by the Federal government for HSR has fallen. It is interesting that there is

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no single comprehensive source for information about the amounts and the sources of funding for HSR, b u t estimates made b y government officials are that expenditures for H S R in the United States are in excess of $100 million annually from all sources. Most funds are from Federal sources, b u t private organizations, including service institutions, carry out much health services research; several foundations also fund research. Industry, too, engages in activities that might properly be termed HSR. The difficulty of determining the actual figures for Federal expenditures for H S R may be illustrated b y the fact that the Office of Management and the Budget lists nine sources that dispense health research funds within the Department of HEW; 12 eight other departments besides HEW fund various types of health research. For example, the Department of Defense spent $103 million on health research in 1975; the Veterans' Administration, $91 million; and the National Science Foundation, $46 million. Some of these funds u n d o u b t e d l y were used to support health services research, as well as biomedical research, b u t H S R cannot be broken out from the aggregate totals. Within HEW, almost 10% of the appropriation for the National Institutes of Health (NIH) supports clinical trials, of which about two thirds, or more than $100 million, was for controlled clinical trials in 1975.13 Moreover, NIH analyses include economic and social, as well as clinical, factors. The demonstration and control activities of the cancer and heart programs of NIH have evaluation components that fall well within the boundaries of health services research. For example, a recent research paper commissioned b y the National Cancer Institute analyzed and made recommendations about improving the geographic siting of cancer centers. 14 In addition, two major federal sources for funding for health services research are not reflected in the Office of Management and the Budget analysis. Under Section 513 of the Public Health Service A c t , is the Secretary of HEW is authorized to spend up to 1% of health program appropriations for their evaluation; the sum comes to about $35 million at present. Most of these monies are spent for contract research and evaluation that are done b y private, profit-making firms. Congressional staff and HEW officials have suggested to the authors that these studies are of an inferior quality, evidence inappropriate timing, and reflect a consideration of issues that are n o t relevant to decision making. Campbell feels that this sort of evaluation funding has been a failure, because the findings are of such limited relevance to the programs being evaluated. 16 The Office of Research and Statistics (ORS) was established under the Social Security Act of 1935 and is a major source for funding and carrying out HSR. 17 The Social Security Amendments of 1972 (Public Law 92-603) expanded the health service research activities of the Social Security Administration, directing the Secretary of HEW to carry out studies and demonstration projects with regard to such issues as prospective payment

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systems, physician services and their reimbursement, and utilization of and payment for ambulatory care services, is A b o u t $9 million was spent for these purposes in 1975; the amounts spent have been increasing rapidly. Other funding for health services research comes from non-Federal sources. A recent survey b y the American Council on Education furnished some information on expenditures for biomedical research, including health services research. 19 Ph.D.-granting schools with a medical school (of which there are about 110) received about 32% of their average of $8 million each for biomedical research from non-Federal sources, about 20% came from State and local government sources, and 28% from foundations and voluntary health agencies. Ph.D.-granting schools without a medical school (of which there are about 178) received about 22% of their average of $1 million each from non-Federal sources, with State and local governments furnishing 31%. We tabulated the sources for funding listed in articles appearing in Medical Care, during 1975. The National Center for Health Services Research is cited twice as often as the next largest source, the private foundations. However, all other HEW sources, including the Social and Rehabilitation Service, the Social Security Administration, and the Health Resources Administration, are acknowledged almost as often as is the National Center. In addition, researchers who do not give a funding source are employed b y a wide variety of organizations, for the most part b y medical schools and schools of public health. Municipal and Federal employees are another fairly large group, and even private practitioners make contributions to HSR. , Thus, the monies received and disbursed b y the National Center are not an accurate indication of the activity in H S R as a whole; nor do they even reflect the size of the Federal share, because the H S R effort at the Federal level that was consolidated in 1968 has again become fragmented. It may be desirable to have multiple sources available for funding for such research, b u t problems multiply as well, especially those of data collection and dissemination. It is also easy to make the case that the field is underfunded, even using the most optimistic estimates of its resources, relative to the overall investment in health care. 2° Problems in Health Services Research

The greatest problem of health services research may well reside in what Williams and Wysong refer to as "disciplinary research". 21 They point out that H S R is, in fact, not a scientific discipline; rather, it is a pragmatically oriented, problem-solving activity. The objective of disciplinary research, on the other hand, is to advance the state of knowledge of a particular field, testing hypotheses derived from a theoretical framework. Gordon and Morse summarize the scholarly opinion that disciplinary

