Best Laid Plans Health Care's Problems and Prospects

Visit the link below to download the full version of this book:

https://medidownload.com/product/best-laid-plans-health-cares-problems-and-prosp
ects/

Click Download Now

103386_90.fm Page iii Thursday, January 24, 2002 8:51 AM

The Best-Laid Plans

Health Care’s Problems
and Prospects

lawrie m c farlane
and carlos prado

McGill-Queen’s University Press

Montreal & Kingston · London · Ithaca
103386_90.fm Page iv Thursday, January 24, 2002 8:51 AM

© McGill-Queen’s University Press 2002

isbn 0-7735-2364-2 (cloth)
isbn 0-7735-2365-0 (paper)

Legal deposit second quarter 2002

Bibliothèque nationale du Québec

Printed in Canada on acid-free paper

McGill-Queen’s University Press acknowledges the

financial support of the Government of Canada
through the Book Publishing Industry Development
Program (bpidp ) for its publishing activities. We also
acknowledge the support of the Canada Council for
the Arts for our publishing program.

National Library of Canada Cataloguing

in Publication Data

McFarlane, Lawrie
The best-laid plans: health care’s problems
and prospects
Includes bibliographical references and index.
isbn 0-7735-2364-2 (bound). –
isbn 0-7735-2365-0 (pbk.)
1. Health care reform – Canada. 2. Medical care –
Canada. i. Prado, C.G. ii. Title.
ra395.c3m39 2002 362.1’0971 c2001-903517-9

Typeset in Palatino 10/13

by Caractéra inc., Quebec City
103386_90.fm Page v Thursday, January 24, 2002 8:51 AM

For Anne and Catherine

103386_90.fm Page vi Thursday, January 24, 2002 8:51 AM
103386_91.fm Page vii Thursday, January 24, 2002 8:52 AM

Contents

Foreword ix
Preface: Health Care Services and/or Disease Management xiii
Introduction 3

PART 1 some theory

1 Health Care and Our Theoretical Base 9
2 Health Care and Power 25
3 Health Care and Chaos 46
4 Chaos, Power, and Ethics 63

PART 2 the practice

5 The Origins and Pathology of Crisis 73
6 The Denial of Crisis 83
7 The Orthodox Approach to Health Care Reform 94
8 How Medicare Works 120
9 The Right to Health Care: The Legal Context 131
10 The Right to Health Care: The Historical Context 141
11 The Privatization Alternative 148
12 A New Approach to Managing Health Services in Canada 162
Notes 181
Bibliography 187
Index 193
103386_91.fm Page viii Thursday, January 24, 2002 8:52 AM
103386_92.fm Page ix Thursday, January 24, 2002 8:53 AM

Foreword

As we begin the twenty-first century, “medicare” is a defining char-

acteristic of being Canadian, although most would be hard pressed
to define it even in general terms. It is our most cherished – and
single most expensive – social program. Repeated public opinion
polls show that medicare’s preservation, indeed its expansion and
enhancement, is in a class by itself among government expenditures
for which people seem prepared to pay more rather than less in taxes.
There is a strong commitment to share publicly the financial risk of
disease and injury – risk that, before medicare, was borne alone by
those affected, their families, and those who would extend them
charity. This commitment is widely shared from coast to coast and is
a tribute to the coherence and underlying goodness of contemporary
Canadian society.
Yet medicare, shorthand for Canada’s health care system, is not
what it seems. At best it is ten provincial and three territorial programs
that use public money to insure people against the costs of hospital
and physicians’ services, loosely coordinated by virtue of their
common adherence, more or less, to the five principles of the Canada
Health Act of 1984. At worst, there is no system, using the word in
its ordinary sense to mean a collection of interrelated components or
parts (physicians, hospitals, pharmacies, home care, etc.) acting together
synergistically so both quality and productivity are greater than
when each acts independently.
This book makes the case that there is not now, nor can there ever
be, a genuine health care system. Neither can there be continuity of
care, because health care is unmanageable; at least it cannot be
managed centrally or on a macro scale. The case is set out theoretically
by application to health care of genealogical and ethical analyses
103386_92.fm Page x Thursday, January 24, 2002 8:53 AM

