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Health care of health : the development of the elements of a plan to address the health needs of the… McPhee, Margaret E. 1977

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HEALTH CARE OR HEALTH: THE DEVELOPMENT OF THE ELEMENTS OF A PLAN TO ADDRESS THE HEALTH NEEDS OF THE ELDERLY IN BRITISH COLUMBIA by Margaret E. McPhee M.A. U n i v e r s i t y of Edinburgh, 1954 Diploma i n Education, U n i v e r s i t y of Edinburgh, 1955 C e r t i f i c a t e i n S o c i a l Studies, U n i v e r s i t y of Edinburgh, 1959 C e r t i f i c a t e i n Medical Work, U n i v e r s i t y of Edinburgh, 1960. A THESIS SUBMITTED IN PARTIAL.FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n the Department of Health Care and Epidemiology We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1977 © Margaret E. McPhee 1977 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced d e g r e e at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Depar tment o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Depar tment o f A/r&./S/ f rt*. f7^S The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook Place Vancouver, Canada V6T 1WS Date £9*{font / g ? 7 I i ABSTRACT T h i s i s an a t t e m p t a t t h e deve lopmen t o f t h e e l e m e n t s o f a p l a n t o a d d r e s s t h e h e a l t h needs o f t h e e l d e r l y i n B r i t i s h C o l u m b i a , w h i c h c o u l d be d i r e c t e d t o t h e m i n i s t e r o f h e a l t h o f t h e P r o v i n c e . I t b e g i n s w i t h a r e v i e w o f p r o v i s i o n s and l e g i s l a t i o n a f f e c t i n g t h i s age g roup a t t h e f e d e r a l and P r o v i n c i a l l e v e l , and c o n c l u d e s t h a t as s e r v i c e s o t h e r t h a n m e d i c a l ones c o n t r i b u t e t o h e a l t h , t h e r e i s an undue emphas i s on a c u t e m e d i c a l and i n s t i t u t i o n a l c a r e , and a c o m p a r a t i v e i n -adequacy o f t h o s e p r e v e n t i v e and s u p p o r t i v e communi ty and s o c i a l s e r v i c e s w h i c h m i g h t meet many needs more a p p r o p r i a t e l y and more e c o n o m i c a l l y . Mos t o f t h e p r o b l e m s seem t o s t em f r o m l a c k o f any c o h e r e n t p o l i c y w i t h r e g a r d t o t h e e l d e r l y - p e r h a p s b e c a u s e i t i s o n l y r e c e n t l y t h a t t h e y have been i d e n t i f i e d as a c a t e g o r y , and p a r t l y b e c a u s e s o c i e t y ' s a t t i t u d e t o them i s so a m b i v a l e n t . I t i s s u g g e s t e d t h a t t he e l d e r l y do n o t r e q u i r e s e p a r a t e s e r v i c e s b u t t h e y do r e q u i r e a s p e c i a l p o l i c y . ' i ' : Mos t o f t h e i n a p p r o p r i a t e a s p e c t s o f t h e p r e s e n t d e l i v e r y o f h e a l t h s e r v i c e s a f f e c t a l l age g r o u p s and t h e e l d e r l y w i l l o n l y be a b l e t o b e n e f i t f r o m recommended changes i f t h e y a r e made t o the s y s t e m as a w h o l e . H o w e v e r , because o f t h e i n c r e a s i n g numbers o f e l d e r l y i n t he p o p u l a t i o n and t h e i r d i s p r o p o r t i o n a t e c o n s u m p t i o n o f m e d i c a l s e r v i c e s , and b e c a u s e o f t h e e v i d e n c e t h a t many o f t h e i r needs a r e b e i n g met i n a p p r o p r i a t e l y and i i i u n e c o n o m i c a l l y , i t seems p a r t i c u l a r l y d e s i r a b l e t o make a l t e r n a t i v e s e r v i c e s a v a i l a b l e t o t h i s age g r o u p . And b e c a u s e o f t h e i r d i s a d v a n t a g e d p o s i t i o n w i t h r e g a r d t o i n c o m e , f a m i l y , f r i e n d s and o t h e r s o c i a l c o n t a c t s , and e n e r g y compared w i t h o t h e r age g r o u p s , i t i s recommended t h a t a p o l i c y o f p o s i t i v e d i s c r i m i n a t i o n be a d o p t e d t o w a r d s t h i s age g roup i n t h e p r o v i s i o n o f p r e v e n t -i v e , communi ty and s o c i a l s e r v i c e s . V a r i o u s r e commenda t i ons a r e made f o r e l e m e n t s w h i c h s h o u l d be c o n s i d e r e d f o r i n c l u s i o n i n a p l a n , t h e m a i n one b e i n g t h a t i t must be made i n v e r y c l o s e c o - o p e r a t i o n w i t h t h e Depar tmen t o f Human R e s o u r c e s and w i t h i n p u t t o a n d / o r f r o m o t h e r r e l e v a n t d e p a r t m e n t s . i v Table of Contents Chapter Page Introduction x i I A H i s t o r i c a l Overview of Services f o r the E l d e r l y i n B r i t i s h Columbia 1 1. Health Services 2 2. Welfare 21 3. Voluntary Services 31 4. Housing 38 II Overview of Developments Relating to the E l d e r l y at the National Level 44 1. Health 44 2. Income Security , . . 52 3. Housing ' 60 4. National Reports 62 III Present S i t u a t i o n - Description and Assessment 67 Pje^crip_tion_ 1. Health Services - I n s t i t u t i o n a l 67 2. Health Services - Community Services 74 3. Mental Health 82 4. S o c i a l Services 84 5. Income Security 91 6. Housing 92 7 . Financing , . 95 8. Administrative Structures . 99 Review V Chapter Page 1. Health Services 101 2. S o c i a l Services 108 3. Income 109 !4i;'. Housing , 110 5. Personnel .„...* 115 6. Lack of Co-ordination and Planning • . . 119 7. Evaluation 122 IV The E l d e r l y Population 128 Aging Populations - Selected Countries and Canada . . . 128 The E l d e r l y Population of B.C. - Numbers and Location . 130 C h a r a c t e r i s t i c s of the E l d e r l y Population 132 V The E l d e r l y Population -" Needs 151 Types of Need 151 C h a r a c t e r i s t i c s of.Need 162 1. Need for Services 168 2. Psychological Needs 174 3. Groups with Similar Needs 180 4. Needs of the System 184 5. S o c i a l Needs 186 Conclusion 186 VI Inappropriate Aspects of Present Provisions 192 Emphasis on Hospitals and Acute Care 193 Mental Health Services 196 R e h a b i l i t a t i o n 197 Relative Neglect of Preventive and Community Services . . 200 Home Care 202 v i Chapter Page Med i c a l i z a t i o n of Need 204 I n s t i t u t i o n s 208 So c i a l Services 212 Income and Housing 216 Problems of Delivery and Organization 217 Psychological Needs 222 Conclusion 222 VII Programming without a P o l i c y 228 System Trends or Features which a f f e c t a l l age groups . . 228 Services for the E l d e r l y 232 Lack of P o l i c y , 235 E f f e c t s of Lack of P o l i c y 238 Reasons for Lack of P o l i c y 240 Lack of Categorization of E l d e r l y 241 Uncertainty about the Role and Status of the E l d e r l y . . 245 Need for a P o l i c y , . 248 VIII Elements of a Plan 258 Health Policy;; for the E l d e r l y 259 Planning for the E l d e r l y 261 Some Assumptions 261 The Planning Process 270 Epilogue 276 Bibliography 277 Appendix A Problem Areas I d e n t i f i e d by Working Group on Health Services for the E l d e r l y 292 v i i L i s t of Tables Table Page I. H o s p i t a l i z a t i o n by Sex and Age for a l l Persons H o s p i t a l -iz e d i n B r i t i s h Columbia, 1975 126 I I . Average Length of L i f e - Selected Years 138 IIIA. L i f e Expectancy at B i r t h i n Selected Countries 138 IIIB. L i f e Expectancy at B i r t h i n Canada ...... . . . 139 IV. Percentage of Population Aged 65 and over , Selected Countries 139 V. Numbers and Percentage of Population aged 65 and over, Canada 140 VI. Absolute and Relative Increases i n the Size of Specified Age Groups, Canada 140 VII. Projected Numbers and Percentage of Population aged 65 . and over, Canada 140 VIII. Canadian Dependency Ratios 141 IX. Population 65+ as Percentage of Total Population by Province 142 X. Over-50 Population i n 000s, B.C. by 5-year age groupings 143 XI. B r i t i s h Columbia Population Projections 144 XII. Proportional Percentage Increase i n Population aged 65 and over 145 XIII. Proportion of the Population aged 65 and over i n some M u n i c i p a l i t i e s 145 XIV. Sex and M a r i t a l Status of over-65 population, B.C., 1971 146 v i i i Table Page XV. National Income D i s t r i b u t i o n of a l l Individuals and of the E l d e r l y Population 146 XVI. Expenditure on Personal Health Care, Canada, 1960-71, Percentage of Gross National Product at Market Prices. 225 XVIIT. Expenditure on Personal Health Care, B r i t i s h Columbia, 1960-1971, i n Thousands of D o l l a r s . . . . 226 XVIII. Estimated National Health Expenditures, Canada, D i s t r i b u t i o n by Category of Expenditure 227 i x L i s t of Figures Figure Page 1 Organization of B.C. M i n i s t r y of Health 127 2 B r i t i s h Columbia Population Projections, 1974-1996 . . . 147 3 Numbers of People Aged 65 and over, B.C. Regional D i s t r i c t s , 1976 and 1980 148 4 Percentage of People Aged 65 and over, B.C. Regional D i s t r i c t s , 1976 and 1980 149 5 Population Pyramids, Surrey, Vancouver, Whiterock . . . . 150 6 Structured R a t i o n a l i s a t i o n of Creative Action (Jantsch) . 256 7 Types of degeneration of the process of r a t i o n a l creative action (ibid) 257 X ACKNOWLEDGEMENTS I w o u l d l i k e t o e x p r e s s my g r a t i t u d e : t o D r . D . 0 . A n d e r s o n , D i r e c t o r , D i v i s i o n o f H e a l t h S e r v i c e s R e s e a r c h and D e v e l o p m e n t , U . B . C . H i s t a l e n t s as a p h i l o s o p h e r I v a l u e d as much as h i s e x p e r t i s e and p e r c e p t i v e n e s s i n t he s t u d y o f h e a l t h c a r e d e l i v e r y , t o M r . P a u l N e r l a n d , a l s o i n t h e H e a l t h S c i e n c e s C e n t r e , who s h a r e d w i t h me some o f h i s e x p e r i e n c e o f t h e P r o v i n c i a l s e r v i c e s , and whose a d v i c e and p a t i e n c e were i n v a l u a b l e i n t h e e a r l y s t a g e s , to D r . A . 0 . C r i c h t o n , Depa r tmen t o f H e a l t h C a r e and E p i d e m i o l o g y , who gave me t h e b e n e f i t o f h e r t h o u g h t s b e f o r e l e a v i n g f o r a s a b b a t i c a l y e a r , t o many o t h e r p e o p l e a t U . B . C , i n g o v e r n m e n t , and i n t h e communi ty who were k i n d enough t o g i v e me t h e i r t i m e and t h e i r i d e a s , t o t h e s t a f f o f t h e D i v i s i o n o f R e s e a r c h and D e v e l o p m e n t , H e a l t h S c i e n c e s C e n t r e , U . B . C , f o r t h e i r u n f a i l i n g h e l p f u l n e s s and good n a t u r e , t o my f e l l o w s t u d e n t s , p a r t i c u l a r l y C a r o l G r a y , K a t h y J a n g , Wendy M a n n i n g and A u d r e y P o p e , who s u p p l i e d me w i t h r e l e v a n t m a t e r i a l and r e f e r -e n c e s , and t o J i m , whose g e n e r o s i t y was e x p r e s s e d i n many ways i n t h e c o u r s e o f t h i s e x e r c i s e . x i INTRODUCTION In the present century, any country which has managed by public health measures, sa n i t a t i o n , higher standards of l i v i n g and advances i n medicine, to lower i t s infant m o r tality rate and the incidence of com-municable disease, to cure the formerly incurable, and to keep a l i v e the impaired and c h r o n i c a l l y i l l , has been faced with an increasing propor-ti o n of e l d e r l y people i n i t s population. These same countries with t h e i r highly developed systems of medical care, financed and administered to d i f f e r e n t degrees by various l e v e l s of government, are also faced with the s i t u a t i o n whereby an ever-increasing proportion of the G.N.P. either i s devoted to health services, or would be i f steps were not taken to change t h i s trend. Both of these phenomena can be observed i n Canada, i n the country as a whole and i n each of the provinces, not l e a s t i n B r i t i s h Columbia. At a time when there i s much t a l k of necessary changes i n the health care system, i t seems appropriate to look at the e l d e r l y population, which i s one of the important consumer groups of health services, and to consider what are the p a r t i c u l a r needs of t h i s group for maintenance of t h e i r health, and how these needs can best be met. I t was decided to undertake t h i s task from the point of view of a consultant required to make recommendations to the B.C. Minister of Health, using secondary data only, since the writer has neither the time nor the resources to obtain new data. The process would begin with a study of the h i s t o r y of the B.C. health services, welfare services, voluntary services, and housing and income security provisions, to f i n d out at which point, i f at a l l , the x i i e l d e r l y were i d e n t i f i e d as a s p e c i a l c a t e g o r y , and what s e r v i c e s and programmes were p r o v i d e d f o r them and a l s o t o i d e n t i f y g e n e r a l s e r v i c e s w h i c h w o u l d i n c l u d e t h e e l d e r l y among t h e i r c l i e n t e l e . The r e l e v a n t f e d e r a l and p r o v i n c i a l r e p o r t s and l e g i s l a t i o n w o u l d a l s o be s t u d i e d , and t h e n a t u r e o f t h e i r r e c o m m e n d a t i o n s c o n s i d e r e d . I t s h o u l d t h e n be p o s s i b l e t o t r a c e t h e t r e n d s and h o p e f u l l y , t h e c a u s e s o f t h e t r e n d s w h i c h have l e d t o t h e p r e s e n t s i t u a t i o n . I f we can a r r i v e a t some u n d e r s t a n d i n g o f t h e n a t u r e and needs o f t h e o l d e r p o p u l a t i o n now and i n t h e n e a r f u t u r e , and compare t h e s e w i t h t h e s e r v i c e s now b e i n g p r o v i d e d and l i k e l y t o be p r o v i d e d i n t h e c o m i n g y e a r s i f p r e s e n t t r e n d s c o n t i n u e , we s h a l l be a b l e t o a s s e s s t h e a p p r o p -r i a t e n e s s o f t h e p r e s e n t a r r a n g e m e n t s . I f t h e r e a r e e l e m e n t s i n t h e p r e s e n t s y s t e m w h i c h a p p e a r i n a p -p r o p r i a t e i n t h e l i g h t o f t h e a p p a r e n t n e e d s , t h e n t h e p l a n n e r w i l l h ave t o a t t e m p t t o f i n d t h e r e a s o n s f o r t h i s d i s c o r d a n c e , and t o make recommen-d a t i o n s w h i c h w o u l d r e s u l t i n a more a p p r o p r i a t e p r o v i s i o n o f s e r v i c e s i n t h e f u t u r e . ^ By ' a p p r o p r i a t e ' we mean t h e most e f f i c i e n t and e c o n o m i c a l f o r m o f c a r e c o m p a t i b l e w i t h t h e o v e r a l l needs o f t h e i n d i v i d u a l , and t h e u s e o f a s e r v i c e i n a way w h i c h i s c o m p a t i b l e w i t h i t s o b j e c t i v e s . 1 CHAPTER I A HISTORICAL OVERVIEW OF SERVICES FOR THE ELDERLY I N B R I T I S H COLUMBIA I n t h i s c h a p t e r we l o o k a t some o f t h e f o r m a l p r o v i s i o n s made f o r t h e e l d e r l y i n Canada up to t h e p r e s e n t t i m e . By ' f o r m a l ' we mean p r o -v i d e d by government o r o t h e r o r g a n i z a t i o n s as d i s t i n c t f rom f a m i l y and f r i e n d s . From t h i s m a t e r i a l we s h a l l a t t e m p t i n a l a t e r c h a p t e r t o d e r i v e some o f t h e r e a s o n s f o r t h e way i n w h i c h s e r v i c e s a r e now made a v a i l a b l e t o t h e e l d e r l y , and f o r t h e i r r e l a t i v e i m p o r t a n c e . I n l o o k i n g a t s e r v i c e s p r o v i d e d i n t h e p a s t f o r t h e e l d e r l y we c h o s e t o l o o k a t h e a l t h s e r v i c e s and a t t h o s e o t h e r s e r v i c e s - s o c i a l o r w e l f a r e s e r v i c e s , income s e c u r i t y , h o u s i n g , and s e r v i c e s p r o v i d e d by v o l u n t a r y a g e n c i e s - w h i c h c o u l d o r do a c t as s u p p o r t s o r a l t e r n a t i v e s t o h e a l t h s e r v i c e s . I n most c a s e s we f o l l o w e d t h e h i s t o r y by l o o k i n g a t t h e a n n u a l r e p o r t s o f t h e v a r i o u s d e p a r t m e n t s , s u c h o t h e r r e p o r t s as a r e a v a i l a b l e , and t o o t h e r books and a r t i c l e s w h i c h a r e c i t e d . We have t r i e d t o p u l l o u t t h e d e v e l o p m e n t s w i t h i n e a c h s e r v i c e w h i c h a f f e c t e d t h e e l d e r l y -b e c a u s e t h e y were p r o v i d e d f o r t h e e l d e r l y , b e c a u s e t h e y were p r o v i d e d f o r t h e p o p u l a t i o n a t l a r g e i n c l u d i n g t h e e l d e r l y , o r b e c a u s e t h e y r e p r e s e n t a need f o r r e s o u r c e s w h i c h c o u l d n o t t h e r e f o r e be d e v o t e d t o t h e e l d e r l y . When c o n s i d e r i n g some o f t h e f o r m a l p r o v i s i o n s made by s o c i e t y f o r t h e e l d e r l y , we have f o l l o w e d t h e d i f f e r e n t s e r v i c e s s e p a r a t e l y b e c a u s e t h i s i s how t h e y a r e p r o v i d e d , f i n a n c e d and r e p o r t e d o n . To t r y t o p r o v i d e a c h r o n o l o g i c a l a c c o u n t o f a l l t h e s e r v i c e s t o g e t h e r w o u l d n o t 2 greatly add to our understanding and might even be misleading, suggesting i n t e r a c t i o n , interdependency or even co-operation and co-ordination and there i s no evidence that any of the services studied had much regard for what was happening i n other sectors, as they made t h e i r decisions or allowed developments to take place i n t h e i r own f i e l d . This chapter also contains a very s e l e c t i v e summary of only the l e g i s l a t i o n and reports which r e f e r to the e l d e r l y or to provisions which could or do a f f e c t the e l d e r l y . This means that some l e g i s l a t i o n i n the f i e l d has been omitted altogether, that what we have highlighted i s not necessarily what are normally considered the most s i g n i f i c a n t aspects of the documents i n question; and we have not always repeated recommendations which have already been made several times. 1. HEALTH SERVICES 1 (a) Public Health Services An outbreak of smallpox i n B r i t i s h Columbia led to the appointment of the f i r s t P r o v i n c i a l Health O f f i c e r i n 1892. In the following year, the f i r s t Public Health Act was passed providing for the establishment of a P r o v i n c i a l Board of Health and for the d i v i s i o n of the Province into Health D i s t r i c t s with l o c a l boards of health who were to appoint Medical Health O f f i c e r s and Sanitary Inspectors. The main concerns of the Board i n the early years were general s a n i t a t i o n , the prevention or ar r e s t of communicable diseases and (by 1924) "the s o c i a l analysis of disease, personal hygiene and education." New con-cerns brought amendments to the public health code-regarding the control of tuberculosis (1901), sanitary inspection and regulation (1904), inspection 3 of foods (1906), medical examination of school c h i l d r e n (1910) etc. It i s not su r p r i s i n g i f l i t t l e a t tention was devoted to the el d e r l y i n the f i r s t 55 years of operation of Public Health Services. In 1895, i t was reckoned that one t h i r d of deaths and sickness resulted from lack of e f f i c i e n t s a n i t a t i o n and one t h i r d of deaths i n many places were o f . c h i l d r e n under 5. In 1911, deaths from reportable disease (measles, etc.) amounted to 58.9 per 100,000. In 1914, measles i n young chi l d r e n was s t i l l commonly f a t a l . In 1919, almost 10 per cent of deaths were i n the age group under 10 years, and 53 per cent were of people between the ages of 20 and 50. In 1922, 12 per cent of h o s p i t a l patients and 25 per cent of asylum patients were victims of venereal disease. In 1930, the death rate from tuberculosis was highest i n the age group 20-29. By 1933, the rate of 76.5 per 100,000 was higher than that of any other province except Quebec and the Maritimes; i n 1940, i t was s t i l l 72.7. And i n 1941, the maternal death rate was 2.7 per 1000 l i v e b i r t h s . In circumstances l i k e these people who survived to old age, f a r from re q u i r i n g s p e c i a l services, might be considered very lucky indeed. There was every incen-t i v e too for the public health a u t h o r i t i e s to take action against the s t r i k i n g problems which existed because measurable r e s u l t s showed that the a c t i o n was worthwhile. By 1926, when the Infant M o r t a l i t y Rate for Canada was 88.1, i t was 50.4 i n B.C. The venereal disease rate was halved between 1922 and 1926 and by 1946 was the lowest i n Canada. Deaths from reportable diseases f e l l from 58.9 per 100,000 i n 1911, to 7.4 i n 1933, and the maternal death rate from 2.7 per 1000 l i v e b i r t h s i n 1941 to 0.6 i n 1952. By 1950, over 70 per cent of deaths were occurring at ages 4 over 60. Some problems showed themselves to require constant v i g i l a n c e . The number of cases of venereal disease, tuberculosis and d i p t h e r i a found a l l rose between 1945 and 1946, for example. And i n 1952, there was p o l i o . (Presently, gonorrhea, diphtheria and r u b e l l a are on the increase again.) Up to 1950 there was the occasional reference to the increasing death rates i n the older age groups-to explain the o v e r a l l increase i n the death rate. In 1950, we have the f i r s t hint of a d i f f e r e n t sort of awareness. "An important feature of the population of t h i s Province i s the increasing proportion of persons i n the older age groups. This f a c t i s of considerable importance to the public health administrator i n as much as the health problems of the aged are m a t e r i a l l y d i f f e r e n t than those i n the younger age groups." The Survey of Health Services and F a c i l i t i e s i n B.C. (1952) c a r r i e d out on a fede r a l health survey grant, made no major recommendations regar-ding the e l d e r l y . The Public Health Nursing D i v i s i o n was described as so busy i n the f i e l d s of maternal and c h i l d health and control of communicable diseases that i t had not been able to expand into the f i e l d s of care of the ch r o n i c a l l y i l l , home nursing and r e h a b i l i t a t i o n . A p i l o t study of home care and home nursing for the c h r o n i c a l l y i l l was proposed. It was further recommended that e f f o r t s be continued to provide s p e c i a l f a c i l i t i e s for the care of se n i l e psychotic patients separate from mental patients r e q u i r i n g more a c t i v e treatment measures, and that clo s e r co-operation be developed between general h o s p i t a l s , the B r i t i s h Columbia Hospital Insurance Service (BCHIS) and the Health Branch. The 1952 Health Branch Report noted that whilst the population of 5 B.C. had increased by 42 per cent between the censuses of 1941 and 1951, the population over 60 had increased by 64 per cent, and B.C. had a greater proportion of over 60s (16 per cent) than Canada as a whole (11 per cent). "The figures h i g h l i g h t not only the necessity of increased f a c i l i t i e s for health care and preventive measures, but also give some i n d i c a t i o n of the changing emphasis which p u b l i c health programmes must envision." By that year, when complete P r o v i n c i a l coverage by health units was i n sight, i t was stated that t h i s would permit the development of a d d i t i o n a l services which would include mental hygiene, beds'ide nursing and g e r i a t r i c s . However, i n 1960 the f i r s t complete s t a t i s t i c a l analysis of the work of the 496 public health nurses and 61 V i c t o r i a n Order Nurses (VON) employed i n the P r o v i n c i a l service showed that 79 per cent of patients r e c e i v i n g v i s i t s were indeed over 60 years of age, but a l l the nursing care home v i s i t s constituted only 2 per cent of the t o t a l number of services ren-dered which included mainly immunizations and school and pre-school services. A Community Housekeeper Service commenced i n Kelowna i n 1946 to permit early discharge from h o s p i t a l or to make admission unnecessary, and the home care programme eventually became a basic part of the nursing a c t i v i t i e s i n the health units. By 1966, the majority of patients i n the home care programme were aged over 60 years of age. The 1966 Annual Report i s the f i r s t one to r e f e r s p e c i f i c a l l y to 'the e l d e r l y ' as a d i s t i n c t category and to g e r i a t r i c care which was con-sidered to involve health supervision of the e l d e r l y at home, i n private nursing homes and i n personal care i n s t i t u t i o n s . The need for a c t i v a t i o n 6 programmes i n the l a t t e r two types of residence was noted. A few units were making plans for health counselling and screening of persons over 65 years of age. By 1971, 56 per cent of the general health supervision v i s i t s and almost 70 per cent of home care v i s i t s were made to patients over the age of 65 years. This implied quite an adjustment i n the approach of the public health nurse from the day when prevention of disease and education were almost her only concerns, and school c h i l d r e n and t h e i r parents her only target, through the f o r t i e s and f i f t i e s when she widened her focus (though i n the 50s, the VON s t i l l had to go to give i n j e c t i o n s to tuber-c u l o s i s patients i n the same homes which public health nurses were v i s i t i n g with an educational purpose). However, i t seems that (1) for a va r i e t y of reasons, the nature of community health problems changed, (2) as l o c a l communities were paying f o r the service, they could c a l l the tune, and t h e i r tune changed, (3) once the home nursing began and was pro-vided by public health nurses i n areas where there was no one else, the demand for i t grew from r e f e r r i n g doctors and the community, and i t was by coincidence that the majority of people referred were e l d e r l y . By 1968, the newer o r i e n t a t i o n was made quite e x p l i c i t - d i r e c t professional nursing services along with promotion of community health services were the two general categories of public health nursing a c t i v i t i e s . In view of t h i s new trend, i t i s not s u r p r i s i n g that the next report published i n the Province was on the subject of home care. The  Report of the Standing Committee on S o c i a l Welfare and Education (1973), on Home Care i n the Province recommended the expansion of home care 7 programmes , t h e p r o v i s i o n by government o f i n t e r m e d i a t e c a r e , e q u i t y i n t h e c o v e r a g e o f a l l l e v e l s o f c a r e , i n c l u d i n g home c a r e , an i n c e n t i v e f o r t r a i n i n g o f ; h e a l t h c a r e s t u d e n t s w i l l i n g t o w o r k i n u n d e r s e r v i c e d a r e a s o f t h e P r o v i n c e and t h e c o - o r d i n a t i o n o f s o c i a l and h e a l t h s e r v i c e s on a l o c a l , r e g i o n a l and P r o v i n c i a l b a s i s . G r e a t e r V a n c o u v e r and G r e a t e r V i c t o r i a r u n H e a l t h D e p a r t m e n t s s e p a r a t e f r o m , t h o u g h i n c o - o p e r a t i o n w i t h t h e P r o v i n c i a l D e p a r t m e n t . These c i t i e s have b e n e f i t t e d f rom t h e a c t i v i t i e s o f t h e VON w h i c h was f i r s t e s t a b l i s h e d i n V i c t o r i a i n 1910. P r o b a b l y b e c a u s e t h e l a t t e r were more c o n c e r n e d w i t h b e d s i d e n u r s i n g , t h e r e i s r e f e r e n c e t o t h e needs o f t h e e l d e r l y a t an e a r l i e r d a t e i n a r e a s where t h e VON a r e i n v o l v e d . I n t h e e a r l y days t h e y were m a i n l y needed f o r home s u r g e r y and d e l i v e r i e s , b u t by 1953, a l m o s t one t h i r d o f VON v i s i t s i n V i c t o r i a w e r e t o p e o p l e o v e r 70 y e a r s o f a g e ; and by 1956, two t h i r d s were t o p e o p l e aged 65 and o v e r . T h e r e i s f r e q u e n t r e f e r e n c e t o t h e f a c t t h a t t h e e l d e r l y p r e f e r t o be c a r e d f o r i n t h e i r own homes and t h a t n u r s i n g v i s i t s o f t e n make t h i s p o s s i b l e . By 1954, t h e S e n i o r M e d i c a l H e a l t h O f f i c e r (MHO) i n V a n c o u v e r was n o t i n g a need f o r expanded s e r v i c e s f o r " c i t i z e n s i n t h e uppe r age b r a c k e t s " . A w e e k l y s c r e e n i n g c l i n i c '60 and up C e n t r e ' t o s e r v e e l d e r l y c i t i z e n s w h i c h opened i n November 1966 was booked f o r s i x months ahead by t h e end o f i t s f i r s t day o f o p e n i n g . I n 1967, t h e s e r v i c e , w h i c h employed d o c t o r s , n u r s e s , s o c i a l w o r k e r s and n u t r i t i o n i s t s was p r o v i d e d i n a l l f i v e h e a l t h u n i t s , b u t t h e c l i n i c s were a l l o w e d t o ' p e t e r o u t ' a f t e r 1972. The m a i n e x p l a n a t i o n s advanced f o r t h i s were t h a t when t h e m e d i c a l p l a n premium 8 for the e l d e r l y was reduced from f i v e d o l l a r s to f i f t y cents per month, people could now afford access to a family physician; the small number of people seen by a doctor i n one morning made the service "an expensive way of doing public health;" and i n some u n i t s , e l d e r l y people apparently came for a second opinion a f t e r v i s i t i n g t h e i r own doctors. (b) Hospital Services Hospitals existed before public health services i n B.C. The f i r s t e d i t i o n of the Vancouver General Hospital (VGH), 1888 (10 beds for men only, toward which the Cit y Council paid two thousand d o l l a r s ) became an Old People's Home i n 1906 when the newer VGH opened. St. Luke's Home too, begun i n 1888 as a h o s p i t a l taking mainly maternity and typhoid cases, was r e b u i l t i n 1925 as a Home for the Aged [Nelson, 1934 p. 5]. So there was at that time acceptance of public r e s p o n s i b i l i t y for at l e a s t some aged. Also, from as early as 1886, the Province was making grants to hos p i t a l s which made s p e c i a l claims for help mainly to pay for indigent patients [Cassidy, 1945]. The P r o v i n c i a l Infirmary was established i n 1937 to care for the ch r o n i c a l l y i l l . Advanced age does not seem to have been the most s t r i k i n g feature of the c h r o n i c a l l y i l l group i n those days. And though blocking of acute beds i s frequently complained of by h o s p i t a l administrators and the P r o v i n c i a l Advisor on Hospital Services, i t i s by " s o c i a l problem cases" not el d e r l y people. In f a c t , age of h o s p i t a l patients i n general does not seem to have been of p a r t i c u l a r i n t e r e s t because, u n t i l 1948 at l e a s t , the Annual Reports on Hospital S t a t i s t i c s deal almost e n t i r e l y with costs and s t a f f i n g . 9 Hospitals seem to have been considered important i n B.C. even before the days of h o s p i t a l insurance. As early as 1929, the VGH had 1400 beds. By 1934 there were 104 h o s p i t a l s i n the Province. In 1936, the B.C. h o s p i t a l i z a t i o n rate of 1515 patient days per 1000 population was 50 per cent higher than the average rate i n the f i v e provinces of Alberta, Saskatchewan, Manitoba, Ontario and Quebec. [Cassidy, 1936]. At,that time the h o s p i t a l , b u i l t l a r g e l y from voluntary funds, was a source of community pride; there was no co-ordination of planning or b u i l d i n g ; and m u n i c i p a l i t i e s and the Province each paid (with a reduction of f o r t y -f i v e cents for 1933 only) seventy cents per day for t h e i r residents. In theory to pay for the cost of indigents, t h i s a c t u a l l y met 40 per cent to 50 per cent of t o t a l operating costs i n the 30s [Ibid. p. 1] already per-mitting a c e r t a i n i r r e s p o n s i b i l i t y with regard to d e f i c i t s . The Hospital  Act (1948-cl52) f i r s t l e g i s l a t e d for the l i c e n s i n g of h o s p i t a l s . In s p i t e of various forms of voluntary insurance against medical and/ or h o s p i t a l costs which became a v a i l a b l e i n the 30s, h o s p i t a l s could s t i l l not obtain enough revenue i n the 40s to finance t h e i r operations and i n 1949, B.C. became the second province to introduce a province-wide hos-p i t a l i z a t i o n programme, financed o r i g i n a l l y by a premium system, l a t e r by co-insurance and general revenues. This plan covered the aged, i n f i r m and c h r o n i c a l l y i l l who had sometimes been refused coverage by a voluntary plan [Taylor, 1956 p. 71]. The Hospital Insurance Act (1948-cl51) l a i d down that insurance was to cover treatment of acute i l l n e s s , a c t i v e treatment for chronic i l l n e s s and d i s a b i l i t y and outpatient treatment and diagnostic services. From 10 1952, the per diem charge for acute care was to be one d o l l a r . From 1949 on, the BCHIS produced an annual report showing among other things, the percentage of discharges and patient days for d i f f e r e n t age groups. From 1952, the P r o v i n c i a l S o c i a l Assistance Medical Care Pro-gramme met costs for indigents. At that time, of 63678 b e n e f i c i a r i e s , 43618 were i n r e c e i p t of old age benefits [Taylor, 1954, p. 752]. This programme i s said to have resulted i n a second cl a s s system of medicine and also one which could jeopardize the l i v e l i h o o d of any doctor who had a high percentage of indigents among his case-load because payment was pro-rated out of a fixed pool, at a rate which was much lower than the regular fee. (It could be as low as 45 per cent.) 'A Hospital Plan and a Professional Education Programme for the  Province of B.C.' (1949) was the survey of h o s p i t a l needs which was required of any province before r e c e i p t of a federal grant for h o s p i t a l recon-s t r u c t i o n . J.A. Hamilton and Associates presented a 20 year programme and proposed four types of units f o r acute care-community c l i n i c and health centres, community h o s p i t a l s , regional h o s p i t a l s and teaching h o s p i t a l s . The report emphasized the importance of h o s p i t a l s . "The modern h o s p i t a l of tomorrow emerges from i t s i s o l a t e d r o l e to form the f r o n t i e r for medical care and the axis about which the e n t i r e integrated system of health agencies revolve" and also mentioned that the increasing proportion of the population i n the older ages " i n which i l l n e s s e s occur with greater frequency" would be one of the factors leading to greater demand for h o s p i t a l care. 11 Hospitals f o r s p e c i a l groups were to be avoided. Outpatient and community services were seen as important. And pr o f e s s i o n a l education i n the f i e l d of g e r i a t r i c s for physicians, s o c i a l workers, nurses, d i e t i t i a n s and r e h a b i l i t a t i o n workers was s p e c i f i c a l l y advocated. The introduction of the Federal h o s p i t a l construction grants i n 1949 provided such an inducement to h o s p i t a l construction, that the operating costs of the new hospita l s became insupportable at the p r o v i n c i a l l e v e l and eventually had to be cost-shared by the Federal Government under the Hospital Insurance and Diagnostic Services Act (1957). The Department of Health Services and Hospital Insurance Act (1959-c38) separated the Health M i n i s t r y out from the M i n i s t r y of Health and Welfare. In 1960, a coverage programme f o r r e h a b i l i t a t i o n , chronic treatment and convalescent care was introduced i n the Province. A broad i n t e r p r e t a t i o n i s placed on ' r e h a b i l i t a t i o n ' and i t applies to a l l age groups. A patient of 75 who can be improved s u f f i c i e n t l y to enable him to return to h i s home, even for a few months, i s con-sidered to be a r e h a b i l i t a t i o n patient j u s t as much as a youth of 19 . . . Even at the inception of the programme, s c a r c i t y of trained s t a f f and h o s p i t a l space were expected to prevent early implementation of the plan i n many ho s p i t a l s . A 1961 amendment to the Hospital Act l a i d down that a 'hospital' does not include anyone re c e i v i n g personal (non-skilled i n nurs-ing) or occasional s k i l l e d care. The extended h o s p i t a l care programme was started i n 1965 when some ex i s t i n g units were designated as su i t a b l e (c. 1020 beds) and others were planned. To be medically e l i g i b l e for coverage, patients must require 12 s k i l l e d nursing service a v a i l a b l e twenty-four hours a day and continuing medical supervision-and be unable to walk or use a wheelchair without assistance. About 60 per cent of patients presently i n nursing home type f a c i l i t i e s were expected to be e l i g i b l e . In s p i t e of the shortage of personnel, i t was hoped that each unit would engage the consultative service of a physiotherapist and/or occupational therapist, to advise on maintenance of function i n e l d e r l y patients, and that d i v e r s i o n a l i n -terests and a c t i v i t y programmes would "slow up the aging process and . . . 2 make l i f e more enjoyable for such patients . . . " From the beginning, the charge of one d o l l a r per day for the extended care h o s p i t a l (the same as for the acute hospital) was anomalous i n that there was no incentive for occupants of extended care beds to progress to the stage of r e q u i r i n g intermediate or personal care which was much more . ^expensive to the patient. The patient charge for extended care was raised to four d o l l a r s per day i n 1976. The B.C. Regional Hospital D i s t r i c t s Act (1967-c5) provided for the d i v i s i o n of the province into twenty-nine large d i s t r i c t s , to enable regional planning, development and financing of h o s p i t a l projects to be ca r r i e d out under a revised formula according to which the P r o v i n c i a l government would give increased assistance toward c a p i t a l costs. The d i s t r i c t s were to have the same boundaries and boards as the regional d i s t r i c t s incorporated under the Municipal Act (1965). Since that time, the Greater Vancouver Regional Hospital D i s t r i c t has produced various reports which r e f e r d i r e c t l y or i n d i r e c t l y to the e l d e r l y . The Patterns of Care Report (1969), s e t t i n g planning and 13 c o n s t r u c t i o n p r i o r i t i e s f o r h o s p i t a l s , saw h o s p i t a l p l a n s as t h e f i r s t s t e p o n l y i n a recommended r e g i o n a l h e a l t h p l a n . L e v e l s o f c a r e were d e s c r i b e d . I t was recommended t h a t e x t e n d e d c a r e h o s p i t a l s be b u i l t c l o s e t o a c u t e c a r e f a c i l i t i e s t o a s s u r e p r o f e s s i o n a l i n t e r e s t and s u p e r v i s i o n . (GVRHD 1969) ** The NDP government w h i c h t o o k up o f f i c e i n l a t e 1972 p u b l i s h e d a ' C l a s s i f i c a t i o n o f Types o f H e a l t h C a r e ' d e f i n i n g 5 t y p e s o f c a r e w h i c h m i g h t be p r o v i d e d i n p u b l i c o r p r i v a t e i n s t i t u t i o n s , p u r c h a s e d a few p r i v -a t e h o s p i t a l s , a u t h o r i z e d more e x t e n d e d c a r e b e d s , s e t up a C e n t r a l R e g i s t -r y i n V i c t o r i a f o r e x t e n d e d c a r e a p p l i c a t i o n s , opened t h r e e i n t e r m e d i a t e c a r e f a c i l i t i e s , and made o u t - p a t i e n t p h y s i o t h e r a p y an ' a u t h o r i z e d b e n e f i t ' a t one d o l l a r p e r v i s i t . I t was n o t e d t h a t as t h e number o f e x t e n d e d c a r e beds i n c r e a s e d , t he number o f p a t i e n t s e p a r a t i o n s , t h e number o f p a t i e n t d a y s , and t h e a v e r a g e l e n g t h o f s t a y i n a c u t e h o s p i t a l s a l l d e c l i n e d . I n t h e t h r e e y e a r s f o l l o w i n g , t h e GVRHD p r o d u c e d f o u r more r e p o r t s on t h e v a r i o u s l e v e l s o f c a r e . The E x t e n d e d C a r e R e p o r t (1973) d e s c r i b e d t h e e x t e n d e d c a r e r p r o - : gramme t o d a t e and the l o c a t i o n o f e x t e n d e d c a r e p a t i e n t s . I t was e s t i m a t -ed t h a t 755 more b e d s w o u l d be r e q u i r e d b y 1976 t o meed needs ^ e s t i m a t e d by BCHIS a t t w e n t y beds p e r 1000 p o p u l a t i o n o v e r s i x t y - f i v e y e a r s ) . T h e r e were v a r i o u s r ecommenda t ions on t h e s i z e o f u n i t s and the f a c i l i t -i e s r e q u i r e d f o r t r e a t m e n t b u t no comments on q u a l i t y o f c a r e . The I n t e r m e d i a t e C a r e R e p o r t (1974) e s t i m a t e d a need f o r 3500 i n t e r m e d i a t e c a r e beds w h i c h w o u l d grow t o 4000 by 1981. V a r i o u s r ecommenda t ions were made f o r t he c a r e o f p a t i e n t s i n c l u d i n g a p o t e n t i a l * * I n t h e b i b l i o g r a p h y , GVRHD i s l i s t e d as G r e a t e r V a n c o u v e r R e g i o n a l H o s p i t a l D i s t r i c t . 14 r o l e for the nurse-practitioner. The G e r i a t r i c Report (1975) showed that personnel i n acute hospita l s did not f e e l that s p e c i a l f a c i l i t i e s were necessary f o r the e l d e r l y patients as a l l patients were and should be treated, not accord-ing to age, but according to p h y s i c a l status. However, concern was expressed about lack of a c t i v a t i o n of long-stay e l d e r l y people i n the acute s e t t i n g and about the lack of adequate discharge planning and community f a c i l i t i e s f o r a f t e r - c a r e . The Home Care Report (1975), recommending an expanded and more f l e x -i b l e use of the service, was the l a s t of the GVRHD reports r e f e r r e d to. Health Security for B r i t i s h Columbians (Foulkes 1974), the report of R.G.Foulkes to the B.C. Minister of Health, a f t e r a year-long study of the P r o v i n c i a l health services, suggested a new health system with community human resource and health centres at the l o c a l l e v e l , r e g i o n a l i z a t i o n of health service provision and eventual j o i n i n g of the Department of Health and the Department of Human Resources i n a Department of S o c i a l A f f a i r s . This was to overcome i n e f f i c i e n c i e s , lack of co-ordination, neglect of some groups, lack of p a r t i c i p a t i o n of r e c i p i e n t s and providers of service i n decision-making, overuse of h o s p i t a l s , etc. 