Sweet Nothings? The BC Conversation on Health
Given the tenor of the provincial government's Throne Speech, the September 28, 2006 formal launch of the Conversation on Health was met with cynicism. Reaction by the BC Health Coalition was typical: "We don't really trust this process because it appears that the premier has already decided we can't afford our public healthcare system and he intends to shape the debate around that view" (BC Health Coalition 2006). State-sponsored participation is rightly regarded with suspicion - a mechanism for manipulation and co-optation (Christiansen-Ruffman 1990). The risk of manipulation is particularly grave when the government's position has been unequivocally stated in advance of consultation. Even the opening question was a leading one: "Why are we so afraid to look at mixed health care delivery models?" (Government of BC 2006: 10).
Casting further doubt about the influence of public voices, the Speech from the Throne committed the government to act before hearing any of the conversation. The Throne Speech promised legislation enshrining the five principles of the federal Canada Health Act plus a new principle of sustainability. The target appears to be the federal government principle of accessibility, which is intended to preclude provincially authorized financial barriers to publicly funded health services. Sustainability, defined as "financial sustainability" of provincial healthcare financing, places limits on "free access" whenever the pressure on the provincial treasury is judged by the provincial government to be too great. Unmentioned in the Throne Speech is the fact that British Columbia already has legislation enshrining the five principles of the Canada Health Act. The BC Medicare Protection Act was introduced by the New Democratic Party specifically to make it more difficult for subsequent BC governments to pursue private healthcare financing and delivery options. As the preamble puts it, "the people and government of British Columbia believe it to be fundamental that an individual's access to necessary medical care be solely based on need and not on the individual's ability to pay" (Medicare Protection Act 1996). Thus, the Campbell government's commitment must mean either significantly amending or rescinding the Medicare Protection Act, presumably in order to permit private payment for hitherto guaranteed public health services. But nowhere does the government refer to this goal of user pay. Instead, the Throne Speech refers to "better access, greater choice, increased flexibility and new options" (Government of BC 2006: 11). Thus, it did seem disingenuous that the question: "How to strengthen the Canada Health Act?" was mandated for public discussion in the Conversation when the government had already unequivocally answered it.
Cynicism grew because both the BC government's purpose and methods were, and remain, questionable. Why, for example, did the government think more consultation was necessary? Extensive public consultations occurred in British Columbia during the New Directions healthcare reform in the mid-1990s (Davidson 1999) and continue up to the present, albeit mainly at the micro-level of health programs and services, through the Regional Health Authorities' Community Health Advisory Committees, patient focus groups and various ongoing regional and local public consultations (Vancouver Coastal 2006). Moreover, major public consultations on macro policy issues were conducted by the National Forum on Health in 1996 and the Commission on the Future of Health Care in Canada in 2002. The findings from those public consultations have been remarkably consistent. Canadians, including British Columbians, "want to keep the core principles of the Medicare model that accord with their strongly held values of universality, equal access, solidarity, and fairness" (Maxwell et.al 2002: vi). Among key themes from the recent Commission on the Future of Health Care rounds of consultation: (1) eliminating waste and improving management is only part of the solution; (2) primary care must incorporate more teamwork and improve coordination; (3) record keeping, communications and healthcare provider accountability must improve; (4) more funding is necessary; (5) additional funding should come from public sources, with increased taxes if necessary; (6) a parallel healthcare system ought not to be permitted; and (7) some private payment and market mechanisms may be appropriate as long as they are restricted to non-core/non-essential health services (Maxwell et al. 2002: vii). Subsequent national polling has yielded similar expressions of support for public funding of healthcare ("The Pollster Will See You Now" 2004).
Equally important is the question: How can consultation be meaningful and its results valid? "First, there must be a suspension of [government] action to create the political space for the deliberation to take place" (Rosenberg 2007: 340). This patently did not happen in British Columbia. Instead of a moratorium on healthcare change until the results of the Conversation were in, a premier fully satisfied that more private healthcare was workable and even desirable contributed to expansion of private healthcare. In light of the Throne Speech, the False Creek Surgical Centre, one of a number of private treatment clinics in the greater Vancouver area, decided to forge ahead with its plan to offer privately financed emergency and outpatient treatment services to walk-in clientele. Its owner wrote the government outlining his plans, and receiving no reply, assumed he was reading the signals correctly. When the clinic opened in late November 2006 to howls of protest, the government belatedly intervened. The private clinic reopened in April 2007 after recruiting doctors who were fully opted out of the provincial medicare plan and is currently operating unmolested by the Campbell government (Rolfsen 2007).
Second, once political space is created, participants must be representative of the relevant population, the process inclusive and means deployed to force meaningful deliberation over values and options (Rosenberg 2007). The National Forum and the Commission on the Future of Health Care came close to meeting those requirements. The Citizens' Dialogue on the Future of Health Care, for example, employed random sampling, scenario construction supported by well-evidenced reports and, perhaps most importantly, design features that forced citizen participants to identify and make trade-offs as opposed to merely tabling observations and suggestions. The Conversation fell far short. Rather than a cross-section of citizens, participants were essentially self-selected. Once discussions were convened, no effort was made to confront differences in values or create a coherent vision of the healthcare system. Participants were free to render whatever comments and observations they had, essentially context-free, without consideration of trade-offs or opportunity costs.
Despite the lack of methodological rigour, the government's approach to consultation at least seemed fair from a procedural standpoint. The Conversation was designed to be open, with questions and issues posed by government but with allowance for citizens to suggest other matters for discussion (Ministry of Health 2007a). Features of the Conversation included a plan for 16 regional forums of 100 lay participants. (Professional healthcare providers were excluded, but paraprofessional and alternative healthcare providers were welcome.) Later, in reaction to criticism, the government added focus groups of professional healthcare providers.
