Although he clearly admires his subject, it would be wrong to call Dan Leger’s recently-published biography of Stephen McNeil a hagiography. To his credit the veteran journalist presents Nova Scotia’s ex-Premier warts and all, albeit while slapping on thick layers of rationalization to conceal the blemishes.

Leger argues that McNeil should “be in the mix” in any discussion about “premiers of consequence,” along with other regional leaders like New Brunswick’s Louis Robichaud and Frank McKenna, Newfoundland and Labrador’s Joey Smallwood, Joe Ghiz of P.E.I and – reaching way back – Nova Scotia’s Angus L. Macdonald.

Leger’s case for admitting McNeil into that group is based on a list of accomplishments including:  his handling of the COVID-19 outbreak; immigration policy; trade with China; ending pollution of Boat Harbour; introducing pre-primary; and taming the provincial deficit while taking “a hard and controversial line in collective bargaining with the public service.”

One could debate the merits of all of the above, as well as the extent to which McNeil can claim credit. But it’s the final two – tackling the deficit and the hard line with the public service – that demand further examination in light of the turmoil in health care that McNeil’s tenure has left behind.

Although he devotes a chapter to the “inside story” of McNeil’s and his advisors’ attack on public sector workers – especially those in the health care sector – Leger pays scant attention to the overall Liberal record on health care.  This is despite the fact that for his entire tenure McNeil was dogged by failure to live up to a 2013 campaign promise to ensure every Nova Scotian access to a family doctor.  Add to this the anger caused by creation of the centralized, top-heavy Nova Scotia Health Authority in place of local district health boards and the Liberal Achilles Heel begins to appear.  

Those two issues – and the interaction between them – provided plenty of question period fodder and newspaper headlines. But it was the combination of fiscal restraint and brutal labour relations that formed the core of the McNeil government’s health care record. Even though Nova Scotians are still trying to recover from the damage caused, Leger glosses over that record.

Leger does tell readers that McNeil believed Nova Scotia had too many public employees, including health care workers. And when it came to those health workers, McNeil was convinced  they had too much power and made too much money. He set out to reduce that clout with legislation – curtailing the right to strike, forcing changes in the collective bargaining process and imposing a wage pattern on the entire public sector that limited increases to less than three per cent over four years (zero, zero,1.0 and 1.5 per cent).

Leger recounts one exchange McNeil had with reporters about nurses that sums up the former Premier’s attitude towards unionized front line health care workers. After noting that Nova Scotia had 980 registered nurses per 100,000 population when the national average was 780 McNeil added: “The question becomes what more…is going to make a difference? What more do you want? And how much above the national average does Nova Scotia have to become before the union is satisfied?”

McNeil asked that provocative question in 2014, a year during which the inflow of nurses exceeded the outflow by 32, according to data from the Canadian Institute for Health Information (CIHI). Over the next four years, CIHI figures show the outflow of RNs exceeded the inflow by 159 – presto, RN-to-population ratio reduced. There was a small net increase in RNs in 2019, but as COVID has revealed, it was too little, too late to meet current needs.

Some missing facts

While succeeding in restraining the pay rates and cutting the number of  RNs, McNeil failed miserably in delivering on the campaign promise of a family doctor for everyone who wanted one. It was a rash commitment, and it soon became clear the Liberals had no idea how to deliver it, especially while negotiating a slightly modified zero-zero wage pattern with physicians. Belatedly the Liberals came around to the idea of promoting more collaborative care centres as a solution to the family doctor shortage. But another initiative – the Need a Family Practice Registry – backfired politically. 

Set up in late 2016 with the goal of connecting patients with physicians, the registry had 25,000 names by March, 2017 and kept growing. Each increment was widely reported in the media, especially in the Chronicle-Herald, where Leger was a columnist. The newspaper also served as a mouthpiece for doctors wanting to take shots at the McNeil-created Nova Scotia Health Authority.  Oddly, none of  this makes it into the book, despite the fact that the McNeil government’s failure to deliver on primary care is a leading cause of the crisis in emergency rooms across the province.  