'Total health care' should replace an emphasis on medical care, the former to include more preventive, community-based and s o c i a l services. The aged were mentioned as a group with s p e c i a l problems. Health services for the e l d e r l y were often so dispersed and various that they were not e a s i l y accessible. However, health services for the e l d e r l y should not be separate from those a v a i l a b l e to the general p u b l i c . Health care programmes for the aged have the same requirements as others 15 discussed i n the study. They must be integrated for personal and i n -s t i t u t i o n a l care. Everything recorded regarding emergency treatment and transportation, n u t r i t i o n a l services, r e h a b i l i t a t i o n programmes, housing, home care, etc. was to apply to the e l d e r l y as to any other group of c i t i z e n s . Community human resource and health centres might provide the answer to many of the problems of the e l d e r l y . It was suggested that i t might be desirable to have a bureau within the Department of Human Resources to promote programmes for everyone aged 65 and over and indeed between f i f t y and s i x t y - f i v e a l s o . P a r t l y as a r e s u l t of t h i s study, the Department, of Health Act was amended to allow for a complete re-organization of the Department whereby the former four branches-Public Health, Mental Health, Hospital Insurance and Medical Services were consolidated into two main branches-a Medical and Hospital Programmes Branch and a Community Health Prog-rammes Branch. The Medical Centre of B r i t i s h Columbia Act (1973 cl24) provided for the set t i n g up of a corporation to e s t a b l i s h and operate a p r o v i n c i a l medical and health sciences centre, to e s t a b l i s h and operate h o s p i t a l s , and to oversee t r a i n i n g and research i n the f i e l d of health. When the B r i t i s h Columbia Medical Centre was evolving plans for the future provision of medical care, i t set up a v a r i e t y of task forces including the G e r i a t r i c Task Force (Chairman Dr. Brock Fahrni) which submitted two b r i e f s - i n February 1974 and Jul y 1975. P a r t i c u l a r emphasis i s l a i d i n the b r i e f s on g e r i a t r i c services required by the 95 per cent of the over-65 population who l i v e outside 16 i n s t i t u t i o n s . I t was established that about one t h i r d of e l d e r l y people i n the community could benefit from some sort of service but most of the needs (Most estimates say about two thirds) are non-medical, at le a s t to begin with. Even health needs are mostly those which can be treated by a l l i e d health professionals. Early i d e n t i f i c a t i o n of needs, a preventive approach, inte g r a t i o n of s o c i a l welfare services, a v a i l a b i l i t y of education and coun-s e l l i n g services, use of para-professionals to assess, t r e a t , and r e f e r , and l o c a l i z e d p r ovision of service, were a l l seen as necessary elements of a g e r i a t r i c programme. There were also some recommendations r e l a t i n g to i n -s t i t u t i o n a l care, education and research. The second b r i e f introduced the idea of regional g e r i a t r i c ser-v i c e areas, hospital-based i n i t i a l l y , i n the community l a t e r , possibly i n association with e x i s t i n g community service areas. The medical care system could not and should not deal with a l l the problems of the e l d e r l y . Even assessment, i t was f e l t , could be l e f t to s a t i s f a c t o r i l y trained a l l i e d health professionals. The family physician's r o l e i s seen as diagnosis and treatment of medical and s u r g i c a l i l l n e s s , working c l o s e l y with, and acting as consultant t o , ' a l l i e d health p r o f e s s i o n a l s t a f f , arranging adequate com-munity resources for patients, helping to s t a f f g e r i a t r i c ambulant and r e s i d e n t i a l care programmes. G e r i a t r i c consultants would a s s i s t family physicians, promote programme development and take part i n education and research. (c) Mental Health Services No separate mental h o s p i t a l provision was made for the e l d e r l y t i l l 1935 when the P r o v i n c i a l Home for the Aged Act was passed and some cottages 17 adjacent to the Boys' I n d u s t r i a l School at Port Coquitlam were given over to the use of aged mental patients. In the following years, when over 20 per cent of admissions to Essondale were aged s i x t y - f i v e and over i t was proposed that the "aged and decadent" should be housed i n a separate bui l d i n g as they in t e r f e r e d with proper c l a s s i f i c a t i o n of patients and were not appropriately accommodated with "those a c t i v e l y disturbed". New 100-bed un i t s for the e l d e r l y were added to the Port Coquitlam complex i n 1946, 1947 and 1952 and one at Essondale i n 1948. Vernon and Terrace M i l i t a r y Hospitals were purchased by the government and opened as Homes for the Aged (for ambulant s e n i l e patients) i n 1948 and 1950. [Mental Health Branch 1972]. On A p r i l 1st 1950, various mental health a c t i v i t i e s were amal-gamated into the P r o v i n c i a l Mental Health Services. The G e r i a t r i c s 'Division-one of five-included the three units of Homes for the Aged and dealt with "the aging group su f f e r i n g from degenerative diseases". • Transfer at age 65 to Homes for the Aged was expected to r e l i e v e the overcrowding at Riverview. I t was recommended that further b u i l d i n g should be for the e l d e r l y and mental defectives "whose outlook for recovery or improvement i s poor", and that i n future the three groups-psychotic, mentally defective and senile-should be c l e a r l y delineated and admitted d i r e c t l y to t h e i r respective i n s t i t u t i o n s . Special accommodation of the e l d e r l y was supposed to enable a more a c t i v e treatment programme and higher discharge rate for younger patients. From 1958 there i s more t a l k of r e h a b i l i t a t i o n to the community (The Boarding Home Programme began i n 1959, also the year i n which the 18 Mental Health Services were placed under the Department of Health Services and Hospital Insurance). From 1960, Homes for the Aged, renamed V a l l e y -view, Dellview and Skeenaview were operated under the Mental Hospitals Act, having been designated public mental hospi t a l s under a 1958 amendment to the 1948 Mental Hospitals Act. Some nurses were sent on courses i n g e r i a t r i c nursing, and an occupational therapy department was set up at Valleyview. From t h i s point on, there seems to have been a change i n philosophy with regard to treatment of the aged mentally i l l . Instead of cu s t o d i a l care only, Valleyview provided an a c t i v e treatment and r e h a b i l i t a t i o n programme and the emphasis was on return to the community-to s e l f care, family care, nursing home care and boarding home care. The Mental Health  Act (1964 c29) established Valleyview Hospital as a Mental Health f a c i l i t y for the care and treatment of aged persons ( i n p r a c t i c e , persons aged seventy and over) suffering from p s y c h i a t r i c i l l n e s s associated with aging. In 1966, 254 patients died at Valleyview, 181 returned to the community and there were 748 i n residence (254 males, 494 females) i n March 1967. Some patients of previous years had returned because of s o c i a l and f i n a n c i a l problems, and the s o c i a l workers arranged 104 a l t e r n a t i v e s to admission. In l a t e 1967 there were 176 persons i n h o s p i t a l who could have been discharged, given other types of i n s t i t u t i o n a l care. In 1969 consideration was being given by the Mental Health Branch to s p e c i a l i z e d extended care f a c i l i t i e s i n as s o c i a t i o n with general hos-p i t a l s , on a regional basis, for severely handicapped retarded and for psychogeriatric patients, but these have not been developed. In 1974, the l a s t year of the Mental Health Branch as a separate 19 ent i t y , the operation of Skeenaview Hospital i n Terrace was transferred to a l o c a l voluntary society. Community Services By the end of the 60s there were over 2600 beds licensed for per-sonal or intermediate care i n the boarding home programme i n Vancouver and the Lower Mainland. Mental Health Centres, also set up for the provision of community care, numbered thirty-one by 1974. In 1967; the Province was divided into eight mental health planning regions. Integrated services f o r the aged mentally i l l were one of the areas supposed to be s p e c i a l l y emphasized i n the new programme. Probably l a r g e l y as a r e s u l t of the new emphasis the number of g e r i a t r i c i n - p atients i n mental i n s t i t u t i o n s had f a l l e n from 2127 i n 1966 to 987 i n 1974. The Greater Vancouver Regional D i s t r i c t has administered i t s own community care programme based on the 'Plan for Vancouver' proposed by Dr. John Cumming i n 1972. Although treated as a blueprint, Dr. Cumming's proposals were apparently intended to be no more than a p o s i t i o n paper for discussion and did not therefore go into any d e t a i l on services required for the e l d e r l y (or children) although the need for a psycho-g e r i a t r i c centre was mentioned. (d) Medical Services Dr. John Sebastian Helmcken, the f i r s t physician to p r a c t i c e h i s profession i n B.C. came to the P a c i f i c Coast i n the service of the Hudson's Bay Company i n 1850 and by 1866 there were twenty-four doctors i n the t e r r i t o r i e s . For many years i n d i v i d u a l s were responsible for obtaining 20 th e i r own medical care though even before 1886 grants were being given to some resident physicians i n outlying d i s t r i c t s to compensate them for 3 serving the poor and i n the 30s, medical services were provided by government to r e c i p i e n t s of unemployment r e l i e f . Insurance schemes developed i n the 40s, and from 1943 there was a government-administered medical services plan ( i n the S o c i a l Welfare Branch) for r e c i p i e n t s of old age pensions and s o c i a l assistance. As well as medical and h o s p i t a l services, i t covered o p t i c a l and li m i t e d dental services, p r e s c r i p t i o n s and transportation, and was financed 80 per cent by the province, 20 per cent by m u n i c i p a l i t i e s ( S p e c i a l i s t services were to be financed 100 per cent by m u n i c i p a l i t i e s ) . In 1946 however, such d i f f i c u l t i e s were noted as unwillingness of many physicians to serve under the plan, gaps i n the programme, p a r t i c u l a r l y i n r e l a t i o n to s p e c i a l services, l a c k of u n i f o r -mity among m u n i c i p a l i t i e s , (There was v a r i a t i o n i n the provi s i o n , for example, of spectacles, dental services and s u r g i c a l appliances, and eight m u n i c i p a l i t i e s did not p a r t i c i p a t e at a l l u n t i l 1948), problems about serving old persons i n i s o l a t e d places, and the i n a b i l i t y of the 4 aged group to grasp written i n s t r u c t i o n s . The Medical Act (1948 c206) defines the p r a c t i c e of medicine i n wide, terms and makes i t i l l e g a l for any person not registered to prac-t i s e medicine, surgery or midwifery. The Dental Technicians Act (1958 cl3) f i n a l l y made l e g a l the setting up of dental laboratories where registered dental technicians could make dentures from impressions received from d e n t i s t s , and where registered dental mechanics could also carry out i n t r a - o r a l procedures 21 i f a.,.certificate rof o r a l health was obtained from a dental surgeon. More people were thus able to afford dentures and no longer required to have recourse to 'back s t r e e t ' operators. In 1965, the Province set up the B.C. Medical Plan to provide medical care insurance to i n d i v i d u a l s regardless of age or phys i c a l condition. The Medical Grant Act (1965 c25) provided for the Minister of Health to pay 90 per cent of the medical insurance premiums of anyone not l i a b l e to pay income tax i n the previous year, 50 per cent where taxable income did not exceed $1000. The Medical Services Act (1967 c24) set up the Medical Services Commission to bring medical care insurance i n B.C. under the nationa l scheme l a i d down i n the Federal Medical Care Act (1966). When the federal Act became e f f e c t i v e i n 1968, B.C. immediately entered the plan. Services covered were physician services, a l i m i t e d range of o r a l surgery i n hos p i t a l s , r e f r a c t i o n s by optometrists, some orthopaedic services, l i m i t e d physiotherapy (up to f i f t y d o l l a r s per person) s p e c i a l nursing (only on the recommendation of a physician and only up to f o r t y d o l l a r s per person per year) Chiropractic and naturopathy (up to one hundred d o l l a r s per person aged s i x t y - f i v e and over). Among services not covered was t r a v e l l i n g , except for emergency cases. The Pharmacare programme introduced i n 1974 i s administered by the Department of Human Resources. 2. WELFARE In the early years of the century e l d e r l y people who could not 22 be independent were treated l i k e anyone else who applied f o r r e l i e f (Matters 1973 p.45) though V i c t o r i a and Vancouver, did e s t a b l i s h old people's homes, the P r o v i n c i a l Home for the Aged and Infirm was opened at Kamloops i n 1983 with 150 places (Cassidy, 1945) and B.C. was the f i r s t province to pass l e g i s l a t i o n ( i n 1927) to e s t a b l i s h old age pensions i n accordance with the fed e r a l Old Age Pensions Act - up to twenty d o l l a r s per month to needy persons aged over 70 of which the f e d e r a l government contributed 50 per cent (75 per cent a f t e r 1931). In the 30s, unemployment was a major problem and most established s o c i a l service programmes were d r a s t i c a l l y c u r t a i l e d i n favour of unemployment r e l i e f . (Cassidy, 1934). At the outbreak of World War I I , at l e a s t a t h i r d of Canadians - of a l l ages - were probably too poor to af f o r d adequate d i e t s . However, a f t e r 1942, the Province supplemented the standard monthly old age pension by f i v e d o l l a r s , and by ten d o l l a r s a f t e r 1947. In 1943, old age pensions were transferred from the Workmen's Compensation Board to the P r o v i n c i a l Secretary's Department where three department o f f i c i a l s formed an administrative board. The S o c i a l A s s i s t - ance Act (1948 R.S. c310) allowed the P r o v i n c i a l Government through i t s Department of Welfare to grant funds to m u n i c i p a l i t i e s to provide f i n a n c i a l assistance, r e s i d e n t i a l care and "generally any form of aid necessary to r e l i e v e d e s t i t u t i o n and s u f f e r i n g " . This included supple-mentation to pensions where s p e c i a l care was required. In 1946, the P r o v i n c i a l Department of Health and Welfare was created with a Deputy Minis t e r of Health and a Deputy M i n i s t e r of Welfare who was i n charge of the S o c i a l Welfare Branch. The Annual Reports of 23 t h i s Department, published from 1946 to 1957 suggest far more awareness of the needs of the e l d e r l y than do the Health Branch Reports of the same period. Of course there was a s p e c i f i c board administering a s p e c i f i c benefit to t h i s age group but even so, the government did not have to provide services along with pensions, nor were the Board of the S o c i a l Service D i v i s i o n obliged to show so much concern for the e l d e r l y . Fieldworkers were trained s o c i a l workers who considered emotional needs and s o c i a l f a c t ors whilst i n v e s t i g a t i n g the f i n a n c i a l needs of the e l d e r l y and even c l e r i c a l s t a f f were given s o c i a l i n f o r -mation to improve t h e i r a b i l i t y to deal with e l d e r l y people. The Old Age Pension Branch also administered from 1943 a plan for medical care for the e l d e r l y and reports show an awareness of the l i n k between health and s o c i a l f a c t o r s , and indeed put forward some ideas which are only now being 'rediscovered' and taken seriously-that medical science has been concerned l a r g e l y with disease of the e a r l i e r years of l i f e whereas the d i s a b i l i t y of the e l d e r l y may be p a r t l y a t t r i b u t a b l e to poor housing and i n s u f f i c i e n t nourishment; a concern with health may suggest lack of other i n t e r e s t s ; while i t i s hoped that the development of adequate programmes by governments and communities w i l l decrease, or at l e a s t delay, admissions to public i n s t i t u t i o n s , nevertheless, there can be no sense of s e c u r i t y for pensioners or those who care for them i f care f a c i l i t i e s are not a v a i l a b l e when required [1946-47]. One i s constantly surprised too by the broad view that the Old Pensions Board took of t h e i r remit. 24 The problem of the phy s i c a l health of our pensioners has been i recognized. That of t h e i r mental health, so c l o s e l y r e l a t e d , i s a much more in s i d i o u s one which involves an understanding of the aging process as a whole. Of progress i n t h i s part of our work, we have l i t t l e of s i g n i f i c a n c e to report Reduced to t h e i r simplest terms, old f o l k s ' needs are found to be much the same as those of younger people. They are summed up i n the term " s o c i a l s e c u r i t y " - i f one looks at i t i n i t s broadest sense as the assurance that one may continue i n the accepted way of l i f e and amidst surroundings such as those to which he has been accustomed. For most of us t h i s "way of l i f e " includes a f f e c t i o n , f r i e n d l y intercourse, i n t e r e s t s and a c t i v i t i e s that make reasonable demands upon a b i l i t i e s and s k i l l s , quickly l o s t when allowed to f a l l into disuse. What means have we of helping the old prospector preserve, i n some degree, h i s sense of freedom and s e l f - s u f f i c i e n c y ? What s a t i s f a c t i o n s are to be found for the older woman whose every thought and a c t i o n during the past f o r t y years has been dictated by the needs of a family, no longer seemingly having any need of her services-even as a grandmother! To the man forced out of employment, what substitute i s there for work-in h i s world the symbol of worth-while l i v i n g and achieve-ment? These are the questions with which our case-workers are constantly faced. They cannot, of course, be expected to provide a l l the answers. We need, i n b r i e f , community programmes of leisure-time i n t e r e s t s and a c t i v i t i e s In the large centre of Vancouver there has been a small beginning. [Report of S o c i a l Welfare Branch 1947-48 pp. 62,63]. Enforced retirement i s deplored as a "tragedy" for both the old person and the community. Together with the incentive not to work because of f o r -f e i t i n g a pension, t h i s could soon face society with an "overwhelming r e s p o n s i b i l i t y i n caring for t h i s large i n a c t i v e group". When working they help to bear the costs of s o c i a l services. The increasing number of e l d e r l y require "our best thinking and planning". In the not distant future the problem may have to be faced of 40 per cent of the people having 25 to support 60 per cent i f present trends continue [1950]. There i s also the fear expressed that as a r e s u l t of assuming f i n a n c i a l r e s p o n s i b i l i t y for the old people, governments are going to be expected by younger r e l a t i v e s to assume t o t a l r e s p o n s i b i l i t y . As t h i s i s good from "neither a psychological nor an economical point of view", frequent contacts and renderings of i n c i d e n t a l services are recommended as a way of encouraging and strengthening family t i e s [1949]. On the other hand i t i s recog-nized that a l t e r n a t i v e plans are e s s e n t i a l i f family l i f e i s threatened as when the burden of caring for a si c k old person becomes too great [1950]. Various studies were made i n the 40s-of the e f f e c t of income on persons, on the length of l i f e of pensioners, m a r i t a l status, accommoda-t i o n , etc. The Board explained the reasons for i t s a n a l y t i c a l approach i n 1950. The S o c i a l Service D i v i s i o n of the Old-age Pension Board at present seems to o f f e r the only f o c a l point for bringing together and examining information i n r e l a t i o n to the many phases of the s o c i a l s i t u a t i o n and needs of the in c r e a s i n g l y large numbers of old people i n the Province. Contacts with the "70 and up" group i n the past seven years have been far reaching and enlightening, p a r t i c u l a r l y since the "Old-age Pensions Act" and regulations have c a l l e d for an o v e r - a l l coverage i n t h i s category, including well-adjusted old f o l k , l i v i n g r e l a t i v e l y comfortably, as well as those s u f f e r i n g from the numerous disadvantages and problems to which older people are subject. One fa c t that emerges c l e a r l y i s that whatever the older age-group included i n our security programme, sound planning i n t h i s as i n other areas of s o c i a l service, must be preventive i n outlook rather than designed to meet only the immediate s i t u a t i o n . Of our t o t a l population i n B r i t i s h Columbia, 15.5 per cent, or 173,672 persons, are now over 60 years of age. What we have learned i n pioneer e f f o r t s with old-age pensioners should surely be c a r r i e d over into our as s o c i a t i o n with t h i s wider group. We do not plan programmes for 5-year-olds. Rather, we develop " c h i l d welfare" services. In the same way, s o c i a l workers cannot 26 think only i n terms of "pensioners," but of what w i l l make for the good l i f e f o r a l l our older c i t i z e n s . Hence i t i s not un-f i t t i n g that t h i s section of the report of the administration of old-age pensions, while p r i m a r i l y concerned with a p a r t i c u l a r category, does have i n c e r t a i n respects a somewhat wider a p p l i -c ation than may seem to come s t r i c t l y within i t s province. Each yearly report shows a s t a r t l i n g increase i n the moneys expended i n the payment of old-age pensions. A t o t a l of a l l P r o v i n c i a l Government expenditures for the benefit of pensioners would include costs of medical care and of other s o c i a l services along with payments for pension and would show a much higher f i g u r e . Annual reports are understood to give an account of stewardship. To t h i s end we may well ask ourselves whether these funds have been expended i n the way that ensures maximum benefit to the pensioners. Since s o c i a l work accepts the premise that i t matters greatly how things are done, we cannot be s a t i s f i e d with providing what i s understood to be merely a f l o o r of protection. In order to make the allowance more e f f e c t i v e , i t i s necessary to supple-ment with c e r t a i n other services. From our experience we venture to suggest which of these may be considered most e s s e n t i a l , i . e . casework, medical care, accommodation, housekeeping services, leisure-time a c t i v i t i e s , employment [Annual Report 1949050 pp. 61,62]. The Board a c t u a l l y functioned to some extent as an accommodation and employment bureau receiving o f f e r s as well as demands. The P r o v i n c i a l Infirmaries Act, (1948 c272) enabled the Lieutenant Governor i n Council to e s t a b l i s h and maintain i n s t i t u t i o n s for the care and maintenance of persons who, being chronic or convalescent patients a f f l i c t e d with some bodily disease or d i s a b i l i t y , did not require or were not l i k e l y to benefit from care or treatment i n a general h o s p i t a l , but nevertheless required i n s t i t u t i o n a l care. The P r o v i n c i a l Home for Incurables, renamed P r o v i n c i a l Infirmary, Marpole, was to be under the Minister of S o c i a l Welfare, with payment for residents being made by the i r m u n i c i p a l i t i e s . (In 1961 i t was transferred to the M i n i s t r y of Health Services and Hospital Insurance.) 27 The Welfare I n s t i t u t i o n s Licensing Act (1948 R.S. c363) set up a Welfare I n s t i t u t i o n s Board to l i c e n s e and inspect various r e s i d e n t i a l establishments, one category of which was "a refuge etc. for old people unemployable on account of age". A 1961 amendment added "and who need attention or care". This Act was superseded by the Community Care  F a c i l i t i e s Licensing Act (1969 c4) (and amendments) now administered by the M i n i s t r y of Health. By 1950 there were f i v e housing projects s p e c i f i c a l l y for the e l d e r l y i n the Province, the number of boarding homes was increased-but lack of privacy and lack of stimulation were already noted as problems by the Old Age Pensions Board. Two m u n i c i p a l i t i e s were experimenting with foster homes. I t was even stated (1949-50) that "From several years' observation i t had been noted that i f placement i s made when older persons f i r s t need boarding-home care, they usually escape the diseases, which attack old age and remain a c t i v e u n t i l death". The d i f f e r e n c e i n the tenor and presentation of Board reports from 1952 i s quite s t r i k i n g , and coincides, with, the implementation i n January 1952 of the Old Age Assistance Act (1951 c2) which introduced univ e r s a l old age security payments (cost shared with the federal government) to people aged 70 and over, old age assistance (means tested and cost-shared) for persons aged 65-70. So pensions for people aged 70 and over were no longer a p r o v i n c i a l concern. And throughout the 50s, there were r a r e l y more than 7000 r e c i p i e n t s of old age assistance, whereas on March 31st 1951, there had been 31,983 r e c i p i e n t s of old age penisons. For some reasons, the new r e c i p i e n t s did not receive the same consideration-maybe 28 because applicants under 70 were the exception rather than the r u l e . Reports were now written up by region, and the only reference to the e l d e r l y i s to the number and costs of t h e i r assistance b e n e f i t s , and to increased longevity. With r e s p o n s i b i l i t y for f i n a n c i a l needs removed, there i s no longer i n t e r e s t i n t h e i r other needs. The Department of S o c i a l Welfare Act, (1959 c76), set up a separate department (formerly part of the Department of Health and Welfare) to have charge of a l l matters r e l a t i n g to s o c i a l and public welfare and s o c i a l assistance. The t i t l e was l a t e r changed to the Department of R e h a b i l i t a t i o n and S o c i a l Improvement. On A p r i l 1, 1967 the D i v i s i o n on Aging was created "to develop services and resources to e l d e r l y people". In addition to administering old age assistance and supplementary s o c i a l allowances, the new authority anticipated becoming involved i n a number of other a c t i v i t i e s , v i z . (a) The development of community resources designed to d i r e c t l y a s s i s t and encourage the r e c r e a t i o n a l , educational, p h y s i c a l , and emotional well-being of the aged. (b) An information, r e f e r r a l , and consultative service on a Province-wide basis. (c) Planning, i n i t i a t i n g , and administering such programmes and projects, experimentations, or demonstrations concerning the aged as i t i s deemed necessary or d e s i r a b l e and f i s c a l l y p ossible. The issuing of bus passes to a l l persons aged 65 and over was seen to be the s t a r t of a trend whereby the D i v i s i o n would i n future be involved with not only those e l d e r l y who were economically disadvantaged. In 1968 Senior C i t i z e n Counsellors began to operate and a Drop-in 29 Centre was opened i n Vancouver. In 1969, a couple of hearing assessment c l i n i c s were arranged-in Abbotsford and Port A l b e r n i , a Pioneer and E l d e r l y C i t i z e n s ' Week was promoted and the Community Care F a c i l i t i e s Licensing Act replaced the Welfare I n s t i t u t i o n s Licensing Act. The number of places i n homes was always increasing and a need was being expressed for 'intermediate care'. In 1971 the s t a f f were said to be in c r e a s i n g l y involved with service-oriented programs-"a r e f l e c t i o n of the current public emphasis upon the ph y s i c a l , s o c i a l and psychological needs of older persons". However, apart from maintaining contact with a v a r i e t y of organizations concerned with the e l d e r l y , the Senior C i t i z e n s ' Counsellor programme, and bus passes were the only programmes provided by the department. The re s -p o n s i b i l i t y for administering the Community Care F a c i l i t i e s Licensing Act (1969) was transferred i n 1971 to the Health Branch. The New Democratic Party took up o f f i c e i n l a t e 1972, and renamed the Department the Department of Human Resources. The a c t i v i t i e s of the Department are reported as services for d i f f e r e n t groups, and one of these groups i s the e l d e r l y . One of the most important innovations of the NDP Government was Mincome. Because B.C. had from 1942 paid a supplement to persons who s a t i s f i e d a very stringent needs te s t , pensioners i n B.C. were s l i g h t l y more favourably treated than those of any other province. P a r t l y as a r e s u l t of the e f f o r t s of the P r o v i n c i a l pensioners' organizations, pensions had become an important issue i n the 1972 p r o v i n c i a l e l e c t i o n campaign, and almost immediately a f t e r the e l e c t i o n , the new NDP government produced i t s 30 Mincome plan with the Guaranteed Minimum Income Assistance Act (1972 c3). Beginning i n December 1972, the province guaranteed a minimum income of two hundred d o l l a r s a month to people s i x t y - f i v e and over by l e g i s l a t i o n providing for a supplement equal to the d i f f e r e n c e between two hundred d o l l a r s and the r e c i p i e n t ' s income from a l l sources (including the unive r s a l pension and GIS) where that income was l e s s that two hundred d o l l a r s . In addition to the s i g n i f i c a n t increase i n the maximum provin-c i a l supplement produced by t h i s change, the number e l i g i b l e for f u l l or p a r t i a l supplementation increased from about 18,000 to over 100,000. In l i n e with an increase i n the combined u n i v e r s a l pension and maximum GIS that came into e f f e c t on October 1, 1973, the Mincome guarantee was increased to $209.14 e f f e c t i v e on the same date. I t was also extended to those between s i x t y and s i x t y - f i v e . When the Department of Human Resources and the Department of Health Services sponsored a conference on the needs of senior c i t i z e n s i n 1972, the seniors strongly advocated d e c e n t r a l i z a t i o n of services. Their main areas of concern were transportation, the cost of drugs, prostheses and other s p e c i a l equipment, meals on wheels, homemaker services and r e -cr e a t i o n a l needs. (In 1975, approximately 25 per cent of the users of the Department's Homemaker Service were aged over s i x t y years of age). The Pharmacare programme introduced on the 1st of January 1974 provides free p r e s c r i p t i o n drugs for p r o v i n c i a l residents aged s i x t y -f i v e and over, 30 per cent of whom suffer from one or more chronic diseases. Also, that year j u s t over one m i l l i o n d o l l a r s were paid out i n community grants for senior c i t i z e n s mainly for h o s p i t a l i z a t i o n , home aid and v i s i t a t i o n s . And the Human Resources F a c i l i t i e s Development Act (1974 c39) enabled the Minist e r of Human Resources to pay grants from the Consolidated Revenue Fund to provide, i n t e r a l i a , centres f o r senior c i t i z e n s . The Community Resources Board Act (1974 cl8) was passed and already f i v e human resource and health centres were being set up, t h i r t y -one groups received grants to set up or develop resources boards outside Vancouver and four boards were elected i n Vancouver. Though these boards of elected c i t i z e n s were to be responsible for the d e l i v e r y of s o c i a l services on an area basis to a l l age groups, there was l i t t l e evidence that services to the e l d e r l y would be accorded any p r i o r i t y . The l a s t l e g i s l a t i o n passed i n B.C. which deals with welfare was the Guaranteed Available Income for Need Act (1976 c l 9 ) , announced i n May, 1976, which requires an assets test as w e l l as an income test to determine e l i g i b i l i t y f o r Mincome. 3. VOLUNTARY SERVICES Voluntary or charitable organizations have never enjoyed quite the same support and prestige i n the west as they d i d i n the older provinces though some voluntary services did spring up to help to meet many u n f i l l e d needs. Between 1910 and 1920, most voluntary e f f o r t s i n the community were on behalf of the unemployed. Homes b u i l t by charitable bodies tended to be for orphans, i n v a l i d s or 'wayward' g i r l s (Matters, 1973). In the ea r l y days of the Province, some nationa l organizations i n the health f i e l d already existed - the Canadian Branch of the Red Cross, the VON which opened i t s f i r s t branch i n Vancouver, l a t e r the CNIB, etc. 32 Most of these organizations were set up to deal with problems as they were brought to public notice. In the l a t e 30s, as Canada was recovering from the Depression, more nationa l s o c i e t i e s sprang up, mostly associated with s p e c i f i c diseases and most of these eventually had B.C. branches. Those dealing with cancer, rheumatism, heart disease, diabetes etc. might include numbers of e l d e r l y i n t h e i r target population, but more often, i t was the diseases which attacked younger age groups which aroused more pub-l i c concern and not a s i n g l e organization was set up for the benefit of the e l d e r l y as a group. By 1927 there were l o c a l organizations as well-the Women's In s t i t u t e s , the Rotary Clubs, the Kiwanis and church organizations-often interested mainly i n c h i l d r e n but also i n health problems and services. Planning Agencies The main organization which has shown concern for the i n t e r e s t s of the e l d e r l y has been the U.C.S. with i t s Committee on Aging, l a t e r to become the Committee on Aging of SPARC of B.C. In 1930 the Council of S o c i a l Agencies was set up and i n 1931, the Welfare Federation-the former to be a planning body to work toward the i n t e g r a t i o n of agency programmes with government sponsored services, the l a t t e r to i n s t i t u t e c e n t r a l financing (In 1946, they combined to form the Community Chest and Council of Greater Vancouver). [Jackson, I960]. At f i r s t , the main i n t e r e s t s were c h i l d r e n , the d e s t i t u t e , public health-and l a t e r , the war e f f o r t . However, i n 1944, a Committee on Aged was planning a t r a i n i n g programme for f r i e n d l y v i s i t o r s to the aged, and there was discussion of a nursing service for older people. In 1946 a 33 sub-committee produced a comprehensive survey on the S i t u a t i o n of the Aged i n Vancouver. By 1951 the Committee on the Welfare of the Aged had become a D i v i s i o n with numerous sub-committees dealing with every aspect of aging and the welfare of the aged. The aims of the organi-zation were 'To ensure the development of s o c i a l services i n a manner that enables them to respond e f f e c t i v e l y and with j u s t i c e to the needs of the people; and to provide for access to the opportunities afforded by society to those persons unable to obtain i t for themselves'-and i t seems that by 1951, the e l d e r l y were recognized as one of the groups of people i n need of help. I t was the Community Chest and Council of Greater Vancouver along with the Extension Department of UBC which held the f i r s t and second B.C. conferences on the needs and problems of the aging i n 1957 and 1960. In 1958 a P r i o r i t i e s Study Committee composed of 24 members from a v a r i e t y of backgrounds rated the r e l a t i v e value to the community of 79 services. Old age assistance was ranked s i x t h , long term medical care tenth, home nursing twenty-sixth, homes for the aged twenty-ninth, and housekeeping services t h i r t y - f i r s t . This was before the days of medicare and on the whole general medical services and services f or c h i l d -ren were accorded higher p r i o r i t y than those for the aged. The P r i o r i t i e s E s t a b l i s h i n g Committee which produced a report based on the p r i o r i t y r a tings [Community Chest and Councils, 1965] recognized a growing need for services f or older people i n Vancouver and for properly q u a l i f i e d s t a f f to run them, but considered that 'increased longevity and the problems associated with advanced age required government funds 34 i n providing services for senior c i t i z e n s ' (In 1966 the Community Chest and Councils took the name of United Community Services). A study of care and shelter f a c i l i t i e s authorized by the Planning Committee i n 1967 ascribed most of the problems i n t h i s area to the lack of a ' t o t a l concept of care' embracing prevention, shelter and intensive medical care, t h i s led to various administrative and organizational anomalies and absence or misuse of resources [ B e l l (1) 1968]. 'A Tot a l Concept of Care' [ B e l l (2) 1968] was a " c r i t i c a l examination of health resources from acute h o s p i t a l to home nursing care". The recommendations, p a r t i c u l a r l y a pplicable to the e l d e r l y , were that planning r e s p o n s i b i l i t i e s of regional h o s p i t a l boards should be expanded to include a l l l e v e l s of care r e q u i r i n g nursing supervision, that m u l t i - l e v e l care f a c i l i t i e s and home care should be encouraged, and that intermediate care should be covered by insurance. I t c r i t i c i z e d the f a i l u r e of the Province to pro-vide adequate community services or care and shelter f a c i l i t i e s as a follow-up or a l t e r n a t i v e to the acute h o s p i t a l . UCS i s committed to optimal a l l o c a t i o n of the funds c o l l e c t e d by the United Way. This com-mitment has necessitated over the years continuous researching of needs and formulation of p o l i c y . I t was probably the f i r s t organization i n t h i s part of the country to recognize, study and p u b l i c i z e the needs of an increasingly e l d e r l y population. UCS however, confines i t s a c t i v i t i e s to the Vancouver area. In 1966, several committees which wished to maintain a province-wide focus formed the Voluntary Association for Health and Welfare (now the S o c i a l Planning and Review Council of B.C.) SPARC undertakes various research 35 projects and acts as a consultative body i n the areas of communication, planning and advocating. The Panel on Aging of UCS became the Committee on Aging of SPARC which might now be said to play the leading r o l e i n the Province ( c e r t a i n l y i n the voluntary sector) i n i d e n t i f y i n g and making known the needs of the e l d e r l y , and which also co-operates with other l o c a l and n a t i o n a l organizations working for the i n t e r e s t s of the e l d e r l y . A major p u b l i c a t i o n was 'Community Care for Seniors' (1972), the f i r s t systematized d e s c r i p t i o n of services for the e l d e r l y and a n a l y s i s of needs i n the Province at a l l l e v e l s of i n s t i t u t i o n a l and community care, i n -cluding a p r o f i l e of services a v a i l a b l e i n each regional d i s t r i c t . In i t s conclusions, the committee noted p a r t i c u l a r l y the inter-relatedness of a l l provisions and services for the e l d e r l y and the increasing involvement of the e l d e r l y themselves i n matters which affected them. It was recommended that much higher p r i o r i t y should be accorded to the needs of the e l d e r l y , that they required an "integrated, humane, comprehensive and a c c e s s i b l e , community-oriented and research-based" system of care. The spectrum of care would include services for the 85 per cent of the e l d e r l y who are independent, the 10 per cent p a r t i a l l y dependent and the 5 per cent depen-dent. In 1972 and 1975, SPARC produced a Senior C i t i z e n s ' Guide to Services i n B.C. Standing Committees on Health, Housing, and the Panel on Handicapped make recommendations, aimed l a r g e l y at government, on issues such as transportation, which are also of concern to the e l d e r l y . Service Agencies The two main voluntary organizations which provide service to the 36 e l d e r l y are the Canadian A r t h r i t i s and Rheumatism Society and the V i c t o r i a n Order of Nurses. CARS was incorporated i n March 1948 and the B.C. D i v i s i o n was organized i n June of the same year. From three physio-therapists and an o f f i c e , i t has now expanded to the stage where i t op-erates a large treatment centre i n Vancouver (opened i n 1969), a sheltered workshop (opened i n 1964), a small residence (opened i n 1965) and three vans which provide t r a v e l l i n g c l i n i c s . About f i v e hundred in-patients and over 5,000 out-patients are treated each year. Of these, about 32 per cent are aged over 65. The VON was established i n Vancouver i n 1897. By 1910 there were f i v e nurses who treated the most needy cases which were most often fa m i l i e s with young ch i l d r e n . By the end of the f i r s t World War, the Order was being paid by the Vancouver Health Department to be responsible for a l l c h i l d r e n under school age, and l a t e r a l l T.B. patients. How-ever, over the years, more and more of the patients referred f or care i n the home have been e l d e r l y - 50 per cent by 1958 were aged s i x t y - f i v e or over. (By then there were branches i n eight m u n i c i p a l i t i e s as w e l l as Vancouver). In 1960, almost 110,000 v i s i t s per annum were being made to provide nursing care to each of the age groups 75-79, 80-84 and 85+. Another 14,000 v i s i t s were made f o r health i n s t r u c t i o n . 3 per cent of patients were 'on the books' for over three years. The VON also took on.-, some v i s i t i n g physiotherapy and occupational therapy, and to a small exTt,: tent, meals on wheels. In June 1972, the B.C. Government took over financing of the service. Then i n 1975 i t said that i t could no longer fund the service and that i t would provide a l t e r n a t i v e home nursing 37 through the Health Department. Although t e c h n i c a l l y a voluntary service, the VON has been so important i n the home care f i e l d that i t could almost be considered a statutory service. Over the years i t was a service which was always included in the P r o v i n c i a l Health Reports and the im-pression one has i s that these nurses showed understanding of and com-passion for the e l d e r l y at a time when public health nurses were t r y i n g to keep clear of both that age group, and p r a c t i c a l involvement-almost as i f the public health nurses were the instrumentalists whose task was to protect the public health whilst the VON had a more expressive r o l e , and provided the caring. Self-help and Community Services Another type of volunteerism i s that whereby the e l d e r l y form groups with the i n t e n t i o n of improving t h e i r s i t u a t i o n . One writer believes that "although the aged have important i n -terests i n common, i t took the shared experience of being pension r e c i p i e n t s to create a perception of common i n t e r e s t s u f f i c i e n t to provide a basis for organization" [Bryden, 1974, p. 194]. The Old Age Pensioners' organization of B.C. was formed i n 1932 to protest the r i g i d administration of the means test. A r i v a l organization with sim i l a r purposes, the Senior C i t i z e n s ' Association of B r i t i s h Columbia was established a few years l a t e r . In 1958 the Federated L e g i s l a t i v e Council was set up to co-ordinate a l l pensioners' organizations i n the Province. Now the various Senior C i t i z e n s ' Associations and Old Age Pensioners' Organizations (250 l o c a l branches with about 50,000 members) seem to organize mainly s o c i a l gatherings whilst the FLC presents an 38 annual b r i e f to the P r o v i n c i a l Government, and as a member of the National Pensioners' Association of Canada, to the Federal Government. Community Groups for older people were slow to develop outside Vancouver and V i c t o r i a but now exi s t i n most centres of population. Some organizations are organized quite p r o f e s s i o n a l l y and recognized for t h e i r importance to the community. The S i l v e r Threads Association of V i c t o r i a would come into t h i s category and there are many more-providing s o c i a l a c t i v i t i e s , day care etc. a l l over the Province. This type of organization tends to receive p r o v i n c i a l government subsidy. Other organizations are e n t i r e l y voluntary or may be funded temporarily, fading away as the funds do. At one time or another, most of the ser-v i c e s that an e l d e r l y person might want, have been provided by someone, somewhere, but not i n any comprehensive way. Volunteers Individual volunteers (including e l d e r l y persons) may be found i n a l l sorts of settings. The Voluntary Action Resource Centre, a department of the Volunteer Bureau of Greater Vancouver, maintains a l i b r a r y on volunteers and voluntary a c t i v i t i e s and organizations, and provides advice on the supervision, recruitment and t r a i n i n g of volunteers. 4. HOUSING It i s not easy to obtain information on housing for the e l d e r l y i n B.C. because, before the Department of Housing was established i n 1973, B.C. had no P r o v i n c i a l Housing Corporation, the Province's housing pro-grams were administered by various departments (Finance, P r o v i n c i a l 39 Secretary, Municipal A f f a i r s ) and do not seem to have been accorded a high p r i o r i t y . For housing the e l d e r l y , B.C. has favoured non-profit corporation housing over public because the former q u a l i f i e d for a 10 per cent fo r g i v a b l e f e d e r a l grant. The B.C..Elderly C i t i z e n s ' Housing  Aid Act (1955 cl9) allowed the Province to make a maximum of one-third contribution towards the project cost of construction or reconstruction of dwelling u n i t s , boarding homes, or s p e c i a l care homes for e l d e r l y c i t i z e n s of low income-to a regional d i s t r i c t , m u nicipality or non-p r o f i t society. O r i g i n a l l y a 10 per cent matching con t r i b u t i o n by a non-profit corporation was required but since 1974 t h i s has been d i s -counted against the 10 per cent figures a v a i l a b l e under the NHA amend-ments. Between 1946 and 1970, 5346 dwelling units and 1747 hostel beds were b u i l t i n B.C. 68.4 per cent under S 15-1 (non-profit), 31.6 per cent under S 40 ( p u b l i c ) . Between 1971 and 1973, 3315 dwelling u n i t s and 2351 hostel beds were b u i l t , 90.1 per cent under S 15-1, 9.9 per cent under S 40. Between 1946 and 1970, B.C. received 1.5 hostel bed approvals per 1000 e l d e r l y persons for CMHG loans (The Canadian average was 12). By 1973, i t had 18.9 hostel places approved per 1000 e l d e r l y persons, (The Canadian average was 14.9). In 1970, B.C. had 26.1 dwelling u n i t s per 1000 over 65 (The Canadian average was 15.7) and i n 1973, 40.0 (Canadian average was 30.3). (The Saskatchewan Housing Corporation would l i k e to be able to house 15 per cent of the e l d e r l y . The Senate Committee estimated a projected need to house 21 per cent of the e l d e r l y ) . By the l a t e 60s, the trend towards b u i l d i n g large h i g h r i s e 40 f a c i l i t i e s for the e l d e r l y was under way, a programme that was slowed down i n 1969 because of the downward economic t r e n d . T h e r e a f t e r , up to 1972, there was a sudden boom during which housing units almost trebled. In 1969, a new area of need was being defined, described by many doctors, s o c i a l workers, operators and private i n d i v i d u a l s as 'intermediate care'. The NDP government which was elected to o f f i c e i n November 1972 i d e n t i f i e d the e l d e r l y as a group r e q u i r i n g s p e c i a l consideration. I t immediately increased the amount a l l o c a t e d f o r senior c i t i z e n accommo-dation i n 1974 to ten m i l l i o n d o l l a r s f o r self-contained and hostel accommodation and two m i l l i o n f o r personal and intermediate-care f a c i l i t i e s . The Department of Housing Act (1973 cllO) set up the f i r s t Department of Housing i n Canada to administer various acts and funds r e l a t i n g to housing and with powers to supervise, acquire, develop, maintain, improve and dispose of housing i n the Province. In the f i r s t year of i t s operation, the Department launched a programme of bui l d i n g 21,412 un i t s of s o c i a l housing, including 1804 p r o v i n c i a l senior c i t i z e n s ' u n i t s , 4,607 non-profit senior c i t i z e n s ' u n i t s and 1239 sp e c i a l care beds. [B.C. Department of Housing, 1975 p. 5]. Under B.C. Housing Management Commission, the Province also undertook a major new programme to b u i l d and operate provincially-owned r e n t a l u n i t s for various income groups, with ample s o c i a l and r e c r e a t i o n a l f a c i l i t i e s , and with rent supplements for those who need assistance. After months 41 of negotiations, the f e d e r a l government agreed, because the costs of b u i l d i n g had r i s e n so much, to new l e g i s l a t i o n whereby no ane i n non-p r o f i t or public housing pays more than 25 per cent of income as rent. The Federal government pays 50 per cent of the subsidy. This led to a large increase i n the demand for t h i s type of accommodation. P r o v i n c i a l expenditure for senior c i t i z e n s ' housing rose from a hundred thousand d o l l a r s i n 1956 to eight hundred thousand d o l l a r s i n 1965, one m i l l i o n i n 1967, almost four m i l l i o n i n 1972, and an estimated twelve m i l l i o n i n 1974. The 12.5 per cent operating subsidy previously required of m u n i c i p a l i t i e s was abolished i n 1974. The Municipal Act was amended i n 1974 to remove the obligatory municipal tax exemptions for new non-profit developments for seniors. P r o v i n c i a l Home Owner Grants were increased i n 1973 to $250 f o r resident home-owners aged 65 or over. Renters were to receive eighty d o l l a r s . (54684 renter grants were ap-proved i n 1974). Another measure was the passing of the Real Property  Tax Deferment Act (1974 c78), which allows e l d e r l y home-owners to defer the payment of taxes on the property they occupy t i l l t h e i r death and/or the sale of the property. 42 COMMENT One m i g h t s a y t h a t i t was a l m o s t i n s i d i o u s l y t h a t t h e e l d e r l y w o r k e d t h e i r way i n t o p u b l i c h e a l t h p r o g r a m s . On t h e o t h e r h a n d , i t i s o n l y r e c e n t l y t h a t c a r e o f t h e e l d e r l y has had much s i g n i f i c a n c e com-p a r e d w i t h t h e o t h e r t a r g e t s o f t h e c o n c e r n o f p u b l i c h e a l t h a u t h o r i t i e s , and l e t i t be s a i d t h a t t h e y d i d e v e n t u a l l y r e s p o n d t o t h a t n e e d . The h e a l t h u n i t m i g h t seem a good b a s e f o r an expanded and c o - o r d i n a t e d s y s t e m o f s e r v i c e s ; y e t t h e p u b l i c h e a l t h ( l e g i t i m a t e ) e m p h a s i s o n p r e v e n t i o n may n o t be any more l i k e l y t o r e s p o n d t o t h e e l d e r l y ' s need f o r c a r e t h a n t h e a c u t e c a r e s y s t e m ' s e m p h a s i s on c u r e . The emphas i s on a c u t e c a r e , e s p e c i a l l y h o s p i t a l c a r e , w h i c h has o n l y r e c e n t l y been r e c o g n i z e d as p r o b l e m a t i c , o b v i o u s l y has e a r l y o r i g i n s and a v a r i e t y o f c o n t r i b u t i n g f a c t o r s . V a l l e y v i e w , t h e o n l y h o s p i t a l w h i c h r e s t r i c t s i t s i n t a k e t o p e r s o n s s e v e n t y and o v e r , a l s o seems t o be t h e o n l y l o n g - t e r m f a c i l i t y w h i c h t a k e s an o p t i m i s t i c v i e w o f t h e p o t e n t i a l o f t h e e l d e r l y f o r r e h a b i l i t a t i o n t o t h e c o m m u n i t y . Somet imes t h e e l d e r l y have b e n e f i t t e d f r o m p r o v i s i o n s made f o r i n d i g e n t s . I n f a c t a s f a r a s w e l f a r e s e r v i c e s g o , t h a t i s s t i l l t r u e t o t h i s d a y . P a r t i c u l a r l y s t r i k i n g i s t h e way i n w h i c h m e d i c a l s e r v i c e s have expanded and d e v e l o p e d compared w i t h any o f t h e o t h e r s e r v i c e s , t h o u g h o f c o u r s e t h i s a f f e c t s a l l age g r o u p s . And i t i s a l s o s t r i k i n g t h a t com-m u n i t y s e r v i c e s have been so s l o w t o d e v e l o p t h o u g h r e c o m m e n d a t i o n s t h a t t h e y s h o u l d have been e m a n a t i n g f r o m one s o u r c e o r a n o t h e r f o r t h e l a s t t w e n t y y e a r s a t l e a s t . 43 NOTES """Almost a l l the information i n t h i s section i s obtained from the Annual Reports of the services from 1895 to the present date. Unless otherwise s p e c i f i e d , the information i s found i n the Annual Report of the year i n question. 2 B.C. Department of Health Services and Hospital Insurance News Release, V i c t o r i a , November 30, 1965. 3 Annual Report of Health Branch, 1966. 4 Report of the S o c i a l Welfare Branch, 1946-47, p. 65. ^Department of S o c i a l Welfare Annual Report 1969-70, p. 43. 