In an attempt to create a functioning provincial health services system, the Ontario government established the Health Services Restructuring Commission (HSRC), giving it a four-year mandate to restructure approximately 225 public hospitals and to advise the government on related services. Riding the Third Rail tells the story of how the HSRC developed a vision of an effective health services system for the twenty-first century and attempted to fill a policy and leadership void.

In the face of fierce resistance to change, especially by hospitals, courageous local leaders created workable strategies for information management, the re-engineering of primary care, and the integration of primary, home, and long-term care with hospital care that resulted in the establishment of acute-care hospitals and the elimination of 9,000-10,000 empty beds. The authors describe the commission's frustration with the slow pace of change caused by powerful interests groups, prolonged legal jousting, a policy vacuum, and political timidity.