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Access to primary health care : a case study of regional disparities in health manpower distribution… Auyeung, Lankwai 1978

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ACCESS TO PRIMARY HEALTH CARE: A CASE STUDY OF REGIONAL DISPARITIES IN HEALTH MANPOWER DISTRIBUTION IN BRITISH COLUMBIA by LANKWAI AUYEUNG B.A., Brock University, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (School of Community and Regional Planning) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1978 Copyright Lankwai AuYeung, 1978 In p r e s e n t i n g t h i s t h e s i s in 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 degree at the U n i v e r s i t y o f B r i t i s h Co lumb ia , I a g ree that the Library 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 tudy . I f u r t h e r agree 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 purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that 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 thout my w r i t t e n p e r m i s s i o n . Department o f School of Community and Regional Planning The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 Date Oct- I V W £ ABSTRACT Pre-paid medical and h o s p i t a l insurance i n Canada has enabled many people to o b t a i n medical s e r v i c e s that they could not p r e v i o u s l y a f f o r d , but equal access to h e a l t h care i s not yet ensured f o r a l l segments of the p o p u l a t i o n . . I t has been suggested that h e a l t h care resources, p a r t i c u l a r l y manpower, tend to concentrate i n urban centres, w h i l e r u r a l and remote areas have inadequate resources. In t e s t i n g the r e l a t i o n s h i p between r u r a l i t y and a c c e s s i b i l i t y to primary h e a l t h care, t h i s t h e s i s aims at e n r i c h i n g the knowledge base f o r m i t i g a t i o n d e c i s i o n s . Seven groups of primary h e a l t h care personnel were examined: general p r a c t i t i o n e r s , pharmacists, d e n t i s t s , general surgeons, p e d i a t r i c i a n s , o b s t e t r i c i a n s and p s y c h i a t r i s t s Nine study regions were ranked by r u r a l i t y and a c c e s s i b i l i t y . R u r a l i t y was measured by (1) p r o p o r t i o n of r u r a l p o p u l a t i o n r e s i d i n g i n the study r e g i o n , and (2) distance of the study r e g i o n to the nearest m e t r o p o l i t a n centre. A c c e s s i b i l i t y was measured by (1) t r a v e l d i stance to the nearest h e a l t h care personnel, and (2) the r a t i o of h e a l t h care personnel to the r e g i o n a l p o p u l a t i o n . R u r a l i t y was then c o r r e l a t e d w i t h a c c e s s i b i l i t y . R u r a l i t y was a l s o c o r r e l a t e d w i t h w a i t i n g time f o r an appointment w i t h a general p r a c t i t i o n e r , and s t a t i s t i c a l t e s t s f o r s i g n i f i c a n t d i f f e r e n c e were performed to determine i f w a i t i n g time v a r i e s w i t h community s i z e . The relationship between practice locations of general p r a c t i t i o n e r s and th e i r personal attributes was tested (1) by corre l a t i n g r u r a l i t y with place and year of graduation, and (2) by testing for s i g n i f i c a n t difference i n place and mean year of graduation among d i f f e r e n t community size groups. S i g n i f i c a n t difference tests were also performed to test the e f f e c t of the federal p o l i c y r e s t r i c t i n g physician immigration on the proportion of foreign physicians i n r u r a l areas. The r e s u l t of the a c c e s s i b i l i t y test supports the hypothesis that a c c e s s i b i l i t y diminishes with r u r a l i t y . It also suggests that serious maldistributions occur i n primary care sub-specialty personnel, namely ped i a t r i c i a n s , obstetricians and p s y c h i a t r i s t s , and that there are i n t r a -regional d i s p a r i t i e s as well as inter-regional d i s p a r i t i e s . General p r a c t i t i o n e r s are the least inequitably d i s t r i b u t e d . The findings reveal that population dispersion and small settlements are the primary obstacles to achieving equal access. Results of the waiting time tests were inconclusive. There i s no evidence to support a l i n e a r r e l a t i o n s h i p between waiting time and r u r a l i t y . Long waiting times appear to associate with both the most r u r a l and the least r u r a l regions. S t a t i s t i c a l tests of waiting time by community size indicate high v a r i a b i l i t y , p r o h i b i t i n g meaningful comparison of the means. iv The tests of personal attributes of general p r a c t i t i o n e r s indicate that age (year of graduation) decreases with r u r a l i t y , and increases with community size, and that the proportion of non-B.C. graduates increases with r u r a l i t y , but i s not affected by community size. Federal immigration r e s t r i c t i o n s have diminished the proportion of foreign physicians i n r u r a l communities, but not i n urban or metropolitan centres. The concluding discussion of po l i c y implications covers: (1) Manpower Planning with special emphasis on the roles of the government, the Colleges and the University, and the potentials of various p o l i c y options, and (2) Regionalization and i t s application i n health manpower planning. V TABLE OF CONTENTS CHAPTER PAGE I. INTRODUCTION 1 Access to Health Care 1 Primary Health Care 4 Research Objective 7 Thesis Organization 7 II. STUDY DESIGN 8 Study Area and Study Population 8 Study Procedure 12 Study Hypotheses 12 III. METHODOLOGY 18 A c c e s s i b i l i t y Analysis 18 Analysis of Factors Influencing Physicians Location 28 IV. DISCUSSION OF RESULTS 31 Relationship between A c c e s s i b i l i t y and Rurality 31 Limitation of the--Research 57 Relationship between Waiting Time and Rurality . . . . , 57 Relationship between Personal Attributes of Physicians and Rurality 63 V. INTRA-REGIONAL ACCESSIBILITY 73 Study Region 1. Kootenays 73 Study Region 2. Okanagan 82 Study Region 3. Central Int e r i o r 85 Study Region 4. South-West 91 Study Region 5. Metropolitan 93 v i Study Region 6. South Vancouver Island . . 94 Study Region 7. Mid Coast 97 Study Region 8. North-West 100 Study Region 9. Peace River 104 VI. POLICY IMPLICATIONS . 107 Nature of D i s p a r i t i e s 107 Manpower Planning 109 Regionalization 118 BIBLIOGRAPHY 123 APPENDICES APPENDIX A: RURALITY RANKING BY STUDY REGION . . 128 APPENDIX B. ESTIMATES OF POPULATION BY COMMUNITY AND SUB-REGION, 1976 129 APPENDIX C.l POPULATION BY TRAVEL DISTANCE TO THE NEAREST GENERAL PRACTITIONERS OR FAMILY PHYSICIANS BY CATCHMENT AREA: 143 APPENDIX C.2 POPULATION BY TRAVEL DISTANCE TO THE NEAREST PHARMACISTS BY CATCHMENT AREA : 147 APPENDIX C.3 POPULATION BY TRAVEL DISTANCE TO THE NEAREST DENTISTS BY CATCHMENT AREA . 151 APPENDIX C.4 POPULATION BY TRAVEL DISTANCE TO THE NEAREST GENERAL SURGEONS BY CATCH.-. MENT, AREA 154 APPENDIX C.5 POPULATION BY TRAVEL DISTANCE TO THE NEAREST PSYCHIATRISTS BY CATCHMENT AREA 156 APPENDIX C.6 POPULATION BY TRAVEL DISTANCE TO THE NEAREST PEDIATRICIANS BY CATCHMENT AREA 157 APPENDIX C.7 POPULATION BY TRAVEL DISTANCE TO THE NEAREST OBSTETRICIANS OR GYNAECOLO-GISTS BY CATCHMENT AREA 158 APPENDIX D TEST OF SAMPLE VARIANCE BETWEEN TWO TEST' SAMPLES'FOR URGENT WAITING TIME ANALYSIS 159 v i i APPENDIX E WAITING TIME FOR AN APPOINTMENT WITH A GENERAL PRACTITIONER 160 APPENDIX F YEAR OF GRADUATION AND PLACE OF GRADUATION 163 APPENDIX G.l .1 ACCESSIBILITY RANKING BY TRAVEL DISTANCE BY STUDY REGION 167 II RANK CORRELATION BETWEEN TRAVEL DISTANCE AND RURALITY 169 APPENDIX G.2 I ACCESSIBILITY RANKING BY POPULA-TION/HEALTH PERSONNEL RATIO BY STUDY REGION 170 II RANK CORRELATION BETWEEN POPULA-. • TION/HEALTH PERSONNEL RATIO AND RURALITY 172 APPENDIX H I WAITING TIME RANKING BY STUDY REGION 173 II RANK CORRELATION BETWEEN WAITING TIME AND RURALITY . 173 APPENDIX I RESULTS OF STATISTICAL TESTS . . . . 174 APPENDIX J I PLACE AND YEAR OF GRADUATION RANKING BY STUDY REGION 178 II RANK CORRELATION BETWEEN PLACE AND YEAR OF GRADUATION AND RURALITY 178 v i i i LIST OF TABLES TABLE PAGE 1. RURAL/URBAN POPULATION ESTIMATES BY STUDY REGION 11 2. RANKING OF STUDY REGIONS BY RURALITY 20 3. ANALYSIS OF WAITING TIME, SAMPLE SIZE AND USABLE RESPONSES 27 4. FACTORS OF INFLUENCE, SAMPLE SIZE 30 5.1 ACCESSIBILITY INDEX A, POPULATION BY TRAVEL DISTANCE BY STUDY REGION, 1975-76 . . . . . . 32 5.2 ACCESSIBILITY INDEX A, POPULATION BY TRAVEL DISTANCE BY STUDY REGION, 1975-76 33 6. ACCESSIBILITY INDEX B, NUMBER AND POPULATION/ HEALTH PERSONNEL RATIO BY STUDY REGION, 1975-76 34 7. RANGE OF POPULATION/HEALTH PERSONNEL RATIOS BY STUDY REGION 38 8.1 TRAVEL DISTANCE (ACCESSIBILITY INDEX A) AS RELATED TO RURALITY BY STUDY REGION . . . . . 39 8.2 POPULATION/HEALTH PERSONNEL RATIO (ACCESSIBILITY INDEX B) AS RELATED TO RURALITY BY STUDY REGION 40 9. ACTUAL AND RECOMMENDED NUMBER OF PRIMARY HEALTH CARE PERSONNEL BY STUDY REGION . . . . 43 10. PERCENTAGE DISTRIBUTION OF POPULATION AND PRIMARY HEALTH CARE PERSONNEL BY STUDY REGION 45 11. MEAN WAITING TIME FOR A G.P. APPOINTMENT AS RELATED TO RURALITY BY STUDY REGION 59 12.1 MEAN WAITING TIME (URGENT) FOR A G.P. APPOINTMENT BY COMMUNITY TYPE (SIZE) 61 12.2 MEAN WAITING TIME (NON-URGENT) FOR A G.P. APPOINTMENT BY COMMUNITY TYPE (SIZE) 61 13. 'MEAN .YEAR OF GRADUATION .AS- RELATED TO RURALITY BY STUDY REGION 64 14. MEAN YEAR OF GRADUATION BY COMMUNITY TYPE (SIZE) 64 i x 15. PLACE OF GRADUATION AS RELATED TO RURALITY BY STUDY REGION 68 16. PLACE OF GRADUATION BY COMMUNITY TYPE (SIZE) 69 17. ANNUAL RATE OF CHANGE, M.S.C. ACTIVE PHYSICIANS 71 18. NUMBER OR NEW REGISTRANTS BY PLACE OF GRADUATION 72 19. POPULATION CENTRE HIERARCHY AND DISTRIBU-TION OF PRIMARY HEALTH CARE PERSONNEL BY POPULATION CENTRE 74 20.1 UNDERSERVICED COMMUNITIES 77 20.2 UNDERSERVICED COMMUNITIES 78 X LIST OF FIGURES FIGURES PAGE 1. TRAVEL DISTANCE BY STUDY REGION 35 2. POPULATION PER PERSONNEL BY STUDY REGION . . . 36 3. ACCESSIBILITY AS RELATED TO RURALITY BY RANK ORDER 41 4. WAITING TIME AS RELATED TO RURALITY BY RANK ORDER 60 5. YEAR OF GRADUATION AND PLACE OF GRADUATION AS RELATED TO RURALITY BY RANK ORDER 65 LIST OF MAPS MAPS PAGE 1. STUDY REGIONS 10 ACKNOWLEDGEMENT The author wishes to acknowledge the supervision and guidance of Professor Brahm Wiesman and Professor Henry C. Hightower. The author also wishes to acknowledge the f i n a n c i a l support provided through the Central Mortgage and Housing Corporation Scholarships. CHAPTER I INTRODUCTION A c c e s s t o H e a l t h Care I n Canada, h e a l t h c a r e d e l i v e r y i s p l a n n e d and f unded by t he p r o v i n c i a l government s . C o n t r a r y t o t he p l u r a l i s t i c U.S. m o d e l , Canada ' s p r o v i n c i a l l y managed u n i t a r y app roach s h o u l d p r o v i d e t he o p p o r t u n i t y t o i n f l u e n c e t he d i s t r i b u t i o n o f h e a l t h c a r e r e s o u r c e s i n m e e t i n g t h e needs o f t he p o p u l a t i o n e f f e c t i v e l y . Y e t , i n p r a c t i c e , governments i n Canada a r e o n l y a b l e t o e x e r c i s e c o n t r o l o ve r f a c i l i t i e s , equ ipment and , t o a l e s s e r e x t e n t , s e r v i c e s , w h i l e t he d i s t r i b u t i o n o f manpower i s s t i l l l a r g e l y d e t e r m i n e d by p r i v a t e marke t f o r c e s . Government-managed p r e - p a i d h e a l t h i n s u r a n c e g u a r a n t e e s a f f o r d a b l e m e d i c a l c a r e , b u t does n o t g u a r a n t e e a c c e s s . As manpower a l o n g w i t h f a c i l i t i e s and money c o n t i n u e t o f l o w t o m a j o r p o p u l a t i o n c e n t r e s , r e g i o n a l d i s p a r i t i e s i n t h e r e c e i p t o f h e a l t h c a r e p e r s i s t ( H a s t i n g s , 1972; LaLonde , 1974; B e n n e t t and K r a s n e y , 1977 ) . Government measures t o i n f l u e n c e t he m i x o f s k i l l s and g e o g r a p h i c d i s t r i b u t i o n o f h e a l t h manpower appear t o be t h e o n l y s o l u t i o n t o i m p r o v i n g a c c e s s t o h e a l t h c a r e f o r r e s i d e n t s i n r u r a l o r remote a r e a s . A p a r t f rom i m p r o v i n g a c c e s s i b i l i t y , r a t i o n a l i z a t i o n o f h e a l t h c a r e r e s o u r c e d i s t r i b u t i o n i s an i m p o r t a n t s t e p t oward 2 more e f f i c i e n t use o f r e s o u r c e s . C u r r e n t s t a t i s t i c s on t he s u p p l y o f p h y s i c i a n s i n Canada s ugge s t t h a t Canada i s no l o n g e r an u n d e r - d o c t o r e d c o u n t r y compared t o a dozen y e a r s ago. I n f a c t , some c r i t i c s b e l i e v e t h a t Canada w i l l soon have an o v e r - s u p p l y o f d o c t o r s i f t he c u r r e n t r a t e o f p r o d u c t i o n o f m e d i c a l p e r s o n n e l c o n t i n u e s (Roos, Ganmont and H o m e , 1976 ) . By i n t e r n a t i o n a l s t a n d a r d s , Canada has l o n g ago r e a c h e d t he Wo r l d H e a l t h O r g a n i z a t i o n ' s g o a l o f 150 d o c t o r s p e r 100,000 p e o p l e . Even t he n a t i o n a l s t a n d a r d o f 175 d o c t o r s p e r 100,000 p e o p l e s e t by t he R o y a l Commiss ion on H e a l t h S e r v i c e s I n 1964 was r e a c h e d by 1976. C o n t i n u i n g t he c u r r e n t t r e n d o f m e d i c a l manpower s u p p l y w i l l n o t o n l y add t o the a l r e a d y s k y r o c k e t i n g c o s t s i n the h e a l t h f i e l d , bu t w i l l r e n d e r t he use o f r e s o u r c e s w a s t e f u l . I t i s e v i d e n t t h a t the most economic s o l u t i o n to b e t t e r a c c e s s t o h e a l t h c a r e i n r u r a l o r remote a r ea s l i e s i n t he r e d i s t r i b u t i o n o f r e s o u r c e s r a t h e r t h a n i n f u r t h e r i n c r e a s i n g t he r a t e o f s u p p l y . R e c e n t l y , s e v e r a l p r o v i n c e s have r e v i e w e d t he o r g a n i z a t i o n o f t h e i r h e a l t h c a r e d e l i v e r y s y s tems , w i t h s p e c i a l a t t e n t i o n t o t he improvement o f r u r a l and remote a r e a a c c e s s t o h e a l t h c a r e p e r s o n n e l and s e r v i c e s . The n o t a b l e ones i n c l u d e M a n i t o b a , Sa skatchewan, O n t a r i o and Quebec. I n B r i t i s h C o l u m b i a , t he l a t e s t comprehens i ve r e v i e w o f t h e h e a l t h c a r e s y s tem, t h e F o u l k e s Repo r t (1974), recommended r e s t r u c t u r i n g t he e x i s t i n g s y s tem t o en su re more e q u i t a b l e h e a l t h c a r e a c c e s s t o r u r a l and i s o l a t e d c ommun i t i e s . Among t he R e p o r t ' s recommendat ions i s t h e d e c e n t r a l i z a t i o n o f h e a l t h c a r e p l a n n i n g . T h i s recommendat ion , however , f e l l s h o r t o f d e v i s i n g e f f e c t i v e 3 planning mechanisms. What i s an optimal regional health care planning unit? How should i t s boundaries be drawn? What i s an acceptable l e v e l of a c c e s s i b i l i t y ? How should a c c e s s i b i l i t y be defined? Exactly who suffers from poor access to health care personnel and services? What are th e i r c h a r a c t e r i s t i c s ? Where are they located? If there i s a shortage of health care personnel i n r u r a l and i s o l a t e d areas, exactly what i s the gap between the desirable l e v e l of manpower provision and the existing l e v e l , and how large i s this gap i n quantitative and q u a l i t a t i v e terms? In both Canada and the U.S.A., empirical research into the problem of access to health care i s s t i l l l argely undeveloped. One of the d i f f i c u l t i e s i n developing a meaningful research framework l i e s i n the attempt to define the term "access" or " a c c e s s i b i l i t y " . While a c c e s s i b i l i t y to a geographer i s commonly associated with s p a t i a l d i s t r i b u t i o n and movement patterns, the same term means the power to buy, or a f f o r d a b i l i t y , to an economist. To a s o c i o l o g i s t or s o c i a l worker, a d e f i n i t i o n of a c c e s s i b i l i t y may be expressed i n terms of the s o c i a l status of the in d i v i d u a l that may affect, the a v a i l a b i l i t y ,of" the;.service to him/her. In Canada, concern has been directed mostly to the geographic imbalance i n the d i s t r i b u t i o n of manpower, and the discrepancies i n the a v a i l a -b i l i t y of health care services between the r i c h and the poor regions, as universal medical care insurance has i n p r i n c i p l e eliminated the a f f o r d a b i l i t y and a v a i l a b i l i t y factors. In b r i e f , t h i s thesis explores the problem of health manpower maldistribution. 4 P r i m a r y H e a l t h Care I n Canada, t he h e a l t h c a r e d e l i v e r y s y s tem has t h r e e t i e r s : p r i m a r y , s e conda r y and t e r t i a r y . A l t h o u g h t h e concep t o f t he t h r e e - t i e r s y s tem has n e v e r been a r t i c u l a t e d by the h e a l t h p r o f e s s i o n , i t i s g e n e r a l l y a c c e p t e d t h a t p r i m a r y c a r e s e r v i c e s a r e t ho se t o w h i c h t he p u b l i c has d i r e c t a c c e s s ; whereas s econda r y c a r e s e r v i c e s a r e o f f e r r e d by s p e c i a l i s t s , a c c e s s i b l e by r e f e r r a l f r om the p r i m a r y s e c t o r ; and t he t e r t i a r y c a r e s e c t o r i s c o n c e r n e d w i t h advanced s p e c i a l i z e d s e r v i c e s t o g e t h e r w i t h m e d i c a l r e s e a r c h and t e a c h i n g . I n t he R e p o r t o f t h e O n t a r i o H e a l t h P l a n n i n g Task F o r c e (1974)', p r i m a r y c a r e i s d e f i n e d t o i n c l u d e . . . n o t o n l y t ho se s e r v i c e s t h a t a r e p r o v i d e d a t f i r s t c o n t a c t between t he p a t i e n t and t he h e a l t h p r o f e s s i o n a l , b u t a l s o r e s p o n s i b i l i t y f o r p r o m o t i o n  and ma i n tenance o f h e a l t h and f o r c omp le te and c o n - t i n u o u s c a r e f o r the i n d i v i d u a l , i n c l u d i n g r e f e r r a l when r e q u i r e d , (p. 11) These f i v e e l ement s o f p r i m a r y h e a l t h c a r e i d e n t i f i e d i n t h i s d e f i n i t i o n : f i r s t c o n t a c t , p r o m o t i o n and m a i n t e n a n c e , c o m p l e t e n e s s , c o n t i n u i t y and r e f e r r a l , a r e s i m i l a r t o S t e w a r t and G o o d r i c h ' s ( i n B r y a n t , 1976: p. 192) f i v e c o n c e p t s o f p r i m a r y c a r e w h i c h d i s t i n g u i s h i t f r om seconda r y and t e r t i a r y s e r v i c e s : . 1... F i r s t i n t i m e . F o r a g i v e n i l l n e s s , the. f i r s t p e r s o n f rom whom a p a t i e n t seeks p r o f e s s i o n a l h e l p i s t he " f i r s t - c o n t a c t " o r p r i m a r y c a r e p r o v i d e r . 2. U s u a l . Time a f t e r t i m e , f o r a s u c c e s s i o n o f i l l n e s s , t he p a t i e n t t u r n s f i r s t t o t he same p r o f e s s i o n a l p r o v i d e r f o r f i r s t - c o n t a c t c a r e . 3. C o n t i n u i n g . F o r a g i v e n p r ob l em o r s e t o f p r o -b l ems , a p a t i e n t r e t u r n s t o t he same p r o f e s s i o n a l p r o v i d e r f o r l o n g - t e r m management. 4. G e n e r a l . Most p a t i e n t s , f o r most m e d i c a l and h e a l t h c a r e p r o b l e m s , r e q u i r e t he s e r v i c e s o f a g e n e r a l i s t r a t h e r t h a n a s p e c i a l i s t . 5 5. Health supervision. Most patients, given the opportunity w i l l benefit from reliance on a single provider, who either gives care d i r e c t l y or arranges for r e f e r r a l s and co-ordinates o v e r a l l management. These concepts suggest that access to and continuity of health care i s c r u c i a l at the primary l e v e l . In Ontario, provision of accessible and continuous primary health care on a 24-hour basis has been a r t i c u l a t e d as a prime p o l i c y concern i n the province's 1974 comprehensive health care study, the Ontario Health Planning Task Force Project. The study also demonstrated that primary health care services developed through primary care groups, can meet more than 80 percent of the demand for health services i n a comprehensive health care system. In suggesting the adoption of the primary care group concept, the Ontario Study recommended the following as the desirable mix of medical s k i l l for primary care practices: general medicine, o b s t e t r i c s , p e d i a t r i c s and mental health. This mix i s well.., supported -by,,vempiriacal. stjidies Q£ .health service u t i l i z a t i o n . In his study of Health Manpower Issues i n Primary Care i n the United States (in Bryant, 1976), Hiestand produced a scheme for primary care manpower based on the empirical examination of u t i l i z a t i o n patterns. His agrees with the Ontario's scheme, but with the in c l u s i o n of one additional group, namely general surgery. In considering manpower requirements, the Community Health Centre Project (1972) recommended a mix of general medicine, general surgery, obstetrics, p e d i a t r i c s , and psychiatry for a community health centre providing primary care. On the non-medical side, dentistry and pharmacy are two important primary health care groups, but the i r primary care roles have often been neglected. In terms of f i r s t contact, health maintenance, and disease prevention, dentists and pharmacists are as essential as any of the aforementioned groups of primary health care professionals. As stated by McFarlane and Ried ( i n Community Health Centre Project, 1972) the major emphasis i n dental care i s prevention, e s p e c i a l l y at childhood, which i s c r u c i a l to long-term dental health. As for pharmacists, th e i r role i s more than dispensing drugs. Bachynsky (in Community Health Centre Project, 1972) i n his paper on Pharmaceutical Services i d e n t i f i e d the functions of a community pharmacist, apart from dispensing prescriptions as guidance of the public i n the use of non-prescription medication, the provision of drug information to health professionals, and the dissemination of health information, supplies and equipment to the public. For many indi v i d u a l s , the f i r s t point of contact for health care i s the community pharmacist, es p e c i a l l y when access to a physician i s d i f f i c u l t Thus, i t i s important that these functions of the pharmacist be performed i n fixed, convenient locations r e a d i l y accessible to the public. In essense, the recent r i s i n g concern about the problems of misuse and misallocation of health care resources stems par t l y from the concept that basic or primary health care i s a fundamental service i n any balanced society. Contemporary communities are no longer w i l l i n g to accept the d i s t r i b u t i o n 7 of basic health services and access to those services as a matter of chance, or as an expression of the "Hidden Hand". The d i s t r i b u t i o n a l equity of the health care system should be subject to the same scrutiny as other s o c i a l requirements such as i n income, housing and work. However, complete d i s t r i b u t i o n a l equity may remain an unattainable goal, because of the high costs of servicing Canada's scattered population. Research Objective This research examines the pattern of geographic v a r i a t i o n i n a c c e s s i b i l i t y to primary health care personnel in B r i t i s h Columbia, and suggests various mitigating p o l i c i e s that may be p r a c t i c a l . Further research i s required to est a b l i s h the costs and benefits of these measures. Thesis Organization In Chapter II, the scope of the research and the s p e c i f i c areas of i n v e s t i g a t i o n are outlined. Chapter III describes the research methodology. Chapter IV i s an overview of the research findings. In this chapter, inter-regional v a r i a t i o n i n a c c e s s i b i l i t y i s analyzed, while the intra-regional a c c e s s i b i l i t y pattern i s examined i n Chapter V. Chapter VI summarizes the nature of regional d i s p a r i t i e s revealed by the study, and discusses various mitigating p o l i c i e s . CHAPTER I I  STUDY DESIGN Study A r e a and Study P o p u l a t i o n The s t udy a r e a o f t h i s t h e s i s c o n s i s t s o f t he e n t i r e p r o v i n c e o f B r i t i s h C o l u m b i a . I n t he l i g h t o f t he o b j e c t i v e o f t h e s t u d y , m e t r o p o l i t a n Vancouver and V i c t o r i a and t h e Lower M a i n l a n d a r e s e p a r a t e d f rom t he r e s t o f t he p r o v i n c e . The r e m a i n i n g a r ea s can be d i v i d e d i n t o seven r e g i o n s s i m i l a r t o t he I .P.A. r e g i o n s u sed by t he Department o f Economic Development o f B.C.