x Foreword

developed by Michel Foucault, analyses primarily developed from

studies of the effects on people of institutional practices and vice
versa. These analyses support the conclusion that planning and man-
agement are not possible in the complex (“chaotic”) institution of
health care, primarily because the behaviours of those affected,
whether agents or clients, cannot be predicted. The theoretical frame-
work is filled in by an examination of actual management decisions
taken by successive federal and provincial governments over the past
twenty years as they have struggled in vain to produce and apply a
viable management model for the delivery of health care services.
Although it remains that most people who have sought and used
hospital and physicians’ services throughout Canada agree that they
have been well served, most informed observers agree that medicare
is a mess. It is beset by many problems, most of them of long-standing
and worsening. There is a strong consensus among Canadians, how-
ever, that medicare should remain a public program, indeed that the
publicly insured services provided should be expanded to include
prescription drugs and home care especially, as well as long-term
care, which also claims priority for many.
To meet people’s growing expectations within a public system for
universal, accessible, portable, comprehensive services of high quality
requires that the providers – physicians, hospitals, nurses, nursing
homes, home care, pharmacists, and so on – coordinate their work to
meet the particular needs of their individual patients/clients/custom-
ers and their families and communities. In other words, they must
conform to the discipline of a system with a clearly defined vision and
mission, with explicit goals, objectives, and policies that create the
incentives necessary to channel individual self-interests and hold
them accountable to serve the common good. Where such systemiza-
tion really counts, however, is at the workface, the level where the
providers and consumers (and prospective consumers) of health care
themselves have a stake in the outcomes of greater synergy – increased
productivity and higher quality services throughout the continuum of
care. Elsewhere the purposes are principally bureaucratic and the
results too often, as the authors point out, counterproductive.
Why is it so difficult to build a genuine system of health care
services? The four principal roadblocks are:

• Our governments shrink from governing; they avoid providing the

leadership every system requires. They persist in the delusion that
103386_92.fm Page xi Thursday, January 24, 2002 8:53 AM

Foreword xi

health services should and can be managed at a distance from the

consumers and providers affected. This book focuses on the theo-
retical and experiential reasons that solving medicare’s problems
through “better management” is not now working and will not
work in future.
• There are no clear lines of accountability between the public and
the providers, managers, and the (absent) governors of medicare.
• Entrenched interests create the perception that even discussion of
change in medicare is the political equivalent of the “third rail.”
Resistance to change by those interests and their capacity to incite
the media to fearmongering are problems of major proportion.
• No province or territory has the capacity for effective health infor-
mation management.

From their two perspectives, theory and praxis, the authors provide
an interesting and provocative analysis of the etiology of medicare’s
ills, and a diagnosis of what is really wrong. Surprisingly, given the
blame attached to and issue taken with health reform’s mavens, the
recommended approach to treatment is not far off what I and many
others believe necessary to make medicare work for the benefit of
Canada’s communities and population into the twenty-first century.1

Duncan G. Sinclair
Chair of the former Health Services
Restructuring Commission (Ontario) and
Visiting Fellow, School of Policy Studies,
Queen’s University at Kingston
103386_92.fm Page xii Thursday, January 24, 2002 8:53 AM
103386_93.fm Page xiii Thursday, January 24, 2002 8:54 AM

Preface
Health Care Services
and/or Disease Management

Sometime in the last century, the bright new words “health care
services” crept into our Canadian vocabulary to replace the more
paternalistic and gloomy implications conveyed by older formulas
involving “medicine,” “doctors,” and “hospitals.” Euphemism? Per-
haps. But the shift in vocabulary reflects several realities: workers in
the field include nurses, physiotherapists, social workers, and teach-
ers, as well as physicians and surgeons; many people who apply
for help are not actually sick; and hospitals are not always the locus
of activity. More recently, and in keeping with the trend, “patients”
have become “clients” or “consumers,” while “workers” are known
as “providers” or members of “teams.” The language of efficient
business management is ascendant. Riding on its coattails is the van-
guard of evidence-based medicine, which relies on randomized con-
trolled trials to generate guidelines for practice that ought to have
wide applicability for all peoples even as they innocently (and erro-
neously) imply that the medicine of the past was based on little or
no evidence at all. These changes have prompted a “managerial”
response to the provision, administration, and periodic reform of
health care.
As attractive and reasonable as the semantic change may be, the
system itself is said to be in crisis. Constraints on funding are often
cited as the cause of the crisis, but McFarlane and Prado demonstrate
that the funding issues are only one symptom of deeper social and
philosophical problems. The concept of “Health Care Services”
ignores certain other realities of our so-called health care system,
and, indeed, the shift in nomenclature proclaims a fundamental
conceptual problem at the root of the current crisis.
103386_93.fm Page xiv Thursday, January 24, 2002 8:54 AM

