Riding the Third Rail: The Story of Ontario's Health Services Restructuring Commission, 1996–2000

K.V. Nagarajan is a professor of economics at Laurentian University.

Although the book lists three authors, it reads as though it all came
from the pen of Duncan Sinclair, Chair of the Health Services
Restructuring Commission (HSRC). Riding the Third Rail is an insider’s
look at the process of change carried forward by HSRC between 1996 and
2000.

The Harris government created the commission and gave it unprecedented
powers to reshape the hospitals across the province. This was, as the
authors note, a “clever trick,” since the province retained all
powers. Nevertheless, the commission moved rapidly and fearlessly to
discharge its mandate.

The story related here is astounding in terms of both what the
commission accomplished and what it did not. At the start, the
commissioners had no idea of the Harris government’s vision for health
care, no policy framework, and little data on which they could rely in
making their decisions. So they had to find their own way among the
health-care “silos.” Their vision was to dismantle the “silos”
and create a true health-care “system.” Their strategy was to
reconfigure the hospitals and get them to function within an integrated
health-care system that would include post-acute home care, continuing
care, and long-term care.

Other than restructuring hospital governance in urban centres, HSRC did
not succeed in making its vision a reality during its mandate. In
dealing with the non-hospital part of restructuring, the commission was
given only an advisory role. As a result, many of its system-building
recommendations were ignored. The authors point to lack of political
will for the stalled reforms.

While admitting their mistakes and missteps, the authors absolve
themselves of responsibility for lack of progress during the later phase
of their mandate and beyond. “The HSRC,” they write, “did its part
and its collective conscience is clear.” Yet, its failures are glaring
without much explanation. Missing, perhaps, are the inside perspectives
of the ministry bureaucrats involved with the commission’s work and
the political operators to explain why they did what they did (or did
not do).

The book ends with a rambling account of some recent developments. The
authors see some sign of their vision being revived and express the hope
that “we can pick up the pace.” It’s about time.