A nurse's remark on how delaying the discharge of her elderly mother from the hospital would negatively affect the unit's performance statistics led Professor Stein to a series of questions: Is efficiency desirable as a public good? Is efficiency actually a justification for other goals, and if so what are they? Do we have a common understanding of what efficiency means and can it be measured for social goods as it is for material production?
To some extent we get what choose to measure which is not necessarily what we either want or need. One trap that the health system can fall into is substituting throughput for efficiency focusing more on cost-containment rather than long term effectiveness. Stein also examines the case of school vouchers where the ostensible goal is to improve quality but the underlying ethos is equality. She finds that that where vouchers are equitably available for everyone (Cleveland, Chile, Ontario), the system favoured the privileged and added to inequality, whereas in Michigan vouchers were only offered to the poor, which achieved the desired goal. Costs weren't lowered but effectiveness was raised.
In practice a free market is rarely if ever efficient in terms of waste, yet it generates enough wealth to make up for it. In the case of government we have a single payer that contracts out to a number of private or public contractors, however price alone is not the sole benchmark. She notes that the utilitarian Jeremy Bentham introduced the notion of accountability. While we turn away from government to provide services we turn back to it to provide standards and monitor quality.
The final chapter looks at a new trend, that governments not only give us the citizen-consumer the liberty to choose, but the additional notion that they guarantee the availability of choice.
The book is organized into six chapters and was originally delivered on CBC radio and in a public forum in six parts for the annual Massey lectures in 2001. There is also short postscript chapter on the nature of Security in the Post Industrial Age, apropos of 9/11. Stein concludes that efficiency is more a means than an end, a process, not a value, a cultic shibboleth that that masks unstated goals. And perhaps it would be better if we say more precisely what we mean so that we achieve what we want.