44 CHAPTER II OVERVIEW OF DEVELOPMENTS RELATING TO THE ELDERLY AT THE NATIONAL LEVEL 1. HEALTH Many of the developments described i n the preceeding chapter were made possible by federal l e g i s l a t i o n . This was usually permissive or enabling as far as the provinces were concerned, and the l a t t e r more often than not, passed corresponding l e g i s l a t i o n to take advantage of federal cost-sharing. A b r i e f summary follows of the l e g i s l a t i o n relevant to our f i e l d of study. I t w i l l concentrate on those aspects which apply, or could apply, to the e l d e r l y , or which may be relevant to planning for the e l d e r l y . Also included w i l l be resumes of a few of the major reports which preceded the more s i g n i f i c a n t pieces of l e g i s l a t i o n . Again what w i l l be highlighted w i l l be references to the e l d e r l y , or to s i t u a t i o n s or services which do or could a f f e c t them. F i n a l l y , income sec u r i t y , out-side Quebec tends to be l a r g e l y a f e d e r a l concern. The B.N.A. Act (1867 30 & 31 V i c t o r i a c3 U.K. Statutes), Section 92 has been interpreted to mean that p r o v i n c i a l governments have r e s p o n s i b i l i t y for general health and welfare matters. Section 91 accords to the Federal parliament the exclusive r i g h t to r a i s e money by any mode or system of taxation, though the provinces have exclusive r i g h t to d i r e c t taxation within the provinces for p r o v i n c i a l purposes. The Report of the Committee on Health Insurance (1943) [Heagerty 45 Report] was presented along with the Marsh Report to the Committee on Post-War Reconstruction. I t proposed an insurance scheme which would cover a f u l l range of medical b e n e f i t s - i n c l u d i n g pharmaceutical and v i s i t i n g nurse. Although i t was recognized that the population was aging, the main d d e f i c i e n c i e s stressed to the Committee were i n co n t r o l of communicable diseases and of diseases of middle age. So i t s recom-mendation was that concentration should s t i l l be on eliminating deaths i n the younger age groups. Department of National Health and Welfare Act (1944 c22) accorded to the Minister control over a l l matters r e l a t i n g to the promotion or preservation of the health, s o c i a l s e c u r i t y and s o c i a l welfare of the people of Canada but not over any health authority operating under p r o v i n c i a l laws. The National Health Grants Programme (1948) was i n s t i t u t e d to a s s i s t the provinces i n extending and improving public health and h o s p i t a l services. The f i r s t grants were for h o s p i t a l construction, health surveys, professional t r a i n i n g , public health research, general public health, mental health, tuberculosis c o n t r o l , cancer c o n t r o l , venereal disease con-t r o l , and c r i p p l e d c h i l d r e n . A Medical R e h a b i l i t a t i o n Grant was introduced i n 1953. I l l n e s s and Health Care i n Canada (1951) contained the r e s u l t s of the f i r s t nationwide study of i l l n e s s i n Canada. The twelve-month Canadian Sickness Survey, begun i n 1950, showed that with almost 80% of the popu-l a t i o n i l l at some point i n the year there were not more i l l people i n the over s i x t y - f i v e group, but that those e l d e r l y who were i l l , were more i l l 46 and for more of the time. Of the 3 per cent of the population who were severely or t o t a l l y disabled, 40 per cent were aged over s i x t y - f i v e . The e l d e r l y received health care at about the same rate as any other age group, though l e s s , i n proportion to d i s a b i l i t y . They received twice the number of home c a l l s by doctors and t h e i r h o s p i t a l stays tended to be longer. Among the more important findings of the survey were that i n every age group, the lower income groups had higher l e v e l s of d i s a b i l i t y and that poverty was more l i k e l y than old age to be associated with i n a -dequate health care. Hospital Insurance and Diagnostic Services Act (1957 c28). Under t h i s act, the federal government would reimburse approximately 50 per cent of the cost of h o s p i t a l care and diagnostic services provided by any province, on condition that the p r o v i n c i a l scheme provided comprehensive coverage of in-patient care, u n i v e r s a l coverage on uniform terms and conditions, and p o r t a b i l i t y . 'Hospital' was to mean a f a c i l i t y providing in-patient or out-patient services and did not include a tuberculosis h o s p i t a l , a h o s p i t a l for the mentally i l l , a nursing home, a home for the aged, an infirmary or other i n s t i t u t i o n the purpose of which i s the pro-v i s i o n of c u s t o d i a l care. The Vocational R e h a b i l i t a t ion of the Disabled Act (1961 c26) provides for cost-sharing between the f e d e r a l and p r o v i n c i a l governments f o r the co-ordination and provision of services to p h y s i c a l l y and/or mentally disabled persons, t r a i n i n g of personnel, research and p u b l i c i t y . A vocational r e h a b i l i t a t i o n programme may include assessment and counselling services for disabled persons and "services and processes of r e s t o r a t i o n , h i r i n g , 47 employment or placement to dispense with the necessity for i n s t i t u t i o n a l care or the necessity for the regular home services of an attendant". The Report of the Royal Commission on Health Services (1964) [Hall Commission] contained the f i r s t d e t a i l e d overview of the health of Canadians and of the health services a v a i l a b l e to them, and recommended a comprehensive,universal Health Services Plan for the Canadian people. The main j u s t i f i c a t i o n for t h i s public expenditure was i n terms of investment i n human resources and contribution to p r o d u c t i v i t y . The health needs of the aged seems to have been seen as something to be considered i n the future. "With improvement i n l i f e expectancy, a s i g n i f i c a n t l y greater number of the population w i l l be over s i x t y - f i v e , and we w i l l be faced with meeting the health needs of the aged" [Volume I, p. 113]. Thousands of Canadians (57,691 i n 1960) were s t i l l dying under the age of s i x t y - f i v e , and i t was f e l t that the needs of the mentally i l l and retarded and c r i p -pled c h i l d r e n should receive much higher p r i o r i t y than those of the aged and i n f i r m . What the committee recommended for the e l d e r l y applied more to t h e i r care i n the community-homes, foster homes, and d o m i c i l i a r y services, p a r t i c u l a r l y home care. I t was recommended that r e h a b i l i t a t i o n services should be extended to any disabled persons, not only those who could be restored to p r o d u c t i v i t y . And i t was pointed out that to make medical care outside the h o s p i t a l setting e f f e c t i v e , a n c i l l a r y services were needed, with insurance coverage of dental care, drugs and protheses and the up-grading of general p r a c t i c e . Administrative recommendations included one that the fe d e r a l government should set general standards and guidelines and provide f i s c a l 48 assistance but leave each province to e s t a b l i s h and operate i t s own programme. Others were for p a r t i c i p a t i o n of consumers and producers i n the decision-making process, i n the s e t t i n g of goals and objectives and the formulation of proposals for meeting human needs. The Prosthetic Services Act (P.C. 1965-218) allows the Department of National Health and Welfare to enter into agreement with p r o v i n c i a l governments to extend prosthetic services to non-veterans according to conditions determined by p r o v i n c i a l health departments. The Medical Care Act (1966 c64 SI) provides for the fe d e r a l government to pay approximately half the cost of insured services i n a province where the medical care plan i s comprehensive, u n i v e r s a l , portable and operated on a non-profit basis, covering a l l medically required ser-v i c e s provided by physicians and a l i m i t e d number provided i n h o s p i t a l by dental surgeons. A r e s t r i c t e d volume of services provided by such prac-t i t i o n e r s as chiropractors, p o d i a t r i s t s , osteopaths, and naturopaths may also be insured. The Task Force Reports on the Cost of Health Services i n Canada (1970) were prepared for a Committee set up by the Health Ministers who were concerned at the r a p i d l y r i s i n g expenditure on medical care and even more so on h o s p i t a l care. The task forces inquired into u t i l i z a t i o n , operational e f f i c i e n c y , s a l a r i e s and wages, beds and f a c i l i t i e s , methods of d e l i v e r y of medical care, p r i c e of medical care, and cost of public health services. It was found that 95 per cent of a l l health expenditure was being devoted to the operational and curative aspects of health-only 5 per cent 49 to education, t r a i n i n g and research. A substantial increase i n the public health (preventive) component was recommended. There were many references to abuse of ho s p i t a l s and recommendations for services and organizational changes which would replace or r e l i e v e h o s p i t a l beds, health centres, a progressive patient care programme covering a l l l e v e l s of care, c a r e f u l discharge planning, more h o s p i t a l day care and out-patient services, hos-t e l s , transportation, more community services, and more f l e x i b l e use of personnel. For planning and research, there should be r e g i o n a l i z a t i o n of a l l health services. With regard s p e c i f i c a l l y to the e l d e r l y , i t was recommended that greater emphasis be placed on defining the needs of e l d e r l y and other d i s -advantaged groups and on evaluating the programmes now direc t e d at these groups i n order to achieve a judicio u s a l l o c a t i o n of resources i n r e l a t i o n to anticipated r e s u l t s . The Community Health Centre i n Canada (1972) was a study of t h i s a l t e r n a t i v e method for the d e l i v e r y of health care, being considered because i t was r e a l i s e d that health insurance has nothing to do with guaranteeing e f f i c i e n t or e f f e c t i v e organization and d i s t r i b u t i o n of ser-v i c e s . Community health centres were seen as one s o l u t i o n to the problem of increasing costs and also as permitting more 'people-centred' and 'problem-centred' approaches to health. I t was recommended that several of these should be developed but that there should be a concurrent reorganization and int e g r a t i o n of a l l health services. The Report made several references to the aged-this was one of the groups whose health and s o c i a l problems were hard to separate, whose 50 s p e c i a l needs were not presently taken adequate account of, and for whom services should be offered i n imaginative and problem-centred ways. Day care and home care were again advocated. Health Care i n Canada: a Commentary (1973) was the report of a study group under Dr. H. Rocke Robertson appointed by the Health Services Committee of the Science Council of Canada to examine the " o v e r a l l l e v e l , adequacy and appropriateness of research r e l a t e d to the development of a comprehensive and co-ordinated system of health care". The Report pointed to lack of co-ordination, a c c e s s i b i l i t y , con-t i n u i t y of care, e f f i c i e n c y , etc. I t recommended research to i d e n t i f y and develop ways of obtaining data which would increase the capacity for measuring the q u a l i t y of health care, and into means of determining how the 'system' of health care i s working. Although the Report confined i t s e l f more or l e s s to the health care system as now defined, i t did however recognize that " I f a better way of l i f e i s the only ultimate s o l u t i o n to the problem of health, so f a r we have only seen the f i r s t glimmer of recognition of the sorts of things that might be done or t r i e d to achieve i t " . Science for Health Services (1974) was a report of the Science Council of Canada which considered "how science and technology can help i n the search for solutions to the problem of improving the d e l i v e r y of health care as a s o c i a l l y supported service". I t noted a consensus that the reform of the health care system has to be guided by a comprehensive d e f i n i t i o n of health, encompassing not only i t s p h y s i c a l , but also i t s s o c i a l and emotional aspects. "This broad concept of health has led to a 51 recognition of the need to integrate health care and s o c i a l welfare to a degree as yet not well determined." Much more emphasis should be given to the protection of health as compared with the care of the sick. The means for maintenance and promotion of health must be greatly i n -creased. (The most e f f e c t i v e short-term measures could be found i n improved organization and management of health care s e r v i c e s ) ; there should be greater involvement of l o c a l communities i n the d e f i n i t i o n of requirements and i n planning and management of l o c a l f a c i l i t i e s , and there i s a need to expand the extent of p u b l i c l y financed health care. A New Perspective on the Health of Canadians (1974) appeared when the annual rate of cost escalation f o r health services was between 12 per cent and 16 per cent. Since self-imposed r i s k s and the environment are the p r i n c i p a l or important underlying f a c t o r s i n each of the major causes of death i n Canada between one year and age seventy, i t i s claimed that what are required to improve the health of Canadians and reduce death rates, are improvements i n the environment, reductions i n self-imposed r i s k s and a greater knowledge of human biology. The Government of Canada has decided to give as much attention to these three elements as i t has to the financing of the health care organization (To date 95 per cent of health expenditures had been directed at curing e x i s t i n g i l l n e s s ) . The Working Paper also mentions some groups who have gone beyond r i s k to actual i l l n e s s but who are often neglected as they do not r e a d i l y lend themselves to cure. Examples are the disabled, the chroni-c a l l y i l l , the retarded, the mentally i l l and the aged. For the needs of these groups to be met 'care' w i l l have to be rai s e d to the same l e v e l of 52 importance as 'cure'. There i s need for t r a i n i n g of more health personnel to work with the e l d e r l y , for consideration of more use of nurses instead of physicians i n chronic care, and for de-emphasis of acute h o s p i t a l beds i n favour of extended care beds. The paper concludes with two broad objectives to be pursued by the Government of Canada-reduction of hazards for populations at r i s k and im-provement of a c c e s s i b i l i t y to health care of those whose present access i s unsatisfactory. Five strategies are proposed i n pursuit of these objec-t i v e s , which in turn give r i s e to 74 possible courses of act i o n . Of these only a small number-including retirement counselling and programmes- to make l i f e more interesting-apply s p e c i f i c a l l y to the e l d e r l y , Since the health f i e l d concept was based on work done on ' l i f e years l o s t ' c a l c u l a t i o n s -that i s years l o s t up to age seventy, i t i s not s u r p r i s i n g i f the needs of the older group do not come through as an i n t e g r a l part of the o v e r a l l scheme. 2. INCOME SECURITY Among provisions for the e l d e r l y , income maintenance has always been the biggest issue i n p o l i t i c a l terms. Outside Quebec income se c u r i t y for the e l d e r l y i s now accepted as a fe d e r a l rather than a p r o v i n c i a l r e s p o n s i b i l i t y . From 1905 trade unions had been pressing for a pension scheme i n Canada, The 1919 Report of the Royal Commission to Investigate I n d u s t r i a l 53 Conditions i n Canada recommended a compulsory s o c i a l insurance system covering old age, unemployment, sickness and i n v a l i d i t y . Though not implemented, these proposals began to enter into p o l i t i c a l debate i n Canada. But i t was 1927 before the f i r s t Old Age Pension Act (1927 c35) was passed. What was provided was not the insurance scheme promised by the L i b e r a l government (The provinces were un w i l l i n g to co-operate i n t h i s and the Department of J u s t i c e said i t would be unconstitutional) but means-tested non-contributory pensions of $240 per annum to persons whose t o t a l annual income including the pension did not exceed $365, f or people seventy years and over, accorded by the provinces and cost-shared by the federal government, 50 per cent t i l l 1931, 75 per cent thereafter. Adult ch i l d r e n were considered to have some r e s p o n s i b i l i t y for maintenance of e l d e r l y parents, and the provinces could make recoveries from estates. The B.C. L i b e r a l government took immediate advantage of the federal l e g i s l a t i o n , b e l i e v i n g that the party's fate depended on t h i s . [Bryden, 1974, p. 73]. By the l a t e 1920s, poverty among the e l d e r l y was being recognized as a s o c i a l problem which was reaching serious proportions i n Canada. Many of the immigrants who had come here at a mature age during the early days of the wheat boom were reaching old age without having been able to lay aside provisions for i t and many aging parents had l o s t t h e i r p o t e n t i a l source of support i n the war. So when the Conservatives took up o f f i c e i n 1930, they recognized public approval of the scheme and increased the federal contribution to three quarters, From 1935 when the Federal Department of Labour ceded administration to the Department of 54 Finance, there was much more concern with economy. Means tests and annual investigations were made more thorough; i t was made e x p l i c i t that contributions which c h i l d r e n could reasonably be expected to make were to be counted as income whether they were made or not; and the power to make recoveries from estates was made more e f f e c t i v e . The Royal Commission Report on Dominion-Provincial Relations (1940) (Rowell-Sirois Report) pointed out that the problems being experienced i n the 20s and 30s were due not only to the Depression, but also to the increasing proportion of e l d e r l y i n the population, the increased s p e c i a l i z a t i o n of the economy, leading to decreased l o c a l and family s e l f - s u f f i c i e n c y , and the growth of c i t i e s . . . a l l normal features of a maturing economy. I t was suggested i n fac t that the depression had simply i n t e n s i f i e d and brought to a head a s i t u a t i o n which was developing i n any case, so that a more comprehensive and constructive approach was necessary instead of the current ad hoc type of arrangement. The Report of the House of Commons Advisory Committee on Post-War  Reconstruction (1943) (The Marsh Report) recommended a two-fold c l a s s i f i -cation of income security r i s k s : u n i v e r s a l r i s k s such as medical care and pensions; and employment risks-unemployment, d i s a b i l i t y , etc. A compre-hensive set of income security proposals designed to guarantee national minimum standards was proposed. After World War I I , the comprehensive national scheme of s o c i a l insurance recommended by Marsh stood l i t t l e chance of being implemented as long as f e d e r a l - p r o v i n c i a l problems were so over-riding, but i n 1950 55 the provinces did agree to the financing by the f e d e r a l government of a u n i v e r s a l f l a t - r a t e non-contributory pension to everyone seventy years and over, (This was the age proposed by the business organizations; the labour centrals opted for s i x t y - f i v e ) with cost-shared supplements to people aged 65-69, The Old Age Security Act (1951 c38) was passed i n 1951 providing for a u n i v e r s a l pension of f o r t y d o l l a r s per month to people who had resided i n Canada for twenty years and had no c h i l d r e n to support them. The pensions were financed by an old age s e c u r i t y tax of 3 per cent on the sale p r i c e of goods taxable under the Excise Tax Act, a 4 per cent tax on i n d i v i d u a l taxable income or $240, whichever was l e s s , and a 3 per cent corporation tax. The Old Age Assistance Act (1951 c51) enabled the fe d e r a l government to pay 50 per cent of pensions up to a l i m i t of f o r t y d o l l a r s per month accorded by any province to a person aged s i x t y - f i v e or over, whose t o t a l income would not be more than $720 per annum (twelve hundred d o l l a r s for a couple). In 1951 also, a c o n s t i t u t i o n a l amendment gave the Parliament of Canada concurrent j u r i s d i c t i o n with the provinces to make laws i n r e -l a t i o n to old age pensions. The Unemployment Assistance Act (1956 c26) defined the "unem-ployed" as "persons who are i n need". Payments which were shared by the federal government were not to cover medical, h o s p i t a l , nursing, dental or o p t i c a l care but could cover supplements to old age assistance pay-ments to persons i n "homes for s p e c i a l care" which included homes for the aged, nursing homes and hostel f a c i l i t i e s provided for the aged within housing projects constructed under the 1956 National Housing Act. (This has been superseded by the Canada Assistance Plan.) 56 T i l l well into the 60s, l i t t l e more was accomplished or even attempted to extend the coverage of u n i v e r s a l s o c i a l s e c u r i t y benefits though rates were increased occasionally. The fact that the e l d e r l y were the f i r s t people covered (with c h i l d r e n coming next) was probably not a t t r i b u t a b l e to a p o l i c y of p o s i t i v e d i s c r i m i n a t i o n i n t h e i r favour. Fe d e r a l - p r o v i n c i a l r i v a l r i e s , a b e l i e f i n s e l f - r e l i a n c e , and i n the 50s, i n d u s t r i a l expansion, economic growth and a f a i r l y high l e v e l of employ-ment, made state-sponsored s o c i a l s e c u r i t y provisions appear unobtainable, undesirable or unnecessary. However, c h i l d r e n and the e l d e r l y were l e a s t able to provide for themselves. So i t may be that provision for these groups was seen as an a l t e r a n t i v e to be chosen over u n i v e r s a l s o c i a l s e c u r i t y coverage. However, the L i b e r a l government which came into power i n 1963, had promised at e l e c t i o n time to introduce a national contributory plan of wage-related pensions, and a f t e r working through the objections of private insurance companies, of Ontario which had i t s own proposals for a plan, and Qeubec which objected on grounds of uncon-s t i t u t i o n a l i t y , the more comprehensive coverage came with the Canada  Pension Plan (1965 c51 SI) and the Canada Assistance Plan (1966 c45 SI). The Canada Pension Plan (CPP) i s a contributory insurance plan which e n t i t l e s e l i g i b l e b e n e f i c i a r i e s to earnings-related retirement, d i s a b i l i t y and survivor pensions. The retirement pension was intended to be 25 per cent of average adjusted l i f e - t i m e pensionable earnings. The Canada Assistance Plan (1966 c45 SI) i s "an Act to authorize the making of contributions by Canada toward the cost of programmes for the provision of assistance and welfare services to and i n respect of 57 persons i n need". The Plan (CAP) authorizes the fe d e r a l government to assume 50 per cent of the costs of providing assistance to persons i n need and of improving or extending welfare services. It covers those costs previously shared under the Unemployment Assistance Act, including payments to employable and unemployable persons i n need, costs of main-tenance of needy persons i n homes for s p e c i a l care, such as nursing homes for the aged, and costs of supplementary assistance to needy r e c i p i e n t s of old age security pensions, bli n d persons' allowances, disabled persons' allowances and unemployment insurance be n e f i t s . I t also extends f e d e r a l sharing to: health care services to needy persons, e.g. p r e s c r i p t i o n drugs, dental services, eye glasses, nursing services, etc., and the extension of welfare services designed to prevent and remove the causes of poverty and to a s s i s t persons r e c e i v i n g assistance to achieve the greatest possible degree of self-support. Welfare services include among others, r e h a b i l i -t a t i o n services, counselling, homemaker, daycare and s i m i l a r services. Need i s determined by a means test which takes into account the person's budgetary requirements and h i s income and resources. The deter-mination of need and conditions of e l i g i b i l i t y are set by the provinces. Maximum amounts are not set i n the fe d e r a l l e g i s l a t i o n . Between 1966 and 1970, the pensionable age was progressively lowered from seventy to s i x t y -f i v e years. The government had intended that the CAP would cover the needs of indigent old people but the opposition p a r t i e s pressed instead for more generous old age pensions, the report of the Senate Special Committee on Aging showed that 70 per cent of women and 40 per cent of men over seventy possessed no other income than the old age pension, and there was such 58 widespread support for a d d i t i o n a l help for the e l d e r l y that the government did not have much choice than to introduce the Guaranteed Income Supplement (GIS) paid from January 1967, s t i l l income-tested, but by a new per i o d i c submission of income statements. Some people wished old age pensions to be abolished when the CPP was introduced but they were retained for various reasons. The CPP payments would be inadequate for a long time, old age pension payments were taxable, so some of the outlay was recoverable, many people were counting on rec e i v i n g old age pensions, and because they had been financed for over twenty years, i n part by a surcharge on personal income tax, people f e l t e n t i t l e d to them. The Special Senate Committee on Poverty while not dwelling to any great extent on the e l d e r l y , did point out that 27 per cent of a l l low-income family heads were s i x t y - f i v e years of age or older and that the old age pension was inadequate. They recommended that the Guaranteed Annual Income they proposed, should apply to the e l d e r l y as well as to people of other ages. The " f i r s t guiding p r i n c i p l e " defined i n the Working Paper on Soc i a l Security i n Canada (1973), was that "the s o c i a l s e c u r i t y system must assure the people who cannot work-the aged, the b l i n d , and the disabled, a compassionate and equitable guaranteed income". In A p r i l 1973, old age pensions were increased to a hundred d o l l a r s per month-to be escalated i n future i n accordance with a cost of l i v i n g increase. On A p r i l 5, 1974 M. Lalonde introduced i n Parliament, a b i l l to amend the Canada Pension Plan so that the year's maximum pensionable earnings 59 earnings would be increased by 12.5 per cent per year u n t i l the sum caught up to average earnings of Canadian workers. This would enable monthly retirement benefits to be raised to $350 per month by 1985. Other recent suggestions have been that the retirement age under the CPP should be reduced to s i x t y , and that housewives should be included i n the plan. ~ In November 1974, a b i l l received royal assent i n the senate which provided f o r widowers to recive pensions i n the same way as widows. (Previously the widower had to be disabled and have been wholly depend-ent on h i s wif e). From January 1, 1975, female and male contributors and b e n e f i c i a r i e s have enjoyed equal status. The earnings t e s t f o r contributors between the ages of s i x t y - f i v e and seventy was also eliminated. In June 1975, a b i l l was introduced which would allow the spouses of o l d age pensioners to receive means-tested pensions between the ages of s i x t y and s i x t y - f i v e . This was expected to apply to about 85,000 spouses. The Mincome scheme administered by the B.C. Department of Human Re-sources supplemented the Old Age Security Pension and Guaranteed Income Supplement f o r those with no other income. In 1973 and 74, t h i s applied to about 97,000 persons aged s i x t y - f i v e and over and 13,000 i n 1973, 23,000 i n 1974, aged between s i x t y and s i x t y - f o u r . It has been replaced by GAIN (Guaranteed A v a i l a b l e Income f o r Need) which introduces an assets t e s t . The l e g i s l a t i o n introducing the New Horizons programme was passed i n 1972. This programme i s f o r r e t i r e d Canadians who wish to plan projects fo r t h e i r l e i s u r e time. Funds are granted to groups of at l e a s t ten volunteers, the majority of whom must be aged s i x t y - f i v e or over. 60 3. HOUSING As far as housing i s concerned, the p o s i t i o n i n e a r l i e r years seems to have been much as with other services, i . e . the housing of the e l d e r l y may have l e f t much to be desired but as the same could be said of the younger age groups also, there was no s p e c i a l concern for the needs of the e l d e r l y , the l e s s so since housing has been, and s t i l l i s , viewed as a market commodity rather than as a s o c i a l service i n Canada. (The f i r s t Housing Act probably had as i t s main objective the stimulation of employment through construction.) The Dominion Housing Act (1935) was the f i r s t housing l e g i s l a t i o n i n Canada. Like the f i r s t National Housing Act, (1938 c49) i t permitted the government to make j o i n t loans f o r house b u i l d i n g with lending i n s t i -tutions and l o c a l a u t h o r i t i e s on a 25/75 per cent basis. In spite of t h i s , there was great concern i n Canada i n the early 40s about the shortage and d i l a p i d a t i o n of houses i n both urban and r u r a l areas, (the r e s u l t of f a i -l u r e of the b u i l d i n g industry to replace obsolete structures or provide for a growing urban populaiton i n the 30s) and several p r o v i n c i a l reports as well as < the^.j Seventh Census of Canada document t h i s s i t u a t i o n . Since that time, both Federal and p r o v i n c i a l governments have made more provisions to aid home-buyers, as well as elderly.low income renters. The National Housing Act (1944 c46) continued the j o i n t lending technique but i t began also to deal with more s p e c i f i c needs such as low-r e n t a l housing, slum clearance and r u r a l housing. After the war, however, the l e g i s l a t i o n f or the p r o v i s i o n of public housing was used mostly to meet the housing needs of young f a m i l i e s . At the time of the Senate 61 Committee on Aging, only 1,300 r e n t a l units had been b u i l t i n Canada, and of these only 167 were for old people. The Central Mortgage and Housing Corporation Act (1945 cl5) set up a Crown agency responsible to government through the Minister of State for Urban A f f a i r s to carry out federal housing l e g i s l a t i o n and to make loans from money advanced out of the Consolidated Revenue Fund. The National Housing Act (1954 c23) substituted a system of loan insurance for the e a r l i e r j o i n t - l o a n technique to p r i v a t e entrepreneurs. Various other amendments have since been made. Amendments made i n 1964 allowed for aid to provinces, m u n i c i p a l i t i e s and non-profit organizations to b u i l d senior c i t i z e n housing projects (as well as public housing) and also made loans and subsidies a v a i l a b l e for hostels and other forms of group l i v i n g accommodation, not only for new construction, but also for a c q u i s i t i o n and conversion of e x i s t i n g housing. In recent years there has been a considerable s h i f t i n emphasis i n the l e g i s l a t i o n administered by the Central Mortgage and Housing Cor-poration from primary concern with making or guaranteeing loans, to an emphasis on a number of s o c i a l l y oriented housing programmes to meet the needs of low and moderate-income persons. In 1972, 85 per cent of the f e d e r a l housing budget was directed to t h i s aspect of the programmes [Minister of National Health and Welfare, 1974], 1973 amendments included provisions to enable low-income f a m i l i e s and cooperatives to buy homes. Increased assistance was made a v a i l a b l e to voluntary groups such as church groups and service clubs who wished to provide housing for low-income persons, p a r t i c u l a r l y the e l d e r l y and other disadvantaged people. 62 S44(1)B (a new amendment i n 1974) indicates that i f a province i s w i l l i n g to designate a non-profit project as a public one, the project or units within the project are e l i g i b l e for cost-sharing of the operating d e f i c i t s . In 1975, l e g i s l a t i o n was passed giving CMHC authority to lease land at favourable i n t e r e s t rates to any organization wishing to under-take a low-rental housing project. 4. NATIONAL REPORTS Two major reports on the e l d e r l y which deal with a whole range of services were the Report of the Special Senate Committee and the Procee-dings of the Canadian Conference on Aging held by the Canadian Council on So c i a l Development i n 1966. The Report of the Special Senate Committee on Aging (1966) The Committee described t h e i r study (p.v)'as "the f i r s t attempt to examine the problems of aged Canadians as a whole on a nationa l scale though the problems of the aged and aging have been r e c e i v i n g a t t e n t i o n i n recent years i n many parts of the world. There i s ample evidence i n Canada of public i n t e r e s t i n the subject and many organizations and in d i v i d u a l s are involved i n tr y i n g to improve the l o t of aging c i t i z e n s " . The Committee was appointed "to examine the problems involved i n the promotion of the aged and aging person, i n order to ensure that i n addition to the provision of a s u f f i c i e n t income, there are also developed adequate services and f a c i l i t i e s of a p o s i t i v e and preventive kind so that older persons may continue to l i v e healthy and us e f u l l i v e s as members of 63 t h e C a n a d i a n communi ty , and t h e need f o r t h e maximum c o - o p e r a t i o n o f a l l l e v e l s o f government i n t h e p r o m o t i o n t h e r e o f " . The Commi t t ee d e a l t w i t h i n c o m e , employment , h e a l t h , h o u s i n g and communi ty s e r v i c e s . B e c a u s e a g i n g i s a n o r m a l and n a t u r a l phenomenon, t h e c o m m i t t e e d e l i b e r a t e l y r e j e c t e d t h e i d e a o f d e f i n i n g s e r v i c e s f o r o l d p e o p l e as " w e l f a r e s e r v i c e s " . I t was p o i n t e d o u t t h a t a p o l i c y f o r o l d p e o p l e must f i t i n w i t h t h e s o c i a l and economic g o a l s o f t h e w i d e r s o c i e t y , b u t t h a t t h e e l d e r l y a r e more v u l n e r a b l e t o change and more d e f e n c e l e s s . C o n -s t r u c t i v e p l a n n i n g f o r o l d p e o p l e c a n n o t p r o c e e d on an ad hoc b a s i s b u t must r e s t on an a n a l y s i s and u n d e r s t a n d i n g o f t h e t o t a l s i t u a t i o n . They need c o n t i n u i t y , and f reedom o f c h o i c e when c o n t i n u i t y has t o be b r o k e n , t h e y need r e c o g n i t i o n o f t h e i r i n d i v i d u a l i t y , and t h e y t r e a s u r e i n d e -p e n d e n c e . V a r i o u s r ecommenda t i ons were made f o r h e a l t h c a r e i n c l u d i n g communi ty f a c i l i t i e s , ( c l i n i c s , o u t p a t i e n t d e p a r t m e n t s o f h o s p i t a l s , e t c . ) t o w h i c h s i c k e l d e r l y p e o p l e c o u l d go o r be b r o u g h t f o r o n - t h e - s p o t a s s e s s m e n t , t r e a t m e n t , c o u n s e l l i n g , e t c . , e x t e n s i o n o f s e r v i c e s ( i n c l u d i n g n u r s i n g homes) c o v e r e d by m e d i c a r e . The need f o r t eam-work among t h e t h r e e l e v e l s o f government was e m p h a s i z e d . D e p a r t m e n t s o f H e a l t h and D e p a r t -ments o f W e l f a r e s h o u l d have s p e c i a l b r a n c h e s c o n c e r n e d w i t h o l d e r p e o p l e and s h o u l d l i a i s e . T h e r e s h o u l d be a s p e c i a l d i v i s i o n a l s o i n t h e Depar tmen t o f N a t i o n a l H e a l t h and W e l f a r e . Needs f o r e d u c a t i o n , p l a n n i n g and r e s e a r c h were p o i n t e d o u t . T h e r e were a number o f r e c o m m e n d a t i o n s r e g a r d i n g i n c o m e , employment , h o u s i n g and s o c i a l s e r v i c e s , and f o r a N a t i o n a l C o m m i s s i o n on A g i n g t o 64 keep under review the needs and problems of older people and to develop recommendations on p o l i c y and programmes for dealing with them, etc. A body should also be established i n each mu n i c i p a l i t y to plan and co-ordinate programmes for the e l d e r l y . The Proceedings of the Canadian Conference on Aging (CCSD. 1966) covered much the same area as the Senate Committee. In hi s opening remarks, Hon. A l l a n J . MacEachen, Minister of National Health and Welfare, described the care of the aged as "probably without question the most d i f f i c u l t problem of our times i n a l l c i v i l i z e d countries. The problem i s becoming more urgent because of the increasing number of people l i v i n g into the l a t e r years. The placing of more emphasis upon older people i n our community i s becoming a permanent feature of our population structure". Rev. Andre Guillemette further set the stage by pointing out that ". . . the existence of mass s o c i e t i e s with large numbers of persons who spend as much time i n retirement as they do i n childhood i s a new phenomenon. To date no adequate s o c i a l theory has been developed to f i n d a function for the aged . . . Our f i r s t concern and our f i r s t a c tion should therefore, be. to restore the p o s i t i o n of the e l d e r l y i n our culture and society i n the i n t e r e s t of the e l d e r l y , of course, and i n the i n t e r e s t of our e n t i r e society. Consideration must be given to d e f i n i n g the value of the e l d e r l y person's experience and wisdom. This r e d e f i n i t i o n i s im-perative at the family l e v e l , i . e . extra f a m i l i a l s o c i a l r e l a t i o n s , and i n the world of work, business and employment. Consequently we must revive our concept of old age, we must rethink the r o l e s and functions of old age" (p. 53). M. Guillemette pointed to the huge gap between medical 65 research and s o c i a l research on the problems of the e l d e r l y . "The advances i n medicine are p a r t l y responsible for the s o c i a l problems which a f f e c t the e l d e r l y , since the s o c i a l structures have not evolved and our s o c i a l a t t i t u d e s have not changed to keep pace with the growing numbers of old people i n our society and with the technological r e v o l u t i o n through which we are passing", (p. 60) Again various recommendations with regard to services and organizations were made, many s i m i l a r to those of the Senate Committee. The CELDIC report, One M i l l i o n Children, published i n 1970 by the Commission on Emotional and Learning Disorders i n Children made recom-mendations about the nature and organization of services for the c h i l d r e n concerned, of which many might equally well apply to the e l d e r l y i n a community, e.g. community service centres i n each area with a population of 25,000 to 50,000; boards who would promote and plan the establishment of a comprehensive and co-ordinated network of personal care services, devo-l u t i o n of service r e s p o n s i b i l i t y to l o c a l l e v e l , that p r i o r i t i e s be decided by l o c a l needs rather than by the funding provisions of governments. There were also recommendations that each p r o v i n c i a l government should estab-l i s h a cabinet committee with a designated chairman responsible for the co-ordination of the personal care services and an advisory council to the cabinet on personal care services (composed of representatives of con-sumers, providers and administrators of s e r v i c e s ) . There was regret at the prejudice against planning which had prevailed at le a s t up to World War I I , and a recommendation that "the Government of Canada undertake such measures as are necessary to ensure that c i t i z e n s i n a l l regions of Canada 66 have available to them those personal care services which are required to assist them towards maximum development of their potentials as persons and as citizens of this nation". What is most interesting about the federal legislation i s that i t enables one to trace the origins of many of the problems, as well as the merits, of today's services. As far as the reports are concerned, usually what i s more striking i s how often recommendations have been ignored though they have been reiterated many times over the years. Now that the federal government has declared an end to i t s open commit-ment to cost-share health services recommendations for less emphasis on acute and medical care, and more on community and social services may at last be heeded. Even now that the increasing size of the elderly population i s recognized by everyone, reports from the health f i e l d s t i l l seem to give low priority to the needs of the elderly. 67 CHAPTER III PRESENT SITUATION In Chapter II we followed the h i s t o r i c a l development of various services which can a f f e c t the health and well-being of the e l d e r l y . In t h i s chapter we look at the present s i t u a t i o n . We have divided health services into i n s t i t u t i o n a l services and community health services, s t i l l keeping mental health services separate because for the e l d e r l y , they are s t i l l mainly provided separately. Then having looked at s o c i a l services (including voluntary s e r v i c e s ) , income se c u r i t y and housing, we look b r i e f l y at the financing of services and at some of the structures within which they are provided. F i n a l l y we review some of the charac-t e r i s t i c s of the present arrangements. PRESENT SITUATION - DESCRIPTION 1. HEALTH SERVICES - INSTITUTIONAL Since September 1973, health care i n B r i t i s h Columbia has been c l a s -s i f i e d into f i v e types''" s i m i l a r to those proposed by a national working party for use throughout Canada, and intended to cover the whole range of health care requirements from Type I-personal care (for persons whose physical d i s a b i l i t i e s are such that t h e i r primary need i s f o r room and board, l i m i t e d l a y supervision, assistance with some of the a c t i v i t i e s of d a i l y l i v i n g and a planned programme of s o c i a l and r e c r e a t i o n a l a c t i v i t i e s ) , through intermediate care (where d a i l y professional nursing i s also required), extended care (requiring s k i l l e d twenty-four-hour a day nursing services and continuing medical supervision), a c t i v a t i o n , and Type V, acute 68 care. Hospital Insurance covers accommodation, meals, necessary nursing services, diagnostic procedures, pharmaceuticals, the use of operating rooms, anaesthetic f a c i l i t i e s and radiotherapy, and physiotherapy i f a v a i l a b l e , i n general and public a l l i e d , r e h a b i l i t a t i o n and extended care ho s p i t a l s . Outpatient services covered include emergency services, minor s u r g i c a l procedures, day care s u r g i c a l services, outpatient cancer therapy, p s y c h i a t r i c day care and night care and some outpatient services, day care r e h a b i l i t a t i o n services, physiotherapy services and d i a b e t i c day care. The authorized charges were rai s e d i n 1976 from one d o l l a r to four d o l l a r s per day for standard ward acute and extended care. Charges for other services are two d o l l a r s and one d o l l a r per v i s i t . There are n i n e t y - f i v e acute hospit a l s i n B r i t i s h Columbia, and 11,429 'general' beds. Most acute h o s p i t a l personnel believe that t r e a t -ment of adults i n the acute h o s p i t a l should be geared to the patient's medical needs and not to his/her age, though the l a t t e r may a f f e c t the nature and extent of the needs, [GVRHD 1975 (2)]. Hospital admission rates are higher and length of stay longer for the e l d e r l y patient mainly because the commonest conditions treated i n t h i s age group tend to be long term. A c t i v a t i o n and R e h a b i l i t a t i o n i s the 'type of care required by persons of any age with physical d i s a b i l i t i e s of a kind that require a planned intensive programme of r e h a b i l i t a t i o n to improve or restore fun-c t i o n as i t r e l a t e s to m o b i l i t y , the a c t i v i t i e s of d a i l y l i v i n g and vocational capacity'. There are three r e h a b i l i t a t i o n , c e n t r e s i n B.C.-the G.F. Strong and the Holy Family R e h a b i l i t a t i o n Centres i n Vancouver 69 (100 and 80 beds) and the Gorge R e h a b i l i t a t i o n Centre i n V i c t o r i a (99 beds) There are also nine r e h a b i l i t a t i o n u n i t s i n other h o s p i t a l s with a t o t a l of 193 beds. New units i n the planning or construction stage w i l l provide an add i t i o n a l 120 beds. The Workers Compensation Board of B.C. also has r e h a b i l i t a t i o n f a c i l i t i e s i n Vancouver. The G.F. Strong serves the whole province, gives p r i o r i t y to the severely disabled, and r a r e l y admits e l d e r l y patients. Holy Family Hos-p i t a l on the other hand, i n 1975, admitted 256 patients aged s i x t y and over and sixty-seven only under age s i x t y . Over 90 per cent had a diagnosis of c.v.a., fractures, or a r t h r i t i s . In t h i s h o s p i t a l a 'programmer' prepares an i n d i v i d u a l program f o r every patient each week which includes group and in d i v i d u a l therapy, occupational therapy, speech therapy i f necessary, etc. There i s progressive nursing care with the f i n a l stage including overnight v i s i t s home and a l l professional s t a f f take part i n planning and discharge conferences. In 1974, the average length of stay was 56.5 days. 68.8 per cent of patients were discharged home, 12.9 per cent to Boarding Homes, 10.2 per cent to acute care and only 7.1 per cent to extended care. The waiting-time for admission usually ranges from four to eight weeks. In a study of acute h o s p i t a l s i n the GVRHD ca r r i e d out i n 1975, [GVRHD, 1975 (2)], i t was found that even i n the few h o s p i t a l s where there 2 were r e h a b i l i t a t i o n u n i t s or areas these were usually considered inade-quate i n s i z e and f a c i l i t i e s . Less than half the patients treated, on average, were aged over s i x t y - f i v e . Most h o s p i t a l s would have appreciated having more r e h a b i l i t a t i o n beds a v a i l a b l e to them because i t was f e l t that the treatment provided to the e l d e r l y by the acute h o s p i t a l would be 70 consolidated by a period of r e h a b i l i t a t i o n before returning home. Home care was not usually considered adequate as a substitute because i t does not include education or t r a i n i n g for independence. The l i n e between r e h a b i l i t a t i o n and a c t i v a t i o n may not be too cl e a r though the l a t t e r seems to be l e s s energetic and applied more to treatment of e l d e r l y patients, p a r t i c u l a r l y stroke patients. There are less than a hundred beds designated a c t i v a t i o n beds i n the Province. There were 3,538 extended care beds i n f i f t y - t w o f a c i l i t i e s i n B.C. i n 1975 mostly attached to general h o s p i t a l s , though seven were f r e e -standing and managed by non-profit boards. The average s i z e was seventy beds. The p r o v i n c i a l formula i s twenty beds per 1,000 population over age s i x t y - f i v e . To be e l i g i b l e for admission, a person must be unable to get i n and out of bed or use a wheelchair unassisted, or must require regular and continuing medical supervision and professional nursing care beyond that a v a i l a b l e i n Intermediate Care f a c i l i t i e s . Names of e l i g i b l e a p p l i -cants are kept on a Central Registry i n V i c t o r i a u n t i l a vacancy occurs, and a f t e r admission patients are assessed at quarterly i n t e r v a l s as to th e i r continuing e l i g i b i l i t y . Of 3,003 patients i n extended care i n 1974, 1,960 were female 1,043 male, 577 were.single, 883 married, (married and sing l e were almost equally divided by sex) but of 1,518 widowed, divorced or separated, 1,221 were female, and 297 male. The chief p r o f i l e was the older widowed female. By age^ 23 per cent were under s i x t y - f i v e years of age, 7 per cent were 65-69, 9 per cent 70-74, 14 per cent 75-79, 18 per cent 80-84, 17 per cent 85-89, and 17 per cent 90-99. A 1972 study (Foulkes .1973) has shown that, the most 71 common diagnoses were c.v. disease and ischemic heart disease, followed by a r t e r i o - s c l e r o s i s , other non-psychotic mental disorders, f r a c t u r e of the femur, p a r a l y s i s agitans, and diabetes m e l l i t u s . Almost half of the patients had stayed beyond six months, and another quarter beyond a year. The GVRHD 1973 study found that i n t h e i r region, 44 per cent of extended care patients had been admitted from acute h o s p i t a l s , 37 per cent from other care f a c i l i t i e s and 14.3 per cent from home. Of ^discharges, 71 per cent had died, 7.4 per cent went to acute h o s p i t a l s , 9.4 per cent went home, and the others to equivalent or lower l e v e l s of care. A study of the c h a r a c t e r i s t i c s of 3,209 1974 patients showed that 88 per cent were rec e i v i n g o r a l medications and 45 per cent regular bedtime sedations, 33 per cent required attention for bowel or bladder problems, 59 per cent could not walk, 39 per cent could walk with assistance and 2 per cent independently. 