Shifting Sands: Government-Group Relationships in the Health Care Sector 9780773564510

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Shifting Sands

COLLECTION ADMINISTRATION PUBLIQUE CANADIENNE CANADIAN PUBLIC ADMINISTRATION SERIES Iain Gow, A. Paul Pross, Co-editors I Co-directeurs J. E. Hodgetts Editor Emeritus I Directeur emerite En publiant cette collection, l'Institut d'administration publique du Canada cherche a promouvoir la recherche sur des problemes contemporains touchant 1'administration publique, la gestion du secteur public, ou les politiques publiques au Canada. Il cherche aussi a favoriser une meilleure comprehension de ces questions chez les praticiens, les universitaires, et le grand public. This series is sponsored by the Institute of Public Administration of Canada as part of its commitment to encourage research on contemporary issues in Canadian public administration, public sector management, and public policy. It also seeks to foster wider knowledge and understanding among practitioners, academics, and the general public.

The Biography of an Institution: The Civil Service Commission of Canada, 1908-1967 J. E. Hodgetts, William McCloskey, Reginald Whitaker, V. Seymour Wilson An edition in French has been published under the title Histoire d'une institution : La Commission de la Fonction publique du Canada, 1908-1967 by Les Presses de 1'Universite Laval Old Age Pensions and Policy-Making in Canada Kenneth Bryden Provincial Governments as Employers: A Survey of Public Personnel Administration in Canada's Provinces J. E. Hodgetts and O. P. Dwivedi Transport in Transition: The Reorganization in the Federal Transport Portfolio John W. Langford Initiative and Response: The Adaptation of Canadian Federalism to Regional Economic Development Anthony G. S. Careless Canada's Salesman to the World: The Department of Trade and Commerce, 1892-1939 O. Mary Hill Conflict over the Columbia: The Canadian Background to an Historic Treaty Neil A. Swainson L'Economiste et la chose publique Jean-Luc Migue (Published by Les Presses de 1'Universite du Quebec) Federalism, Bureaucracy, and Public Policy: The Politics of Highway Transport Regulation Richard J. Schultz Federal-Provincial Collaboration: The Canada-New Brunswick General Development Agreement Donald J. Savoie Judicial Administration in Canada Perry S. Millar and Carl Baar The Language of the Skies: The Bilingual Air Traffic Control Conflict in Canada Sandford F. Borins An edition in French is distributed under the title Le francais dans les airs: le conflit du bilinguisme dans le controle de la circulation aerienne au Canada by Les Presses de 1'Universite du Quebec L'Analyse des politiques gouvernementales: trois monographies Michel Bellavance, Roland Parenteau et Maurice Patry (Published by Les Presses de 1'Universite Laval)

Canadian Social Welfare Policy: Federal and Provincial Dimensions Edited by Jacqueline S. Ismael Maturing in Hard Times: Canada's Department of Finance through the Great Depression Robert B. Bryce Pour comprendre 1'appareil judiciaire quebecois Monique Giard et Marcel Proulx (Published by Les Presses de 1'Universite du Quebec) Histoire de 1'administration publique quebecoise 1867-1970 James Iain Gow (Published by Les Presses de 1'Universite de Montreal) Health Insurance and Canadian Public Policy: The Seven Decisions That Created the Canadian Health Insurance System and Their Outcomes Malcolm G. Taylor Canada and Immigration: Public Policy and Public Concern Second Edition Freda Hawkins Canada's Department of External Affairs: The Early Years, 1909-1946 John Hilliker An edition in French has been published under the title Le ministere des Affaires exterieures du Canada, 1909-1946: Les debuts by Les Presses de 1'Universite Laval Getting It Right: Regional Development in Canada R. Harley McGee Corporate Autonomy and Institutional Control: The Crown Corporation as a Problem in Organization Design Douglas E Stevens Shifting Sands: Government-Group Relationships in the Health Care Sector Joan Price Boase