^" These g e o g r a p h i c r e g i o n s c o r r e s p o n d r e a s o n a b l y w e l l t o t he n a t i o n a l census d i v i s i o n s and sub -d i v i s i o n s . There a r e 29 census d i v i s i o n s i n B.C. , w h i c h c o r r e s p o n d t o t h e 29 r e g i o n a l d i s t r i c t s and t he 29 r e g i o n a l h o s p i t a l and m e d i c a l i n s u r a n c e d i s t r i c t s . The g r o u p i n g o f the s t u d y r e g i o n s f o r t he pu rpo se o f t h i s s t udy i s as f o l l o w s ( a l s o shown i n Map 1 ) : -X I . P . A . ( I n t e r i m P l a n n i n g Agreement) r e g i o n s were e s t a b l i s h e d i n p u r s u i t o f t h e r e g i o n a l d e v e l o p m e n t a l p l a n n i n g s t u d i e s j o i n t l y s pon so red by the governments o f B r i t i s h Co l umb i a (Department o f Economic Deve lopment) and Canada (Department o f R e g i o n a l Economic E x p a n s i o n ) under t he terms o f t he I n t e r i m P l a n n i n g Agreement s i g n e d i n 1974. The I .P.A. r e g i o n s were d e l i n e a t e d on t he b a s i s o f demography, economic and g e o g r a p h i c c h a r a c t e r i s t i c s , and deve lopment p o t e n t i a l s . Census Divisions/Regional d i s t r i c t s / Study Region Regional Hospital D i s t r i c t s  1. Kootenays Region 2. Okanagan Region 3. Central Interior Region 4. South-West Region 5. Metropolitan Region 6. South Vancouver Island Region 7. Mid Coast Region 8. North-West Region 9. Peace River Region Central Kootenay East Kootenay Kootenay Boundary Central Okanagan North Okanagan Okanagan-Similkameen Bulkley-Nechako (Subdiv. A) Cariboo C olumb ia-Shuswap Fraser-Fort George Squamish-Lillooet (Subdiv. A) Thompson-Nicola Central Fraser Valley Dewdney-Alouette Fraser-Cheam Squamish-Lillooet (Subdiv. B) Sunshine Coast Capital Greater Vancouver Alb erni-C1ayo quo t Cowichan Valley Nanaimo Comox-Strathcona Mount Waddington Ocean F a l l s / C e n t r a l Coast Powell River Skeena-Queen Charloote (Subdiv. B) Bulkley-Nechako (Subdiv. B & C) Kitimat-Stikine Skeena-Queen Charlotte (Subdiv. A) Stikine Peace River-Liard For the purpose of comparison, the study regions are ranked i n terms of t h e i r r u r a l i t y as determined by the proportion of population i n that study region c l a s s i f i e d as r u r a l i n the 1976 Census. Rural population are those l i v i n g R p g i n n a l Hospital D i s t r i c t j 1 East Kootenay I 2 Central Kootenay : 2a Kootenay Boundary 3 Okanagan-Simi1kameen 4 Col umbi a-Shusv:ap 5 North Okanagan 6 Central Okanagan ; 7 Thompson-Nicola : 8 Cariboo 9 Squamish-L i l looet 1 0 ' Fraser-Cheam 11 Central Fraser Va l l ey . 12 Dev,'dney-Al ouette i 13 Greater Vancouver | 14 Sunshine Coast I 15 Powel1 Ri ver I 16 Mount Haddington , 16a Ocean Fal1s 17 Skeena-Queen Char lo t te 18 K i t i m a t - S t i k i n e 19 Bulkley-Nechako 20 F raser -For t George 21 Peace R i v e r - L i a r d 22 S t i k i ne 23 Cap i ta l : 24 Cowichan Va l l e y 25 Nanaitno 26 • A lbern i -C layoquot 27 Comox-Strathcona Map 1. STUDY REGIONS • F o r t N C W O Q Fort St. John * BRITISH COLUMBIA (1) KOOTENAYS (2) OKANAGAN (3) CENTRAL INTERIOR (4) SOUTH-WEST (5) METROPOLITAN (6) S. VANCOUVER IS. (7) MID COAST (8) NORTH-WEST (9) PEACE RIVER 11 outside urban areas, and an urban area has a population concentration of 1,000 or more and a population density of 1,000 or more per square mile (386 per square kilometre). Estimates of rural/urban population breakdown are given i n Table 1. Table 1. RURAL/URBAN POPULATION ESTIMATES BY STUDY REGION (population i s given to the nearest 100 persons) TOTAL RURAL POP URBAN POP STUDY REGION POPULATION NO. 7 NO. SOUTH-WEST 216,100 112,100 51. .9 104,000 48, .1 MID COAST 98,100 48,300 49. .2 49,800 50, .8 PEACE RIVER 44,800 20,000 44. .6 24,800 55, .4 C. INTERIOR 277,900 123,700 44. ,5 154,200 55, .5 S. VAN. IS. 141,200 59,800 42. .2 81,400 57, .6 KOOTENAYS 127,100 53,400 42. ,0 73,700 58, .0 OKANAGAN 169,600 69,900 41. ,2 99,700 58, .8 NORTH-WEST 75,900 29,500 38. .9 46,400 61, .1 METROPOLITAN 1, 315,800 53,000 4. .0 . 1,262,800 96, .0 B.C. 2, 466,500 569,700 23. ,1 1,896,800 76, .9 12 Study Procedure In order to meet the objective of this study, the following procedures were adopted: 1. Determine a c c e s s i b i l i t y measures such that the d i s p a r i t y i n terms of access to primary health care personnel among the nine study regions can be examined. 2. Using this information, i d e n t i f y regions or areas within regions where improvements are needed. 3. Examine factors that influence the pattern of d i s t r i b u t i o n of health care personnel which i n turn influences a c c e s s i b i l i t y to health care 4. Explore p o l i c y options to mitigate de f i c i e n c i e s that may be revealed,by the study. Study Hypotheses The hypotheses to be tested in- this study centre around two areas of investigation: (1) the s p a t i a l d i s t r i b u t i o n of primary health' care personnel i n B r i t i s h Columbia, and t h e i r a c c e s s i b i l i t y ( D i s t r i b u t i o n a l Inequality), and (2) the reasons for the d i s t r i b u t i o n (Factors of Influence). 1. D i s t r i b u t i o n a l Inequality The phenomenon of health manpower maldistribution i s somewhat obvious, and studies and documentation of t h i s phenomenon i n both Canada and the United States have not been lacking. It i s generally proven that physicians and other personnel and f a c i l i t i e s are most numerous r e l a t i v e to population i n urban centres, while r u r a l population are disadvantaged by having r e l a t i v e l y less available personnel. In many instances, r u r a l population are found doubly disadvan-taged by having to t r a v e l longer distances i n order to obtain needed services. In B r i t i s h Columbia, the d i s t r i b u t i o n of health manpower i s documented annually by the Health Manpower Research Unit of the Ministry of Health. However, there appears to have been no studies analyzing the distance factor i n health care delivery. In attempting to analyze the a c c e s s i b i l i t y patterns of primary health care personnel i n B r i t i s h Columbia, this thesis examines both the a v a i l a b i l i t y factor and the distance factor. General Hypothesis 1: that a c c e s s i b i l i t y to primary health care personnel diminishes with r u r a l i t y . Three s p e c i f i c hypotheses can be derived from this general hypothesis:-l . a . that the t r a v e l distance to primary health care personnel increases with r u r a l i t y . l.b. that the number of available primary health care personne r e l a t i v e to population diminishes with r u r a l i t y . 1. e. that the length of the waiting period to see a physician i s r elated to r u r a l i t y . 2. Factors of Influence Research into the factors a f f e c t i n g the location of physicians and other health care personnel has t r a d i t i o n a l l y been undertaken by economists, and to a lesser extent by geographers. Most studies of this subject are s t i l l within the domain of the economics d i s c i p l i n e . Among the most commonly applied economic theories i n l o c a t i o n a l analysis of health manpower d i s t r i b u t i o n are (1) that physicians locate where they can maximize the i r income, (2) that economic s t a b i l i t y of a community determines the a v a i l a b i l i t y of 14 physicians, (3) that the supply of physicians i s a function of demand for physician services, and (4) that the l o c a t i o n a l choice of a physician's o f f i c e , s imilar to any private i n d u s t r i a l firm, w i l l respond to urbanization economies and l o c a l i z a t i o n economies. Schultz (1969: pp. 24-25) defined urbanization economies as the reductions i n average cost which r e s u l t from the location of f a c i l i t i e s i n areas where many other economic a c t i v i t i e s are concentrated, and high population densities occur. Costs are affected through improved a c c e s s i b i l i t y to the l o c a l labour supply and sources of purchased goods and services. A concentration of economic a c t i v i t i e s also attracts outpatients and v i s i t o r s who may make mulipurpose t r i p s which involve stops at a health f a c i l i t y and nearby stores and o f f i c e s . L o c a l i z a t i o n economies, on the other hand, r e s u l t from a number of f a c i l i t i e s o f f e r i n g similar and related services being near each other. By being close to one another, physicians can refer patients and exchange knowledge and s k i l l s more e f f i c i e n t l y . Shonnon and Dever (1974) c r i t i c i z e d the application of economic theories i n the lo c a t i o n a l analysis of health care manpower as useless i n of f e r i n g solutions to the maldistibution problem, and alleged that the primary l i m i t a t i o n of this approach i s the lack of studies below the state (macro) l e v e l . The f a i l u r e of the majority of the l o c a t i o n a l analyes of s i g n i f i c a n t value i s a r e s u l t of th e i r r e s t r i c t i n g economic assumptions, be they "economic man" and his p r o f i t maximization or whatever. 15 Recently, more and more studies have pointed out the significance of psychological behaviour i n influencing the lo c a t i o n a l choice of physicians' practice. Among the most ci t e d behavioural factors i n recent times are (1) family-oriented goals, stressing the best environment for bringing up children and s a t i s f y i n g the s o c i a l needs of the mother, (2) s o c i a l prestige goals, stressing a l i f e s t y l e and environment consistent with the s o c i a l status of physicians, (3) professional i n t e r a c t i o n goals, stressing professional and s o c i a l i n t e r a c t i o n among people sharing common s k i l l s , values and interests, and (4) personal expectation goals, stressing a l i f e s tyle and environment consistent with the personal value and past experience of physicians (de Vise, 1973; Shonnon and Dever, 1974). The a p p l i c a b i l i t y of these theories to the Canadian s i t u a t i o n i s perhaps best summarized by Greenhill i n his discussion paper for the Community Health Centre Project (1972, p. 8):-In spite of the present a b i l i t y to demonstrate the f i n a n c i a l advantages to be derived from p r a c t i s i n g i n currently under-doctored semi-isolated regions, doctors obviously do not wish to locate i n communities remote from urban centres. Additional f i n a n c i a l incentives, such as basic s a l a r i e s plus fee-for-service or free housing, have attracted some physicians to Canada's under-doctored l o c a l i t i e s but not as many as might be hoped. It would seem that f i n a n c i a l reward i n i t s e l f i s not the prime factor i n determining where a physician decides to locate i n Canada, The laws of supply and demand are-inoperable i n a ' n i l - p r i c e - i n f i n i t e demand' si t u a t i o n . Canadian physicians p r a c t i s i n g under 'guaranteed' fee-for-service systems can generate adequate incomes form what might seem inadequate patient populations. ... Canadian physicians l i k e the general populations of a l l i n d u s t r i a l i z e d nations, seek the material comforts and non-material advantages of urban l i v i n g education opportunities for themselves and families, c u l t u r a l and i n t e l l e c t u a l stimulation, closer t i e s • with professional colleagues, broader community health resources and bigger and more impressive disease-treating f a c i l i t i e s . The a t t r a c t i o n of the urban centres to a l l and sundry i s one of today's s o c i a l facts. It must be taken into account when considering regional d i s p a r i t i e s of physician d i s t r i b u t i o n . If possible, the very attractiveness of the urban centre must be c a p i t a l i z e d upon when planning r a t i o n a l i z a t i o n of health personnel and services. These remarks are equally applicable to the p r o v i n c i a l scene. In B r i t i s h Columbia, the fact that physicians are attracted to urban centres i s more than obvious. What i s less known or has not been e x p l i c i t l y investigated i s the difference i n personal attributes between urban physicians and r u r a l physicians, that might a f f e c t t h e i r l o c a t i o n a l choices. In the l i g h t of the scope of this thesis and the a v a i l a b i l i t y of data, only two factors are examined, place of graduation and year of graduation. General Hypothesis 2 that where a physician chooses to practise i s related to his/her personal a t t r i b u t e s . Two s p e c i f i c hypotheses can be derived from this general hypothesis:-2.a. that where a physician chooses to practise i s related to his/her year.of graduationv 2.b. that where a physician chooses to practise i s related to his/her place of graduation. In 1975, the federal government introduced a 'zero-point' p o l i c y as a measure to c u r t a i l foreign physician immigration. In order to test the e f f e c t of such a p o l i c y c the health manpower si t u a t i o n i n B r i t i s h Columbia, th i s thesis examines, the pattern of change i n the d i s t r i b u t i o n of physicians by place of graduation i n this province for the period of 1975-78. CHAPTER III METHODOLOGY A c c e s s i b i l i t y Analysis In order to test hypotheses l . a through l . c r u r a l i t y was correlated with a c c e s s i b i l i t y . For each of the study regions, the two variables were determined as follows -. -1. Measuring Rurality Table 1 rank ordered the study regions by the proportion of regional r u r a l population. It has been suggested that remoteness i s also a factor of r u r a l i t y . In this study, remoteness was measured by the distance between the non-metropolitan study region and the closest metropolitan centre, be i t Vancouver or V i c t o r i a . In the case of Kootenays and Peace River, i t has been suggested that Calgary and Edmonton respectively, exercise greater influences than Vancouver. However, whether these influences also apply to health care services i s not certain. Thus, two sets of measures were made, one using Vancouver and V i c t o r i a for a l l regions, the other using Calgary and Edmonton for Kootenays and Peace River respectively, while using Vancouver and V i c t o r i a for the remaining regions. An o v e r a l l index of r u r a l i t y for each study region was derived by multiplying the distance factor by the r u r a l population factor. Since the purpose of this exercise i s to determine the r e l a t i v e r u r a l i t y of the study regions, the actual computed values are not relevant. The study regions were then ranked based on the r u r a l i t y index. Table 2 shows the computed xesults of the ranking exercise. Appendix A gives the detailed computa-tions . The results suggest that the rank order of Kootenays i s affected l i t t l e by the a l t e r a t i o n of metropolitan centres, but the rank order of-Peace River i s greatly affected by such a l t e r a t i o n . Peace River i s more r u r a l when related to Vancouver than to Edmonton 2. Measuring A c c e s s i b i l i t y A c c e s s i b i l i t y was measured by (1) the t r a v e l distance to the nearest primary health care personnel and (2) the r a t i o of the number of available personnel to the t o t a l population of the study region. Seven groups of primary health care personnel were studie (1) General Practitioner/family physician 2,252 (2) Pharmacist,: 1,658 (3) Dentist 1,208 (4) General Surgeon 252 (5) P s y c h i a t r i s t 201 (6) P e d i a t r i c i a n 123 (7) Obstetrician/gynaecologist': 125 5,819 20 Table 2. RANKING OF STUDY REGIONS BY RURALITY PR'OPOR DISTANCE" RURALITY RURAL' TO METRO INDEX STUDY REGION POP (a) CENTRE(b) (a)x(b) RANK"" (1) (2) NORTH-WEST .389 1360 Km. 529 1% 1 PEACE RIVER .446 1270 Km. (640) 566 (285) 1% 3% C. INTERIOR .445 670 Km. 298 4 3% KOOTENAYS .420 660 Km. (640) 277 (269) 4 3% MID COAST .492 530 Km. 261 4 3% OKANAGAN .412 450 Km. 185 6 6 SOUTH-WEST .519 90 Km. 47 7% 7% S. VAN. IS. .424 100 Km. 42 7% 7% METROPOLITAN .040 _ _ 9 9 Read distance .or equivalent (see footnote 1 on p. 22) i s measured between the population centre that i s nearest to the central point of the study region for each study region and the metropolitan centre, be i t Vancouver or V i c t o r i a , whichever i s closer. The centres chosen for each study regions are Fort St. John for Peace River, Terrace for North-West, Quesnel for Central Interior, Nelson for Kootenays, Port Hardy for Mid Coast, Kelowna for Okanagan, ;.Duncan for South Vancouver Island and Chilliwack for South-West (see Map 1). In the case of Kootenays and Peace River, a second distance i s given i n brackets. They are distances to Calgary and Edmonton respec-t i v e l y . Set (1) i s based on the i n i t i a l set of measurements. Set (2) takes into account the measurements i n the brackets. Also see Appendix A for detailed c a l c u l a t i o n . 21 Data on the number and the location (by community) of the seven groups of personnel were available from the Health Manpower Research Unit. The most recent available data i s for the period of September 1975 to August 1976. The data correspond to the 1976 Population Census data used i n this study. The source of data for the health care personnel group (1) and groups (4) through (7) i s the B r i t i s h Columbia Medical Services Commission and the B r i t i s h Columbia College of Physicians and Surgeons. Only the B.C.M.S.C. 'active physicians' were considered i n the study. B.C.M.S.C. active physicians are defined as those not i n post graduate work who have been assigned a v a l i d b i l l i n g number by B.C.M.S.C. These physicians are generally available to the public whether t h e i r type of practice i s private, group or sa l a r i e d ( R o l l c a l l 75, 1976). The source of data for the health care personnel group (2) i s the College of Pharmacists of B r i t i s h Columbia. Only pr a c t i s i n g pharmacists were considered i n this study. The source of data for the health care personnel group (3) i s the College of Dental Surgeons of B r i t i s h Columbia. Only non-specialist-dentists were considered i n this study. Two indices were used to determine the r e l a t i v e a c c e s s i b i l i t y of each study region for each group of personnel:-22 Index A- Mean travel distance of population i n the study region having to t r a v e l more than 25 Km. (road distance or equivalent) to the nearest personnel In order to determine the mean, the catchment area of each physician/dentist/pharmacist was determined. Population estimates for each catchment area were based on the population s t a t i s t i c s prepared for t h i s study, as shown i n Appendix B. I t gives a breakdown of the population of the province by community and sub-region, including Indians on Reserves. Population by t r a v e l distance i n the following i n t e r v a l s was determined: ( i ) under 25 Km., ( i i ) 25-49 Km., ( i i i ) 50-74 Km., (iv) 75 Km. and over, and (v) 2 scattered. The mean tr a v e l distance was calculated based on the estimates for each catchment area. As-, for general surgeons, p e d i a t r i c i a n s , obstetricians/ gynaecologists and p s y c h i a t r i s t s , only two distance' categories were applied: (i) under 75 Km. and ( i i ) 75 Km. and over. These four groups are generally considered primary care sub-specialists. Their services are less ubiquitous, and longer t r a v e l + I n case of ferry t r a v e l , estimates were made of the travel time involved which was then converted into a road distance equivalent. For example, i f t r a v e l l i n g time by ferry i s 30 min., i t was assumed that i t has a road distance equivalent of 40 (Highway) Km. No attempt, however, was made to assess t r a v e l conditions (weather, type of road, speed l i m i t , monetary costs, mode of transportation, etc.) of ''~ i n d i v i d u a l t r i p s . 2 Population with unknown s p e c i f i c locations are c l a s s i f i e d as scattered. In Appendix B, they are grouped under Sub-regions. d i s t a n c e s t o them a r e i n e v i t a b l e . I t was t h e r e f o r e c o n s i d e r e d more m e a n i n g f u l t o d e t e r m i n e t h e p r o p o r t i o n s o f p o p u l a t i o n w i t h i n each s t u d y r e g i o n h a v i n g t o t r a v e l more t h a n 75 Km. t o t h e s e s p e c i a l i s t s t h a n t o d e t e r m i n e the mean t r a v e l d i s t a n c e s . T h i s p r o p o r t i o n was u s ed as t h e measure f o r A c c e s s i b i l i t y Index A. Index B P o p u l a t i o n p e r p h y s i c i a n / p h a r m a c i s t / d e n t i s t by s t u d y r e g i o n The r a t i o o f p o p u l a t i o n t o each o f the s e ven groups o f h e a l t h c a r e p e r s o n n e l was d e t e r m i n e d and compared by s t u d y r e g i o n . As i t i s n o t p o s s i b l e t o d i s t i n g u i s h t ho se p e d i a t r i c i a n s , o b s t e t r i c i a n s / g y n a e c o l o g i s t s and p s y c h i a t r i s t s p r a c t i s i n g t e r t i a r y c a r e f r om tho se p r a c t i s i n g p r i m a r y c a r e , and as t e r t i a r y c a r e i s c o n c e n t r a t e d i n Vancouver w h i c h has t he e n t i r e p r o v i n c e as i t s ca tchment a r e a , t h e r e g i o n a l r a t i o s f o r t he se t h r e e g roups cannot be c o n s i d e r e d as a r i g o r o u s measure. The s t udy r e g i o n s were r a n k e d a c c o r d i n g t o t h e i r r e l a t i v e a c c e s s i b i l i t y s c o r e s on b o t h i n d i c e s . The r a n k i n g r e s u l t s were t hen compared t o t he r u r a l i t y r ank r e s u l t s t o d e t e c t any c o r r e l a t i o n . 