21 per cent were aphasic, 5 per cent had severely impaired v i s i o n , 24 per cent were confused and disoriented and 6 per cent were di s r u p t i v e , noisy or with unacceptable behaviour. Intermediate Care Beds are a f a i r l y recent innovation i n B.C. which now has 820 i n Vancouver, Burnaby, V i c t o r i a , Kamloops, Penticton and Nanaimo, Again, applicants are registered i n the Central Registry i n V i c t o r i a . There i s a 3-4 months waiting time for Vancouver, l e s s f o r Burnaby. Residents pay ten d o l l a r s per day which i s subsidized by the Department of Human Resources for those (50 per cent) who are unable to pay the f u l l cost. The actual cost to the government i s at le a s t twice the amount charged, and t h i s also i s paid f o r by the Department of Human Resources. In 1974, an Intermediate Care Study Committee recommended that i n the GVRD alone, four thousand such places should be provided by 1981, though some of these could be provided by the modification of e x i s t i n g private f a c i l i t i e s . The Province estimates a need by 3 per cent to 4 per cent of persons over s i x t y - f i v e for intermediate and personal carer., The number of Priv a t e Hospitals has decreased s t e a d i l y over the past ten years presumably because of the provision of extended care h o s p i t a l s so that i n 1974 there were f i f t y - t h r e e h o s p i t a l s and 2,541 beds, mostly located i n Vancouver and V i c t o r i a . Private Hospitals are licensed under the Pr i v a t e Hospitals Licensing Act and are required to provide twenty-four-hour s k i l l e d nursing care. They are supposed to provide type II care, but to an unknown extent also provide for l e v e l s 1 and I I I . Five year old data give a 2:1 female to male r a t i o , an average age of eighty-seven for females and eighty for males, and an average length of stay of s i x months. About half the patients are 'welfare' patients who are evaluated i n l o c a l DHR o f f i c e s , and must have assets no greater than f i f t e e n hundred d o l l a r s i f s i n g l e , and twenty-five hundred d o l l a r s i f a married couple. Charges may be as high as nine hundred d o l l a r s per month. In s p i t e of t h i s , some owners f i n d that as long as government pays only $525 per month for welfare patients, they can no longer operate except at a l o s s , and are c l o s i n g down (.Vancouver Prov-ince 'Hospital Owner regrets he had to close down', July 17, 1976) In 1975 there were about 485 Personal Care Homes i n the Province licensed by the Community Care F a c i l i t i e s Licensing Board. 75 per cent of these f a c i l i t i e s containing 55 per cent of the known beds, are p r i v a t e l y owned. Most of the remainder are owned by voluntary organizations. The 73 average siz e i s 25.9 beds though sixteen have over one hundred beds. Of the 12,000 residents, about ha l f are subsidized by the p r o v i n c i a l govern-ment, under a cost-sharing agreement with Ottawa. Department of Human Resource expenditures to a s s i s t persons i n boarding and r e s t homes and private h o s p i t a l s more than doubled i n 1975 as the number of persons assisted more than doubled. In July 1975, the president of the B.C. Rest Homes Association claimed that r i s i n g costs and low revenue (even at $400 to $600 per month) were fo r c i n g p r i v a t e operators out of business, and claimed that i n the previous twelve months, twenty out of eighty private homes i n V i c t o r i a had closed. Residents unable to pay the costs could be subsidized by the government by $250-$400 per month i n a d d i t i o n to a twenty-five d o l l a r per. month comforts allowance and a twice yearly c l o t h i n g allowance (for those whose assets do not exceed $500). Mr. Hanrahan wanted a government subsidy 3 of eight d o l l a r s per day f o r a l l residents. The Minister of Health had stated i n the 1973 C l a s s i f i c a t i o n of Types of Health Care that the provision of several types of health care i n one f a c i l i t y or under the auspices of one agency would be encouraged. Examples of t h i s are the Penticton and D i s t r i c t Retirement Complex which provides a six-storey apartment unit for 156 residents aged s i x t y - f i v e and over, adjoining a 9,000 square foot recreation centre which i n turn i s linked to a Care Home with ninety-seven intermediate care beds. In Vancouver, Seton V i l l a provides self-contained s u i t e s , board residence and personal care. Then i n February 1976, the f i r s t intermediate care (79 beds)and personal care (23 beds) unit to be associated with and operated 74 by an acute h o s p i t a l was opened i n Nanaimo. 2. HEALTH SERVICES - COMMUNITY SERVICES Community services for the e l d e r l y may be provided by independent p r a c t i t i o n e r s , the Health Department, the Department of Human Resources, voluntary agencies funded to varying degrees by either or both of these, and other sources a l s o . The Medical Services Plan of B r i t i s h Columbia provides services upon uniform terms and conditions for a l l residents of the Province who choose to pay the premium (now $7.50 per sing l e adult per month, $3.75 for people with taxable income below $1,000). The Plan provides insurance coverage for a l l medically required services rendered by medical prac-t i t i o n e r s and for optometric assessment. Chiropractic i s a v a i l a b l e up to a cost of seventy-five d o l l a r s per year for people under s i x t y - f i v e , one hundred d o l l a r s f o r those over s i x t y - f i v e . Naturopathic services, podiatry and orthoptic services, physiotherapy, provided outside the h o s p i t a l are av a i l a b l e up to f i f t y d o l l a r s per patient per year, s p e c i a l nursing up to fo r t y d o l l a r s . Covered now also are services rendered at outposts approved by the Commission within the Province of B.C., where the services of a medical p r a c t i t i o n e r are not r e g u l a r l y a v a i l a b l e , by nurses employed by the Canadian Red Cross Society-to be paid at the rate of two d o l l a r s per o f f i c e service, and four d o l l a r s per house v i s i t , where such services of the Red Cross nurse are rendered under the i n s t r u c t i o n s of a medical p r a c t i t i o n e r or consist of treatment for minor i n j u r i e s and i n f e c t i o n s . E l d e r l y persons have the same r i g h t to services as other members of 75 the P r o v i n c i a l medical insurance plan. Since s t a t i s t i c s are not kept according to age, i t i s not possible to obtain figures on the number and nature of services provided by family doctors to ambulant ..elderly patients. Nor i s there any documentation of how often e l d e r l y patients who present with medical problems i n fac t require a d i f f e r e n t form of attention or intervention. There i s a free p r e s c r i p t i o n drug programme for residents over s i x t y - f i v e . More p r e s c r i p t i o n s are now f i l l e d for e l d e r l y persons than before introduction of Pharmacare. The Department of Human Resources provides transportation for low income persons i n need so that they may go to c l i n i c s , h o s p i t a l s , r e -h a b i l i t a t i o n centres and nursing homes. Over 60 per cent of users of the emergency transportation service are e l d e r l y and the emergencies are mostly of a medical nature. The Department may also pay for medical services, supplies and equipment not covered by medical insurance. Special Needs Committees assess the needs of people who are not already i n rece i p t of s o c i a l assistance. Public Health Services-Nineteen Public Health Units i n B.C., (Just over one hundred public health o f f i c e s ) provide a v a r i e t y of pre-ventive and treatment services. The services most used by the e l d e r l y are home care and v i s i t i n g nursing, physiotherapy, consultation and support to community groups, assistance to community support services, e.g. home-makers, meals-on-wheels, and v i s i t i n g . The units also provide l i a i s o n with h o s p i t a l s i n planning home care, provision of s p e c i a l c l i n i c s -"over-60", hearing, podiatry, n u t r i t i o n , screening-and counselling about 76 g e n e r a l h e a l t h i s s u e s , e t c . A few u n i t s p r o v i d e s p e e c h t h e r a p y t o s t r o k e p a t i e n t s . H e a l t h Depar tmen t s t a f f i n s p e c t Community C a r e F a c i l i t i e s t o d e t e r m i n e t h e i r e l i g i b i l i t y f o r l i c e n c e and n u r s e s f rom some u n i t s v i s i t p e r s o n a l c a r e homes t o o f f e r s u p e r v i s i o n and c o n s u l t a t i o n . T h e r e a r e e i g h t h e a l t h u n i t s i n M e t r o V a n c o u v e r , N u r s e s have some d e a l i n g s w i t h t h e e l d e r l y bu t t h e r e i s no one c o n c e n t r a t i n g on t h e e l d e r l y as s u c h . E a c h o f f i c e e x c e p t B u r r a r d has a c o - o r d i n a t o r o f v o l u n -t e e r s who v i s i t t h e e l d e r l y - a s e r v i c e f i n a n c e d by Human R e s o u r c e s . A d o c t o r and a n u r s e f rom t h e V a n c o u v e r E a s t U n i t t a k e p a r t i n two W e l l - B e i n g C e n t r e s f o r S e n i o r s , e a c h h e l d once a month i n Columbus Towers and L i o n s ' M a n o r . S t a f f e d m a i n l y by v o l u n t e e r s , t h e programmes a r e m o s t l y r e c r e a t i o n a l and e d u c a t i o n a l , b u t p e o p l e 'who d o n ' t want t o b o t h e r ' t h e i r f a m i l y d o c t o r may a p p r o a c h t h e H e a l t h U n i t d o c t o r , and may a l s o be p e r -suaded t h a t t h e y s h o u l d c o n s u l t t h e i r f a m i l y d o c t o r . Home C a r e - B . C . may have t h e most advanced Home C a r e Programme i n Canada w i t h s e r v i c e s a v a i l a b l e t o abou t 90 p e r . cent t o 95 p e r c e n t o f t h e p o p u l a t i o n . The programme i s a d m i n i s t e r e d by t h e H e a l t h U n i t s and v i s i t s a r e made, on t h e r e q u e s t o f a p h y s i c i a n , by r e g u l a r l i n e p u b l i c h e a l t h n u r s e s who a l s o c a l l on R . N . s , p h y s i o t h e r a p i s t s , o r d e r l i e s , v i s i t i n g homemakers, m e a l s - o n - w h e e l s p e r s o n n e l , v i s i t i n g v o l u n t e e r s , o c c u p a t i o n a l and r e c r e a t i o n a l w o r k e r s . T i l l 1976, i n V a n c o u v e r and V i c t o r i a , and a few o t h e r a r e a s , t h e Home C a r e s e r v i c e s were a v a i l a b l e t h r o u g h t h e V . O . N , and more o f t h e c o s t s o f s e r v i c e s were c h a r g e d t o t h e p a t i e n t s . The B . C . M e d i c a l S e r v i c e s P l a n p a i d t h e V . O . N , two d o l l a r s p e r v i s i t . I n 1973, 67.1 p e r c e n t o f p e o p l e r e c e i v i n g home c a r e s e r v i c e s were 77 aged s i x t y - f i v e and over (excluding the V.O.N, areas i n Vancouver, V i c t o r i a and Surrey, and s p e c i a l p r o j e c t s ) . And the number of new ad-missions i n that age group rose from 2,525 i n 1969 to 3,928 i n 1974. The fi g u r e s vary markedly from one d i s t r i c t to another, depending to a large extent on the s i z e of the e l d e r l y population i n the area. Special Home Care Projects i n nineteen areas ( i . e . almost a l l major population areas) provided care to patients discharged early from acute h o s p i t a l s , and to a very few patients instead of admission. They were financed completely by the P r o v i n c i a l Government, and a l l services required, i . e . nursing, physiotherapy, homemaker, meals-on-wheels, medi-cation, supplies, s o c i a l worker, orderly, transportation, laboratory, d i e t i t i a n , etc. are provided without charge to the patient. In B.C. i n 1974, 2,501 patients (31.4 per cent) discharged from the Special Pro-gramme were aged s i x t y - f i v e years or over. In 1976, the t r a d i t i o n a l and s p e c i a l programmes were amalgamated and a l l services are now provided com-p l e t e l y without charge to the patient i f they are provided as h o s p i t a l replacement. Otherwise, only nursing and physiotherapy are free and there i s not time l i m i t on nursing. In the age group 60+, 25 per cent of home care i s h o s p i t a l r e -placement and 75 per cent support. A study of Home Care undertaken by the GVRHD i n 1975 recommended more admissions from the community to the programme, more use of i t for long term and terminally i l l patients and more education of h o s p i t a l s t a f f and patients regarding the programme. V.O.N.-Until 1976, the V.O.N., funded since 1974 by the p r o v i n c i a l 78 Department of Health, provided home nursing and physiotherapy and i n some areas administered homemakers, meals-on-wheels, and home aides i n Greater Vancouver, Surrey and V i c t o r i a . In addition, i n some areas, V.O.N, physiotherapists would pay predischarge v i s i t s to assess a patient's home, and would i n s t r u c t r e l a t i v e s on how to care for patients. When BCMP coverage ( f o r t y d o l l a r s per annum for nursing, f i f t y d o l l a r s for physio-therapy) was exhausted, people were charged according to means, with the Department of Human Resources paying for low-income persons. The present government decided that these services should be taken over by public health u n i t s to avoid d u p l i c a t i o n of services and t h i s take-over was com-pleted i n October 1976, when the services of the Vancouver Branch were taken over. Homemakers-Several non-profit s o c i e t i e s i n the Province h i r e and t r a i n homemakers. The Department of Human Resources makes annual grants to these s o c i e t i e s to help defray costs. Services may be provided for from four hours once a week up to twenty-four hours a day i n a c r i s i s . Fees charged to low-income f a m i l i e s or patients on h o s p i t a l replacement home care, are paid by the Department. An A p r i l 1974 survey showed that i n the several non-profit agencies which provided the p r o v i n c i a l homemaker service, there were 1,345 home-makers (some on a part-time b a s i s ) , over eighty home-aides and seventyffive supervisors. The usual payment was the minimum wage of $2.50 per hour. Care f o r the e l d e r l y and the c h r o n i c a l l y i l l were the types most commonly required. It was thought that the lack of middle income consumers sug-gested, not the absence of need for services but deterrence by the cost. 79 [Rosettis, 1974]. A survey done i n Vancouver i n February 1974 by the Department of Health Care and Aging found that of the 206 cases helped, eighty-six were aged eighty and over, and fifty-Psix between s i x t y - f i v e and seventy-nine. In the course of the GVRHD G e r i a t r i c s study i t was claimed that demand for t h i s service far exceeded supply. Also, a rather r i g i d d i v i s i o n of function was r e g r e t t e d - u n t i l r e cently a homemaker had not been allowed to get a patient out of bed. In 1975 i n the Province as a whole, services expanded considerably and costs of $6.5 m i l l i o n were almost double the 1974 expenditures. 58 per cent of services were to the e l d e r l y . (GVRHD 1975 (2)). Meals-on-wheels-These are provided i n most centres of population (forty-two altogether), administered by health u n i t s , V.O.N, or voluntary organizations, and staffed by volunteers. Meals i n most units are provided e n t i r e l y to the e l d e r l y . Some groups receive grants from the Department of Human Resources to o f f s e t the administrative costs or to p a r t i a l l y sub-s i d i z e the cost of the meals. Health C l i n i c s - A few communities have organized l o c a l l y c o n t r o l l e d health c l i n i c s with f i n a n c i a l assistance from the P r o v i n c i a l Health Department. The only one which seems to have a large number of e l d e r l y people among i t s c l i e n t s i s the Downtown Community Health Society i n Vancouver. Funded o r i g i n a l l y by the community and a National Health grant, now by the P r o v i n c i a l Government, and staffed by twenty-five professionals or paraprofessionals and t h i r t y - n i n e volunteers, i t runs a medical and dental c l i n i c , a home care programme serving i s o l a t e d and l o n e l y aged and handicapped, providing nursing care, s o c i a l companionship and other 80 assistance. I t has a mid-day soup programme and also o f f e r s r e c r e a t i o n a l services. The f a c i l i t i e s are used mainly by male residents of the Skid Row area, 60 per cent of whom are e l d e r l y (and 25-30 per cent of whom are chronic a l c o h o l i c s ) . Community Human Resource and Health Centres-The Queen Charlotte Islands was one of the f i r s t parts of the Province to apply for a CHRHC with the o r i g i n a l i n i t i a t i v e coming from the Hospital Board. Others are at James Bay, V i c t o r i a , Grand Forks-Boundary, Houston and Granisle. They tend to be seen as o f f e r i n g the best s o l u t i o n for p r o v i s i o n of services i n remote areas with scattered populations, problems i n a t t r a c t i n g p r o f e s s i o n a l s t a f f , etc. However, because these areas may also consist l a r g e l y of recently established company towns or Indian settlements, the percentage of e l d e r l y i n them tends to be small. (3 per cent over s i x t y -f i v e i n the Queen Charlottes) and s p e c i a l services for the e l d e r l y are almost nonexistent (and unnecessary). The James Bay Centre i s the excep-t i o n with 40 per cent of the population of the area over the age of s i x t y . The lunch hour i s set aside each day as a time when appointments i n the health component can be made by e l d e r l y people wishing to come at a quiet period. Home v i s i t s by a doctor and nurse may also be booked d a i l y between nine and noon. Health education classes are held, a public health nurse attends a New Horizons Group to discuss i n d i v i d u a l problems, check blood pressures, etc. The p r o v i n c i a l government has a v i s i o n care programme i n the Queen Charlottes-one ophthalmologist, one optometrist and one d i s -pensing o p t i c i a n go up three times a year for three days. Voluntary Agencies-The B.C. D i v i s i o n of CARS runs the A r t h r i t i s 81 Centre i n Vancouver where a s t a f f of rheumatologists, t h e r a p i s t s , nurses and s o c i a l workers provide outpatient r e h a b i l i t a t i v e treatment to patients of whom the majority suffer from a r t h r i t i s . This was declared a non-bedded h o s p i t a l f or funding by BCHIS i n November 1972. There are 1. also therapists located at f i v e other stations i n the Greater Vancouver Area, and three t r a v e l l i n g vans provide service i n many other areas of the Province. CARS has t h i r t y - s i x beds i n three Vancouver h o s p i t a l s . Rufus Gibbs Lodge i s a residence for out of town patients attending the Centre. Carscraft i s a sheltered workshop and sales o u t l e t . Club 985 i s a s o c i a l club. Funding i s provided approximately 40 per cent by government grants, 32 per cent from voluntary contributions, including United Appeals and 28 per cent from treatment fees including those from medical plans. Of 277 patients treated i n the t h i r t y - s i x beds i n 1975, ninety-two were aged over s i x t y . And over 60 per cent of physiotherapy time and over 50 per cent of occupational therapy and nursing time were devoted to patients i n the same age group. Other voluntary agencies which may provide services to the e l d e r l y include the Red Cross which supplies on free loan, sickroom equip-ment including h o s p i t a l beds and wheelchairs. The C r i s i s Intervention and Suicide Prevention Centre of Greater Vancouver administers a Telephone Tree for Seniors - a regular c a l l from a senior to a senior to combat lo n e l i n e s s , (Voluntary agencies providing ' s o c i a l ' services w i l l be included i n a l a t e r section though the d i v i s i o n i s a very a r t i f i c i a l one.) 82 3. MENTAL HEALTH I n s t i t u t i o n a l Care-Psychiatric patients under age seventy are admitted to Riverview Ho s p i t a l , and the c h r o n i c a l l y i l l who cannot be d i s -charged remain at Riverview, so that over a quarter of the approximately 1,200 Riverview patients are aged s i x t y - f i v e and over. Organic brain syndrome patients are accepted for care i n a s p e c i a l unit i n which turn-over i s low. In fact as younger people seek help from general h o s p i t a l s and community teams, the Riverview population tends to be older, and to have more physical i n f i r m i t i e s . Valleyview Hospital i s more or l e s s the only p s y c h i a t r i c f a c i l i t y for in-patient treatment of the e l d e r l y i n B r i t i s h Columbia, accommodating about 650 patients at any one time nowadays, a l l aged at l e a s t seventy, and with an average of 75 per cent confused and a r a t i o of two females to one male. Of approximately 4,000 admissions per year, about 5 per cent to 10 per cent are admitted f o r p s y c h i a t r i c treatment, (Few doctors think of t h i s as a p o s s i b i l i t y ) and most are admitted for c u s t o d i a l care because of mental disorders causing behaviour which i s not s o c i a l l y t o l e r a b l e . A pre admission screening programme was started seven to eight years ago, 15 per cent to 25 per cent of people seen are rejected as not req u i r i n g hos-p i t a l i z a t i o n and the s o c i a l worker i s able to make a l t e r n a t i v e arrangement Nor i s admission seen as "terminal d i s p o s a l " . Many patients respond to treatment. Each year discharges are equal to j u s t under half the number o admissions ((Deaths are equal to over h a l f ) , and of the 1974 discharges, thirty-one returned to spouse or pri v a t e care, seventy-two to boarding homes, forty-one to nursing homes, and twenty-seven to extended care. 83 Skeenaview i n Terrace and Dellview i n Vernon, formerly designated as mental health f a c i l i t i e s , are now care f a c i l i t i e s only, under the Department of Human Resources. Skeenaview, for men only, has been operated since 1974 by a l o c a l society, i n an area where i t has proved impossible to develop boarding homes. Many of the approximately two hundred men now at Skeenaview were people without r e l a t i v e s , transferred from Riverview where they had been long-term patients i n s t i t u t i o n a l i z e d and many bedridden. In Terrace emphasis was placed on increasing ambulation so that today a l l patients are ambulatory, wear outdoor clothes and lead comparatively f u l l and a c t i v e l i v e s . However the buildings are apparently o l d , d i l a p i d a t e d army huts which the Board has been t o l d can be replaced provided that i n exchange they reduce physiotherapy, the core of t h e i r ambulatory programme. Dellview, i n Vernon, with about 180 beds occupied mainly by l o c a l people, o f f e r s no ac t i v e treatment, though i t does discharge a few patients to community care. Community Services-B.C. i s divided into eight mental health planning regions each of which includes several school d i s t r i c t s and a l l or part of at least two health u n i t s . There are t h i r t y Mental Health Centres operating i n the Province and nine Community Care teams operating under the Greater Vancouver Mental Health Services project. The Mental Health Centres are intended to provide preventive, treatment and r e h a b i l i t a t i v e services. However, i t i s generally agreed that almost nothing i s done for the e l d e r l y i n these centres. A two to three year survey of mental health centres i n the Lower Mainland showed that l e s s than 1 per cent of t h e i r patients were aged over s i x t y - f i v e . Doctors do not r e f e r and e l d e r l y people are r a r e l y 84 anxious to seek help with mental i l l n e s s . In Greater Vancouver approxi-mately 15 per cent (285) of the caseload of community care teams are aged s i x t y - f i v e and over. This means that these patients are included i n groups i f there are any, not that they are r e c e i v i n g i n d i v i d u a l treatment. The Boarding Home Program was begun i n 1959 and by October 6, 1975, there were 1,866 patients i n three hundred homes i n every region of the Province (Some homes of course have as few as two patients)-discharged patients who s t i l l require some care or r e h a b i l i t a t i o n or have nowhere else to go, and temporary residents who are normally looked a f t e r by r e l a t i v e s . Administration has been shared by the Health Branch and the Department of Human Resources. Homes taking three or more residents must be registered. Exact numbers by age are not a v a i l a b l e but i t appears that a large percentage of people i n the Boarding Home Programme are aged s i x t y -f i v e years and over. 4. SOCIAL SERVICES Department of Human Resources - The Department of Human Resources provides few d i r e c t services and those which are provided are mostly a v a i l -able only to people who are i n r e c e i p t of allowances from the Department. In the case of the e l d e r l y t h i s means people i n r e c e i p t of Mincome allowance. Senior C i t i z e n s Counsellor Service was begun i n 1968 to provide a counselling and information service to senior c i t i z e n s by counsellors who are themselves senior c i t i z e n s . In 1975 there were 160 senior c i t i z e n counsellors i n the Province. They undertake a l l kinds of service from giving advice and f i l l i n g i n forms, to a s s i s t i n g i n the development of 85 a c t i v i t y centres, v i s i t i n g , providing transportation etc. In 1975, 66,750 persons were served. Counsellors may be reimbursed for expenses up to s i x t y d o l l a r s per month. Available to senior c i t i z e n s who are i n re c e i p t of G.I.S. or Mincome are the Courtesy cards which cost f i v e d o l l a r s for si x months and which allow them to t r a v e l f r ee on B.C. Hydro metro services and at reduced rates on suburban services v e h i c l e s on the Lower Mainland. On production of t h e i r pharmacare cards, any senior c i t i z e n may make a t h i r t y - f i v e cent journey for f i f t e e n cents. In l o c a l resource board o f f i c e s , arrangements may be made for e l d e r l y low-income persons to receive homemaking help, counselling, r e f e r r a l to other s o c i a l agencies, help with s p e c i a l medical expenses, etc. The Department subsidizes personal care, intermediate care and priva t e h o s p i t a l care. Requests to the l o c a l Human Resources o f f i c e s for r e f e r r a l of patients to care f a c i l i t i e s are made by r e l a t i v e s , f r i e n d s , doctors, etc. and l o c a l departmental s t a f f are responsible for reviewing each a p p l i c a t i o n and making placement i n the most appropriate f a c i l i t y . The Special Care Adults D i v i s i o n of the Department was created i n May 1974 and i s responsible for personal and intermediate care r e s i d e n t i a l f a c i l i t i e s and community'facilities f o r adults including the e l d e r l y and disabled. The emphasis of the d i v i s i o n i s on fi n d i n g a l t e r n a t i v e s to i n s t i t u t i o n a l care. The Department of Human Resources also makes community grants to senior citizens': centres and projects (to a t o t a l of $415,142 i n 1975). Vancouver now has f i f t e e n Community Resource Board o f f i c e s . The 86 Vancouver Resource Board has agreed that counselling services w i l l be pro-vided for a l l e l d e r l y persons and most o f f i c e s now w i l l provide a service to seniors-but seniors may not know t h i s . In most areas i n Vancouver and the surrounding m u n i c i p a l i t i e s , s p e c i a l i z e d caseloads are developing. Boards decide on the a l l o c a t i o n of Community Grants. The Advisory Committees have a duty i n t e r a l i a to assess needs and p r i o r i t i e s for s o c i a l services i n the l o c a l communities and to encourage i n t e g r a t i o n and co-ordination of services. As well as dealing with GAINS and bus passes, the Services for Seniors Section located at 411 Dunsmuir provides a restaurant and a s o c i a l centre where many old people come, some t r a v e l l i n g quite a distance and some spending t h e i r whole day there f i v e days a week. The Centre i s also seen as somewhere where the e l d e r l y and t h e i r friends or r e l a t i v e s may turn for advice or information and they receive enquiries from out of town as well as from l o c a l people. Voluntary Services-As opposed to the finaneing of services, most of the providing of services to e l d e r l y persons i s done by voluntary organi-zations or by i n d i v i d u a l volunteers. Voluntary services or service may take several forms. There are voluntary bodies which are heavily subsidized by public funds and which provide statutory or at l e a s t necessary or desirable services. There are other voluntary bodies such as SPARC of B.C. which may act as advocates, to measure and create awareness of the needs of groups such as the e l d e r l y and recommend and even press for measures to meet them. Like the V.O.N., the s t a f f of such organizations may be sa l a r i e d p r o f e s s i o n a l s . Some volunteer organizations, such as the Lower Mainland Stroke Association, some 87 clubs for seniors, even transportation services, may be run by unpaid volunteers. Then some i n d i v i d u a l s serve v o l u n t a r i l y - f r o m the members of ho s p i t a l boards (Technically, a h o s p i t a l i s run by a voluntary society) to ' f r i e n d l y v i s i t o r s ' . And some volunteers prefer the more impersonal task of r a i s i n g funds to purchase service or f a c i l i t i e s . (An example of t h i s would be the Intermediate Care and Personal Care F a c i l i t y opened i n Nanaimo on March 1, 1976, a project conceived and financed to a large extent by the l o c a l Kiwanis Club). Women A u x i l i a r i e s i n hospita l s often r a i s e funds f o r s p e c i a l projects i n addition to providing services. Some hos p i t a l s are now employing Directors of Volunteers-a d i f f e r e n t group from the a u x i l i a r i e s . In the community, volunteers work for a v a r i e t y of senior c i t i z e n organizations. F a c i l i t i e s have been developed recently to which seniors may go or be taken f o r s o c i a l i z a t i o n and/or treatment as well as to r e l i e v e family members for short periods. Senior A c t i v i t y or Drop-in Centres, often developed by senior c i t i z e n groups, provide d i v e r s i o n and an oppor-tunity to remain active. Adult Day-Care Centres provide opportunities f o r s o c i a l i z a t i o n , r e h a b i l i t a t i o n or protective care. They provide a change of environment for the e l d e r l y and r e l i e v e pressure on f a m i l i e s . These are found mainly i n the Lower Mainland. Examples are Cross Reach i n Vancouver which provides various r e c r e a t i o n a l a c t i v i t i e s and lunch three days a week to people (twenty-two on average) who l i v e i n t h e i r own homes and who are provided with transportation to the Centre. One day i s set aside for more planned group a c t i v i t i e s offered mainly to people l i v i n g i n homes or pri v a t e h o s p i t a l s , and another f o r v i s i t i n g the home bound. Over 88 the years, Cross Reach has received funding from f e d e r a l , p r o v i n c i a l and municipal governments, United Way and churches. S i l v e r Harbour Manor i n North Vancouver with s i x s t a f f and four hundred volunteers ( a l l seniors) has almost 2,000 members. Confederation House, North Burnaby provides recreation and minor services for old people-to about seventy-two people per day from nursing homes and re s t homes. Edmonds House i n Burnaby has two f u l l time s t a f f , ten part time i n s t r u c t o r s (trained to teach painting, pottery, French, etc.) and over 1,200 members. Forty people use the centre seven days a week, and 150 f i v e days a week. People from rest homes are brought i n once a week. Neighbourhood Services Service Units at Cedar Cottage and Gordon House provide day care, and two more centres are preparing programmes. A l l seven units o f f e r s o c i a l and r e c r e a t i o n a l f a c i l i t i e s and counselling. The Parks Board finances a Day Care Programme started f i v e years ago at the Mount Pleasant Community Centre i n Vancouver, held every Wednesday for r e f e r r e d patients who are discharged from the VGH and Holy Family h o s p i t a l s . Five years ago there was a hope i n the Parks Board of one i n every Community Centre, but t h i s has not mate r i a l i z e d . Other organizations provide other services. The Senior C i t i z e n s ' Service Bureau of New Westminster provides transportation, home v i s i t s with various tasks undertaken, information centre, day-care-drop-in (to allow people who are usually looking a f t e r an el d e r l y person to keep appointments, shop, etc.) and a home help service whereby crews from Woodlands School help with gardening, window-washing, etc. In Surrey, the Community Resource Centre provides information services (35 per cent of the c l i e n t s are the elderly) and transportation to 89 medical f a c i l i t i e s (58 per cent of these services go to the e l d e r l y ) . In West Vancouver, 'Seniors Helping Seniors' i s a group of services organized to help seniors with the help of a New Horizons Grant. Various organizations w i l l do shopping, and several provide transportation. These were often funded by L.I.P. grants, though the P r o v i n c i a l Government i n 1975 a l l o c a t e d community grants amounting to $661,878 to eighteen trans-portation programmes for handicapped senior c i t i z e n s . Individual volunteers may be found i n h o s p i t a l s , i n the Volunteers i n Nursing and Boarding Homes Programme run by Vancouver Ci t y Department of Health or the P r o v i n c i a l programme 'Auxiliary Workers for Public Health Nursing Programmes' (In 1972 volunteers donated 10,930 hours of t h e i r time to the health services and provided 10,494 services to i n d i v i d u a l s . ) . Organizations l i k e the Kinsmen, the Rotarians, the Lions, the Kiwanis, may choose to take on the financing of large scale operations-bowling clubs, housing, [Moore et a l , 1975], Senior C i t i z e n s ' Organizations comprise over twenty groups or s o c i e t i e s . The Federated L e g i s l a t i v e Council of E l d e r l y C i t i z e n s Associa-tions of B.C. i s the umbrella group which has representatives from each organization. The OAP's Organization of B.C. has p r o v i n c i a l membership of approximately 17,500 i n 118 branches and the Senior C i t i z e n s ' Association of B.C. has approximately 10,000 members i n seventy branches throughout B.C. The aim of these associations i s to aid i n the improvement of the q u a l i t y of l i f e of the e l d e r l y . They have s o c i a l and r e c r e a t i o n a l a c t i v i t i e s and also provide a v e h i c l e for senior c i t i z e n s to gain access to government and to make th e i r views and needs known to the p u b l i c . At 90 present, the FLC i s becoming interested i n pre-retirement. They are also concerned about middle-income people. They seem to be able to i d e n t i f y various needs and complaints of e l d e r l y people but there i s not a l o t of evidence that they have achieved many improvements. Leisure and Recreation-Most municipal re c r e a t i o n departments (In Vancouver, the Board of Parks and Recreation) run community centres o f f e r i n g r e c r e a t i o n a l and s o c i a l programmes for seniors. Various colleges and the u n i v e r s i t i e s provide s p e c i a l courses for senior c i t i z e n s or make sp e c i a l f i n a n c i a l concessions to those who take the regular courses. At the s i x week Summer Programme at UBC, no fees are charged to persons over s i x t y - f i v e years of age, free accommodation i s provided on campus for per-sons from out of town, regular undergraduate and s p e c i a l i n t e r e s t courses are available-exams, essays and r e g i s t r a t i o n for c r e d i t are optional. Under the New Horizons programme, groups of ten or more r e t i r e d people who undertake a c t i v i t i e s f o r the benefit of themselves and others i n the community can apply for fe d e r a l grants for eighteen months. Many grants seem to have gone to e x i s t i n g organizations for and of old people rather than to bring out i s o l a t e d old people [Hepworth, 1975, p. 73]. Grants tend to be given as seed money to projects which can l a t e r become s e l f - s u f f i c i e n t . The money i s not a v a i l a b l e f or s a l a r i e s or c a p i t a l con-s t r u c t i o n . To date, since 1972, eighty thousand people have been involved i n eight hundred projects in the Province. In 1975, B.C. received $1.3 m i l l i o n . Age of Options i s a T.V. information programme for seniors broad-cast on Channel 10. O r i g i n a l l y a project of Simon Fraser University, i t 91 i s now p r o d u c e d by s e n i o r s who have o b t a i n e d a New H o r i z o n s g r a n t . F i n a l l y , t h e r e a r e v o l u n t a r y o r g a n i z a t i o n s w h i c h g i v e n e i t h e r f u n d s ( I n d e e d t h e y a r e fund s e e k e r s ) n o r i n d i v i d u a l s e r i v c e s , b u t p r o v i d e an i m p o r t a n t a d v o c a c y r o l e . SPARC o f B . C . w i t h w i d e p r o v i n c i a l r e p r e s e n t a t i o n i n i t s b o a r d membersh ip i s v e r y a c t i v e i n i d e n t i f y i n g t h e needs o f v a r i o u s g r o u p s i n c l u d i n g t h e e l d e r l y , and i n m a k i n g t h e s e needs known t o g o v e r n m e n t . I t a r r a n g e s c o n f e r e n c e s and s e m i n a r s , c o n d u c t s s u r v e y s , p u b l i s h e s r e s u l t s and a d v i s e s and a c t i v a t e s c o m m u n i t i e s and i n d i v i d u a l s t o r e c o g n i z e and p l a n t o s o l v e t h e i r own p r o b l e m s . The V a n c o u v e r A c t i o n R e s o u r c e C e n t r e , a d e p a r t m e n t o f t h e V o l u n t e e r B u r e a u o f G r e a t e r V a n c o u v e r has been o p e r a t i n g unde r a communi ty g r a n t f rom t h e Depa r tmen t o f Human R e s o u r c e s t o p r o v i d e a p r o v i n c e - w i d e c l e a r i n g house o f i n f o r m a t i o n r e l a t e d t o v o l u n t a r y a c t i o n and t o p r o v i d e c o n s u l t a t i o n and t r a i n i n g f o r v o l u n t e e r g r o u p s . 5. INCOME SECURITY The p r e s e n t s i t u a t i o n w i t h r e g a r d t o i ncome s e c u r i t y i s t h a t a l l C a n a d i a n s aged s i x t y - f i v e o r o v e r who meet t h e r e s i d e n c y r e q u i r e m e n t s ( t e n y e a r s i n Canada) a r e e l i g i b l e to r e c e i v e o l d age s e c u r i t y payments o f $137 p e r month ( J u l y 1976) i n d e x e d q u a r t e r l y t o t h e c o s t o f l i v i n g and r e g a r d l e s s o f o t h e r income o r a s s e t s . Spouses aged s i x t y t o s i x t y - f i v e r e c e i v e an income t e s t e d p e n s i o n . The Canada P e n s i o n P l a n p ay s p e n s i o n s t o c o n -t r i b u t o r s and s u r v i v o r s . The f u l l r e t i r e m e n t p e n s i o n i s 25 p e r c e n t o f a c o n t r i b u t o r ' s a v e r a g e d a d j u s t e d p e n s i o n a b l e e a r n i n g s , (The c e i l i n g was $8,300 i n 1976'.) Maximum p e n s i o n was $154.86. A s u r v i v o r r e c e i v e s 60 p e r c e n t o f t h e s p o u s e ' s p e n s i o n (maximum $99.51), T h e r e i s a lump sum d e a t h 92 benefit (maximum $830.00). Contributions are 1.8 per cent of the earnings up to a maximum of $135 per annum by both employer and employee. Income Supplement (maximum ninety-six d o l l a r s per month for a sing l e person, eighty-f i v e d o l l a r s per month for a married person) i s paid to anyone whose income amounts to l e s s than $233 per month ($445 f or a couple). Mincome i s a B.C. programme a v a i l a b l e to people over s i x t y who have resided i n B.C. for at lea s t f i v e years, which brings income up to the minimum of $272.07 per single person ( i . e . net $49.65). Of the 241,000 senior c i t i z e n s i n the Province i n 1975, over 50 per cent had no taxable income. In 1974, when the o v e r - s i x t y - f i v e population numbered 230,000, 97,000 over s i x t y - f i v e (42 per :cent) and 19,000 aged s i x t y to si x t y - f o u r were i n rec e i p t of Mincome. The GAIN programme incorporates an assets t e s t . The government encourages p a r t i c i p a t i o n i n Registered Pension Plans by o f f e r i n g income tax exem-ptions on contributions up to a maximum of $2,500 per year. Deferred tax r e l i e f i s a v a i l a b l e on up to a t o t a l of $4,000 per year (maximum i s 20 per cent of income) for Registered Pension Plans and Registered Retirement Savings Plan contributions. 6. HOUSING At'the time of the 1971 census, of B.C. residents aged s i x t y - f i v e and over, 92 per cent of r u r a l dwellers and 69 per cent of urban dwellers were home-owners (73.1 per cent altogether). I t i s f a i r l y uncommon for persons over the age of s i x t y - f i v e to enter the housing market as buyers and when they do i t i s normally to s e l l one house i n order to buy more manageable accommodation. On the other hand, the e l d e r l y do move as renters into accommodation 93 b u i l t by government, non-profit organizations or of course regular com-mercial developers. Few entrepreneurs b u i l d housing s p e c i a l l y f o r the el d e r l y . In 1973 only 7 per cent of CMHC loan approvals for housing the el d e r l y went to entrepreneurs [Yudelman, 1974, p. 75] and i t i s now a much smaller proportion. As well as self-contained u n i t s , boarding homes, personal care u n i t s and intermediate care units may a l l be e l i g i b l e for government a i d . S-15(l) of the National Housing Act provides funds d i r e c t l y to non-profit organizations and allows up to a 100 per cent low cost loan (8 per cent amortized over f i f t y years) with a 10 per cent forgiveness. CMHC does not impose income l i m i t a t i o n s i n projects spon-sored by non-profit organizations which cater to s p e c i a l disadvantaged groups such as the e l d e r l y whose housing choices i n the market are very l i m i t e d . In B.C. the p r o v i n c i a l government allows grants of 33 per cent for self-contained, 35 per cent for hostel places and f a c i l i t i e s providing s p e c i a l care. The B.C. Housing Department w i l l purchase the s i t e tem-p o r a r i l y , i f necessary. Some non-profit organizations continue to manage developments they have b u i l t ; others hand them over to the B.C. Housing Management Commission. S-40 allows the CMHC to enter into partnership with the Province to d i r e c t l y provide the housing, with a 75 per cent contribution from CMHC, 25 per cent from the Province. Under S-43, the Corporation lends funds to the P r o v i n c i a l housing bodies who d i r e c t the construction of the housing-up to 90 per cent of the c a p i t a l cost of the project. S-40 and S-43 are public housing, normally with rent geared to income so that no e l d e r l y person spends more than 25 per cent of income on rent. CMHC provides 75 per cent of operating d e f i c i t s 94 under S-40 and 50 per cent under S-43, Developments (over 7,000 units) are managed by the B.C. Housing Management Commission who use a point system. Needy applicants with at l e a s t twelve months' residence i n B.C. are given p r i o r i t y and rent i s geared to income. Non-government groups may apply for a grant of up to $10,000 to get a project under way. Loans are a v a i l a b l e to i n d i v i d u a l s to buy mobile homes and f o r home conversions. CMHC may also construct and administer housing on i t s own account. There has been more senior c i t i z e n housing b u i l t i n B.C. r e l a t i v e to the population than i n any other province. Over 19,000 un i t s had been b u i l t with government assistance by the end of 1975. Of those b u i l t since 1957, 9,131 were community sponsored and 3,872 government sponsored. The P r o v i n c i a l grant for the l a s t three years has been about twelve m i l l i o n d o l l a r s ten m i l l i o n d o l l a r s for self-contained u n i t s and two m i l l i o n d o l l a r s for care places. Many m u n i c i p a l i t i e s make s p e c i f i c lands a v a i l a b l e at nominal taxes or on easy purchase terms for non-profit old person housing and they may r e f r a i n from charging property taxes. (Tax exemption was obligatory before 1974.) This can make a d i f f e r e n c e of twenty d o l l a r s to t h i r t y d o l l a r s per suite per month. The Greater Vancouver Housing Department acts as agent for senior government and works with non-profit groups, c i t i z e n groups and municipal housing committees. For e l d e r l y persons, the Department has tended to b u i l d large high-rises which incorporate communal f a c i l i t i e s f o r s o c i a l i -zation and recreation. They have also b u i l t hostel accommodation for e l d e r l y 95 men i n down-town east side Vancouver. By the end of 1975, over 15,000 of the housing u n i t s for seniors were i n the GVRD. The percentage of low-income households served varied from a low of 8.8 per cent i n Delta to a high of 108.4 per cent i n Port Coquitlam. [Bairstow, Mercer, 1976, Table I.] In the regional d i s t r i c t , i t i s estimated that about 27,000 e l d e r l y low-income households are housed i n the p r i v a t e housing market and many experiencing very high housing costs i n r e l a t i o n to t h e i r incomes. [Bairstow, Mercer, 1976, p. 3.] Vancouver has now accepted the " f a i r share" concept f i r s t proposed by the Senior C i t i z e n s Housing L i a i s o n Committee and has set senior c i t i z e n housing targets for l o c a l planning areas which w i l l help to r a t i o n a l i z e funding decisions. I t i s hoped by the developers of the concept that i t may be accepted also by other m u n i c i p a l i t i e s . Other provisions which benefit e l d e r l y renters are the Renters' Tax Credit Programme under which a l l renters over s i x t y - f i v e are e l i g i b l e for a Renters' Tax Credit of eighty d o l l a r s . From 1976, depending on i n -come, t h i s could be up to one hundred d o l l a r s . The grant to resident home-owners i s $250 plus s i x t y d o l l a r s to eighty d o l l a r s school tax removal grant. F i n a l l y , under the Real Property Tax Deferment Act, anyone over s i x t y - f i v e can defer taxes payable to a municipality u n t i l the property i s sold, transferred or l e f t vacant for over ten years. 