However, public response, perhaps because of the background conditions, was muted. Out of British Columbia's over-19 population (3,339,470), a total of 4,586 (0.1372%) applied to attend the 16 forums (Statistics BC; personal communication BC Ministry of Health, April 27, 2007). Although the target size of each forum was 100 participants, only between 61 and 88 were actually recruited to the 11 forums held before May 1, 2007, with a mean attendance figure of 75 (Ministry of Health 2007b).
Participants were mailed a Regional Public Forum Participant Registration Package consisting of a letter from the minister of health and 11 "conversation starters." The packages made clear the difference between what was envisaged in the Conversation and a citizen deliberative process. Citizen deliberation relies on balanced expert opinion with regard to technical issues and strategies, looking to citizens primarily for synthesis and consensus on normative dimensions (Abelson et al. 2003, 2007; Dryzek 2000). The conversation starters, in contrast, were deliberately one-sided and provocative. For example, starters feature highlighted text boxes with such content as, "Did you know in Sweden and France, patient cost-sharing and co-payments are required for many services, such as doctor's visits, hospital care, medical devices and pharmaceuticals?" Those claims appear without context, explanation or reference. One starter, "About Seniors and Aging," resorts to apocalyptic demography. Projections of growth in numbers of seniors are coupled with the statement "studies show that people in their 90s use approximately $22,000 in health services each year - 10 times what people use on average in their 50s" (Ministry of Health 2007b).
Strangely, though, forum facilitators did not use the starters, indeed barely referred to them. The format of the regional forums, to the government's credit, left participants free to suggest areas of discussion and to choose their own focus groups and topics. Government reports on regional forum discussions indicate participants set their own agenda and largely ignored the government's resource material. Strong support for existing public programs is the common thread, along with recommendations for their expansion into more effective home care and drug programs (Ministry of Health 2007c). While many excellent ideas have been expressed for healthcare improvements, there has been little evidence of appetite for more healthcare privatization or private financing. This is scarcely surprising, as one would expect the supporters of medicare to mobilize against a government they regard as misguided, whereas those supporting the government no doubt believe it will travel its established course (Contrandriopoulos 2004).
At first glance, the Conversation is an example of British Columbia's commitment to citizen deliberation. It is apparent that the BC government has been influenced by trends in California, the United Kingdom and elsewhere to use deliberative bodies to resolve policy issues. In fact, the province was briefly a leader in this regard when the Campbell government chose to use a citizen panel, the BC Citizens' Assembly, to research and identify for government appropriate changes to the BC provincial electoral system. The government followed through by taking the Assembly's recommendation to the general public in a 2005 referendum - a high point in BC democracy. Unfortunately, the Conversation, in contrast, marks something of a low point.
The complexity and expense, and the language of deliberation and consensus building, imply the government must have been reaching for something beyond mere information seeking - not just "consultation" but some kind of "citizen participation" (Culyer 2005). However, while superficially deliberative, the Conversation's eclectic mix of face-to-face discussions, electronically mediated communications and "conversation starters" were not designed to yield specific recommendations or even focus on any specific questions. The website and the minister's letter to forum participants talked only vaguely about information gathering. Characterizing the activity as merely information gathering is accurate, because the Conversation is not any known form of citizen participation in policy formation - it does not fit the typology of citizens' panel, deliberative polling, consensus conferencing, citizen's jury or planning cell (Abelson et al. 2003; Pratchett 1999). That incongruity makes sense if and only if the Conversation is not about informing healthcare policy making.
If the Conversation is not about policy making, what could it conceivably be about, apart from a random collection of inputs? Government's goals could be one or all of the following three possibilities: educative, socially integrative and co-optive. Educative goals could include helping citizens to see how complex and difficult healthcare policy decision-making can be or simply getting healthcare-related information in circulation. It is easy to see how either could diffuse resistance to unpopular policy. Socially integrative goals might include fostering democratic norms of debate and tolerance or, more fundamentally, transforming participants through their interaction with fellow citizens. Those are undoubtedly valuable things, but how they link to government's healthcare agenda is unclear, except perhaps to diffuse dissent, which leads directly to co-optation. Essentially, co-optation boils down to using the Conversation as a cloaking and legitimating device for predetermined outcomes.
But all good romances involve mystery and surprises. Starting with this surprise: the government made good on reporting honestly the feedback it received through the Conversation. That feedback is the familiar National Forum and Romanow Commission refrain. "Most participants in the Conversation on Health argue for the maintenance of a fully publicly delivered and funded system" (Ministry of Health 2007d: 4). Favoured solutions are: publicly funded primary care centres, faster implementation of best practices and implementation of the Romanow Report recommendations (Ministry of Health 2007e: 7). The mysteries are, "What did government expect?" and "What will they make of the feedback, given their position as expressed in the Throne Speech?"
Mots tendres ? Consultations sur la santé, en Colombie-Britannique
RésuméLe jour de la Saint-Valentin, en 2006, le gouvernement de la Colombie-Britannique promettait des discussions publiques sur les services de santé. Les réunions intitulées « Conversation on Health » ont pris fin en juillet dernier. La province a mis en place plus de partenariats public-privé (PPP) pour des projets de construction liés à la santé et a permis l'expansion du sous-secteur des services de santé privés. L'auteur compare les réunions « Conversation on Health » aux processus de consultation publique et conclut que la cooptation était le but principal de l'exercice du gouvernement de la Colombie-Britannique.
About the Author(s)
Alan Davidson, PhD
Associate Professor, Health Studies
University of British Columbia Okanagan
Correspondence may be directed to: Alan Davidson, Associate Professor, Health Studies, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC V1V 1V7; tel: 250-807-9969; e-mail: firstname.lastname@example.org.
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