Prescription for Excellence, by Michael Rachlis
AbstractDr. Michael Rachlis' Prescription for Excellence is a timely book written for a broad readership. It is both easy to read and easy to understand with respect to the strengths and weaknesses of the healthcare system. The issues facing the Canadian healthcare system are complex and often intractable; however, he is able to analyze the problems, examine the causes and provide examples of innovative best practices and solutions that exist in Canada as well as in other Western countries. Dr. Michael Rachlis is a well-known health policy analyst who has served as a source of expert opinion on Canada's healthcare system. He is a specialist in community medicine, consultant to government and royal commissions and a part-time associate professor at the University of Toronto's Department of Health Policy Management and Evaluation. He has written two other books, Second Opinion (with Carol Kushner) and Strong Medicine.
The book's general style is evidence-based storytelling. Stories and vignettes delineate key issues and serve as a starting point for analysis - for example, a graphic account of inappropriate prescribing, poorly managed palliative care or slow response times. The anecdotes are interspersed with selective research or data that are used support Dr. Rachlis' premises or ideologies.
What is the main thesis of the book? Dr. Rachlis contends that we don't need to spend a lot more money on healthcare to give Canadians a more effective system - financing is not the issue. Rather, we need to focus on a system that provides quality care for patients and high-quality work environments for providers. Rachlis concludes that health is politics, and as a political construct, continuous tax cuts have undermined our ability to sustain our programs. He believes that if governments refrain from further tax cuts, we could accommodate a whole host of policy reforms without huge infusions of money. Further, he believes that we can do a better job of more efficiently managing resources and improving the quality of care - improving quality leads to sustainability.
The author begins with a brief historical context for medicare and key studies and milestones in the chronology of our universal public healthcare system. Despite the plethora of reports reviewed, the author discusses the Romanow report but sidesteps the Kirby report. The omission is noteworthy given that the latter was a significant review done contemporaneously with the Romanow report and was receptive to both private sector involvement and significant funding infusions to the healthcare system - neither of which the author advocates.
Much of the book is devoted to a description of the key system issues and solutions. There are chapters dealing with how good-quality palliative care can improve the quality of end-of- life care and how enhanced chronic disease management improves the duration and quality of life of millions of Canadians living with chronic illnesses. The author looks at home care's role in improving system reengineering, long-term- care innovations for the care of severe chronic illness and disease prevention and promotion as a way to free up more expensive resources. Separate chapters deal with some of the most intractable system issues - improving physician access, dealing with our exploding drug bill and improving the quality of therapeutics and prescribing, and reengineering services to manage wait times.
In the chapter on death and dying, Rachlis describes dying patients who seek only symptomatic relief, but end up in intensive care units; patients who could benefit from palliative care services, but don't get them; and patients and families who don't get adequate pain relief, emotional or spiritual comfort. He cites several examples of effective end-of-life programs in Canada, and in some provinces, ascribes regionalization as being instrumental to improving the situation for palliative care patients. Examples that Rachlis provides include the regional palliative care programs in Calgary, Edmonton and New Brunswick (part of the Extra Mural Hospital program). Also noteworthy are the results of palliative care pilot projects in Quebec. Evaluations of these and other programs point to not only better care for patients but to savings in other parts of the health system.
Rachlis discusses the "alleged" shortage of physicians and reduced access to them in Canada. He provides a high-level analysis of the number of physicians in Canada and builds a case that the per capita numbers are basically the same as they have been for 10 years. He claims that the structures in which physicians are working are inefficient rather than the number being insufficient. The per capita analysis is deficient in that it does not look at trends by gender, age or number of general practitioners and specialists, nor does it look at geographic distributions. Despite the lack of a rigorous analysis on the supply side, Rachlis maintains that current payment structures and fee for service payment schedules do not financially reward the right behaviour nor optimize access to healthcare services. To provide better access to physicians, Rachlis advocates teamwork with nurses or nurse practitioners, social workers, pharmacists, mental health workers and so on, as well as the move from fee-for-service to capitation or salaried payment models.
The final chapters discuss how to reengineer our system for better quality. Rachlis eschews plowing more money into the system. He does not favour private financing strategies (e.g., user fees, P3s and health spending accounts), nor is he a proponent of private or for-profit healthcare. Instead, he supports better coordination and integration of services within the confines of a publicly financed and non-profit delivery of health services.
He prescribes patient-centred care and allowing patients to have a greater say in what they want vis-à-vis their care. He underscores the relationship between highly motivated people working in safe environments and better-quality care. Focusing on better human resources and management practices in healthcare environments would go a long way toward optimizing human potential (e.g., improved safety, workplace wellness, development, staff assignment, decentralized accountability and decision-making and teamwork). While Rachlis does not provide an overall policy or economic plan to fix our system, he lists five strategic directions to get there - leadership to promote innovation, investment in training and education, prevention, broad communication and maximization of information technology. The book is peppered with fine examples of these strategies being implemented and the direct impact that they have had on the quality of healthcare.
Rachlis' ideas are not new but perhaps require continuous reinforcement and broader adoption in order to obtain the desired system changes. For example, he strongly advocates long-standing solutions such as primary health centre models (e.g., CLSCs in Quebec), capitation or salaried physicians (e.g., Group Health Centre in Sault Ste. Marie), the use of nurse practitioners and a focus on preventive medicine.
The book is clearly directed at the general public; however, it would be of interest to specific stakeholders in the healthcare sector because of the anthology of innovative programs and the series of questions it poses. He also encourages readers to challenge the status quo and provides some of the tools to confront and provoke the need for change. The conclusion to each chapter cleverly presents a series of practical questions for the reader, reinforcing the consumer-oriented nature of the book.
The consumer-oriented style of the book is a strength; however, the uninformed reader might believe that the solutions, with generally positive results (some substantiated with research), are a panacea for addressing the issues. There are those who hold contrary views and would seriously challenge the author's opinions and approach to many of these issues. These piecemeal (and long-standing) strategies, coupled with limited analyses, call into question the feasibility of the author's solutions in achieving sustainability and addressing the current system supply/demand imbalances.
Will innovation provide the remedy for the weary Canadian healthcare system? Throughout the book, there is the promise of, or optimism about, a better way as achieved through the range of innovative strategies in Canada and abroad. While Rachlis does not minimize the severity of the problems in the system, the reader is left with the possibility that healthcare policy is not impervious to sound decision-making or change. However, amid rising healthcare costs and increasing health needs, the author's solutions may not be pervasive enough to effect the changes needed in the system.
Prescription for Excellence
by Michael Rachlis
© 2004 HarperCollins Publishers Ltd., 418 pages
About the Author
Debbie Fischer, B.Sc., MHA, CHRP, is Senior Vice-President of Organizational Development and Strategic Projects at Mount Sinai Hospital in Toronto. She has an extensive background in private and public healthcare sectors, life sciences and government, where she was involved in public policy analyses, strategic planning and organizational effectiveness initiatives.
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