7. FINANCING The services which we have described are financed by various l e v e l s of government and by voluntary funds. Each regional h o s p i t a l d i s t r i c t i s able to pass money by-laws 96 authorizing debentures to be issued covering the t o t a l cost of one or more h o s p i t a l projects. (This includes general, r e h a b i l i t a t i o n , and extended care hospitals.) The P r o v i n c i a l Government pays i t s share of the amortization costs each year through the Hospital Insurance Service, and each d i s t r i c t r a i s e s the remainder by taxation. Operating costs i n B.C. are met from general p r o v i n c i a l revenues and u t i l i z a t i o n charges. Approximately 50 per cent of agreed costs are reimbursed by the fede r a l government. Local health services are financed by p r o v i n c i a l and municipal governments. The per capita cost;-, of services i s now about ten d o l l a r s per annum. M u n i c i p a l i t i e s contribute t h i r t y cents ( f o r t y cents i f there i s a home care service) per head. In Greater Vancouver, services operated by the Metropolitan Board are funded 100 per cent by the Province. For services provided by l o c a l health departments, funding i s approximately 50 per cent l o c a l and 50 per cent p r o v i n c i a l . In the Ca p i t a l Region, funding i s 70 per cent p r o v i n c i a l and 30 per cent l o c a l . Mincome and payment for care i n nursing homes and private h o s p i t a l s and services provided by the Department of Human Resources to people ' i n need of assistance' are 50 per cent cost-shared by the fede r a l government. Services and allowances provided to persons other than those t e c h n i c a l l y i n need have to be financed e n t i r e l y by the P r o v i n c i a l Government-e.g. Pharma-care. (To be ' i n need' e l d e r l y persons must have assets of no more than $1,500, i f si n g l e , $2,500 for a couple, and income no higher than the O.A.P. + G.I.S.) In the case of home care, nursing i s financed by Health Department } 97 home maker service by the Department of Human Resources. In the bu i l d i n g of housing and homes for the e l d e r l y , CMHC, the Province, regional d i s t r i c t s , m u n i c i p a l i t i e s and private organizations may a l l be contributing funds. CMHC and the P r o v i n c i a l Department of Housing subsidize rents. And the Department of Human Resources pays a l l or part of the fees for nursing homes, intermediate, or personal care for persons who cannot meet the costs themselves. When i t comes to income security, old age sec u r i t y and the G.I.S. are financed through sales, corporation and personal income taxes. The Canada* •-• Pension Plan i s e n t i r e l y self-supporting so far i n that a l l benefits and costs are financed by contributions and i n t e r e s t earned from the investment of funds. In the f i s c a l year 1975-76, the Department of Human Resources spent $106.2 m i l l i o n on Mincome, $20.4 m i l l i o n on Pharmacare, $4.3 m i l l i o n on housekeeper and homemaker services, and $20.8 m i l l i o n on Adult Care. The $8,810,410 contribution to the cost of keeping 2,600 persons per month i n private h o s p i t a l s and $18,417,750 paid towards the upkeep of 13,000 persons per month i n intermediate care presumably includes comfort allowance. Community grants, for which p r i o r i t y i s given to projects which show a heavy demand from the public and high community support and use of volunteers amounted to $8.25 m i l l i o n altogether. Of t h i s , $661,878 was allocated to eighteen projects throughout B.C. to provide transportation for handicapped persons and seniors. Another $415,142 went to senior c i t i z e n centres-nine i n Vancouver, one i n North Vancouver, one on the North Shore, one i n V i c t o r i a and one i n Penticton. The C i t y of Vancouver also 98 dispenses some funds. For example, i t gave a grant-in-aid of $127,000 to the Neighbourhood Services Association for 1977 (for services to a l l age groups). Compared with government funds, voluntary funds form a minor part of financing but may nevertheless provide some very u s e f u l services. An organization j u s t beginning to take an i n t e r e s t i n the needs of the e l d e r l y i s the Vancouver Foundation. The Vancouver Foundation was incorporated i n 1950, by P r o v i n c i a l Statute to provide funds for various c h a r i t a b l e purposes. In 1974, with c a p i t a l funds of $40,000,000 i t ranked among the f i r s t ten Community Foundations i n North America. It administered 106 funds and had committees on C u l t u r a l A c t i v i t i e s , Youth A c t i v i t i e s , Education, Child Welfare, and Medical Research Services. Up t i l l r ecently, none of i t s grants has been s p e c i f i c a l l y for the e l d e r l y , though there were some to CARS, VON etc. However, i n 1976 the Board became aware that the needs of the e l d e r l y were among the most often reported, and that they should develop t h e i r input i n t h i s area; and have fo r example, made $250,000 a v a i l a b l e for development of a care f a c i l i t y f o r the e l d e r l y . Charitable funds are s o l i c i t e d d i r e c t l y by or donated d i r e c t l y to a v a r i e t y of voluntary organizations. Many organizations however, have delegated fund-raising to the United Way. UCS i n 1972 increased t h e i r support f o r Day Care f o r Older Persons, f o r Counselling, including of aged persons, of group work services with seniors, Day care support was increased again i n 1973 and 1974. In 1975, i t a l l o c a t e d $2,739,093 altogether. Of t h i s , $10,000 went to the Adult Day Care Centre on the 99 North Shore (whose t o t a l budgeted revenue was $58,109), $147,500 to the B.C. D i v i s i o n of CARS ( t o t a l revenue-$l,478,315), $290,000 to Neighbour-hood Services Association of Greater Vancouver which has some small pro-grammes for seniors ( t o t a l budget-$462,250), $33,500 to the VON Richmond-Vancouver ( t o t a l budget $277,160) and $24,200 to SPARC of B.C. ( t o t a l budget $205,364). Services for the e l d e r l y do not have high p r i o r i t y for 1977. UCS does not fund a c t i v i t i e s which i t considers to be the r e s p o n s i b i l i t y of government. 8. ADMINISTRATIVE STRUCTURES  Min i s t r y ' Elgure 1 shows the present organization of the Health M i n i s t r y . The programme consultant i n G e r i a t r i c s i s a member of the 'Departmental Planning and Support Services Group'. Regional Hospital D i s t r i c t s The Municipal Act, 1965, provided f o r the establishment of regional d i s t r i c t s i n B.C. and by the end of 1968, twenty-eight regional d i s t r i c t s had been established. Regions administer services, some s t a t u t o r i l y , some on an e l e c t i v e basis, which are considered to be provided more s a t i s f a c t o r i l y at regional rather than municipal l e v e l . Regional Boards are composed of Directors appointed by and from t h e i r elected councils i n the case of i n -corporated m u n i c i p a l i t i e s , and by d i r e c t e l e c t i o n from non-municipal areas. Following the Regional Hospital D i s t r i c t s Act, 1967, these Regional Dis-t r i c t s also became the Regional Hospital D i s t r i c t s , and the Regional Boards, the Regional Hospital D i s t r i c t Boards, who are responsible for regional planning and development of h o s p i t a l projects, and for obtaining the 100 necessary funds. Advisory Committees are also set up under the Regional Hospital D i s t r i c t s Act and each Regional Hospital D i s t r i c t Board decides on the composition of i t s advisory board. Often the vice-chairman of the Regional Board i s chairman of the Regional H o s p i t a l Board. At le a s t 50 per cent of the membership must be non-medical. The vast majority of Canadian hospi t a l s are s t i l l i n theory at least 'voluntary organizations' whose a f f a i r s are conducted and managed by Hospital Boards elected from the h o s p i t a l s o c i e t i e s . Health Units are administered by Union Boards of Health composed of p u b l i c l y elected persons seconded from other bodies such as school boards, member m u n i c i p a l i t i e s and regional d i s t r i c t s . Each Unit has a Medical Health O f f i c e r and may have several a s s i s t a n t d i r e c t o r s as well as a nursing supervisor, health inspectors and sundry other professional and non-professional employees. Outside Vancouver and V i c t o r i a , s t a f f numbers range from fourteen to f i f t y - f o u r . A structure introduced i n 1974 was the Community Human Resource and  Health Centre. This mechanism for providing health and s o c i a l services together was advocated i n the Foulkes Report but the idea was not received with much enthusiasm, e s p e c i a l l y by the medical profession, and the Govern-ment did not press i t , but did set up a Community Human Resources and Health Centre Development Group to help with the development of centres where there was l o c a l demand. A CHRHC as envisioned by the P r o v i n c i a l Government was "an organization for the provision of l o c a l l y planned, co n t r o l l e d and operated health and s o c i a l services programmes functioning within p r o v i n c i a l standards". [ Development Group, 1974, p. 2.] The 101 organization would operate out of one or more f a c i l i t i e s but would have a 'one door' approach to the provision of services so that unnecessary r e f e r r a l s between agencies could be reduced and a r t i f i c i a l b a r r i e r s between services eliminated. PRESENT SITUATION - REVIEW 1. HEALTH SERVICES E l d e r l y persons i n Canada, and B.C. have the same entitlement to health services as persons of any other age, and as far as acute medical care i s concerned, i f measured by the conventionally accepted health i n d i c a t o r s , the care received i n B.C. compares favourably with other Canadian provinces and with other countries. For a s t a r t , the l i f e expectancy at b i r t h for males i n B.C. i s 69.3, which i s the same as the Canadian average and makes B.C. rate the fourth i n Canada. For females i t i s 76.7, marginally above the Canadian average and s i x t h i n Canada. [Romeder, McWhinnie, 1974.] B.C. had s i x h o s p i t a l beds per 1,000 i n 1974 when the Canadian 4 average was 5.3. In 1973 i t had 5.1 short term beds (the Canadian average was 5.4) and 1.7 long term beds per 1,000 (the Canadian average was 1.4). It had more ' r e h a b i l i t a t i o n , readaptation, convalescent' beds than any other province except Quebec-i.e. 701 out of a Canadian t o t a l of 2,712. In 1971, the average number of days of h o s p i t a l i z a t i o n per person was 1.9 i n Canada, 1.8 i n B.C. For persons aged over s i x t y - f i v e , i t was 8.3 in Canada, 6.7 in B.C. And the charge of four d o l l a r s per day should not cause great hardship. 102 It can be seen from Table I, (1975), that average days of stay, and patient separation and length of stay rates a l l increase markedly i n the older age groups. This i s also true of a l l the regional d i s t r i c t s i n B.C. except seven where the rates of h o s p i t a l cases are higher under 1 year and one (Stikine) where two other age groups had longer average length of stay. According to the mental health s t a t i s t i c s , B.C. at 2.6 per 1,000, has the t h i r d highest rate of mental h o s p i t a l beds i n Canada, and the rate of mental h o s p i t a l f i r s t admissions, 877 per 100,000 of population aged s i x t y and over, was also the t h i r d highest i n Canada. However, there i s also now a reasonably high discharge rate, and S o c i a l Workers can arrange a l t e r n a t i v e s to admission. In 1970, B.C. had 18.9 hostel places approved, per 1,000 population over 65. The Canadian average was 14.9 [Yudelman, 1974]. Since at l e a s t 1968, B.C. has c o n s i s t e n t l y had the lowest r a t i o of population to a c t i v e physicians being 533:1 i n 1975 [Division of Health Services Research and Development, 1976] and the per capita costs of i n -sured services $71.59) was the highest i n Canada i n 1975 when the Canadian average was $65.i-14. It i s d i f f i c u l t to obtain data i n Canada on u t i l i z a t i o n of medical services by age, and figures are not a v a i l a b l e for B.C. In 1961, (before the introduction of Medicare) 17 per cent of physicians' services were delivered to patients s i x t y - f i v e and over. (Kohn 1965 p. 301.] Figures from Ontario [Clute 1963] Quebec [Clark, Collishaw, 1975 p. 19] and g Saskatchewan show that persons aged s i x t y - f i v e and over consume medical 103 services, home v i s i t s by doctors, h o s p i t a l v i s i t s by family doctors and other services such as c h i r o p r a c t i c , at a rate which i s considerably above that of persons aged under s i x t y - f i v e . (Of course they also had the high-est rate of d i s a b l i n g and non-disabling i l l n e s s i n 1951, when t h i s was l a s t assessed.)^ We do know that i n 1974, the e l d e r l y , accounting for l e s s than 10 per cent of the population, received 22 per cent of a l l p r e s c r i p t i o n s and accounted for 28 per cent of a l l drug expenditures. In 1975, B.C. had above the Canadian average rate per population of d i e t i t i a n s , chiropractors, O.T.s and p o d i a t r i s t s . Of sixteen types of health personnel studied for R o l l c a l l ( D i v i s i o n of Health Services Research and Development, 1976), a l l increased i n metropolitan areas between 1974 and 1975, except for food supervisors, and i n non-metropolitan areas, ex-cept for p u b l i c health inspectors and dental laboratory technicians. Apart from p o d i a t r i s t s , O.T.s and d i e t i t i a n s , health care personnel were f a i r l y w e ll dispersed throughout the Province, though taking twenty-five types of health personnel, S t i k i n g was "underdeveloped" f o r twenty-one, Ocean F a l l s for eighteen, and Mount Waddington for sixteen. In the nursing care programme i n 1973 (excluding s p e c i a l home care projects) patients aged s i x t y - f i v e and over received 65.9 per cent of v i s i t s . They made up 31.4 per cent of patients discharged from s p e c i a l home care programmes i n the Province. They received 58 per cent of the homemaker services subsidized by the Department of Human Resources. They were more or less the only r e c i p i e n t s of meals-on-wheels. And at CARS, they received 60 per cent of physiotherapy time and 50 per cent of O.T. 104 time. However, such s t a t i s t i c s say l i t t l e about the q u a l i t y and appro-priateness of care and most are measures of input rather than output. There are many ways i n which the acute h o s p i t a l with i t s rapid tempo and emphasis on recovery and cure does not s u i t the slower pace of the e l d e r l y and t h e i r tendency to suff e r from chronic and long-term i l l -nesses. There i s l i t t l e p r o v i s i o n f or a c t i v a t i o n ; some hos p i t a l s don't have O.T.s or speech therapists on s t a f f ; so that some e l d e r l y persons obliged to occupy an acute bed for several months while waiting for a l t e r -native accommodation, may a c t u a l l y deteriorate. Convalescent areas are not favoured i n B.C. even though h o s p i t a l s t a f f tend to believe that many older people who take longer than young people to recover from an opera-t i o n , could benefit from a convalescent period to 'catch, t h e i r wind'. A few personal care homes provide convalescent care for as l i t t l e as t h i r t e e n d o l l a r s a day, but the Government w i l l not pay for private hos-p i t a l care i f the person's home (an asset) i s temporarily empty. It i s generally believed that many more e l d e r l y patients could benefit from r e h a b i l i t a t i o n i f i t were a v a i l a b l e . (The Royal Commission on Health Services recommended 0.5 beds per 1,000 population.) Even for Holy Family Hospital which o f f e r s a well thought-out programme, there i s nevertheless a four to eight week waiting time during which the older person occupies an acute bed or waits at home-in both cases probably without a c t i v a t i o n . Whilst the Province may now have the 'recommended' number of extended care beds (though how does one judge t h i s i f waiting time for 105 some ho s p i t a l s can s t i l l be over a year?) acute h o s p i t a l beds may s t i l l be occupied for many months by patients on the waiting l i s t s with the a l t e r n a t i v e being a private h o s p i t a l bed. People who are i n t h e i r own homes while waiting for admission are not v i s i t e d t i l l t h e i r names come to the top of the l i s t , which i n West End Vancouver may be eighteen months, and i t may be only at t h i s point that they learn that for some reason they are i n e l i g i b l e . Few extended care h o s p i t a l s , i f any, have the recommended quota of one therapist for every seventy-five patients and patients do not seem to be expected to improve to a point where they could perhaps be d i s -charged. The c r i t e r i a for admission are so stringent as to exclude some persons who may need nursing care only so that there i s a group, f a l l i n g between extended and intermediate care, which i s not r e a l l y provided f o r -that i s , i f one i s to continue to a l l o c a t e people to the d i f f e r e n t l e v e l s e n t i r e l y according to t h e i r medical status as the current c l a s s i f i c a t i o n d i c t a t e s . Provision of intermediate care i s also generally considered i n -adequate. And there are few examples of m u l t i - l e v e l f a c i l i t i e s though these seem to be appreciated by the e l d e r l y . There are marked anomalies between the charge to the patient of d i f f e r e n t l e v e l s of care-from four d o l l a r s per day i n the acute and ex-tended care h o s p i t a l to ten d o l l a r s per day i n intermediate care, up to $600 per month i n a personal care home and $900 i n a p r i v a t e nursing home. And f a c i l i t i e s are unevenly d i s t r i b u t e d . Four Regional d i s t r i c t s for example-Sunshine Coast, Mount Waddington, Ocean F a l l s , K i t i m a t - S t i k i n e have no community care f a c i l i t i e s at a l l , and 3 more have only one f a c i l i t y , Surrey i s said to be low i n p r i v a t e h o s p i t a l and extended care beds but 106 well provided with intermediate l e v e l care with plenty of good l o c a l guest houses and r e s t homes, and good community f a c i l i t i e s f o r old people. In Whiterock, there i s no: private nursing home so that anyone admitted to a nursing home may be separated from a spouse i n an area where transportation i s a problem also. Although the average length of stay i n the f a c i l i t i e s which do exist i n B.C., i s s i x months, many lack any arrangements for therapy, recreation, or volunteer a c t i v i t y . L i c e n -sing standards r e f e r only to physical requirements and there i a no r e a l way of supervising the q u a l i t y of care in these i n s t i t u t i o n s . Foulkes [1973 Tome V p. 116] r e f e r s to a survey of private h o s p i t a l s i n B.C. c a r r i e d out by BCHIS which showed that "the standards of administration, bVdsii'H'e records, etc. are very much lower than those encountered i n the general h o s p i t a l s of the province". A study done i n Kelowna found that 63.3 per cent of patients i n p r i v a t e h o s p i t a l s and boarding homes had no hobbies-not even reading, and 25 per cent did not in t e r a c t with any other residents. I t was questioned i f the high use of medications meant that psychotropic drugs were taking the place of occupational and diversionary therapy. (Kelowna Medical Society and South Okanagan Union Board of Health 1973.) It i s not only the privately-owned i n s t i t u t i o n s which are low i n provision for recreation. Dogwood Lodge (152 residents) has one OT and a Recreational Director, no a c t i v i t y aides (Government funding was refused) and eight attendants, part of whose time i s spent on ' a c t i v i t y ' . At Burnaby there i s no O.T. or Recreational Therapist. Staff of several acute h o s p i t a l s complain about d i f f i c u l t y i n 107 'placing' p s y c h i a t r i c patients aged between s i x t y - f i v e and seventy, par-t i c u l a r l y i f they are s u f f e r i n g from organic brain syndrome of symptoms r e s u l t i n g from alcoholism or other long term conditions. Very l i t t l e of the mental health services provided i n the community go to the e l d e r l y . In f a c t very few community health services of any kind are a v a i l -able to the e l d e r l y - c l i n i c s , outpatient treatment, etc. Even when services e x i s t , they may not be a v a i l a b l e or accessible i n c e r t a i n places or at c e r t a i n times. In Vancouver i n 1969 for example, 45.6 per cent of Vancouver physicians were i n Fairview and 18.4 per cent i n the Central Business D i s t r i c t [Morgan, Mansfield, 1969]. Probably the community service which i s most lacking and which could make one of the biggest contributions to allowing the e l d e r l y to gain access to services and to function more independently, i s s u i t a b l e transportation. Items l i k e eye glasses, dentures, a r t i f i c i a l limbs, braces, etc. a l l have to be paid for by e l d e r l y persons unless they are i n r e c e i p t of Mincome. The structure and financing of the health care system i s not con-ducive to preventive care. If i t i s practised anywhere i t i s i n health units-yet i n 1974 there were only seventeen physicians and 377 nurses em-ployed i n health units i n B.C. When nurses have been employed f u l l time,or part time i n Senior c i t i z e n s housing developments, they are kept f u l l y em-ployed and also d i v e r t some people from doctors and h o s p i t a l s but there are few such p o s i t i o n s i n the Province. Whilst we noted an above average supply of physicians i n B.C. (and t h i s i s true even of Medical Health O f f i c e r s ) the Province has a below average supply of physiotherapists (almost half the national average), 108 L.P.N.s and R.N.s-all personnel who are important i n caring for the e l d e r l y . There i s almost a complete absence of g e r i a t r i c i a n s and psycho-geriatricians 2 . SOCIAL SERVICES There are almost no personal.' s o c i a l services provided by government for the e l d e r l y , except to those who t e c h n i c a l l y q u a l i f y as being ' i n need'. Self-help voluntary organizations for the e l d e r l y tend to be more l i k e clubs Their funds are derived from membership fees and not from public support on the whole. As clubs, o f f e r i n g s o c i a l and r e c r e a t i o n a l a c t i v i t i e s , they ob-v i o u s l y perform a valuable function for people who enjoy t h i s sort of i n -volvement (a minority of the e l d e r l y , that i s ) . The Federated L e g i s l a t i v e Council i n B.C. has obtained a few concessions for the e l d e r l y , e.g. agreement for people to go d i r e c t l y to a denturist instead of a d e n t i s t , an arrangement with a V i c t o r i a hearing-aid supplier for modestly priced aids. They may point out arrangements which are unsuitable for the e l d e r l y , e.g. the locati o n s of some senior c i t i z e n housing-but t h i s i s reaction to f a i t s accomplis. They do not seem to be consulted at the planning stage of ser-v i c e s . Also, though they have access to the p r o v i n c i a l government, and as a member of the National Pensioners' Association of Canada, can have the ear of Marc Lalonde once a year, t h i s smacks of tokenism. There i s no evidence that these pensioners' organizations achieve changes i n l e g i s l a t i o n or p o l i c y and i n fact they themselves seem to consider i t an achievement j u s t t receive an audience. In other words, they do not seem to have any r e a l power as p o l i t i c a l pressure groups, Unlike th e i r counterparts i n the U.S. they are quite unmilitant. In f a c t , the FLC prefers to maintain an a^ -109 p o l i t i c a l stance. Though strong i n number of votes, they f e e l that they have "no way of demanding".''"''" Some e l d e r l y people, and often t h i s means the white c o l l a r types who hold executive o f f i c e i n these organizations, are very hard on t h e i r contemporaries. And of course that generation tends to be very much i n favour of independence; so they may not always be the most convinced advocates of improved treatment of the e l d e r l y . Most voluntary organizations concerned with the e l d e r l y i n B.C. are providers of service or of funds for obtaining service. Organizations l i k e the Kinsmen, Rotarians, etc. are at the mercy of c h a r i t a b l e giving but on the other hand, as they have no fixed commitments, can t a i l o r t h e i r a c t i -v i t i e s to f i t t h e i r resources. Organizations which have programmes, from CARS to a four-person transportation organization are much more i n need of a guarantee of regular funding; yet they don't have t h i s , either with regard to c h a r i t a b l e giving or even i n the form of government grants which have to be applied for anew every year. 3. INCOME In both 1961 and 1971 B.C. a f t e r Ontario had the lowest population of poor e l d e r l y i n Canada. [Bairstow, 1973 pp. 61 and 78.] But the number of e l d e r l y with annual incomes below $2,000 has scarcely changed i n Vancouver, V i c t o r i a and New Westminster between 1961 and 1971 (about 50,000 i n both years) although $2,000 was worth much l e s s i n 1971, and was well below the u n o f f i c i a l S t a t i s t i c s Canada low-income cut-off i n both years. In 1973, 51 per cent of the r e t i r e d i n B.C. were e l i g i b l e for Guaranteed Income Supplement. (In other words, they had no income other than the old age pension.) The present GAINS allowance does bring people 110 above the poverty l i n e . The maximum sum to which a sin g l e e l d e r l y person i s e n t i t l e d i s now $272.07 per month. However, i t i s s t i l l only enough for basic needs-and indeed, a single person would f i n d i t hard to pay an unsubsidized rent out of GAINS. Rent increases (even at or below the statutory maximum of 10.6 per cent) are the most common cause f o r which e l d e r l y persons appeal to the B.C. rentalsman. Increased prices generally are the main source of the complaints brought by the e l d e r l y to the fe d e r a l Department of Consumer and Corporate A f f a i r s . A 1975 study showed that when Mincome was $243, the average single e l d e r l y homeowner spent $236 per month on housing, food and u t i l i t i e s and o v e r a l l expenditure was 119.9 per cent of income; sin g l e renters spent 99.5 per cent of income. Couples did better because they shared the rent. [Bairstow 1976.] (Pensions are at l e a s t indexed to the cost of l i v i n g . Private pension plans do not carry t h i s guarantee.) Of the people surveyed for the report Housing Needs and Expenditure Patterns of the Low-income E l d e r l y i n B.C., 1976; 45 per cent were not s a t i s f i e d with t h e i r monthly income. The most repeated f i g u r e for desired monthly income seemed to be $600 for a couple and at l e a s t $300 for a sin g l e person ($350 i n the Okanagan and Northern B.C.). (Bairstow 1976) 4. HOUSING Costs seem to be the main problem a c t u a l l y with regard to the housing of the e l d e r l y . 77 per cent of persons on the B.C. Housing Manage-ment Commission's waiting l i s t are on the l i s t because t h e i r present housing costs are too high i n r e l a t i o n to income ( i . e . over 25 per cent to I l l 30 per cent of income). The average homeowner couple i n 1975 were spen-ding $172 (35 per cent of combined income) on shelter ( p r i n c i p l e , i n t e r e s t , taxes and r e p a i r s ) , the average single person spent $115 (45 per cent). For renters the proportion of income spent thus was 25.7 per cent for couples, and 38.6 per cent for single persons [Bairstow, 1976]. 87 per cent of the respondents i n the Bairstow study were s a t i s f i e d with t h e i r housing; many of the d i s s a t i s f i e d were i n accommodation that was too large. Many of the homeowners who were l i v i n g alone were on a waiting l i s t for senior c i t i z e n housing i n smaller u n i t s because they could not afford to keep up t h e i r own homes. (The importance of finance should not be allowed to obscure the fa c t that e l d e r l y persons of a l l income groups require con- venient accommodation). About 25 per cent of persons appealing to the Rent Review Commission are aged s i x t y - f i v e and over and most of them are com-pla i n i n g about rent increases below the permitted maximum of 10.6 per cent because they say that t h e i r pensions j u s t won't cover them. Compared with other provinces, B.C. has a good record i n the pro-v i s i o n of housing.for"the e l d e r l y {forty dwelling"units per 1,000 over s i x t y -f i v e i n 1973) but the public housing i s a l l i n metropolitan areas and the t o t a l p r ovision f a l l s f ar short of the demand. In f a c t , there i s l i t t l e evidence that housing i s a high p r i o r i t y with the B.C. government. In 1975, the P r o v i n c i a l budget for s p e c i a l care senior housing was so low that i n the whole of B.C. only two 125-bed projects i n the north were funded. Also, seniors are competing with low-income f a m i l i e s for grant money. There are over 20,000 un i t s f or seniors i n B.C. now, Over 100,000 renters i n B.C. are over s i x t y ; 60,000 of these are poor. There are another 37,000 'poor' 112 homeowners [Bairstow, 1976]. But there i s no p o l i c y as to the percentage for whom the government should attempt to build-complete uncertainty as to what the target should be. To date, funding to non-profit groups has been reac t i v e so that complexes have been b u i l t without regard to l o c a t i o n . I t i s thought for example that the Burnaby community may now be oversupplied by 1,000 places. Applications for funds from non-profit s o c i e t i e s far exceed government budgets but to date i t i s d i f f i c u l t to f i n d any r a t i o n a l e i n the way i n which decisions were made. One e f f o r t at r a t i o n a l i z a t i o n i n the Province has been thee Senior C i t i z e n s ' Housing L i a i s o n Committee organized by the Centre for Continuing Education at UBC and the CMHC. The group which consisted of i n d i v i d u a l s representative of d i f f e r e n t l e v e l s of government concerned with housing for older people, and other interested c i t i z e n s , undertook a project 'Housing for Older People", has produced an "Information K i t " for people wishing to sponsor a project, and i s now working with the administrators of non-profit care f a c i l i t i e s who are forming an organization. They recently developed the ' f a i r shares' concept for housing-a means for c a l c u l a t i n g and comparing the need for senior c i t i z e n housing i n various m u n i c i p a l i t i e s and they are hoping that housing a u t h o r i t i e s w i l l implement the concept. Recent r e -organizational changes i n the CMHC, giving more r e s p o n s i b i l i t y and resources to f i e l d o f f i c e s , may mean that they are better able to i d e n t i f y and respond to the needs of l o c a l areas. At both federal and p r o v i n c i a l l e v e l s there i s a lack of any comprehensive planning system for senior c i t i z e n s ' accommodation which provides a range of d i f f e r e n t accommodation types and care l e v e l s to meet 113 varying needs and to allow for some sort of choice. No one i n c i d e n t a l l y has to date set up an o f f i c e or a network of o f f i c e s where i n d i v i d u a l s seeking a change of accommodation may go for information, counselling and/or r e f e r r a l . Summarizing the workshop discussions at the conference of 'Quality of L i v i n g i n Housing f o r the E l d e r l y ' sponsored by SPARC of B.C. and the Canadian Council on Soci a l Development on October 4, 5, 1974, J e f f r e y Paterson, Director of the Housing Programme at the CCSD concluded [SPARC, 1974] that the housing of the e l d e r l y was the r e s p o n s i b i l i t y of the pro-v i n c i a l government which "should prepare comprehensive plans for the accommodation and care of th e i r senior c i t i z e n s which embrace a range of housing options i n a continuum of supportive s e r v i c e s , - t h i s to be donee' in co-operation with the CMHC and DNH&W, p r o v i n c i a l departments of health and s o c i a l services, municipal a f f a i r s , labour, c i t i z e n s h i p , housing corporations and municipal governments, public and voluntary health and s o c i a l s e curity and recr e a t i o n agencies and c i t i z e n groups of a l l types'. When considering housing for the e l d e r l y i n Vancouver one should probably give separate a t t e n t i o n to the Skid Row area. A study of the area i n 1965 by the Ci t y of Vancouver Planning Department found that there were about 1,500 men over the age of s i x t y - f i v e l i v i n g there, some of whom were sic k and disabled. There were already several missions and hostels under voluntary auspices i n the area. Since then, the C i t y has b u i l t two hostels-Strathcona Lodge and Antoinette Lodge, and a t h i r d i s planned. However, i t appears that many people are s t i l l l i v i n g i n hotels and rooming houses which do not meet c i t y by-law standards and are l i a b l e to be closed 114 but which are not e l i g i b l e for improvement grants or loans because the owners are not non-profit corporations. At present neither the quantity nor the nature of housing offered seems to match the demand. Waiting l i s t s have already been mentioned. With regard to the type of service provided, i t was found that i n B.C. i n 1972 only 4 per cent of a l l projects had nurses on s t a f f (19 per cent i n Canada). [Audain, 1973.] Few residences provide any sort of health ser-v i c e s though doctors and nurses may come i n . Many projects are b u i l t f a r from community f a c i l i t i e s and services-wherever land i s a v a i l a b l e or i s cheap. Some m u n i c i p a l i t i e s discourage b u i l d i n g of housing for seniors because concentrations of e l d e r l y people lead to increased costs for s o c i a l and health services. There may be a complete lack of s o c i a l f a c i l i t i e s . Managers and sponsors do not usually see the s o c i a l well-being of residents as t h e i r concern, e s p e c i a l l y i n developments o f f e r i n g self-contained accommodation, and i t i s stated [Audain, 19731 that i n a t y p i c a l development about 20 per cent of the residents are s t i l l leading i s o l a t e d l i v e s and f e e l i n g lonely. Only 14 per cent of occupants of self-contained housing receive f r i e n d l y v i s i t o r v i s i t s . Several studies have i n fac t come to the conclusion that housing d i s s a t i s f a c t i o n i s p r i m a r i l y a manifestation of an income problem [Bairstow, 1974, 1976; Rosow 1967] and that s p e c i a l housing i s not necessary, Many e l d e r l y persons would prefer government subsidy of rent i n private accommodation over government-built apartments [Yudelman 1974]. No province i n Canada has a f u l l y fledged ' i n s i t u ' rent supplement scheme. It i s considered to be administratively complicated and to end up by 115 b e n e f i t t i n g landlords. B.C. i s the only province with a rent c o n t r o l programme operating. So far no study appears to have been ca r r i e d out of the cost d i f f e r e n t i a l s between d i f f e r e n t types of accommodation and s o c i a l f a c i l i t y and service arrangements. Bairstow compared the economics for B.C. of government bui l d i n g and shelter allowances. To b u i l d 1,750 senior c i t i z e n units i n B.C. would cost federal and p r o v i n c i a l governments approximately f o r t y m i l l i o n d o l l a r s . If the average subsidy were to be $150 per unit per month, another $2.6 m i l l i o n would be required. To b u i l d units for everyone on the present waiting l i s t whose rents are too high, would costinver $100 m i l l i o n (which might be better spent on m u l t i - l e v e l f a c i l i t i e s ) . Whereas i f one took the e l d e r l y single persons with monthly accommodation costs of n i n e t y - f i v e d o l l a r s and sub-sidized them by the extent that that i s i n excess of 25 per cent of t h e i r income, i t would cost $420 per person per annum, at most $1.9 m i l l i o n for everyone on the waiting l i s t whose rents are too high. This sort of s o l u t i o n i s not one that to date had been considered by government at any l e v e l , u n t i l the B.C. announcement i n March 1977. (See page 260). 5. PERSONNEL In s p i t e of the large amount of health resources now devoted to the e l d e r l y medical personnel may not be e s p e c i a l l y interested i n caring for the e l d e r l y or be f i t t e d to do so. Physicians appear to be more interested i n l i f e preservation than i n promotion of health or q u a l i t y of l i f e , Of Canadian medical school graduates between 1959 and 1967, only 30 per cent were i n general p r a c t i c e providing primary medical care by 1972, i G r e e n h i l l 116 1972.] In a study of 86 general p r a c t i t i o n e r s i n Ontario and Nova Scotia i n the early 60s, i t was found that only one out of eighty-six said that g e r i a t r i c s was of s p e c i a l i n t e r e s t . [Clufie 1963.] I t i s s i g n i f i c a n t that despite the f i n a n c i a l advantage under the fee for service system, of seeing several patients i n the same l o c a t i o n , i t i s s t i l l said to be d i f f i c u l t to get doctors to v i s i t t h e i r patients i n the extended care h o s p i t a l s . BCMA has no section of g e r i a t r i c s among i t s twenty-two sections, nor a g e r i a t r i c committee among i t s sixteen Health Planning Council Com-mittees and has c a r r i e d out no studies of the e l d e r l y though the Committee on Chronic Care and R e h a b i l i t a t i o n would of course include some provisions for some e l d e r l y i n i t s f i e l d of i n t e r e s t . Nurses also seem to see t h e i r work as contributing to the cure or management of acute disease. One writer believes that the nursing function has become so t e c h n i c a l and impersonal that the nurse i n extended care observes psycho-social care as a non-nursing function, resents the involve-ment and busies herself with mechanical duties because she lacks confidence and knowledge i n a people-oriented environment. [Mclver, 1973.] In 1966, a l l public health nurses i n the G.V.A* were given the opportunity to attend i n - s e r v i c e t r a i n i n g on the aging. Apparently i t i s nurses i n t h e i r t h i r t i e s and f o r t i e s who are the most w i l l i n g to work with the e l d e r l y . Younger ones are' more l i k e l y to wish to work with young people. Those who are approaching retirement themselves may already be caring f or e l d e r l y r e l a t i v e s at home, and also prefer not to be faced with a s i t u a t i o n which they may soon be i n themselves. There i s no actual shortage of doctors or nurses. When i t comes to * Greater Vancouver Area 117 therapists who do see a r o l e for themselves i n the care of the e l d e r l y and are p a r t i c u l a r l y valuable i n r e h a b i l i t a t i o n , or maintenance of persons i n -dependently i n the community there i s a r e a l dearth. Even of those who are employed i n the Province, 40 per cent are trained outside Canada. At any one time there are about t h i r t y vacancies advertised i n the Province-not to mention the posts there would be i f the optimal amount of therapy were to be a v a i l a b l e i n the community and i n i n s t i t u t i o n s . UBC has an intake of f o r t y students per year for the four year combined O.T.-P.T. course, and cannot obtain permission to increase t h i s number. With Soc i a l Workers there i s a d i f f e r e n t sort of problem. Soc i a l Workers i n hos p i t a l s take i t for granted that more than half t h e i r time w i l l be spent on making discharge arrangements for the e l d e r l y . Department of Human Resources S o c i a l Workers i n the community are used to e l d e r l y persons i n t h e i r case load and may see them as more 'deserving' than other cate-gories of persons who receive b e n e f i t s . However, s o c i a l workers too have an i n d i v i d u a l i z e d 'pick up the b i t s ' approach. In a study of a l l 1971 and 1972 graduates of Canadian Schools of So c i a l Work, Community College S o c i a l Services Courses and CEGEPS, i t was found that more than 91 per cent were p r a c t i s i n g i n the area of casework or groupwork whereas only 5 per cent were p r a c t i s i n g i n planning, p o l i c y and administrative r o l e s only. The. writer noted that "the commitment of s o c i a l services education , , . con-tinues to be overwhelmingly i n the d i r e c t i o n of remedial and s u b s t i t u t i v e s o c i a l services rather than toward s o c i a l a ction and s o c i a l p rovision', [Crane, 1974.] Yet s o c i a l workers could be among those people who point to and help to implement a new o r i e n t a t i o n for the care of the aged. 118 Teamwork and i n t e r c h a n g e a b i l i t y o f p e r s o n n e l a r e o f t e n m e n t i o n e d a s n e c e s s a r y e l e m e n t s o f any s y s t e m o f h e a l t h c a r e f o r t h e e l d e r l y . N u r s e s a r e w e l l aware o f how much more r e s p o n s i b i l i t y t h e y c o u l d be t a k i n g -and a r e t a k i n g i n t h e n o r t h f o r e x a m p l e , where t h e r e a r e n ' t d o c t o r s . B u t as n u r s e s a r e r e g i s t e r e d , n o t l i c e n s e d , and as t h e f e d e r a l government c o s t -s h a r e s t h e c o s t o f c a r e by a p h y s i c i a n o n l y , i t i s d i f f i c u l t u n d e r t h e p r e -s e n t s y s t e m t o a l l o w n u r s e s t o become i n v o l v e d i n d i a g n o s i s and t r e a t m e n t as n u r s e p r a c t i t i o n e r s . The d i r e c t o r o f R e h a b i l i t a t i o n M e d i c i n e a t UBC c o n s i d e r s t h a t w i t h t h e s o r t o f t r a i n i n g t h e y r e c e i v e nowadays , t h e r a p i s t s and s o c i a l w o r k e r s employed i n t h e commun i ty , c o u l d a l s o be p r i m a r y d i a g -n o s t i c i a n s i n t h e c a r e o f t h e e l d e r l y . D o c t o r s do n o t t a k e e a s i l y t o t h e i d e a o f teamwork e i t h e r ( v i d e t h e h o s t i l e r e a c t i o n t o t h e H a s t i n g s R e p o r t ) . T h i s m i g h t r e q u i r e a l e s s h i e r a r c h i c a l v i e w o f h e a l t h p r o f e s s i o n a l s . I n f a c t t h e s t a t u s o f c a r e o f t h e e l d e r l y may n o t i m p r o v e u n t i l t h e h i e r a r c h i c a l v i e w o f ' l e v e l s ' o f c a r e changes a l s o . The e l d e r l y c a n n o t be b e s t s e r v e d e i t h e r where t h e r e i s r i g i d a d h e r e n c e t o f u n c t i o n , o r r i g i d demand f o r f o r m a l q u a l i f i c a t i o n s f o r j o b s w h i c h do n o t r e a l l y r e q u i r e them. E d u c a t i o n - T h e o r i e n t a t i o n o f h e a l t h p r o f e s s i o n a l s i s no doub t h e a v i l y i n f l u e n c e d by t h e i r e d u c a t i o n . M e d i c a l e d u c a t i o n f o r example t e n d s t o em-p h a s i z e d e t a i l s o f u n u s u a l d i s e a s e s b u t make no m e n t i o n o f t h e s o c i a l s y s t e m . I t i s g e n e r a l l y b e l i e v e d t h a t e d u c a t i o n w o u l d a l s o b r i n g abou t more u n d e r s t a n d i n g o f t h e e l d e r l y and t h e i r n e e d s , and t h e r e f o r e more i n t e r e s t i n w o r k i n g w i t h them. A t p r e s e n t i n B . C . t h e r e i s l i t t l e on t h e e l d e r l y i n t h e u n d e r g r a d u a t e m e d i c a l c o u r s e , s e n i o r r e s i d e n t s i n t h e f a m i l y p r a c t i c e p r o g r a m m e p s p e n d r o n e u m o h t h : . : i n 7 a g e r i a t r i c s r e s i d e n c y a t S h a u g h n e s s y , 119 nurses are considered to obtain experience of g e r i a t r i c care i n various c l i n i c a l s e t t ings, s o c i a l workers have education s p e c i f i c to g e r i a t r i c s / gerontology i n t h e i r Human Behaviour and S o c i a l Environment sequence. People who are concerned about the care of the e l d e r l y consider that the g e r i a t r i c s component i n the education of a l l health and s o c i a l care person-n e l could p r o f i t a b l y be increased. This would undoubtedly bring better understanding of the e l d e r l y . And people who are to work mainly i n the community would also need t r a i n i n g for that medium. Whether personal attitudes to aging and the aged can be changed by education i s , i n the opinion of the writer, a moot point, or at best one that has s t i l l to be demonstrated. The formal education sustem may have l i t t l e e f f e c t against the attitudes which pervade the whole of society. 6. LACK OF CO-ORDINATION, PLANNING In the health f i e l d there i s no body with the r e s p o n s i b i l i t y for looking at a l l l e v e l s of care, including home care, together, and deciding which one i s most appropriate for any p a r t i c u l a r i n d i v i d u a l . Some people believe that i n B r i t a i n the family doctor i s best placed to mobilize and co-ordinate health and welfare services i n the i n t e r e s t s of any one i n d i v i d -ual [(British Medical Association Standing Medical Advisory Committee, 1963] but the fee for service option makes t h i s even less f e a s i b l e i n Canada than i n B r i t a i n and anyway at present there are fewer welfare services to mobilize. Nor i s there one body responsible f o r deciding on the amount and l o c a t i o n of the d i f f e r e n t services seen i n a co-ordinated way. The present system i s self-perpetuating and not conducive to the search for new solutions. For example the need for more acute h o s p i t a l beds i s deduced 120 from h o s p i t a l u t i l i z a t i o n . It i s not the r e s p o n s i b i l i t y of the h o s p i t a l service to consider a l t e r n a t i v e s to acute h o s p i t a l care. An example of a service where a f a i r amount of co-ordination and int e g r a t i o n i s achieved i s the mental health f i e l d where there i s more in t e g r a t i o n between the ho s p i t a l and community services than i s the case with the p h y s i c a l l y i l l . The consultant i n g e r i a t r i c s appointed to the M i n i s t r y of Health i n 1975 acts i n an advisory capacity. I t i s the Deputy Ministers who are i n charge of the a l l o c a t i o n of funds to the d i f f e r e n t services and categories. There are not many f i e l d s where the Department of Human Resources has enough d i r e c t i o n or autonomy to do much planning on i t s own. So many services depend on cost-sharing agreements and on the tec h n i c a l state of 'need'. In the matter of accommodation It cannot decide what f a c i l i t i e s can be b u i l t but i s only involved i n operating costs. One example of p r i o r i t y s e t t i n g at the l o c a l l e v e l i s with community grants. S o c i e t i e s submit ap-p l i c a t i o n s through l o c a l o f f i c e s of the Department of Human Resources. Sub-missions are considered by the l o c a l o f f i c e and Community Resource Board i f there i s one, before being forwarded to the Regional Director, so as to avoid d u p l i c a t i o n and fragmentation and to assure that they f a l l within departmental p r i o r i t y guidelines. The Regional Director reviews them again and sends them on to the Community Programs D i v i s i o n i n V i c t o r i a . In t h i s way, the non-statutory services required are determined by the people most knowledgeable about the unique needs of a community and region. There i s a tendency for p r i v a t e agencies to provide services i n an a r b i t r a r y and unsupervised fashion with l i t t l e p u blic a c c o u n t a b i l i t y . The sort of evaluation done by UCS can be applied only to i t s member agencies. Government funding of voluntary agencies ( l i k e housing) appears to~be~reactive 121 rather than according to defined p o l i c y . If North Shore Vancouver can organize several f a c i l i t i e s for the e l d e r l y which apply for funding, they w i l l a l l be considered, whereas other areas may not have the necessary s k i l l s to make the o r i g i n a l request. There i s no formal mechanism either for co-operation betweed d i f -ferent departments or m i n i s t r i e s or for any o v e r a l l planning which encom-passes more than one of these. In Vancouver, the Welfare Department was o r i g i n a l l y responsible for chronic care, from 1936 public health nurses were employed by the Department to look a f t e r the boarding home programme, and there were two doctors and two nurses employed i n the Medical Section. Later when the Medical Section became the Department of Health Care and Aging, i t was s t a f f e d by s o c i a l workers and seconded nurses. Since the p r o v i n c i a l takeover of the Department of Human Resources, the boundaries of health and welfare areas are no longer co-terminous i n Vancouver and; the 'health care teams' which dealt with a v a r i e t y of needs, no longer e x i s t . Nowadays even home helps who may recognize various needs or poten-t i a l needs would not know who i f anyone could deal with them. There are not many centres l i k e the Marpole Centre i n Vancouver where the Day Centre i s housed i n the same b u i l d i n g as the Resources Board o f f i c e , and homemaker and meal-on-wheelsi service. Even the departments involved i n planning, l i c e n s i n g , operating and financing care f a c i l i t i e s do not have j o i n t committees so that areas of r e s -p o n s i b i l i t y may not be c l e a r l y established nor common aims c l a r i f i e d . And of course present financing arrangements provide no incentive for one depar-tment (e.g. Human Resources) to d i r e c t more funds to services which w i l l 122 contribute to economies i n another department (e.g. Health). 