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

What are the effects?

The effects of informal relations can be difficult to discern. Without direct access to negotiations over time, a researcher is forced to rely on other sources of information, namely, the accounts of the practitioners themselves. This has potential pitfalls, however, since practitioners may misremember events, or present skewed accounts. This applies when we consider the impacts that informal relations have on the working group writ large. Because informal relations are intangible, their effects are not evident. While certain interview subjects made statements such as “informal relations account for 50% of my work”, these were obviously meant as approximations.

Overcoming the issue of relying on a second hand account is possible if we consider a few separate questions. First, does the account match that of other participants? If many officials are making the same points, they likely have some basis in truth. Second, does the account have external corroboration? That is to say, is there other evidence to support it? This becomes important when we consider the tangible results of the HCIWG’s work. As we shall see, evidence (or a lack thereof) can make an important point about the impacts of informal relations. The impacts of informal relations can be categorized in three general ways. The first deals with the personal impacts, the second with professional impacts, and the third with policy impacts.

Personal effects

The first issue concerns the impacts of informal relations on a strictly personal level. Good interpersonal relations make for a more pleasant workplace, and while this may not seem like a major impact when considering informal relations as a whole, it can be significant for those who work in the trenches of intergovernmental relations.

Good interpersonal relations were the norm, according to those interviewed. Several officials mentioned that they had enjoyed the work and gotten along with their colleagues. One external stakeholder, who was otherwise skeptical of the work of the HCIWG, still mentioned the good working relationship: “I can say it was a pleasure… and the people from the government, the civil servants… were delightful and very competent, very committed, for sure they were committed, so all that was beautiful.”

Officials were hard pressed to think of examples of poor interpersonal relationships. As noted above, where certain individuals had incompatible personalities, they tended to move on from IGR work. As one official noted, “…most people who are in IGR are in it because they enjoy it. And they enjoy the dynamic of the negotiation and discussion with other, with their counterparts.” As such, it can be said that the impact of informal relations on the personal level was to improve the work for those officials doing it.

However, most interviewees were careful to note something along the lines of the following: “It works because we have to make it work. As officials, we have to make it work.” In some cases, participants were quite forceful in their insistence of that point. This brings us to the point that good informal relations were treated as being important, but not for their own sake. The effects were evident at the personal level, but not limited to it or at their most influential there.

Professional effects

The professional role of informality in intergovernmental relations is essential. The ‘professional’ role refers to the importance of informality in ensuring that civil servants are able to do their jobs quickly and efficiently. This speaks to the broader role of informality in bureaucracy. As Blau succinctly puts it, “…congenial informal relations between co-workers, and not completely detached ones, are a pre-requisite for efficient bureaucratic operations” (1963: 177). We can expect that one of the major effects of informal relations in the HCIWG is to allow for the speedy exchange of information, and, indeed, the above noted results of interviews with civil servants confirm this point.

All officials interviewed noted this ‘professional’ impact of informal relations. In the formal context, civil servants were constrained by their ‘official’ role as representatives of various governments or stakeholder organizations. This, in combination with the formal structure of an agenda and the time limits of official meetings, made formal meetings a poor setting for the exchange of information. It was only in informal settings that officials could relay the reasoning behind their government’s position, or could indicate how a proposal might be modified to be more acceptable, or were able to act as a go between for other jurisdictions, to name a few examples.

If the professional impact of informal relations can be summarized in word, it is speed. The speed with which the work could be accomplished was dependent on informal relations, according to officials. This was especially the case in the working group, because of its time-constrained nature. The report that emerged from the initial “hundred day challenge” would simply not happened: “If it had to be through a structured process, any kind of communication, we would not have achieved the outcomes that we achieved… So especially for time-sensitive items, where you’re under tight timelines, it’s quite important.” This was apparently the case in later work as well. Commenting on the work that was done on drug pricing, one official observed the importance of developing relationships with people working on pharmaceutical policy already:

“So, we don’t negotiate lower prices on pharmaceuticals. Our drug-plan departments do that, those folks, so building that really good, strong relationship with them, that’s critical… Because you can’t do that work by yourself, you don’t know. You don’t have that knowledge and expertise. So you can make that up, but then the program area comes up to you and says “What it this? This is nothing””

Interestingly, the development of informal relations seems to be a virtually mandatory impact of the HCIWG itself. In other words, the HCIWG would simply not function without informal relations, at least according to officials. This seems to be corroborated by the very existence of work such as From Innovation to Action. Creating that kind of document in such a short period of time required working outside the bounds of official weekly teleconferences. Personal impacts are secondary to the need for rapid, reliable exchanges of information. Informal relations turn on the issue of communication, and while happier interpersonal relationships are often the result, these are incidental.

As a result, we can conclude that, so far as the HCIWG was concerned, the impacts of informal relations on the professional component were significant. Work was accomplished and mandates were fulfilled because of the ability of civil servants to communicate efficiently and as needed. However, a consideration of informal relations inevitably brings us to the question of the broadest impact. If informality was necessary for accomplishing the work that was produced, did it have an impact on the substance of that work?

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.”