This section is designed for readers who want to delve deeper into any of the Big Ideas. Under each heading I include a short list of my top picks: books, websites, and online articles that I frequently recommend to people who want to learn more, and that are current as of 2016. Some are written for a lay audience, while others are more academic. They don’t represent an exhaustive list or cover the whole landscape—they’re just my favourites.
THE BASICS
1. For a rigorous overview of the structure, governance, financing and delivery, and quality of Canadian health care, including the Canada Health Act and its implications, see Gregory Marchildon’s 2013 book Health Systems in Transition: Canada, Second Edition, or Katherine Fierlbeck’s 2011 Health Care in Canada: A Citizen’s Guide to Policy and Politics.
2. For a good snapshot of wait times in Canada, the Wait Time Alliance produces reliable reports, which can be found at www.waittimealliance.ca.
3. Other general dimensions of health system performance can be explored using the interactive tools found on the website of the Canadian Institute for Health Information (CIHI), including the user-friendly site http://yourhealthsystem.cihi.ca.
4. Excellent myth-busters on the aging population, private funding for public wait times, user fees, and other health care zombies can be found in the Canadian Foundation for Healthcare Improvement’s Mythbuster series.
BIG IDEA 1 ABIDA: THE RETURN TO RELATIONSHIPS
1. A good way to think about the importance of primary care is to be aware of the “ecology of care”: the rates of ill health (chronic conditions) and health care use among Canadians. Well-known Canadian researcher Moira Stewart and her colleagues have quantified how much we use primary care in relation to other services in their article “Ecology of Health Care in Canada,” which was published in Canadian Family Physician.
2. A clear and moving articulation of the unique perspective of generalists can be found in a lecture entitled “The Importance of Being Different” by Dr. Ian McWhinney, often thought of as the father of Canadian family medicine. The lecture was published in the British Journal of General Practice and is available online.
3. The Four Principles of family medicine (found at www.cfpc.ca/principles) form the basis of the “three relationships for health” and are the foundation of that discipline.
4. A more academic perspective on the same set of issues is set out by Dr. Iona Heath from the U.K. in her lecture “Divided We Fail,” which was the 2011 Harveian Oration when she was president of the Royal College of General Practitioners.
5. The seminal works demonstrating that strong primary care systems are associated with better outcomes, fewer disparities, and higher satisfaction in relation to costs were conducted by the late Barbara Starfield and her colleagues. She summarized her work in a paper entitled “Primary Care and Equity in Health: The Importance to Effectiveness and Equity of Responsiveness to People’s Needs.”
6. More recently and closer to home, Marcus Hollander and colleagues in British Columbia quantified the value of primary care to system costs in their 2009 article “Increasing Value for Money in the Canadian Healthcare System.” They found that the sickest patients without a close alignment to primary care incurred an annual system cost of $30,000 each, whereas similar patients with a close alignment to primary care incurred an annual system cost of only $12,000.
7. The changes underway in Canadian primary care are well summarized in an excellent 2011 piece entitled “Primary Health Care in Canada: Systems in Motion” by Brian Hutchison, Jean-Frederic Levesque, Erin Strumpf, and Natalie Coyle (The Milbank Quarterly, 89[2], pages 256–288); abstracts of this article can be found online.
8. When it comes to “measuring what matters,” the work on the Starfield Model by Dr. George Southey has been adapted and applied by Carol Mulder and other terrific leaders in the Association of Family Health Teams of Ontario. I hope that academic publications on this model will be forthcoming. In the meantime, those who want to learn more about the D2D experiment should start with the pdf entitled “Valuing Comprehensive Primary Care: The Starfield Principles” on the AFTHO website (www.afhto.ca).
9. A good introduction to the concept of population-oriented, relationship-centred primary care can be found in the “Patient’s Medical Home” model. The Canadian articulation of this concept (www.cfpc.ca/A_Vision_for_Canada) comes from the College of Family Physicians of Canada.
10. The “Family Medicine for America’s Health” initiative commissioned an exhaustive bibliography in order to understand the capacity of primary care to improve America’s health care system. The resulting “Primary Care and the Triple Aim” annotated bibliography, produced by the Graham Center, is an extremely thorough look at the evidence relating to primary care and the Triple Aim; it can be found at www.graham-center.org.