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r e i n f o r c e s the status q u o , a l t h o u g h it m a y be n e c e s s a r y for scientific w h e r e a s an " e x t e r n a l " or p r o b l e m - s o l v i n g o r i e n t a t i o n is a n e c e s s a r y f o r change or i n n o v a t i o n . T h e y say t h a t such e x t e r n a l criteria the social relevance of the research. 22 B u m s identifies the basic q u e s t i o n as one of a t t i t u d e , the scientifically selfish approach. The health services are viewed as yet another area in which the social scientist can test the appropriateness and universality of concepts he has forged or in which he can test the validity and applicability of his hypotheses of relationships. The second attitude is the professionally helpful approach. The social scientist can apply himself to the problems with which the health professions are struggling and put his knowledge and research skills to use in solving them. 23

A l t h o u g h r e c o g n i z i n g t h a t i n t e r d i s c i p l i n a r y p r o b l e m solving is desirable, Pflanz n e v e r t h e l e s s a d v o c a t e s a u t o n o m y for t h e social science discipfines w h e n t h e y f u n c t i o n w i t h i n the m e d i c a l s y s t e m . 24 T h e b a l a n c e o f p o w e r and o f p r o f e s s i o n a l values resides so heavily w i t h i n the m e d i c a l e s t a b l i s h m e n t t h a t a u t o n o m y f o r the social scientist, w i t h the a t t e n d a n t self-esteem, is a n e c e s s a r y a n t i d o t e to c o - o p e r a t i o n . He c o n c l u d e s : " R a r e l y is c o o p e r a t i o n realized in such a w a y t h a t each c o n t r i b u t e s his t a l e n t a n d k n o w l e d g e while t r y i n g to grasp the t h o u g h t a n d o p e r a t i o n a l processes o f the o t h e r discipline." I n short, i n t e r d i s c i p l i n a r y research is all t o o rare; and it is difficult to achieve, a l t h o u g h it deserves to b e n u r t u r e d . T h e slow d e v e l o p m e n t o f i n t e r d i s c i p l i n a r y activity s h o u l d n o t j u s t i f y c o n t i n u i n g b r o a d s u p p o r t f o r disciplinary research t h a t is easier to achieve a n d rests on an e s t a b l i s h e d a c a d e m i c base. P r o b l e m s in the h e a l t h care s y s t e m are t o o pressing for p o l i c y m a k e r s to rely o n disciplinary research t o p r o d u c e n e e d e d choices a n d answers. T h e b e s t e n v i r o n m e n t , if the f o r m u l a t i o n o f G o r d o n a n d Morse is c o r r e c t , 22 m u s t be t h a t in w h i c h w e l l - g r o u n d e d disciplinarians f u n c t i o n in i n t e r d i s c i p l i n a r y settings. As S c o t t a n d S h o r e s h o w , variables o f interest to a sociologist m a y n o t b e a m e n a b l e to m a n i p u l a t i o n a n d to c o n t r o l in the c o n t e x t o f an o p e r a t i n g p r o g r a m . 2s T o b e p o l i c y - r e l e v a n t , research m u s t ask the a p p r o p r i a t e q u e s t i o n s so t h a t p o l i c y decisions can a t t e m p t the p r o p e r answers. E i c h h o m a n d Bice state: Health services research conducted by university-based disciplinarians has had little impact on policy formulation . . . . Academics argue that managers and government officials cannot state objectives with sufficient clarity to make research possible . . . . On the other hand, academics are considered to be cavalier about deadlines, speciously precise about experimental conditions, and generally disinterested in the relevance of their findings to policy. Consequently, leaders . . . [in] government question the value of social science research as an aid to decision-making, while academics grow wary of the intentions of decision-makers and feel misused and misunderstood. 26

