The heart, as the poetic locus of courage, is a critical component of the anatomy of change.
People are creatures of habit. If I learned as part of my medical training to order a urine test on every patient who comes to my office for a checkup, it would feel unnatural, and somehow less than attentive, for me to stop doing so. I might know that there’s no evidence to do it. In fact, it’s a waste of money and could harm my patients by picking up meaningless abnormalities that I’d feel compelled to investigate. And yet…my hand itches to tick that box on the requisition form. It’s also hard for my patients, who might be used to having their urine checked, to feel just as well cared for when I tell them we shouldn’t do it anymore.
Yelling louder at doctors to practise “good medicine” or at patients to “use the system responsibly” isn’t enough. Decades of research in human psychology and organizational change show that if you want people to change their behaviour, you need to make the right thing to do the easy thing to do—or perhaps sometimes the only thing to do. People need the path of least resistance to be the one that leads to the highest standard of care. They shouldn’t be expected to alter their behaviours and their expectations otherwise.
We can’t change the way we address the social determinants of health, the organization of primary care, the delivery of services, and their coverage without brave people in governments and health authorities who are willing to help us push for those changes. And in a publicly funded health system nested in a democratic country, governments will muster this courage only when they hear from voters that they should.
The biggest challenge for politicians and governments is saying no to the public. When the evidence shows that stroke units are the best way to deal with acute strokes, that means telling some communities that their local hospital may not offer stroke services anymore because they don’t have the full suite of services needed or the volume of patients to warrant it. When the best practice for certain knee injuries points to non-surgical approaches, that means deciding not to pay for the unnecessary operation. People may be upset because their local hospital no longer offers every service, or their neighbour got the procedure five years ago and it was covered then. Deciding to say no, even on the basis of strong evidence and in the interest of reducing variations in care, can quickly lead to a public fight. That’s hard, but it doesn’t make the decision wrong. These are circumstances where political courage is the only answer.
Hard conversations with voters are just that—hard. But until our politicians are willing to have them and the public is willing to accept that some “local” or “special” solutions can actually hold us back from ensuring the spread and scale of high-quality care, we’ll remain in a world where mediocrity looms.
Some jurisdictions create arm’s-length agencies to do the heavy lifting. In the U.K., the U.S., and increasingly in Canada, this has been an effective strategy. Allowing regional health authorities, arm’s-length agencies like Canadian Blood Services, and Health Quality Councils to make unpopular decisions gives governments some cover. But that means governments have to be willing to cede control and accept those bodies’ recommendations even when it’s difficult to do so. Citizens have a right to demand that non–democratically accountable organizations do their work based on the best available evidence and free from political and industry interference. We should also applaud political courage when we see it.
Whether it’s the Ministry of Health, an arm’s-length agency, or a health authority, someone has to be in charge of planning services, identifying problems, and fostering change across the entire system. Without the heart, a system that’s designed to support large-scale change can’t do its job.