Shifting Sands Government-Group Relationships in the Health Care Sector

JOAN PRICE BOASE

The Institute of Public Administration of Canada L'Institut d'Administration publique du Canada McGill-Queen's University Press Montreal & Kingston • London • Buffalo

c McGill-Queen's University Press 1994

ISBN 0-7735-1158-x Legal deposit second quarter 1994 Bibliotheque nationale du Quebec Printed in Canada on acid-free paper This book has been published with the help of grants from the Social Science Federation of Canada, using funds provided by the Social Sciences and Humanities Research Council of Canada, and the University of Windsor.

Canadian Cataloguing in Publication Data Boase, Joan Price Shifting sands: government-group relationships in the health care sector (Collection Administration publique canadienne — Canadian public administration series, ISSN 0384-854X) Includes bibliographical references and index. ISBN 0-7735-1158-X 1. Medical policy - Canada. 2. Medical policy Ontario. I. Title. II. Series: Canadian public administration series. RA184.B63 1994 362.1'0971 C93-090659-4 Typeset in Times 10/12 by Caractera production graphique inc., Quebec City.

To my remarkable father, Reginald Price, and to the memory of my mother, Kathleen

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Contents

LIST OF TABLES AND CHARTS ABBREVIATIONS PREFACE ACKNOWLEDGMENTS

xi xiii XV xvii

INTRODUCTION

xix

PART ONE: H E A L T H C A R E POLICY C O M M U N I T I E S A N D POLICY N E T W O R K S 1 The Nature of the Health Care Policy Community 2 Group-State Traditions and Policy Networks

3 21

PART TWO : THE EVOLVING E N V I R O N M E N T

3 The Evolving Environmental Background 4 First Steps Toward Anticipatory Policy Making 5 A Policy Community in Action PART T H R E E : P R O V I N C I A L RESPONSES 6 Culture, Institutions, and Traditions 7 The Ontario Review 8 Slowly Shifting Sands

39 63 90 115 134 165

CONTENTS APPENDICES

A Questionnaire to Selected Health Disciplines in Ontario B Questionnaire to Selected Health Disciplines in Alberta and Nova Scotia C Questionnaire after HPLR Submission of Proposed Legislation

177

NOTES INDEX

181 209

X

179 180

Tables and Charts TABLES

1.1 Statutory Status of Ontario Groups, Prior to 1991 Legislation 4.1 Chronology of Documents Discussed 6.1 Alberta's Fragmented Administrative Structure for Health Care Professions 7.1 Timetable of Ontario Review

xxiv 89 121 163

CHARTS 1.1 Health policy community, late 1960s to early 1970s 1.2 Health policy community in Alberta, late 1970s, 1980s (selected professions) 1.3 Health policy community in Nova Scotia, late 1970s, 1980s (selected professions) 1.4 Health policy community in Ontario, late 1970s, 1980s (selected professions)

9 9 10 10

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Abbreviations

AMS CCA CHA CMA CMCC CNA CNAS COHA CPA CPSO DPA EPFA HDA HPLR 1'Office MCA NSAP NSCNAA OAO OARNA OCA OCP ODA OHIP OMA ONA OPA PANS

Alberta Medical Association Canadian Chiropractic Association Canada Health Act (1984) Canadian Medical Association Canadian Memorial Chiropractic College Canadian Nurses Association Certified Nursing Assistants Committee on the Healing Arts (Ontario) Canadian Physiotherapy Association College of Physicians and Surgeons of Ontario Drugless Practitioners Act (Ontario) Established Programmes Financing Act Health Disciplines Act (Ontario) Health Professions Legislation Review (Ontario) Office des Professions du Quebec Medical Care Act (1966) Nova Scotia Association of Physiotherapists Nova Scotia Certified Nursing Assistants Association Ontario Association of Optometrists Ontario Association of Registered Nursing Assistants Ontario Chiropractic Association Ontario College of Pharmacists Ontario Dental Association Ontario Health Insurance Plan Ontario Medical Association Ontario Nurses Association Ontario Physiotherapy Association Pharmacists Association of Nova Scotia

