Better Now Six Big Ideas to Improve Health Care for All Canadians

Dr. Danielle Martin

Allen Lane, 2017

Reviewed by Johny Van Aerde, MD, PhD

BOOK REVIEW

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In her book, Better Now, Danielle Martin proves to be a great storyteller. She integrates elements from many respected evidence-based publications on health care systems,1-7 adds her perspective as a system physician, and interweaves superb narratives about patients throughout the book. The result is an absolute page-turner — a must-read for anyone who knows little about the Canadian health system and would like to understand some of its underlying limitations and read about some suggestions for improvement.

 

Two dominant threads run through the book. First, whatever ideas, big or small, one pursues, they have to comply with the principles of triple aim, i.e., better health, better care, better value, and with our Canadian value of equity. Second, all stakeholders — physicians, patients, and government — have to accept their part of the responsibility to keep our health care system sustainable. Without that commitment, no innovation, no matter how big, has a chance of surviving.  Top

 

Martin offers six “big ideas” to improve health for Canadians. The first, “the return of relationships,” is perhaps the most important one in terms of how primary care physicians can contribute to health care transformation. In primary care, everything is about relationships and connections. Someone either has to make those connections to the benefit of the patient or develop new types of connections by changing the way services are delivered. That someone is the general practitioner or the family doctor, who sees the patient as a whole, in her or his own setting and socioeconomic context. Where the specialist zooms in to look at an organ or body part, the GP zooms out to see the overall picture and form the relationships that are needed. Top

 

Big idea 5 is closely related to idea 1, in that it looks at socioeconomics and the influence of poverty on the health gap. Although Michael Marmot5 wrote extensively about the topic, Martin places it within a Canadian context, with two specific solutions for basic income that seem logical and worthy of pilot studies.

 

Big idea 2 — universal pharmacare — also becomes part of the poverty conversation, when those who need medication cannot pay for it. Pharmacare seems feasible in Canada, according to a study by Morgan et al.8 (of which Martin was a co-author) and would create an overall annual tax burden of 1 billion dollars or $28 per person. To work well, the pharmacare system would have to include an extensive and integrated database, a change in some of our prescribing habits, and prices negotiated between government and the pharmaceutical industry. Top

 

The numbers Martin quotes for the cost of drugs in Canada are staggering and about the highest in the world. In New Zealand, for example, some drugs cost 2% of what we pay in Canada. The biggest resistance to universal pharmacare is expected to come from those who have the most to lose financially: the pharmaceutical industry, private insurance companies, and pharmacy chains. Perhaps that helps explain why a similar recommendation on drug affordability in the report from the Advisory Panel on Healthcare Innovation2 hasn’t gone anywhere. Indeed, many of Martin’s big ideas, including this one, require what she calls real “political courage.”

 

Big idea 3 — reducing the number of unnecessary interventions and tests by practising evidence-based medicine, minimizing variation in treatment, and having conversations with patients about “choosing wisely” — is already gaining more and more traction in the context of triple aim. Top

 

Big idea 4, doing more with less, is a synthesis of the Advisory Panel on Healthcare Innovation’s recommendations on integration of services, value for money, and empowering patients.2 Martin explains how we can do more and different things with the same amount of money by managing wait lists creatively, redesigning care closer to home, incorporating disruptive technology, and, most important, engaging and empowering patients. She makes a strong argument for accepting innovation failures as part of organizational and systems learning and for having the political courage to accept this type of failure. So far, that courage has been lacking in Canada, as evidenced by the research of Lazar et al.4 Perhaps such innovations have to be found in partnership with private industry, which can serve as an economic driver and innovation catalyst, as suggested by the Advisory Panel.2 It is surprising that Martin did not make that link with her fifth big idea.

 

The sixth big idea, “the anatomy of change,” tries to describe what large-scale change looks like. Although this big idea is crucial to accomplishment of the other five, the topic is explored only rather superficially. Top

 

Understandably, as a founding member of Canadian Doctors for Medicare, Martin wrote this book from the sole perspective of a publicly funded health care system. If we accept that this is the only premise, then two fundamental questions must be asked. First, what is the purpose of our health care system? Because that question has never been asked, let alone answered, in Canadian history, the future demands on the system will continue to expand into areas that it was not intended to fund. Second, while keeping the Canadian health care system equitable for all, what are the many possible meanings of the word “private” that could benefit each and all of us?

 

In short, this is a book that belongs in the library of most politicians, who must find the courage to support what needs to be done. It belongs on the coffee tables of patients and Canadian citizens, who want to become knowledgeably and responsibly involved in health care system transformation. And it belongs on the desk of physicians, who must find out what leadership skills they need to lead health system reform. Top

 

References

1.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2013. http://tinyurl.com/p4y9grn (accessed 22 July 2015).

2.Advisory Panel on Healthcare Innovation (the Naylor Report). Unleashing innovation: excellent healthcare for Canada. Ottawa: Health Canada; 2015. http://tinyurl.com/qx2cf8z (accessed 18 Sept. 2015).

3.Marchildon G, Di Matteo L. Bending the cost curve in health care: Canada’s provinces in international perspective. Toronto: University of Toronto Press; 2015.

4.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press; 2014.

5.Marmot M.  The health gap. New York: Bloomsbury; 2015.

6.Meili R. A healthy society. Saskatoon: Purich Publishing; 2012.

7.Simpson J. Chronic condition. Toronto: Allen Lane; 2012.

8.Morgan S, Law M, Daw J, Abraham L, Martin D. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ 2015;187(7):491-7

.

