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PROGNOSIS

The Current State and Shaky Future of Canada's Health System

By John Lawrence Reynolds

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Penguin Canada, 253 pages, $24

Prognosis bills itself as an examination of "the current state and shaky future of Canada's health system." Yet John Lawrence Reynolds is wiser than that. Despite the alarming subtitle, he begins by noting, "We are not facing a crisis in our health-care system. We are facing problems that we can all address and help to solve."

The book is wide-ranging, with chapters on doctors, information technology, pharmaceutical companies, "efficiency experts," the right's "private enterprise option," "the coming tsunami" of an aging population, patient safety, hospitals, deciding how much care we can afford to offer, consumers and international lessons. Recommendations are made.

A major strength of this book is also a major weakness. Reynolds - whose many books include crime fiction and works on personal finance, ballroom dancing and secret societies - tells stories. He revels in his status as an ordinary person rather than an expert insider. He has shrewd instincts. He asks good questions.

Yet treatment depends upon accurate diagnosis. The book relies heavily on newspaper stories telling dramatic tales, and selected interviews; it avoids the extensive scholarly literature dealing with many of its topics. (Disclosure: I authored some of that literature.) A nitpicker can find many nits to pick.

One problem in writing about Canada's health system is that it is neither national nor a system. About 70 per cent of Canadian health expenditures are publicly paid. A series of provincial/territorial insurance plans must cover all insured services ("medically necessary" hospital and physician services) for all insured persons in order to receive federal funding.

Provinces and territories can, but are not required to, fund other services, including home care and outpatient pharmaceuticals. However, in contrast to Britain or Sweden, delivery is not public, but through private providers, both for-profit and not-for-profit. This distinction between who pays and who provides confuses the public-private debate.

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Reynolds sometimes recognizes this; in several places, he notes that doctors are small private businesses. Yet his discussion of hospitals assumes that they are "publicly owned provincial hospitals" (they're mainly private not-for-profits), and his recommendations about private care display similar confusion.

Reynolds's opening story concerns a surgeon using extracorporeal shock-wave therapy to treat joint ailments. The service is not on the Ontario fee schedule, so patients wishing it must pay $1,500. Although presented as illustrating two-tier health care - a beneficial therapy not publicly insured - one might also view this as an example of the difficulties in deciding what should be included on the fee schedule, a topic that he addresses in a later chapter. He sways between assuming that access is paramount and recognizing the importance of including appropriateness: More care is not always better, if the care is not needed.

Similarly, Reynolds accepts the horror scenarios about population aging, projecting differences in expenditures by age cohort. But if most health care costs are incurred in the last months of life, then - as he recognizes elsewhere - one cannot just extrapolate. As Keynes pointed out, in the long run we are all dead. If those costs are incurred at 85 rather than 55, there is no crisis; the issue is, instead, what additional costs are incurred in those intervening 30 years, the benefits received and who pays for them. Most analysts have concluded that those additional costs are real, but small and manageable.

To pick one more nit, Canada does not need to allow private delivery; it already exists. But like most other industrialized countries, Canada does try to control private financing, and for solid economic reasons. When we accept that people cannot be denied a service, price signals cannot achieve cost control. Two-tier care for necessary services is usually associated with making waiting lists worse, because there is no reason for people to pay extra to jump a queue unless a queue exists.

Reynolds mentions some reforms, but gives short shrift to improvements that are already happening. There are Canadian success stories, many consistent with the recommendations of this book. He focuses on physicians, ignoring most other health professionals. Nurse practitioners are mentioned, but not nurses or rehabilitation professions. But primary care reform in many provinces is attempting to change how physicians are being paid and how services are organized.

Reynolds's chapter on medical error focuses largely on malpractice litigation, and seems less aware of continuing efforts to improve patient safety that have drawn heavily upon insights from industrial engineering.

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That being said, I enjoyed this book. Along with the horror stories and the ominous subtitle, there is some appropriate skepticism and much wisdom. One is left with the heartening conclusion that the sky is not falling. Improvements can be and are being made.

Raisa Deber is a professor in the University of Toronto's department of health policy, management and evaluation.

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