Where to from Here: Keeping Medicare Sustainable by Stephen Duckett (review)

Popularly referred to as medicare, Canada has had a universally accessible, publicly financed health-care system since the early 1970s. During the ensuing years, it has achieved iconic status with the Canadian public. Any efforts by government to significantly alter the major aspects of this treasured public program have been met with significant public disapproval. Yet, since its inception, there has been an almost endless debate about the need to reform the health-care system. Academics have written numerous articles and books chronicling both the political debate and the proposed solutions. In his latest effort, Stephen Duckett provides a detailed overview and discussion of the issues facing Canadian health care and the range of possible solutions.

The book begins with a discussion of the historical development of the Canadian health-care system and the underlying debates. He pays particular attention in Chapter 2 to the most recent political discourse on sustainability that has emerged since the late 1990s. The reader is reminded that Canada’s medicare remains extremely popular, even in the face of mounting pressures for change because of rising costs, plateauing revenue sources, and increasing potential for health care to crowd out other major public program expenditures. The aging population is portrayed less as an approaching “silver tsunami,” as per the current political discourse, than a creeping glacier.

For the author, the problem facing decision makers is to gradually reorient the system to allow for the efficient and effective management of chronic health conditions that will affect an increasing percentage of the population over the next several decades. While recognizing the continuing importance of acute care, Duckett argues that more resources should be shifted toward caring for chronic conditions outside of hospitals and preventing these illnesses from occurring. In essence, this requires that the system ensures that “the right person enables the right care, in the right setting, on time, every time” (p. 41).

This single sentence provides an outline for the discussion that dominates the majority of the book. Basically, the book argues that efficiency, effectiveness, and quality can be achieved through strategic changes to how services are delivered and who delivers these services. Unlike many books on health-care reform, Where to from Here? suggests that part of this transformation requires reorienting our thinking to focus on health promotion and prevention. Accordingly, the way forward is an assessment of what works in preventing illness, particularly cancer.

From here, the book turns to primary care. No Canadian who is paying attention can fail to have noticed that primary care has been in a state of disrepair for some time. For Duckett, primary care reform requires employing an integrated team approach to care that facilitates patient self-management of chronic conditions where appropriate. In keeping with the current discourse and emerging best practice, the book includes the patient as an important member of the health-care team. Changing how physicians are paid and how they deliver primary care are also central to transforming primary care, if not other aspects of the system. In short, the way in which doctors are reimbursed needs to change to encourage holistic care. Access to care needs to be increased by allowing all primary care providers to practice to their full scope of practice. Underpinning this transformation is an effective infrastructure for collecting and sharing patient information. On this last matter, Canada is lagging behind many Western nations.

From primary care, the book shifts gears to tackle a second major weakness of the Canadian health-care system. In short, Canadians pay too much for drugs and lack a universal plan. Duckett observes that current research supports establishing a universal drug plan because it will save money through bulk purchasing, encouraging innovation, and price control. In a broader sense, greater integration of academic research and technology innovation is presented as a way to create a learning health system that will allow for smarter decisions about the introduction of new technologies.

Chapter 6 starts...