Health care practitioners: an Ontario case study in policy making Patricia O'Reilly University of Toronto Press, Toronto; 2000 432 pp. $60 (cloth) ISBN 0-8020-4420-4 $24.95 (paper) ISBN 0-8020-8224-6
Patricia O'Reilly's case history of the making of Ontario's Regulated Health Professionals Act of 1991 describes the representations from the many professional, semiprofessional and nonprofessional groups involved in health care delivery, explains the process by which these submissions were considered, and assesses the impact of the new model for health professions regulation that subsquently arose. It begins with a lengthy account of the methodology the author uses in telling this story and presents a clever intellectual framework for organizing the material. As O'Reilly argues, this history can be presented in two ways.
The first, “institutionalist,” approach is to give an account of the differences between institutional structures and regulations before and after the passage of the act. The second, “ideational,” approach requires that one tell stories that exemplify the changing ideas and cultures that surround the different groups. Enticed by the promise of policy stories, I looked forward to a gritty tale of colourful characters, pressure groups, smoke-filled rooms and passionate debate: the kind of narrative that portrays the ebb and flow of politics and policy-making in the world of Queen's Park. Instead, I was led through a rather abstract but still interesting process of well-mannered representations before a well-behaved committee that used a set of agreed-upon criteria to test submissions. The struggles were not between personalities, but between abstract ideas, such as the scientific orientation of medicine versus the much more empirical approach of homeopathy. Other differences distinguished the power of already embedded professions from aspiring seeds scattered over the professional garden. There were no individual people and few individuals' words, let alone descriptions of their dress or what they had for lunch. Everything was presented at the level of professional bodies: how they positioned submissions to the panel, and how the panel responded. The summary of results concerned who became more deeply embedded, whose professional seeds germinated and whose never got planted at all.
Being a little disappointed after such a promising beginning, I wondered how more life could have been breathed into this thorough but disembodied account. What I came up with was the following animated version of O'Reilly's tale.
Once upon a time not so very long ago there lived a king. One day he called all his healers to the court. When everyone from the stately court physician to the lowly foot masseuse had arrived, he said, “I would like you to tell me what you do, why you do it and what you think your rights and obligations should be to me and to the people of this fair kingdom.”
The king's request was seen as insulting by the court physician, who had spent years studying his science at great institutions of learning. He had built up a large practice with a staff of chemists, nurses and trained therapists. Why should he have to justify himself like the lowly masseuse, who had only a modicum of education and was indistinguishable from a camp follower? But the king's request had to be met. And so each of the healers, including those in the physician's retinue, made representations. The king himself had to attend to other business. He had a country to reign over, balls to attend, foreign dignitaries to greet and taxes to assess. Since there was such a large entourage of healers he appointed a blue-ribbon panel of wise people to receive submissions and make recommendations. He took their task seriously and so worked with them to identify questions to be asked and criteria for assessing the answers.
The healers had various arguments for bolstering their positions. The physicians, who were deeply embedded in the garden, wished to retain and increase their hegemony by keeping all others out. The partly established, whose seeds had germinated, wished to increase their clinical autonomy while distinguishing themselves from physicians. The truly excluded wished merely to gain entry to the garden and be recognized as part of the healing bouquet. The criteria were important for the panel, but as they listened they kept looking at the king's face whenever he was in the room, hoping to discern whom he favoured. As a result, some charming quacks were admitted because the king happened to smile at them, while some worthy but less graced healers were excluded by the caprice of a royal frown. In truth, many of the king's facial expressions reflected only the quality of the lunches served to the panel. To be fair, the panel was also influenced by communications from several patients and by advocates and enemies of those making representations.
In the end, some changes were made in the array of healers. But, most important, the entire exercise made everyone realize that they fulfilled their roles at the pleasure of the king. They were not as autonomous as before, because at any moment they could be asked to account for their practice. (The king, for his part, died soon after and his heir had no inclination to repeat the exercise.)
At this point my rendition enters the realm of surmise. We may speculate that one of the wise women on the committee thought (and one might agree) that the process was important enough to merit a permanent record. She gave one of her best students free run of the documents. The student immersed herself in the work, developed a helpful conceptual frame and found a way to tell the story without mentioning any of the players. This combination of diplomacy and erudition was so successful that she was herself certified as a wise woman. One might imagine that in future researches, which this reader awaits with interest, she may be wiser still — and bolder.