ABBREVIATIONS

RCDS RNAA RNAS RNANS RNAO

xiv

Royal College of Dental Surgeons (Ontario) Registered Nursing Assistants Association (Ontario) Registered Nursing Assistants (Alberta) Registered Nurses Association of Nova Scotia Registered Nurses Association of Ontario

Preface This project developed from a need to explain the perceived change in the pattern of interest intermediation in the area of health policy in Ontario. When my comparative interest group study of chiropractors and physiotherapists was published in 1982,' several health care groups in Ontario asked me to speak to their associations—they wanted a "how to" session in lobbying government. At about the same time, the Ontario health minister announced a Health Professions Legislation Review (HPLR), and it soon became apparent that my 'bottom-up' study was no longer relevant—the playing field had shifted. With this review, conducted at arms length from the Ministry of Health by an outside consultant, Ontario had clearly moved away from its former approach to the development of policy toward the health disciplines. The groups to whom I spoke were resistant to my suggestions that formerly successful activities might no longer effect favourable policy, and I sought to explain—and to understand—this shift from interest group pluralism to a more positive state. The research took me further afield than I had at first anticipated, and revealed more than I expected about the development of political will in this sector. Across Canada, the medical disciplines have been the focus of expensive, extensive and exhaustive studies, yet the development of legislation permitting the self-regulation of the various health groups has become an endless exercise; legislation is reviewed, revised and reviewed again. With its HPLR, Ontario appeared motivated to resolve its regulatory conundrum. The strength of purpose of the move by the Ontario government became evident as the review progressed, first because the traditional routes of contact between the groups and governments had clearly been proscribed and second because the review team had been given a most unusual mandate; it was expected to present draft legislation rather than the recommendations reviews of this type normally yield.

PREFACE

This legislation, in almost its original form, was eventually presented to the legislature and it passed third reading in December 1991, nine years after the review was first announced. It became apparent that the remarkable nature of the Ontario review, clearly undertaken in response to the difficulties encountered in previous attempts to determine regulatory legislation in this sector, presented a unique opportunity to examine the pressures on the government that induced it to deliberately alter its approach to public policy development in this crucial area. It also precipitated questions about how other provinces were addressing what must be very similar problems. Both time and financing prohibited a comparative study of all ten provinces, so the decision was made to specifically study two others. Nova Scotia and Alberta were chosen because, with Ontario, they are representative of east, west, and central Canada, and are examples of a small province (Nova Scotia, population just under 900,000), a medium province (Alberta, population almost 2.5 million), and a large province (Ontario, population 10 million). At the time that the Ontario review was commissioned, these provinces all had wellentrenched Progressive Conservative governments, which ensured that policy differences were not determined by a difference in party ideology or a change in government. (In fact, when Ontario changed to a Liberal government in 1985 and an NDP government in 1990, policy in this area did not change perceptibly.) Much information on Quebec has also been included, because although Quebec does not meet the long-entrenched Conservative government criterion, it did move very early (1972), under a Liberal government, to strengthen its regulatory control, and it has established a rather innovative system. All of these provinces have published the discussions and recommendations of task forces and commissions that studied legislation governing the health disciplines, and some of these are quite revealing.