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Conclusion

It is clear that many important policies will be formulated or modified on political g r o u n d s - t h a t is, on the basis of the fundamental values and wishes of society; and then on changes in these values that are fed back through the political process of a democracy. Nevertheless, many decisions or changes can be influenced b y sound information and analysis. Health services researchers and health services research consumers alike may be expecting too much. Beddard admonished, "research will seldom, if ever, give cut and dried answers to cut and dried problems in a cut and dried area. It may do no more than supply the information for an informed guess, or set another set of questions demanding study in an entirely different area. ''27 However, as the number and variety of consumer groups in government for health services research information suggest, there is still a large untapped demand for high quality health research. It must then be asked whether such research is available, and h o w it may be improved. Anderson has stated that "systematic data gathering and research do n o t appear until a public policy consensus emerges providing a framework for social and economic research bearing on policy. ''a Despite the difficulties of the policy process in a democracy such as the United States, it does appear that the broad outlines of a consensus have begun to emerge in this country, forced b y the problems of cost, access, and the quality of medical care, all of which are therefore essential areas for health services research activity. The question r e m a i n s - h o w to make this happen. The critical task is to develop and to test the methodology for interdisciplinary, targeted problem solving. This does not mean an end to fundamental research in a disciplinary context, b u t it should mean that such endeavors should not be called health services research, thus perpetuating false expectations. We believe that Britain provides a fruitful example of h o w the field could evolve in this country. In 1971, Lord Rothschild proposed that more explicit priorities be developed in government-funded research and development, 2s and an organizational structure was therefore established. 27 This structure addresses the need that had been identified for a three-pronged organization to bring together the Department of Health and Social Security and its planning process, practitioners and research workers in the field, and a strong expert advisory team led b y a Chief Scientist. Research liaison groups have since been set up in different subject areas to meet this need and to present advice on research objectives. 29 Williams and Wysong propose an alternative b u t similar structure with the same objective, that is, to link those responsible for planning and for funding research, to those responsible for doing it, and to those responsible for making policy decisions concerning specific policy problems. ~1 The National Center for Health Services Research has already taken

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steps in this direction. 11 It may be hoped that interdisciplinary research will be nurtured within health services research centers, by means of the intramural research program mandated by Congress in the 1974 Act (Public Law 93-353). More important, the National Center has changed its direction from disbursing grants that sought an understanding of the fundamental questions in health services. That focus-which did n o t ask for policy-relevant research-probably explains in large part the perceived irrelvancy of the Center evident in some parts of Congress and the subsequent loss of support for the Center. The Center is presently endeavoring to focus its resources on issues of social utility and has defined seven program areas of special significance, including quality of care, inflation and productivity, health care and the disadvantaged, health manpower, health insurance, planning and regulation, and emergency medical services. In specifying these areas, the National Center sought consultation widely, both inside and outside the government. These steps represent principles and objectives that have been stated in the British approach. The central problem, then, is to improve the image, substance, and process of health services research without at the same time fostering overly high expectations that technical information can answer broad political and value questions. The links between the policy-making and research communities must be explicitly forged, if the questions asked are to be relevant and the answers found used. REFERENCES 1. Improving Health Care Through Research and Development, Report o f the Panel on Health Services Research and Development o f the President's Science Advisory Committee. Washington, DC, Government Printing Office, 1972. 2. White KL, Murnaghan JH: Health care policy formation: analysis, information and research. Int J Health Serv 3:81-89, 1973. 3. Anderson OW: Influence of social and economic research on public policy in the health field, a review. Milbank Mem Fund Q 44, Pt 2 : 1 1 4 8 , 1966. 4. Titmuss RM: Social Policy: A n Introduction. New York, Pantheon Books, 1974. P 23. 5. Mechanic D: Politics, Medicine, and Social Science. New York, J o h n Wiley & Sons, 1974. 6. Sundquist JL: Politics and Policy: The Eisenhower, Kennedy and Johnson Years. Washington, DC, Brookings Institution, 1968. 7. Falcone D, Jaeger BJ: The policy effectiveness of health services research. J Community Health (in press). 8. Ellwood P: Uses of data in health policy formulation. Presented at the annual meeting of the Association of Teachers of Preventive Medicine, Chicago, November 16, 1975. 9. Lindblom CE: The Policy-Making Process. Englewood Cliffs, NJ, Prentice-Hall, 1968. Pp 72-73. 10. Worthington NL: National health expenditures, 1929-74. Soe Sec Bull 38:3-20, 1975. 11. Forward Plan, F Y 1977-1981. National Center for Health Services Research, Department of Health, Education, and Welfare, 1975. 12. Special Analysis, Budget o f the United States Government, Fiscal Year 1976. Washington, DC, Government Printing Office, 1975. P 195. 13. Issue Paper--NIH Support o f Clinical Trials. National Institutes of Health, Department of Health, Education, and Welfare, August 27, 1975. 14. Ellwein LB, Lakberer JT: Optimal locations of cancer centers on the basis of population access. Fed Proc 34:1411-1416, 1975.

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Health services research and health policy.

Health services research (HSR) has the potential to influence the decision-making process in a health services system that is acutelearchers feel, wit...
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