Health reforms, in theory, aim at creating some form of systemness, which includes, on the one hand, a more solid connection between healthcare providers, organisations and professionals and, on the other, the broad policy or systemic goals. The question of medical engagement, leadership and accountability in healthcare system reforms has been an enduring issue in health policy (Baker and Denis, 2011). Medical doctors have played a crucial role in determining the allocation and utilisation of resources in health systems and in shaping capacities to renew policy orientations and models of care (Denis and van Gestel, 2016). This book explores the role of the medical profession in health reforms in two mature welfare states: England and Canada. Both states have a publicly funded healthcare system (PFHS) through taxation. Comparative works on these two systems have already been undertaken by political scientists (Tuohy, 1999, 2012), but less attention has been paid to the specific role of medical doctors in health reforms. The role of the medical profession and the bilateral monopoly between states and the profession have been underlined as a major cause for blockages in health reforms in Canada (Lazar et al, 2013; Tuohy, 2018). In England, the medical profession has been supportive of universality of care, a central element of the National Health Service (NHS); however, during successive waves of reforms medical doctors have fiercely opposed governments’ efforts to rationalise the provision of healthcare services, trying to protect egalitarian values at the core of the system and their professional autonomy (Ham, 2009; Klein, 2013). The book investigates the multifaceted and paradoxical situation where a dominant profession – medicine – faces increasing pressures to become an active player and an ally in major policy efforts and system-wide reforms driven by governments.
The conceptual underpinning of this work builds on the contribution of various areas of studies, namely the sociology of professions, studies on professions and organisations and on healthcare law and policy. The analysis documents reformative processes from the inception of two Canadian and the English PFHS, and identifies the role of the medical profession in policy formulation. Our focus is predominantly the role of organised medicine (unions, professional associations and colleges) with their political struggles to promote and advance medical values and interests in a context where governments have attempted to transform healthcare systems. The analysis goes beyond the professional autonomy thesis to understand contemporary manifestations of medical doctors’ agency within health reforms. Empirically, the book builds on a socio-historical and institutional narrative (Suddaby and Greenwood, 2009) of healthcare reforms in both England and Canada,
The book is structured in six chapters and an epilogue. The Introduction sets out the research objectives and defines the key concepts of healthcare reforms, agency within reforms and the medical profession and government (and State) as the main agents of reform. It looks briefly at the instruments of reform available to government and at the notion of context as an element of analysis. Chapter 1 presents the theoretical framework that underpins the research. Interactions between the two main protagonists – the medical profession and government – take place in a negotiated mediating space shaped by legal and political contexts and coloured by the predispositions of each that evolve in context and through interaction over time to shape reforms. Chapter 2 describes the methodology used to trace the role of medical doctors in healthcare reforms, including the selection of cases in PFHS that enable comparative analysis, data sources and analytical processes.
Chapters 3 and 4 then present the case studies, structured according to a common template. The first section of each chapter provides a detailed case narrative tracing the main periods of reform, with key context events, government reform proposals and the responses and strategies of the medical profession and governments as the reforms unfold. A second section then analyses each of these periods of reform, looking at the drivers and shapers of medical politics, the strategies used by the protagonists, and their implications for medical politics and healthcare reforms.
This common approach to the presentation of each case enables us to provide, in Chapter 5, a comparative analysis, based on our theoretical model, to explain variations and points of convergence across the cases, and to understand how the foundation experience at the start of the PFHS, the approaches taken by government, the institution of medical politics and interactions within the mediated space come together to influence healthcare reforms over time. We conclude the book in Chapter 6 with insights into government’s ability to bring about change in healthcare and involve medical doctors in this change.