7. EVALUATION In Canada and B.C. i t i s possible to obtain d e t a i l e d and accurate v i t a l ' s t a t i s t i c s on b i r t h s and deaths, the causes of death and the age and sex and l o c a t i o n at time of death. S i m i l a r l y , s t a t i s t i c s are a v a i l a b l e on the number of people i n h o s p i t a l and the nature of the conditions treated. ( S t a t i s t i c s on morbidity are not a v a i l a b l e l a t e r than the 1951 survey and even the B.C. Handicapped Register i s quite u n r e l i a b l e on numbers of adult handicapped.) TA New Perspective on the Health of Canadians' (p. 26) c i t e s three o v e r a l l i n d i c a t o r s of the l e v e l of health services-the r a t i o of various health professionals to the t o t a l population, the r a t i o of t r e a t -ment f a c i l i t i e s to the population, and the extent of prepaid coverage. Looking at these f i g u r e s , Canada i s seen to be 'among the world leaders for health care services'. [Lalonde, 1974] But measures of m o r t a l i t y and morbidity say nothing on the q u a l i t y of l i f e and are probably no longer r e a l l y appropriate i n a developed coun-try as indices of health care. To measure personnel i s to concentrate on inputs. We have no way of measuring the e f f e c t s of these inputs-or the e f f o r t s of d i f f e r e n t types of personnel (or when we do have methods, be-cause there has been some d i f f e r e n t i a l cost-benefit analysis, we don't take advantage of them). The amount of technical equipment or p r e c i s i o n of methods used i s also often considered a measure of q u a l i t y . Thought i s r a r e l y given to a c c e s s i b i l i t y or e f f i c i e n c y of d i s t r i b u t i o n as i n d i c a t o r s . In any case whose objectives should one be meeting-that of the health care provider who believes i n high t e c h n i c a l q u a l i t y of care-or that of the 123 e l d e r l y p a t i e n t who may have d i f f e r e n t p r i o r i t i e s ? S t a n d a r d s o f c a r e t o o , may be measu res o f t he s e r v i c e p r o v i d e d . We have no measu re s o f t h e s e r v i c e r e c e i v e d . The q u e s t i o n o f e v a l u a t i o n i s i m p o r t a n t f o r s e v e r a l r e a s o n s . We may have t o r e t h i n k what we s h o u l d be e v a l u a t i n g . E v a l u a t i o n s h o u l d be a g a i n s t s t a n d a r d s o r p r i o r i t i e s , bu t whose s t a n d a r d s and p r i o r i t i e s ? H a v i n g d e c i d e d what i s i m p o r t a n t we have to c o n s i d e r how we c a n e v a l u a t e . And f i n a l l y , how y o u e v a l u a t e , how y o u c o l l e c t s t a t i s t i c s , i n f l u e n c e s t h e s e r -v i c e s p r o v i d e d and t h e way i n w h i c h s t a f f and a d m i n i s t r a t o r s t h i n k . I f a s h o r t a v e r a g e l e n g t h o f s t a y seems a r e c o m m e n d a t i o n , t h e y w i l l g e t s h o r t s t a y s , i f l o w m o r t a l i t y r a t e s a r e i m p o r t a n t , t h e y w i l l f i g h t t o keep a l i v e p e o p l e who a r e f i g h t i n g t o be a l l o w e d t o d i e . And i f t h e number o f i n t e r -m e d i a t e c a r e beds y o u p r o v i d e i s g o i n g t o s a t i s f y t h e demands o f a l l s o r t s o f p r o f e s s i o n a l s and o t h e r e x p e r t s , who i s g o i n g to pu t t h e i r money i n t o home c a r e ? I n t h i s c h a p t e r we have l o o k e d a t what i s p r e s e n t l y b e i n g p r o v i d e d t o meet t h e h e a l t h and a l l i e d needs o f t h e e l d e r l y . The p r o v i s i o n s have d e v e l o p e d o v e r t h e y e a r s somet imes i n r e s p o n s e to t h e p e r c e i v e d o r e x p r e s -sed needs o f t h e e l d e r l y , b u t more o f t e n c o i n c i d e n t a l l y . The e l d e r l y p o p u -l a t i o n f o r whom t h e s e r v i c e s have been p r o v i d e d has changed o v e r t h e y e a r s a l s o - n o t o n l y i n numbers b u t i n r e s p o n s e t o a w h o l e c o m p l e x o f e c o n o m i c , t e c h n o l o g i c a l , s o c i o l o g i c a l and p s y c h o l o g i c a l f a c t o r s . I n t h e n e x t c h a p t e r we s h a l l a t t e m p t t o a r r i v e a t some u n d e r s t a n d i n g o f t h e n a t u r e o f t h e e l d e r l y p o p u l a t i o n f o r whom we a r e p r o v i d i n g s e r v i c e s i n t h i s day and a g e . 124 From t h e r e we s h a l l a t t e m p t t o i d e n t i f y t h e needs o f t h e p r e s e n t g e n e r a t i o n ( s ) o f e l d e r l y w i t h a v i e w to c o n s i d e r i n g l a t e r , how w e l l t h e p r e s e n t a r r a n g e m e n t s meet t h o s e n e e d s . NOTES "'"See the B r i t i s h Columbia C l a s s i f i c a t i o n of Types of Health Care, B.C. Department of Health, September 1973. 2 Twenty beds i n Surrey Memorial Ho s p i t a l , thirty-one at the Royal Columbian, sixteen used as r e h a b i l i t a t i o n beds i n St. Paul's Since then, ward C8-9 of the Heather P a v i l i o n , V.G.H. has been set as i d as a Rehab.ili&atdonUUnit. 3 Vancouver Province, J u l y 12, 1975 p. 13. 4 S t a t i s t i c s Canada, 1975. Hospital S t a t i s c s 1974. ^Research D i v i s i o n , Hospital Programmes, Department of Health, V i c t o r i a . S t a t i s t i c s of Hospital Cases Discharged during 1975. Tables XVII and XVIII, pp. 134, 135, 136. S t a t i s t i c s Canada. Mental Health S t a t i s t i c s 1973. Vol. I Catalogue 83-204 Annual. I n s t i t u t i o n a l Admissions and Separations. ^Health and Welfare Canada. Medical Care. Annual Report 1976. g S t a t i s t i c s Canada. Medical Services and Associated Diagnoses Saskatchewan 1971 Catalogue 82-533 (occasional) December 1975. 9 Department of National Health and Welfare and Dominion Bureau S t a t i s t i c s , I l l n e s s and Health Care i n Canada. Catalogue No. 82-518 Occasional, Queen's P r i n t e r 1960. "*"^ In the U.S., a national organization, the Grey Panthers, has been formed to combat age disc r i m i n a t i o n . "'"''"Interview with Mr. Frank Way, president of F.L.C. on 3rd May, 1976. TABLE I Average Age P o p u l a t i o n days s t a y (pe rcentage d i s t r i b u t i o n ) HOSPITALIZATION BY SEX AND AGE FOR ALL PERSONS HOSPITALIZED IN B . C . , 1975 MALE FEMALE R a t e s per 1 , 0 0 0 P o p u l a t i o n P a t i e n t S e p a r a t i o n s days s i n c e d u r i n g y e a r a d m i s s i o n R a t e s p e r 1 , 0 0 0 P o p u l a t i o n P a t i e n t Average S e p a r a t i o n s days s i n c e P o p u l a t i o n days s t a y d u r i n g y e a r a d m i s s i o n ( p e r c e n t a g e d i s t r i b u t i o n ) - e x c l u d i n g newborn 1 0 0 . 0 9 . 6 1A0 .2 1 , 3 4 6 . 1 1 0 0 . 0 8 . 4 1 8 7 . 4 1 , 5 7 4 . 2 - i n c l u d i n g newborn Newborn Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 . - 39 40 - 44 45 - 49 5 0 - 5 4 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 SO - 84 85+ 1 . 5 6 . 2 8 . 2 9 . 8 9 . 7 8 . 9 8 . 6 7 . 4 6 . 2 5 . 9 5 . 6 5 . 3 4 . 3 4 . 0 3 . 1 2 . 3 1 .4 0 . 9 0 . 7 9 . 3 6 . 0 7 . 8 5 . 3 4 . 9 5 . 7 6 . 9 7 . 4 7 . 1 7 . 3 7 . 9 8 . 4 8 . 8 1 0 . 1 1 0 . 8 1 1 . 5 1 3 . 2 1 4 . 0 1 5 . 0 1 6 . 7 1 8 . 7 1 5 5 . 2 3 5 4 . 6 1 6 0 . 1 9 0 . 9 6 0 . 9 78..2 9 4 . 6 8 5 . 8 7 . 1 0 1 . 1 1 6 . 1 4 2 . 7 1 7 5 . 6 2 1 5 . 5 2 5 0 . 7 2 9 5 . 1 3 5 3 . 3 4 3 0 . 3 4 9 2 . 5 5 7 0 . 1 1 , 4 3 5 . 9 2 , 7 8 1 . 2 8 4 8 . 1 4 5 0 . 1 3 4 7 . 8 . 5 4 0 . 3 7 0 0 . 5 6 1 3 . 7 6 4 3 . 4 8 0 1 . 9 9 7 9 . 2 1 , 2 5 5 . 1 1 , 7 6 8 . 1 2 , 3 3 8 . 0 2 , 8 8 3 . 3 3 , 8 8 4 . 7 4 , 9 5 6 . 0 6 , 4 7 8 . 2 8 , 2 0 5 . 1 1 0 , 6 6 3 . 2 1 . 4 5 . 9 8 . 0 9 . 4 9 . 4 8 . 8 8 . 6 7 . 1 5 . 7 5 . 4 5 . 4 5 . 6 4 . 8 . 4 . 4 3 . 3 2 . 5 2 . 0 1 .4 1 . 2 8 . 2 5 . 8 8 . 5 5 . 5 4 . 4 5 . 8 5 . 2 5 . 4 5 . 7 6 . 3 7 . 2 8 . 1 9 . 0 9 . 7 1 1 . 0 1 1 . 9 1 3 . 1 1 4 . 3 1 6 . 5 1 8 . 9 2 0 . 4 2 0 1 . 9 2 6 6 . 0 1 1 9 . 9 7 0 . 6 5 4 . 8 1 5 6 . 1 2 8 5 . 3 2 9 7 . 0 2 2 2 . 8 1 8 1 . 1 1 6 6 . 0 1 7 0 . 9 1 7 8 . 0 1 8 2 . 1 •200.8 2 3 2 . 1 2 6 2 . 4 2 9 8 . 4 3 4 5 . 4 3 6 8 . 2 1 , 6 5 8 . 4 2 , 2 6 0 . 1 6 5 9 . 9 3 1 1 . 1 3 2 0 . 0 8 1 7 . 7 1 , 5 3 0 . 8 1 , 6 9 0 . 4 1 , 4 0 4 . 1 1 , 2 9 6 . 4 1 , 3 4 5 . 5 1 , 5 3 5 . 5 1 , 7 3 3 . 9 1 , 9 9 9 . 2 2 , 3 9 7 . 8 3 , 0 4 6 . 5 3 , 7 5 4 . 2 4 , 9 1 6 . 4 6 , 5 3 3 . 8 7 , 4 9 6 . 8 S o u r c e : R e s e a r c h D i v i s i o n , " H o s p i t a l Programmes, Department of H e a l t h , V i c t o r i a , S t a t i s t i c s o f H o s p i t a l Cases D i s c h a r g e d d u r i n g 1 9 7 5 , B . C . , T a b l e 2 , pp 1 4 , 1 5 , 1 6 , 17 FIGURE 1 HEALTH ADVISORY COUNCIL DEPUTY MINISTER MEDICAL & HOSPITAL PROGRAMS BRANCH SUPPORT SERVICES C h a i r m a n MEDICAL SERVICES COMMISSION A s s o c . Dep. M i n HOSPITAL PROGRAMS MINISTER Depu ty M i n i s t e r o f H e a l t h DEPARTMENTAL PLANNING & SUPPORT SERVICES DEPUTY MINISTER COMMUNITY HEALTH PROGRAMS EMERGENCY HEALTH SERVICES COMMISSION FORENSIC PSYCHIATRIC SERVICES COMMISSION A s s o c . Dep . M i n MENTAL HEALTH PROGRAMS BRANCH SUPPORT SERVICES BUREAU OF S P E C I A L HEALTH SERVICES A s s o c . Dep . M i n . , PUBLIC HEALTH PROGRAMS DIAGNOSTIC SERVICES AUTHORITY COMMUNITY HEALTH ' CENTRE DEVELOPMENT GROUP COMMUNITY CARE F A C I L I T I E S LICENSING BOARD 128 CHAPTER IV THE ELDERLY POPULATION Everyone who writes about the e l d e r l y agrees that there i s no one age at which everyone becomes " e l d e r l y " and neither do d i f f e r e n t aspects or systems of one person begin to slow down or deteriorate at the same time or the same rate. However, for the purposes of study, most people end up by choosing the age of s i x t y - f i v e as the one at which old age i s considered to begin and we follow that custom. I t i s the o f f i c i a l retirement age for pension purposes and a cut-off point of many s t a t i s t i c s . We use i t , recog-n i z i n g that chronological age may be a poor i n d i c a t i o n of the need of service for the e l d e r l y . Aging Populations - Selected Countries and Canada At the second B.C. Conference on Aging, Ralph Goldman presented a table which shows how average length of l i f e has increased over the ages. (Table II) This means that l i f e expectancy at b i r t h has also r i s e n . The Economic Council of Canada included i n i t s 11th Annual Review, tables showing comparative recent figures for some selected countries, (Table III A) and comparative figures f or Canada and the provinces from 1931 to 1971. (Table I I I B) The increase i n l i f e expectancy can be a t t r i b u t e d to such factors as lowered infant m o r t a l i t y rates, c o n t r o l of i n f e c t i o u s diseases and other environmental hazards, advances in medicine, improved access to medical care, 129 higher l i v i n g standards ( n u t r i t i o n , housing) etc. This increase i n longevity has meant that i n the countries where i t has taken place, there has been eventually also an increase i n the numbers and proportion of e l d e r l y (people aged s i x t y - f i v e and over) i n the popula-t i o n . In B r i t a i n the proportion of old people more than doubled between 1901 and 1961. [Sumner and Smith, 1969, p. 31.] Between 1960 and 1970, the proportion rose from over 12 per cent to over 13 per cent i n Sweden and France, from over 11 per cent to over 12 per cent i n England and Wales, over 10 per cent to over 12 per cent i n Norway and Denmark and from 9.3 per cent to 9.87 per cent i n the U.S. [UN, 1963, 1972.] Comparative figures for some selected countries are given i n Table IV. Canada's lower percentage i n the past has resulted l a r g e l y from higher b i r t h and immigration rates than those of countries with more se t t l e d popu-l a t i o n s , but i t s percentage i s increasing also now, and a f a l l i n g b i r t h rate accentuates the proportional increase i n the number of e l d e r l y . (Table V) There has been a substantial increase even since the l a s t census. (In 1901, the proportion was 5 per cent.) The population projected for 1986 i s shown i n Table VI. At that time, the number of people aged s i x t y - f i v e and over i s expected to be almost 50 per cent higher than the 1971 f i g u r e , and to represent 9.8 per cent of the population. S t a t i s t i c s Canada projects for l a t e r years, an e l d e r l y population which continues to increase but at a slower rate a f t e r 1986 (Table VII). It i s frequently pointed out that i f the present low f e r t i l i t y rates continue, i n future years, a decreasing proportion of working people 130 and tax payers w i l l have to care for and support increasing numbers of e l d e r l y . As the proportion of the population aged nineteen years of l e s s i s expected to decrease even more, the t o t a l dependency rate (proportion of people aged nineteen years or l e s s and s i x t y - f i v e orimore, compared with the proportion aged twenty to sixty-four) should f a l l . (Table VII.) Whilst a precise c a l c u l a t i o n would be d i f f i c u l t i f not impossible, the i n -crease i n the aged dependency rate should be at l e a s t p a r t l y compensated for by the decrease i n the other-though numbers are not complete measures of dependency needs which may be greater as the number of very aged i n -creases. The E l d e r l y Population of B.C.-Numbers and Location-From Table IX, i t can be seen that people aged s i x t y - f i v e and over form a higher pro-portion of the population i n B.C. than the Canadian average, but that the B.C. f i g u r e i s expected to equal the Canadian average i n 1936. In 1971, the Province had 10.1 per cent of the Canadian population, 11.8 per cent of the population over s i x t y - f i v e . [Audain, 1973 p. 38.] For four selected years, Table X gives a breakdown into f i v e year age groups from f i f t y years onwards, so as to include the cohorts who w i l l proceed to become the e l d e r l y i n f i v e , ten and f i f t e e n years. Figure 2 and Table XI show the t o t a l population breakdown. From Table X, i t can be deduced that over time, i t i s i n the oldest age group that the larges t proportional increases w i l l occur. (Table XII.) Also the discrepancies i n the s u r v i v a l rates of men and women can be seen to be expected to increase, both with age, and over time. Even though by 1985, and i n 1990 up to the age of- s i x t y , males are expected to outnumber females the proportion i s 131 reversed for those over s i x t y . There w i l l be more than twice as many females as males over e i g h t y - f i v e by 1985, and the proportion of women i n a l l the age groups over s i x t y i s higher by 1980. B.C. Research also provides a breakdown i n f i v e year age groups up to age 70+ annually from 1974 to 1981 and from 1986 to 1991, for each regional d i s t r i c t i n the Province. [B.C. Research, 1974.] Figures 3 and 4 are derived from some of these data. The main concentrations of the e l d e r l y are expected to be i n the southern rim of the Province and the lower quarter of Vancouver Island. Table XII shows the proportion of population aged s i x t y - f i v e and over i n some m u n i c i p a l i t i e s i n 1961 and 1971. V i c t o r i a and Vancouver are unique i n Canada, i n that net in-migration r a t i o s for age groups s i x t y - f i v e to 75+ are higher than 10 per cent (or were up u n t i l 1969 at l e a s t ) , the majority coming from the P r a i r i e s . [Capital Region Planning Board of B.C., 1969.] In the Livable Region 1976/1986, the GVRD has produced forecasts by age group to 2001!! and trends and targets by municipality to 1986. {GVRD Planning Department, 1975.] Population pyramids vary considerably from one municipality to another (Figure 5.) It i s also possible to have the 1971 population i n f i v e year groups up to age twenty-four, ten year groups up to age s i x t y - f o u r , the number aged s i x t y - f i v e to sixty-nine and seventy over i n 200 census t r a c t s . This means that one can have highly l o c a l i z e d figures regarding the d i s t r i b u t i o n of the elderly-though i t i s doubtful i f such figures are completely v a l i d for long [Pries t , 1970]. 132 CHARACTERISTICS OF THE ELDERLY POPULATION We propose now to consider some c h a r a c t e r i s t i c s of the e l d e r l y population-in Canada and more p a r t i c u l a r l y i n B.C. Sex and M a r i t a l Status-Up to and including the 1951 census, i n Canada the t o t a l population and the population aged s i x t y - f i v e and over, had a s l i g h t l y higher proportion of males. This was s t i l l true i n 1961 i n B.C. By 1973, there was a s l i g h t preponderance of females i n the t o t a l population of the country and the Province, and a considerable preponderance i n the age s i x t y - f i v e and over group, which increased with age. Because more women survive into the older age groups and because, as census data t e s t i f y , most men marry women i n the next lower f i v e year age group, more older women than men are l i k e l y to have l o s t a spouse. By age seventy, widows outnumber married women.''' Table XIII shows the population s i x t y and over, by f i v e year age groups, sex and m a r i t a l status for B r i t i s h Columbia i n 1971. Accommodation-In 1971, of the s i x t y - f i v e and over population i n B.C., 81.7 per cent l i v e d i n urban areas, 18.3 per cent i n r u r a l . 92 per cent of these r u r a l dwellers and 69 per cent of the urban dwellers owned th e i r homes. [ S t a t i s t i c s Canada, 1972.] In a study of the housing needs of the e l d e r l y i n B.C. i t was found that 30 per cent were married and the res t alone [Bairstow, 1976]. 40 per cent were home owners, 60 per cent renters (The proportion of owners was much higher i n r u r a l areas which o f f e r l i t t l e or no rented accommodation.) 52 per cent of owners were married, though i n V i c t o r i a 67 per cent of owners l i v e d alone. 46 per cent i n B.C., 59 per cent i n Vancouver and 57 per cent i n 133 V i c t o r i a l i v e d alone. 29 per cent i n B.C. l i v e d with a spouse (more i n r u r a l areas, l e s s i n the c i t i e s ) 13.5 per cent l i v e d with a c h i l d (25.4 per cent-the highest r a t e - i n metro Vancouver). In B.C. 52 per cent l i v e d i n s i n g l e family homes, 30 per cent i n apartments,10 per cent i n hostel u n i t s or care homes. 35 per cent were one-bedroom, 33 per cent two-bedroom, 16 per cent three-bedroom and 16 per cent bachelor apartments. A l l the evidence suggests that most e l d e r l y people prefer to l i v e as long as possible i n th e i r own homes-near but not with t h e i r f a m i l i e s , i f possible. More e l d e r l y women than men l i v e alone, and more women than men 2 move i n with adult c h i l d r e n . The 1971 census returns show that of family heads over s i x t y - f i v e , hot maintaining t h e i r own households, i n B r i t i s h Columbia, almost 87 per cent of women and 69 per cent of men were l i v i n g with r e l a t i v e s , confirming, as so many writers have maintained that for younger adults to care for t h e i r e l d e r l y r e l a t i v e s i s not a thing of the past. Another r e s u l t of the age/ sex d i s t r i b u t i o n i s that men who have outlived t h e i r wives and are now alone may be very old. 42 per cent of t h i s category were aged over eighty i n V i c t o r i a i n 1969 and most were over seventy-five. [Capital Region Planning Board of B.C. 1969, p. 28.] Employment-Though the o f f i c i a l retirement age and the age of e l i g i -b i l i t y f o r old age pension, Canada Pension Plan etc. i s s i x t y - f i v e , some people continue to work a f t e r that age, or at le a s t to r e g i s t e r for employ-ment, l e s s now than formerly for men, more for women. The average age at ap p l i c a t i o n f or the Canada Pension Plan i n 1973 was sixty-seven [SPARC, 1974]. Employment rates for males of a l l ages declined from 85 per cent to 134 78.8 per cent i n Canada between 1950 and 1963, the biggest decrease being i n the 65+ group-from 40.4 per cent to 26.3 per cent. (The only other decrease was i n the fourteen to twenty-four group.) Among women, the t o t a l rate rose from 23.2 per cent to 29.6 per cent, r i s i n g i n a l l groups except under nineteens, and r i s i n g i n the 65+ group from 4.2 per cent to 5.8 per cent. [Martin, 1970, p. 84] By 1974, the unemployment rate among people 65+ was 5.4 per cent and .the p a r t i c i p a t i o n - r a t e s were 17.8 per cent for males and-.4.. 2 per cent for females. In B.C. the p a r t i c i p a t i o n rates i n 1971 and 1974 were 8.8 per cent and 7 per cent r e s p e c t i v e l y , and the unem-ployment rates were 7 per cent and 7.3 per cent. The p a r t i c i p a t i o n rate was the lowest i n Canada, though Quebec and the A t l a n t i c Provinceshave higher unemployment rates [Brown, 1975, pp. 29,30]. Income-Table XIV shows the r e l a t i v e deprivation with regard to income, of those aged 65+. In r e a l terms, t h e i r buying power has not i n -creased. E l d e r l y median income had r i s e n i n ten years from 35 per cent of t o t a l median to 44 per cent. The number of e l d e r l y people with incomes below $2,000 scarcely changed between 1961 and 1971, i n Canada or i n B.C. (where the number of people involved dropped from j u s t over 125,000 to almost 119,000 (57.9 per cent)) [Bairstow, 1976, p. 62]. The munici-p a l i t i e s of New Westminster and V i c t o r i a have some of the lowest propor-tions of e l d e r l y with incomes below $2,000 i n Canada ( r e f l e c t i n g the e l d e r l y r e t i r e e s ) . In Vancouver, on the other hand, 39,300 (68.4 per cent) had incomes below $2,000 [Bairstow, 1976, pp. 76,77]. As further evidence of the number of people with minimal incomes, i n 1972, of 206,455 OAS pensioners i n B.C., 100,460 (48.7 per cent) had no Guaranteed Income Supplement, 57,792 (28 per cent) had p a r t i a l G.I.S. and 135 48,203 (23.3 per cent) had f u l l GIS [DHH&W 1972]. In 1974, of 230,000 "Seniors", 97,000 (42 per cent) were i n rec e i p t of Mincome. [SPARC 1974 p. 1.] What we have then i s a group of people, the majority of whom are f i t and a c t i v e who are mostly obliged to r e t i r e from the work force at age s i x t y - f i v e , which many fi n d demoralizing and for whom one of the main prob-lems i s inadequate income, p a r t i c u l a r l y to meet market rents. We know that t h i s group i s an important consumer of health services, which are the most expensive of the government-financed services which they receive. And we know that t h i s group i s going to increase i n s i z e , es-p e c i a l l y the oldest part of the group who (those over age seventy-five), make the heaviest demand on services, at the same time as there i s a decline i n the proportion of people comprising the work force who generate the taxes which finance the various services. If 1971 patterns of h o s p i t a l i z a t i o n for example were to continue, and i f the d i s t r i b u t i o n of diseases i n the popu-l a t i o n remained unchanged, i n 2001, the group aged s i x t y - f i v e and over would u t i l i z e 53 per cwt-of-"all:;patientcdays, and i n 2031, 72.4 per cent [Rombout, 1975]. I f , the discrepancies i n the s u r v i v a l rates of older men and women increase as anti c i p a t e d , there w i l l be more widows i n the population i . e . people without the immediate support of a spouse, and also more people who wish to remain i n the community since women on t h e i r own are l e s s l i a b l e than men to give up th e i r own home, and when they do are more l i k e l y than men to move i n with c h i l d r e n rather than into i n s t i t u t i o n s . We a l s o know t h a t i f n e c e s s a r y we c a n o b t a i n p r e d i c t i o n s a b o u t f u t u r e p o p u l a t i o n s i z e s by age g roup f o r q u i t e s m a l l a r e a s i f a p l a n n e c e s s i t a t e s a l o c a l i z e d a p p r o a c h . We now p r o p o s e t o l o o k a t what a p p e a r t o be t h e needs o f t h e e l d e r l y a t t h i s t i m e w i t h a v i e w to c o n s i d e r i n g w h e t h e r t h e s e r v i c e s p r o v i d e d meet t h e s e needs i n t h e most a p p r o p r i a t e ( i n c l u d i n g e c o n o m i c a l ) way , and what t h e i m p l i c a t i o n s a r e now and f o r t h e f u t u r e i f t h e y do n o t . 137 NOTES "'"Statistics Canada 1971 Census Book 2-2 pp. 61-65. 2 21 per cent women and 11 per cent men over seventy-five accor-ding to Health and Welfare Canada Staff Papers. Long Range Health Planning, May 1975, p. 9. 3 S t a t i s t i c s Canada, 1971 Census Book 2-2 pp. 51-21, 51-22. TABLE II Average Length of L i f e E a r l y Iron & Bronze Age, Greece 18 years 2000 years ago, Rome 22 years Middle Ages, England 35 years 1687-1691, Breslau 33.5 years Before 1789, Mass & N.H. 35.5 years 1838-1854, England & Wales 40.9 years 1900-1902, United States 49.2 years 1945, United States 65.8 years 1957, United States 69.3 years (Data from Metropolitan L i f e Insurance Company TABLE I I I A Life Expectancy at Birth in Selected Countries1 at Birth Year Males Females Sweden 1967 71.9 76.5 Norway 1966-70 71.1 76.8 Iceland 1961-65 70.8 76.2 Netherlands 1970 70.7 76.5 Denmark 1969-70 ' 70.8 75.7 Switzerland 1958-63 68.7 74.1 1971 69.3 76.4 Canada (1966) (68.8) (75.2) France 1970 68.6 76.1 Japan 1968 69.1 74.3 England and Wales 1968-70 68.6 74.9 Australia 1960-62 67.9 74.2 United States 1971 67.4 74.9 Federal Republic of Germany 1968-70 67.2 73.4 1 Accidental and violent deaths are included; data are for the most recent years available. S O U R C E United Nations, Statistical Yearbook, 1972 (New York, 1973); and U.S. Office of Management and Budget, Social Indicators, 1973 (Washington, 1973). Source: Economic Targets and S o c i a l I n d i c a t o r s , Eleventh Annual Review E.C.C. 1974 Table 4 - 1 0 , p82. TABLE I I I B 139 Life Expectancy at Uirth (ICxciuJins Accidental and Violent Deaths except Suicide;,' by Sex, Canada, by Region,* 1931-71 Atlantic Region* Prairie Re&oa1 Canada Newfound-land Prince Edviard Nova hland Sotia New Brunswick Quebec Ontario Manitoba Sas'^al-chewan Alberta Sritish (Years) J911- -Miles Females 61.8(1.8) 61.1 (0.6) 62.0(1.8) 62.4(0.5) 57.8(1.6) 58.1(0.5) 61.2(1.9) 64.6 (0.7) 65.1 (1.61 66.1 (0.6) 64.6(2.4) 66.1 (0.8) I M I -1951-• Wales Females -Males Females 64.8(1.8) 66.9(0.6) 63.1(1.9) 71.5 (0.7) 63.7(2.0) 65.2(0.6) 66.5(1.9) 71.1(0.6) 61.7(1.5) 63.6(0.5) 66.5 (I.S) 65.1 (0.5) 65.5 (1.9) 69.2(0.8) 68.7(1.8) 72.6 (0.7) 67.1 (1.7) 65.8(0.6) 70.1 (1.7) 72.9 (0.6) 66.1 (2.4) 69.7 (0.7) 69.3 (2 .0 73.1(0.9) 1956-Miles Females 69.5(1.9) 73.6(0.7) 69.9 (2.C) 73.5 (0.6) 68.0(1.9) 71.7(0.7) 69.7(1.9) 74.1 (0.7) 71.1 (1.8) 74.9(0.7) 70.5 (2.4) 74.7 (0.8) 1961-Males Ft/rules 70.2(1.8) 74.9(0.7) 70.6(2.0) 74.6(0.7) 69.1 (1.8) 73.4 (0.6) 70.0(1.7) 75.1 (0.7) 71.6(1.8) 76.1 (0.6) 71.1(2.4) 76.3(0.9) 1966- -Males Females 70.8 (2.0) 76.0 (O.S) 70.9 (2.0) 75.0(0.6) 71.0(2.7) 70.6(2.3) 76.4 (0.9) 75.6(0.8) 71.1 (2.6) 76.2(0.9) 69.9(2.0) 74.7(0.$) 70.4(1.7) 76.3(0.S) 71.7(1.9) 77.0 (0.9) 72.6(2.1) 77.4 (0.9) 72.3 (2.2) 77.1 (0.9) 71.7(2.5) 76.9(1.1) 1971-Males Females 71.4(2.0) 77.3 (0.9) 70.9(1.7) 76.4 (0.7) 71.6(2.3) 70.5(2.2) 73.2(0.5) 76.8(0.6) 71.4 (2.3) 77.2(0.5) 70.3 (2.1) 76.2(0.9) 71.2(1.6) 77.5 (O.Sj 72.2(2.0) 77.9 (1.0) 73.1(2.2) 73.4 (0.8) 72.7(2.3) 78.3(1.0) 72.5(2.6) 77.9(1.2) . _ , . . r r . ^ a . l S . „.- ,« id" .<- ! a - i violent deaths on life e»pe«a«y at birth. Subiraflinf the fis-ares in parentheses from the ftjures to their ' ^ ^ ^ ^ l ^ ^ ^ ^ l ^ auoun. - that a. the i * eapectancv usual,, p r e y e d . . J Eicludmj Ne»faaadlar.a in 1931 and 1941. . and 3 c c i a l Iiroicstoi's, Eleventh Annual davieu. Source; Economic T ^ r ^ L S .t.C.u. 1974 Table 4-9, p 91. TABLE IV Percentage of Population Aged 65 and Over Selected Countries T o t a l Population Percentage Country Sweden (1970) Population Aged Over 65 Aged Over 65 8,076,903 1,109,327 13. 73 France (1968) - 49,654,556 6,662,484 13. 41 Norway (1970) 3,888,305 503,322 94 England & Wales (1970) 47,135,510 5,855,720 12. 42 Denmark (1969) 4,890,687 590,575 12. 07 Netherlands (1970) . 13,038,526 1,325,361 10. 16 United States (1970) 203,211,926 20,065,502 9. 87 New Zealand (1969) 2,808,590 236,650 8. 42 A u s t r a l i a (1970) 12,551,707 1,047,778 8. 34 Canada (1971) 21,568,315 1,744,405 8. 10 Source: Demographic Year Book 1971. United Nations. New York 1972 140 TABLE V Year Persons 65 and over Percentage 65 and over 1961 . •  1,086,400 7.7 1971 1,744,410 8.1 1973 (estimated) 1,834,200 8.3 Source: S t a t i s t i c s Canada , TABLE VI •. A b s o l u t e 'ar.'J R e l a t i v e I n c r e a s e s in the S i z e of S p e c i f i e d A,",e G r o u p s , C a n n d i i , 1956 - 1971 and 1971 - 1 9 S G •. .• A c c r o i s s e m c i i t en v a l o u r r e l a i U c c t a b s o l u c d e s e f f e c l i f s de c e r t a i n s c r o u p e s d ' i j t c - s , C a n a d a , 19jf> - 1 9 7 1 ct 1971 - 193G 1986 Age group Number Per cent change fio.T. 1256 to 1971 Lo'.v rerlillty (1.8) 60.000 :r.igrants Falble focor.ditf (1.8) et 60,000 n'sta.tts Hiyh fertil ity (2.6) 100,000 migrant:! Fort" rornrdito (2.6) et 100,000 .Migrantj Grouse iJ'Scss Ef feed's "en % de 1956 a -1971 1 Number I'er cent chance from 1S71 to 1SS6 Number Per cent chance f;".'n 1971 to 19F.G 1S5S 1971 Effectifs Variation en % de 1971 a 19S5 Effect i fs Variation en % rie 1971 a IHSS •000 •000 '000 0 - 1 9 years — ans.. . . 6.383 8.495 33 7,430 - 13 9, 432 11 6 - 19 " " .... 4.018 6.268 56 5,053 - 19 .5.899 - 6 2 0 - 4 4 " '* .... 5.633 7,305 29 10.648 46 11. 002 51 4 5 - 6 4 " " 2,7GS 4.023 45 4.739 18 4.793 19 65 * " . " „ 1.214 1.743 40 2,560 47 2.584 48 Total _. 16.0S1 21,568 34 25,383 18 27.811 29 Sources: Stat ist ics Canada. Por-htion 1921-1971 (Ottawa: Information Car.ada. 1973) pp. 4 5 - 6 0 ; also Part III and unpublished data. - v S t 2 t i s : : c u 8 Car.ada, Population 1921-1971 (Ottawa Inforrattion Canada. l S 7 3 ; ? p . 45-60; igalement tioisierae pattie et dcnne«s r.or. p . :b i i t rs . Population P r o j e c t i o n s f o r Canada and the Provinces 1972 - 2001, p 89 ' TABLE' VII Population 65+ % of T o t a l Population 2.6 m i l l i o n 9.8 3.0 m i l l i o n 11.4 3.3 m i l l i o n 11.6 S t a t i s t i c s Canada Source: Year 1986 1990 2001 Source: TABLE VIII 141 CANADIAN DEPENDENCY RATIOS (1) C h i l d U > . A g e d l b ; ., ' ' . T o t a l Dependency Dependency Aged-to- Dependency Year Rat i o Ratio C h i l d Ratio R a t i o 1 9 6 1 ^ 0.83 0.15 0.18 0,93 1 9 7 1 ) ^ 0.75 0.15 0.21 0.90 1 9 8 1 W 0.61 0.16 0.26 0.77 1991 0.63 ' 0.18 - 0.28 0.81 2001 0.62 0.18 0.28 0.80 SOURCE: L. Auerbach and A. Gerber, "Implications o f the Changing Age S t r u c t u r e of the Canadian Population," Source book f o r a Working Par t y , Science Council of Canada, Ottawa, 1974, p. 42 (a) C h i l d - Age 0 - 19 (b) Aged - Age 65 and over (c) 1961, 1971 - c a l c u l a t e d from Census data (d) 1981-2001 - c a l c u l a t e d from Canada, S t a t i s t i c s Canada, P o p u l a t i o n P r o j e c t i o n s f o r Canada and tha Provinces 1972-2001 . (Ottawa: Information Canada, 1974), P r o j e c t i o n A, f e r t i l i t y -2.42, net m i g r a t i o n - 100,000 C h i l d Aged T o t a l Dependency Dependency Aged-to- Dependency Ratio R a t i o C h i l d Ratio Ratio 0.83 0.15 0.18 0.98 0.75 0.15 0.21 0.90 0.55 0.16 0.30 0.71 0.47 0.18 0.39 0.65 0.43 0.19 0.44 0.63 CANADIAN DEPENDENCY RATIOS (2) (a) (b) Year 1961<c> 1 9 7 1 d 1 9 8 1 ( d ) 1991 2001 SOURCE: L. Auerbach and A. Gerber, "Implications of the Changing Age S t r u c t u r e of the Canadian Po p u l a t i o n , " Source book f o r a Working Par t y , Science Council of Canada, Ottawa, 1974, p. 40. (a) C h i l d - Age 0 - 1 9 (b) Aged - Age 65 and over (c) 1961, 1971 - c a l c u l a t e d from Census data (d) 1981-2001 - c a l c u l a t e d from Canada, S t a t i s t i c s Canada, P o p u l a t i o n P r o j e c t i o n s f o r Canada and the Provinces 1972-2001 (Ottawa: Information Canada, 1974), P r o j e c t i o n D, f e r t i l i t y -1.90, net migration - 60,000. Source: How Much Choice, C.C.S.D. p 8 TABLE I X P O P U L A T I O N 6 5 + A S P E R C E N T A G E OF T O T A L P O P U L A T I O N BY P R O V I N C E C a n a d a B . C . A l t a . S a s k . M a n . O n t . Q u e . N . B . N . S . P . E . I . N f I d . 19 71 N u m b e r % o£ T o t a l P o p u l a t i o n 1 , 7 4 4 , 4 1 0 S . 1 2 0 5 , 0 1 C 9 . 4 1 1 8 , 7 4 5 7 . 3 9 4 , 8 0 5 1 0 . 2 9 5 , 5 5 5 9 . 7 6 4 4 , 4 1 0 8 . 4 4 1 3 , 0 1 5 6 . 8 -5 4 , 7 0 5 8 . 6 7 2 , 4 7 0 9 . 2 1 2 , 3 4 5 1 1 . 1 32 , 0 7 5 6 . 1 1 9 7 3 ( e s t ) N u m b e r 7. o f T o t a l P o p u l a t i o n 1 , 8 3 4 , 2 0 0 8 . 3 2 1 6 , 6 0 f 9 . 4 1 2 5 , 5 0 0 7 . 5 9 8 , 1 0 0 1 0 . 8 99 , 5 0 0 1 1 0 . 0 6 7 5 , 9 0 0 8 . 5 4 3 9 , 6 0 0 7 . 2 5 6 , 7 0 0 8 . 7 74 , 9 0 0 9 . 3 1 2 , 8 0 0 1 1 . 1 3 3 , 4 0 0 6 . 2 19 8 6 ( P r o j e c t e d ] Z o f T o t a l P o p u l a t i o n 9 . 0 . 9 . 8 8 . 7 1 5 . 0 1 2 . 2 9 . 5 9 . 6 1 0 . 3 1 1 > 3 1 1 . 4 7 . 8 S o u r c e : S t a t i s t i c s C a n a d a Immediate. Source: 'The National Context: A Report on Governrr.ent Programs for the E l d e r l y 1 John Yudelman, Sept. 1974 p 12 K3 TABLE X 143 Age 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ TOTALS TOTAL Source: •50 Population in (000s) B.C. by 5-year Grouping 1976 1980 1985 1990 M 64.8 69.9 76.0 84.6 F 66.7 66.7 69.4 79.1 M 54.5 61.7 68.4 74.2 F 59.5 66.2 67.3 70.0 M 49.8 50.9 58.3 64.5 F 53.9 58.1 65.8 66.9 M 38.3 44.1 46.1 52.7 F 41.4 50.3 56.2 63.6 M 29.3 31.7 37.4 39.0 F 31.8 36.9 46.9 52.5 M 18.1 21.6 24.1 28.4 F 23.9 26.9 32.6 41.5 M 11.0 11.4 14.0 15.7 F 16.5 17.9 20.9 25.5 M 6.2 5.6 5.9 7.2 F 9.2 10.0 11.6 14.0 M 2.9 3.1 3.0 3.1 F 4.1 4.7 6.2 8.1 M 1270.4 1437.8 1667.4 1898.2 F 1242.3 1400.5 1620.4 1843.4 2512.6 2838.3 3287.8 3741.6 Statistics Canada, Population Projections for Canada and the Provinces, 1972 - 2001, Ottawa, Information Canada 1974 i TABLE XI . . « » • t i . C . P.FSrAfrCH * 0 * H P I T I S H COtUl i f t lA POPULATION PROJECTIONS * * « 9 /74 **• H i STORICAl Y F A ' S » » BR IT ISH COLUMBIA - TOTAL 196 I 1 9 6 6 T97T t * « * « * « A * « * » * t « * * * t * * » « * < > » » « * * * * » * * FORFCAST YEAPS • • » » « « * » o » » « » « » » « » » • « » » « « « » • * » « « » » « » ~T9'n Vi~15 i 9 V 6 1977" ' 1 9 7 5 - W 7 9 W O F J 3 I M » 6 • I S v T t9'96 B I R T H S 2 6 4 3 0 3 2 3 6 7 3 4 7 7 0 3 6 5 5 8 3 7 3 1 0 3 8 U 9 3 9 4 2 3 4 0 7 4 6 4 2 1 1 0 4 3 4 9 7 4 4 8 4 5 4 9 6 0 7 5 1 7 2 9 5 4 5 9 4 A G E -" 2 8 1 3 6 6 ' ' J - 4 1 6 6 7 9 3 1 6 8 7 7 7 : 1 7 5 4 0 1 1 0 9 6 9 6 1 9 6 3 2 9 ~ 2 0 " 3 3 C ' 2 ~ T O ' 9 6 4 1 " ~ 2 1 5 9 2 9 ~ 2 2 2 1 6 3 2 2 8 2 3 9 2 6 ( 3 0 5 5 - 9 1 7 1 6 6 1 2 0 2 7 2 7 2 1 2 2 2 5 1 9 7 4 4 1 1 9 3 1 5 3 1 9 0 3 1 3 _ 1 9 4 ( I 7 1 _ 1 9 9 5 0 8 2 0 6 1 0 0 2 1 3 6 4 5 2 2 1 4 5 9 _ 2 5 0 2 4 8 _ 2 7 3 4 8 0 2 8 3 7 1 9 1 0 - 1 4 1 5 0 6 G 2 1 8 2 4 2 1 2 2 2 3 3 5 2 2 6 7 6 T 2 2 5 7 0 6 2 2 3 7 > 6 2 1 9 1 4 6 2 1 4 1 9 8 2 0 9 5 3 1 2 0 5 7 2 2 2 0 3 3 5 2 2 3 3 3 0 5 2 6 2 1 5 6 2 3 6 2 0 0 " ' _ 1 5 - 1 9 1 1 2 6 5 6 T5846~6~~" " 2 0 1 1 0 5 2 2 1 4 1 7 ' ' " 2 2 7 4 3 0 " ' " 2 3 2 0 5 6 " ' 2 3 5 4 3 6 " ' 2 3 7 7 0 2 2 3 9 0 5 4 ' ~i; 3 9 2 1 5 " ' ' 2 3 0 2 0 8 " 2 1 4 3 9 7 " 2 4 4 G 6 6 ' 2 7 4 7 2 3 2 0 - 2 4 9 5 2 2 8 1 2 9 7 4 1 1 5 0 0 0 2 2 0 9 9 2 & 2 1 7 3 6 1 _ 2 _ 2 4 4 9 8 _ 2 3 2 6 0 9 ._ J 1 ? 5 1 5 _ J 5 8 6 2 9 _ 2 6 0 6 6 7 2 3 3 2 2 4 _ _ 2 6 5 9 7 9 2 5 - 2 9 _ 3 0 - 2 4__ 3 5 - 3 9 " 4 0 - 4 4 4 5 - 4 9 1 0 1 0 5 7 1 1 4 8 1 7 1 5 6 8 0 7 1 1 2 2 1 6 1 1 2 0 6 0 1 3 6 1 1 9 1 1 3 7 5 4 1 2 2 1 1 2 1 3 0 0 9 0 1 1 0 0 5 5 I t 0 2 79" ' " l 2 4 7 8 7 " 9 8 6 9 3 1 1 2 3 6 0 1 2 5 7 7 4 2 3 0 4 6 9 2 4 7 2 2 & - " 2 5 5 4 1 1 " " 2 6 3 0 7 7 " " " 2 9 5 4 3 9 " " 2 9 4 7 7 6 2 6 2 7 5 0 2 0 4 9 3 9 _ 2 1 0 4 8 7 2 3 1 8 3 3 _ 2 4 4 6 0 0 _ 2 3 6 5 3 1 _ 3 1 9 9 8 2 _ _ 2 1 8 9 2 8 1 6 5 6 8 4 1 7 5 3 2 9 1 0 5 9 2 2 1 9 7 3 9 1 2 6 5 2 9 8 3 0 3 B 9 4 3 4 4 3 8 5 1 4 0 1 1 0 1 4 4 4 B 0 ' ' 1 4 9 6 6 0 " 1 5 5 7 3 9 " 2 0 2 7 1 6 ' " 2 7 0 6 0 6 " " 3 1 4 7 0 6 1 2 0 7 4 3 1 3 1 2 7 2 1 3 4 2 3 9 1 3 7 6 1 6 1 5 9 6 2 6 _ 2 0 7 0 7 8 _ _ 2 7 6 0 0 2 ' 5 0 - 5 4 8 6 1 2 7 1 C 0 6 0 9 1 1 7 6 2 2 5 5 - 5 9 6 7 0 9 7 0 1 7 0 9 1 0 3 7 1 3 6 0 - 6 4 5 6 4 4 1 6 7 6 1 1 0 7 4 8 2 6 5 - 6 9 5 0 7 5 7 5 5 4 5 7 6 6 1 3 5 7 0 - 1 1 4 0 5 1 1 2 2 7 7 3 1 3 6 8 3 5 1 2 3 9 5 7 1 2 5 4 0 5 1 2 6 7 3 5 1 2 7 2 4 1 7 7 4 2 0 8 0 6 4 0 8 4 4 35 1 4 9 4 2 2 , 1 5 4 9 3 3 ' 1 6 1 2 4 8 8 8 6 7 0 9 2 9 0 1 ' 1 4 0 B 8 5 ' - 1 6 2 9 1 4 2 1 1 0 0 5 1 2 9 1 6 4 _ 14 0 7 6 9 _ 1 6 2 7 3 7 1 3 0 0 9 1 1 3 1 8 1 4 1 4 3 4 8 2 " 1 1 72 9 5 " " " i S o & I ' a " " " 1 3 2 2 8 3 2 5 8 G 2 8 2 8 3 3 1 9 3 2 U 4 3 T O T A L 1 6 2 9 0 7 0 1 B 7 3 8 0 9 2 1 B 4 2 3 2 2 3 5 1 6 1 1 2 4 0 9 5 1 4 2 4 6 9 9 2 9 2 5 4 0 2 2 0 2 6 1 3 1 5 0 2 6 8 7 9 7 0 2 7 6 . 3 9 3 3 2 0 4 0 2 9 4 3 2 0 1 0 2 6 3 5 3 6 0 0 3 3 3 7 9 4 1 3 5 0 . fl 5 0 . ft 5 0 . 4 -P-S o u r c e : B r i t i s h C o l u m b i a P o p u l a t i o n P r o j e c t i o n s , B . C . R e s e a r c h , 1974, p 9 145 TABLE XII Proportional Percentage Increase i n Population Aged 65 and Over Numbers to nearest 1000 Proportional Percentage Increase to: Age 1976 1980 1985 1990 65-69 79,700 19 10 14 70-74 61,100 28 10 9 75-79 42,000 12 21 23 80-84 27,500 4 18 21 85-89 15,400 0 13 24 90+ 5,000 0 29 22 TABLE XIII . In 1961 and 1971, the proportion of the population aged 65 and over i n some MUNICIPALITIES 1961 1971 Vancouver 13.8 13.5 V i c t o r i a 20.9 22.9 Burnaby 8.6 7.9 Surrey 8.7 7.9 Saanich 12.0 10.2 New Westminster 11.2 12.9 Richmond 4.9 5.2 North Vancouver 5.6 4.1 Prince' George 3.6 3.0 Source: Dale Bairstow 'Demographic and Economic Aspects of Housing Canada's E l d e r l y ' P o l i c y Planning D i v i s i o n CMHC, Ottawa, 1973, p 39 i TABLE XIV 146 Sex and M a r i t a l S t a t u s , K r i t i s h C o l u m b i a , 1971 6 0 - 6 4 6 5 - 6 9 7 0 - 7 4 7 5 - 7 9 8 0 - 8 4 8 5 - 8 9 90+ S i n g l e T 6 , 1 4 0 5 , 6 5 5 4 , 3 5 0 3 , 2 4 0 2 , 4 1 0 1 , 4 2 5 615 M 3 ,445 3 , 3 8 5 2 , 6 1 5 1 , 7 6 5 1 , 3 8 5 755 305 F 2 , 6 9 5 2 , 2 7 0 1 , 7 3 5 1 , 4 7 5 1 , 0 2 0 670 310 M a r r i e d • T 6 5 , 2 2 5 4 4 , 7 2 0 3 0 , 3 S 0 1 9 , 2 1 0 1 1 , 0 0 0 4 , 4 4 5 1 , 1 9 0 M 35 ,595 2 7 , 7 2 5 1 8 , 8 4 5 1 1 , 9 0 5 7 , 4 5 5 3 , 1 7 0 875 F 2 9 , 6 3 0 1 9 , 9 9 5 1 2 , 5 3 5 7 , 3 0 5 3 , 5 5 0 1 , 2 7 5 320 Widowed T 1 0 , 6 1 0 1 3 , 2 0 5 1 5 , 2 0 0 1 5 , 6 2 0 1 3 , 6 5 0 8 , 5 6 0 3 , 5 0 0 M 1 , 6 7 5 . 2 , 2 3 0 2 , 5 5 0 2 , 9 7 5 3 , 1 8 5 2 , 4 2 0 1 , 0 7 5 F 8 , 9 3 5 1 0 , 9 7 5 1.2,655 1 2 , 6 4 0 1 0 , 4 6 5 6 , 1 4 0 2 , 4 2 5 D i v o r c e d T 2 , 6 4 5 1 , 6 5 5 985 530 305 115 45 M 1 , 2 7 0 855 560 270 170 55 25 F 1 ,375 795 • 430 255 130 60 20 S o u r c e : Census 1971 book 1 : 2 TABLE XV N a t i o n a l Income D i s t r i b u t i o n o f a l l I n d i v i d u a l s and o f t h e E l d e r l y (65+) P o p u l a t i o n f o r 1 9 6 1 , 1 9 6 5 , 1967 and 1971 I N C O M E ^ 1961 1965 1967 1971 GROUPS TOTAL 65+ TOTAL 65+ TOTAL 65-t- TOTAL - 65+ 0 ^ 1 , 9 9 9 3 9 . 3 7 7 . 9 3 7 . 2 7 3 . 0 3 2 . 9 6 3 . 4 - 3 2 . 0 6 0 . 8 2 - 3 , 9 9 9 3 0 . 9 1 4 . 6 2 4 . 7 1 8 . 0 2 1 . 5 1 8 . 9 1 6 . 6 2 1 . 0 4 - 5 , 9 9 9 1 8 . 6 -- — 5 . 5 2 0 . 7 7 . 4 1 4 . 9 8 . 5 6 , 0 0 0 + 1 0 . 3 — — 3 . 5 2 4 . 8 5 . 2 3 6 . 5 9 . 8 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 MEDIAN INCOME 2 , 6 1 5 926 3 , 0 5 2 1 , 0 8 4 3 , 6 0 6 1 , 3 9 8 4 , 1 8 6 1 , 8 4 0 S o u r c e : Based on s p e c i a l t a b u l a t i o n s f rom S t a t i s t i c s Canada ( D a l e B a i r s t o w : Demograph ic and Economic A s p e c t s o f H o u s i n g C a n a d a ' s E l d e r l y , p 53) i • • 147 | FIGURE 2 BRITISH C O L U M B I A P O P U L A T I O N P R O J E C T I O N S 1974 - 139S October, 11)74 I .5. GrcJlcf V ; i r . «u i\c f . POPULATION PYRAMIDS Source: Social Trends in Greater Vancouver, Michele Lioy, Social Policy and Research Department, United Way of Greater Vancouver, 1975, appendices. 151 CHAPTER V THE ELDERLY POPULATION - NEEDS So c i a l services ( i n which we would include health and s o c i a l s e r v i c e s ) , are usually defined as interventions outside the market system (Titmuss, 1968) and usually considered to respond to human needs (Thayer, 1973). This may be why p o t e n t i a l planners of services for the e l d e r l y , or those who t r y to influence planners or decision-makers, often attempt to i d e n t i f y and measure needs. There may be at l e a s t two r a t i o n a l e s behind t h i s behaviour. One i s that one should i d e n t i f y needs because needs should be met. The other i s that as i t i s perceived needs which generate demand, one must be able to predict the former i n order to decide how to deal with the l a t t e r . Types of Need At l e a s t four kinds of need may be described. Normative need i s what the expert or professional defines as need i n any given s i t u a t i o n , as measured against some desirable standard. This d e f i n i t i o n of need w i l l vary according to the d i f f e r e n t standards set by experts, which again may depend on t h e i r personal values, t h e i r view of the importance of the need, and t h e i r views on the s o l u b i l i t y of the problem. Comparative need measures need by comparing the services received by one i n d i v i d u a l , group or area with those received by another (which s t i l l does not imply an optimal l e v e l ) . F e l t need i s want. I t depends to some extent on a per-son's expectations and i s not normally experienced unless a so l u t i o n i s known to be possible. If the person's expectations do not coincide with 152 the normative standards of the expert, the expert may deny that a need e x i s t s . F i n a l l y , expressed need i s the economist's 'demand' which i s f e l t need translated into action and which again may not coincide with normative need as described by experts. A l l of these d e f i n i t i o n s of need may be found si n g l y or together, i n the various studies, surveys and reports on the health and s o c i a l status and requirements of the e l d e r l y . Assessment of normative need may involve interviewing i n d i v i d u a l patients. In the Health Care of Aged Study [University of Rochester, 1968] a random sample of the e l d e r l y population was interviewed by teams composed of physicians and public health nurses using a questionnaire which was adjusted u n t i l a set of questions was found which brought the conclusions of nurses, on needs, into l i n e with the assessments of a group of physicians.. The f i n a l questionnaire required subjective and objective responses regar-ding health, by the patient, subjective and objective observations by the interviewer and the l a t t e r ' s assessment of the patient's need for services of i n s t i t u t i o n a l care. Later, eight c l a s s i f i c a t i o n s of physical status and f i v e of mental status were d i f f e r e n t i a t e d . This sort of approach presumes that the appropriate service depends on the p h y s i c a l , even medical status of the person concerned and i t neglects various s o c i a l f a c t o rs which might a f f e c t the need, and psychological factors which might a f f e c t the s o l u t i o n . Studies of normative need involving medical examinations of sample populations by doctors u s u a l l y bring to l i g h t various unreported health problems (Williamson, 1964) or even patients with unreported conditions 153 who would have l i k e d a v i s i t from a general p r a c t i t i o n e r [Cartwright, 1967]. For the GVRD Extended and Intermediate Care Reports i n d i v i d u a l patients (or t h e i r records) were studied but t h i s was done by researchers and s t a f f members. These two studies d i f f e r e d from the e a r l i e r ones men-tioned i n that they were not open-ended. They were looking only at the s u i t a b i l i t y of patients for s p e c i f i c l e v e l s of i n s t i t u t i o n a l care. Sometimes data are based on interviews with professionals (e.g. the GVRHD G e r i a t r i c s Report, (1975 (2)) and Sumner and Smith's 1969 study. Sometimes people take i t for granted that without any s p e c i a l r e -search th e i r expertise or experience permits them to make judgments and or pronouncements. I t may be the expertise of f a m i l i a r i t y (e.g. the Health and Human Resources Council of the Queen Charlotte Islands who know the area) or experience (e.g. the BCMA 1968 Annual Report which notes various needs of the e l d e r l y , the 1976 Report of a Working Party of the B r i t i s h Medical Association on Services for the E l d e r l y ) . The writers of the l a s t report even take upon themselves to propose the o v e r a l l approach which should be taken i n the care of the e l d e r l y [BMA 1976]. Perhaps the epitome of contribution by experts i s produced when a committee with a v a r i e t y of expertises collaborate i n discerning the needs of one p a r t i c u l a r group and i n making recommendations as was the case when the G e r i a t r i c Task Force prepared and submitted t h e i r b r i e f to BCMC. Comparative need i s sometimes deduced by comparing the services received by d i f f e r e n t groups or the status of d i f f e r e n t groups, the l a t t e r being considered to imply c e r t a i n needs. Two researchers i n B r i t a i n deduced 154 the need for domestic help of poor disabled people who had no help by measuring the amount of help being purchased by b e t t e r - o f f equally d i s -abled persons. (Townsend, Wedderburn, 1965.) Sometimes i t requires quite a l o t of imagination, as i n t h i s case, to work out methods for measuring comparative needs. At other times, people r e l y e n t i r e l y on printed figures, i . e . the numbers or rates of service provided by d i f f e r e n t pro-vinces are noted. Sometimes there i s an assumption that more (of h o s p i t a l beds for example) means better though no basis i s offered for t h i s assum-ptions . Perceived need may be met or unmet, but i s need as seen by the person experiencing i t . Probably the most important study i n Canada of the perceived needs of the e l d e r l y i s the ten-volume Aging i n Manitoba (Manitoba Department of Health and,Social Development, 1973) based on research undertaken' •-. ' i n order to provide a comprehensive know-ledge base on the needs and resources of Manitoba, necessary to meet the need being f e l t for long-range planning of services for the e l d e r l y . Eighteen areas of need i d e n t i f i e d from an extensive review of the l i t e r a t u r e r e l a t i v e to needs and of community based surveys and studies of the e l d e r l y , were reduced a f t e r various forms of pre-testing, to nine d i s c r e t e need areas,-psycho-social; shelter^ household maintenance, food and cl o t h i n g ; language,-religion-ethnic-cultural^ physical health and functioning", mental health and functioning", economic; proximity to family/friends, fami-l i a r community,' and family/friends a v a i l a b l e resources-each with f i v e scales of need. Since i t was believed that the needs of the e l d e r l y were best r e -vealed by the e l d e r l y themselves, 4,805 persons over age s i x t y - f i v e (3558 155 from the general community and 1247 residents i n f a c i l i t i e s ) were selected according to c a r e f u l sampling techniques and interviewed according to a standard questionnaire by f i f t y trained students between June and mid-September, 1971. The questionnaires which took approximately one hour to complete, asked respondents for f a c t u a l information and wishes regarding the nine "need areas". They also asked for the interviewer's assessment of the respondent's a t t i t u d e , state of mind, and comprehension of questions. For 680 p o t e n t i a l resources i d e n t i f i e d i n the community (305 r e s i d e n t i a l , 375 non-residential) data were c o l l e c t e d from c e n t r a l sources, by mailed questionnaires and by interviews with s t a f f of the f a c i l i t i e s r e -garding the population served, the services and f a c i l i t i e s provided, types of s t a f f , costs, and t h e i r judgment of the degree of unmet need experienced by the e l d e r l y . Other data used were Dominion Bureau of StatisticsiiandaManitoba Health Services Commission past and projected population d i s t r i b u t i o n s and community information data derived from several sources, e s p e c i a l l y the Department of Industry and Commerce. From the data from the e l d e r l y person interviews and the resources a v a i l a b l e , matched p r o f i l e s were prepared for each geographic area ( v i l l a g e and towns as well as regions) to be used along with demographic data and cost a n a l y s i s to e s t a b l i s h p r i o r i t i e s , a l t e r n a t i v e s and innovations for long and short term planning and for subjective assessment of health fu n c t i o n a l status and l i f e s a t i s f a c t i o n . Snider's study (Snider, 1973) attempted to provide systematic i n f o r -mation regarding the health and r e l a t e d needs of n o n - i n s t i t u t i o n a l i z e d 156 senior c i t i z e n s i n Edmonton. 