Efficient and More Equitable? The Delegation of Authority to Determine Facility Closings in a Public Medical Health Care System: A Case Study of Ontario, Canada.

Abstract

The Independent Commission on Base Realignment and Closure represented an unusually broad and successful delegation of authority by the United States Congress. Kenneth R. Mayer (1995) argues that the Commission succeeded in its work, in part, because the process restricted activity to areas on which there was broad consensus to act and because the process insured a high degree of objectivity. Mayer also suggests that the process succeeded because it insulated individual members of the House and Senate from public displeasure over facility closings in their districts and/or states, allowing them to engage in blame avoidance while voting for closures. This paper presents a case study of another situation where an expert commission has been established to determine facility closures, the hospital system of the Canadian province of Ontario. As Ontario has a Westminster style political system and the government of the day has a majority in the legislature, there was little doubt that the decision to seek closures would be carried out. However, the government sought to minimize opposition by employing an expert commission to decide which facilities should close. While the process has proved to be efficient (in narrow economic terms) it has not succeeded in shielding the members of the governing party from hostility over the closures and claims that the process is arbitrary and inequitable. The paper presents three arguments as to why an expert commission proved less efficacious in this case than in the case of U.S. base closures: In a Westminster system with a majority government it is more difficult for the members of the governing party to escape responsibility for adverse consequences via delegation to a temporary agency.There is less consensus as to what constitutes good health facility policy than good defence facility policy. Therefore, it was not possible to achieve as broad a consensus on the guidelines that should structure the commission's work before its appointment or for the commissioners to build such a consensus themselves. At times the government has had to intervene in the process to provide guidance. This has tarnished the commission's reputation as an impartial agency.Although Ontario has a publicly financed medical health care system, the province's hospitals are (for the most part) owned by charitable trusts associated with different religious, ethnic, linguistic and civic groups. Consequently, the commission's conceptions of rationality and efficiency were often challenged for not including social equality and non-technical concerns.The paper concludes by confirming Mayer's findings that expert commissions can only successfully operate as allocators of resources if there is a clear consensus on what constitutes good policy before a commission is appointed. Therefore, their usefulness is restricted to a small number of issue areas (of which health care is not one). These problems were magnified by the structure of hospital ownership present in Ontario. The paper also suggests that the expert commission process is more likely to succeed in producing broadly supportable decisions in polities in which there is an American style division of powers or in parliamentary systems in which there is a tradition of minority governments.