3. M e a s u r i n g W a i t i n g Time A l t h o u g h i t has been s u g ge s t ed t h a t due t o t h e u n a v a i l a -b i l i t y o f p h y s i c i a n s i n r u r a l a r e a s , p a t i e n t s t e n d t o w a i t l o n g e r t o o b t a i n needed s e r v i c e s , i t has been d e m o n s t r a t e d , on t he o t h e r hand, t h a t because o f t he u n a v a i l a b i l i t y o f and the i n a c c e s s i b i l i t y to physicians i n r u r a l areas, patients tend to l i m i t t h e i r v i s i t s to them for curative rather than preventive purposes (cited by Shannon and Dever, 1974: p. 97). As a re s u l t , the u t i l i z a t i o n pattern i n r u r a l areas should be di f f e r e n t from that of urban areas. Rural physicians tend to.provide services for urgent needs, and the i r o f f i c e s are often operated as drop-in c l i n i c s . In the urban areas where there are more physicians, many v i s i t s to them are routine, and are usually by appointment, days or weeks i n advance. In order to determine the relationship between waiting time to see a physician and r u r a l i t y , the following investigation was conducted. A systematic random sample of 100 general p r a c t i t i o n e r s / family physicians was drawn from the 1978 telephone directory. Telephone interviews with the physicians' o f f i c e s were conducted between the months of March and A p r i l , 1978. The interviewees approached were persons responsible for arranging appointments. In most cases they were either the rece p t i o n i s t or the nurse. Two questions were asked during the interviews:-1. I f you were assume I am a patient c a l l i n g for an appointment to see the doctor, when i s the e a r l i e s t one that can be arranged? If the.answer was "right away" or "within four hours of the telephone c a l l " , no further question were asked. I f the time given was more than four hours, or i f the interviewees asked for the purpose of the v i s i t , the second question was asked:-2. What i s the e a r l i e s t appointment for an urgent v i s i t as opposed to a non-urgent v i s i t ? 25 Waiting times i n terms of days for both types of v i s i t s were 3 recorded. In cases where the second question was unnecessary, the waiting times for both types of v i s i t s were assumed to be the s ame. The purpose of the interview and the i d e n t i t y of the researcher were revealed before these questions were asked. Test interviews were conducted before the actual i n t e r -views were carried out. For the test interviews, the test sample was divided into two groups. One group was informed of the purpose of the survey and the i d e n t i t y of the researcher, the other group was not. The res u l t s of both groups were compared, and no s i g n i f i c a n t difference i n the variance was found. In other words, whether the questions asked were for research purpose or "for r e a l " made no difference to the answers the interviewees gave (see Appendix D). The prodedure for selecting the sample of 100 general practitioners/family physicians was as follows:-Step 1 For each study region, communities with physicians were ranked in.order based on the number of physicians i n the community. "^Physicians i n this survey were assumed to practise from 8:30 a.m. to 4:30 p.m., Monday through Friday. Therefore, Saturday and Sunday were not counted i n the waiting time. Any waiting time involving less than four hours was c l a s s i f i e d as 0 day, four to eight hours i s 0.5 day, and from there on, each additional four hours was counted as an addition of 0.5 day. Thus, i f the interview was made at 11:00 a.m. on a Thursday and an appointment was given at 3:00 p.m. on the following Monday, the recorded waiting time would be 2.5 days. Step 2 A random sample of communities was selected such that communities of high, intermediate and low ranks were represented. Step 3 A random sample of physicians was selected from each selected community, from the 1973 telephone directory. In a l l cases, a random number table was used. The sample and the re s u l t s of the survey are recorded i n Appendix E. For c o n f i d e n t i a l i t y , the i n d i v i d u a l physicians o f f i c e s are not i d e n t i f i e d . Of the 100 interviews conducted, 93 were usable. 6 were disgarded for the following reasons: the doctor i s semi-retired ( i . e . i n a c t i v e ) , on holiday, unwilling to give information, or has moved. Table 3 gives the size of the sample for each study region and the number of usable responses. The mean waiting time for each study region was calculate The study regions were then ranked accordingly, and the resultant ranks were compared with the r u r a l i t y ranks to detect any co r r e l a t i o n . The analysis was carried out for both urgent and non-urgent v i s i t s . In addition to measuring mean waiting time by study region, mean waiting time by type of community was also measured. 27 Table 3. ANALYSIS OF WAITING TIME, SAMPLE SIZE AND USABLE RESPONSES ~ ~~ ~ STUDY REGION n USABLE RESPONSE KOOTENAYS 9 9 OKANAGAN 9 9-C. INTERIOR 15 13 SOUTH-WEST 12 10 METROPOLITAN 30 29 S. VAN. IS. 5 5 MID COAST 12 11 NORTH-WEST 5 5 PEACE RIVER 3 2 100 93 • It i s suggested that even within each study region, there may well be s i g n i f i c a n t variations i n the waiting time among communities, depending on t h e i r size. Thus, i n order to deter-mine such v a r i a t i o n , the mean waiting times of three groups of communities were compared : (1) metropolitan centres ( i . e . Vancouver and V i c t o r i a with population 100,000 and:over), (2) urban centres with population 10,000 to 99,999, and (3) r u r a l communities with population less than 10,000 (those within 25 Km. of an urban centre were grouped under (2)). A population size of 10,000 was;...chosen, because i t i s generally considered the minimum required to support some type of special i z e d primary cafe such as general surgery. S t a t i s t i c a l tests were performed to determine i f the mean waiting times among the three groups of communities were s i g n i f i c a n t l y d i f f e r -ent . 28 Analysis of Factors Influencing Physicians Location Two independent variables were examined:year of graduation and place of graduation. The dependent variable i s r u r a l i t y . The purpose of the analysis was to determine i f physicians' choice of location of practice i s related to t h e i r age, o r i g i n , or professional t r a i n i n g . Data on these factors., however, were not available. Indirect measures were therefore used. Year of graduation was taken as a proxy for age, and place of graduation was taken as proxy for o r i g i n . Data on these two variables were obtained from the Directory of the College of Physicians and Surgeons which i s published and updated annually (in September). Two sets of samples were drawn, one from the 1975-76 Directory and the other from the 1977-78 Directory. Nineteen seventy-five marked the year of the introduction of the federal 'zero-point' p o l i c y designed to r e s t r i c t immigration of foreign physicians into Canada. The purpose of examining the place of - graduation for these,two periods was to explore the possible impact of t h i s p o l i c y on the d i s t r i b u t i o n of foreign-trained physicians. Foreign graduates have been observed i n Alberta and Manitoba to be more l i k e l y to practise i n r u r a l areas than domestic graduates (Ross, Gaumont and Home, 1976). The v a l i d i t y of this observation i n B r i t i s h Columbia was also tested. A random sample of 127 physicians (general p r a c t i t i o n e r s / family physicians) was drawn for each period of time. Year of graduation and place of graduation were recorded i n 29 Appendix F. Table 4 gives the breakdown of the samples by-study region. The mean year of graduation was calculated for each study region which was then ranked accordingly. As for the place of graduation, four categories were i d e n t i f i e d : (1) B.C., (2) other provinces, (3) Europe/U.S.A., and (4) other countries. The combined percentages of categories (2) through (4) were used for ranking the study regions. Both sets of ranking results were compared with the r u r a l i t y r e s u l t s to detect any cor r e l a t i o n . Similar to the waiting time argument, the type of community ( s p e c i f i c a l l y i t s size) has just as much influences as the type of region, on the physician's choice of practice location. Thus, i n addition to the analysis of these factors by region, they were also studied by size of community, using the same categories as those employed i n the waiting time analysis. S t a t i s t i c a l tests were performed to determine i f the mean years of graduation were s i g n i f i c a n t l y d i f f e r e n t among the three types of communities. As for the place of graduation, chi-square tests were performed to determine i f (1) the proportions of B.C. graduates versus non-B.C. graduates were s i g n i f i c a n t l y d i f f e r e n t among the three types of communities, (2) the proportions of non-B.C. Canadian graduates versus European/U.S.A. graduates were s i g n i f i c a n t l y d i f f e r e n t among the three types of communities, and (3) these proportions for each type of community are s i g n i f i c a n t l y d i f f e r e n t between 1975-76 and 1977-78. ... 30 Table 4. FACTORS OF INFLUENCE, SAMPLE SIZE STUDY REGION n 1 = ri^^ (a) KOOTENAYS 10 OKANAGAN 10 C. INTERIOR 20 SOUTH-WEST 10 METROPOLITAN 40 S. VAN. IS. 10 MID COAST 10 NORTH-WEST 10 PEACE RIVER 7 127 n-^  = sample size for Year of Graduation n2 = sample size for Place of Graduation CHAPTER IV  DISCUSSION OF RESULTS Relationship between A c c e s s i b i l i t y and Rurality The o v e r a l l a c c e s s i b i l i t y forreach study region was determined by measuring A c c e s s i b i l i t y Index A (travel distance) and A c c e s s i b i l i t y Index B (population/health personnel r a t i o ) . Tables 5.1 and 5.2 give the proportions of population by tr a v e l distance to the nearest personnel within each study region for each of the seven groups of primary care personnel. Detailed estimates of these proportions can be found i n Appendix C. Table 6 indicates the population/health personnel r a t i o s . In this table, the o v e r a l l p r o v i n c i a l r a t i o s and the recommended ra t i o s of the authorized agencies, i . e . the Canadian Medical Association, the Canadian Dental Association and the Canadian Pharmaceutical Association, for each group of primary health care personnel are given. Regional deviations from these two sets of r a t i o s are noted. Figures 1 and 2 give a v i s u a l comparison of the a c c e s s i b i l i t y of the nine study regions. The regional r a t i o s given i n Table 6, however, are highly generalized, and cannot be used to; detect intra-regional v a r i a -Table 6. lc c e s s i M i J ^ X _ I J 3 d e x _ B ^ N j i j b e r ^ i U J B A L PRJCJITIQNE8_ (a) ih) POPOLATION MQJL-1. KOOTENAYS 127,100 119 2. OKAKAGAN 169,600 135 3. C. INTERIOR 277,900 211 4. SOUTH-WEST 216,100 164 5. METROPOLITAN 1,315,800 1,3 3 1 6. SOUTH VAN. IS. 141,200 102 7. HID COAST 98, 100 SO 8. NOBTH-WEST 75,900 73 9. PEACE BIVEB 44,800 27 E.C. 2,466,500 2,252 <c) &_Diff_ J _ D i f f _ R a t i o f r_a ve f r re c 1,068 1,256 1 ,317 1,318 989 1,384 1,090 1,040 1 ,659 1,095 If) (1,750) 2. 5 -14.7 -20. 3 -20. 3 9. 7 -26. 4 0.5 5.0 -51. 5 39.0 28.2 24.7 24.7 43.5 20. 9 37.5 40.6 5.2 PHAJJJCIST. CENT 1ST £atio_ l _ D i f f _ % D i f f $„Diff_.- S_Dif f f r : aye fr,,,rec Mo*.- £at:io_- f £_ive_- f I_;f eg 68 1,869 - 25.7 6.6 41 3,100 - 51.8 -24.0 99 1 ,713 - 15.2 14.4 69 2,458 - 20.4 1.7 128 2, 171 - 46.0 - 8.6 99 2, 807 - 37.5 -12.3 121 1, 786 - 20. 1 10.7 73 2,960 - 45.0 -18.4 1 ,074 1,225 17.6 38.8 802 1,641 19. 6 34.4 81 1,743 - 17.2 12.9 58 2,434 - 19.2 2.6 43 2, 281 - 53.3 -14.1 36 2,725 - 33.4 - 9.0 31 2,448 - 64.6 -22.4 17 4, 465 -118. 7 -78.6 13 3,446 -131.7 -72.3 13 3,446 - 63.8 -33.8 1 ,658 1,487 1,208 2, 042 (2,000) (2,500) (a) Source : S t a t i s t i c s Canada, Po p u l a t i o n Census, 1976. Number i s rounded o f f to the nearest 100 persons. |b) Source : Health Hanpower fiesearch U n i t , 1975-76. T h i s data source a l s c a p p l i e s to the r e s t cf the s i x c a t e g o r i e s of personnel. <c) Ratio = P o p u l a t i o n per personnel (d) % d i f f e r e n t from the E.G. average = B.C. average r a t i o - study r e g i o n r a t i o / B.C. average r a t i o (e) % d i f f e r e n t from the rcccmmenckd r a t i o = recon. r a t i o - study r e g i o n r a t i o / recom. r a t i o (f) F i g u r e s given i n bracke t s are recommended r a t i o s by Canadian Medical A s s o c i a t i o n , Canadian Dental A s s o c i a t i o n and Canadian Pharmaceutical A s s o c i a t i o n . (g) Ihe p o p u l a t i o n of the south-Mest fiegion are within 75 Km. of m e t r o p o l i t a n Vancouver, t h e r e f o r e , they are w i t h i n t hat catchment area. (Tie 75 Km. r a d i u s a p p l i e s to the s u b - s p e c i a l i s t groups cf G. S., Ped. , Obs., and Psy.) (h) Begicns without h e a l t h personnel of a p a r t i c u l a r type are assumed to be w i t h i n the catchment area of the nearest Region with the personnel. 34 GIJIEAI , S 0 E G j C J J _ D i f f _ % D i f f No,.,. R a t i o f r ave_ f r rec 16 7,944 18.8 20.6 18 9,422 3.7 5.8 23 12,083 -23. 4 -20. 8 10 |g)9,065 7.4 9.4 159 9,065 7.4 9.4 11 12,836 -31. 1 -28. 4 6 16,350 -67.0 -63.5 6 12,650 -29. 2 -26. 5 3 14,933 -52. 6 -49.3 252 S,788 (10,000) PEIIATRICIAN % D i f f % _ D i f f NOj,_ Ratio £r_ave_ f r r e c 4 31,775 - 58,5 - 5 6.9 5 33,920 - 69.2 - 69.6 7 46,100 -129.9 -130.5 1 15,019 25 .Vi 24. 9 101 15,019 25. 1 24.9 2 70,600 -252.1 -253.0 2 49,050 -144.6 -145.3 1 75,900 -278.5 -279.5 0 46, 100 -129.S -130.5 123 20,053 (20,000) OBSTJ^RICIM^GYNAJCgXOGIST. Ratio J _ D i f f _ f r ave f r rec 2 6 3,550 -222. 1 -217.8 6 28,267 - 4 3.3 - 41.3 9 30,878 - 56.5 - 54.4 1 15,957 19. 1 20. 1 95 15,957 19. 1 20. 1 6 23,533 - 19.3 - 17.7 3 3 2,700 - 6 5.7 - 63.5 1 75,900 -284. 7 -279.5 2 22,400 - 13.5 - 12.0 125 19,732 (20,000) i PSYCHIATRIST J,£iff- J ^ D i f f Ja t.jo_ 3 42,367 -245.3 -182.4 7 24,229 - 97.4 - 61.5 4 99,650 -712.7 -564.3 7 8,65 5 29.5 73.3 170 8,655 29.5 73.3 7 20,171 - 64.4 - 34.5 3 32,700 -166.5 -1 18.0 0(h) 99,650 -712.1 -564.3 0 99,650 -712.1 -564.3 201 12.271 115,000) Tafcle 5.1. A c c e s s i b i l i t y Index A, Populat, (G.P., Pharmacist and Dentist) * -L§l<25_Knu SJDEY_BEGICN_ GBCUP_ JOjL_ ~ J _ 1. KOCTENSYS ( D 112,100 88 (2) 108,700 85 0) 105,000 80 2. OKAMGAN C D 163,600 97 (2) 163,000 96 (3) 159,300 94 3. C. INTEBIOR ( D 239,700 86 (2) 235,000 85 (3) 216,400 78 4. SOUTH-WEST I D 208,500 96 (2) 209,600 97 13) 207,400 96 5. SETFCFCLITAN C D 1,314, 100 100 12) 1,313,600 100 (3) 1,3C9, 800 100 6. S0G3.H VAN. IS. ( D 134,500 95 (2) 133,700 95 (3) 133,700 95 7. HID COASf I D 85,600 88 (2) 76,300 78 (3) 76,500 79 8. NOETH-MEST ( D 62,000 81 C2) 58,900 77 (3) 59,500 78 9. PEACE BIVEB ( D 37,100 83 (2) 35,800 80 (3) 34,000 76 B. C. < D 2,357,400 96 (2) 2,334,600 95 (3) 5,298,600 93 ioj3_Jj_Trayel_ Distan«_By_S J b l 2 5 z 49 Km. JC150- 7 4 Kffi* Jdl>75. No^_ %_ 3- lSb._ 5,200 4 1 ,000 1 200 0 5,700 5 1,800 1 2,500 2 S,2 00 7 2,600 2 4,900 4 500 0 C 0 0 0 1,100 1 0 0 0 0 4,500 3 300 0 0 0 8,800 3 5,700 2 7,900 3 11,100 4 6,100 2 9,700 3 8,400 3 10,200 4 27,100 10 3,500 2 300 0 0 0 1,300 1 8C0 0 600 0 1,600 1 1,600 1 1,700 1 50 0 0 900 ' 0 200 0 70 0 0 700 0 700 0 4,600 0 500. 0 800 0 3,€C0 3 0 0 300 0 4,400 3 0 0 300 0 4, 400 3 0 0 300 0 1,400 1 1,500 1 1,600 2 4,300 4 3,200 3 3,500 4 4,600 5 1,700 2 5,200 5 1,400 2 700 1 3,400 5 1,400 2 1 ,700 2 3,500 5 1,400 2 700 1 3,300 4 300 1 100 0 200 0 300 1 100 0 1,500 3 300 1 100 0 3,300 7 55,20C 1 10,200 0 13,800 1 30,300 1 14,400 0 22,300 1 39,000 1 17,700 1 46,600 2 32 -76 J e l S ca 11 ere d_ - fot-aljbj JiJSce.s.s.a. lJ3dejr„A 8, 200 7 14,600 12 65 8,200 7 18,200 15 74 8,200 7 24,900 20 85 5,200 3 5,700 3 48 5,200 3 6,300 4 47 5,200 3 10,000 6 44 15,800 6 38,200 14 109 16,000 6 42,90 0 15 101 15,800 6 61,500 22 128 3,3 00 2 7,100 4 49 3,300 2 6,000 3 61 3,300 1 8,200 4 65 0 0 1,600 0 56 0 0 2, 100 0 60 0 0 5,900 0 51 2,600 2 6,500 5 45 2,600 2 7,300 5 44 2,600 2 7,300 5 44 7,500 8 12,000 12 77 10,300 11 21,300 22 84 9,600 10 21,100 22 108 8,200 11 13,700 19 184 10,200 14 16,800 23 220 10,800 14 16,200 22 245 7,100 16 7,700 17 270 7, 100 16 9,000 20 252 7,100 16 10,800 24 236 57,900 2 107,100 4 109 62,900 3 129,900 5 1 12 62,600 3 165,900 7 123 * GfiCUE {1) = G.P. <2) = Pharmacist <3) = D e n t i s t Access. Index A = mean t r a v e l d i s t a n c e of popula t i o n having to t r a v e l more than 25 Km. Table 5.2. A c c e s s i b i l i t y Index A. Population. By T r a v e l Distance by Study Region, 1975-76 ~ -(G. Surqeon, P e d i a t r i c i a n , Gbs/Gyn S P s y c h i a t r i s t l ** J c c e s s ^ Index A 33 STUDY BEGION 1. KOOTENAYS 2. GKAEAGAN 3. C. INTERIOB 4. SCUTH-HEST 5. K ETBOPCIITAN 6. SCDTH VAN. IS. 7. J3ID COAST 8. NOBTH-REST 9. PEACE BIVEB E.C. (4) (5) <6) (7) iH 15) (6) C7) <<*) (5) (6) (7) (4) (5) (6) (7) (4) (5) (6) (7) <4) 15) (6) (7) <<0 (5) 16) O) in (5) (6) (7) in (5) <6) {7) 44) (5) <6) (7) (a)<75 Km. JJlU75_ Km. No. J _ J _ 119,900 9 4 7,200 6 87,800 69 39,300 31 43,400 3 4 83,700 66 60,600 48 66,500 52 160,300 95 9,300 5 160,300 95 9,30 0 5 160,30 0 95 9,300 5 160,300 95 9,300 5 210, 400 76 67,500 24 155,200 56 122,700 44 155,200 56 122,700 44 151,900 55 126,000 45 209, 700 97 6,400 3 199,900 93 16,200 7 199,900 93 16,200 7 194,400 90 21,700 10 1,315,200 100 600 0 1,314,200 100 1 ,600 0 1,3 14,200 100 1,600 0 1 ,315,200 100 600 0 137,500 97 3,700 3 103,000 73 38,200 27 106, 500 75 34,700 25 137,500 97 3,700 3 67,200 69 30,900 31 66,500 68 31,6 00 32 67,200 69 30,900 31 66,500 68 1 31,600 32 45,300 60 3 0,600 4 0 29,000 38 46,900 62 29,000 38 46,900 62 0 0 75,900 100 30,800 69 14,000 31 0 0 44,800 100 30,800 69 14,000 31 0 0 44,800 100 2,296,300 93 170,200 7 2, 115,900 86 350, 6G0 14 2,106,500 85 360,000 15 2,C8€,ICQ 85 380,100 15 .06 .31 .66 .52 .05 .05 .05 .05 .24 .44 .44 .45 .03 .07 .07 .10 .00 .00 .00 .00 .03 .27 .25 .03 .31 .32 .31 . 3 2 .40 .62 .62 1.00 .31 1. 00 .31 1.00 .07 .14 . 15 .15 * GBOUP (4) (5) 16) (7) G. Surqeon P e d i a t r i c i a n O b s t e t r i c i a n / G y n a e c o l o g i s t P s y c h i a t r i s t ** Access, index A = p r o p o r t i o n of p o p u l a t i o n havinq to t r a v e l 75 Km. or more F i g u r e 1. TRAVEL DISTANCE BY STUDY REGION % 30 20 10 J 0 Km. 200 J 100 % pop, t r a v e l l i n g over 25 Km. SBlH Mean t r a v e l d i s t a n c e of pop, t r a v e l l i n g over 25 Km. VOSMKICNP VOMSKICNP VOMSKICPN G . P . PHA DEN % pop, t r a v e l l i n g over 75 Km. K= KOOTENAYS 0= OKANAGAN C= CENTRAL INTERIOR S= SOUTH-WEST M= METROPOLITAN V= S . VAN. I S . 1= MID COAST N= NORTH-WEST P= PEACE RIVER % 100 90 80 70 r 60 50 L 40 30 L 20 10 MSVOKCIPN M0SVKICNP MOSVKICNP MVOSICKPN G.S . PED OBS/GYN PSY to F i g u r e 2 . POPULATION PER PERSONNEL BY STUDY REGION Pop per P e r s o n n e l Pop per Personne l Recommended R a t i o K= K00TENAYS 0 = OKANAGAN C = CENTRAL INTERIOR S = SOUTH-WEST M= METROPOLITAN V = SOUTH VANCOUVER ISLAND 1 = MID COAST N = NORTH-WEST P = PEACE RIVER ml II [ 60,000 100,000 80,000 L 40,000 20,000 MNKIOCSVP MOSVKCINP MOVICSKPN G . P . PHA DEN KMSOCVNPI MSKOCPTVN MSPVOCIKN MS VQIKCPN G . S . PED OBS/GYN PSY tions. Based on the detailed estimates i n Appendix C, Table 7 was prepared, showing the range (highest and lowest) of r a t i o s within each study region for each type of personnel. These estimates are based on the catchment area, for each health care personnel. For example, i n the Kootenays Region, dentists were found p r a c t i s i n g i n eleven locations (communities). Each location of practice has a defined catchment area, on the assumption that a person only travels to the nearest dentist. Thus, the size (in terms of population served) of each of these eleven catchment areas varies from one to the other, and so does the population/dentist r a t i o of each of these eleven catchment areas. Table 3.1 and 8.2 give the a c c e s s i b i l i t y index scores and the ranking r e s u l t s . Appendix G gives the d e t a i l of the . calculations. Figure 3 shows the relationship between accessi-b i l i t y and r u r a l i t y . The findings indicate that the worst-off regions are the North-West, the Peace River and the Central Interior, followed by the Mid Coast, the Kootenays and the South Vancouver Island. Outside the Metropolitan Region, the South-West Region and the Okanagan Region are the better-off regions. The results suggest that the north-West Region, the Peace River Region and the Central Interior Region are similar i n many respects and constitute a d i s t i n c t group. A l l rank l a s t by a c c e s s i b i l i t y . The South Vancouver Island Region, the Kootenays Region and the Mid Coast Region rank f i f t h . There i s a d i s t i n c t gap between this group of Regions and the next higher order Regions, as indicated by the absence of the t h i r d and fourth ranks. By o v e r a l l a c c e s s i b i l i t y , Table 7. RANGE (g iven by the h i g h e s t and the lowest) OF POPULATION/HEALTH PERSONNEL RATIOS BY STUDY REGION STUDY REGION G . P . PHARMACIST DENTIST G. SURGEON PEDIATRICIAN OBS /GYN ' PSYCHIATRIST KOOTENAYS 567 929 2,189 5,700 21,550 62,350 40,800 3,400 3,300 7,900 13,300 46,300 62,350 43,100 OKANAGAN 600 600 1,050 6,743 26,450 23,800 14,300 2,700 4,100 5,600 12,400 80,900 80,900 80,900 C. INTERIOR 650 . 1,396 1,838 6,933 51,900 19,500 44,100 2,900 6,200 6,650 25,300 149,700 51,900 219,800 SOUTH-WEST 800 7 700 2,332 8,706 14,009 16,192 7,579 1,600 2,525 7,000 26,200 51,300 51,300 52,400 METROPOLITAN 941 1,221 1,601 6,985 14,009 12,828 7,579 999 1,246 1,859 8,706 22,558 16,192 : 9 , 6 0 4 S . VAN. I S . 783 1,515 2,063 10,317 22,558 18,800 15,700 1,900 6,100 6,100 23,550 50,450 46,700 32,100 MID COAST 700 1,740 1,500 6,500 22,200 22,200 22,200 2,800 7,150 6,300 29,800 73,400 72,200 36,700 NORTH-WEST 811 1,800 2,433 7,533 70,100 70,100 219,800 2,400 5,600 6,000 16,100 70,100 70,100 219,800 PEACE RIVER 600 1,800 2,425 10,100 149,700 20,200 219,800 2,044 4 ,600 6,567 24,600 149 ,700 24,600 219,800 B.C. AVERAGE 1,095 1,487 2,042 9,788 20,053 19,732 12,270 RECOMMENDED 1,750 2,000 2,500 10,000 20,000 20,000 15,000 Note : The r a t i o s are based on p o p u l a t i o n served per personnel by catchment a r e a . See Appendix C. Table 8 . 1 . TRAVEL DISTANCE (ACCESSIBILITY INDEX A) AS RELATED TO RURALITY BY STUDY REGION (A) INDEX SCORE* STUDY REGION G . P . PHA - DEN •G.,s; - PSY- RED OBS'/GYN METROPOLITAN 56 60 51 0 0 0 0 SOUTH-WEST 49 61 65 3 10, 7 7 S . VAN. IS . . 45 44 44 3 3 27 25 OKANAGAN 48 47 44 5 5 5 •5 KOOTENAYS 65 74 85 6 52 31 66 MID COAST 77 84 108 31 32 32 31 C. INTERIOR . 109 101 128 24 45 44 44 PEACE RIVER: •270 252 236 31 100 100 31 NORTH-WEST 184 220 248 40 100 62 62 (B) RANK ORDER** (a) OVERALL RURALITY STUDY REGION G . P . PHA DEN G.S . PSY . PED . . • OBS/GNY RANK RANK METROPOLITAN 3k 3 1 1 1 1 2 9 SOUTH-WEST 43s 3k 4 2k 4 3 3 4 ik S. .VAN. I S . ik Ik ik 2k 2 4 4 2 ik OKANAGAN: - ik ik 4*2 3 2 2 2 6": KOOTENAYS 5k 5 4% 6 6 8k 5k 4 MID COAST 4% 5k 6k ik 6 6 5k 5k 4 C. INTERIOR 7 1 6 6 6 1 8 4 PEACE RIVER 9 8k 8k ik 8k 9 5k 8 ik NORTH-WEST. . 8 8k 8k 9 8k 8 8k 8 ik r s v a l u e j - . 6 1 3 - . 8 5 8 - . 6 8 3 - . 8 2 5 - . 8 7 9 - . 7 9 2 - . 5 9 2 - . 7 5 4 * The v a l u e s are e x t r a c t e d from Tables 5 . 1 and 5 . 2 . **':See Appendix G f o r the c a l c u l a t i o n of the rank order: and the c a l c u l a t i o n : of the Rank C o r r e l a t i o n C o e f f i c i e n t (r s ) which measures the degree of c o r r e l a t i o n of the rank orders of A c c e s s i b i l i t y Index A and R u r a l i t y . The c r i t i c a l va lue of r s i s - . 6 8 3 at .05 l e v e l of s i g n i f i c a n c e . (a) The O v e r a l l Rank i s the r e s u l t of r a n k i n g the average rank of a l l seven groups of p e r s o n n e l . Table 8 .2 POPULATION/HEALTH PERSONNEL RATIO (ACCESSIBILITY INDEX B) AS RELATED TO RURALITY BY STUDY REGION (A) INDEX SCORE* STUDY REGION G . P . PHA '; DEN; . G..S. • • PSY r PED" ' OBS 7 GYN METROPOLITAN 989. 1225 1641 9065 8655 15019 15957 SOUTH-WEST 1318 1786 2960 9065 8655 15019 15957 Sv VAN. I S . 1384 1743 2434 12836. 20171 70600 23533 OKANAGAN 1256 1713 2458 . 