xvi

Acknowledgments

The process of writing and rewriting this book has absorbed much of my time outside the classroom over the last five years. The policy process that it traces, originally expected to reach fruition by 198788, in fact carried on until 1991. A study such as this is highly dependent on the cooperation and openness of the people interviewed, and I have been fortunate in finding these qualities in many of those whom I have contacted. While they are not identified by name, I am extremely grateful to them—their assistance has been invaluable. Much of the empirical detail appeared as part of a doctoral dissertation at York University under the demanding but gentle supervision of the late Donald Smiley. Although the final manuscript bears little resemblance to the original dissertation, I would like to think that Don would be pleased. The "writing and rewriting" has been done in response to the comments and criticisms of the reviewers of the manuscript. I owe a particular debt to Dr J. E. Hodgetts, the former general editor of the Canadian Public Administration series, of which this book is a volume. His extensive and thorough comments on the original and subsequent drafts helped me with some particularly difficult issues; the finished product owes much to his perceptive analysis. Paul Pross of Dalhousie University, who prefers not to be an anonymous reviewer, reviewed the entire manuscript more than once for the Institute of Public Administration of Canada (IPAC) and unerringly made suggestions that added insight and breadth. To the anonymous referees, one for IPAC and two for McGill Queen's University Press and the Social Science Federation, I also extend my gratitude. Although the process at times seemed onerous, I believe that the manuscript improved greatly as a result of their careful comments. I hope that they agree. When the manuscript reached the publication stage, this was facilitated by the encouragement of Joan Harcourt, Acquisitions

ACKNOWLEDGMENTS

Editor for McGill-Queen's, and by the meticulous copy editing of Frances Rooney. I am grateful to them both for their help and their good humour. A word of thanks goes to the staff at the University of Windsor, who so patiently produced the several drafts. Barbara Faria, in the Political Science Department, cheerfully deciphered my handwriting and typed the original draft, and our invaluable Word Processing Centre, staffed by Lucia Brown, Pat Jolie, and Diane Dupuis, put the drafts on disk, and produced an impeccable final product. Support for my research travels was entirely a family affair. My husband and I provided most of the funding, and I am grateful to my brother, Stanley Price of Calgary, for financial assistance. Finally, I must express my appreciation to my family for their unfailing support and encouragement. My husband, Jim, and my children Mary Kay, Christina, John, Jeff, and Daniel, have patiently endured the predictable family disruptions and disorder that occur when a wife and mother is constantly absorbed by a project such as this. This book has been published with the help of a grant from the Social Science Federation of Canada, using funds provided by the Social Sciences and Humanities Research Council of Canada. I also wish to thank the Faculty of Social Science at the University of Windsor for a grant in support of publication.

xvm

V \

Introduction

With the growth of a complex, technologically based society, and the development of mass education and universal suffrage, the task of pluralism in reconciling democracy and elite control is growing heavier. This is particularly true in areas where the elite predominance produces policies that are too self-serving for the democracy to accept. Naturally, this is most likely to occur in periods of economic difficulty when resources are scarce. Yet pluralism is, itself, a cause of such periods by preventing rational planning of a global nature for the society at large. H.G. Thorburn "Canadian Pluralist Democracy in Crisis"

The Thorburn quote above captures much of the essence of the changing health care sector, and underlines its increasingly troublesome nature. The disciplines involved, composed of semi-autonomous professionals and paraprofessionals, absorb a substantial proportion of health care funds, 1 yet their relationships with governments and among themselves have remained largely unexplored. Although these groups are all self-regulating to some degree, provincial legislation determines the manner in which they provide services to the public, and the manner in which they are remunerated. Historically, this is an area that has been dominated by an elite group—the medical profession— which is now competing for scarce resources with other, highly-educated groups (registered nurses, chiropracters, physiotherapists, among others). Mass education has also added to the problems governments face when developing regulatory legislation in this area, for the consumers of medicare make demands for services based on their high expectations of the system. The difficulties are exacerbated by the esoteric and technologically complex nature of the health care field

