Health care systems throughout the Western world are receiving unprecedented attention to detail. Without such detail – with an incomplete picture – decision makers are unlikely to respond wisely in the current climate of economic restraint. In health care and all policy sectors, the policy makers and stakeholders need as complete a story of reality as possible. The more complete the story, the more likely it is that the designs and solutions arrived at will have the effect sought. One of the most important sets of actors in the contemporary health care story is its practitioners. Their roles and relationships...

To understand today’s political struggles in health care we must begin with its history of embedment and divestment. The European precursors to our present-day health care organizations embedded health care practices with the ideas of a highly controlled, hierarchical society.¹ As time went by, the embedded world of the medical practitioner of the Middle Ages underwent the pressures of the alternative ideas of the modern liberal, democratic organization of society. The political role of the church was superseded by an enlarged role for the state which carried a new balance between the private actions of citizens, such as running a...

The nineteenth- and twentieth-century reorganization of the health practitioners provided a new regulatory blueprint of monopolistic licensure for some, less-protectionist certification and/or registration for others, and exclusion for the rest. This blueprint, once institutionally adopted, reshaped the distribution of benefits and burdens within the health sector, particularly for the provider groups, the state, and the public.

What the elite health care professionals won with their gaining of licensure for their profession was, first and foremost, the right to restrict the practice of their own members as well as any intruders on their self-defined practice territory.¹ This monopolistic privilege was granted...

While the organization of the health care providers was continuing in the mid-twentieth century, the organization of both the delivery and funding of health care¹ was also being influenced by the patterns which had dominated that earlier organization. This new organization would both exacerbate the public–private tension and continue to invest in the scientific–bureaucratic rationalism along with its specialization and hierarchy. As the welfare state developed, public funding programs were put in place for hospitals and medical services.² The combination of public funding and private decision making, which was adopted in the 1960s and 1970s, left a somewhat...

Proposed restructuring of the Ontario health professions legislation in the 1980s, which began with the Health Professions Legislation Review in 1983 and culminated in the Regulated Health Professions Act of 1991, came as a result of the ad hoc relations which had developed over time in the sector. Interest group pressures on the Ministry of Health had reached inordinate proportions by the early 1980s.² In November 1982 Health Minister Grossman announced a review of the regulatory legislation governing Ontario’s health professions. It was decided that the task would best be done by a review team external to the ministry.³ The...

The restructuring process initiated by the Health Professions Legislation Review called into question the privileges, obligations, and investments contained in the existing legislation, with its history of favouring some practitioners and marginalizing or excluding others. We have seen the patterns this historical process embedded as it continued to organize the health sector in keeping with the sometimes static, sometimes shifting, principles and blueprints of the larger societal milieu in which the sector lay. Two aspects of organization on which I have concentrated, the degree of organization and the mode of organization, played important roles in shaping these patterns. They were...

Earlier we saw the overall patterns of connection which had developed over time among the provider groups. Some were antagonistic, some neutral, and some supportive, thus making up the relationships of enemies, strangers, or friends.¹ As in any policy process involving a large number of affected interests, old friends might be deserted or new enemies made. As designs for the realignment of the historical positions of authority were put forth and accepted during this policy process, the health practitioner groups struggled to adjust to the implications that this realignment would have for those positions of connection which had developed throughout...

The legislation which now largely governs Ontario’s health professionals was the product of a decade-long process of assessment, reinterpretation, and restructuring. The embedded ideas associated with health professionalism were once again being challenged by contemporary principles and blueprints for change. In Chapter 6 we saw the key ideas which had informed the original mandate of the 1983–9 policy review. The main purposes for reviewing and redesigning the existing legislation governing health professionalism were (a) to coordinate the health practitioner groups, and hopefully diffuse many of the long-standing conflicts among them, and (b) to align the rules and regulations of...

At the formal end of this health policy event, as in all policy events, a restructuring had taken place. Like the new ‘Snakes and Ladders’ board game, at the end of the game ideas which once sat outside the institution (the game board) were now embedded in it; positions were now altered; old relationships had been sustained or severed and replaced with new ones.¹ There is freedom for change in a restructuring process but the game is never played as freely as it might appear at first glance. There is always continuity as well, or as William Faulkner put it,...