9422 24229 33920 28267 KOOTENAYS 1068 1869 3100 7944 42367 31775 63550 MID COAST 1090 1281 2725 16350 32700 49050 32700 C . INTERIOR 1317 2171 2807 12083 99650 46100 30878 PEACE RIVER 1659 3446 3346 14933 99650 46100 22400 NORTH-WEST - 1040 2448 4465 12650 99650^ 75900 75900 'k'k (B) RANK ORDER (a) OVERALL COMBINED RURALITY STUDY REGION G . P . PHA . \ DEN G.S . ' . PSY ' 'PED:. OBS/GYN RANK RANK RANK METROPOLITAN 1 ik 1 3 ik ik ik 1 1 9 SOUTH-WEST 6h 4% 6 3 • ik ik ih 2' 2h ik S , VAN. I S . . 8 4Js 2k 6 4% 8k 3k 5*5 5 : ik OKANAGAN — 5 hh 2k 3- 4% 3k 6 3k 2h 6 . KOOTENAYS 3 hh 6 1 4*2 3k 8k 3k 5 4 MID COAST 3 ik 6 9 4*g 6 ; 6 5k 5 4 C . INTERIOR. 6k 7 6 6 8 6 6 8 8 4 PEACE RIVER 9 9 6 8 8 6 3k 8 8 ik NORTH-WEST 3 8 9 6 8 8k 8k 8 8 ik r va lue s - . 1 0 8 - . 5 8 8 - .600 - . 4 0 0 - . 7 0 0 - . 5 0 2 - . 4 2 9 - . 7 2 9 - . 7 5 0 *. The v a l u e s are e x t r a c t e d from Table 6. ** See Appendix G f o r the c a l c u l a t i o n of the rank order, and the c a l c u l a t i o n of the Rank C o r r e l a t i o n C o e f f i c i e n t (: r s ) which measures the degree of c o r r e l a t i o n of the rank orders of A c c e s s i b i l i t y Index B and R u r a l i t y . The c r i t i c a l va lue : of r s i s - . 6 8 3 at .05 l e v e l of £ s i g n i f i c a n c e . (a) The Combined Rank i s the r e s u l t of r a n k i n g the average rank of A c c e s s i b i l i t y . I nd ices :and B. . - . • 4> O 41 V F i g u r e 3 . ACCESSIBILITY AS RELATED TO RURALITY BY RANK ORDER 42 the Okanagan Region and the South-West Region rank second aft e r the Metropolitan Region. The ranks are similar between Accessi-b i l i t y Index A and A c c e s s i b i l i t y Index B, with the exception of those of the Okanagan Region, the South-West Region and the South Vancouver Island Region. Both the Okanagan Region and the South Vancouver Island Region scored better i n A c c e s s i b i l i t y Index A than i n A c c e s s i b i l i t y Index B; the reverse i s true for the South-West Region and the Kootenays Region. The r e l a t i o n -ship between a c c e s s i b i l i t y and r u r a l i t y i s negative and the co r r e l a t i o n i s s i g n i f i c a n t l y strong ( r s = -.750). The Okanagan Region ranks sixth by r u r a l i t y but second by a c c e s s i b i l i t y , suggesting that the region i s better-off than i t ' s r u r a l c h a r a c t e r i s t i c s may otherwise suggest. The reverse i s true for the South Vancouver Island Region and the Central Interior Region. On the whole, the hypothesis that a c c e s s i b i l i t y diminishes with r u r a l i t y i s strongly supported. In b r i e f , for the province as a whole, there i s no shortage of manpower i n the seven groups of primary health care personnel examined i n this study. In fact, for the province as a whole, there i s an excessive supply of general p r a c t i t i o n e r s / family physicians, pharmacists and dentists, with general p r a c t i t i o n e r s and family physicians being most over-supplied (see Table 9). Inter-regional v a r i a t i o n occur i n a l l seven groups of personnel, and i n a l l cases, the Metropolitan Region, followed by the South-West Region, the Okanagan Region and toe.some extent the South Vancouver Island Region are the most favoured, while the North-West Region, ;;the:.Peace..River Region and the Central / Int e r i o r Region are the most disadvantaged. With no o v e r a l l 1 '•TaDle "9'.' ACTUAL AND RECOMMENDED NUMBER OF PRIMARY HEALTH CARE PERSONNEL BY STUDY REGION STUDY REGION METRO . '. OKANAGAN S-W S VAN IS KOOT .... MID C C INT~ PEACE R N-W B.C. G.P. PHARMACIST DENTIST G. SURGEON PSYCHIATRIST PEDIATRICIAN POPULATION 1,315,800 169,600 216,100 141,200 127,100 98,100 277,900 44,800 75,900 2 ,466,500 ACT 1,331 135 164 102 119 90 211 27 73 2,252 REC 752 97 123 81 73 56 159 26 43 1,410 ACT 1,074 99 121 81 68 43 128 13 31 REC 658 85 108 71 64 50 139 22 38 ( 1 : 1 , 7 5 0 ) 1,658 1,235 (1 :2 ,000) ACT 802 69 73 58 41 36 99 13 17 1,208 REC 526 68 87 56 51 39 111 18 30 986 ACT 159 18 10 11 16 6 23 3 6 252 REC 132 17 22 14 13 9 28 5 8 248 ACT REC 170 7 7 7 3 3 4 0 0 11 14 9 8 7 19 3 5 (1 :2 ,500) (1 :10,000) 201 164 (1 :15,000) ACT REC 101 5 1 2 4 2 7 0 1 66 9 11 7 6 5 14 2 4 123 124 (1 :20 ,000) S T U D Y OBS /GYN: M E D I C A L T O T A L . A L L T O T A L R E G I O N P O P U L A T I O N A C T R E C ... A C T R E C A C T R E C METRO-, t 1,315,800 95 66 1,856 1,104 „ 3,732 2,288 OKANAGAN 169,600 6 9 171 143 339 296 S-W 216,100 1 11 183 181 377 376 S V A N I S 141,200 6 7 128 118 267 245 KOOT""' 127,100 2 6 144 106 253 221 M I D C. 98,100 3 5 104 82 183 171 C I N T 277,900 9 14 254 234 481 484 P E A C E R 44,800 2 2 32 38 58 78 N-W 75,900 1 4 81 64 129 132 B . C . 2,466,500 125 124 2,953 2,070 5,819 4,291 (1 :20 ,000) * Recommended numbers are es t imated based on the recommended r a t i o s (g iven i n b r a c k e t s ) . T o t a l i s the summation of a l l seven groups of p e r s o n n e l ; the medica l t o t a l exc ludes pharmacist and d e n t i s t . -1^ oo 44 p r o v i n c i a l manpower shortage, these variations can only be interpreted as a maldistibution (see Table 10). Maldistribution i s most serious for p s y c h i a t r i s t s , followed by pediatricians and obstetricians/gynaecologists. Dentists, pharmacists and general surgeons are less inequitably d i s t r i b u t e d . A l l study regions have an adequate supply of general p r a c t i t i o n e r s / family physicians. For the province as a whole, less than 87, of the population i s outside the 25 Km.-catchment of a G.P., a pharmacist or a dentist; less than 87> i s outside the 75 Km.-catchment of a general surgeon, and about 157. i s outside the 75 Km.-catchment of a p e d i a t r i c i a n , an obstetrician/gynaecologist or a p s y c h i a t r i s t . Measured by the distance c r i t e r i o n , most of the under-serviced communities are found i n the Central Interior Region, progressively less i n the North-west Region, the Kootenays Region, the Peace River Region, and the Mid Coast Region. But the underserviced communities i n the Peace River Region, the North-West Region and the Mid Coast Region i n general have longer mean tr a v e l distances to primary health care personnel, r e f l e c t i n g population dispersion. General Practitioners/Family Physicians In terms of the r a t i o c r i t e r i o n , a l l study regions, with the exception of the Peace River Region, have r a t i o s at least 207> better than the CM.A. recommended r a t i o of one G.P. for every 1,750 persons, while the Metropolitan Region has almost double the required number. Even the Peace River Region i s 57o b e t t e r - o f f than the recommended r a t i o . This suggests that considering each study region as a whole, there i s no shortage of G.P.'s. Table 10. PERCENTAGE DISTRIBUTION OF POPULATION AND PRIMARY HEALTH CARE PERSONNEL BY STUDY REGION STUDY REGION POP'' " G'.P. ' . PHA/. -"DEN : G..S. .: -. .PSY . P.KD ' 0BS,:/GYN TOTAL METRO 53.35 59.10 64.78 66.39 63.10 84.58 82.11 76.00 64.13 OKAN 6.88 5.99 5.97 5 .71 7.14 3.48 4.07 4.80 5.83 S-W 8.76 . 7.28 7.30 6.04 3.97 3.48 .81 .80 6 .48 S VAN IS 5.72 4 .53 4.89 4.80 4.37 3.48 1.63 4.80 4 .59 KOOT 5.15 5.28 4.10 3.39 6.35 1.49 3.25 1.60 4.34 MID C 3.98 4 .00 2.60 2.98 2.38 1.49 1.63 2.40 3.14 C INT 11.27 9.37 7.72 8 .20 9.13 1.99 5.69 7.20 8.27 PEACE R 1.82 1.20 .78 1.08 1.19 0 0 1.60 1.00 N-W 3.08 3.24 1.87 1.41 2.38 0 .81 .80 2.22 B.C. 100.01 99.99 100.01 100.00 100.01 99.99 100.00 100.00 100.00 46 Nevertheless, these r a t i o s do not convey a complete picture of the intra-regional a c c e s s i b i l i t y pattern. Within each study region there may be unserviced or under-serviced areas due to distance b a r r i e r s . Table 5.1 shows that i n at least f i v e study regions, more than 107o of the population have to tra v e l more than 25 Km. to see a G.P. These are the North-West Region (18%), the Peace River Region, (177o) , the Central Int e r i o r Region (147o) , the Kootenays Region (12%) and the Mid Coast Region (12%). The problem appears to be one of population dispersion and vastness of the hinterland, rather than an i n s u f f i c i e n t number of G.P.'s. For instance, the North-West Region ranks second by population/ G.P. r a t i o , yet lowest by tra v e l distance. These findings suggest that the a c c e s s i b i l i t y problem within the study regions should be examined on a micro-scale. This w i l l be the main concern of the following chapter which w i l l examine the study regions i n d i v i d u a l l y and i n d e t a i l . Pharmacists The d i s t r i b u t i o n of pharmacists i s less even than that of the general p r a c t i t i o n e r s . Four study regions f a l l below the desirable standard of one pharmacist per 2,000 persons. They are the Peace River Region with a r a t i o of 1:3,446, 72% below the recommended r a t i o , the North-West Region with a r a t i o of 1:2,488, 22% below the recommended r a t i o , the Mid Coast Region with a r a t i o of 1:2,281, 14% below the recommended r a t i o , and the Central Interior Region with a r a t i o of 1:2,171, 9% below the recommended r a t i o . The Metropolitan 47 Region, again, ranks most favourably, with a 657D surplus of approximately 400 pharmacists. Redistributing only one-tenth of this surplus to the under-serviced regions w i l l eliminate the shortage problem. S t r i c t l y speaking, only the Peace River Region should be considered seriously under-serviced, as the Region's r a t i o does not even meet the World Health Organization requirement of one pharmacist per 2,500 persons. Again, these regional r a t i o s are only crude indicators of the regions' a c c e s s i b i l i t y . Close examination of in d i v i d u a l study regions i s necessary to i d e n t i f y s i g n i f i c a n t i n t r a -regional d i s p a r i t i e s . By travel distance, the North-West Region, the Peace River Region, the Mid Coast Region, the Central Interior Region and the Kootenays Region are the under-serviced. About 15-237o of the population of these f i v e study regions have to tr a v e l more than 25 Km. to the closest pharmacist. Dentists Among the G.P!s, the pharmacists, and thejdentists-, the.':, l a t t e r i s the most unevenly dis t r i b u t e d . With the exception of the Metropolitan Region, the South Vancouver Island Region and the Okanagan Region, a l l study regions experience a shortage. The most seriously underserviced region i s the North-West, with a population/dentist r a t i o of 1:4,465, 797, below the recommended r a t i o . It i s followed by the Peace River Region (1:3,346, 3470 below the recommended r a t i o ) , the Kootenays Region (1:3,100, 2470 below the recommended r a t i o ) , the South-West Region (1:2,960, 187. below the recommended . r a t i o ) , and the Central Interior Region (1:2,807, 127o below 48 the recommended r a t i o ) . More people i n the province have to tra v e l long distances to see a dentist than to see a G.P. or a pharmacist. At the regional l e v e l , this i s also true (see Figure 1). Regions with at least 207o of the i r population having to tr a v e l more than 25 Km. to a dentist include the Peace River Region (247,) , the North-West Region (22%) , the Mid Coast Region (22%) , the Central Int e r i o r Region (227>) and the Kootenays Regions (20%). Although the South-West Region has a poor population/dentist r a t i o , i t ranks second by tr a v e l distance, due to i t s proximity to the Metropolitan Region, which ranks highest by o v e r a l l a c c e s s i b i l i t y . It has a surplus of 357o as measured by the recommended r a t i o , and i s the only one Region where an excessive number of dentists are found. General Surgeons General surgeons, together with p e d i a t r i c i a n s , o b s t e t r i -cians/gynaecologists and p s y c h i a t r i s t s , are generally considered s p e c i a l i s t s , although t h e i r services are basic to the health care of a community. At present, t h e i r services can only be obtained by r e f e r r a l , and i n many instances, require the support of specialized f a c i l i t i e s , and supporting personnel, so that they cannot be delivered on an ubiquitous basis. Thus, the presence of adequate hospital f a c i l i t i e s and supporting personnel i s usually an important factor i n the a t t r a c t i o n of these s p e c i a l i s t s . It i s not surprising that regions with large hospital f a c i l i t i e s are also the ones with high concentration of these s p e c i a l i s t s . 49 Among these four groups of s p e c i a l i s t s , the general surgeon i s the least maldistributed. Even compared with the pharmacist and the dentist, the general surgeon i s more equitably distributed. The average r a t i o of general surgeon to population of the province (1:9,788) i s very close to the recommended r a t i o (1:10,000). The Metropolitan Region which has a substantial surplus i n the other types of health care personnel f a i l s to lead the rest of the province i n the supply of general surgeons. The Metropolitan r a t i o (1:9,065) i s only s l i g h t l y above the recommended r a t i o as well as the p r o v i n c i a l r a t i o (970 and 77o respectively) . The reason that the Metropolitan Region i s not as over-supplied i n the general surgeon as i n other types of health personnel i s probably that the Region has the highest degree of health care service s p e c i a l i z a t i o n . Substitutes are available from other s p e c i a l t i e s such as orthopaedic surgeons, gynaecologists, urologists, etc. The study region which appears to have the largest r e l a t i v e supply of general surgeons i s the Kootenays Region. Its population/general surgeon r a t i o i s 1:7,944, the best of a l l study regions, and i s 197o and 127. above the p r o v i n c i a l average and the recommended r a t i o respectively. This r a t i o alone, however, should not be used for measuring the adequacy of general surgeon supply i n the Region. It may be a r e f l e c t i o n of a deficiency i n the supply of other types of medical s p e c i a l i s t s . It has been known that i n r u r a l communities, where sub-specialty surgeons .are unavailable or d e f i c i e n t , general surgeons have to substitute for them (Herdman, 1975). This appears to be 50 the case i n the Kootenays Region. Although i t has a s a t i s f a c -tory supply of general surgeons, i t i s the second poorest i n the supply of obstetricians and gynaecologists. The only other study region which does not have a deficiency i n the supply of general surgeons i s the Okanagan Region. Its r a t i o (1:9,422) compares facourably with the recommended r a t i o of 1:10,000. The Central Interior Region (1:12,083), the Mid Coast Region (1:16,350), the North-West Region (1:12,65.0) and the Peace River Region (1:14,430) which consistently rank among the lowest by a c c e s s i b i l i t y i n other personnel groups remain the poorest for general surgeons. The South Vancouver Island Region which has a favourable supply of general p r a c t i t i o n e r s , pharmacists and dentists i s not as well supplied with general surgeons. Nevertheless, i t s proximity to V i c t o r i a suggests that i t s r a t i o of one general surgeon to 12,836 persons may be under-estimating i t s accessi-b i l i t y . I t i s perhaps more r e a l i s t i c to consider this study region within the catchment area of V i c t o r i a , as i n the case of the South-West Region being considered within the catchment area of metropolitan Vancouver." While the 'distance' a c c e s s i b i l i t y appears more favourable than the 'ra t i o ' a c c e s s i b i l i t y for the South Vancouver Island Region, the reverse i s true for the North-West Region, the Peace River Region, the Mid Coast Region and the Central Inter i o r Region. The proportions of population not within a 75 Km. radius of a general surgeon for these four Regions are 407o, 317o, 317. and 247> respectively, which when converted to 51 actual figures represent 30,600 persons, 14,000 persons, 30,900 persons and 67,500 persons respectively, t o t a l l i n g 143,000 persons (see Table 5.2). Pediatricians The d i s t r i b u t i o n of pediatricians i n the province i s considerably worse than that of general surgeons. The population/pediatrician r a t i o s of the ric h e s t (Metropolitan) and the poorest (North-West) Regions are 1:15,019 and 1:75,900 respectively, a f i v e - f o l d difference. The entire North-West Region with a population of 75,900 has only one p e d i a t r i c i a n . Both the South-West Region and the South Vancouver Island Region have poor r a t i o s , but by vi r t u e of the i r proximity to the Metropolitan Region, t h e i r ease of access to a p e d i a t r i c i a n i s only second to the Metropolitan Region. Of the 123 pediatricians i n the province, only 19 ,(157o) are outside the Metropolitan Region and i t s two adjacent Regions. However, the pediatricians i n the Metropolitan Region do not serve only the Metropolitan population,.as some practise t e r t i a r y care, thus, t h e i r c l i e n t e l e i s the entire population of the province. On the other hand, even accepting that the Metropolitan r a t i o of one p e d i a t r i c i a n to every 15,019 persons i s somewhat misleading, the gap between the Metropolitan Region and the rest of the province i n terms of the number of pediatricians found i n each i s simply too large to be taken without contention. Perhaps the ra t i o s are not accurate indicators of deficiencies i n health manpower supply. The CM.A. recommended 52 r a t i o of one p e d i a t r i c i a n to 20,000 persons which i s a general guide for the p r o v i n c i a l manpower planning purpose may not be e n t i r e l y appropriate for the estimation of regional needs, esp e c i a l l y when the service i s not s t r i c t l y ubiquitous. Nevertheless, the ra t i o s can be used for the purpose of inter-regional comparison. Outside the Metropolitan Region, pediatricians are s c a n t i l y and unevenly dis t r i b u t e d . Peace River, North-West, Mid Coast and Central I n t e r i o r are the four poorest Regions. Mid Coast has two ped i a t r i c i a n s , with a r a t i o of 1:49,050. North-West has one, while Peace River has none. Central Interior has seven pe d i a t r i c i a n s , but i t has a larger population base than the other three, and the pediatricians also serve the Peace River Region since this Region does not have one. The combined r a t i o for these two Regions i s 1:46,100. When compared to the Metropolitan r a t i o , i t suggests a three-fold difference. The Kootenays Region and the Okanagan Region are r e l a t i v e l y b etter-off, but t h e i r r a t i o s (1:31,775 and 1:33,920 respectively) also compare unfavourably with that of the Metropolitan Region. By t r a v e l distance, the population of the province as a whole i s less accessible to pediatricians than general surgeons. About 147o of the province's population (356,600 persons) are not within 75 Km. of a p e d i a t r i c i a n , while only 77o (170,200 persons) are not within 75 Km. of a general surgeon. The services of a p e d i a t r i c i a n are considered important not only for c h i l d care, but also i n supporting family l i f e . Of the 3 5 6 , 6 0 0 persons not within a radius of 7 5 Km. of a p e d i a t r i c i a n , about one-third ( 1 2 2 , 7 0 0 persons) are found i n the Central Interior Region which constitutes 4 4 7 o of the Region's population. A corresponding proportion for the North-West Region i s 6 2 7 Q ( 4 6 , 9 0 0 persons), and the Peace River Region i s 1 0 0 7 . ( 4 4 , 8 0 0 persons). The proportions for the Kootenays Region and the Mid Coast Region are about the same, 3 1 7 > and 3 2 7 0 respectively. Although the South Vancouver Island Region i s adjacent to V i c t o r i a , and thus has easy access to a p e d i a t r i c i a n , c e r t a i n parts of this study region, p a r t i c u l a r the north-west are r e l a t i v e l y i s o l a t e d . About 2 7 7 > of the Region's population i s not within 7 5 Km. of a p e d i a t r i c i a n . The positions of the Okanagan Region and the South-West Region remain favourable. Obstetricians/Gynaecologists The d i s t r i b u t i o n of obstetricians and gynaecologists i s s l i g h t l y improved from that of p e d i a t r i c i a n s , but the discre-pancies between the poor Regions and the r i c h Regions are enormous. Of the t o t a l number of obstetricians and gynaecologists ( 1 2 5 ) found i n the province, 9 5 ( 7 6 7 « ) are found within the Metropolitan Region. If those i n the South-West Region and the South Vancouver Island Region are included, the number i s up to 1 0 2 ( 8 2 7 . ) . Obstetricians and gynaecologists, however, are similar to pediatricians i n that cer t a i n members of the group practise t e r t i a r y care, thus, they need to be close to the..medical centre of the province. Again, the r a t i o of one obstetrician/gynaecologist to 1 5 , 9 5 7 persons for the 54 Metropolitan Region where the province's medical centre i s located may be over-estimated. Despite of this p o s s i b i l i t y , the concentration i n the Metropolitan Region i s s t i l l high. Outside the Metropolitan Region, the Peace River Region has the best r a t i o (1:22,400), followed by the Okanagan Region (1:28,267). These r a t i o s , however, are s t i l l below the recommended 1:20,000. The poorest Region i s North-West, with a r a t i o of 1:75,900 which is a f i v e - f o l d difference from that of the Metropolitan Region, followed by the Kootenays Region (1:63,550), the Mid Coast Region (1:32,700), and the Central Interior!.Region (1:30,878). By t r a v e l distance, 667, of the population of the Kootenays Region have to t r a v e l 75 Km. or more to an o b s t e t r i c i a n or gynaecologist; 627, of the North-West Region have to t r a v e l more than 75 Km. to the Region's only o b s t e t r i c i a n . The corresponding proportion for the Central I n t e r i o r Region i s 447o. For both the Mid Coast Region and the Peace River Region the proportion i s 317,. Although some of the inhabitants of the South Vancouver Island Region are within the catchment area of V i c t o r i a , 257, of the regional population are nevertheless more than 75. Km.: from an o b s t e t r i c i a n or a gynaecologist. The corresponding proportion for the Okanagan Region, the South-west Region and the Metropolitan Region i s less than 77,. Similar to pediatricians, obstetricians and gynaecologists are important not only to one p a r t i c u l a r segment of the popu-l a t i o n (female), they also provide important services i n support of the family. In r u r a l - f r o n t i e r communities where family 55 support services are meagre, the deprivation of health services to women may have broader implications for the family and s o c i a l l i f e of these regions. P s y c h i a t r i s t s The d i s t r i b u t i o n of p s y c h i a t r i s t s i s the most inequitable of a l l . Even accepting the fact that p s y c h i a t r i s t s are to some extent s p e c i a l i s t s , and that some degree of d i s p a r i t y between the Metropolitan Region and the r e s t of the province i s inevitable, the d i f f e r e n t i a l between the two i s simply too high to be tenable. The Metropolitan Region has a t o t a l of 170 p s y c h i a t r i s t s or 85% of the province's t o t a l , and i f those of the South-West Region and the South Vancouver Island Region are included, the proportion i s up to 92% ( i . e . 184 p s y c h i a t r i s t s out of a t o t a l of 201), leaving only 6%, ( i . e . 