BIG IDEA 2 AHMED: A NATION WITH A DRUG PROBLEM
1. The growth of precarious and part-time work in Canada makes the need for pharmacare ever more pressing. In 2015, the Wellesley Institute produced an excellent paper that brings together the important evidence on this topic: “Low Earnings, Unfilled Prescriptions: Employer-Provided Health Benefit Coverage in Canada” can be found at www.wellesleyinstitute.com.
2. For an overview of how over two hundred Canadian academics see the problems of—and the solutions to—prescription medication policy in Canada, I strongly recommend the Pharmacare 2020 report entitled “The Future of Drug Coverage in Canada,” which was produced under the leadership of Professor Steve Morgan from the University of British Columbia (and which I had a very small hand in). It can be found at pharmacare2020.ca.
3. For an academic and very thorough analysis of how we’ve ended up at an impasse on pharmacare and what can be done to get us out of this longstanding rut, I recommend Katherine Boothe’s book Ideas and the Pace of Change: National Pharmaceutical Insurance in Canada, Australia, and the United Kingdom.
4. International comparisons of drug prices do not paint Canada in a very favourable light. For a flavour of how big the differential is, see the “Generic Drugs in Canada, 2013” report from the Patented Medicine Prices Review Board. As well, in the Review Board’s “Annual Report 2013,” see the “Comparison of Canadian Prices to Foreign Prices.” Both can be found on the PMPRB website.
5. To learn about the New Zealand experience of bringing prices down for pharmaceuticals, I recommend the highly readable series of background papers listed in “Your Guide to PHARMAC” on the www.pharmac.govt.nz site.
BIG IDEA 3 SAM: DON’T JUST DO SOMETHING, STAND THERE
1. A terrific and highly accessible book for understanding overdiagnosis and the harms of too much medicine is Overdiagnosed: Making People Sick in the Pursuit of Health by Dr. H. Gilbert Welch and colleagues.
2. Excellent resources on unnecessary tests and treatments, and how to have a conversation with your doctor about risks and harms, can be found on the Choosing Wisely Canada website (http://choosingwisely.ca); interested readers can also peruse the specialty-specific recommendations on this site.
3. The National Institute for Health and Care Excellence in the U.K. (www.nice.org.uk) also has a well-known “Do Not Do Recommendations” list that covers a variety of areas.
4. For a good academic overview of the problem of overprescribing in the elderly in particular, I recommend the article “Better Prescribing in the Elderly” by Geneviève Lamay and Bill Dalziel at www.canadiangeriatrics.ca.
5. An excellent set of resources on deprescribing can be found at deprescribing.org.
BIG IDEA 4 SUSAN: DOING MORE WITH LESS
1. On methods to redesign health care, including the notion of “pivoting,” I recommend Steve Blank’s “Why the Lean Startup Changes Everything” from the Harvard Business Review (hbr.org) and Brian Golden’s “Improving the Patient Experience Through Design” from the Rotman Management Journal (rotman.utoronto.ca).
2. On the care of high-needs, high-cost individuals, it was Atul Gawande’s “The Hot Spotters” piece in The New Yorker that put this issue on the radar across North America, although the skew in health spending was described as early as the 1960s in Canada. Gawande’s many terrific pieces can be found on The New Yorker website, and his books are all interesting and eminently readable.
3. A more thorough examination of the issue and some nice infographics can be found in the Commonwealth Fund (www.commonwealthfund.org) reports on high-needs, high-cost patients, such as the one entitled “Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis.”
4. In the United States, the Affordable Care Act established the Center for Medicare and Medicaid Innovation in order to test innovative payment and service delivery models that achieve the Triple Aim for beneficiaries of public health care. The stated goal includes a transformation of the American health care delivery system “from one that rewards volume of care to one that provides coordinated, patient-centered, and outcome-driven care.” An interesting perspective on that work so far can be found in Ashish K. Jha’s 2015 article entitled “Innovating Care for Medicare Beneficiaries: Time for Riskier Bets and Embracing Failure.”
