There should be a law.

Two new publications should be of interest to our readers. These are Accountability in Health Care and Legal Approaches (Canadian Policy Research Networks), and Prescription for Excellence: How Innovation Is Saving Canada's Health Care System (HarperCollins Canada).

The Accountability report, authored by Nola M. Ries and Timothy Caulfield, describes the legal and legislative approaches currently used in Canada and other countries to enable patients to assert their claims on the health care system. It also discusses newer proposals for a patients' bill of rights and quality control laws, including those advocated in the Romanow and Kirby reports.

Legal approaches are constantly being tested in the courts and administrative tribunals as they relate to specific cases. Patients argue for certain types of treatment and health care administrators respond that the care demanded is not only expensive but highly experimental, untested, and questionable. Other cases have involved the effect of lengthy waiting lists on the health of patients.

Currently, the most important case wending its way through the courts is the one involving the treatment of a child for autism. The British Columbia case, in which the trial and appeal courts have supported the parents' claims, will shortly be argued in the Supreme Court of Canada. The parents want the provincial health care system to pay for certain procedures. The provincial authorities argue that the school system can handle the problem adequately.

The legal approach is useful because it focuses attention on special needs of small numbers of people who might be overlooked in broader health policy decisions. It may force health-care professionals and policy makers to consider alternatives to conventional thinking. However, the legal approach is a time-consuming and costly way to create health care policy.

Legality can also encourage a certain amount of chicanery among policy makers. In response to judicial decisions the administrators might shift resources and spread the burden to other treatment programs rather than spend more money on the required program. Pressures to shorten waiting lists for cardiac care have caused longer waiting lists for other forms of care. Recent improvements in critical care have come at the expense of public health, home care for the elderly and disabled, and other social programs.

These shifts have had serious consequences. Two examples illustrate the impact of these shuffles. To meet critical care problems over the past decade, cuts have been made to public health programs that left us poorly prepared to deal with the recent SARS epidemic. Another example is the impact that years of cuts in social and housing programs has contributed to the rise in tuberculosis rates and other serious illnesses among both the homeless and those people who provide services to this population.

It is too bad that we have no law for innovative thinking, the subject of Prescription for Excellence by Professor Michael Rachlis. Renowned for his criticism of the health care system, he found examples of innovation among professionals and institutions that have managed to look after their clientele at the same time that politicians did badly by cutting back on funds and resources to this vulnerable group.

Dr. Rachlis presents "evidence-based story telling"--descriptions of well thought out actions to illustrate his point. He tells of the Group Health Cooperative in Sault Ste. Marie, Ont. and other innovative health care operations across Canada. He relates tales of hospitals that have dealt creatively with their emergency room line-ups, services that provide homecare efficiently, and the effective management of diabetes problems. These are accomplished without the wringing of hands about lack of funds. (We would like to see what these groups can accomplish with more adequate funding.)

The stories that Dr. Rachlis tells provide a picture of the efficient use of physicians, nurses, nurse-practitioners, midwives, social workers and other health-care professionals. Such approaches seldom meet with enthusiasm in the health care establishment.

Dr. Rachlis believes that health policy debates that begin and end only with discussions about money achieve little. Changes in health care should begin and end with the delivery of needed services, allowing for and encouraging innovation to obtain the maximum benefit for people, resources and dollars expended.

--L.K.