17 p s y c h i a t r i s t s ) for the balance of the province. Of these 17 p s y c h i a t r i s t s , more than one-third, or seven, are i n the Okanagan Region which i s the best serviced area outside the Metropolitan Region. The remaining ten are d i s t r i b u t e d i n the Kootenays Region, the Central Interior Region and the Mid Coast Region. The entire north, including the Peace River Region and the North-West Region i s without a p s y c h i a t r i s t . The closest p s y c h i a t r i s t that can be reached from the Regions i s i n Prince George, and there i s only one i n the community, already serving a population of 135,000 i n the Central Inte r i o r Region. Although for reasons mentioned e a r l i e r , r a t i o s are not t o t a l l y accurate indicators of a region's health care manpower needs, they can be used to detect regional d i s p a r i t i e s . 56 Measured against the CM.A. recommended r a t i o of one p s y c h i a t r i s t for every 15,000 persons, the Metropolitan Region i s more than 90% over-supplied, with an exceptional r a t i o of 1:8,655. On the other hand, the entire north, including the Peace River and the North-West Regions, has a r a t i o of 1:99,650. The d i f f e r e n t i a l i s more than eleven-f o l d . The r a t i o for the Kootenays Region i s 1:42,367, the second poorest, and i s 18270 below the recommended r a t i o . The Mid Coast Region has similar deficiency, with a r a t i o of 1:32,700, 188% below the recommended r a t i o . The Okanagan Region has a r a t i o of 1:24,229, again the most favourable outside the Metropolitan Region and i t s v i c i n i t y . The d i s t r i b u t i o n of p s y c h i a t r i s t s as measured by the t r a v e l distance c r i t e r i o n i s similar to that of obstetricians and gynaecologists for most parts of the province. The proportions of population not within the 75 Km. radius of a p s y c h i a t r i s t for the nine study regions i n ascending orders are: 0% for Metropolitan Region, 3% for the South Vancouver Island Region, 5% for the Okanagan Region, 10% for:the South-west Region, 32% for the Mid Coast Region, 45% for the Central Interior Region, 52% for the Kootenays Region, and 1007o for both the North-West Region and the Peace River Region. For the province as a whole, the proportion i s 15% (I.e. 380,100 persons), the same as obstetricians and gynaecologists. Whether p s y c h i a t r i s t s are the only appropriate profes-sionals to care for the mental health of a population, or whether there are good substitute approaches to better mental health care i s beyond the scope of t h i s thesis. As long as p s y c h i a t r i s t s maintain t h e i r authoritative p o s i t i o n i n the mental health care f i e l d , t h e i r u n a v a i l a b i l i t y to a s i g n i f i c a n t proportion of the population i n B r i t i s h Columbia should be viewed as a serious deficiency i n basic health care delivery. Limitations of the Research The d i s p a r i t i e s revealed i n the a c c e s s i b i l i t y analysis i s only a crude overview of the problem. To better under-stand the problem, further research needs to be done, p a r t i c u l a r l y on the service functions of the professionals. Whether a region or a community i s adequately serviced also depends on the productivity of the professionals, and the po t e n t i a l of r e a l transfer of functions between members of the formal and informal health care team ( R o l l c a l l 77, 1978). Relationship between Waiting Time and Rurality The research on waiting time to see a physician as a function of r u r a l i t y was exploratory. Since a major determinant of waiting time i s the type of v i s i t , whether urgent of non-urgent (routine), i t was decided that this factor should be considered i n the survey. Thus, two sets of data were collected, .one for urgent v i s i t s and the other for non-urgent v i s i t s , and both were correlated with r u r a l i t y . The choice of sample size for the survey was a r b i t r a r y . It should be observed that the samples selected for certain study regions were<;very small, e s p e c i a l l y those for the Peace River Region and the South Vancouver Island Region. Since the Peace River Region and the North-West Region are similar i n th e i r r u r a l i t y and a c c e s s i b i l i t y ranks, they were combined to form a larger sample. Nevertheless, the r e l i a b i l i t y of the results derived from small samples i s l i k e l y low, because of the p r o b a b i l i t y of biases and dispersion of the sample values from the true values i s great. Table 11 compiles the survey findings by study region. Eigure 4 shows the relationship between waiting time and r u r a l i t y . The results are not conclusive. The v a r i a t i o n i n mean waiting time for both urgent and non-urgent v i s i t s across regions i s not remarkable, although the range for either type of v i s i t s appears wide. For urgent v i s i t s , the range i s from .15 day (South-West Region) to .88 day. (Metropolitan Region), with the majority (six out of the eight study regions) being not more than .50 day. For non-urgent v i s i t s , the range i s from .39 day (Kootenays Region) to 1.21 days (Metropolitan Region), with the majority (seven out of the eight study regions) not more than 1 day, and none more than 2 days. A p o s i t i v e l i n e a r relationship between r u r a l i t y and waiting time, however, does not appear to hold true. A d i f f e r e n t pattern of association between the two variables emerges instead: the most r u r a l regions, namely the Peace River Region and the North-West Region as well as the least r u r a l region, namely the Metropolitan Region, appear to have longer mean waiting times than those i n between for urgent v i s i t s ; as for non-urgent v i s i t s , waiting time 59 Table 11. MEAN WAITING TIME FOR A G . P . APPOINTMENT AS RELATED TO RURALITY BY STUDY REGION STUDY REGION n ( a > URGENT RANK .(b) NON-URGENT R A N K ^ RURALITY RANK (days) (days) METROPOLITAN 29 ;88 1% 1.21 ih 8 SOUTH-WEST 10 . 15 8 1.00 ih bh Sv VAN. I S . 5 .50 3 .50 1 6h OKANAGAN 9 .44 5 1.00 4 5 KOOTENAYS 9 .39 5 .39 8 3 MID COAST 11 .41 5 .86 4 3 CENTRAL INTERIOR 13 .35 7 .73 6 3 N-W & PEACE R 7 .86 ih .93 4 1 B .C. 93 .56 .92 r s • 036 - . 3 3 9 ^ a ^Usable sample responses • ^ See Appendix H f o r the c a l c u l a t i o n . of the. rank order - and the Rank C o r r e l a t i o n C o e f f i c i e n t ( r s ) which measures the degree of c o r r e l a t i o n of the rank orders of mean w a i t i n g t ime and r u r a l i t y . The c r i t i c a l v a l u e of r s i s - . 7 3 8 at .05 l e v e l of s i g n i f i c a n c e . appears to decrease with r u r a l i t y , although this relationship i s weak. Table 12.1 and Table 12.2 describe the results of the second analysis which compares waiting times by community si z e . There are three community size groups: (1) metropolitan centres. (2) urban centres, and (3) r u r a l communities. Most of the observations made i n the f i r s t analysis apply to the second. The majority of waiting times are not more than .50 day for both types of v i s i t s . The longest waiting time for urgent v i s i t s i s found i n the metropolitan centres (4.5 days). The longest waiting time i n the urban centres i s 1.50 days, and 60 Figure 4. WAITING TIME AS RELATED TO RURALITY BY RANK ORDER x = urgent ( r s = .036) o = non-urgent ( r s = -.339) Waiting Time 9 8 7 6 5 4 3 2 1 R u r a l i t y Table 1 2 . 1 . MEAN WAITING TIME (URGENT) FOR A G . P . APPOINTMENT BY COMMUNITY TYPE (SIZE) COMMUNITY WAITING TIME (DAYS) TYPE (a) n(b) 0 0 .5 1 1.5 .2 2 MEAN(c 1. METRO 29 3 15 7 0 2 2 .88 = 2. URBAN 27 10 14 2 1 0 0 .39 = 3 . RURAL 37 19 11 2 3 2 0 .43 = B.C. 93 32 40 11 4 4 2 .56 Table 1 2 . 2 . MEAN WAITING TIME (NON-URGENT) FOR A G . P . APPOINTMENT BY COMMUNITY TYPE (SIZE) COMMUNITY WAITING TIME (DAYS) TYPE (a) n(b) 0 0 . 5 1 1.5 2 2 MEAN(c 1. METRO 29 3 10 8 0 4 4 1.21 = 2. URBAN 27 4 14 3 1 3 2 .96 = 3 . RURAL 37 14 11 3 4 5 0 .66 = B.C. 93 21 35 14 5 12 6 .92 (a) (b) Populat i o n s i z e : 1. — 100,000 and over ; 2, 3 . = l e s s than 10,000 Usable sample responses . = 1 0 , 0 0 0 - 9 9 , 9 9 9 ; and (c) From Appendix I: x _1 x 2 and ^2 s i g n i f i c a n t l y d i f f e r e n t ^ and X 3 not s i g n i f i c a n t l y d i f f e r e n t x-^  and s i g n i f i c a n t l y d i f f e r e n t yi and y2 not s i g n i f i c a n t l y d i f f e r e n t Y2 and ^3 not s i g n i f i c a n t l y d i f f e r e n t and 3^3 s i g n i f i c a n t l y d idderent ( A l l p a i r s have h i g h v a r i a b i l i t y except y^ and 62 i n .the r u r a l communities, i t i s 2.00 days. There i s al s o a higher p r o p o r t i o n of urgent v i s i t w a i t i n g times of l e s s than 1 day i n the urban centres than i n e i t h e r the m e t r o p o l i t a n centres or the r u r a l communities. O v e r a l l , urban centres appear to have shorter w a i t i n g times for.rurgent v i s i t s than e i t h e r of the other groups of communities. But s t a t i s t i c a l l y the sample v a r i a b i l i t y among the three groups of communities i s too h i g h l t o a l l o w meaningful comparison of the means. For non-urgent v i s i t s the sample variance between the met r o p o l i t a n centres .and the r u r a l communities and between the urban centres and the r u r a l communities i s a l s o too high to a l l o w meaningful comparison of the means. Between the m e t r o p o l i t a n centres and the urban centres the means are not s i g n i f i c a n t l y d i f f e r e n t . (See appendix I f o r the r e s u l t s of the t e s t s . ) The f i n d i n g s seem to support the n o t i o n that r u r a l medicine i s d i f f e r e n t from urban medicine i n th a t the former emphasizes th e r a p e u t i c treatment, w h i l e the l a t t e r i s l a r g e l y provided f o r r o u t i n e , non-urgent purposes. The case i s l a r g e l y demonstrated by the long w a i t i n g times f o r both r o u t i n e and urgent v i s i t s i n the m e t r o p o l i t a n centres and the short w a i t i n g times f o r both types of v i s i t s i n r u r a l communities. There are a few long w a i t i n g times f o r urgent v i s i t s recorded i n the m e t r o p o l i t a n centres, but they should not be considered a serious hindrance to access to primary h e a l t h care, as there are many a l t e r n a t i v e s such as o u t - p a t i e n t s e r v i c e s i n h o s p i t a l s , emergency s e r v i c e s , or the opportunity of f i n d i n g another immediately a v a i l a b l e p h y s i c i a n . Long w a i t i n g times for urgent v i s i t s i n some r u r a l communities, on the other hand, can be undesirable. Unlike the urban and the metro-po l i t a n centres, r u r a l communities have lim i t e d and sometimes no alternatives. The survey results suggest that at least 20% of the r u r a l communities in -"this province do. not have r e a d i l y available primary care, as seven out of the thirty-seven r u r a l c l i n i c s or G.P. o f f i c e s surveyed have long waiting times (at least one day) for urgent v i s i t s . The percentage could be higher i f the 'no-doctor' communities and those with only a part-time physician are considered. Relationship between Personal Attributes of Physicians and  Rurality Year of Graduation Age d i f f e r e n t i a l s as infer r e d from year of graduation across study regions are not remarkable. Table 13 summarizes the findings. The mean year of graduation by study region ranges from 1966 (the South-West Region, the North-West Region and the Peace River Region) to 1958 (th South Vancouver Island Region), suggesting an age range of 36-44 (assuming on the average a graduate of 1972 i s 30 years of age and the age i s inversely proportional to the year of graduation). Correlation between year of graduation and r u r a l i t y (shown i n Figure 5) suggests a weak negative rel a t i o n s h i p . In the South Vancouver Isalnd Region and the Okanagan Region there are proportionally more older physicians than other study regions. The average ages of the G.P.'s i n these two Regions are 44 and 45 respectively, as compared to the Table 13. MEAN YEAR OF GRADUATION AS RELATED TO RURALITY ' BY STUDY REGION STUDY (a) (c) be fore a f t e r (b) INFERRED (d) RURALITY REGION n 1972 1942-51 1952-61 1962-71 1971 MEAN MEAN AGE RANK RANK METRO 40 2 6 9 15 8 62.1 40 4% 9 s-w.. 10 0 0, 2 5 3 66.1 36 7k ik S VAN IS 10 1 1 4 2 2 58.9 44 2 Ik OKAN 10 1 2 4 2 r 57.4 45 h 6 ROOT 10 0 1 3 2 4 65.5 37 Ik 4 MID C 10 0 3 0 4 3 62.2 40 hk 4 C INT 20 2 2 5 9 2 60.9 42 3 4 PEACE R 7 0 0 2 3 2 66.6 36 ik ik N-W 10 0 1 1 4 4 66 .1 36 ik ik B.C. 127 6 16 30 46 29 62.5 40 (100%) (4%) (13%) (24%) (36%) (22%) r s = - . 4 2 5 (a) Sample s i z e (b) 6 2 . 1 = January 1962; 57 .4 = May 1957; and so f o r t h . (c) Assumes on the average a graduate of 1972 i s 30 years of age and that age i s i n v e r s e l y p r o p o r t i o n a l to year of g r a d u a t i o n . (d) See Appendix J f o r the c a l c u l a t i o n s of the rank orders and the Rank C o r r e l a t i o n C o e f f i c i e n t ( r g ) which measures the degree of c o r r e l a t i o n of the rank orders of mean year of g raduat ion and r u r a l i t y . The c r i t i c a l v a l u e of r g at .05 l e v e l of s i g n i f i c a n c e i s - . 6 8 3 . Table 14. MEAN YEAR OF GRADUATION BY COMMUNITY TYPE (SIZE) COMMUNITY (a) TYPE n before 1942 1942-51 1952-61 1962-71 a f t e r 1971 MEAN 1. METRO 40 2 (5%) 6 (15%) 9 (23%) 15 (38%) 8 (20%) 62.2 = 2. URBAN 46 4 (9%) 6 (13%) 13 (28%) 13 (28%) 10 (22%) 60.4 = 3 . RURAL 41 0 (0%) 4 (10%) 8 (20%) 18 (44%) 11 (27%) 65.1 = B .C . 127 6 (5%) 16 (13%) 30 (24%) 46 (36%) 29 (23%) 62.5 INFERRED MEAN AGE 40 42 37 40 (a) x 2 a n d . x 3 a re s i g n i f i c a n t l y d i f f e r e n t ; and x 2 > and x i and X 3 are not s i g n i f i c a n t l y d i f f e r e n t . See Appendix I. ' 65 F i g u r e 5. YEAR OF GRADUATION AND PLACE OF GRADUATION AS RELATED TO RURALITY BY RANK ORDER x = year of g r a d . ( r s = -.425) o = % n o n - B . C . g r a d . ( r s = -.508) Year of g r a d . or P l a c e of Grad . 1 (Okanagan) x (S-W) (C. I n t e r i o r ) (Mid Coast ) oo \ XX 6 5 4 R u r a l i t y p r o v i n c i a l average of 40. These two Regions are among the best serviced outside the Metropolitan Region. The G.P.'s in the Kootenays Region, the South-West Region, the North-West Region and the Peace River Region are on the average :" three to four years younger than the p r o v i n c i a l average. It can be inferred from the findings that the South Vancouver Island Region and the Okanagan Region are the most a t t r a c t i v e for G.P.'s to practise (and to l i v e ) , and thus more older physicians are found, while r u r a l regions as represented by Peace River and North-West are the least a t t r a c t i v e , and thus become the 'staging' places for younger physicians (also non-B.C. trained physicians as explained l a t t e r ) to establish t h e i r practice i n a less competitive environment. This inference i s further supported by the res u l t s i n Table 14. Non-metropolitan urban G.P.'s are on the average f i v e years older than r u r a l G.P.'s, and two years older than metropolitan G.P.'s. S t a t i s t i c a l tests indicate that metropolitan G.P.'s and urban G.P.'s are not s i g n i f i c a n t l y d i f f e r e n t i n age, but both groups are s i g n i f i c a n t l y d i f f e r e n t from the r u r a l group (see Appendix I, Part I I ) . In the Rural communities, about 737> of the G.P.'s are more than 30 years of age, but only about 307. are over 40. In the urban communities, 787, of the G.P.'s are over 30, and 507. are over 40. In the metropolitan centres, about 807o of the G.P.'s are over 30, and 4270 are over 40. Place of Graduation Table 15 describes the d i s t r i b u t i o n of the 127 sample physicians (G.P.'s) according to th e i r place of graduation by study region. Table 16 describes the same d i s t r i b u t i o n by community type ( s i z e ) . The relationship between place of graduation and r u r a l i t y i s shown i n Figure 5. In 1977-78, two out of ten G.P.'s i n B.C. were graduates of U.B.C, three out of ten were graduates of European countries or the U.S.A., and f i v e out of ten were graduates of other provinces i n Canada. Only 3%'are graduates of other foreign countries. It i s observed from Table 15 that i n the South Vancouver Island Region and the Okanagan Region, there are s l i g h t l y more G.P.'s graduated from B.C. than the p r o v i n c i a l average. Three out of ten G.P.'s i n these two study regions are graduates of U.B.C., as opposed to two out of ten i n the province as a whole. The Metropolitan Region and the Mid Coast Region are close to the p r o v i n c i a l average. In the remaining Regions, B.C. graduates comprise about 107o of the t o t a l number of G.P.'s. The majority of the G.P.'s i n the Peace River Region are graduates of European countries, or the U.S.A., and i t i s similar to the Central Interior Region. The proportions of G.P.'s who are non-B.C. Canadian graduates i n the North-West Region, the Kootenays Region, the Okanagan Region, the South-West Region and the Mid Coast Region are higher than the p r o v i n c i a l average. Although the Table 15. PLACE OF GRADUATION AS RELATED TO RURALITY BY STUDY REGION STUDY REGION 1977-78 METRO S-W S VAN IS OKAN KOOT MID C C INT PEACE R N-W B.C. 1975-76 METRO S-W S VAN IS OKAN KOOT MID C C INT PEACE R N-W B.C. NON-B.C. NON-B.C . 0 . EUR/ 0 . 0 . EUR/ 0 . (a) RURALITY B.C. CANA U .S . COUN TOTAL B.C. CANA U.S . COUN TOTAL RANK RANK (NUMBER) (PERCENTAGE) 40 9 18 10 3 31 22.5 45.0 25.0 7.5 77.5 3k 9 10 1 7 2 0 9 10.0 70.0 20.0 0 90.0 6k ik 10 3 3 3 1 7 30.0 30.0 30.0 10.0 70.0 ik ik 10 3 7 0 0 7 30.0 70.0 0 0 70.0 ik 6 10 1 7 2 0 9 10.0 70.0 20.0 0 90.0 6k 4 10 2 6 2 0 8 20.0 60.0 20.0 0 80.0 3k 4 20 2 6 12 0 18 10.0 30.0 60.0 0 90.0 6k 4 7 0 2 5 0 7 0 28.6 71.4 0 100.0 9 ik 10 1 8 1 0 9 10.0 80 .0 10.0 0 90.0 6k ik 127 22 64 37 4 105 17.3 50.4 29.1 3 . 1 82.6 r s = - . 5 0 8 40 10 15 10 5 30 25.0 37.5 25 .0 12.5 75.0 10 4 4 2 0 6 40 .0 40 .0 20.0 0 60.0 10 3 4 3 0 7 30 .0 40 .0 30.0 0 70.0 10 2 6 0 2 8 20.0 60.0 0 20.0 80.0 10 1 5 4 0 9 10.0 50 .0 40 .0 0 90.0 10 1 4 5 0 9 10.0 40 .0 50 .0 0 90.0 20 3 6 11 0 17 15.0 30 .0 55 .0 0 85.0 7 1 1 5 0 6 14.3 14.3 71.4 0 85.7 10 0 4 5 0 9 0 40 .0 50 .0 0 90.0 127 25 49 46 7 102 19.7 38.6 36.2 5 .5 79.3 (a) See Appendix J f o r the c a l c u l a t i o n s of the rank orders and the Rank C o r r e l a t i o n C o e f f i c i e n t ( r s ) which measures the degree of c o r r e l a t i o n of the rank orders of p r o p o r t i o n of n o n - B . C . graduates and r u r a l i t y . r The c r i t i c a l v a l u e of r s a t .05 l e v e l of s i g n i f i c a n c e i s - . 6 8 3 . Table 16. PLACE OF GRADUATION BY COMMUNITY TYPE (SIZE) NON-B.C .  COMMUNITY OTHER EUROPE/ OTHER TYPE n B .C . CANADA U .S .A . COUNTRIES. TOTAL 1977-78 1. METRO 40 9 (23%) 18 (45%) 10 (25%) 3 (8%) 31 (78%) 2. URBAN 46 6 (13%) 24 (52%) 15 (33%) 1 (2%) 40 (84%) 3 . RURAL 41 7 (17%) 22 (54%) 12 (29%) 0 (0%) 34 (83%) B .C . 127 22 (17%) 64 (50%) 37 (29%) 4 (3%) 105 (83%) 1975-76 1. METRO 40 10 (25%) 15 (38%) 10 (25%) 5 (13%) 30 (75%) 2. URBAN 46 10 (22%) 23 (50%) 13 (28%) 0 ( 0%) 36 (78%) 3 . RURAL 41 5 (12%) 11 (27%) 23 (56%) 2 ( 5%) 36 (88%) B .C . 127 25 (20%) 49 (39%) 46 (36%) 7 ( 6%) 102 (80%) Note : The/proport ions of n o n - B . C . Canadian graduates and European/U.S.A. graduates f o r the r u r a l communities ; v a r e s i g n i f i c a n t l y d i f f e r e n t between 1975-76 and 1977-78. See Appendix I . relationship between place of graduation and r u r a l i t y i s weak, the findings do suggest.that urban and metropolitan Regions are more a t t r a c t i v e to B.C. trained physicians, while the r u r a l regions r e l y more on non-B.C. sources. Table 16, however, suggests that community size i s not an important factor of physicians' choice of practice location. D i s t r i b u t i o n of G.P.'s by place of graduation across the three groups of communities i s not s i g n i f i c a n t l y d i f f e r e n t (see s t a t i s t i c a l test results i n Appendix I, Part I I ) . Thus, i t can be inf e r r e d that the location of a community, whether i n a remote-frontier region such as the Peace River Region and the North-West Region, or an urban region such as the Okanagn Region, i s a more important factor i n the choice of practice location of a physician than the community siz e . A comparison of the d i s t r i b u t i o n of G.P.'s by place of graduation by community type between 1975-76 and 1977-78 indicates that the 'zero-point' p o l i c y on immigration of physicians has had l i t t l e impact on the d i s t r i b u t i o n of G.P.'s i n B r i t i s h Columbia, except i n r u r a l communities. S t a t i s t i c a l tests suggest that within this period, there was a s i g n i f i c a n t s h i f t of G.P. d i s t r i b u t i o n by place of graduation i n the r u r a l communities ( i . e . communities with less than 10,000 population), with non-B.C. Canadian graduates replacing foreign graduates. This phenomenon i s not evident i n either the metropolitan centres or the urban centres. Table 17. ANNUAL RATE OF CHANGE, M.S.C. ACTIVE PHYSICIANS STUDY REGION 1974-75 1975-77 METROPOLITAN 2.22 5.88 4.14 4.71 5.67 5.73 11.11 4.67 3.45 3.48 2.16 1.86 -1.05 -1.09 5.64 -4.26 3.10 SOUTH-WEST S. VAN. IS OKANAGAN' KOOTENAYS MID COAST C. INTERIOR PEACE RIVER -10.91 NORTH-WEST B.C. 16.20 3.30 Annual rate of change (in percent) i n the number of active M.S.C. physicians (physician not i n post-graduate work) per 10,000 population. Source: R o l l c a l l 77, 1978 (Health Manpower Research Unit) Table 17 indicates the rate of change i n the number of physicians i n B.C. r e l a t i v e to population by study region for the period of 1974-77. The rates of change suggest that the r u r a l regions have declined i n the number of physicians r e l a t i v e to population faster than the urban regions, and only the Metropolitan Region has gained physicians. Table 18 further supports the findings that r u r a l regions have suffered from the r e s t r i c t i v e immigration policy, as the decline i n the number of new physician registrants i s d i r e c t l y a t t r i b u t a b l e to the decline i n the number of foreign new registrants i n the r u r a l regions. In sum, there i s some in d i c a t i o n that personal attributes measured by age and place of graduation influence a physician's 72 Table 18. NUMBER OF NEW REGISTRANTS'BY PLACE OF GRADUATION* OTHER OTHER STUDY REGION B.C . CANADA COUNTRIES TOTAL 1975-77, METROPOLITAN 60 130.5 103.5 294 SOUTH-WEST 4 .5 8 4 16.5 S . VAN. I S . 2 .5 5 . 5 3 . 5 11.5 OKANAGAN 1.5 10.5 2 .5 14.5 KOOTENAYS' 2 .5 5 7 14.5 MID COAST 1.5 5 5 .5 12 C. INTERIOR 2 13.5 7 22.5 PEACE RIVER 0 1.5 2 .5 4 NORTH-WEST 1 5 2 8 B .C . 75.6 184.5 137.5 397.5 1974-75 METROPOLITAN 68 137 127 332 SOUTH-WEST 4 6 9 19 S . VAN. I S . 0 10 3 13 OKANAGAN 3 9 4 16 KOOTENAYS 1 3 10 14 MID COAST 1 7 4 12 C. INTERIOR 2 18 21 41 PEACE RIVER 0 3 3 6 NORTH-WEST 0 4 13 17 B .C . 