Managed care, reengineering, privatization - these are the buzzwords of the healthcare profession in the face of shrinking budgets and increasing financial stress on hospitals and government healthcare systems. But what are the effects on healthcare administrations and patient care in the face of these issues? That's the question answered in Beyond Restructuring: A collection of papers from a King's Fund international seminar, edited by Sholom Glouberman, Ph.D.

Glouberman is Philosopher in Residence at the Baycrest Centre for Geriatric Care in North York, Ontario, and leads the Health Network of Canadian Policy Research Networks. He is also a Fellow of the King's Fund exchange, a foundation based in London, England. King's Fund conferences are held every two years, and bring together participants from numerous English-speaking countries. Beyond Restructuring is an edited compilation of papers from the most recent meeting held in Banff, Alberta, in 1995.

The book offers readers an international perspective on healthcare restructuring, demon-strating that reorganization may not always be the most effective means of achieving optimum healthcare provision. What also makes Beyond Restructuring invaluable to Canadians is the diverse perspective the Banff participants bring to the table. The book is divided into three distinct sections: "Dimensions of Restructuring", which outlines theories of restructuring and engages in philosophical and policy debates about its merits; "Divisions and Splits after Restructuring", which gives readers a perspective on the outcomes of restructuring; and "Some Ways Forward", which proposes options for achieving successful restructuring outcomes without sacrificing the delivery of optimum healthcare.

The theme"Managed Care: Pro or Con" was addressed by John King, President and Chief Executive Officer of Legacy Health System in Portland, Oregon and James Mongan, Executive Director, Truman Medical Centre in Kansas City, Missouri. King proposes that managed competition in Portland has proven successful because both healthcare providers and health insurers there share the financial risk in healthcare delivery. However, Mongan postulates that U.S. healthcare reform has proven to be a dismal failure, resulting in a higher uninsured patient population and a market-based approach to healthcare delivery.

Post-restructuring concerns were addressed by Peter Brennan, Commissioner of Health for the Health Department of Western Australia in Perth, and Michael Gracey. They suggest that despite healthcare reform initiatives undertaken recently in Australia, Aboriginal groups still remain a sadly underserviced population and their healthcare needs remain, on the whole, unmet.

Robert Maxwell, Chief Executive of the King's Fund in London, proposes that there are no simple fixes in reforming healthcare and suggests that policy makers undertaking massive changes would do well to "see change as a learning process where it is in everyone's interest to assess effects before anyone intervenes again."

Looking to the future, Frederick Alley, President and Chief Executive Officer of the Brooklyn Hospital Center in New York, posits that a multi-disciplinary network is required to achieve restructuring success: "Providers who have pursued network and system approaches aggressively will be most able to absorb the impacts of change and continue to operate in the best interest of the communities they serve."

The international perspectives presented in the book, says Glouberman, "will show Canadian readers that there isn't one single point of view, or only one direction that can be taken in healthcare restructuring. The experiences reported by people from different countries show both positive and negative consequences, and their views must be tolerated and listened to."

However, Beyond Restructuring is more than simply a collection of papers. Each entry is prefaced by Glouberman's editorial comments, giving readers an overview of its salient points.

Glouberman also skillfully weaves anecdotes and first-person narratives of healthcare delivery throughout the book. These insertions serve to enlighten readers about the broader issues of restructuring by illustrating the tangible consequences of the theories outlined by each author. Moreover, he says, "The anecdotes allow readers to pause and reflect on what they're reading: I didn't want people to read the book too quickly and, as a result, not really discover its overall themes."

Feedback to date about Beyond Restructuring has been mixed, says Glouberman. "Some people love it and embrace its theories, while others don't understand its meaning at all." He attributes this to the quirkiness of its structure and suggests that "not all readers are prepared to think differently."

Still, Glouberman hopes that the book will help readers understand that restructuring is not a simple cure for the ills of global healthcare delivery. "People must recognize that restructuring in and of itself is not enough, that it's a fantasy to believe that if you simply reorganize processes, everything will come out alright," he says. "The fragmentation in healthcare isn't just an organizational, it's also attitudinal, and the book shows that situation can and must be changed."

Beyond Restructuring can be obtained by contacting Sholom Glouberman at the Baycrest Centre for Geriatric Care, 3560 Bathurst Street, North York, M6A 2E1, telephone 416/785-2500, ext. 2150. The book costs $47 (including tax and shipping).

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