Almost Like a Play’: Discretion and the Health Care Innovation Working Group Emmet Collins

Policy effects

The question of the policy impacts of informal relations is a challenging one. What is a ‘substantial policy impact’? Professional impacts revolved around quick turnaround and effective communication. A policy impact should therefore go beyond that. This can occur at the beginning of the process, by shaping what outcomes are sought, or at the end of the process, by linking outputs to outcomes. It is necessary here to distinguish between policy outputs and outcomes; Mills-Scofield distinguishes between the two by arguing that: “Outcomes are the difference made by the outputs” (2012). In the example of the HCIWG, From Innovation to Action would be an output, whereas the adoption of the recommendations it contains would be an outcome. In attempting to understand a substantial impact, we can adopt the following definition: Informal relations can be said to have had a substantial policy impact if they result in outputs or outcomes which are different from those set out in official communications.

At the level of civil servants, these effects could manifest themselves in two obvious ways. First, they could be evident through a whole-sale change of mandate. If officials indicate that they were able to change the mandate of the HCIWG after working together, or if the mandate noted at the end is different from the mandate at the beginning of the process, then we can argue that informal relations may have had an impact. The second manifestation is shown through inaction: even if recommendations are implemented, this is not necessarily a sign of the effect of informal relations. However, if recommendations are not implemented, this is evidence that informal relations were unable to overcome certain factors. As a result, if recommendations are not implemented, the effects of informal relations cannot be said to extend to the policy level. In sum, to understand whether informal relations had substantial policy impacts in the HCIWG, we can ask two questions: was there a change in mandate, and were recommendations implemented? In both cases, the answer appears to be no.

In the case of examining the mandate, this is accomplished fairly easily by comparing the mandate set out in the initial press release to the one noted in the 2012 report⁴. The mandates are the same in both documents: scope of practice, human resource management, and clinical practice guidelines (see COF 2012a, COF 2012b). The lack of change is consistent with the comments of people working on the file, who repeatedly noted, for instance, that: “government officials get very nervous when the premier mandates something… they will get the work done, make no mistake.”

In the case of linking outputs to outcomes, or the implementation of recommendations, the answer is less straightforward, but the conspicuous silence of the HCIWG on the issue is telling. Following the 2012 report, there have not been publicly available follow-up reports or even communiques which tracked the implementation of the recommendations. The only exception is with pharmaceutical pricing, but as noted, this work predated the HCIWG. The working group set out new mandates, but did not revisit the old ones. According to one official, this reflected the fact that the exercise was largely a political one: “We’ve been reporting all these things every year, I don’t want to dismiss it, because it created a conversation, but they haven’t really improved outcomes in any way.”

This point was a major issue for external stakeholders, most of whom felt that the HCIWG was a missed opportunity. At the outset, external stakeholders felt that they were fully involved, and dedicated time and effort to the creation of the initial report. When this report failed to translate into results, they felt that momentum dissipated, and their relationship with government became less collaborative, noting that subsequent work was presented to them as a “fait accompli”, reflecting a return to a typical “government relations exercise”. One external health stakeholder expressed frustration at the lack of follow-up between recommendation and implementation: “You can’t just say “Oh, we expect everybody tomorrow to wear purple”, and expect that to work out. People don’t know where to buy purple, they don’t know how purple exactly looks, what shade of purple, how do I wear purple, etc.”