79 197 194 470 D i r e c t o r y a c t i v e p h y s i c i a n s Source: R o l l c a l l 77, 1978 (Heal th Manpower Research U n i t ) The s t a t i s t i c s g iven are the annual averages of 1975-77. c h o i c e of p r a c t i c e l o c a t i o n . Thus, the hypotheses are supported. Changes i n f e d e r a l immigration p o l i c y although.short l i v e d has a l s o a f f e c t e d the d i s t r i b u t i o n of p h y s i c i a n s . CHAPTER V INTRA-REGIONAL ACCESSIBILITY In this chapter, the nine study regions are examined i n d i v i d u a l l y i n d e t a i l . The purpose i s to i d e n t i f y the under-serviced areas within each Region. Table 19 and Tables 20.1 and 20.2 summarize the d i s t r i b u t i o n of personnel at the community l e v e l . The d e t a i l s of these tables can be obtained from Appendix C. Table 19 l i s t s the communities by study region i n h i e r a r c h i c a l order, and indicates the number of primary health care personnel i n each community to f a c i l i t a t e comparison. It i s evident that some higher order communities have fewer personnel than the lower order communities. Table 20.1 i d e n t i f i e s communities that completely lack certain types of personnel, and Table 20.2 shows the degree of manpower inadequacy at the community l e v e l . These tables form the basis for the following discussions. Study Region 1. Kootenays This study region comprises the Regional D i s t r i c t s of East Kootenay, Central Kootenay and Kootenay Boundary, and has a population of 127,100. The Region i s characterized by i t s resource industries i n mining and forest products. Table 19. POPULATION CENTRE HIERARCHY AND DISTRIBUTION OF PRIMARY HEALTH CARE PERSONNEL BY POPULATION CENTRE STUDY REGION 1st Order (> 100,000) 2nd Order POPULATION BY LEVEL OF HIERARCHY 3rd Order (20 ,000 -99 ,999) 4th Order (5 ,000-19 ,999) (1 ,000 -4 ,999) 5th Order (< 1,000) METROPO- Greater Van 3,091 LITAN V i c t o r i a 619 Sooke 6 7 V i l l a g e s S a l t s p r i n g Is 13 SOUTH-WEST .C. F r a s e r V a i l 144 Squamish Dewdney-Alouett 85 Hope C h i l l i w a c k 88 16 13 Gibsons Seche l t 12 15 24 V i l l a g e s S c a t t e r e d r u r a l p o p u l a t i o n : 3,300 SOUTH VANCOUVER ISLAND Nanaimo 135 Duncan 44 P t . A l b e r n i 53 Ladysmith L. Cowichan Youbou U c l u e l e t Tof ino 10 6 0 4 1 18 V i l l a g e s S c a t t e r e d r u r a l p o p u l a t i o n : 2,200 OKANAGAN Kelowna KOOTENAYS Vernon P e n t i c t o n 127 Summerland-74 West Bench 67 Armstrong Peach land -Westbank O l i v e r Cranbrook T r a i l Nelson Cas t legar Kimber ley Creston Fe rn ie 9 9 11 11 37 42 36 18 18 20 17 Osoyoos 9 P r i n c e t o n 9 Enderby , 5 Lumby 3 Keremeos 1 Rossland 10 Grand Forks 12 Sparwood 7 Invermere 11 Nakusp 5 E l f o r d 0 Salmo 4 F r u i t v a l e 4 17 V i l l a g e s S c a t t e r e d r u r a l p o p u l a t i o n : 5,200 65 V i l l a g e s S c a t t e r e d r u r a l p o p u l a t i o n : 8 ,200 4> Table 19 - Continued STUDY POPULATION BY LEVEL OF HIERARCHY REGION 1st Order 2ndmOrder 3rd Order 4th Order 5 th Order (> 100,000) (20 ,000 -99 ,000) (5 ,000-19 ,000) (1 ,000 -4 ,999) (< 1,000) Greenwood 2 Canal F l a t s 0 Kas lo 3 MID Courtenay - Campbell R i v e r 38 Por t Hardy 7 64 V i l l a g e s COAST Comox 56 P o w e l l R i ve r : 43 Cumberland 5 Gold R i v e r 3 S c a t t e r e d r u r a l Tahs is 2 p o p u l a t i o n : 5 ,700 Masset 8 Por t A l i c e 1 Por t McNe i l 4 Ocean F a l l s 2 < Queen Char loote 4 CENTRAL INTERIOR P r i n c e George 127 Kamol lps 149 W i l l i a m s Lake Quesnel Salmon Arm M e r r i t t Reve ls toke Mackenzie 27 Golden 9 31 A s h c r o f t 7 35 For t St• James 6 15 Vanderhoof 8 11 1 0 0 - M i l e House 5 5 L i l l o o e t 5 F raser Lake 4 Chase 4 L y t t o n 3 Chache Creek 0 Sicamous 4 Logan Lake 2 Valemount 0 McBride 5 Lac La Hache 0 B a r r i e r e 0 C l i n t o n 2 C learwater 5 117. V i l l a g e s S c a t t e r e d r u r a l p o p u l a t i o n : 15,800 Table 19 - Continued STUDY REGION POPULATION BY LEVEL OF HIERARCHY 1st Order 2nd Order (> 100,000) (20 ,000 -99 ,999) 3rd Order (5 ,000 -19 ,000) 4th Order (1 ,000 -4 ,999) 5 th Order (< 1,000) NORTH-WEST P r i n c e Rupert 37 Smithers 17 46 V i l l a g e s Terrace 31 Houston 4 K i t i m a t 24 Burns Lake 8 S c a t t e r e d r u r a l Telkwa 0 p o p u l a t i o n : 3 ,100 Stewart 2 Haze l ton 5 Por t Edward 0 G r a n i s l e 0 C a s s i a r 1 PEACE Dawson Creek 26 For t Nelson 7 18 V i l l a g e s RIVER For t S t . John 20 Chetwynd 4 Hudson Hope 1 S c a t t e r e d ' r u r a l populat i o n : 6 , 3 0 0 •'*•The number g i ven i s the t o t a l number of pr imary h e a l t h care personnel found i n the c e n t r e , i n c l u d i n g ' G . P . ' s , p h a r m a c i s t s , ' d e n t i s t s , . " g e n e r a l surgeons, p s y c h i a t r i s t s . , , p e d i a t r i c i a n s and obs/gyn. Note that 2nd o r d e r , 3rd order and 4th order cent res are f u r t h e r subd iv ided i n t o the f o l l o w i n g groups , and the l i n e s are used to separate the sub-groups w i t h i n the same column: 2nd order c e n t r e s : 2 0 , 0 0 0 - 4 9 , 9 9 9 , 5 0 , 0 0 0 - 9 9 , 9 9 9 3rd order c e n t r e s : 5 , 0 0 0 - 9 , 9 9 9 , 1 0 , 0 0 0 - 1 9 , 9 9 9 4 t h order c e n t r e s : 1 , 0 0 0 - 2 , 4 9 9 , 2 , 5 0 0 - 4 , 9 9 9 The cent res are g i ven i n descending order by p o p u l a t i o n s i z e . Table 2 0 . 1 . UNDERSERVICED COMMUNITIES G.P (a) PHARMACIST (b) DENTIST (c) GENERAL SURGEON (d) R COMMUNITY POP' R COMMUNITY POP R COMMUNITY POP' ; C B a r r i e r e 1,000 C L y t t o n 2,300 K Nakusp 2,000 C Canal F l a t s 1,100 I P t . A l i c e 1,500 C A s h c r o f t 4,000 C Valenount 1,300 I P t . M c N e i l 1,500 C L y t t o n 2,000 I Ocean F a l l s 1,500 C 1 0 0 - M i l e House 2,500 C F t . S t . James 3,200 M Sooke 4,300 I Cumberland 2,200 I Gold R i v e r 2,000 R COMMUNITY POP' C M e r r i t t S Squamish 7,700 9,100 PSYCHIATRIST. (e), PEDIATRICIAN ( f ) OBSTETRICIAN/GYNAECOLOGIST (g) R COMMUNITY POP';' R COMMUNITY POP R COMMUNITY POP K Cranbrook 16,100 C Quesnel 14,800 K Cranbrook 16,100 C W i l l i a m s L. 16,000 V P t . A l b e r n i 26,300 C Quesnel 14,800 C Salmon Arm 14,400 I Campbell R. 17,500 V P t . A l b e r n i 26,300 I Campbell R. 17,500 N P r i n c e Rupert 15,000 I Campbell R. 17,500 N K i t i m a t 12,600 P Dawson Creek 15,900 N P r i n c e Rupert 15,600 N Ter race 15,000 N P r i n c e Rupert 15,000 P Dawson Creek 15,900 P F t . S t . John 12,600 *R = STUDY REGION K = KOOTENAYS 0 = OKANAGAN C = CENTRAL INTERIOR S = SOUTH-WEST M = METROPOLITAN V = SOUTH VANCOUVER ISLAND I = MID COAST N = NORTH-WEST P = PEACE RIVER (a) Communities w i t h f a m i l y p h y s i c i a n . (b) Communities w i t h (c) Communities w i t h (d) Communities w i t h (e) Communities w i t h ( f ) Communities w i t h (g) Communities w i t h or g y n a e c o l o g i s t . p o p u l a t i o n 1,000 and over without a g . p . or p o p u l a t i o n 1,500 and over without a p h a r m a c i s t , p o p u l a t i o n 2,000 and over without a d e n t i s t , p o p u l a t i o n 7,500 and over without a g e n e r a l surgeon, p o p u l a t i o n 10,000 and over without a p s y c h i a t r i s t , p o p u l a t i o n 15,000 and over without a p e d i a t r i c i a n , p o p u l a t i o n 15,000 and over without an o b s t e t r i c i a n Table 2 0 . 2 . UNDERSERVICED COMMUNITIES* G . P . R< COMMUNITY G . P . K Sparwood 3 ,400 K Greenwood 2,700 0 Keremeos 2,700 C Chase 2,900 C C l i n t o n 2,400 C W i l l i a m s Lake 2,700 C F r a s e r Lake 1,900 1 Ocean F a l l s 2,600 I Tahs is 2,800 N Stewart 2,400 N Houston 2,300 N For t S t . John 2,044 K New Denver 567 (best r a t i o ) METROPOLITAN 989 B .C . AVERAGE 1,095 RECOMMENDED 1,750 PHARMACIST ** P O P R COMMUNITY PHARM K Nakusp 3 ,300 K Nelson 2 ,483 K F r u i t v a l e 2 ,700 K Greenwood 2 ,700 0 O l i v e r 2 ,650 0 Osoyoos 2 ,500 C Golden 3 ,000 C Reve ls toke 3 ,533 C A s h c r o f t 5 ,700 C C learwater 3 ,800 C C l i n t o n 2 ,400 C M e r r i t t 2 ,700 C Quesnel 2 ,971 C W i l l i a m s Lake 2 ,913 C L i l l o o e t 4 ,100 C For t S t . James 6 ,200 C F r a s e r Lake 3 ,800 C Vanderhoof 5 100 C Mackenzie 5 500 C P r i n c e George 2 370 S Squamish 2, 525 M Sooke 2, 450 V Lake Cowichan 6, 100 I Por t Hardy 7, 150 I Masset 2 , 300 I Cumberland 3 , 700 I Tahs is 2 , 800 N K i t i m a t 3 , 060 N Stewart 3 , 900 N Houston 4 , 600 P Dawson Creek 4 , 600 F Fo r t Neson 2 , 450 P Fo r t S t . John 3 , 283 S Mader ia Park 700 (best r a t i o ) METROPOLITAN B.C. AVERAGE RECOMMENDED DENTIST R COMMUNITY POP-/ DENTI K F e r n i e 6 ,500 K Inyermere 6 ,700 K Sparwood 6 ,800 K C a s t l e g a r 7 ,900 K .Rossland 5 ,100 0 P r i n c e t o n 5 ,600 0 Armstrong 5 ,350 C Golden 3 ,050 C Reve ls toke 6 ,650 C Chase 4 ,200 C C learwater 3 ,800 C M e r r i t t 5 ,867 C W i l l i a m s L. 4 ,300 C F r a s e r L. 3 ,800 c Vanderhoof 5 ,650 c Mackenzie 5 ,500 c McBride 3 ,000 S Squamish 2 925 s Hope 7 000 s C. F raser V. 3 139 s Dewdney-A 3, 082 s Gibsons 3, 050 s Seche l t 3 , 100 M S a l t s p r i n g I s . 3 , 600 V Ladysmith 4, 700 V L. Cowichan 6, 100 V U c l u e l e t 3 , 400 I P t . Hardy 3 , 050 I P t . M c N e i l 6, 300 I Campbell R. 3 , 886 N P r i n c e Rupert 6 , 000 N Haze l ton 3 , 500 N K i t i m a t 3 , 825 N Ter race 5 , 350 N Burns L. 5 , 600 N Houston 4 , 600 1,225 P F t . S t . John 6,567 1,487 2,000 0 Rut land 1,050 (best r a t i o ) METROPOLITAN 1,641 B.C . AVERAGE 2,042 RECOMMENDED 2.500 GENERAL SURGEON ;R COMMUNITY !K F e r n i e JO O l i v e r |C Salmon Arm C W i l l i a m s L. C P r i n c e George C Vanderhoof S C h i l l i w a c k S Seche l t |I Courtenay-C i l Campbell R. :N K i t i m a t N Terrace P F t . S t . John JK Cranbrook i (best r a t i o ) 'METROPOLITAN JB .C. AVERAGE RECOMMENDED 78 PSYCHIATRIST P E D I A T R I C I A N OBSTETRICIAN/GYNAECOLOGIST POP / ** POP--/ ** POP- / : G SURG R COMMUNITY PSYCHI R COMMUNITY PEDIAT 13,300 K Nelson 40,800 K Cranbrook 46,300' 12,400 K T r a i l 43,100 K Nelson 35,300 20,800 0 Kelowna 23,800 0 P e n t i c t o n 26,450 15,550 0 Vernon 80,900 0 Kelowna 35,700 13,258 C Kamloops 52,650 0 Vernon 80,900' 25,300 C Quesnel 44,100 C W i l l i a m s L. 51,900 25,650 C P r i n c e George 219,800 C P r i n c e George 149,700 12,300 V Namaomo 20,633 S C h i l l i w a c k 51,300 29,800 V P t . A l b e r n i 32,100 V Nanaimo 50,450 21,800 I Courtenay-C 36,700 I Courtenay-C 73,400 15,300 I Powel l R. 22,200 N Terrace 70,100 16,100 24,600 M G't'v Vancouver. 7,57-9 M Gt . Vancouver 14,009 (best r a t i o ) (best r a t i o ) 5 ,700 METROPOLITAN 8,655 METROPOLITAN 15,019 B. C. AVERAGE 12,271 B. C. AVERAGE 20,053, 9,065 RECOMMENDED 15,000 RECOMMENDED 20,000 9,788 10,000 1 ** POP / R COMMUNITY 0BSTET K T r a i l 62,350 0 P e n t i c t o n 26,450 0 Vernon 80,900 C W i l l i a m s L. 51,900 C P r i n c e George 34,967 S C h i l l i w a c k 51,300 V Ladysmith 46,700 I Courtenay-C 72,200 N Terrace 70,100 P F t . S t . John 24,600 M V i c t o r i a 12,828 (best r a t i o ) METROPOLITAN 15,957 B.C. AVERAGE 19,732 RECOMMENDED 20,000 / ; Communities w i t h p o p u l a t i o n / h e a l t h care personnel -x I at l e a s t 10% below the recommended ta rget ( r a t i o s ) . , The r a t i o s are est imated by catchment a r e a . \-See Appenix C. ** R = STUDY REGION K = KOOTENAYS 0 OKANAGAN C = CENTRAL INTERIOR s = SOUTH-WEST M = METROPOLITAN V = SOUTH VANCOUVER ISLAND I = MID COAST N = NORTH-WEST P = PEACE RIVER Central Kootenay and Kootenay Boundary, commonly known as the West Kootenays are more i n d u s t r i a l l y d i v e r s i f i e d . Three out of the four major towns i n the study region with population ranging from 10,000 to 16,000 are located i n the West Kootenays, including T r a i l , Nelson, and Castlegar. The only major; i n d u s t r i a l town i n East Kootenay i s Cranbrook. Settlements, however, are more dispersed i n the West Kootenays than East Kootenay: The primary health care group consists of 119 general p r a c t i t i o n e r s and family physicians, 68 pharmacists, 41 dentists, 16 general surgeons, 4 p e d i a t r i c i a n s , ,2 obstetricians or gynaecologists and 3 p s y c h i a t r i s t s with the following r a t i o s D i s t r i b u t i o n of G.P.'s i s reasonably even. 88% (112,300) of the population i s within 25 Km. and 92% (117,500) i s within 50 Km. of a G.P. Sparwood and Greenwood appear to have f a i r l y poor population/G.P. r a t i o s , but the population s p i l l - o v e r i s adequately served by G.P.'s i n nearby communities. Population i s dispersed south of Fernie, north of Kaslo, north of Nakusp, around Needles-Edgewood areas and north of Greenwood, and thus, d i f f i c u l t to serve. A reasonable approach to improve access to G.P.'s for this population i s to introduce more v i s i t i n g G.P.'s (or mobile c l i n i c s ) to the i s o l a t e d communities, or to provide Exist i n g Recommended, r. G.P. Pharmacist Dentist General Surgeon P e d i a t r i c i a n Obs/Gyn Ps y c h i a t r i s t 1:1,068 1:1,869 1:3,100 1:7,944 1:31,775 1:63,550 1:42,367 1:1-750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 80 -better transportation for patient movement. Di s t r i b u t i o n of pharmacists i n East Kootenay and Kootenay Boundary i s similar to G.P.'s. D i s t r i b u t i o n i n Central Kootenay, however, i s less balanced. The northern hal f of the Regional D i s t r i c t has only two pharmacists, one located in Nakusp, the other i n Kaslo, serving a population of 5,400. About 157, (18,400) of the study region's population i s not within 25 Km. of a pharmacist. For dentists, apart form imbalanced d i s t r i b u t i o n , the supply for the Region as a whole i s inadequate. Communities that have unsatisfactory population/dentist r a t i o s are Fernie ( 1 :6 ,500 ) , Invermere ( 1 :6 ,700 ) , Sparwood (1:6,800) and Castlegar ( 1 :3 ,850) . Rossland has only one dentist for 5,600 people, but i t s population s p i l l - o v e r i s absorbed by T r a i l . Nakusp and Salmo are sizable communities with the minimum population required (1,500) to support a dentist, and yet without one. About 207> (25,000) of the study region's population i s not within 25 Km. of a dentist. The d i s t r i b u t i o n of general surgeons i s s a t i s f a c t o r y , and the supply i s the most adequate of a l l study regions. The population/general surgeon r a t i o s range from 1:5,700 i n Cranbrook to 1:13,300 i n Fernie, with an average of 1:7,944. Only 67o (7,200) of the Region's population have to t r a v e l more than 75 Km. to a general surgeon. However, as there i s a shortage of obstetricians and gynaecologists i n the study region -- there are two i n T r a i l -- and general surgeons are known to substitute for this group of s p e c i a l i s t s , the o v e r a l l a c c e s s i b i l i t y of the study region to general surgeons may be 81 over-estimated. I f such substitution i s assumed, Fernie, Kimberly and Creston would be under-serviced. Both the d i s t r i b u t i o n and the supply of pediatricians and p s y c h i a t r i s t s are poor. There are only four pediatricians i n the study region, one i n each of Cranbrook and Nelson, and two i n the study region's largest r e f e r r a l centre, T r a i l . There are only three p s y c h i a t r i s t s i n the study region, two in Nelson and one i n T r a i l . There i s none i n the entire East Kootenay. 3170 of the study region's population i s more than 75 Km. from a p e d i a t r i c i a n and 527, from a p s y c h i a t r i s t . While the entire Region i s disadvantaged by the shortage of primary care sub-specialists, the East suffers most. Among the r u r a l Regions, Kootenays i s bett e r - o f f than Central Interior, North-West and Peace River i n terms of the supply and the d i s t i b u t i o n of primary care professionals. A v a i l a b i l i t y of G.P. services i s sa t i s f a c t o r y , and the average patient waiting time to see a G.P. for both urgent and non-urgent matters i s less than h a l f of a day. The average year of graduation of G.P.'s i s 1965, an age equivalent of 37. Four out of ten G.P.'s i n the Region are under 30. The p r o v i n c i a l average i s two out of ten. The young age group suggests high turn-over rates. I t has been demonstrated that physicians serving i s o l a t e d and r u r a l communities are most . transient (Scarrow, 1969; Foulkes, 1973). Many stay i n a community for only a short period of time u n t i l better oppor-t u n i t i e s are available i n urban centres. This s i t u a t i o n has the most adverse e f f e c t on 'one-doctor' communities, as losing the community's only physician means a t o t a l disruption of service. 82 In terms of G.P.'s1 place of graduation, the Region has a higher proportion of non-B.C. Canadian trained G.P.'s (707.) than the p r o v i n c i a l average (497.). B.C. graduates are less l i k e l y to practise i n this Region than the Metro-p o l i t a n Region, the South-West Region, the Okanagan Region or the South Vancouver Island Region. Similar to other r u r a l regions, the Kootenays Region has t r a d i t i o n a l l y depended on the supply of physicians from foreign countries ( p r i n c i p a l l y from Europe). Since the introduction of the r e s t r i c t i v e immigration policy, the Region has turned to other provinces within Canada for i t s physician, supply. For example, i n 1975-76, 407. of the G.P.'s were graduates of European countries or the U.S.A., . and 507o were graduates of other provinces i n Canada, but i n 1977-78, the percentages changed to 207> and 707. respectively. Study Region 2. Okanagan This Region i s composed of the Regional D i s t r i c t s of Central Okanagan, North Okanagan and Okangan-Similkameen and i s one of the best serviced outside of the Metropolitan Region. It has a population of 169,600, of which 707. are found i n three adjacent urban centres, Kelowna (60,400) , Vernon (29,900) and Pentiction (23,900) . They are also the Region's major r e f e r r a l centres. Most r u r a l towns and v i l l a g e s are within 50 Km. of these urban centres. The study region represents one of the few regions i n the province that i s close to s e l f - s u f f i c i e n c y i n terms of the supply of health care personnel and services. It has some of the most sa t i s f a c t o r y r a t i o s of primary health care personnel to population among the nine study regions, and d i s t r i b u t i o n of the personnel i s reasonably balanced. There are 135 G.P.'s, 99 pharmacists, 69 dentists, 18 general surgeons, 5 pediatricians, 6 obstetricians and gynaecologist and 7 p s y c h i a t r i s t s , with the following r a t i o s : The only area needing improvement i n the supply of G.P.'s i s Keremeos and i t s surroundings, including the 300-population Indian Reserve south-west of the town. There are about 5,000 people scattered to the eat of Vernon and Enderby, but they are estimated to be accessible to G.P. services i n town (within 50.Km.). Access to pharmacists i s good throughout the Region. The supply and the d i s t r i b u t i o n of dentists are appropriate with the exception of Princeton where the only dentist serves a population of 5,600. Princeton represents a t y p i c a l i s o l a t e d community i n the non-metropolitan regions. It does not contain the necessary population to support a viable group of primary care personnel (including some primary care sub-specialists) and yet i t i s too far away from major r e f e r r a l centres to allow continous and complete primary care delivery. Ex i s t i n g Recommended G.P. Pharmacist Dentist General Surgeon Pe d i a t r i c i a n Obs/Gyn Ps y c h i a t r i s t 1:1,256 1:1,713 1:2,458 1:9,422 1:33,920 1:28,267 1:24,229 1:1,750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 Due to the lack of r e f e r r a l centres north of Okanagan, some s p i l l - o v e r of patient care from the Central Interior to Kelowna and Vernon i s inevitable. Thus, the population/ physician r a t i o s , e s p e c i a l l y for s p e c i a l i s t s may not be r e a l i s t i c . An examination of the r e f e r r a l pattern of the Region would be useful. An urgent v i s i t to a G.P. requires less than 4 hours of waiting time on the average. For routine v i s i t s , waiting time averages one day. The mean year of graduation of the Region's G.P.'s i s 1957, with approximately 70% graduated before 1959. The G.P. population represents the most stable group i n the province. The majority are between 40 and 50 years of age, the least transient of a l l age groups. On the other hand, the high percentage of older physicians i n the Region i s suggestive of more physicians at or near to the i r retirement age. The implication i s that there may be less f u l l - t i m e physicians than otherwise suggested. Three out of ten G.P.'s are graduates of B.C., while the remainder i s made up of graduates from other provinces within Canada. Foreign graduates are least l i k e l y to practise i n the Region, probably because the market i s f a i r l y saturated. It has been observed that. Okanagan i s one of the most suitable areas within the province for studying the appro-priate requirements of health care manpower for a unit of population. The Region i s b a s i c a l l y self-contained, with an adequate supply of both primary and secondary care personnel and f a c i l i t i e s for the Region's population (Scarrow, 1969). Unlike those i n the Metropolitan Region, a c t i v i t i e s of the health care personnel i n the Region are e s s e n t i a l l y confined to the regional scale, such that the pattern of health care delivery i s not distorted by too much s p i l l - o v e r care from the rest of the province. Study Region 3. Central Interior The study region should i d e a l l y be divided into two, the northern Central Interior and the southern Central I n t e r i o r . The north centres on Prince George and the south on Kamloops, the Region's two major r e f e r r a l centres. The Region covers about one-third of the area of the province, yet has only 117. of the province's population (277,900), of which almost h a l f l i v e i n Prince George (68,000) and Kamloops (58,300). The Region consists of the eastern h a l f of the Regional D i s t r i c t of Bulkley-Nechako, the Regional D i s t r i c t s of Cariboo Columbia-Shuswap, Thompson-Nicola and Fraser-Fort George and the northern portion of the Regional D i s t r i c t of Squamish-L i l l o o e t . There are only three urban centres with population more than 10,000 i n addition to Prince George and Kamloops: Williams Lake (16,000), Quesnel (14,800) and Salmon Arm (14,400). 