This timely comparative study assesses the role of medical doctors in reforming publicly funded health services in England and Canada.
Respected authors from health and legal backgrounds on both sides of the Atlantic consider how the high status of the profession uniquely influences reforms. With summaries of developments in models of care, and the participation of doctors since the inception of publicly funded healthcare systems, they ask whether professionals might be considered allies or enemies of policy-makers.
With insights for future health policy and research, the book is an important contribution to debates about the complex relationship between doctors and the systems in which they practice.
This chapter presents the conceptual framework underpinning our research. It looks at elements of the legal and political context that influence the role of medical doctors in healthcare reforms. It then analyses scholarly work on the sociology of professions and the interface between professions and organisations in order to better understand the predispositions of medical doctors in the context of reforms. The chapter closes with a presentation of the theoretical model that guides our empirical inquiry.
Social scientists have long been interested in the study of change in institutions (Pettigrew et al, 2001), which requires attention to the intricacies of context (political, economic and legal), history and process that impact on change (Langley et al, 2013). Context is thus considered an environment in which agency and change co-evolve as a response to situational or conjectural opportunities and limitations (Johns, 2006). Norms and rules within a given context limit or encourage the expression of human agency. For example, national political and legal institutions (Immergut, 1990), such as courts with judicial power, provide an overarching context that shapes the negotiating space where governments and medical doctors engage in reforms.
In this first section we focus on specific components of the legal and political context that condition the space in which governments and professions interact in healthcare reforms. Legal and political elements associated with this context operate alongside secular trends such as changing demographics, economic conditions and technological and epidemiological shifts to impact the healthcare system’s ability to meet population needs.
The objective of empirically exploring the role of medical doctors in healthcare reforms and policy changes raises a number of methodological questions. What data set should be considered? What is the appropriate period of study (that is, when should analysis of reforms start and end our)? What context-specific elements, whether jurisdictional or situational, influence agency in healthcare reforms? What characterises the roles played by various actors in the reform process? With what influence on context and policy outcomes? What methods should be used to compare case studies? These questions led us to consider methodological developments in contextualist and process research (Mintzberg and Waters, 1982; Pettigrew, 1987, 2012; Langley, 1999), which appear as a plausible way to approach policy research. We thus look at policy changes, such as healthcare reforms, as a continuing system in becoming (Pettigrew, 1987; Tsoukas and Chia, 2002). We rely on comparative longitudinal case studies (Fitzgerald and Dopson, 2009) to track the evolving dynamics of healthcare reforms and medical politics in two national empirical contexts: the NHS in England and the healthcare systems of two Canadian provinces: Quebec and Ontario.
A number of logical arguments support the selection of these two national jurisdictions for our research. Both have a tax-based PFHS. Both have been fertile ground for healthcare reforms and are frequently selected as case studies in comparative health policy analysis (Tuohy, 1999, 2018).
The federal context in Canada warrants attention as it influences the negotiating space for provincial governments and medical doctors. While healthcare services are mostly under provincial jurisdiction (Section 92, Constitution Act 1867), the federal government plays an important role, particularly by using its spending power to uphold national standards (for example, with respect to insurance coverage for services provided in hospital or by medical doctors via the Canada Health Act, 1985).1 To various degrees and at different times in the history of Medicare in Canada, provincial governments have seen federal spending intervention as an attempt to exert control in a provincial domain (see Commission d’enquête sur la santé et le bien-être social, 1967–1972, for example). Frustrations were especially high when the federal government significantly reduced its financial contribution to provincial health systems during the recession of the 1990s (CPHA, 1995; Snoddon, 1998; BCMA, 2000: 14) while still requiring that provinces meet the same national standards.
Spending power is the federal government’s main means of influencing provincial or territorial health insurance plans. As part of the reformative social policy agenda that emerged after the Second World War, the federal government adopted the Hospital Insurance and Diagnostic Services Act in 1957. Under the Act, the federal government would cover approximately 50 per cent of provincial and territorial expenses for hospital and diagnostic services, conditional on provinces or territories respecting criteria such as universality (such criteria would later be integrated into the Canada Health Act).
For a better understanding of the historical role played by medical doctors in the NHS healthcare reforms, we need a few preliminary words on the process of law-making to reform the healthcare system in England.
Usually, the reformative process is ignited by an inquiry or policy proposal. In the early years of the NHS, the government established Royal Commissions as ad hoc committees (House of Lords, 2007) tasked to lead investigations that triggered reforms. This long and burdensome process later gave way to more targeted inquiries to inform policy changes (for example, the Griffiths Report or NHS Management Inquiry, 1983).
The government could also put forward reform strategies and policy proposals in a publicly released White Paper, offering stakeholders the opportunity to provide written or oral responses that are valuable in highlighting any controversial areas. Parliament has, at times, been convened to debate responses to White Papers before the government proceeds with a formal legislative proposal or Bill to be ‘read’ (examined and debated) three times in Parliament (Select Committee on the Constitution, 2017–19). The draft law is then presented either to the House of Commons or the House of Lords (or sometimes both) and, if passed, receives Royal Assent before becoming law.
