FOUR STRONG WINDS:
Understanding the Growing Challenges to Health Care
By Michael B. Decter
Managing Director,
Michael Decter and Associates, Ltd.
Toronto: Stoddart Publishing, 2000

Over the past decade, the winds of change blowing through healthcare systems worldwide have reached gale force. And there will be at least another decade of upheaval as the powerful forces for change continue to struggle against entrenched systems and ideas, says one of Canada's leading healthcare gurus.

But have no fear. Despite dire predictions in the media, says healthcare management consultant and policy expert Michael Decter, what should emerge when the dust finally settles is a better, stronger system - providing healthcare managers understand the forces blowing into every corner of their organizations.

In a refreshingly straightforward and balanced fashion Decter identifies four important forces of change - forces which are indifferent to national borders, the manipulations of politicians, or the entrenched traditions of physicians and nurses. Decter's four strong winds of change are:

• Powerful new ideas, including the displacement of curative health as a primary function in medicine by disease prevention and health promotion.
• A consumer revolution in which a knowledgeable public expects quality, speed, affordability, appropriateness, and accessibility in its healthcare services.
• Technological transformation through computerized information management, new drugs, advances in biotechnology and changing clinical practice.
• Financial pressure from governments and employers to deliver more services more efficiently, driven by global competitive pressures.

Decter supports his theses with case studies of the varied responses to changes in healthcare delivery gleaned from extensive experience as a consultant, lecturer, and seminar participant. He describes how changes in healthcare are being accomplished in different countries with varying degrees of success - the market driven reforms of the United States, regionalization and more emphasis on out-patient care in most Canadian provinces, larger and more integrated health-services delivery organ-
izations in Australia and New Zealand, and the increased efficiencies of the once pioneering National Health Service in the United Kingdom. All countries are in the midst of a major shift from a world of hospitals to a world of health systems.

While financial constraints determined the timing of the revolution in healthcare, the other forces shaped the direction. Decter deplores the unnecessarily high cost of restructuring in human terms, but he believes that in the long run we will have obtained a better bargain in healthcare.

The hospital, for example, will endure as an important institution but its role is being powerfully affected by the four strong winds. The twenty-first century's hospital will be focused on services rather than on beds; its patients treated not only as individuals in need of medical care, but also as consumers.

Outsourcing of non-clinical services has taken hold in hospitals as in other industries and is enabling hospitals to concentrate on their core competencies - treating and preventing illness. Hospital storerooms and kitchens are disappearing, replaced by the same kind of just-in-time inventory systems that has revolutionized other industries. The hospital no longer builds patient care from scratch. Rather, it operates as the hub of an emerging system. Managed services and technological advances within and beyond hospital walls link hospitals into one information highway, which improves information, timeliness of care, and the ability to assess outcomes.

At the same time, yesterday's patients are becoming today's informed, aggressive consumers. In our experience, providing managed services for 497 health care sites and locations, ARAMARK has recognized and responded to the fact that patients' attitudes are changing. They expect the same level of service in hospital as they have become accustomed to in other areas of their lives. They are becoming more vocal and demanding, especially on the non-clinical side, where quality evaluations are easily made. Was the toast warm enough? Is the hospital as clean as it could be? Are there loud noises or distractions?

This trend is accelerated by the wider use of over-the-counter medications, the proliferation of home-testing products, and the chip-driven push towards miniaturization and Iower-cost diagnostic technologies.

Decter dedicates his book "To the millions of men and women throughout the world who have devoted their lives to caring for their fellow human beings." He includes a devout wish that "As healthcare services change and transform, I hope you retain your humanity and compassion".

The author isn't maudlin about the passing of the stand-alone hospital, the solo-practice physician, the hospital-based nurse, and he is realistic about the trauma the winds of change are causing to these stalwarts of traditional healthcare. He is insistent that the changing role of these healthcare providers will continue to be important, but in contexts much changed from the past. The developed world is moving toward large physician groups that are more formally linked to the rest of the health system, and an increased emphasis on primary care - both physician-led and nurse-led - is emerging. In the end, the potential for benefits to patients will steadily increase.

On the horizon, and probably the far horizon of two or three decades, is the practical application of emerging knowledge in human genetics - knowledge that recently took a major leap with the announcement that 90% of the human genetic code has been mapped. With policies in place to prevent the abuse and misuse of genetic information, the major benefit of genetic research for healthcare will be its ability to provide more precise diagnoses leading to better decisions regarding treatment.

Decter's purpose in writing Four Strong Winds was twofold: to identify the forces driving change in healthcare systems, and to describe where these forces are taking our health systems. His first purpose is admirably filled in his careful description of the changes occurring in the countries he has examined. Those changes are consistently tied in with the forces driving them - or better, the forces driving them are consistently related to the changes, which are occurring.

Where are our health systems going? "The three-way tug of war among those who pay for health services, those who provide them, and those who receive them will not abate." Decter deplores, but accepts as inevitable, the pressures on policy makers and management from media headlines, which usually include the word "crisis" close to the word "healthcare." And he is right when he stresses the pressing need for better and more frequent communication from those leading health organizations: "Only with diligent, patient explanation will an increasingly anxious public become informed and confident."

Decter predicts that the two primary mandates of health-services organizations will be to provide health services to the ill and injured, and to focus on the health of the population. He believes this second mandate is what distinguishes the integrated or regional health organization from the hospital and that it represents a profound change in the health world.

Decter's humanitarianism shines through his concluding words: "Our globe may be a village, but it is one with an unacceptable degree of difference between the health of our wealthiest and that of our poorest citizens. We know how to reduce these disparities."

Whether or not you agree with his analyses of the winds of change and their effect on healthcare services, Decter has produced an informative, thoughtful book on a subject that has vitally important implications for everyone. Medical providers, service administrators, and policy-makers can learn from what he has written. Consumers can gain sympathy for and understanding of the enormous difficulties facing those who are re-setting their sails in the face of the shifting winds, and have some confidence that eventually the health of all peoples in all nations will be improved.

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