The best-laid plans: health care's problems and prospects Lawrie McFarlane and Carlos Prado Montreal and Kingston: McGill-Queen's University Press; 2002 196 pp $70 ISBN 0-7735-2364-2 (cloth) $24.95 ISBN 0-7735-2365-0 (paper)
When Lawrie McFarlane and Carlos Prado argue in The best-laid plans that health care cannot be run like a business, they mean it really can't be, not only that it shouldn't be. McFarlane, former deputy minister of health for BC, and Prado, professor of philosophy at Queen's University, believe that health care is an enterprise unlike no other and that its problems are not receptive to mechanistic solutions.
One needs a certain tolerance of theory to read this book — or the first four chapters at least, which review Michel Foucault's poststructural analyses of institutional behaviour. The main point taken from Foucault is that “the control that institutions exert ... is exerted on people who are protean, who are continuously adapting to a multitude of external and internal influences.” Health care is profoundly dynamic in the way that it affects and is affected by attitudes and behaviours, and this makes the impact of change unpredictable. Indeed, health care is so complex as to be a chaotic system: like weather patterns (only worse), it is too complex to be accurately modeled.
Despite my tolerance for theory, I arrived with some relief at this sentence on page 70: “However, we cannot make further progress at the present level of abstraction.” At this point, McFarlane and Prado pose questions that occupy the rest of the book: “how the present health care crisis arose, how health care reforms have failed, just what entitlements health care serves, and how we might improve things.”
The authors' treatment of the first question has some omissions, but it is a useful refresher on the juncture of influences that led to the mess we're in now. The “orthodox reforms” that arose in reaction to deepening deficits, escalating costs and the realization that no direct correlation existed between health care spending and outcomes succeeded at little except in curbing spending. In the 1990s provincial expenditures on health care increased by 21%, as opposed to 187% in the previous decade. However, the “array of ad hoc cost-cutting measures” was “bewildering,” and one result was uncertainty about what sort of entitlements medicare implied, and how permanent those entitlements might be.
Two basic approaches to reform have arisen, the authors write, and neither of them work. The first is to try to fix medicare from within through regionalization, amalgamation of services and corporate-style management. The second is to accept that medicare has “failed the test of affordability” and to introduce a private tier of service delivery. As for the first, the societal benefit of removing redundancy in a costly system is not sufficient to reconcile individuals, or facilities, to change, and so reforms imposed across a system are prone to backfire at a local level. Similarly chaotic has been a shift toward community care to take the heat off acute services, but this has lacked sufficient integration between the funding, administrative and ideologic frameworks that support acute and long-term care. Again, this has raised questions about entitlements and created a loss of confidence that in turn compounds the crisis.
It doesn't help, McFarlane and Prado write, that the Canada Health Act doesn't stipulate the services that medicare secures; rather, it sets out “operational principles.” But they staunchly defend those principles, which in their view have been remarkably successful in fostering “medical due process” — i.e., fairness.
The second medicare fix, privatization, is disputed by the authors on the grounds that it will provoke changes in physician and patient behaviour that will destabilize “medical due process.” The introduction of new financial opportunities (and barriers) will muddy the waters with respect to, among other things, standards of care, patient selection, labour allocation, insurance costs and the quality of the patient–physician relationship. Moreover, none of these effects is likely to relieve the pressure on the public system; they may even make it worse.
So what is the answer? First, McFarlane and Prado argue, we need to make up our minds about the “deliverables” of medicare. The federal government should set out a national framework for health-care entitlements though a Health Charter. The authors outline what they would like such a charter to contain: a restatement of the five principles of the Canada Health Act and a clearer articulation of operating principles (partly to obviate the negative effects of privatization). Second, we must admit that regionalization has failed and return administration to the level of the facility. Third, primary care must be brought into sync with the rest of the health network.
After a rather elaborate theoretical warm-up, the densely-packed practical suggestions laid out in the last chapter seem a little cramped. One hopes the authors will soon elaborate their outline for reform, or else that the bedevilling details will be taken up by those with a similar talent for analysis.
Anne Marie Todkill CMAJ
Figure.
Photo by: Barbara Sibbald