xiv Preface

For example, if these “services” are to be run on a market model

of supply and demand, which is amenable to business management
concepts, then we should have a clear idea of their product: “health.”
But the definition of health is slippery and individualistic. It has
challenged generations of scholars who, in exasperation, resort to
defining it as the lack of its apparent opposite, disease. The oft-cited
definition used by the World Health Organization tries to avoid this
problem by investing health with positive attributes, not just the
absence of disease. Health is defined as a state of physical, mental,
and social well-being. But whatever positive attributes “health” may
enjoy, it must not include disease. The task of health care services
becomes clear and simple when it fixes on this common denomina-
tor: the “services” are predicated on treating, identifying, or prevent-
ing disease, whether or not the product is health. Their success is
charted, even by the World Health Organization, in statistics on mor-
bidity, mortality, and elimination of disease. To qualify for “health
care services,” the “client” must present through a disease rubric and
with potential disease in mind. Despite the lip service paid to the
social determinants of health – education, literacy, employment, wealth,
personal autonomy, and political freedom – we do not offer health
care services in our current system; we offer disease management
and prevention.
For at least fifty years, historians and philosophers have shown that
disease concepts are ideas that are socially constructed, related to cul-
tural norms as well as individual biological functions. If social values
enter into what we classify as “sick,” they also enter into what we
classify as “healthy.” Analysis of the hidden messages in public- and
private-sector health information shows that images of health are inad-
vertently young, able-bodied, thin, white, and middle-class. We know,
however, that the elderly, the poor, and the disabled can be healthy
within their own frames of reference. In fact, each person should
reasonably be the best judge of the state of his or her own health.
Since the middle of the nineteenth century, however, most educated
people concede some power in that decision to the judgment of a
physician. They know that the stethoscope, the blood pressure cuff,
the blood test, the urinalysis, the Pap smear, the X-ray, and scanners
can detect traces of disease long before symptoms are felt. And early
detection, we believe, is a good way to prevent devastating illness.
Immunization is another. Without diminishing the crucial role of
medical and surgical treatments, reassurance is a huge part of what
103386_93.fm Page xv Thursday, January 24, 2002 8:54 AM

Preface xv

should be meant by “care,” both for those who are dying and for
those without symptoms who display entirely normal results follow-
ing investigations. Care must include recognition of the vulnerability
and dependence of the “client” upon personal contact with an expert.
But what about “care” in our so-called health care system? How is
caring a management model? Even if treatment is not working, even
if normal tests fail to assuage fears, must we dismiss the individual
by a Tayloristic1 formula that proscribes further investment in her
problem? In a privileged society such as ours, does not everyone
have the right to speedy attention and sympathetic concern, an ear
to listen, a hand to hold? Are these old-fashioned notions associated
with traditional nursing and medicine no longer worthy of public
resources? And can a collectivity of bureaucrats or insurance provid-
ers using population-based statistics determine how much care is
appropriate for each problem, when – as we have already seen – the
so-called “health” problems are as myriad as individual personalities
and life experiences? Are we prepared to allow the private sector to
determine premiums for a caregiving that will hold just the right
number of hands and preserve life for just the right number of years,
while it also yields a profit to the insurance industry? Programmatic
definitions of health care needs are impossible because they seek to
impose a uniform order on chaotic perceptions of health, a chaos that
we should honour and celebrate. Little wonder that the various
guidelines generated for disease management and prevention are
lauded more than they are used.
In sum, our health care system forces individuals to cede power to
experts whom they must approach through a disease-based system.
Far from accepting that health and health needs are concepts as
widely diverse as the peoples of our land, we try to ignore the dom-
ination of disease and pretend that health is a non-controversial,
material commodity to be meted out in rationalized allotments by
managers. Money is neither the biggest nor the only problem. As
McFarlane and Prado show, illusion and misunderstanding contribute
to the reasons that our health care system is sick; more important,
attempts to fix the system that are based on managerial assumptions
ignore these intrinsic reasons for its problems.

Jacalyn M. Duffin, md , frcp (c )

Hannah Chair, History of Medicine,
Queen’s University