Best-Laid Plans

Best-Laid Plans: Health Care's Problems and Prospects

Copyright Date: 2002
Pages: 216
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  • Book Info
    Best-Laid Plans
    Book Description:

    Is health care like the BC Ferry Service or Ontario Hydro? Lawrie McFarlane and Carlos Prado argue that health care is being treated as though it were just another public utility and that the present crisis in medicare has developed precisely because of this approach. In The Best-Laid Plans they contend that what health care needs is less centralized management and the restoration of empowerment to both patients and care-givers.

    eISBN: 978-0-7735-7021-4
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Foreword
    (pp. ix-xii)
    Duncan G. Sinclair

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

  4. Preface: Health Care Services and/or Disease Management
    (pp. xiii-2)
    Jacalyn M. Duffin
  5. Introduction
    (pp. 3-6)

    Medicare is the operational system by which Canadians receive essential health services. It embodies certain obligations and confers certain entitlements. Widely believed to be one of the defining accomplishments of our nationhood, medicare has grown, in less than forty years, from a distant objective to a present entitlement of all Canadians.

    This book was written because the authors believe that medicare is imperilled to a significant degree, for reasons largely unknown to most Canadians. Few would disagree that something is seriously amiss with health care in Canada. However, that consensus is matched by another that we think is wrong-headed. This...

    • CHAPTER ONE Health Care and Our Theoretical Base
      (pp. 9-24)

      Robert Burns warned that our best-laid plans often go awry, and Murphy’s Law holds that if anything can go wrong, it will. It is a hard fact of life that our endeavours are plagued by unexpected and undesired results, even when we avoid making mistakes. This is especially true when those endeavours involve large numbers of people, and nowhere is this more evident than in health care’s management, periodic reforms, and recent history.

      The frequency with which health care policies and management have yielded unexpected and undesired results suggests that the reasons usually given for why things go wrong do...

    • CHAPTER TWO Health Care and Power
      (pp. 25-45)

      InMadness and CivilizationFoucault considers institutionalized exclusionary, manipulative, and restrictive treatment of the insane. InThe Birth of the Cliniche considers institutionalized exclusionary, manipulative, and therapeutic treatment of the physically afflicted. InDiscipline and Punishhe considers institutionalized exclusionary, manipulative, and rehabilitative treatment of lawbreakers. InThe History of Sexuality, volume 1 , he considers the socially constructed nature of sexuality. The deeper focus of these works, especiallyDiscipline and Punish, is how disciplinary techniques develop and work to control populations segregated either physically or through classification and categorization, and how those techniques redefine the members of those...

    • CHAPTER THREE Health Care and Chaos
      (pp. 46-62)

      Assessing how health care works and fails to work is ananalyticexercise; it is a matter of looking at a whole and seeing how its parts work or fail to work. But designing or – more important for us – reforming a health care system, is not an analytic exercise; it is asynthesizingexercise and so vastly harder to achieve successfully. The problem is that in synthesizing we have to begin with various elements or components and put them together in a way that will ensure that each works as it is supposed to work when it is integrated into...

    • CHAPTER FOUR Chaos, Power, and Ethics
      (pp. 63-70)

      In the preceding chapters we have considered how health care’s human components – its agents and clients – may not behave as expected or directed to behave because of contextual influences and/or subjective influences or, in Foucauldian terminology, because of power relations and/or ethical effort. What they actually do and how they do it is only partly determined by what they are told to do or are supposed to do. Their behaviour also is partly determined by how others’ actions influence their own actions, and by how they feel they need to act to comply with their own internal imperatives. The result...

    • CHAPTER FIVE The Origins and Pathology of Crisis
      (pp. 73-82)

      In the preceding four chapters we developed a theoretical framework that we believe can explain the failure of health care reforms to meet their intended goals. In the following eight chapters, we examine the actual management decisions that Ottawa and the provinces have taken over the last twenty years, as they attempted to develop a viable management model for health service delivery. We use our conceptual framework to explain what went wrong with this model. We also review the new round of policy changes currently being considered, as the Medicare crisis escalates. These include the privatization alternative now being actively...

