This Introduction defines our research objectives and the key concepts underpinning our inquiry. We look at reforms in contemporary welfare states, which include England and Canada (Denhardt and Denhardt, 2000; Bejerot and Hasselbladh, 2011; Ferlie and McGivern, 2013) and on their implications for the potential roles and manifestations of the agency of medical doctors (Denis et al, 2016).

Setting the scene: reforms in contemporary healthcare systems

The question of healthcare reforms has attracted growing interest among policy analysts and health researchers (Greener, 2009; Ham, 2009; Lazar et al, 2013; Tuohy 2018; Germain, 2019). Reform is a privileged mode of intervention used by liberal democracies to intervene in various policy areas (Rocher, 2008). In their comparative analysis of public management reforms, Pollitt and Bouckaert (2017) define reforms as ‘deliberate changes to the structures and processes of a system with the objective of getting them (in some sense) to run better’ (Pollitt and Bouckaert, 2017: 2). In the healthcare context, this means improving patient experience, healthcare professionals’ satisfaction with work, population health and long-term system viability. Pollitt and Bouckaert's analysis suggests that reform is embedded in a complex web of institutional arrangements and political processes that shape the destiny of reformative ideas and reformers (Marmor and Wendt, 2012; Tuohy, 2018; van Gestel et al, 2018). As suggested by Mechanic and Rochefort (1996), comparable healthcare systems of various nations face similar challenges but their responses vary according to national context and institutions.

Reforms tend to unfold according to sedimentation logic where previous structures, positions and views re-emerge to frame current ambitions and scope for change (Pollitt and Bouckaert, 2017). Timing is central to the process and reinforces the importance of context in shaping the destiny of reforms (van Gestel et al, 2018). In addition, insufficient capacity to resolve persisting issues creates a propensity in some health systems, including in England and Canada, to embark in cyclical reforms (Greener, 2009; Ham, 2009; Forest and Martin, 2018; Germain, 2019). Escalating healthcare costs and technological breakthroughs in drug development, artificial intelligence (AI) and digital health suggest that systems will face increasing challenges to design, deploy and renew policy instruments. Healthcare reforms, with their trail of destabilisation and reorganisation, are a permanent feature of welfare states (Klein, 2018).