INTRODUCTION

which ensures that governments depend on the various groups within the sector to aid in the formation and implementation of public policy. These features have led to complicated relationships that are often highly competitive on the one hand and cooperative on the other. The need for government-group cooperation has increased directly with government intervention in this area, but the competition among the groups has steadily intensified. That is, with the development of a welfare state of which health care is an integral part, the importance of consensual relationships redoubles, yet these relationships have become more conflictual. It is the thesis of this book that the increasing conflict within a fundamentally changing environment provoked the provincial governments to re-examine their health care systems, specifically the regulatory legislation governing the various disciplines, in an attempt to bring rational planning to a complex problem. In Ontario, for example, where the pressures were most acute, the government embarked on its unusual Health Professions Legislation Review (HPLR), a comprehensive review of the legislation governing all the health disciplines in Ontario conducted quite apart from the ministry of health by a neutral third party utilizing consultation and carefully managed and controlled interest group input. The mandate of the HPLR was to devise draft legislation, not recommendations, a very different approach from the many previous task forces and commissions. Its top-down thrust and tightly co-ordinated approach met resistance from the well-entrenched interests long accustomed to governments responsive to individual and isolated interest group input. This last point illustrates the importance of institutionalized structures and processes to the patterns of policy development. In fact, it could be argued that the long-institutionalized pluralist relationships in this sector, dominated by the medical profession but also exploited by other health care groups, led to institutions incompatible with evolving state policy objectives. If, as Stephen Krasner suggests, "the range of options available to policymakers at any given point in time is a function of institutional capabilities that were put in place at some earlier period, possibly in response to very different environmental pressures,"2 then the nature of the Ontario review suggests that it was the government's attempt to expand its range of options. That is, it would appear that the constraints of long-established patterns of interest intermediation led to state-initiated changes in these patterns. This book, then, attempts to describe and understand very complex interdependent relationships by examining the actions of governments, the actions of societal interests, and their reciprocal effects on one another. The relationships are changing because of the extreme internal and external pressures on both governments and groups of an uncertain xx

INTRODUCTION

environment, difficult economic conditions, strained federal-provincial relations, and the changing roles of professionals in society. It has been necessary to employ several different theoretical frameworks in an effort to clarify these complicated, changing relationships. Although these theories have been developed to analyse and explain policy phenomena in various economic sectors, they can assist in understanding policy outcomes in this essentially social sector as well. For example, the recent and expanding literature on the concepts of policy communities and policy networks is particularly relevant to a policy field so greatly influenced by societal interests; this literature allows for flexibility in the community and in the types of networks that can develop. Second, theoretical models which recognize the autonomy of state institutions are also important, since this is a sector in which governments have steadily increased their intervention and direction and have tried to eschew reactive policy making in favour of a more anticipatory approach. Another theoretical model that is crucial to this area is Theodore Lowi's conception of redistributive politics.3 Paul Pross develops Lowi's concept in an important 1982 article,4 and suggests that redistributive politics (of which medicare is an example) requires an ideological "paradigm shift," a move from pluralist to more state-directed, planned policy making. This has also been suggested by the Thorburn quote cited above, and it is the evidence and causes of this creeping paradigm shift over the decades since medicare that this study examines. The shift is most apparent in Ontario, although it has been evident in Quebec since the 1970s, and is nascent in Nova Scotia and Alberta as well. PURPOSE AND ORGANIZATION The central purpose of this study is to explore the causes and implications of Ontario's precipitous move. A second purpose is to attempt to explain cross-provincial policy divergences in this area, since other provincial governments face similar environmental pressures (economic, federal-provincial and interest group) but have responded in different ways. The comparison of Ontario with Alberta and Nova Scotia, and to a lesser degree Quebec, also underlines the uniqueness of the Ontario action in the 1980s. Part One sets the stage by applying theoretical concepts to establish the nature of this policy community and examining the importance of group-state traditions to its development. Chapter 1 begins with a brief discussion of the policy community/policy network debate and its application to this sector. It then describes the policy community and its internal dynamics and examines some of the sector-specific features relating to the political xxi

