Do We Care? Renewing Canada’s Commitment to Health
edited by Margaret Somerville.
McGill-Queens 1999.
Who Cares? Do managers Care? Do Doctors Care? Do Nurses Care? Do Canadians Care?
This book is a record of the first "Directions for Canadian Health Care Conference" sponsored by Merck Frosst. It provides some new perspectives on the problems we are facing in our Canadian health care system. Over the last fifteen years we have gone from the almost smug belief that our health care system was among the best in the world, to the fear that it would not be there should we need it. It was heartening to see so many very clever people who are thinking very hard about what has gone wrong with medicare and trying to find some answers. Most of the pieces were innovative and interesting and provided insights into problems that have been plaguing the Canadian health care system in the last decade of the last millenium - problems which continue to this very day.
For this particular review it is worth rehearsing those presentations with particular relevance to managers and management. The most noteworthy among these is the paper by John Ralston Saul, which includes a polemic against the introduction of managerialism and corporatism into medicare.
He says ... our growing dependency on managers is killing medicare, not openly, but behind a pervasive rhetoric that claims to be saving it through such utilitarian dogmas as "efficiency" at the expense of the practical application of ideas which would result in such concepts as "effectiveness."
And again ... the abstract control-oriented approach typical of a management-dominated corporatist system leads to the simple denial of such obvious problems as the shortage of nurses and the destructive delisting of certain services.
Saul argues that the concern of medicare has shifted from truly caring for patients to a concern for the bottom line. At the same time there is a continuing denial that the primacy of this concern for efficiency and more bang for the buck has harmed medicare. He argues that as this value took precedence over everything else the system lost its direction and most particularly lost its capacity to do its work appropriately.
This challenge to the value added by managers to the health care system and the usefulness of many of the ideas associated with management to the care process is echoed in some of the other presentations as well. Although it is most direct in Ralston Saul’s presentation, the question "Do Managers Care?" continues to be raised albeit more indirectly in other parts of the book. In Richard and Sylvia Cruess’ discussion of professionalism, they argue that "physicians must reassert their commitment to individual patients." By implication this must take precedence over any obligation to efficiency or to the corporate benefit of their hospital which is the mandate of managers. Raisa Deber argues that blind use of market approaches is as bad as blind use of managerialism. Lois Simpson berates the commodification of health care. She argues that "health care should not be for sale." Presumably it should also not be managed as a marketable commodity. Monique Bégin, the protector of the Canada Health Act questions the value of adding "affordability" or "sustainability" to the Act because it would become a rationalization for cutting services. Once more the notion that the managerial imperative of watching the bottom line is invoked as destructive of the real values behind medicare. Similar discussions occur throughout the book.
These questions raise issues about a conflict of values between a managerial approach that emphasizes efficiency and an approach that stresses "respect for the dignity of persons, caring relationships, protection of the vulnerable." Nuala Kenny worries that the values that underlie our society, not only those that stand behind healthcare may be changing. She argues that we must think about those values again. "What values do we choose now, and what kind of society will they care for?"
As a result of the questions it raises, this book is of great value because it presents serious challenges to health care managers. What are their values? How managerial are they? Do they really value efficiency over all else? If not, how is this manifested in their organization? Given their mandate can they balance a concern for efficiency with efforts to improve the patient experience of care in their organizations? What is the distributive or control role of managers in the health care system? Should doctors take the final decisions about resource allocation or should managers take them? To what extent are managers’ actions responsible for the deterioration of trust in medicare? Questions like these are worth thinking about in that they not only question the place of managers in the system today, but they challenge the nature of the future role of managers and management thinking in medicare.
But the book and the presentations in them also have some shortcomings. The book, "Do we Care?" has a complete absence of a nursing position on this issue. If anyone is supposed to care it is the nurse. Are nurses caring less? If so, how has this happened? How are nursing related problems contributing to the current crisis of medicare? These and other questions about nursing are not considered in the book. It may well be that ignoring such a large part of the system is part of an unconscious denial of the role of the nurse and of how badly nurses have been treated over the recent period of restructuring.
The Cruess’ article suggests a second shortcoming of the book. Their very thoughtful discussion of professionalism and the future role of doctors does not consider what relationship such doctors would have with managers or even nurses. Many of the other presentations do not consider how work in the health care system and especially the hospital is done. No line managers of hospitals presented their views at the conference. The presence of nursing and management advocates would have made the debate richer and the book even better.
London, England
February, 2001