While stakeholders are not invited to interact directly in the House of Lords or the House of Commons, their support or objections are relayed by Lords or members of the House of Commons who act as unofficial spokespersons because their political interests align or because they are themselves members of a Royal College of Medicine or the British Medical Association (BMA) (Select committee on the Constitution, 2017: 14).
In this section, we present a set of analytical themes and considerations derived from our analysis of the three empirical cases in England and Canada. The intent is to elucidate the implications of our research on how we understand the medical doctor–healthcare reform nexus and to test our theoretical model’s ability to explain key variations and points of convergence across the cases.
We first examine the impact on healthcare reforms of the deals and policy parameters set at the inception of PFHS. We identify foundational elements that set the scene for future debates and negotiations between the government and medical doctors in the development of reforms. Contextual factors push governments into this most significant health reform, and the creation of PFHS is a revelatory moment. It shows how the two protagonists become engaged in a common endeavour with different expectations and abilities to influence the architecture of the system. The spirit of the initial agreement and the growing interdependence between governments and the medical profession has enduring implications for their future relationship.
Second, we delineate how governments address core policy dilemmas in the context of PFHS. Manifestations of the agency of governments within the mediated space of reforms are shaped by intense political pressures to respond to dilemmas such as escalating costs and problems with access to care. They also interface with the medical profession’s reactions to reformative propositions. On the one hand, governments need to secure the collaboration of a powerful insider, the medical profession, and mobilise a diversity of policy instruments that go beyond coercion.
Healthcare is central to the functioning of contemporary states, so much so that political scientists have coined the term ‘mature healthcare states’ (Tuohy, 2012; Ferlie and McGivern, 2013). Our research focuses on the role of medical doctors in reforms within mature healthcare states. Narratives of network governance in the last 30 years highlight governments’ inability to achieve policy changes and objectives on their own (Rhodes, 1996; Torfing, 2005). They need the expertise and agency of non-state actors to bring about policy innovations and change. As suggested by Rhodes (1996), governing without governments opens up a rich dynamic where state, non-state, traditional and non-traditional policy actors, each with their own projects and preferences, reinvent society. Our research looks at the prospect of joint policy-making in healthcare, focusing on the specific case of the relationship between governments and medical doctors in healthcare reforms.
Tensions and conflict persist in the network narrative of governance, but can, in principle, be transcended by setting up adequate, effective and collaborative modes of governance (Ansell and Gash, 2008). The political and policy modus operandi embodied in the network governance narrative is associated with the challenge of achieving consensual politics in a landscape of potentially conflicting preferences, values and interests. Our research empirically probes these tensions and the difficulties of achieving consensual politics while responding to governmental demands for major change. The basic intuition of network governance is that a participatory and open policy process becomes a predominant principle of policy-making in contemporary states as the legitimacy and scope of coercion is reduced.
As an epilogue, we completed this analysis just before the COVID-19 pandemic. We have since been able to observe the commitment and dedication of front-line clinicians, medical doctors and others healthcare professionals and workers in dealing with extraordinary and immense pressure to deliver care, often at considerable risk to their own health. In a sense, the commitment of medical doctors confirms one of the key findings of our study: the discrepancy between medical politics and the day-to-day accommodation between the medical profession and the healthcare system. It is self-evident that healthcare systems would greatly benefit if the dedication and willingness seen in clinical matters could percolate to policy level decision-making. This is the main reason we stress that joint policy-making is not just a responsibility of medical doctors, but also of governments that need to find a way to adequately mobilise medical doctors at a collective or policy level.
Beyond this, COVID-19 has become part of the distal context that could trigger policy shifts and radical healthcare reforms. This major public health crisis has created a significant burden on government finances, led to an important reorganisation of resources in healthcare systems – including the delay of essential care such as cancer treatments – and generated an extra burden on some healthcare professionals now facing increased fatigue and burnout (Denning et al, 2021; Gemine et al, 2021). It has also revealed how painfully inadequate healthcare systems have become in dealing with public health issues.
This Introduction defines our research objectives and the key concepts underpinning our inquiry. We look at reforms in contemporary welfare states, which include England and Canada (Denhardt and Denhardt, 2000; Bejerot and Hasselbladh, 2011; Ferlie and McGivern, 2013) and on their implications for the potential roles and manifestations of the agency of medical doctors (Denis et al, 2016).
The question of healthcare reforms has attracted growing interest among policy analysts and health researchers (Greener, 2009; Ham, 2009; Lazar et al, 2013; Tuohy 2018; Germain, 2019). Reform is a privileged mode of intervention used by liberal democracies to intervene in various policy areas (Rocher, 2008). In their comparative analysis of public management reforms, Pollitt and Bouckaert (2017) define reforms as ‘deliberate changes to the structures and processes of a system with the objective of getting them (in some sense) to run better’ (Pollitt and Bouckaert, 2017: 2). In the healthcare context, this means improving patient experience, healthcare professionals’ satisfaction with work, population health and long-term system viability. Pollitt and Bouckaert’s analysis suggests that reform is embedded in a complex web of institutional arrangements and political processes that shape the destiny of reformative ideas and reformers (Marmor and Wendt, 2012; Tuohy, 2018; van Gestel et al, 2018). As suggested by Mechanic and Rochefort (1996), comparable healthcare systems of various nations face similar challenges but their responses vary according to national context and institutions.