It must be acknowledged that the McNeil government was not alone in putting the brakes on health care spending during the second decade of the 21st century. As I have reported previously, between 2011 and 2019 the annual average increase in health spending by provincial governments was less than four percent, about double the inflation rate. However, immediately after McNeils’  clampdown on wages, the rise in health care spending in Nova Scotia dropped below inflation, increasing by an average of just 1.6 per cent a year per-capita from 2015 to 2018. Only Manitoba, delivered smaller increases over that period.

The belt-tightening was especially tough on Nova Scotia’s nursing homes. According to CIHI figures, the category Other Institutions, mainly nursing homes, received annual average increases of only 0.85 per cent from 2015 to 2018. Lack of nursing home beds put pressure on already scarce hospitals beds. Although there have been recent efforts to add nursing home capacity, the number of people in hospital who should be in nursing homes continues to hamper emergency care – another legacy of restraint.

McNeil’s Fault?

There has been a tendency – perhaps laudable in an era of hyper-partisanship – not to assign blame for the health care crisis to any particular government. The current premier buys himself time by saying the problems were many years in the making and will take years to fix. But Tim Houston’s rhetoric notwithstanding, not all Nova Scotia governments have approached health care, specifically health spending, in the same manner.

Under the Hamm-MacDonald Tory governments spending went up an average of more than seven per cent a year. During its four years in power the Dexter New Democrats reduced that to five per cent a year. The only government in the last three decades to attack health spending like McNeil did was that of John Savage in the mid-1990s. 

Savage gave up the effort (and the job) after a few years, but it wasn’t enough to save the Liberals from defeat after only six years in power. Health cuts dominated the 1998 election that saw the Liberals lose 21 seats while being reduced to a minority government. Health care remained the top issue in the 1999 campaign when the Liberals, led by Russell MacLellan, finished in third place. 

Although there are still a few holdouts (like ex-federal finance minister Morneau), most people are coming around to the view that in addition to increased focus on primary care our health care system needs more resources – human and fiscal. During most of his tenure, McNeil starved the system of both.

COVID reprieve

Leger makes the case that with the bump in popularity he gained through his much-admired response to the pandemic McNeil would likely have been re-elected for a third term had he chosen to run. Given the success of several of his provincial counterparts who won snap elections during COVID that could well have happened, especially if he had gone to the polls early when his famous “Stay the Blazes Home”  was still resonating. However, according to the book, McNeil had already decided to step down and was preparing to announce the decision just as the pandemic hit.

A decision to retire in 2020 before getting turfed out makes sense, especially if you take into account the fate of the only other Nova Scotia government of recent times who’ve taken the axe to health spending.

In the 2017 provincial election, the McNeil Liberals barely squeaked back to power, watching their share of the vote drop by more than six percentage points. For a couple of hours on election night, a Liberal minority government appeared likely.

Post election, the Angus Reid Institute’s quarterly popularity poll of provincial premiers consistently had McNeil near the bottom, with an approval rating as low as 16 per cent in the spring of 2019. A provincial by-election in Sackville-Cobequid in the fall of 2019 gave the Liberal candidate only 10.4 per cent of the vote. Until the pandemic changed things, the McNeil Liberals looked like they were on the same downward trajectory as the health-care-jinxed Savage-MacLellan Liberals 20 years earlier.

Obviously none of this proves McNeil would have experienced the same fate if he had stuck around for another election. But consider this: it has become a political adage that doing a decent job on health care will not win an election, but screwing up health care and cutting services will lose one.

As noted, every province significantly restrained health care spending in the years leading up to the pandemic. There were no doubt many other factors at play, but it can’t be entirely coincidental that between 2016 and 2019, voters in eight of those provinces threw out the incumbent government. It took until 2021 and a platform “laser-focussed on fixing health care” for the Houston PCs to convince Nova Scotians to do the same thing.

Dan Leger’s biography of McNeil is an easy read and will be enjoyed by political junkies, especially those whose sympathies lie with the Liberals. However, it is disappointing that despite giving such prominence to McNeil’s clash with health care unions the author fails to explore the impact of that hard-line approach on the health care services people need. It would be too bad if in future McNeil’s handling of the health file is seen strictly as a roadmap to personal political success rather than as a cautionary tale.

Stephen McNeil: Principle & Politics, is published by Nimbus with a cover price of $26.95.