Hospital restructuring in smaller urban Ontario settings: unwritten rules and uncertain relations

Important changes are underway in the management and provision of welfare service activities in advanced capitalist societies as governments scale back their responsibilities and commitments to social security and health care. In order to understand the processes by which the reform imperatives of the central state are implemented at the local level, it is necessary to account for particular organizational and place-based contingencies which influence decision making and strategic response. This paper presents a framework for understanding the context of executive decision making in the human services sector and uses the framework to illustrate issues of locally designed hospital restructuring in smaller urban centres in the province of Ontario, Canada. Specific experiences of the Chief Executive Officers of two non-metropolitan hospital settings are examined to explore the unwritten rules of hospital conduct and the relations of uncertainty that characterize efforts to restructure hospital services through formal arrangements with other independently governed hospitals and health care delivery organizations.