428 fa m i l i e s (500 would have been 10 per cent systematic sample) represented by a person aged s i x t y - f i v e or more were interviewed by trained interviewers using a questionnaire which included closed and open ended questions on demographic d e t a i l s , health status, use of agencies, morale, anxiety, a t t i t u d e s to old age, a c t i v i t i e s and employ-ment. Health was measured by self-reported health status, s p e c i f i c i l l n e s s and medical care h i s t o r i e s , and fu n c t i o n a l health scores. Forty health and rela t e d agencies were also contacted about the services which they provided. An example of a study of needs on a d i f f e r e n t scale was that ca r r i e d out by the Cedar Cottage Neighbourhood Services i n Vancouver i n 1972. Responses to a pamphlet e n t i t l e d 'Can we Help?' showed that i n spite of the many e x i s t i n g services i n that community, there s t i l l existed many unmet needs, p a r t i c u l a r l y for an::.individualized type of service-which the organization proceeded to provide. It i s not usual for a sp e c i a l study to be undertaken to measure expressed need or demand as t h i s i s - u s u a l l y equated with u t i l i z a t i o n and these f i g u r e s are a v a i l a b l e as long as s t a t i s t i c s are kept. The planner who t r i e s to predict demand i s r e a l l y t r y i n g to meet his own needs as a planner-for information-so as to f o r e s t a l l any apparent dearth or superabundant p r o v i s i o n of services and f a c i l i t i e s which might embarrass future p o l i t i c i a n s and c i v i l servants or inconvenience personnel or c i t i z e n s . The simplest method then used to predict future needs (of the system, not the consumer) i s to look at present u t i l i z a t i o n , of ho s p i t a l beds for example, per thousand of population, and extrapolate f u t u r e needs f rom p o p u l a t i o n p r o j e c t i o n s . To be a b l e t o r e s p o n d t o demands f o r s o p h i s t i c a t e d p o p u l a t i o n p r o j e c t i o n s , S t a t i s t i c s Canada i s c o n t i n u o u s l y engaged i n p r o j e c t i o n s - o r i e n t e d r e s e a r c h and d e v e l o p m e n t o f t h e d a t a base and t e c h n i c a l c a p a b i l i t i e s . ' ' " The R e s e a r c h D i v i s i o n , B . C . H o s p i t a l P rog rams p u b l i s h e s an a n n u a l r e p o r t o f h o s p i t a l s t a t i s t i c s i n t h e P r o v i n c e w h i c h g i v e s i n f o r m a t i o n on d i a g n o s i s , l e n g t h o f s t a y , e t c . by age g r o u p . More s o p h i s t i c a t e d e s t i m a t e s o f t h i s t y p e o f demand (based on u t i l i z a t i o n ) t a k e i n t o a c c o u n t t h e number o f bed days by age g roup and by d i a g n o s i s . I n B r i t a i n and some p a r t s o f t h e U . S . , t h e ' c r i t i c a l bed number ' i s based o n p r e s e n t h o s p i t a l a d m i s s i o n s p l u s w a i t i n g l i s t a d d i t i o n s , t i m e s a v e r a g e l e n g t h o f s t a y . To d e r i v e t h e ' c o r r e c t number ' two s t a n d a r d d e v i a t i o n s a r e added t o a l l o w f o r f l u c t u a t i o n s i n demand. I n t e r n a t i o n a l d i f f e r e n c e s i n U t i l i z a t i o n c a n d e m o n s t r a t e t h e e f f e c t s o f d i f f e r e n t d e l i v e r y s y s t e m s , economic f a c t o r s , p s y c h o l o g i c a l and s o c i a l a t t i t u d e s and s t r u c t u r e s t h o u g h t h e r e a r e s t i l l some d i f f e r e n c e s w h i c h c u r r e n t i n f o r m a t i o n does n o t e x p l a i n . ( S h a n a s , 1968 and Kohn and W h i t e , 1976.) Some p e o p l e w o u l d add a n o t h e r c a t e g o r y known as u n e x p r e s s e d demand, t h a t i s need t h a t i s f e l t b u t n o t t r a n s l a t e d i n t o demand b e c a u s e t h e s o l u t i o n s a r e n o t known o r n o t a v a i l a b l e o r a c c e p t a b l e t o t h e p e r s o n who f e e l s t h e n e e d . The S e n i o r C i t i z e n H o u s i n g S t u d y c a r r i e d o u t i n B . C . [Gutman, 1975] m i g h t be c o n s i d e r e d t o f a l l i n t o t h i s c a t e g o r y , b e c a u s e i t was d e s i g n e d " t o d e t e r m i n e t h e e x p e c t a t i o n s and h o u s i n g p r e f e r e n c e s o f s e n i o r c i t i z e n s " i . e . i t l o o k e d a t s o m e t h i n g r a t h e r w i d e r t h a n t h e i r i m -m i n e n t h o u s i n g change . I n t e r v i e w s f o l l o w i n g a s t a n d a r d q u e s t i o n n a i r e were 158 conducted with 146 applicants for a nineteen-storey h i g h - r i s e b u i l d i n g o f f e r i n g four l e v e l s of care, f i f t y applicants for accommodation i n two fourteen-storey blocks of self-contained suites i n a retirement housing complex, and a control group of f i f t y persons l i v i n g i n t h e i r own homes and not on any housing waiting l i s t . Applicants were interviewed one to four months p r i o r to moving and twelve to eighteen months a f t e r moving i n . Some studies seek out more than one type of need. The Special Senate Committee on Aging s o l i c i t e d and/or received evidence from federal government departments, provinces, various c i t i z e n organizations repre-senting health and welfare, r e l i g i o n , education, business, labour, and the e l d e r l y themselves. The Aged and Long Term I l l n e s s Survey Committee i n Saskatchewan (1963) obtained information on e x i s t i n g programmes from adminis-t r a t o r s and other providers of service, received eight b r i e f s from organi-zations, studied programmes, services, and research i n other countries, consulted i n t e r n a t i o n a l experts, surveyed samples of employers, of i n s t i -t u t i o n a l i z e d patients aged s i x t y - f i v e and over and 1,000 other s e l f selected aged persons. The Community Care for Seniors Study [SPARC, 1972] reviewed other projects and studies, v i s i t e d 24 regional d i s t r i c t s to obtain f i r s t -hand impressions of a community, i t s resources, i t s a b i l i t y to plan, held hearings, contacted senior c i t i z e n organizations, s o l i c i t e d information from various groups. 1,800 questionnaires (819 returned) were sent to s t a f f of various statutory and voluntary agencies, asking what they saw as the major gaps and most pressing needs i n t h e i r communities. 450 question-naires were sent to Senior C i t i z e n Counsellors to be f i l l e d i n by ' c l i e n t s ' 159 (185 were processed). A small survey was undertaken of p r i v a t e physicians i n Vancouver to assess a v a i l a b i l i t y and use of community services, and another of homemakers i n the Province. Some studies do not even attempt to be s c i e n t i f i c , or to do o r i g i n a l research. 'Pour une P o l i t i q u e de l a V i e i l l e s s e ' [Martin, 1970], Appendix 17 of the Castonguay Report, derived the needs of the e l d e r l y from the Special Senate Committee F i n a l Report and b r i e f s , the Proceedings of the 1961 White House Conference on Aging, and the writings of Peter Townsend. 'Target for Senior C i t i z e n s ' [Don M i l l s Federation of Labour 1973] was based on eighteen hearings held across Ontario. For 'The Health Needs of the Independent E l d e r l y ' [SPARC 1976] the SPARC s o c i a l planner arranged workshops i n the four communities studied and accepted whomever turned up. 'Housing the E l d e r l y ' [CCSD$ 1976] i s the r e s u l t of regional seminars and workshops. The concept of need i s basic to a technique developed by the UCS of Greater Vancouver over the l a s t four years with Welfare Grant funding. Over the years, the United Way s h i f t e d from an agency to a service or programme or i e n t a t i o n for budgetting, based on established service p r i o r i t i e s . The l a t e s t development i s an attempt to budget according to community problems and needs. LOGAN ( l i s t i n g of o v e r a l l goals and needs) i d e n t i f i e s six basic goals of Canadian Society, eighteen sub-goals or conditions to be achieved, and f i f t y - t w o s p e c i f i c i n d i v i d u a l and community need conditions that must be met for the subgoals and eventually the major goals to be r e a l i z e d . These were developed by a committee of United Way volunteers, mainly from the business community, and based on the United Way of America i * Canadian Council on S o c i a l Development 160 Service I d e n t i f i c a t i o n System. The s i x goals are Economic Opportunity and Income Protection, Provision of Basic Material Needs, Assurance of Optimal Environmental Conditions, (3) Optimal Physical and Mental Health, Adequate Knowledge and S k i l l s , Optimal Personal and S o c i a l Development, Adequately Organized S o c i a l Means. Sub-goals of (3) for example are : (1) Creation, Preservation, Maintenance of Good Health (2) H a b i l i t a t i o n and R e h a b i l i t a t i o n of Mentally and P h y s i c a l l y Handicapped (3) Care and Treatment of I l l - h e a l t h . Needs are 3.1.1. Optimal Biological/Organic Make-up of the Body 3.1.2. Community (Environmental) Conditions Conducive to Good Health 3.1.3. Develop and Maintain L i f e Style Conducive to Good Health 3.2.1. Reduce Handicapping E f f e c t s of D i s a b i l i t y by Personal Adaptation and Adjustment 3.2.2. Reduce Handicapping E f f e c t of D i s a b i l i t i e s by Changing Environmental Conditions. 3.3.1. Care and Treatment of the Ambulatory 3.3.2. Bed Related Care and Treatment 3.3.3. Emergency Medical Care and Treatment Agencies applying for funding are assessed as to whether they meet the needs elaborated. UCS considers that basing p r i o r i t i e s on funding guide-l i n e s or agencies tends to maintain the e x i s t i n g system; p r i o r i t i e s based on services or programmes act to r e i n f o r c e present strategies and ways of doing things; problem or need based p r i o r i t i e s tend to i d e n t i f y problem and need s i t u a t i o n s and give agencies and communities freedom to innovate and experi-ment with a l t e r n a t i v e approaches and d e l i v e r y systems. This could probably be applied also to health planning [Jaques, 1976]. To make recommendations based on 'major obstacles to maintaining the health of the e l d e r l y ' does not always wait on the i d e n t i f i c a t i o n of needs. The Working Group on the Study of Health Services for the E l d e r l y 1976 to the Advisory Committee on Community Health, Department of Health and Welfare 161 ([Working Group] chose to i d e n t i f y sixteen }':problem areas' (Appendix A), on which they based t h e i r recommendations. These problem areas were enunciated a f t e r a study of current g e r i a t r i c and gerontological l i t e r a t u r e , a look at the current s i t u a t i o n of e l d e r l y Canadians, analysis of the recommendations of other committees and working groups, a review of Canadian research on a aging and the aged, v i s i t s to various health and welfare d e l i v e r y projects, and input from the e l d e r l y themselves. The group does not mention needs i n i t s o v e r a l l objectives which i s "to make recommendations for ways of protecting, promoting and maintaining the health of the e l d e r l y population of Canada". Some studies aim at providing information on which the development of services can be based. The N u t r i t i o n Canada B.C. Survey i d e n t i f i e d the el d e r l y as the group most vulnerable to nutrient d e f i c i e n c i e s . [Bureau of N u t r i t i o n a l Services 1975]. The 1963 Saskatchewan Study aimed at gathering fac t s about people and resources "so as to sketch a broad framework" for the development of needed services. [Aged and Long Term I l l n e s s Survey Committee, 1963]. The Major comparative study of e l d e r l y people i n three i n d u s t r i a l s o c i e t i e s [shanas et_ a l 1968] wished to provide "fundamental information about the l i f e of old peoplexin the >thr.ee.icountries":lto:Lprovide i n t e r a l i a , a basis for s o c i a l p o l i c y . The findings were based on s t r u c t -ured interviews with s t r a t i f i e d multi-stage p r o b a b i l i t y samples of about 2,500 e l d e r l y people i n pr i v a t e households i n each of Denmark, B r i t a i n and the U.S. The recent massive i n t e r n a t i o n a l study of Health Care [Kohn and White, 1976] i s not t r y i n g to discover needs as a l l the other studies were, i n order to t r y to meet them, but rather i t assumes (p.99) that perception of morbidity i s a measure of need and therefore a major determinant of 162 p o t e n t i a l demand and use. Because i t i s the task of decision-makers to balance a v a i l a b l e resources with perceived and expressed needs (p. 352), i t w i l l be useful for them to have information on the dynamics of the health care system, including the various factors which contribute to a perceived need for medical care. The information on which t h i s highly a n a l y t i c a l report was based, was obtained from 47,648 i n d i v i d u a l s i n households i n twelve areas, seven countries, selected by standard i n t e r n a t i o n a l l y accepted sampling plans. The f i n a l questionnaire adminis-tered by s p e c i a l l y selected and trained interviewers (307 items for a responding adult-,:, 236 for a child ) covered psychological and demographic c h a r a c t e r i s t i c s , l e v e l s of i l l - h e a l t h , perceived morbidity, use of health services, etc. Ch a r a c t e r i s t i c s of Need Several c h a r a c t e r i s t i c s of need should be noted. D i f f e r e n t ' a u t h o r i t i e s ' may have d i f f e r e n t opinions about need. Obvious examples are the question as to whether long term care f a c i l i t i e s should a l l be attached to acute h o s p i t a l s , the value of screening, and of regular health examinations-even whether old people prefer to be segregated. (If old people were seen as i n d i v i d u a l s instead of a group, t h i s l a t t e r would not be a problem-or even a question). There i s a common tendency to define needs according to the a v a i l a b l e services and structures which often serve the convenience of the providers more than the needs of r e c i p i e n t s of care. Some people-providers of care specially-more or l e s s equate need state with t h e i r s o l u t i o n because of an occupational bias or-lack of: awareness 163 of a l t e r n a t i v e s . Needs may also c o n f l i c t - e s p e c i a l l y as seen by d i f f e r e n t agents-as i n home care. In other words, there i s not such a thing as uncontestable objec-t i v e need. This applies even to medical care because there can be a lack of consensus among physicians i n some cases as to the type of procedures necessary (e.g. with regard to tonsillectomies, hysterectomies, the timing of e f f o r t s to correct deformities). However, there are some needs on which only doctors are q u a l i f i e d to make decisions, mainly because they are the only people capable of per-forming the necessary procedures, and the only people who know the prog-nosis, the natural., h i s t o r y and that c e r t a i n r e s u l t s are possible. Needs as seen by experts and self-perceived needs do not d i f f e r markedly i f the experts and the persons concerned share the same goals for the l a t t e r and i f the experts have experience with the l a t t e r . How-ever, studies of self-perceived need do cast doubt on some previously held ideas such as that old people l i k e to l i v e with t h e i r c h i l d r e n , that c h i l d r e n nowadays neglect e l d e r l y parents, that r e l a t i v e s are more s i g n i f i -cant than f r i e n d s , that old people do not wish to be housed near contem-poraries, that most old people are f r a i l and i l l , etc. [Townsend, 1957, Shanas 1968, Audain 1973 etc. R i l e y 1968]. Staff may rate needs higher than e l d e r l y persons and tent to extrapolate the needs of the f r a i l e l d e r l y to a l l e l d e r l y . [Manitoba Department of Health and S o c i a l Development, 1973.] Needs vary from place to place and time to time. Untimately i t i s the needs of each l o c a l area which must be assessed because these w i l l vary 164 according to d i f f e r e n t economic status, state of agedness, as well as various s o c i o - c u l t u r a l f a c t o r s . For example, because the old-timers i n the Queen Charlottes are part of a small community and respected for t h e i r s t i l l relevant experience i n logging and f i s h i n g , and because respect for the e l d e r l y i s t r a d i t i o n a l among the Haidas, 'As a group, senior c i t i z e n s on the Islands do not always share many of the problems of t h e i r contempora-r i e s i n the c i t i e s ' [Q .C. Islands Regional Health and Human Resources Council, 1974]. Community Care for Seniors looked at each regional d i s t r i c t . The Saskatchewan Report assessed needs for nursing home care and sheltered accommodation i n sixteen health regions and the Manitoba Report also took the l o c a l area view. The UCS, already referred to, i s now proceeding to produce l o c a l need p r o f i l e s . To obtain l o c a l information, i t modified the Geographically Referenced Data Storage and R e t i r l w a l System (GRDSR) , commonly known as Geocoding, developed by S t a t i s t i c s Canada which can tabulate census information for any 'standard area' and 'user s p e c i f i e d ' areas such as planning d i s t r i c t s , t r a f f i c zones, neighbourhood areas, school d i s t r i c t s , etc. For GVRD data, the PPBS Address Conversion, P l o t t i n g and S t a t i s t i c s System has been set up at UBC for public use. Needs change also as new solutions, medical and other, emerge, and as s o c i a l conditions alter-even as the demographic pattern of the over s i x t y - f i v e s changes. There may be c e r t a i n times when people are s p e c i a l l y vulnerable such .as a f t e r bereavement,'.or p a r t i c u l a r l y i n need of support services i . e . immediately a f t e r discharge from the acute h o s p i t a l ^Marshall, French and Macpherson, 1976]. Need occurs and should be assessed at a v a r i e t y of l e v e l s from the 165 t o t a l population to the i n d i v i d u a l . D i f f e r e n t d i s c i p l i n e s have to be resorted to f o r guidance on the needs at d i f f e r e n t l e v e l s - epidemiology, economics, sociology, administration and psychology, - and some w i l l be f a r more important than others at any p a r t i c u l a r l e v e l . (For example, sociology and psychology are probably the most v a l u a b l e . d i s c i p l i n e s for the study of the needs of i n s t i t u t i o n a l i z e d old people. A l i m i t a t i o n of the value of global figures was shown i n the Health Care of Aged Study [University of Rochester, 1968]. According to the c r i t -e r i a used to study an i n s t i t u t i o n a l i z e d population, 46 per cent were con-sidered misplaced, including 93 per cent of p s y c h i a t r i c i n - p a t i e n t s . Yet the o v e r a l l a l l o c a t i o n of places for the p h y s i c a l l y impaired was not much d i f f e r e n t from the p r e v a i l i n g a l l o c a t i o n because under and over placement of patients cancelled each other out. Needs may be c o n d i t i o n a l . I t seems possible that the e l d e r l y prefer to be with t h e i r contemporaries i n housing but not i n h o s p i t a l . They vary greatly before and a f t e r seventy-five years of age. Needs are often interdependent or substitutable e.g. d i f f e r e n t types and l e v e l s of accommodation and community serv i c e s . The 1962 H o s p i t a l Plan for England and Wales was expressly intended to "complementary to the expected development of the services for. prevention and f o r care i n the community". [Ministry of Health 1962]. The 1963 recommendations for places to be provided i n l o c a l authority homes were calculated f or "when domestic and h o s p i t a l services would be adequate" [Committee on Community Care 1963]. In some areas i n England, welfare o f f i c e r s and h o s p i t a l s co-operate i n planning the o v e r a l l accommodation needed. [Committee on Local Authority and A l l i e d Personal S o c i a l Services 1968, p.115]. 166 The Seebohm Report on Local Authority Health and Welfare Services noted that these services were bound to be over-extended unless the r£ght kinds of accommodation were provided i n adequate amounts, i n the r i g h t pro-portions and i n the r i g h t places. [Committee on Local Authority and A l l i e d Personal S o c i a l Services, 1968]. Conversely, the 1973 CCSD study on housing for the e l d e r l y [Audain 1973] found that to study housing needs meaningfully i t also had to look at needs related to health, s o c i a l s e r v i c e s , recreation and community contact. In A l b e r t a , s a t i s f y i n g one need led to recognition of another. A year a f t e r an active treatment h o s p i t a l i z a t i o n program was i n i t i a t e d i n 1958, i t was found that 10 per cent to 15 per cent of acute bed days were taken up by long-term patients - up to 25 per cent i n some r u r a l areas. So the A u x i l i a r y Hospital Act was passed i n 1962, and by 1972, two r e h a b i l -i t a t i o n h o s p i t a l s and twenty-nine a u x i l i a r y h o s p i t a l s were providing 2,965 beds (1.8 per 1,000). F i n a l l y the Nursing Homes Act was passed i n 1964 to f i l l the gap which had become apparent between the a u x i l i a r y h o s p i t a l l e v e l and the senior c i t i z e n homes programme. A s i m i l a r phenomen occurs when pro v i s i o n of a new service to meet some recognized need c a l l s f o r t h a l l sorts of latent demand. [Committee on the Economic and F i n a n c i a l Problems of the Provision for Old Age, 1954] Needs are r e l a t i v e to aims and r e s u l t s . If you aim to keep the e l d e r l y out of i n s t i t u t i o n s , you provide more community services. The lady with a pain whose aim i s to be r i d of i t , may think that she needs an operation. The doctor who knows that an operation w i l l not remove the cause of the pain, w i l l not believe that she needs an operation. It i s inappropr-i a t e to attempt to meed a need with a service which cannot produce the required or desired r e s u l t . 167 Also the i n d i v i d u a l c i t i z e n w i l l go for the s o l u t i o n that i s most v i s i b l e or e a s i l y obtainable though i t i s not always most appropriate. F i n a l l y there i s a tendency to confuse needs, and ways of meeting needs. A medical diagnosis does not automatically imply a c e r t a i n t r e a t -ment, even l e s s the need for a c e r t a i n form of i n s t i t u t i o n a l care. S i m i l a r l y the d e f i n i t i o n of any other sort of need i s not the d e f i n i t i o n of a s o l u t i o n . B a s i c a l l y needs are for r e s u l t s not for services. There i s s t i l l room for a l t e r n a t i v e s or choices as to how and by whom the needs w i l l be met and a need for the development of techniques for evaluating methods of meeting need. Sometimes need i s based on diagnosis plus previous u t i l i z a t i o n for the diagnosis. But maybe the u t i l i z a t i o n pattern should be changed. Is a home-help a need or a solution? Automatic supply of the s o l u t i o n may prevent e l u c i d a t i o n of the r e a l need. Before supplying health and welfare solutions, one should perhaps look at needs for housing and income to see i f i n f a c t the health and welfare services are not being expected to patch up the holes i n the other services (Sumner, Smith 1969 p. 362). Automatic presumption of a s o l u t i o n may also lead to inappropriate use of a service i . e . you put an e l d e r l y person i n an acute h o s p i t a l and then complain that the h o s p i t a l i s so intent on cure that i t f a i l s to give t h i s person care. I t might be more appropriate to decide that as the v a l i d objective of the acute h o s p i t a l i s to cure, t h i s person i s misplaced. He/ she does not need an acute h o s p i t a l bed. We are most l i k e l y to f i n d the appropriate s o l u t i o n i f we study how the need arose i n the f i r s t place i . e . why a person can no longer manage without help. 168 And f i n a l l y o f c o u r s e , t h e r e has t o be a d e c i s i o n as t o what needs t h e government and v o l u n t a r y a g e n c i e s s h o u l d mee t . NEEDS FOR SERVICES I t i s g e n e r a l l y e s t i m a t e d t h a t a t l e a s t 85 p e r c e n t o f p e o p l e aged s i x t y - f i v e and o v e r a r e i n d e p e n d e n t , t h a t abou t 10 p e r c e n t r e q u i r e some f o r m o f h e a l t h a n d / o r s o c i a l s e r v i c e s i n o r d e r t o r e m a i n i n t h e commun i ty , and t h a t t h e r e m a i n i n g 5 p e r c e n t r e q u i r e ma jo r s u p p o r t i v e c a r e , i . e . c o n g r e g a t e o r t w e n t y - f o u r h o u r s u p e r v i s i o n . [ N u f f i e l d F o u n d a t i o n 1947, Aged and L o n g Term I l l n e s s Commi t t ee 1963, S p e c i a l S e n a t e Commi t t ee 1966, Shanas 1968, M c D o n n e l l 1972, BCMC T a s k F o r c e on G e r i a t r i c s 1974, e t c . ] Recommenda t ions have been made w i t h r e g a r d t o t h e e l d e r l y i n a c u t e h o s p i t a l s [GVRHD 1975 (2)] and f o r t h e t r e a t m e n t o f t h e e l d e r l y i n v a r -i o u s t y p e s o f i n s t i t u t i o n s . [World F e d e r a t i o n of O c c u p a t i o n a l T h e r a p i s t s 1964, A g e d and L o n g TErm I l l n e s s Commi t t ee 1962, 1963, S p e c i a l S e n a t e Commi t t ee 1966, BCMA 1968 A n n u a l R e p o r t , B e l l 1968, SPARC 1972, GVRHD 1973, 1974, BCMC T a s k F o r c e on G e r i a t r i c s 1974, W o r k i n g Group 1976, e t c . ] . The m a i n r ecommenda t i ons f o r t h e c a r e o f t h e s e p a t i e n t s a r e f o r more a s s e s s -ment u n i t s , more a c t i v a t i o n and r e h a b i l i t a t i o n , more d i s c h a r g e p l a n n i n g and f o l l o w - u p , more m u l t i - l e v e l a c c o m o d a t i o n , more f l e x i b i l i t y i n t h e use o f s t a f f , more a t t e n t i o n t o a s p e c t s o t h e r t h a n t h e m e d i c a l needs o f p a t i e n t s and more aware o f p s y c h o l o g i c a l n e e d s . I t i s o f t e n recommended t h a t home c a r e s h o u l d be d e l i v e r e d i n i n s t i t u t i o n s and t h a t v a r i o u s s e r v i c e s s h o u l d be made a v a i l a b l e t o p r i v a t e i n d i v i d u a l s who c a r e f o r p e r s o n s who w o u l d o t h e r w i s e have t o be i n s t i t u t i o n a l i z e d . A l t e r n a t i v e l y s t u d e n t s o f s h e l t e r e d r e s i d e n t i a l a ccommoda t ion recommend 169 that medical attention be more r e a d i l y available [Audain 1972, Gutman 1975]. When health needs i n terms of medical needs are considered f o r persons i n the community, the need for a gradation of provisions i s again pointed to, with a more f l e x i b l e blending of l e v e l s e.g. nurses and s i c k bays i n senior c i t i z e n accommodation, c l i n i c s and outpatient departments f o r assess-ment, treatment and r e h a b i l i t a t i o n , day hospitals-and halfway houses, more services provided by nurses instead of doctors, more use of volunteers, day centres - for the mentally i l l too and therapy for the l a t t e r . Numerous studies point to the importance of good health for l i f e s a t i s f a c t i o n i n old age, but a s i g n i f i c a n t f i n d i n g of most studies, whether of health needs or of needs i n general i s that what are commonly known as health services (and which i n fa c t are medical, services) are not the most needed services. Indeed when they are needed, medical services are more l i k e l y to be received than any other types of service. [BCMC Task Force Committee on G e r i a t r i c s , 1974, e t c ] . In the Saskatchewan Information and Opinion Survey, 1962 [Aged and Long Term I l l n e s s Survey Committee, 1962], 87.4 per cent of respondents i d e n t i f i e d problems. Of these, 94.2 per cent i d e n t i f i e d economic problems, and 45.3 per cent health and welfare ones. (That was before CPP and CAP but also before Medicare.) In Snider's study (1973), p h y s i c a l health problems were mentioned as problems of aging by 25 per cent but when i t came to choosing the most important things which could be done for old people, 22 per cent made recommendations on finance, 16.1 per cent on a c t i v i t y and r e l i e f of boredom, 15.2 per cent on housing and only 6.8 per cent gave recommendations on 170 health, f i r s t p r i o r i t y . Every study of the needs of the e l d e r l y which has been done i n t h i s country points to the unmet need for adequate community services to supply the approximately 10 per cent who require them i f they are to avoid i n t i t -t u t i o n a l i z a t i o n and to prevent the 85 per cent who are independent from d e t e r i o r a t i n g as:, long as t h i s can be avoided. [also Shanas 1968, re other countries.] Even the 10 per cent who do need some i n d i v i d u a l l y provided health or s o c i a l services to remain i n the community may s t i l l not require p r i -marily medical services and c e r t a i n l y not the most highly technical medical services. Community Care for Seniors l i s t s telephone reassurance services, c r i s i s l i n e s and/or emergency numbers, various transportation services. (Other sources recommend escorts with or without transportation), and v i s i t i n g counselling, meals-on-wheels, home-making, home maintenance, r e l o c a t i o n services and night s i t t e r s . Health aids noted as necessary are home nursing and physiotherapy, adaptation of homes, appliances, equipment, drugs, dental and podiatry services, a c t i v i t y and day centres and mental health community care services. (In Beyond Shelter (p. 316) i t was noted that 19 per cent of the sample group studied had a cane, crutch, brace or a r t i f i c i a l limb.) For the other 85 per cent Community Care for Seniors recommended counselling services for i n d i v i d u a l s and f a m i l i e s , access to health centres, physicians, screening c l i n i c s as appropriate, low r e n t a l and s p e c i a l l y designed housing; adjustment of incomes according to cost of l i v i n g , f i n a n c i a l aid for extra-ordinary health and s o c i a l needs, n u t r i t i o n a l 171 counselling, more sui t a b l e and cheaper transportation, s o c i a l , r e c r e a t i o n a l and educational f a c i l i t i e s , drop-in and information centres and/or m u l t i -service 'Senior Centres', provision of resource information and a r e f e r r a l system, more f l e x i b l e and accessible l i b r a r y f a c i l i t i e s , opportunities for continued involvement i n and contribution to the community as resource people, volunteers, etc. (Most of these recommendations come up again and 2 again i n the literature".) The Aging i n Manitoba study found that a v a i l a b i l i t y of resources was the lowest mean unmet need, shelter came second, mental health services t h i r d . In the areas i n B.C. where community human resource and health centres have been set up, the needs noted for the e l d e r l y are l e g a l advice and a drop-in centre ( i n Houston), drop-in centres i n Grand Forks, f r i e n d l y v i s i t o r s , readers, v i s i t i n g h a i r -dressers i n Greenwood where the e l d e r l y have appreciated talks on protec-3 ting t h e i r homes from vandalism, on pensions, and on funerals. When, i n 197 6, SPARC undertook a study of the Health Needs of the Independent E l d e r l y (SPARC, 1976),the major need i n every area, which i t was f e l t should be met by the P r o v i n c i a l government was for intermediate care (which i n fa c t i s s o c i a l rather than medical care and may only be demanded because of the lack of a l t e r n a t i v e sources of care i n the com-munity) , and much further down the l i s t came temporary placements i n extended and intermediate care. But the other services for which the greatest need was f e l t were p u b l i c l y funded transportation using accessible v e h i c l e s , for r u r a l and semi-rural areas, extended, expanded and l e s s expensive home care services (see also the GVRHD Home Care Report, 1975) expensive prostheses orthoses and s p e c i a l devices, and g e r i a t r i c day 172 centres. Voluntary organizations and l o c a l governments were asked to look to the co-ordination of transportation under various auspices, i n f o r -mation service, emergency phone number, telephone tree, commercial ou t l e t s for dissemination of information, low cost housing near services innovative services i n the home e.g. podiatry, meals-on-wheels, hair-dressing, voluntary v i s i t i n g and r e c r e a t i o n for the homebound. Various writers mention the need for pre-retirement courses and for the opportunity for education. F i n a l l y the e l d e r l y suffer along with the handicapped from a general environment (and communication and transportation systems) which does not take account of a slow or unsteady walking pace, f o r example. E l d e r l y people themselves are more i n c l i n e d to ask for the means to help themselves rather than for d i r e c t service. For example, the Don M i l l s Ontario Federation of Labour 1973 Task Force on Senior C i t i z e n s based on eighteen hearings held across Ontario, found that the main needs were for more income, extension of coverage of health expenditures, more housing which the e l d e r l y can a f f o r d , transportation, and community and i n f o r -mation centres and retirement counselling. The Saskatchewan Senior C i t i z e n s ' Commission (1974) found on interviewing 3,309 e l d e r l y persons that the main needs expressed were for finance, housing and transportation and for 'the development of mechanisms for the more e f f i c i e n t planning, co-ordination and d e l i v e r y of services, and methods whereby community organizations and i n d i v i d u a l s can p a r t i c i p a t e i n assessing needs and planning services to meet them on a continuing basis.' In B.C., senior c i t i z e n counsellors have had the opportunity to express the needs of the e l d e r l y at conferences sponsored by the Department 173 of Human Resources At these meetings, senior c i t i z e n s stressed that co-ordination and integr a t i o n of services must begin at the l o c a l d e l i v e r y l e v e l , and l o c a l services such as housekeeper/homemaker services, meals-on wheels, and information services must be made a v a i l a b l e i n coopera-t i o n with l o c a l Human Resources o f f i c e s . Transportation, the cost of drugs, the cost of prostheses and other s p e c i a l equipment, meals-on-wheels, homemaker services, and r e c r e a t i o n a l needs, were some of the items of concern raised by p a r t i c i p a n t s . (Services for People, B.C. Dept. of Human Resources, Annual Report 1973, V i c t o r i a , 1974, p. 59) A 1976 survey of transportation needs i n Chilliwack where 12.75 per cent of the population i s e l d e r l y , showed that 4 per cent are homebound because of lack of sui t a b l e transportation. 16 per cent get out with d i f f i c u l t y and 3 per cent use the present public transportation system. About 90 per cent of respondents would have l i k e d a ccessible buses. A voluntary organization which w i l l transport patients for medical v i s i t s at 4 a cost of $4.25 per t r i p has an average of s i x t y - f i v e c a l l s per month. Inherent : i n these needs or sometimes mentioned separately are (1) personnel needs-for doctors or someone to undertake co-ordination and r e f e r r a l , for professionals to have more t r a i n i n g i n the needs of the el d e r l y , for l i c e n s i n g of more health care providers, a more generous supply of r e h a b i l i t a t i o n and other home care personnel to provide services i n various accommodations, and (2) organizational needs-more emphasis on pre-vention, precautions to ensure that services are accessible (geographically, psychologically, f i n a n c i a l l y ) and known about and co-ordinated. This u s u a l l y requires d e c e n t r a l i z a t i o n , outreach, and modification to l o c a l needs and u t i l i z a t i o n patterns. 174 The s t u d i e s w h i c h we have l o o k e d a t were done i n v a r i o u s p a r t s o f Canada i n c l u d i n g B . C . and o v e r abou t t w e n t y y e a r s . I n t h a t t i m e needs have changed as p r o v i s i o n s have changed and as e c o n o m i c c o n d i t i o n s have f l u c t u a t e d . T h e r e i s no way o f m e a s u r i n g e x a c t l y what t h e p r i o r i t y needs a r e a t any t i m e b u t as f a r a s one c a n g a t h e r f r o m t h e e l d e r l y them-s e l v e s and f r o m t h o s e who d e a l w i t h them, t h e two needs w h i c h a r e c a u s i n g most u r g e n t c o n c e r n i n B . C . a t t h i s t i m e a r e f o r m o d e r a t e l y p r i c e d accommoda t ion adn f o r t r a n s p o r t a t i o n s p e c i a l l y a d a p t e d t o t h e needs o f t he f r a i l a n d / o r h a n d i c a p p e d . 2 . PSYCHOLOGICAL NEEDS As t h e e l d e r l y become more numerous , t h e i r c h a r a c t e r i s t i c s and needs a r e r e c e i v i n g e v e r - i n c r e a s i n g a t t e n t i o n f r o m p s y c h o l o g i s t s . The r e s u l t s o f p s y c h o l o g i c a l s t u d i e s a r e r a r e l y q u o t e d and more r a r e l y u s e d by p l a n n e r s and a d m i n i s t r a t o r s , h o w e v e r . To many h e a l t h p l a n n e r s a g i n g seems t o a p p e a r as p u r e l y b i o l o g i c a l r a t h e r t h a n as a b i o - p s y c h o - s o c i a l p r o c e s s . Y e t i t i s o n l y i f we u n d e r s t a n d the needs o f t h e e l d e r l y t h a t we can h e l p them t o c o n t i n u e t o meet t h e i r own n e e d s , t h a t we c a n h e l p t o meet t h e needs o f t h o s e who a r e no l o n g e r a b l e t o h e l p t h e m s e l v e s , and t h a t we w i l l be a b l e t o p r e s e n t s e r v i c e s i n ways w h i c h w i l l make them a c c e p t a b l e t o a v e r y h e t e r o g e n e o u s p o p u l a t i o n . What most p s y c h o l o g i s t s a g r e e o n i i s t h a t t h e i n d i v i d u a l d i f f e r e n c e s b e t w e e n most p e o p l e o v e r 6 5 , i n c l u d i n g p e r s o n a l i t y and m o r a l e , a r e g r e a t e r t h a n i n any o t h e r age r a n g e . One most a l s o remember t h a t t he o v e r - s i x t y -f i v e p o p u l a t i o n nowadays s t r e t c h e s o v e r an age r ange o f more t h a n t h i r t y -f i v e y e a r s w h i c h i n i t s e l f i m p l i e s w i d e v a r i a t i o n s i n s t a t u s and n e e d s . On 175 the other hand, i t i s generally agreed also that the e l d e r l y have the same psychological needs as people of any other age, Maslow's scale of f i v e basic human needs (p h y s i o l o g i c a l needs, need for secur i t y , need to belong and be loved, need f o r self-esteem, need for s e l f - a c t u a l i z a t i o n ) [Maslow, 1959, pp. 35-38] i s frequently pointed to as a model to be followed when tr y i n g to meet: the needs of the e l d e r l y . However, there may be more threats to the meeting of these needs i n old age-involved i n retirement, los s of mobilit y , maybe loss of spouse, etc. The 1976 CCSD study, 'Housing the E l d e r l y ' i d e n t i f i e d the same sort of needs-for status, s e c u r i t y and independence. The study concludes that the e l d e r l y can maintain t h e i r status by p a r t i c i p a t i n g i n the decisions that a f f e c t t h e i r l i v i n g conditions, they can f e e l secure i f they have a choice of housing and they can remain independent i f adequate income, services and accommodation are a v a i l a b l e to them. The e a r l i e r CCSD study [Audain 1973] showed that residents of sheltered accommodation appreciated the lower rent, security, services a v a i l a b l e and companionship. The study also concluded (p. 403) that for most residents of senior c i t i z e n housing, the development represented t h e i r world and that i t was therefore expected to provide them with "most of the s o c i a l , p h y s i c a l , mental, emotional, and to some extent s p i r i t u a l , stimu-l a t i o n that l i f e has to o f f e r " . If we look at some of the i n d i v i d u a l needs f e l t by many e l d e r l y people i n whatever se t t i n g a f e e l i n g frequently complained of i s lon e l i n e s s . [Aged and Long Term I l l n e s s Survey Committee, Saskatchewan 1962 (1), Special Senate Committee on Aging 1966, Snider 1973, Gutman 1975, 176 Havens and Thompson 1975]. Over 60 per cent of respondents i n the Aging i n Manitoba Study experienced extreme i s o l a t i o n . Loneliness may be l i t e r a l l y 'alonehess', i t may be lack of a v a i l a b i l i t y of 'important' people such as friends or r e l a t i v e s . I t may be "desolation" following lo s s of a loved one [Shanas 1968]. Abraham Kaplan defines lon e l i n e s s as the experience of being denied an i d e n t i t y , or f r u s t r a t i o n of the need for interpersonal r e l a t i o n s h i p s . Loneliness ranks high among the common causes of depression and suicide among the e l d e r l y . [Bancroft, 1971.] Loneliness may be a reason for seeking the help of the family doctor-or some other form of medical care [Freeman, 1969]. Low health status i s commonly associated with f e e l i n g s of lo n e l i n e s s i n the com-munity. And among patients i t may lead to demanding behaviour, unfounded physical complaints, etc. For the s a t i s f a c t i o n of e l d e r l y persons therefore, and for those who care for them, as well as perhaps to prevent some overuse of health services, thought should be given to the a l l e v i a t i o n of lone l i n e s s i n the community and i n i n s t i t u t i o n s , i n any plan f o r the health care of the e l d e r l y . At i t s simplest t h i s would require only arrangements for f r i e n d l y v i s i t i n g - f r e q u e n t l y advocated by the e l d e r l y themselves, and also enough f a c i l i t i e s for people to be cared for i n t h e i r own l o c a l i t y when they may continue to int e r a c t with family, f r i e n d s , and the f a m i l i a r com-munity. I t i s important also that s t a f f should be trained to recognize l o n e l i n e s s i n e l d e r l y persons. [Brennan, 1975] E l d e r l y people also need to be involved. They need s o c i a l i n t e r -action and stimulation i f they are to remain a l e r t , they need access to the usual community f a c i l i t i e s - s h o p s , doctors, transportation, church, clubs. 177 (Shopping i s a very important s o c i a l a c t i v i t y f o r e l d e r l y people who are f i t enough to get to shops). This i s a l l the more important i n that most of them have l o s t many of the s o c i a l contacts provided by employment. (Havighurst, Friedman, 1954, E l k i n 1964, Clark 1968, Special Senate Committee 1966, Weinstock and Bennett 1971, SPARC 1972, Working Group 1975) . E l d e r l y people with hobbies tend to be people who have had these i n t e r e s t s i n e a r l i e r years (Hepworth 1975). Other people seem not necess-a r i l y to choose group a c t i v i t i e s , or highly organized ones. A popular a c t i v i t y for those for whom i t i s possible, i s v i s i t i n g friends or r e l a -t i v e s , i . e . seeking out compatible company. The f a c i l i t a t i o n of the coming together of compatible people i n i n s t i t u t i o n s would probably be much more apprecieted than the almost routine p r o v i s i o n of f a c i l i t i e s f o r bowling i n c o r r i d o r s . It i s hard to understand why the e l d e r l y should be expedted to develop an i n t e r e s t i n a sport which appeals to so few people of younger years. A c t u a l l y , e l d e r l y people want t h e i r a c t i v i t y to be meaningful. Many would l i k e to contribute to the community, to be of service to others. Oft-en people i n i n s t i t u t i o n s would be delighted to be able to work (Kraus, 1976) '- i n the kitchens or the gardens, etc., but t h i s seems to be almost unheard of - too dangerous, too time-consuming, the s t a f f gardener f e e l s that gardens that are le s s than perfect d i s c r e d i t him-, etc. They need some v a r i e t y of r o l e . The only r o l e open to the i n s t i t u t i o n a l resident i s that of 'patient'. Kastembaum (1972) reports on an experiment i n a g e r i a t r i c h o s p i t a l where wine-drinking sessions were introduced d a i l y 178 at 3:00 p.m. i n the day rooms for patients and any s t a f f who cared to attend. For the f i r s t time the patients spontaneously formed groups, began to function as members of a 'club' and t h e i r behaviour became much more p o s i t i v e , varied and communicative. The e l d e r l y need to f e e l secure [Audain 1972, Working Group, 1975.] Most of us f e e l r e l a t i v e l y safe for most of our l i v e s . In youth we are protected by parents, i n middle age we can r e l y on our s k i l l s , our capacity to earn, maybe a spouse. In old age people may continue to f e e l safe i f there are c h i l d r e n at hand, or fr i e n d s , or a s o c i a l worker or doctor to whom they know they can turn. If they know of no-one, they f e e l insecure and abandoned. Often i t i s enough to know that help i s a v a i l a b l e for times of i l l n e s s or stress. Co sin found i n Oxford that requests for admission to his continuing care program for g e r i a t r i c s diminished as people were reassured of the p o s s i b i l i t y of rapid readmission for new medical or s o c i a l c r i s e s . It i s frequently pointed out that successful aging requires con-t i n u i t y JNeugarten, 1964, Atchley, 1971, Kuypers 1973, Rosow, 197 2, Seguin, 1973], not to be suddenly removed from what i s f a m i l i a r [Havinghur'st, 1963, Special Senate Committee, 1966, SPARC 1972]. This seems to be the main reason for the popularity of m u l t i - l e v e l care accommodation. Security too depends on the atti t u d e s of s t a f f who are working with the e l d e r l y . If they are not understanding and compassionate, the e l d e r l y cannot be :but f e a r f u l or untrusting. F i n a l l y some people, to f e e l secure, may need p a t e r n a l i s t i c treatment. Some people have been by nature dependent a l l t h e i r l i v e s and whilst the problem to date has often been that far too many e l d e r l y people were treated i n p a t e r n a l i s t i c ways, even i n t r y i n g to 179 counteract t h i s , one should perhaps s t i l l leave room for 'protecting' the minority who want t h i s . Most e l d e r l y people of the present day do wish to be independent and s e l f - d i r e c t i n g f o r as long as possible-to set t h e i r own goals, make thei r own plans-to remain i n c o n t r o l of t h e i r own l i v e s . [Special Senate Committee 1966, Clark 1968, R i l e y and Foner 1968, Palmore and Luikart 1972, SPARC 1972, Lawton 1974.] This need-most people would say t h i s r i g h t - i s very frequently denied the e l d e r l y by even the most well-meaning f r i e n d s , care personnel and s t a f f of i n s t i t u t i o n s who believe they know best what the e l d e r l y person needs. At worst, the e l d e r l y have to f i t i n with s t a f f needs. (In fa c t the only needs which sane i n d i v i d u a l s cannot assess for themselves are s t r i c t l y medical ones.) To allow people to c o n t r o l t h e i r l i v e s i s to recognize t h e i r d i g n i t y . [Special Senate Committee 1966, SPARC 1972.] Dignity and privacy aire also important to the e l d e r l y and again often denied them e s p e c i a l l y i n i n s t i t u t i o n s . [Audain 1972, Gutman 1975.] We are not saying that any of these needs are s p e c i f i c to the e l d e r l y or that these are t h e i r only needs but these have to be stressed p a r t i c u l a r l y because they do not always seem to be taken s u f f i c i e n t l y into account when plans and provisions are being considered for them. F i n a l l y , any plan contains incentives, encouragement, d i r e c t i o n . The planner has to decide how f a r he must decide on the goals; what, i f any, incentives can be b u i l t i n without depriving the i n d i v i d u a l of the r i g h t to self-determination; and how the common i n t e r e s t i s to be balanced against that of the i n d i v i d u a l when or i f they are i n c o n f l i c t . 