Author

Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past president of the Canadian Society of Physician Leaders.

 

Correspondence to: johny.vanaerde@gmail.com

 

Top

 

In her book, Better Now, Danielle Martin proves to be a great storyteller. She integrates elements from many respected evidence-based publications on health care systems,1-7 adds her perspective as a system physician, and interweaves superb narratives about patients throughout the book. The result is an absolute page-turner — a must-read for anyone who knows little about the Canadian health system and would like to understand some of its underlying limitations and read about some suggestions for improvement.

 

Two dominant threads run through the book. First, whatever ideas, big or small, one pursues, they have to comply with the principles of triple aim, i.e., better health, better care, better value, and with our Canadian value of equity. Second, all stakeholders — physicians, patients, and government — have to accept their part of the responsibility to keep our health care system sustainable. Without that commitment, no innovation, no matter how big, has a chance of surviving.  Top

 

Martin offers six “big ideas” to improve health for Canadians. The first, “the return of relationships,” is perhaps the most important one in terms of how primary care physicians can contribute to health care transformation. In primary care, everything is about relationships and connections. Someone either has to make those connections to the benefit of the patient or develop new types of connections by changing the way services are delivered. That someone is the general practitioner or the family doctor, who sees the patient as a whole, in her or his own setting and socioeconomic context. Where the specialist zooms in to look at an organ or body part, the GP zooms out to see the overall picture and form the relationships that are needed. Top

 

Big idea 5 is closely related to idea 1, in that it looks at socioeconomics and the influence of poverty on the health gap. Although Michael Marmot5 wrote extensively about the topic, Martin places it within a Canadian context, with two specific solutions for basic income that seem logical and worthy of pilot studies.

 

Big idea 2 — universal pharmacare — also becomes part of the poverty conversation, when those who need medication cannot pay for it. Pharmacare seems feasible in Canada, according to a study by Morgan et al.8 (of which Martin was a co-author) and would create an overall annual tax burden of 1 billion dollars or $28 per person. To work well, the pharmacare system would have to include an extensive and integrated database, a change in some of our prescribing habits, and prices negotiated between government and the pharmaceutical industry. Top

 

The numbers Martin quotes for the cost of drugs in Canada are staggering and about the highest in the world. In New Zealand, for example, some drugs cost 2% of what we pay in Canada. The biggest resistance to universal pharmacare is expected to come from those who have the most to lose financially: the pharmaceutical industry, private insurance companies, and pharmacy chains. Perhaps that helps explain why a similar recommendation on drug affordability in the report from the Advisory Panel on Healthcare Innovation2 hasn’t gone anywhere. Indeed, many of Martin’s big ideas, including this one, require what she calls real “political courage.”

 

Big idea 3 — reducing the number of unnecessary interventions and tests by practising evidence-based medicine, minimizing variation in treatment, and having conversations with patients about “choosing wisely” — is already gaining more and more traction in the context of triple aim. Top

 

Big idea 4, doing more with less, is a synthesis of the Advisory Panel on Healthcare Innovation’s recommendations on integration of services, value for money, and empowering patients.2 Martin explains how we can do more and different things with the same amount of money by managing wait lists creatively, redesigning care closer to home, incorporating disruptive technology, and, most important, engaging and empowering patients. She makes a strong argument for accepting innovation failures as part of organizational and systems learning and for having the political courage to accept this type of failure. So far, that courage has been lacking in Canada, as evidenced by the research of Lazar et al.4 Perhaps such innovations have to be found in partnership with private industry, which can serve as an economic driver and innovation catalyst, as suggested by the Advisory Panel.2 It is surprising that Martin did not make that link with her fifth big idea.

 

The sixth big idea, “the anatomy of change,” tries to describe what large-scale change looks like. Although this big idea is crucial to accomplishment of the other five, the topic is explored only rather superficially. Top

 

Understandably, as a founding member of Canadian Doctors for Medicare, Martin wrote this book from the sole perspective of a publicly funded health care system. If we accept that this is the only premise, then two fundamental questions must be asked. First, what is the purpose of our health care system? Because that question has never been asked, let alone answered, in Canadian history, the future demands on the system will continue to expand into areas that it was not intended to fund. Second, while keeping the Canadian health care system equitable for all, what are the many possible meanings of the word “private” that could benefit each and all of us?

 

In short, this is a book that belongs in the library of most politicians, who must find the courage to support what needs to be done. It belongs on the coffee tables of patients and Canadian citizens, who want to become knowledgeably and responsibly involved in health care system transformation. And it belongs on the desk of physicians, who must find out what leadership skills they need to lead health system reform. Top

 

References

1.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2013. http://tinyurl.com/p4y9grn (accessed 22 July 2015).

2.Advisory Panel on Healthcare Innovation (the Naylor Report). Unleashing innovation: excellent healthcare for Canada. Ottawa: Health Canada; 2015. http://tinyurl.com/qx2cf8z (accessed 18 Sept. 2015).

3.Marchildon G, Di Matteo L. Bending the cost curve in health care: Canada’s provinces in international perspective. Toronto: University of Toronto Press; 2015.

4.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press; 2014.

5.Marmot M.  The health gap. New York: Bloomsbury; 2015.

6.Meili R. A healthy society. Saskatoon: Purich Publishing; 2012.

7.Simpson J. Chronic condition. Toronto: Allen Lane; 2012.

8.Morgan S, Law M, Daw J, Abraham L, Martin D. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ 2015;187(7):491-7

.

Author

Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past president of the Canadian Society of Physician Leaders.

 

Correspondence to: johny.vanaerde@gmail.com

 

Top