457, of the population i n the study region are r u r a l , and mostly scattered. The region has 211 G.P.'s, 128 pharmacists, 99 dentists, 23 general surgeons, only 7 p e d i a t r i c i a n s , 9 obstetricians and gynaecologists and 4 p s y c h i a t r i s t s , with the following r a t i o s : E x i s t i n g Recommended 86 G.P. Pharmacist Dentist General Surgeon Pe d i a t r i c i a n 1:1,313 1:2,171 1:2,807 1:12,083 1:46,100 1:30,878 1:99,650 1:1,750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 Obs/Gyn Ps y c h i a t r i s t It i s one of the poorest serviced Regions of the province, and i s p a r t i c u l a r l y under-supplied with primary care sub-s p e c i a l i s t s . With the exception of G.P.'s, the d i s t r i b u t i o n of health care personnel i n the Region i s extremely uneven. About 60-65% of the Region's pharmacists, dentists and general surgeons are found i n Kamloops and Prince George, while 6 out of the 7 pediatricians, 8 out of the 9 obstetricians/gynaeco-l o g i s t s and 3 out of the 4 p s y c h i a t r i s t s are also found i n these two centres. The major d i f f i c u l t y i n serving the r u r a l population i s i t s dispersal. Given this constraint, the d i s t r i b u t i o n of G.P.'s i s actually more equitable than i s s u p e r f i c i a l l y apparent. Similar to the i s o l a t e d areas of the Kootenays Region, many v i l l a g e s and towns do not have the required population to support a f u l l - t i m e G.P. V i s i t i n g doctors and mobile c l i n i c s appear to be more r e a l i s t i c solutions. Areas that can benefit from such operations include communities spread along Highway 95 between Golden and Invermere, the section leading north from Kamloops toward Prince George v i a Blue River, v i l l a g e s and towns that spread along Highway 97 between Vernon and Kamloops, the Douglas Lake area,, the Bralorne-Gold Bridge area, the out-lying v i l l a g e s of the Williams Lake and the Quesnel hinterlands, and the Indian Reserves between Pinchi Like and Stuart Lake to the west of Port St. James. The 87 western h a l f of the Cariboo Regional D i s t r i c t i s largely-undeveloped and sparsely inhabited. The only physician i n this area practises on a part-time basis i n Kleena Kleene. The supply of G.P.'s i n general i s adequate, with the exception of Williams Lake where there are only eight G.P.'s to serve an urban population of 17,000, plus a group of r u r a l communities lying outside the urban area. The re s u l t i n g G.P. r a t i o i s c r i t i c a l l y and undesirably poor, 1:2,800. Some r u r a l communities are adjacent to one another and can provide an aggregate population that i s needed to support a f u l l - t i m e G.P. For example, a f u l l - t i m e G.P. can be located at McLeese Lake (60 Km. north of Williams Lake), with a population of 500 i n the v i l l a g e , to serve McLeese Lake and the adjacent v i l l a g e s of Castle Rock, Marguerite and Macalister, with an aggregate population of approximately 1,200. The A l k a l i Lake-Dog Creek area, 75 Km. south of Williams Lake, has a population of appro-ximately 1,600 and may also be able to support-a f u l l - t i m e G.P. For the Region as a whole, about 147o (38,200) of the population have to tr a v e l 25 Km. or more to a G.P., 117> (29,400) have to tr a v e l more than 50 Km. The d i s t r i b u t i o n of pharmacists i s about the same as G.P.'s. The supply, however, i s s l i g h t l y less on a per capita basis, with some areas worse-off than others. Golden and Revelstoke and th e i r hinterlands are among the poorest serviced areas. These two moderate sized towns are segregated from the regional urban centres, Salmon Arm and Kamloops, and each has a sizable r u r a l hinterland. The population of the hinterland 88 i s d i f f i c u l t to serve due to extreme dispersion of population. For example, the Parson-Spilliamacheen area (population:700) i s 45 Km. south of Golden, while the v i l l a g e of F i e l d (population:500) i s 60 Km. east. Movement between Golden and Revelstoke i s d i f f i c u l t as the section of Highway 1 through the Glacier Mountain Park i s often impassable i n winter. North of Revelstoke, the population (estimated as 2,900) i s scattered; the only sizable v i l l a g e , Mica Creek (population:900) i s 140 Km. away from town. Apart from these d i f f i c u l t i e s , the supply of pharmacists i n the towns i s poor: Only two pharmacists i n Golden to serve a population of 6,000 (1:3,000) and three i n Revelstoke to serve 10,600 people (1 :3 ,533) . Similar situations exist i n Ashcroft ( 1 :5 ,700 ) , Clearwater ( 1 :3 ,800) , M e r r i t t ( 1 :2 ,700) , Quesnel ( 1 :2 ,971 ) , Williams Lake ( 1 :2 ,913) , L i l l o o e t ( 1 :4 ,100 ) , Fort St. James (1 :6 ,200) , Fraser Lake ( 1 :3 ,800 ) , and Vanderhoof ( 1 :5 ,100 ) . In the Regional D i s t r i c t D i s t r i c t of Fraser-Fort George, even the regional centre, Prince George, i s undersupplied, and the i s o l a t e d resource community of Mackenzie (5,500) has only one pharmacist. Dentist d i s t r i b u t i o n i s among the poorest. Almost 207o (53,100) of the study region's population i s not within 50 Km. of a dentist. Although the main d i f f i c u l t y i n the delivery of dental services i s caused by community i s o l a t i o n and dispersion, the inadequate supply of dentists i n general i s another cause. For the study region as a whole, there i s one dentist to every 2,807. Sizable communities without a dentist 89 include Fort St. James, 100-Mile House, L i l l o o e t , Ashcroft and Lytton (see Table 20 .1 ) . Communities with a serious under-supply of dentists include Golden, Revelstoke, Chase, Clearwater, Merritt, Williams Lake, Fraser Lake, Vanderhoof and Mackenzie (see Table 20 .2 ) . For the very small and i s o l a t e d communities, mobile dental c l i n i c s appear to be reasonable substitutes. The Region's most serious shortage i s i n the supply of primary care sub-specialists. With reference to the CM.A. recommended rati o s the Region i s undesirably short of psychia-t r i s t s , followed by pediatricians and obstetricians/gynaeco-l o g i s t s . Serious maldistribution further undermines the Region's o v e r a l l a c c e s s i b i l i t y . As many as 457> of the Region's residents are not within 75 Km. of these three groups of personnel, and 257o cannot reach a general surgeon within 75 Km. Almost a l l the Region's sub-specialists are located i n Kamloops, Prince George and Williams Lake. Despite such concentration, Prince George i s s t i l l undersupplied with p e d i a t r i c i a n s , and both Prince George and Kamloops are undersupplied with p s y c h i a t r i s t s . The well-populated areas of Merritt-Nicola and Fraser Lake-Vanderhoof, and the community of Quesnel are without complete pe d i a t r i c , o b s t e t r i c and p s y c h i a t r i c services. Understandably, the population base of some of these areas i s too small to support the f u l l - t i m e services of the sub-specialists. Special arrangements to provide the services should be explored. This topic w i l l be discussed i n more d e t a i l i n the f i n a l chapter. Mean waiting time to see a G.P. on urgent matters i s .35 day and on non-urgent matters i s .73 day, indicating a s a t i s f a c t o r y a v a i l a b i l i t y of G.P.'s. Nevertheless, out of the thirteen sample responses, two had an urgent waiting time longer than .50 day, and four had anon-urgent waiting time longer than 1 day. The former includes L i l l o o e t (1 day), Vanderhoof (2 days), Prince George (2 days) and Me r r i t t (1.5 days). The u n a v a i l a b i l i t y of G.P.'s i n L i l l o o e t and Vanderhoof i s re f l e c t e d i n the long waiting times; and the minimal difference between urgent and non-urgent waiting times i s attri b u t a b l e largely to the shortage of physicians i n these communities. It can be further inferred that the shortage i s c r i t i c a l l y a f f e c t i n g the a c c e s s i b i l i t y of patients to physicians. The average waiting time for the study region f a i l s to r e f l e c t a c c e s s i b i l i t y i n the 'no-doctor' communities and communities with only a semi-retired or part-time physician such as Blind Bay and Kleena Kleene. Average year of graduation of physicians i n the study region i s 1960. However, the d i s t r i b u t i o n shows 557o graduated after 1962, and 407, graduated afte r 1967, which can be i n t e r -preted as over one-half of the G.P.'s i n the Region being under the age of 40, and of this one-half, the majority are most . l i k e l y under 35. This transient age group also appears to associate with the 'under-serviced' communities such as Golden, Fraser Lake, Williams Lake and Vanderhoof. The more stable age group, those over 40, are found.almost exclusively i n the communities that are adequately serviced. In terms of place of graduation, 607o of the physicians are European or U.S.A. trained, versus the p r o v i n c i a l average of 337>. The remainder i s made up of non-B.C. trained Canadian physicians (30%) and B.C. trained physicians (10%). The B.C. trained physicians are concentrated i n the Region's major r e f e r r a l centres, such as Prince George. Again, the under-serviced communities r e l y heavily on foreign-trained physicians. Since the introduction of the r e s t r i c t i v e immigration policy, the number of physician r e l a t i v e to the Region's popultion has decreased. This i s a t t r i b i t a b l e to the decline i n the number of new physician registrants i n the Region, which i n turn i s caused by the decline i n the number of immigrant physicians i n the Region (see Tables 17 and 18). Study Region 4. South-West This Region has a population of 216,100, covering the. Regional D i s t r i c t s s k i r t i n g Metropolitan Vancouver. The Region contains the Regional D i s t r i c t s of Central Fraser Valley, Dewdney-Alouette, Fraser-Cheam, Squamish-Lillooer (southern portion) and Sunshine Coast. Central Fraser Valley, Dewdney-Alouette and the portion of Fraser-Cheam are b a s i c a l l y urban; whereas Squamish-Lillooet, Sunshine Coast and the northern portion of Fraser-Cheam are r u r a l i n character. Ideally, these two groups shoud be considered separately, because the aggregate results of the analyses associated with the entire study region may not be representative of a l l communities within i t . The study region as a whole has 164 general p r a c t i t i o n e r s / family physicians, 121 pharmacists, 73 dentists, 10 general surgeons, 1 p e d i a t r i c i a n , 1 obstetrician/gynaecologist and 7 p s y c h i a t r i s t . G.P. and pharmacist r a t i o s appear satisfactory. The dentist r a t i o i s 187, below the recommended r a t i o . However, this could be due to the Region's proximity to Vancouver, and thus functionally within i t s catchment area. Since dental services are more speci a l i z e d than general practice and pharmaceutical services, as suggested by the r a t i o hierarchy, they are more centralized. The same reasoning applies to sub-specialist d i s t r i b u t i o n i n the Region: Over 957, of the population of this study region are within 25 Km. of a G.P., a pharmacist and a dentist. Less than 87, travel more than 75 Km. to a general surgeon, a p e d i a t r i c i a n or an obstetrician/gynaecologist; but appeoximately 107, tr a v e l more than 75 Km. to a p s y c h i a t r i s t . Areas adversely affected by the distance include the Pemberton-D'Arcy, the r u r a l hinter-land of Schelt and North Bend-Boston Bar. Mean waiting times for both urgent and non-urgent v i s i t s appear sat i s f a c t o r y : .15 day and 1.00 day respectively. The longest waiting time for an urgent v i s i t , i s not more than one day. The study region's G.P.'s are among the youngest groups i n the province. Their mean year of graduation i s 1966. The majority (807,) graduated a f t e r 1961. Inferred ages of G.P.'s range from 27 to 50. Place of graduation r e f l e c t s a dominance of non-B.C. trained G.P.'s (seven out of ten), similar to the Kootenays Region and the North-West Region. Ex i s t i n g Recommended G.P. Pharmacist Dentist General Surgeon Pe d i a t r i c i a n Obs/Gyn Ps y c h i a t r i s t 1:1,318 1:1,786 1:2,960 1:9,065 1:15,019 1:15,957 1:8,655 1:1,750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 93 Study Region 5. Metropolitan This study region comprises Greater Vancouver and the Capital Regional D i s t r i c t , the province's two largest urban centres. The population of Greater Vancouver i s approximately 1,085,200 and Capital Regional D i s t r i c t ' s i s approximately 230,600. Both serve as major secondary r e f e r r a l centres, the former primarily ...for the Mainland, while the l a t t e r primarily for Vancouver Island. Greater Vancouver i s also a t e r t i a r y r e f e r r a l centre for the province as a whole. Both Regional D i s t r i c t s share similar population/primary health care personnel r a t i o s , and similar a c c e s s i b i l i t y patterns. The Region has the most favourable r a t i o s and the best distance measures. The ra t i o s of the seven groups of personnel are .as follows: E x i s t i n g Recommended G.P. 1:989 1:1,750 Pharmacist 1:1,225 1:2,000 Dentist 1:1,641 1:2,500 General Surgeon 1:9,065 1:10,000 Pe d i a t r i c i a n 1:15,019 1:20,000 Obs/Gyn 1:15,957 1:20,000 Ps y c h i a t r i s t 1:8,655 1:15,000 The primary health care personnel group consists of 1,331 G.P.'s, 1,074 pharmacists, 802 dentists, 159 general surgeons, 101 pediatricians, 95 obstetricians/gynaecologists and 170 p s y c h i a t r i s t s . The only r e l a t i v e l y i s o l a t e d areas are thePbrt Renfrew-Jordon River and the Gulf Islands i n the Capital Regional D i s t r i c t . Access to primary care i n these areas i s , therefore, less s a t i s f a c t o r y . However, the population affected i s small, about 6,000. 94 Waiting time for a G.P. v i s i t averages to .88 day for urgent matters and 1.21 days for non-urgent matters. Although these averages are higher than the other eight study regions, they indicate s a t i s f a c t o r y G.P. a v a i l a b i l i t y . However, i t must be noted that waiting times i n the c i t y centre of Vancouver appear exceptionally long (at least two days for urgent v i s i t s ) . In this respect, the c i t y centre i s comparable to some northern r u r a l communities such as Hazelton or Vanderhoof. The average age of the G.P.'s i n the Region i s close to the p r o v i n c i a l average of 40. The age d i s t r i b u t i o n shows a dominant range of 30 to 40 (407.) , with another 407, over the age of 40, indicating a stable age group. G.P. d i s t r i b u t i o n by place of graduation i s also similar to the p r o v i n c i a l average: 207. are B.C. graduates, 457, are non-B.C. Canadian graduates, 257. are European or U.S.A. graduates and 77o are graduates of other countries. The metropolitan centres are the second most a t t r a c t i v e place for B.C. trained physicians to practise after the Okanagan Region and the South Vancouver Island Region. Study Region 6. South Vancouver Island This Region comprises the central part of Vancouver Island, excluding areas north of Qualicum Beach and the Capital Regional D i s t r i c t . Major urban centres include Nanaimo (60,000), Port Alberni (26,000) and Duncan (23,000) . The Region i s similar to the Okanagan i n many respects: size, promimity of the urban centres to one another, t o t a l population as well as sizes of urban centres, r e l a t i v e closeness to the Metropolitan Region, o v e r a l l a c c e s s i b i l i t y to primary health care, and physician c h a r a c t e r i s t i c s . The population of the Region i s 141,200. The primary health care group consists of 102 G.P.'s, 81 pharmacists, 58 dentists, 11 general surgeons, 2 ped i a t r i c i a n s , 6 obstetricians/ gynaecologists and 7 p s y c h i a t r i s t s . Due to the Region.'s proximity to V i c t o r i a , a c c e s s i b i l i t y i s actually higher than the ra t i o s suggest: The o v e r a l l a c c e s s i b i l i t y of the study region i s second to"the Okanagan Region and the South-West Region. At the community l e v e l , the Indian Reserves to the west of Port Alberni along the coastal areas of the Island are the most, di s -advantaged. These include Ahousat, Zarlus, and Bamfield. The primary d i f f i c u l t y i s long t r a v e l distances. Again, mobile c l i n i c s appear to be a p r a c t i c a l solution. Pharmacist and dentist r a t i o s of some communities within the Regional D i s t r i c t of Cowichan Valley appear to be undesirably poor. Ladysmith and Lake Cowichan have dentist r a t i o s of 1:4,700 and 1:6,100 respectively. Lake Cowichan also has the same r a t i o for pharmacist. This may be due to these communities' proximity to V i c t o r i a . Dental care p a r t i c u l a r l y i n the Tofino-Ucluelet area needs to be improved, as there i s only one dentist at present to serve the entire-area with a population of 3,400. Exi s t i n g Recommended G.P. Pharmacist Dentist General Surgeon Pe d i a t r i c i a n Obs/Gyn Ps y c h i a t r i s t 1:1,384 1:1,743 1:2,434 1:12,836 1:70,600 1:23,533 1:20,171 1:1,750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 D i s t r i b u t i o n of primary care sub-specialists i s unsatis-factory at the community l e v e l . Duncan has only two general surgeons to serve the area's population of 47,100. Both Nanaimo and Port Alberni have shortages of ps y c h i a t r i s t s (1 :20,633, and 1:32,100 respectively). Also, the number of pediatricians can be improved i n Nanaimo. The current r a t i o i s poor, 1:50,450. Both Duncan and Port Alberni do not have a p e d i a t r i c i a n or an obstetrician/gynaecologist. Since Duncan i s within the catch-ment area of V i c t o r i a , access to either type of personnel i s r e l a t i v e l y easy. The population of Port Alberni arid sourroun- ; dings (with a t o t a l of 3.2,000) , however, have to depend on Nanaimo for p e d i a t r i c and obst e t r i c services, and have to tr a v e l longer than 75 Km. to get them. Mean waiting time to v i s i t a G.P. i n the study region i s r e l a t i v e l y short for both urgent and non-urgent matters. It i s not more than .50 day i n either case. Mean year of graduation of the G.P.'s i n the study region is 1958. The infered average age i s 44, among the oldest i n the province. Age d i s t r i b u t i o n i s comparable to that of the Okanagan Region. The majority (607o) are over the age of 40, suggesting a very mature and stable age group. The G.P.'s are least l i k e l y to move out of the study region. But similar to the Okanagan Region, there may be more r e t i r e d or r e t i r i n g physicians than the remainder of the province. Hence the a v a i l a b i l i t y of physicians may be lower. D i s t r i b u t i o n of G.P.'s by place of graduation shows that the Region i s most a t t r a c t i v e to B.C. graduates. Proportionally, there are more B.C. graduates (three out of ten) than the 97 province as a whole (two out of ten). But there i s a smaller proportion of non-B.C. Canadian trained G.P.'s than the pr o v i n c i a l average. The percentage of European or U.S.A. trained G.P.'s i s about the same as non-B.C. Canadian trained G.P.'s (three out of ten). Study Region 7. Mid Coast This study region covers the northern half of Vancouver Island (including the Regional D i s t r i c t s of Comox-Strathcona and Mount Waddington), the Regional D i s t r i c t s of Ocean F a l l s and Powell River on the Mainland, and the Queen Charlotte Islands. The population of the Mid Coast Region i s 98,100, approximately 4% of the p r o v i n c i a l t o t a l . About 45%, of which (45,000) reside i n the Comox Valley-Campbell River"area, which i s the only urban complex i n the Region. It comprises Courtenay, Comox, Cumberland and Campbell River. To the north of the urban complex, settlement i s sparse and scattered. Queen Charlotte Islands are p a r t i c u l a r l y i s o l a t e d from the rest of the study region. A high percentage of Indians on Reserves are found i n Mount Waddington Regional D i s t r i c t (1,200 persons, equivalent to 107o of the population of the Regional D i s t r i c t ) , Queen Charlotte Islands (1,100 persons, 227,), and Ocean F a l l s (1,300 persons, 31%). In general, Indians on Reserves i n the Mid Coast Region are the least accessible to health care services, mainly because many of the Reserves are accessible only by boat or plane. Many coastal f i s h i n g communities share e s s e n t i a l l y the 98 same d i f f i c u l t y . In addition, the Region's resource-oriented economy i s responsible for the seasonal population fluctuations. The Region's two largest industries, f i s h i n g and logging are also sensitive to c y c l i c a l disturbances r e s u l t i n g i n "booms and busts" of employment i n the Region. A l l these contribute to the d i f f i c u l t y of delivering health care services. The Region as a whole has 90 G.P.'s, 43 pharmacists, 36 dentists, 6 general surgeons, 2 p e d i a t r i c i a n s , 3 o b s t e t r i -cians/gynaecologists and 3 p s y c h i a t r i s t s . The r a t i o s i n r e l a t i o n to population r e f l e c t inadequacy, p a r t i c u l a r l y i n dentists, general surgeons, ped i a t r i c i a n s , obstetricians/ gynaecologists and p s y c h i a t r i s t s : E x i s t i n g Recommended G.P. 1:1,090 1:1,750 Pharmacist 1:2,281 1:2,000 Dentist 1:2,725 1:2,500 General Surgeon 1:16,350 1:10,000 P e d i a t r i c i a n 1:49,050 1:20,000 Obs/Gyn 1:32,700 1:20,000 P s y c h i a t r i s t 1:32,700 1:15,000 Although the number of G.P.'s for the Region as a whole i s adequate, a few communities are inadequately served, p a r t i c u l a r l y Ocean F a l l s and Tahsis. Both are one-physician communities and have f a i r l y large catchment areas containing a population of 2,600 to 2,800. Due to the geographic b a r r i e r s , long t r a v e l distances to a G.P. i s perhaps inevitable i n many instances. Over 127o of the Region's population (12,000) t r a v e l 77 Km. on the average to a G.P. Correspondingly, 227o (21,300) t r a v e l 84 Km. on the average to a dentist. In addition, many communities do need more dentists and pharmacists on a permanent basis. These include Port Hardy, Port McNeil, Campbell River 99 and Gold River. Primary sub-specialists i n the Region are found exclusively i n the urban complex of Comox-Campbell River and Powell River. As a r e s u l t , over 30% of the Region's population ( i . e . over 30,000 persons) are not within convenient (75 Km.) distances of a primary sub-specialist. Although none of the communities north of Campbell River are adequately populated to support any primary sub-specialist, this should not deprive the entire north of primary sub-specialty care, considering the aggregate population base of 30,000. Improvement of sub-s p e c i a l i s t d i s t r i b u t i o n l i e s i n a three-part solution: (1) recruitment of more sub-specialists for the study region as a whole, (2) establishment of a fourth r e f e r r a l centre i n the northern area, preferrably i n the Regional D i s t r i c t of Mount Waddington for i t s central location between the north and the south; i t can be a s a t e l l i t e of the r e f e r r a l centre i n Comox, providing primary sub-specialty services (discussed further i n the f i n a l chapter), and (3) adoption of a system of v i s i t i n g consultants who provide primary sub-specialty services to outlying communities on a rotating basis from the r e f e r r a l centres (also discussed further i n the f i n a l chapter). With the exception of the few is o l a t e d communities, a l l communities are adequately supplied with gneral p r a c t i t i o n e r s or family physicians. The mean waiting time for a G.P. appointment i s .41 day and .86 day for urgent and non-urgent matters respectively. The survey results indicate that Ocean F a l l s and Tahsis have less r e a d i l y available G.P. services than 100 other communities. Waiting time for a G.P. appointment for an urgent matter i s at least one day. These two communities also happen to have the poorest population/G.P. r a t i o s within the Region. Mean year of graduation of G.P.'s (1962) r e f l e c t a young age group (30-40), Northern G.P.'s i n general are younger than southern G.P.'s. The majority (607.) are under 35. The age structure and d i s t r i b u t i o n of the G.P.'s suggest that many are transient, p a r t i c u l a r l y those i n the is o l a t e d north. Place of graduation d i s t r i b u t i o n suggests a strong relaiance on non-B.C. Canadian graduates. Six out of ten G.P.'s are in-migrant physicians. Two out of ten are B.C. graduates, close to the p r o v i n c i a l average. As a r e s u l t of the r e s t r i c t i v e immigration p o l i c y e f f e c t i v e since 1975, the importance of foreign countries as a source of physician supply for the Mid Coast Region has diminished -- i n 1975-76, foreign G.P.'s accounted for 507> of the t o t a l , but i n 1977-78, they only amounted to 207>. Study Region 8. North-West The North-West Region comprises the western half of the Regional D i s t r i c t of Bulkley-Nechako, the Regional D i s t r i c t s of Kitimat-Stikine, Stikine, and the mainland portion of the Skeena-Queen Charlotte Regional D i s t r i c t . The population i n the Region i s about 76,000. Settlement i s extremely uneven. Almost one-half of that i s concentrated near the Highway 16 corridor, where the three major population centres of Prince 101 Rupert, Kitimat and Terrace l i e . I t has been