Entrenched interests and exogenous change: Doctors, the state and policy change in Canada and the United Kingdom

Abstract

This paper discusses state—medicine relations in Canada and Britain as an expression of medicine's perceived dominance of the health policy field. The two main questions addressed by the paper are: how do institutional frameworks affect the outcome of state‐medicine conflicts, and how does the medical profession react to challenges to its policy monopoly? These questions are considered in two instances where determined state actors enacted legislation in the face of widespread and vocal medical opposition: the 1984 Canada Health Act and the 1990 NHS and Community Care Act. Contrary to much of the literature on professional dominance this paper highlights the predominant role of the state in the state‐medicine nexus and shows the conditional and ephemeral nature of medicine's policy monopoly and this monopoly's reliance on a co‐operative and acquiescent state actor. The paper further shows that institutional factors, such as centralisation, do not offer a greater opportunity for the solidification of the medical policy monopoly.