    • CHAPTER SIX The Denial of Crisis
      (pp. 83-93)

      Despite the apparent evidence of recurrent crisis over the last two decades, some defenders of medicare argue that the surface level aspects of crisis portray a misleading picture of reality. While conceding theappearanceof crisis, they insist that nevertheless theobjective realitiesof the situation do not bear out the claim that a crisis exists. And indeed, there are points to be made in favour of this view. Given the far-reaching nature of the reform process, it was to be expected that the upheaval would lead to a period of instability. This in turn was bound to fixate the...

    • CHAPTER SEVEN The Orthodox Approach to Health Care Reform
      (pp. 94-119)

      In this chapter we examine in greater detail the specific management initiatives that comprise the orthodox approach to health reform. We comment on the shortcomings of these initiatives, and we argue that their failure to achieve the stated goals of health reform can be traced to a fundamental design flaw. This flaw consists of attempting to treat all of the various, and largely separate, components of health care delivery as one organic entity, capable of functioning as a unified system. We argue that there may be heuristic value in visualizing the health system as an integrated whole, in order to...

    • CHAPTER EIGHT How Medicare Works
      (pp. 120-130)

      It is our claim that health reform has failed because it embodies deepseated conceptual flaws that undermine the whole enterprise. In the case of the orthodox approach, the flaws reside in an organizational model so complex that an immense field of unintended consequences and perverse behaviour has been opened up, which has defeated the goals of health reform. Many of the chosen methodologies are either inappropriate to the special circumstances of health service delivery or are so opposed by health professionals that they cannot gain acceptance. Worse still, the lack of fiscal discipline that characterized the previous delivery structure remains...

    • CHAPTER NINE The Right to Health Care: The Legal Context
      (pp. 131-140)

      We argued in the previous chapter that if proposals to introduce a private system of health care delivery are to be fully analyzed and understood, it is necessary first to comprehend how key aspects of the public system work. In this context, we developed the concept of medical due process, and showed how this body of administrative procedures is analogous to due process in the legal field. It is this system of working rules that ensures that whatever high-level entitlements are entrenched in medicare, such as equality and accessibility, are actually translated into the way medicine is practised in the...

    • CHAPTER TEN The Right to Health Care: The Historical Context
      (pp. 141-147)

      In the previous chapter we showed how the recent history of litigation and court judgments in Canada enables us to clarify the status of health care entitlements. Specifically, we argued that the entitlement of Canadians to receive essential health services has evolved over the last forty years to a right of citizenship. It is necessary to seek this sort of clarification, because Parliament did not, for constitutional reasons, adopt unequivocal language when framing the medicare statutes.

      We argue in the present chapter, however, that even without the evolution of legal and judicial thinking, it is possible to decipher Parliament’s original...

    • CHAPTER ELEVEN The Privatization Alternative
      (pp. 148-161)

      We turn now to an analysis of the privatization approach to health reform. While both the Ontario and Alberta governments have recently introduced elements of private medicine, only the latter has, to date, given this policy an explicit statutory base. We therefore direct our attention in this chapter to reform proposed by the Government of Alberta. In the 2000 Spring Session of the Alberta Legislature, the Government of Alberta introduced Bill 11 , aimed at allowing private clinics to carry out a range of both insured and non-insured medical/surgical procedures. Government spokespeople, including Premier Klein, have assured Canadians that they...

    • CHAPTER TWELVE A New Approach to Managing Health Services in Canada
      (pp. 162-180)

      We have argued that health care presents unique challenges to planners and managers. This is in part because of the huge number of variables involved. If the delivery of health care is conceived as the functioning of one large, organic system, the sheer size and complexity of the resulting model renders it unpredictable at the level of detail required by managers, in the same way that meteorologists cannot predict the path of a tornado or where a hurricane will come ashore. It is also because, unlike inanimate systems such as the weather, the variables in health care systems, namely, people,...

  8. Notes
    (pp. 181-186)
  9. Bibliography
    (pp. 187-192)
  10. Index
    (pp. 193-196)