INTRODUCTION

sociology of professionalism (professional development, ambition, and evolution) which make this a particularly difficult area for policy development. Chapter 2 discusses the relationships among factors such as state autonomy, institutions, and the types of networks that can be expected to develop, focusing on the macro or nation-state level. The discussion suggests that these factors are also useful to explain state behaviour at the meso or sectoral level and at the micro or provincial level. The chapter also examines the relevance of pluralist and corporatist policy networks to medical politics in Canada and the conditions for reactive and anticipatory policy making. Part Two shows how the inherent difficulties in this sector have been exacerbated by the development of a national medical insurance program since 1966, and Chapters 3 and 4 examine this evolving environmental background and various provincial moves toward anticipatory policy making. Chapter 3 takes a historical approach to the development of health insurance and the imposition of economic restraint as the federal government decided to extricate itself from financial responsibility for the rapidly escalating and unpredictable costs. The gradually more proactive moves traced in this chapter exemplify the centralized decision-making that Theodore Lowi associates with redistributive policies and the protracted conflict that such policies engender. Chapter 4 examines some of the documentary evidence produced by committees in these provinces; the drafters of these documents clearly foresaw the problems inherent in the implementation of health insurance, and they emphasized the growing need for coordinated planning. Chapter 5, which looks at interest group activity, helps to explain why attempts at anticipatory policy making have so frequently been frustrated and reactive policy making has been the norm. It argues that here is an example of the failure of "interest-group liberalism"5 that has encouraged moves toward a more positive state in this sector. Part Three examines government and group responses to the gathering pressures and changing context. Chapter 6 relates divergent provincial political culture and institutionalized relationships to policy making patterns, and Chapter 7 is a close examination of Ontario's rather remarkable review. The concluding chapter discusses the implications of the findings for group-state relationships in Canada. It argues first that the fundamental shift from distributive to redistributive politics in this sector has been accompanied by a requisite underlying shift in the ideology of policy making. Second, it suggests that the different policy networks that have developed in the different provinces have reflected underlying structures, historical backgrounds, and political culture. Finally, it concludes that the unusual move in Ontario in xxii

INTRODUCTION

the 1980s was a deliberate attempt by the government to alter the historical patterns of interest intermediation by channeling input away from government representatives and effectively delegating decisionmaking authority to an extra-governmental body. It also suggests that with this conscious and dramatic effort by the Ontario government to alter the institutional arrangements through which group-government interactions had traditionally been channeled, a clear and unwelcome message of the "shifting sands" of policy making was sent to the health care groups. Many of the groups were unwilling to relinquish the historical patterns of intermediation, and demonstrated by some of their actions that although the state has become "embedded" in this sector of society, the sector remains embedded in the state.6 THE PARTICIPANTS The groups which will be discussed (physicians, registered nurses, registered nursing assistants, optometrists, chiropractors, pharmacists, physiotherapists, dentists, dental hygienists, denturists) are the highprofile groups long recognized as members of the health care community (see Table l.l). 7 In the 1970s and 1980s, they were joined by many other groups seeking to establish relationships with the government (150 briefs from individuals and groups were submitted in response to the Ontario Review team's first call for input). Many health-related disciplines with active interest groups have not been included in the study (such as midwifery, shiatsu therapy, acupuncture, respiratory technology) because they did not meet the criteria that they be long-established occupations with a recognized period of professional training, institutionalized group structure,8 and governing legislation permitting some degree of self-regulation. Most of the groups discussed have national as well as provincial associations and areas of practice that they feel constrained to protect and enhance. Some of them (nurses, physiotherapists, chiropractors) have developed strong and militant national associations in an attempt to realize consistent legislation; others (certified nursing assistants, dental hygienists, denturists, pharmacists) have more active provincial organizations. Many have strong and aggressive national and provincial associations (chiropractors, nurses, physiotherapists, optometrists). The "senior" professions (medicine and dentistry) have powerful, well-organized national and provincial associations that have enjoyed a symbiotic relationship with governments, and they share a desire to protect and sustain the hierarchical, independent, and paternalistic status quo of medicine. These groups have all established contacts with specific public servants within the health ministries, some with xxiii

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