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

Position rules

As indicated by the name, position rules dictate the positions held by participants in the ‘action situation’. They essentially provide the scaffolding for the scenario, and different positions may hold different levels of authority (Ostrom and Crawford 2005: 193). Some scenarios may have only one position held by all participants, but this is unlikely.

Boundary rules

As defined by Ostrom and Crawford (2005), boundary rules “define (1) who is eligible to enter a position, (2) the process that determines which eligible participants may enter (or must enter) positions, and (3) how an individual may leave (or must leave) a position” (194).

Aggregation rules

Aggregation rules relate to the decision making process that is necessary to move forward. For instance, an asymmetric aggregation rule might see one participant have veto power while others do not. As Ostrom and Crawford (2005) note, “aggregation rules are necessary whenever choice rules assign multiple positions partial control over the same set of action variables.” (202). This situation describes IGR in Canada, since decision making is inherently multilateral. Moreover, IGR tends to operate on a consensus basis (with certain exceptions), meaning that it follows symmetric aggregation rules.

Information rules

Rules relating to the information available to participants in an action situation constitute an important part of Ostrom and Crawford’s framework (2005: 206). Specific examples of information rules could include rules establishing channels for communication, frequency, subjects, or official languages of communication.

The Health Care Innovation Working Group

The Health Care Innovation Working Group is an intergovernmental working group created under the auspices of the Council of the Federation (COF). It is composed of provincial and territorial health ministers, chaired by a rotating group of premiers. The working group was created in January of 2012 with a mandate “to identify innovations in health delivery that could be shared across Canada” (COF 2012b: 7). In the initial phase of the working group, the two co-chair premiers, Brad Wall of Saskatchewan and Robert Ghiz of Prince Edward Island, set out a “hundred day challenge”³, mandating the working group to draft a report on innovations that could be taken in three particular theme areas: clinical practice guidelines, team-based health care delivery models, health and human resource management initiatives. The HCIWG achieved this goal, producing the July 2012 report From Innovation to Action.

Satisfied with the initial work of the HCIWG, the premiers then extended the mandate of the working group by three years in July of 2013 and determined a new set of theme areas to seek innovation on: pharmaceutical pricing, senior care, and appropriateness of care (COF 2013b). In addition, paramedics were included in the discussions around team-based models of care, along with doctors, nurses, and pharmacists, who had been involved at the outset (ibid). In August of 2014, the premiers mandated the HCIWG to continue its work, particularly in the area of senior care (COF 2014). Significantly, the government of Québec also agreed to join the HCIWG as a full participant. Prior to 2014, its participation in this work had been limited in some respects, for instance in the work on drug pricing, although this is not unusual in the context of Canadian intergovernmental relations (see Noël 2003, Gibbins 1999). In fact, while it is beyond the scope of this paper, the decision of the Couillard government to make necessary legislative changes to allow Québec’s participation is a major development in intergovernmental relations in Canada, one worth studying further.

The HCIWG has operated on an ad-hoc basis, which is to say that it received little in the way of additional resources or funding. Many officials commented that the work was done “off the side of their desks”. Given that the working group was initially a limited exercise, this is unsurprising. With the lengthening in the mandate, this has changed slightly in recent years, for example through the creation of a secretariat to work on the issue of drug pricing.

The issue of pharmaceutical pricing has probably been the most prominent for the HCIWG, and not always for positive reasons: a much publicized 2014 report was highly critical of the seemingly arbitrary way in which the price for generic drugs was determined (Beall et al 2014). In general, the drug-pricing work of the Council of the Federation has received periodic attention and actually predates the creation of the HCIWG. The pan-Canadian Pharmaceutical Alliance (pCPA) was created in 2010, and its work was later attached to the HCIWG. The creation of a pCPA secretariat was announced in September 2014, but as this work is centered on pharmaceutical pricing in particular, this does not necessarily constitute a formalization of the working group itself.

All of the sources interviewed for this research noted that the HCIWG was a direct reaction to the federal government’s unilateral announcement in December of 2011 that it would not renegotiate a new health accord after 2014, when the previous accord expired, and would instead move to a funding model based on nominal growth in gross domestic product. According to these sources, the premiers had expected negotiation of the new health accords to be a major intergovernmental issue, and were caught at unawares when then federal Finance Minister Flaherty made his 2011 declaration. As the premiers had already planned a January 2012 meeting of the Council of the Federation, they decided to put their efforts into a common approach towards provincial-territorial health management.

The assessment of IGR officials and health stakeholder groups is reflected in the messaging that emerged from the January 17, 2012 premiers’ meeting, which was still very much focused on the surprise announcement of the previous month. Take for instance then Québec Premier Jean Charest’s comments at the press conference: “No one expected the federal government and the prime minister to side-swipe us, which happened on the 19^th of December. It is unprecedented that the federal government would walk in without any exchange of information, any discussion, any dialogue and debate, on the issue of transfers and say “here’s the decision, that’s it””(Fitzpatrick 2012).

Relatively little has been written about the HCIWG, although the issue of health administration in Canada is well covered by scholars (Banting and Corbett 2002, Lazar and St. Hilaire 2004, Wilson 2008). While certain works have mentioned the working group as part of a broader discussion of health and public administration, the Health Care Innovation Working Group has not yet been considered from the standpoint of intergovernmental relations. This is unsurprising, as the working group is one small example in the broad spectrum of Canadian IGR, but it does represent an interesting case study. As an initially limited group, it faced significant pressure to produce results in its first year. This changed to a degree with the extended three year mandate. As a provincial-territorial (PT) group, it operates without the federal ‘elephant’ in the room, but also without the related funding potential. As is common in Canadian intergovernmental relations, particularly in PT relations, the HCIWG operates on a consensus basis, which creates important limitations. It also brought in external health provider groups in a way that those providers described as unprecedented (at least initially). The HCIWG represents an interesting test-case for studying the effects of informal relations.