Explaining pragmatic trials to pragmatic policy-makers

In seeking to differentiate between explanatory and pragmatic trials of new interventions Malcolm Maclure is keen to argue that pragmatic trials are more likely to be useful, and therefore of interest to "policy- makers". But as is so very common in the health policy literature, it remains unclear precisely who "policy-makers" are.

The strength of Maclure's commentary is that he observes that the persons that trials are meant to influence are diverse. Unlike many, he has a more variegated concept of "policy-maker" which include clinicians and persons working for what he describes as "central government" and "regional governments" by which it would seem he is thinking of regional health authorities.

But this is only a start. Any given trial, indeed any incremental bit of health policy research, will potentially be of interest to a wide range of so-called policy-makers and will inform (or not) a wide range of decisions. However, a much more sophisticated conception, dare I say model or even theory, of policy-making is required if we are to be able to understand the potential of pragmatic trials. In this commentary there is the usual ambiguity as to whether the policy-maker is an elected official, a public servant, a senior administrator in a health region or a hospital, or an individual clinician. There is also the usual ambiguity as to the nature of the decision the putative policy-maker is expected to make based, at least in part, on the results of the trial. Surely it makes a difference if the policy affects the patients of a single physician as compared to the citizens of all of Canada, assuming that the federal government has the authority to decide.

In other words, while Maclure is correct to say that policy-makers values pragmatism, how much they value it depends on who they are, the nature of the decision they are making, and how many other people are involved in the decision.

Conflict of Interest:

None declared