5. Much has been written about disruptive technology in health care. One of the most frequently cited works is Clayton M. Christensen’s book The Innovator’s Prescription: A Disruptive Solution for Health Care. His perspective is summarized in an article in the Harvard Business Review called “Will Disruptive Innovations Cure Health Care?” While I don’t subscribe to all his solutions, I do find them to be a helpful way to think about which kinds of technology are likely to be most useful in redesigning care.
6. On failure in redesigning health care, an entire issue of HealthcarePapers (www.longwoods.com/publications/healthcarepapers) was released in February 2016 on this topic. It was guest co-edited by Dr. Joshua Tepper and me.
BIG IDEA 5 LESLIE: BASIC INCOME FOR BASIC HEALTH
1. For an excellent overview of the social determinants of health in Canada, I recommend the book Social Determinants of Health: The Canadian Facts, which can be downloaded from www.thecanadianfacts.org.
2. For a seminal work on the Social Determinants of Health, see Michael Marmot and colleagues’ “Closing the Gap in a Generation,” which can be found on the website of the WHO. Marmot’s recent book, The Health Gap: The Challenge of an Unequal World, offers a deeply moving account of how the social determinants lead to domestic and global health inequities.
3. Dr. Ryan Meili’s book, A Healthy Society: How a Focus on Health Can Revive Canadian Democracy, illustrates the importance of the social determinants of health in a highly accessible way. The organization he founded, Upstream, has an excellent website (www.thinkupstream.net) that includes videos, articles, and analysis on current issues relating to the social determinants of health in Canada.
4. The Mincome experiment in Manitoba has been summarized by Professor Evelyn Forget in her paper “The Town with No Poverty.”
5. For a comprehensive look at Basic Income literature from an academic perspective, a recommended resource is Basic Income: An Anthology of Contemporary Research, edited by Karl Widerquist, Jose A. Noguera, Yannick Vanderborght, and Jurgen De Wispelaere.
6. To learn more about the links between inequality and social problems, the seminal work is Richard G. Wilkinson and Kate Pickett’s book The Spirit Level: Why More Equal Societies Always Do Better.
7. For more on the effects of poverty on children, see the 2015 article entitled “Association of Child Poverty, Brain Development, and Academic Achievement” by Nicole Hair, Jamie Hanson, Barbara Wolfe, and Seth Pollak.
8. For more on social assistance and its limits, see “Poverty, Health, and Social Assistance” by Andrew Pinto, Gary Bloch, Ritika Goel, and Fran Scott; this 2011 report was a submission to the Committee for the Review of Social Assistance in Ontario.
BIG IDEA 6 JONAH: THE ANATOMY OF CHANGE
1. Variations in health care around the world are a focus of much academic work. A 2014 OECD report entitled “Geographic Variations in Health Care: What Do We Know and What Can Be Done to Improve Health System Performance?” looks at this issue from an international perspective, with Chapter 4 focusing on such variations in Canada.
2. In their 2008 book, High Performing Healthcare Systems: Delivering Quality by Design, Ross Baker and colleagues explore a series of case studies of systems that achieve excellence and show the capacity to improve. It is available at longwoods.com.
3. Steven Lewis’s essay “Spare the Policy, Spoil the Profession,” also hosted at longwoods.com, offers a damning summary of critiques of the way in which health care policy has dealt with the medical profession in Canada.
4. Dennis Kendel is a Canadian doctor who’s been very thoughtful about the tension between physician accountability and autonomy; see, for example, his 2014 essay entitled “Are We Afraid to Use Regulatory and Policy Levers More Aggressively to Optimize Patient Safety?”
5. Dr. Atul Gawande from the U.S. has written extensively on this issue. One of my favourites is “Cowboys and Pit Crews,” his 2011 commencement speech to the graduating Harvard medical school class. It was published on The New Yorker’s website.
6. In his piece “Era 3 for Medicine and Health Care,” published in JAMA in 2016, Don Berwick beautifully encapsulates the transition that is upon us in the way we think about our work as doctors and our relationship to the health care system.