180 3 . GROUPS WITH SIMILAR NEEDS Many of the needs or problems of the e l d e r l y are shared with other groups-the unemployed, the c h i l d l e s s , the disabled, the c h r o n i c a l l y i l l , c h i l d r e n , e s p e c i a l l y those with emotional and learning disorders, and the mentally i l l . And of course personal and family stress and c r i s i s may occur at any age. Some e l d e r l y would benefit from programs to prevent and a l l e v i a t e s o c i a l i s o l a t i o n but so would many divorces, many middle-aged unmarrieds, widow(er)s of any age, young people who do not wish to become part of the 'system', and even those i n the system who, i n today's world are prey to various e x t e r n a l i t i e s which reduce t h e i r control over the attainment of th e i r goals and put i n doubt the wisdom of c l e a r l y defined expectations. Sudden l e i s u r e (retirement) may be a problem of old age, but i n -creasing l e i s u r e and the need for preparation for i t s use, applies to a l l age groups. The decline i n labour force p a r t i c i p a t i o n begins at age f o r t y - f i v e . Unemployment may bring i n s e c u r i t y and unhappiness. I t has psychological as well as material implications and these may be greater for people below retirement age who do not have society's sanction for t h e i r i d l e state. The CMA b r i e f to the Senate Committee on Aging recommended community workshops. Would these be needed only or even most by the elderly? The c h i l d l e s s e l d e r l y are almost a separate category. But at any age, the l i f e s t y l e s of parents and c h i l d l e s s persons d i f f e r considerably. Many of the needs of the handicapped coincide with those of the elderly-needs for better transportation, housing, access to recreation and buildings. 181 There has not been a survey of chronic i l l n e s s i n Canada but i n the CMA b r i e f to the Senate Committee on Aging i t was estimated that 50 per cent of patients with chronic i l l n e s s were aged under f o r t y - f i v e . They may a l l need counselling on management of t h e i r i l l n e s s , adaptation of t h e i r physical environment and s o c i a l arrangements, may a l l need various aids and services. The writers of the CELDIC Report*(esp. pp. 11, 299) emphasized the need for more co-ordination and co-operation between d i f f e r e n t departments, services and professionals. And whilst they confined t h e i r d e t a i l e d con-si d e r a t i o n to the needs of c h i l d r e n only, they did recommend (p. 306) "that service programs for c h i l d r e n be developed at the l o c a l l e v e l as i n t e g r a l components of agencies serving the needs of a l l age l e v e l s i n the community", co-ordinated by a community board and integrated by a community services centre. The organizational and operational p r i n c i p l e s to which the B.C. CELDIC Committee was committed (pp. 2,3) could also be p r o f i t a b l y applied to services for the e l d e r l y . These p r i n c i p l e s included i n t e g r a t i o n of separate government and private agencies at the l o c a l l e v e l , community r e s p o n s i b i l i t y for control of funding, planning, operating and developing services; voluntary c i t i z e n and p r o f e s s i o n a l p a r t i c i p a t i o n , - v a r i a t i o n s i n service organizations and community based f a c i l i t i e s , guaranteeing that the i n d i v i d u a l can be cared for i n or close by his own community; an accent on prevention and early intervention; continuity of care, and increased use of volunteers and paraprofessionals. [SPARC 1973 (2)] J u s t i c e Councils, i n i t i a t e d i n May 1974 i n B.C. are tano'ther'"mechanism ^Committee on Emotional and Learning Disorders i n Children 182 set up to f a c i l i t a t e c i t i z e n p a r t i c i p a t i o n , d e c e n t r a l i z a t i o n , communi-cation, co-ordination, cross-system planning and innovation [Lajeunesse, 1976]. D.B. Coates^ has outlined a model of l e v e l s of care for the mentally disturbed which i s d e s c r i p t i v e - a t l e a s t of the better s i t u a t i o n s . I t could be applied normatively to the e l d e r l y a l s o . Features which might p r o f i t a b l y be copied would be the gradual- gradation upwards i . e . i t does not require an acute episode i n order that an intermediate need be recognised and met; t o t a l care i s at the apex of a t r i a g l e , not at the end point of a l i n e which slopes i n one d i r e c t i o n ( i . e . the need for t o t a l care i s seldom permanent or i r r e v e r s i b l e ) ; emergence from the system i s gradual also and various workers who were i n on the treatment and diagnosis stage have to be re-involved. (The e l d e r l y p a r t i c u l a r l y l a c k a connecting l i n k into the service system and out of i t . ) F i n a l l y intimates or casefinders may be able to o f f e r or f i n d s a t i s f a c t o r y solutions without r e f e r r a l to a higher l e v e l of care. The Greater Vancouver Community Mental Health Project i s developing l o c a l area community care teams of a p s y c h i a t r i s t , senior mental health workers ( s o c i a l workers, nurses or psychologists), several mental health workers, an occupational therapist and s e c r e t a r i a l s t a f f to tr y to treat patients i n the community instead of i n h o s p i t a l . The BCMC G e r i a t r i c s Task Force,1975 pointed to the p r o v i n c i a l pat-tern established by CARS i n respect to t h e i r a r t h r i t i s program as having many c h a r a c t e r i s t i c s a p p l i c a b l e to g e r i a t r i c s , i . e . the stress on preven-t a t i v e e x t r a - i n s t i t u t i o n a l aspects of care, working with family practitione-183 and lay organizations i n d i s t r i c t s , employment of a l l i e d health profess-i o n a l s , p r o v i s i o n of w e l l - t r a i n e d consultants, c e n t r a l i z e d records and s t a t i s t i c s , co-ordination of volunteer and community e f f o r t , recognized p r o v i n c i a l base. There are ways then, i n which some e l d e r l y may be more s u i t a b l y i d e n t i f i e d with a category other than one of age. On the other hand other categories may be quite inappropriate. For example, the various provisions such as s p e c i a l c l i n i c s which serve young 'deviants' may be quite inappropriate for the e l d e r l y residents of Skid Row, j u s t as neighbourhood information centres s t a f f e d e n t i r e l y by young persons i n unconventional garb may scare o f f older people however non-donforming or i n need of information they may be. A l l t h i s h i g h l i g h t s one of the problems which the planner must face-j u s t how f a r i f at a l l should s p e c i a l provisions be made for the e l d e r l y . The Foulkes Report [Foulkes 1973] saw no need for a separate system to deal with the health needs of the e l d e r l y . The Special Senate Committee (1966) pointed out (p.4) that "older people can often satisfy, many of t h e i r needs and i n t e r e s t s through e x i s t i n g or emerging community arranges . ments, or could do so i f the opportunity were as r e a d i l y a v a i l a b l e to them as to other age groups i n areas l i k e education arid community recreat-ion, for example" and ( i n t r o ) that "to segregate on the basis of age i s degrading". In a way, to make s p e c i a l p r o v i s i o n for the e l d e r l y i s to say that they are not an i n t e g r a l part of the mesh .that i s society and which i s spontaneous. We don't think out what the status of spouse, c h i l d r e n , cousins, i s , or should be, or f e e l any need to separate o f f t h e i r needs. 184 M o s t p e o p l e w o u l d p r o b a b l y a g r e e t h a t no p u b l i c l y p r o v i d e d s e r v i c e s a v a i l a b l e t o anyone e l s e s h o u l d be r e f u s e d t o t h e e l d e r l y . What has t o be d e c i d e d i s w h e t h e r a l l t h e e l d e r l y need i s a w a t c h -dog w h i l s t v a r i o u s s e r v i c e s a r e l e f t t o d e a l i n t e r a l i a w i t h t h e p r o b l e m s o f t h e e l d e r l y . I n Quebec , p r o v i s i o n f o r t h e e l d e r l y , as f o r p e r s o n s o f a l l a g e s , i s d i v i d e d n o t even a c c o r d i n g t o s e r v i c e , bu t by f u n c t i o n - p l a n n i n g , p r o g r a m m i n g , e t c . The danger i n u n i v e r s a l s e r v i c e s o r f u n c t i o n s i s t h a t s t a t u t o r y s e r v i c e s may be c a r r i e d ou t a t t h e expense o f n o n - s t a t u t o r y ones and w i t h o v e r a l l p l a n n i n g and p rogramming t o o , t h e r e i s s t i l l a d e c i s i o n t o be made as t o how r e c i p i e n t s o f s e r v i c e a r e t o be c a t e g o r i z e d . 4 . NEEDS OF THE SYSTEM O t h e r needs w h i c h a r e r e p o r t e d o r c a n be d e r i v e d , may be c a l l e d t h e needs o f t h e s y s t e m . A t p r e s e n t t h e r e i s no o r g a n i z e d f ramework f o r t h e d e l i v e r y o f p r i m a r y h e a l t h o r s o c i a l c a r e t o a m b u l a t o r y p a t i e n t s o r o t h e r members o f t h e communi ty o f whom many a r e e l d e r l y , and t h e r e i s need f o r some w e l l r e c o g n i z e d e n t r y p o i n t t o t h e s y s t e m w h i c h i s a c c e s s i b l e and a v a i l a b l e and p r e f e r a b l y where s e v e r a l s e r v i c e s may be o b t a i n e d i n one l o c a t i o n . C o - o r d i n a t i o n o f t h e v a r i o u s h e a l t h and s o c i a l s e r v i c e s a t l o c a l l e v e l and c o - o r d i n a t i o n o f p l a n n i n g a t r e g i o n a l l e v e l w o u l d seem t o be t h e b e s t way o f m e e t i n g t h e needs o f t h e e l d e r l y and c o - o r d i n a t i o n o f t h e v a r i o u s ' l e v e l s ' o f c a r e m i g h t e n s u r e more c o n t i n u i t y , w h i l s t a v o i d i n g o v e r - l a p p i n g , d u p l i c a t i o n and o v e r u s e o f t h e more h i g h l y s k i l l e d f a c i l i t i e s and p e r s o n n e l . M o s t o f t h e r e p o r t s we have m e n t i o n e d recommend some s o r t o f body a t n a t i o n a l , p r o v i n c i a l and ( some t imes ) l o c a l l e v e l t o s t i m u l a t e , c o - o r d i n a t e and i n t e g r a t e 185 programmes for the aged. There i s need for teamwork i n the care of the e l d e r l y , and for more services now provided by physicians to be delivered by l e s s highly trained professionals, p a r t i c u l a r l y nurses. (Lalonde points out that at the Kaiser Permanente Foundation i n Oakland, C a l i f o r n i a where nursing personnel carry out procedures and provide counselling i n the chronic care c l i n i c s , four nurses i n c o l l a b o r a t i o n with one M.D. can d e l i v e r as much care as four M.D.s and-at a much lower cost. [Lalonde 1974 p. 60 .J ) The chairman of the Task Force on G e r i a t r i c s to the BCMC believes that a v a r i e t y of health professionals could be trained to carry out an adequate c l i n i c a l evaluation. [Fahrni 1974] Personnel need to be educated to accept that there are oth e r o b j e c t i v e s than cure i n the care of the e l d e r l y , but that the e l d e r l y also want to be as independent as possible. (Administrators need to le a r n that education rather than regulation w i l l improve a t t i t u d e s to the e l d e r l y and therefore the q u a l i t y of the i r treatment. And the population needs to be educated to l i v e l i v e s which may prevent some of the ailments which presently accompany old age and also to recognize that doctors cannot 'cure' old age, or lon e l i n e s s , and that solutions should not be sought from the health care system. A need i s usually expressed f o r research/ In e a r l i e r years, t h i s tended to be research on 'the needs of the e l d e r l y ' . Now there i s more often reference to research into what fa c t o r s contribute to dependency states and to demand for medical care, or the solutions to c e r t a i n needs, or the use and outcome of services. 186 There are problems of resource allocation-between the d i f f e r e n t services f o r the e l d e r l y and between them and those f o r other age groups-i f these should be separated. At l e a s t there should be some means of guaranteeing that i n a time of economies and cutbacks the e l d e r l y do not suffer disproportionately j u s t because of the nature of the i r needs. It w i l l have to be decided i f the main need i s merely for some mechanism l i k e the Council on Aging for Ottawa-Carleton which seeks to i d e n t i f y and p u b l i c i z e the needs of the e l d e r l y i n the community and to mobilize and co-ordinate the resources to meet them, 5. SOCIAL NEEDS Other needs which have to be met are economic needs because unwil-lingness to support the burden of any further r i s e i n the rate of esca-l a t i o n i n health services costs i s what has begun the recent rethinking about provision for health care. And of course the plan w i l l have to be p o l i t i c a l l y v i a b l e which means i n accordance with the o v e r a l l aims of the government and acceptable to the publ i c , as taxpayers, and producers and consumers of services. Conclusion In view of the d i f f i c u l t y of def i n i n g health [Kohn 1965, Robertson 1973, Economic Council of Canada, 1974 p. 89] i t i s not sur-p r i s i n g to f i n d the opinion that "any ch a r a c t e r i z a t i o n of the dimensions, quantitative and q u a l i t a t i v e of requirements for health services i s a r b i t a r i l y defined, at le a s t within the l i m i t s of the present s c i e n t i f i c ignorance". [Kissick, 1968.] 187 We do know that at the present time i n Canada there i s a move to contain the very rapid increase i n health expenditure and i t would be desirable to make economies on services which are now perhaps superfluous i n q u a l i t y or i n s o p h i s t i c a t i o n . One of the groups which may be 'overusing' services i s the e l d e r l y , i n the sense that they may be using medical services when medical services can e f f e c t l i t t l e change i n t h e i r physical status and when other types of service might e f f e c t the improvement i n t h e i r s o c i a l adjustment which i s the most they can hope for and may even be what they are r e a l l y seeking. The major 1976 International Study of health care [Kohn and White 1976] showed that whereas perceived morbidity was the most important v a r i a b l e predisposing to the use of health services i n the twelve areas studied, the strongest predictor of use was perceived a v a i l a b i l i t y of care i . e . health services organization and resource a l l o c a t i o n . It was furthermore put forward that the d i f f e r e n c e s i n use between areas was more l i k e l y explained by s o c i e t a l values and the organization of health services than by i n d i v i d u a l perception of health and health needs, and that i n equating needs for and use of services, resources and systems factors may be more aamenable to s o c i e t a l manipulations than v a r i a b l e s which measure perceived morbidity and a t t i t u d e s . We think that i t i s abundantly clear from the various reports and studies on the needs of the e l d e r l y as perceived by themselves and other people, that one way i n which the need for and use of health services by them may be equated i s by d i v e r t i n g some of the resources now devoted to health services into a v a r i e t y of community s o c i a l services. 188 This would probably be cheaper. I t would probably meet more exactly the perceived needs of the e l d e r l y , who, we suspect, turn to the health care system at present for the sort of help which the s o c i a l system i s f a i l i n g to provide. I f they want love, attention, s e c u r i t y , but cannot be transported to a s o c i a l club or have a f r i e n d l y v i s i t o r , then they may seek what they want i n a home f o r the aged or the emergency department of a h o s p i t a l . Evidence of the reverse trend was given i n the Saskatchewan Report. Over the years several studies have been done of persons attending day centres. They have disclosed that a reduction i n c l i n i c v i s i t s occurred from the time o l d s t e r s became members of day centres. In the c i t y of New York, a study done i n the day centres showed the reduction to be 50 to 70 per cent. The extent of an i n d i v i d u a l ' s involvement i n the a c t i v i t i e s of the day centre c l o s e l y p a r a l l e l e d the reduction i n his c l i n i c v i s i t s . Pre-occupation with i l l n e s s , use of the doctor's w . w a i t i n g room to f i n d needed companionship, the attention sought from c l i n i c personnel a l l became les s important to the old person. Those requiring health care sometimes needed to be prompted to attend c l i n i c s f o r they became so absorbed i n the l i f e of the centre they forgot medical appointments. It therefore appears that when old people be-come active p a r t i c i p a n t s i n organized a c t i v i t i e s there i s less tendency for them to show excessive concern about t h e i r health. [Aged and Long Term I l l n e s s Survey Committee, 1962, p. 132] Weinstock (1974) reports on a programme i n i t i a t e d f o r g e r i a t r i c out-patients of a metro h o s p i t a l to o f f e r opportunity for older people to i n -teract with a group of t h e i r peers to modify t h e i r s o c i a l behaviour. I t was r e a l i s e d that at l e a s t some of the older patients were attending the c l i n i c i n a search f o r s o c i a l i n t e r a c t i o n . "These patients i n part play the 'sick r o l e ' which i s then reinforced by the sympathetic treatment of s t a f f . But i f they are given substitute s o c i a l l y i n t e r a c t i v e opportunities and receive negative reactions to constant p h y s i c a l complaints, t h e i r need to be s i c k might diminish along with the 'need' to attend the c l i n i c . . . " In fact 189 Weinstock's group made considerable progress i n solving t h e i r own problems on t h e i r own and with the help of other members. When old people are asked what they most f e e l the lack of, they do not say h o s p i t a l beds. They say . income (which represents freedom), transportation, community services which enable people to remain i n t h e i r own homes, etc. They make good use of senior c i t i z e n counsellors, s e l f -help programs, nurses i n senior c i t i z e n housing. To screening c l i n i c s they bring as many s o c i a l as health problems. Various studies show that old people prefer to l i v e independently as long as possible. There i s l i t t l e reason to suppose that many people would demand the more expensive forms of health care (usually i n s t i t u t i o n a l ) , i f they could function i n the community. I t i s sometimes objected that even i f the e l d e r l y do not make excessive demands on the system, t h e i r r e l a t i v e s w i l l . It i s true that e l d e r l y people l i v i n g near or with r e l a t i v e s seem to have a higher u t i l i z a t i o n of health services than those l i v i n g alone [Adams and S i n d e l l , 1969, Cartwright 1967], but they also manage to remain i n the community for longer [shanas 1968, Adams and S i n d e l l 1968]. As we have already suggested, a switch of resources from the health to the s o c i a l service system might be more e f f e c t i v e for keeping e l d e r l y people independent and i n the community for longer and more appropriate to t h e i r needs considering the sort of outcomes one can a n t i c i p a t e from the respective services. So not only would manipulation of 'the system' be enough. The r e s u l t might a c t u a l l y coincide with the perceived needs of the e l d e r l y themselves, with regard to which they often seem to be more r e a l i s t i c than health professionals i n recognizing the i n e v i t a b i l i t y of some chronic 190 d i s e a s e and p h y s i c a l d i s c o m f o r t . [WHO 1959, p . 8, Shanas 1968, L i n n 1975J] I t i s i n c r e a s i n g l y r e c o g n i z e d t h a t i n d e v e l o p e d c o u n t r i e s w i t h good p u b l i c h e a l t h f a c i l i t i e s , t h e need t o be h e a l t h y i s no l o n g e r a need f o r mere m e d i c a l c a r e . A p e r s o n ' s l e v e l o f h e a l t h i s r e l a t e d t o many t h i n g s ; an a d e q u a t e income f o r h i m s e l f and h i s f a m i l y , j o b s a t i s f a c t i o n and j o b s e c u r i t y , a d e q u a t e h o u s i n g , f e e l i n g s o f s e l f w o r t h and c o m p e t e n c e , a sound p h y s i o l o g i c a l s y s t e m t h a t has been n o u r i s h e d and c a r e d f o r s i n c e c o n c e p t i o n , a d e q u a t e i n t e l l e c t u a l and e d u c a t i o n a l s t i m u l a t i o n , a c c e s s t o q u a l i t y m e d i c a l and d e n t a l c a r e , s a t i s f a c t o r y m a r i t a l and f a m i l y r e l a t i o n s h i p s , o p p o r t u n i t y f o r r e c r e a t i o n a l and o t h e r l e i s u r e p u r s u i t s , p l u s t h e f e e l i n g o f h a v i n g some c o n t r o l o v e r h i s own d e s t i n y . [ F o u l k e s 1972, Tome I I p . 43.] The h e a l t h c o n c e r n s o f a s o c i e t y have become p a r t o f t h e g e n e r a l s o c i a l s e r v i c e c o n c e r n s o f t h a t s o c i e t y and h e a l t h becomes p a r t o f t h e c o n c e r n f o r t h e p u b l i c w e l f a r e o r w e l l - b e i n g . E v a l u a t i o n o f t h e i m p a c t and i n t e r a c t i o n o f a l l s o c i a l s e r v i c e s c a n l e a d t o more s o p h i s t i c a t e d d e c i s i o n - m a k i n g and r e s o u r c e a l l o c a t i o n , and t o t h e f o r m u l a t i o n o f p o l i c y q u e s t i o n s w h i c h a r e more s p e c i f i c and a r e c o n c e r n e d w i t h l o n g - t e r m e f f e c t s . [Kohn and W h i t e 1976, p . 396.] and f i n a l l y , The W o r k i n g Group b e l i e v e s t h a t h e a l t h g o a l s c a n be a c h i e v e d by n o n - h e a l t h t y p e s o f p r o j e c t s and t h a t s o c i a l s e r v i c e s a r e a s i m p o r -t a n t a s h e a l t h s e r v i c e s i n m a i n t a i n i n g t h e h e a l t h o f t h e e l d e r l y . [ W o r k i n g Group on t h e S t u d y o f H e a l t h S e r v i c e s f o r t h e E l d e r l y 1976.] 191 NOTES " P o p u l a t i o n Projections for Canada and the Provinces 1972-2001 Cat. 91-514, occasional 1974, gave the f i r s t o f f i c i a l Stats Canada population projections by age and sex for Canada and each province and each year from 1972-2001. The four a l t e r n a t i v e sets of projections which allow for d i f f e r e n c e s i n m o r t a l i t y and migration rates are to be revised at three year i n t e r v a l s . 2 The Reports of the 1st and 2nd B.C. Conferences on the Needs and Problems of the Aged, 1957 and 1960, the Aged and Long Term I l l n e s s Survey Committee Report, Saskatchewan, 1963, Health Care i n Nova Scotia, 1963, Special Senate Committee A p r i l 1966, the Canadian Welfare Council Reports, S o c i a l P o l i c i e s for Canada, 1969, and Information and R e f e r r a l Services for the Aged 1970, Aging i n Manitoba, 1970, the Report of the Commission of Inquiry on Health and S o c i a l Welfare, Quebec, 1970, Health Security f o r B r i t i s h Columbians, 1974, etc. etc. 3 Personal communication from Mrs. K e l l e r . 4 Information provided by member of Transportation Committee of SPARC of B.C. ^This i s reproduced i n Equality as an Organizing Concept i n Health Care i n Canada by Anne Crichton, (National Welfare Grant 2559-26-7) mimeo, 1976 p. IV-lOa. ^Proceedings of Senate: Special Committee on Aging, 1964, Vol. 20, Nov. 5. 192 CHAPTER VI INAPPROPRIATE ASPECTS OF PRESENT PROVISIONS There i s a c e r t a i n amount of disagreement among experts as to the a t t r i b u t e s of the e l d e r l y . Do they withdraw from l i f e a c t i v i t i e s (Bromley 1966) and disengage psychologically too (Cumming, Henry 1961)^" or do they enjoy the best years of t h e i r l i v e s ? (Maas, Kuypers 1974). Much of the discrepancy may be accounted for by the fa c t that i n studying 'the e l d e r l y ' , people may be looking at an age range from s i x t y to one hundred, and t h i s w i l l obviously include a whole range of a t t r i b u t e s also. The date of the research may also be s i g n i f i c a n t as each cohort of e l d e r l y seems to push forward somewhat the l i m i t s of what they can do, do,do, and expect to do. We do know that on the whole, the e l d e r l y have the same s o c i a l and psychological needs as any other age group though there may be more f r u s t r a t i o n s i n the way of a t t a i n i n g them. Most old people wish to be independent, s e l f - d i r e c t i n g , goal-oriented and involved as long as possible, and t h i s normally means being part of the community and as far as possible i n t h e i r own homes. To remain i n the community and reasonably independent, they require adequate income, adequate accommodation and varying amounts of support services. And for them to be independent and to obtain s a t i s f a c t i o n from l i f e , good health i s an important, i f not the most important contributing f a c t o r . However, as we have already seen, medical services are only one of the services which contribute to health; 193 medical services on the whole are e f f e c t i v e only i n tre a t i n g (some)active i l l n e s s and i n fac t only a small percentage of the e l d e r l y population requires medical and/or nursing care at any time. (5 per cent i s the usual estimate). Yet over the l a s t twenty years, these people i n common with the re s t of the population, have been offered a 'health care system' i n which the major emphasis has been on treatment of sickness, on h o s p i t a l s , on diagnosis and cure, and on acute care. . Much more attention and resources have been devoted to i n s t i t u t i o n a l care than to community ser-v i c e s . And there has been a 'medicalization' of needs and of services which might have been more appropriately viewed and dealt with i n a d i f f e r e n t way. EMPHASIS ON HOSPITALS AND ACUTE CARE We s h a l l look l a t e r at the factors which encouraged the bu i l d i n g of h o s p i t a l s i n Canada, and then the increase i n the use and cost of medical care. How costs have escalated i s shown i n Table XVI for Canada and Table XVII f o r B.C. Even before the introduction of medicare, pro-v i n c i a l expenditure on health services rose more than eight times i n current d o l l a r s between 1947 and 1963 i . e . from 12 per cent to 22 per cent of t o t a l p r o v i n c i a l expenditure per annum (Hanson 1964), but as t o t a l government expenditure on health services was s t i l l only 3 per cent of G.N.E., no concern was expressed about costs at that time. Indeed when Medicare was being considered, i t was anticipated that t o t a l government spending would eventually r i s e to 5^ per cent, but "Canadians can af f o r d a high standard of health services, a v a i l a b l e to a l l , and the funds required can be made a v a i l a b l e l a r g e l y from a d d i t i o n a l 194 growth. The challenge facing the Canadian people i s to devise the appropriate p o l i c i e s and measures needed to tran s l a t e the objective of comprehensive health services for a l l into r e a l i t y " [Hanson 1964, p. 123]. However the further increases i n costs-from $3.7 b i l l i o n i n 1967 to a projected $6.2 b i l l i o n i n 1972-after the passing of the Medical Care Act (1966) led to the set t i n g up of the Committee on the Cost of Health Services i n 1969 to f i n d ways to r e s t r a i n the growth of cost increases. In 1969 the cost of health services, at 5.5 per cent of G.N.P. was s t i l l d i s turbing •-. . •[ Robertson, 1973, p. 108]. In 1974 when the fi g u r e was 7 per cent, the fede r a l government f i n a l l y decided to take a firm stand. At present the na t i o n a l costs of health care i n Canada are among the highest i n the world. This importance accorded to medical services, e s p e c i a l l y acute h o s p i t a l care, has had various repercussions which have affected the el d e r l y (and most of which have affected other age groups a l s o ) . F i r s t of a l l , the benefits of advances i n medicine and tech-nology have meant that the e l d e r l y can be succ e s s f u l l y treated for con-d i t i o n s that would once have been d i s a b l i n g or f a t a l . When sickness s t r i k e s there are excellent f a c i l i t i e s a v a i l a b l e . However s t a f f consider that the tempo of acute h o s p i t a l s i s not always suited to the e l d e r l y patient [GVRHD' 19;7^55(2)a];they probably take longer to recover so that s t a f f may become impatient or uninterested, and discharge planning, which i s very important f o r very many e l d e r l y people may be e n t i r e l y neglected. If they occupy an acute bed for long whilst waiting for a long-term bed, lack of a c t i v a t i o n may a c t u a l l y hasten t h e i r d e t e r i o r a t i o n . 195 Some acute h o s p i t a l s do not even have occupational therapists or speech therapists on s t a f f . In spite of t h i s , e l d e r l y patients may be occupying acute beds unnecessarily whilst waiting for an extended or intermediate care bed. In the summer of 1975, the waiting times for the extended care units at Lions Gate, St. Pauls and St. Vincent Hospitals i n Greater Vancouver ranged from a year to eighteen months. Sometimes patients have to wait so long for extended care beds that they improve to intermediate care l e v e l . This requires re-assessment and transfer to another waiting l i s t . On the contrary, a long wait for a r e h a b i l i t a t i o n place often allows the e l d e r l y patient to deteriorate. Some h o s p i t a l administrators and s o c i a l workers r e a d i l y admit that they take a "very firm hand" i n order to free up beds occupied by extended care patients, mainly by saying that the a l t e r n a t i v e s are a private nursing home l o c a l l y or an extended care bed i n a remote part of the province. Increasing the number of extended care beds has not to date lessened the waiting time-perhaps because extended care patients are l i v i n g longer, perhaps because an increase i n bed numbers has made entrance requirements l e s s s t r i c t ( u n o f f i c i a l l y any way). On the other hand some people believe that already we are preparing to over-provide with extended care beds. I t i s pretty i n c o n t r o v e r t i b l e that no matter how many beds are provided, they w i l l be f i l l e d (except perhaps i n cer-t a i n geographic l o c a t i o n s ) . The present apparent shortage of extended care beds might well be a l l e v i a t e d i f more community services were made 196 a v a i l a b l e which would allow actual or p o t e n t i a l extended care patients to return to the community. Mental Health Services In p s y c h i a t r i c units of general h o s p i t a l s very few e l d e r l y patients are accepted. Various reasons are given for this-most are 'geared' to t r e a t i n g young acute, the programme i s designed to change at t i t u d e s and the old are slow to change, t r y i n g to motivate the old i s d i f f i c u l t , noisy young people may annoy them, shortage of boarding homes and intermediate care f a c i l i t i e s i n some areas may make placement d i f f i -c u l t . This despite the fa c t that r e a c t i v e depressions and other psychi-; a t r i c i l l n e s s e s i n the e l d e r l y have been shown to respond to treatment, [Campbell, 1974] (In f a c t , disturbed brain function i s often the r e s u l t of organic processes which are r e v e r s i b l e ) and i t i s also coming to be accepted that the stereotype of the e l d e r l y as slow to change may not be as accurate as has been believed. A psychologist appears to be used to considerable advantage i n the Sunnybrook Medical Centre i n Toronto extended care department (average age over 75 years)-for i n d i -v i d u a l , couple, family group therapy and for s t a f f consultation, [shedletsky 1976] Staff of some acute h o s p i t a l s claim that i t i s d i f -f i c u l t or impossible to arrange admission to Riverview of patients aged under seventy with brain syndromes or symptoms r e s u l t i n g from alcoholism which makes them unmanageable i n the community, and of other long-term patients s t i l l i n need of treatment. The lack of f a c i l i t i e s for dealing with patients between the ages of s i x t y - f i v e or even s i x t y , and seventy 197 i s d e p l o r e d by many, and c a n be a b u r d e n on t h e a c u t e g e n e r a l h o s p i t a l w h i c h may be l e f t w i t h them. The G r e a t e r V a n c o u v e r M e n t a l H e a l t h S e r v i c e has no i n p u t i n t o programmes i n homes f o r t h e e l d e r l y . I t i s f e l t by many t h a t t h i s p o p u l a t i o n c o u l d b e n e f i t f rom a d v i c e s u c h a s t h e i n a d v i s a b i l i t y o f s e g -r e g a t i n g t h e s e x e s , e t c . bu t t h e s e r v i c e has been s p e c i f i c a l l y t o l d by government t h a t t h i s i s n o t i n c l u d e d i n t h e i r r e m i t . ( I t _is i n t h e man-d a t e o f o t h e r M e n t a l H e a l t h C e n t e r s i n B . C . t h o u g h i t i s n o t p r o v i d e d . ) What t h e V a n c o u v e r s e r v i c e p r o v i d e s i n f a c t i s i n d i v i d u a l t r e a t m e n t f o r t h e s e v e r e l y d i s t u r b e d . T h e r e i s no c o n s u l t a t i o n t o f a m i l i e s o f e l d e r l y p e r s o n s (as i n t h e U . S . M e n t a l H e a l t h S e r v i c e s ) and no c o n s u l -t a t i o n and p r e p a r a t i o n f o r r e t i r e m e n t . The Broadway C l i n i c f o r e x -R i v e r v i e w p a t i e n t s does r u n a w e e k l y S e n i o r s Group f o r p e o p l e who have d i f f i c u l t y i n s o c i a l i z i n g and c o p i n g w i t h e x c e s s i v e l e i s u r e t i m e . One o f t h e f a c t o r s c o n t r i b u t i n g t o t h e i n a d e q u a c y o f f a c i l i t i e s f o r t h e e l d e r l y p s y c h i a t r i c p a t i e n t i s t h e l a c k o f q u a l i f i e d s t a f f . So f a r B . C . has t e n d e d t o i m p o r t d o c t o r s f o r p s y c h i a t r i c w o r k i n i n s t i t u t i o n s . P s y c h o g e r i a t r i c s i s a p p a r e n t l y u n i n t e r e s t i n g t o most d o c t o r s and i t a p p e a r s t h a t l i t t l e e f f o r t has been made t o make i t a n i n t e r e s t i n g o r c h a l l e n g i n g f i e l d i n t h i s P r o v i n c e . R e h a b i l i t a t i o n The c o n c e n t r a t i o n on a c u t e c a r e and on p a t i e n t s w i t h p o t e n t i a l f o r r a p i d o r d r a m a t i c improvement has o t h e r i m p l i c a t i o n s t o o f o r t h e e l d e r l y . T h e r e i s a t e n d e n c y f o r p e r s o n n e l t o behave a s i f o n l y t h e a c u t e l y i l l c a n r e s p o n d t o t h e r a p y . To a t t e m p t to i m p r o v e t h e f u n c t i o n 198 o f t h e i m p a i r e d p a t i e n t , e s p e c i a l l y t h e e l d e r l y one i s t o o o f t e n s e e n as a w a s t e o f t i m e . T h i s a t t i t u d e o f t e n s p i l l s o v e r t o t h e e x t e n d e d c a r e h o s p i t a l where a c t i v a t i o n o f l o n g t e r m p a t i e n t s i s n o t a h i g h p r i o r i t y . I n f a c t , c h r o n i c a l l y i l l p a t i e n t s a r e o f t e n c o n s i g n e d t o a l o n g t e r m f a c i l i t y w i t h o u t a d e q u a t e a s s e s s m e n t o f t h e i r p o t e n t i a l f o r r e h a b i l i t a t i o n . The i n a d e q u a c y o f r e h a b i l i t a t i o n f a c i l i t i e s i n B . C . , m e s p e c i a l l y o u t s i d e V i c t o r i a and V a n c o u v e r , has b e e n documented [ F o u l k e s , 1974 Tome I V ] . The R o y a l C o m m i s s i o n on H e a l t h S e r v i c e s [ H a l l 1964, V o l . I , pp .633-35] f o u n d t h a t r e h a b i l i t a t i o n s e r v i c e s were on t h e w h o l e i n s u f f i c i e n t i n Canada and u s u a l l y d i r e c t e d by o r t h o p a e d i s t s o r p o d i a t r i s t s . I t n o t e d t h a t r e h a b i l i t a t i o n i s n o t a s p e c i f i c t y p e o f s e r v i c e b u t an o b j e c t i v e u n d e r l y i n g a g r e a t v a r i e t y o f s e r v i c e s , and means more t h a n must m e d i c a l r e s t o r a t i o n . " R e h a b i l i t a t i o n s e r v i c e s f o r t h o s e above r e t i r e m e n t age m i g h t r e s t o r e them f r o m h e l p l e s s n e s s and dependency t o s e l f - c a r e and a c o n s i d e r a b l e d e g r e e o f i n d e p e n d e n c e " . (The C o m m i s s i o n recommended 0.5 beds p e r 1000 o f p o p u l a t i o n f o r r e h a b i l i t a t i o n / a c t i v a t i o n ) . The S p e c i a l S e n a t e Commi t t ee on A g i n g (1966) a l s o had recommended t h a t i n a l l i n s t i t u t e : i o n a l f a c i l i t i e s , a p o s i t i v e a t t i t u d e be a d o p t e d t o w a r d t h e p o s s i b i l i t y o f r e h a b i l i t a t i n g e l d e r l y p e o p l e . ( A t l e a s t one a d v a n t a g e o f a c u t e h o s p i t a l t r e a t m e n t i s t h a t p a t i e n t s a r e e x p e c t e d t o r e c o v e r ) . T h a t t i m e s p e n t on r e h a b i l i t a t i o n o f t h e e l d e r l y i s n o t w a s t e d i s shown w h e r e v e r s u c h f a c i l i t i e s a r e p r o v i d e d . [ C o s i n , 1973, S t a t i s t i c a l R e p o r t s o f H o l y F a m i l y A c t i v i t i e s C e n t r e ] . As there." i s s s c a n t p r o v i s i o n o f , o r b e l i e f i n , t h e need f o r c o n v a l e s c e n t c a r e e i t h e r , a f t e r 199 the acute phase of i l l n e s s , the acute h o s p i t a l does not appear to be suited to the needs of the e l d e r l y . Whilst we recognize that many c r i t i c i s m s have been made of the g e r i a t r i c h o s p i t a l , we have nevertheless been impressed by those organi-zed by Dr. Ferguson Anderson i n the C i t y of Glasgow i n Scotland. The c i t y i s divided into f i v e sectors, each with a population of about a quarter of a m i l l i o n , with a g e r i a t r i c unit i n each, attached to a major general h o s p i t a l . A 1972 study showed that of patients referred from home or by the acute f a c i l i t y , two-thirds were accepted for a program of f u l l medical and s o c i a l i n v e s t i g a t i o n and r e h a b i l i t a t i o n . [Isaacs et a l , 1972] There were four c r i t e r i a for admission to the G e r i a t r i c Unit- -therapeutic optimism (one-third) (discharge l i k e l y within three months), medical emergency (one-half), basic care (one-quarter) (patient lacked food, warmth, cl e a n l i n e s s or safety as a r e s u l t of i l l n e s s ) and r e l i e f of s t r a i n (one-third) ( i f helper was su f f e r i n g undue physical or mental exhaustion). (N.B. G e r i a t r i c care was not an automatic a l t e r n a t i v e to the acute h o s p i t a l a f t e r a c e r t a i n age.) When four groups of e l d e r l y people drawn from g e r i a t r i c patients, general medical patients, a random group and a matched group of non-patients were studied, the g e r i a t r i c patients were found to be older, more l i k e l y to be sing l e or widowed, to l i v e alone and to be s o c i a l l y deprived. There was among them a much higher incidence of f a l l s , i n a b i l i t y to walk, incontinence and mental abnormality-dementia or confusion (about 50 per cent) and of a longer period of care at home (25 per cent over a year) before admission. For g e r i a t r i c patients 200 the average stay was s i x months. Most medical patients who survived were discharged r a p i d l y ; of the g e r i a t r i c s , one-third went home a f t e r one to three months, one-third died within three months and one-third were transferred to long stay wards. 51 per cent of g e r i a t r i c patients were incontinent. Of these 15 per cent went home continent, but on the whole patients with mental abnormality and/or incontinence were u n l i k e l y to be discharged home. The majority of patients transferred from general medical and s u r g i c a l wards f a i l e d to improve a f t e r f u l l i n v e s t i g a t i o n and treatment and while some responded favourably to intensive r e h a b i l i t a t i o n , a large proportion became long-stay patients. It i s not clear where such a group would be found i n Canada-probably dispersed between acute care, intermediate care and extended care. What does seem l i k e l y i s that i n the l a s t two l o c a t i o n s at l e a s t they would never have such a good chance of r e h a b i l i t a t i o n as they would i n a G e r i a t r i c Unit. In fact i n spite of the reported d i s l i k e of the e l d e r l y of being segregated i n an i n s t i t u t i o n s p e c i a l l y f or t h e i r age group, they might well receive more o p t i m i s t i c a l l y a c t i v e treatment i n the G e r i a t r i c Hospital ( e s p e c i a l l y one attached to an acute hospital) than i n i n s t i t u t i o n s categorized according to the patients' physical status, where the possible modification of that status may not even be considered. Relative Neglect of Preventive and Community Services The bias i n favour of h o s p i t a l and acute care i s evident i n the amount of financing devoted to various parts of the health care system (Table XVIII). The h o s p i t a l i s also patently the focus of care. 45 per cent of physicians i n B.C. were functioning as s p e c i a l i s t s i n 1975 [ D i v i s i o n of Health Services Research and Development, U.B.C, 1976]. Shanas et a l (1968) found 21 per cent i n England and Wales, and 30 per cent i n Denmark. Also, of 12,347 R.N.s p r a c t i s i n g i n B.C. i n 1975, there were only 1188 i n community services (public health, occupational health, home care, community health), 239 i n physicians' o f f i c e s , eighty-nine i n nursing homes and 9544 i n h o s p i t a l s . [ D i v i s i o n of Health Services Research and Development, U.B.C, 1976]. (Yet Castonguay reported that 80 per cent to 90 per cent of demand involves only the primary care l e v e l ) [Government of Quebec, 1970, Vol. IV, Tome II p.32]. This means that there i s a comparative neglect to provide preventive ser v i c e s , such as screening, counselling, education, which might prevent more serious i l l n e s s i n a l l age groups but may be p a r t i c u l a r l y e f f e c t i v e with the e l d e r l y . Community services are also r e l a t i v e l y undeveloped. Any system of care for the e l d e r l y which i s to keep them out of i n s t i t u t i o n s requires a comprehensive, co-ordinated system of community services - nurses, c l i n i c s , physiotherpay, home-makers, n i g h t - s i t t e r s , O.T. (So f a r the B.C. Government refuses to pay for O.T. services i n the home), and, attached to i n s t i t u t i o n s i f necessary, out-patient care, day h o s p i t a l s . There i s nothing i n B.C. equivalent for example to the four Oxford Day Hospitals with m u l t i - d i s c i p l i n a r y f a c i l i t i e s f o r three hundred patients having f i v e hundred attendances each f i v e day week, which provide continuing physiotherapy, O.T., and speech therapy to patients who have had t h e i r c a r d i o - r e s p i r a t o r y or mild cerebro-vascular episodes treated at home by the primary care physician. [Cosin, 1973]. 202 T r a n s p o r t a t i o n w o u l d make s e r v i c e s a c c e s s i b l e and t h e r e f o r e a v a i l a b l e t o t h e e l d e r l y who w o u l d p e r h a p s u s e s e r v i c e s e a r l i e r and so a v o i d u n n e c e s s a r y d e t e r i o r a t i o n , u s e a p p r o p r i a t e s e r v i c e s i n s t e a d o f t h e o n l y a c c e s s i b l e ones ( e . g . p h y s i c i a n ' s o f f i c e by c a r i n s t e a d o f emergency d e p a r t m e n t by ambulance ) and be a b l e t o t a k e an a c t i v e p a r t i n communi ty l i f e so t h a t t h e y w o u l d p r o b a b l y p r e s e n t f ewer h e a l t h p r o b l e m s i n any c a s e , and f i n a l l y , i t w o u l d p o s t p o n e o r remove t h e need f o r i n s t i t u t i o n a l i -z a t i o n . I t ems l i k e eye g l a s s e s , d e n t u r e s , h e a r i n g a i d s , b r a c e s and a r t i f i c i a l l i m b s a l l have t o be p a i d f o r by e l d e r l y p e r s o n s ; y e t t h e s e t o o a r e i m p o r t a n t a s a i d s t o i n d e p e n d e n t f u n c t i o n i n g . A s a m a t t e r o f f a c t , i n t h e c a s e o f p r o s t h e s e s , o r t h e s e s and s p e c i a l d e v i c e s , i t i s e s t i m a t e d t h a t o n l y f i v e p e r c e n t o f p a t i e n t s pay f o r t h e i r own s e r v i c e s b u t a s t h e r e a r e t w e n t y - s e v e n a g e n c i e s , p u b l i c and p r i v a t e , p r o v i d i n g f i n a n c i n g , t h e " s h o p p i n g a r o u n d " r e q u i r e d i s t i m e - c o n s u m i n g f o r s o c i a l w o r k e r s - a n d i m p o s s i b l e f o r most p a t i e n t s . [SPARC 1973] HOME CARE From t h e i n c e p t i o n o f t h e N a t i o n a l H e a l t h Programme, g r a n t s were made a v a i l a b l e t o a s s i s t n e w l y e s t a b l i s h e d home c a r e programmes , b u t a s t h e i n i t i a t i v e had t o come f r o m t h e l o c a l a r e a s c o n c e r n e d , and e x p e r i m e n -t a t i o n was e n c o u r a g e d , t h e r e was no s y s t e m a t i c o r g a n i z a t i o n d e v e l o p e d . E s t i m a t e s o f t h e s a v i n g s e f f e c t e d by home c a r e p l a n s v a r y . H o w e v e r , i t i s q u i t e c l e a r t h a t u n l e s s t h e r e i s an a c c o m p a n y i n g r e d u c t i o n i n h o s p i t a l b e d s , h o s p i t a l c o s t s w i l l i n f a c t go u p . I f t h e o b j e c t i v e i s t o e c o n o m i z e , i t w i l l f a i l i f e l d e r l y p e o p l e a r e k e p t o u t o f a c u t e beds by p r o v i s i o n o f c a r e , b u t t h e beds a r e t h e n o c c u p i e d by younge r peop le . . 203 There are various d i f f i c u l t i e s . Some administrators i n h o s p i t a l s with short waiting l i s t s fear empty beds. I t i s easier for doctors to v i s i t patients i n h o s p i t a l , and i t may be cheaper for patients to be i n h o s p i t a l . (From the point of view of the financing agency, even t h i r t y -f i v e d o l l a r s to f i f t y - f i v e d o l l a r s per day for a twenty-four hour home-maker service i s cheaper than the acute h o s p i t a l per diem.) The main ad-vantage of home care for the e l d e r l y appears to be that i t could help to keep them out of i n s t i t u t i o n s . In Sweden where homehelpers are a v a i l a b l e to 4.7 per cent of people over s i x t y - f i v e , 5 per cent are i n homes for the aged. In Denmark, the Netherlands and Finland, corresponding f i g u r e s are 2.3 per cent and 6 per cent, 0.6 per cent and 8.2 per cent, 0.5 per cent and 10 per cent [Brickner et a l , 1975]. The Chelsea-Village Programme i n Manhattan was started i n January 1973 to meet the health-associated needs of the homebound, i s o l a t e d e l d e r l y with the doctors, nurses and s o c i a l workers of St. Vincent's H o s p i t a l , plus a co-ordinator and a d r i v e r . In the f i r s t sixteen months of operation, they had two hundred r e f e r r a l s . I t i s reckoned that without the program, seventy would have been i n s t i t u t i o -n a l i z e d . Sixteen a c t u a l l y improved to being no longer homebound. That home care services could be expanded i n B.C. i s evidenced apart from anything else by the widely d i f f e r i n g use of the service at present from one area to another [GVRHD 1975(1) p7]. If i t i s to be expanded there would have to be a big increase i n the number of homemakers and probably also the incorporation of some s k i l l s not so far included, such as r e c -r e a t i o n a l therapy, OT and volunteers. An expanded Home Care Service would have to be a-more h i g h l y organized operation than i t i s at present and not 204 arranged through a h o s p i t a l based l i a i s o n person. A d e c i s i o n would have to be made as to who i s to be responsible for deciding on the type and length of services required, and what i s to be the mechanism for co-ordinating the various services. A good model might be the O f f i c e of Continuing Care established i n 1974 i n the Community Services D i v i s i o n of the Manitoba Department of Health and S o c i a l Development. [Shapiro 1976] Shanas found (1968 p.112) that e l d e r l y persons without a spouse, ch i l d r e n or other r e l a t i v e s were more l i k e l y to be i n i n s t i t u t i o n s . And lack of community services may also force people to apply for i n s t i t u t i o n a l care. [Kraus, 19761] Indeed, with many people the f i r s t public intervention may come only when they need or apply for i n s t i t u t i o n a l care. Even where there are clear medical problem