estimated that between 20 and 25 percent of the t o t a l population i n the Region i s accounted for by Status and non-Status Indians (B.C. Dept. of Economic Development, 1977). The resource export-oriented economy of the Region i s associated with the c y c l i c a l employ-ment which i n turn relates to the seasonal population f l u c t u a t i o n i n some communities. This Region, thus, shares many of the d i f f i c u l t i e s that the Mid Coast Region has. It has a vast, sparsely populated hinterland. Servicing the communities i n this vast area i s d i f f i c u l t by vi r t u e of i t s size i f for no other reason. There i s a t o t a l of 73 G.P.'s, 31 pharmacists, 17 dentists, 6 general surgeons, 1 p e d i a t r i c i a n and 1 obstetrician/gynaeco-l o g i s t , but no p s y c h i a t r i s t i n the Region. A l l the sub-, s p e c i a l i s t s and 70% of the G.P.'s are found i n the urban centres. The r a t i o s , i n general, as related to population are the poorest among a l l study regions. With the exception of G.P.'s, a l l primary health care personnel are i n short supply, and excessively below the standard requirements, at both the regional and the community l e v e l s : The Houston-Burns Lake area and the settlements stretching between Terrace and Cassiar including Stewart and the Indian Reserves are about the poorest serviced. In l i g h t of the Existin g Recommended G.P. Pharmacist Dentist General Surgeon Pe d i a t r i c i a n Obs/Gyn Ps y c h i a t r i s t 1:1,040 1:2,448 1:4,465 1:12,650 1:75,900 1:75,900 1:99,650 1:1,750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 102 nature of the problem, a similar mitigation approach as that recommended for the Mid Coast Region should be adopted for t h i s Region. A fourth s a t e l l i t e r e f e r r a l centre can be established i n Houston which i s midway between Burns Lake to the east and Hazelton. to the north-west. To service the area north of Highway 16, v i s i t i n g consultants and mobile c l i n i c s are p r a c t i c a l solutions. The shortage of priamry sub-specialists appears most severe among-all the study regions. The issue goes beyond equity. It i s a case of deprivation of needed basic health care. There i s evidence that the study region has higher than p r o v i n c i a l average needs but unduely less than p r o v i n c i a l average care. In general, the Region has a youthful population: 7170 of the 1971 t o t a l population was under the age of 35 (as opposed to the p r o v i n c i a l average of 597o) . Although males comprised 53.47. of the regional population, s l i g h t l y above the p r o v i n c i a l average of 50.47., the female f e r t i l i t y rate i s generally higher than the p r o v i n c i a l average. This i s supported by the 1971 Census information which shows that average house-hold size i n the Region was 4.0 persons, while the p r o v i n c i a l average was 3.2 persons. (Average household size on the Indian Reserves was 6.4 persons'.) The proportion of regional population i n the 0-14 age group also exceeded the p r o v i n c i a l average. The in d i c a t i o n of the need for above-provincial-average care i n p e d i a t r i c , o b s t e t r i c and dental services i s c l ear. Yet the manpower supply does not r e f l e c t these needs. Indeed, the sub-specialist r a t i o s are about three times below the p r o v i n c i a l average. Furthermore, the general 103 surgeon and p s y c h i a t r i s t r a t i o s f a i l to r e f l e c t the high r i s k nature of the resource-extraction-oriented vocations most people i n the Region pursue, and the Region's high levels of h o s p i t a l i z a t i o n for mental dysfunction (B.C. Dept. of Economic Development, 1977). On the average, waiting time for a G.P. appointment i s .86 day and .93 day for urgent and non-urgent matters respectively. The former i s the longest waiting time next to the Metropolitan Region. Nevertheless, the majority of the 'doctored' communities have r e a d i l y available G.P.'s.. Only one out of the f i v e communities surveyed indicated d i f f i c u l t y : Hazelton, where the waiting time for a G.P. appointment for an urgent v i s i t i s two days. It must be cautioned, however, that due to the small sample size, the re s u l t s of the survey do not provide conclusive inferences. The G.P.'s i n the Region are among the youngest of a l l i n the province. The mean year of graduation i s 1966 (inferred age i s 36) . Eight out of ten G.P.'s graduated a f t e r 1967, suggesting a majority i n the age group of 25-35. This group i s even more transient than the group i n the Mid Coast Region. The North-West Region also r e l i e s heavily on a non-domestic supply of G.P.'s. In 1975-76, 60% of the G.P.'s i n the Region were graduates of European countries or the U.S.A., and 40% were in-migrant G.P.'s from other provinces. In 1977-78, the percentage share of B.C.-trained G.P.'s had grown s l i g h t l y , amounting to 107o of the t o t a l i n the Region. Due to the r e s t r i c t i v e immigration po l i c y , the Region turns to other provinces within Canada for i t s G.P. supply. This i s refected 104 in the percentage increase of this group from 407, i n 1975-76 to 807, i n 1977-78, while the percentage of G.P.'s as immigrants from Europe or U.S.A. has diminished to 107. from 607,. Also since the enforcement of the po l i c y , the number of physicians i n the Region r e l a t i v e to the population has declined substan-t i a l l y . The decline r e f l e c t s the decrease i n the number of foreign immigrants as new physician registrants during t h i s period (see Table 17 and Table 18). Study Region 9. Peace River Conditions i n this Region are almost i d e n t i c a l to those i n the North-West Region. It shares those problems t y p i c a l of any northern resource-frontier region i n B r i t i s h Columbia or elsewhere i n Canada. Poor access to health care services i s among them. The a c c e s s i b i l i t y l e v e l i n terms of r a t i o s and distances i n the Peace River Region i s similar to that of the North-West Region. The population of the Region i s 44,800. About 27. are Indians on Reserves. Almost 907> of the regional population i s concentrated i n the Fort St. John-Dawson Creek-Chetwynd tri a n g l e . A Small population concentration i s i n Fort Nelson, 630 Km. north or Fort St. John. The rest of the population i s scattered. The Region i s served by 27 G.P.'s, 13 pharmacists, 13 . dentists, 3 general surgeons, 2 obstetricians/gynaecologists but there i s no p s y c h i a t r i s t and no pediatrician;.in the Region. The shortage i n personnel i s r e f l e c t e d i n the regional r a t i o s : 105 E x i s t i n g Recommended Obs/Gyn Ps y c h i a t r i s t G.P. Pharmacist Dentist General surgeon Pe d i a t r i c i a n 1:1,659 1:3,446 1:3,446 1:14,933 1:46,100 1:22,400 1:99,650 1:1,750 1:2,000 1:2,500 1:10,000 1:20,000 1:20,000 1:15,000 The f i v e primary care sub-specialists are found exclusively i n Fort St. John and Dawson Creek. The two centres also have 467c of the Region's pharmacists, 747, of the Region's G.P.'s, and 847, of the Region's dentists. Despite the concentration these two centres s t i l l experience a shortage of dentists and pharmacists. Since the nature of i n a c c e s s i b i l i t y i n this Region i s very similar to that of the North-West Region, the same approach to mitigate the deficiency should be applied. In addition to r e c r u i t i n g more primary care professionals to the Region, i t i s necessary to improve the delivery system. Many settlements are simply too small and too scattered to warrant employment of any of the professionals i n the l o c a l communities on a fu l l - t i m e basis. V i s i t i n g physicians and dentists and a u x i l i a r y personnel (such as nurse p r a c t i t i o n e r s and possibly para-medics) can be employed on a complementary basis to improve delivery i n these communities. Although the survey r e s u l t s on waiting times for G.P. appointments are l i k e l y to have low r e l i a b i l i t y , the long waiting times (1.5 days) recorded for both urgent and non-urgent v i s i t s for Chetwynd and Dawson Creek, and the fact that the only physician i n Hudson Hope has d e f i n i t e plans to 106 move are not e n t i r e l y meaningless findings. It i s suggestive of possible u n a v a i l a b i l i t y of G.P.'s on a continuous basis. The Peace River. Region also has a youthful G.P. population, l i k e the North-West Region. A majority i s i n the 25-35 age group, with an infer r e d average age of 36. Mean year of graduation i s 1966. The Region also has a high proportion of non-B.C. trained G.P.'s. However, there are more European trained G.P.'s than G.P.'s from other provinces i n Canada. This i s quite d i f f e r e n t from the North-West Region. The federal r e s t r i c t i v e immigration p o l i c y has altered the pattern l i t t l e . I t appears that European G.P.'s w i l l continue being the dominant group i n the Peace River Region for some time. In the long run, however, the r e s t r i c t i v e p o l i c y w i l l i nevitably create a 'vacuum', unless either B.C. graduates are encouraged to take an intere s t i n p r a c t i s i n g i n the Region, or in-migrant physicians from other parts of Canada f i l l the 'vacuum'. CHAPTER VI POLICY IMPLICATIONS Nature of D i s p a r i t i e s The findings of this study reveal that B r i t i s h Columbia has an adequate o v e r a l l supply of primary health care personnel. There i s , i n fact, a trend toward an over-supply of general pra c t i t i o n e r s i f the current rate of increase continues to hold true."'" However, the professionals are disproportionately d i s t r i b u t e d i n favour of the metropolitan and the urban regions. At the community l e v e l , general p r a c t i t i o n e r s are generally s a t i s f a c t o r i l y d i s t r i b u t e d throughout the province. Some isol a t e d communities have d i f f i c u l t y i n acquiring an optimal r a t i o , but these are few i n number, and the d i f f i c u l t y i s largely due to i n s u f f i c i e n t population base and settlement i s o l a t i o n or dispersion. Pharmacist d i s t r i b u t i o n i s only s l i g h t l y less s a t i s f a c t o r y than that of general p r a c t i t i o n e r s . But dentist d i s t r i b u t i o n both at the regional l e v e l and The annual growth rate of physicians i n B.C. has exceeded 4% since 1972. The number of general p r a c t i t i o n e r s and family physicians as a percentage of the t o t a l number of physicians i n B.C. has remained at about 55% since then. During 1972-76, the annual p r o v i n c i a l population growth rate has declined from 3.07o to 1.3%. Thus, the growth of G.P.'s has exceeded popula-tion growth. There i s no in d i c a t i o n that either growth rate w i l l change d r a s t i c a l l y i n the immediate future. (Source: Selected S t a t i s t i c s and Projections, Physicians Manpower supply  i n B.C., compiled by Health Manpower Research Unit, U.B.C, 1976.) 108 'a^ihja^community; l e v e l shows d i s t i n c t biases against r u r a l regions, p a r t i c u l a r l y the north. D i s t r i b u t i o n of medical primary sub-specialists at the regional scale i s highly un-desirable. Redistribution of this group i s imperative. The results of the analyses suggest that regional factors d e f i n i t e l y have strong influences on a c c e s s i b i l i t y . These include location of the region i n r e l a t i o n to the metropolitan centres, vastness of r u r a l hinterland, proximity of regional urban centres to one another, degree of dispersion of s e t t l e -ments within the region and to some extent the geographic characterstics of the region (e.g. topography). These regional factors also influence the lo c a t i o n a l choice of physician practice. They are found to be more important factors than • °2 community size. The primary d i f f i c u l t y of r u r a l health care delivery i s recruitment and retention of physicians and other related health personnel. There are generally high health manpower turn-over rates i n r u r a l regions (Scarrow, 1969), as r e f l e c t e d i n the youthful population of general p r a c t i t i o n e r s / f a m i l y physicians i n these regions. Rural regions t r a d i t i o n a l l y had been charac-terized by high percentages of European or U.S.A. trained physicains. The federal r e s t r i c t i v e p o l i c y on physician immi-gration has been proven i n this thesis to be disadvantageous to the r u r a l regions. The po l i c y has also worsened the d i s t r i b u -tion problem between the "have" and the "have-not" regions. - .xS.ee- Appendix. --.I ,i Part I I. 109 Manpower PI arming Manpower i s one of the most important components of the health care delivery system, yet i t i s the resource over which the government has the least control. In B r i t i s h Columbia, 3 as i n most other provinces i n Canada, health manpower planning and management i s s t i l l i n i t s infancy.^*" At the p r o v i n c i a l l e v e l , at least three parties have direc t r e s p o n s i b i l i t y for the existing manpower si t u a t i o n : the Colleges ( i . e . the College of Physicians and Surgeons, the College of Dentists and the College of Pharmacists) as the lic e n s i n g and regulating bodies; the University as the educating body and the Ministry of Health as the financing body. The Ministry also has a l e g i s l a t i v e role i n the manpower area. But more money and e f f o r t are devoted to processing physician earnings which are aggregates of insurance claims than to regulating physician supply and d i s t r i b u t i o n (explained l a t t e r ) to r e f l e c t the r e a l needs of the populace. While each of these Although the practice of health manpower planning i s a r e l a t i v e l y new approach i n the health f i e l d , i t s theory i s the same as any other resource planning. Planning i s a set of procedures, and regardless of the substantive or geographic focus, a l l procedures involve (1) the selection of ends and c r i t e r i a , (2) the i d e n t i f i c a t i o n of alternatives and the selection.of a desired alternative, and (3) guidance of action toward determined ends (after Davidoff and Reiner, 1962). These procedures apply equally well to resource planning as to land use planning, economic planning, and others. In health manpower planning, the focus i s on the i d e n t i f i c a t i o n of health care needs (procedure 1) and the e f f e c t i v e and e f f i c i e n t a l l o c a t i o n of the manpower resources to meet these needs (procedures 2 and 3). 4 The most up-to-date account of the health manpower planning a c t i v i t i e s i n B.C. can be found i n Anderson, 1975. 110 bodies exerts tremendous influences on the manpower si t u a t i o n , none has taken an active role i n planning and managing the resource. However, to expect any one of them singly or any other single organization to assume such a r o l e would be unreasonable, given there are many formidable obstacles, including the entrenched professional l o y a l t y to the free-enterprise system ( p a r t i c u l a r l y with regard to a professional's r i g h t to work wherever and whatever he/she chooses), the lack of basic organization structures for effectuating the planning process, and the i n a b i l i t y of the ex i s t i n g information system to provide useful data for planning purposes."* To overcome such obstacles, the endeavour must be a collaborative e f f o r t of a l l parties concerned. Nevertheless, the p r o v i n c i a l government s t i l l needs to play a leading r o l e i n determining the o v e r a l l d i r e c t i o n of the delivery system,since i t controls funding and most of the planning and decision-making mechanisms. The government should also be the o v e r a l l co-ordinator of a l l c o l l e c t i v e decisions (government or otherwise) that a f f e c t the future health manpower si t u a t i o n of the province. With respect to influencing the number, types and location of health care professionals i n the province, a number of options are worth exploring within the j u r i s d i c t i o n s of the p r o v i n c i a l government, the Colleges and the University:-B.C.'s health manpower data bank which has a hi s t o r y of about f i v e years i s capable of providing up-to-date and f a i r l y detailed data on health manpower i n the province, but the system has. not'yet been equipped to assess or i d e n t i f y community needs which are essential information for the determination of requirements by geographic area. I ' l l (1) That University education programs be scrutinized to r e f l e c t the manpower needs of the province. Training positions by number and specialty should r e f l e c t the manpower requirements for the province by geographic area and by community. Since B.C. graduates have a demonstrated preference for a medical practice i n the metropolitan and urban areas, the recent adopted p o l i c y of the Medical School to double the size of the enrollment would only heighten the geographic d i s p a r i t i e s between the r u r a l and the urban regions. Instead of focusing on the mere expansion of the tr a i n i n g school, p r i o r i t y should be given to encouraging more r u r a l practice among B.C. graduates. The academic programs can be expanded or modified to allow more opportunities for undergraduates to gain p r a c t i c a l experience i n r u r a l and northern areas through manatory preceptorship and/or r u r a l residency. It has been said that the reluctance of B.C. graduates to assume r u r a l practice i s largely due to the i r fear of the uncertain demands that r u r a l i s o l a t e d practice e n t a i l s and t h e i r general lack of knowledge of practice opportunities outside the metropo-l i t a n areas. Through i t s education programs, the University can help students overcoming such d i f f i c u l t i e s . (2) That incentive programs be developed to encourage practice i n deprived areas. Health professionals choose an urban p r i c t i c e over a r u r a l practice for i t s d i s t i n c t advantages, including s o c i a l and professional interaction, c u l t u r a l and educational opportunities and urban amenities. The lack of such attractions i n the r u r a l deprived areas must therefore be 112 compensated by special incentives, i f physicians and other health care personnel were to be attracted to these areas. Elements i n such a program might include f i n a n c i a l incentives, assistance i n housing and practice f a c i l i t i e s , opportunities for continuing education, and guaranteed time-off for private l i f e and continuing education. In special cases such as physicians assigned to i s o l a t e d communities under special arrangements (discussed l a t t e r ) , guaranteed minimum incomes af e lady i s able .'• In B.C., the existing form of incentive i s the northern allowances as a bonus payment to physicians prac t i s i n g i n designated r u r a l areas. Many, however, believe that the bonus i s too marginal to be e f f e c t i v e . A more substantial incentive; i s needed. Moreover, In Ontario, i t has been suggested that to a t t r a c t competent physicians to the less populous areas of the pro-vince more than money i s needed; community p a r t i c i p a t i o n i s es s e n t i a l . Many communities i n the province were given the r e s p o n s i b i l i t y for supplying adequate housing and c l i n i c a l f a c i l i t i e s at a reasonable rent, and were advised that a modern health care centre would help to a t t r a c t physicians, as part of a 1969 program designed to place physicians i n areas of Ontario deemed to be medically underserviced. By 1973, of the 75 communities who b u i l t modern a t t r a c t i v e medical centres, almost a l l have been successful i n obtaining physicians (Bass and Copeman, 1975). (3) That disincentives be developed to control the supply i n over-doctored areas It has been suggested that through the B.C. Medical Services Commission payments, the government can experiment with 113 regional disincentives together with regional incentives by reducing fee schedules i n over-doctored areas while increasing those i n under-doctored areas. However, studies have shown that because of the discretionary power physicians have over the l e v e l of service u t i l i z a t i o n and over the choice of technology, marginally d i f f e r e n t fee schedules w i l l bave l i t t l e impact on the physician's income. As monopolies, physicians can generate demand to meet the i r target income l e v e l (Evans and Wolfson, 1978). But even i f fee d i f f e r e n t i a l s can be made substantial enough to be e f f e c t i v e -- i t has been said that regardless of a p h y s i c i -an's discretionary power to induce demand, there i s a l i m i t to the number of patients he/she can attend -- the very idea of income control w i l l generate enough resistence for the program to be p o l i t i c a l l y possible. An alternative form of disincentive can be a l i m i t a t i o n on the number of physicians permitted to b i l l B.C. Medical Services Commission within each region, thereby equalizing regional d i s t r i b u t i o n . However, this control mechanism again may not be tolerated by either the professionals or the society at large at this time. (4) That co-operation of the Colleges be sought such that practice p r i v i l e g e s are equitably distributed. Through the Colleges, temporary licenses can be issued to physicians and other professionals to practise i n s p e c i f i e d areas. This mechanism i s directed toward in-migrant and immigrant physicians i n p a r t i c u l a r , at least i n the short-run u n t i l the incentive program and the t r a i n i n g programs have produced r e s u l t s . (5) That special appointments be arranged for s p e c i f i e d communities or geographic areas. This mechanism i s p a r t i c u l a r l y appropriate for dentist and pharmacist appointments as both professional groups are not under any public insurance scheme. It can also be applied to medical s p e c i a l i s t s as well. Appointments can be of contractual, s a l a r i e d or the l i k e , and be administered by the Regional Health Council (discussed l a t t e r ) . (6) That group practice be encouraged i n the r u r a l areas. Group practice involves a group of primary health care per-sonnel of various categories functioning as a team to provide services to a population within a defined geogra-phic area. Group practice has been demonstrated not only as a more e f f i c i e n t form of practice than solo practice (Ontario Health Planning Task Force Report, 1974), i t also offers some d i s t i n c t advantages for professionals who practise i n r u r a l areas. It allows both professional con-su l t a t i o n and moral support, thereby a l l e v i a t i n g the f e e l i n g of i s o l a t i o n . Group practice also provides f l e x i b i l i t y . For instance, by alternation, physicians can f i n d time for private l i f e and education, while ensuring uninterrupted services to patients. (7) That improved arrangements for underserviced areas be made. As i d e n t i f i e d i n this thesis, many r u r a l i s o l a t e d communi-ti e s do not have s u f f i c i e n t population to support f u l l - t i m e personnel. Special techniques to provide services to i s o l a t e d communities already e x i s t . A prime example i s the 115 mobile dental program providing dental services to pre-school and school children as well as to adults (B.C. Ministry of Health, 1976; Vancouver Sun, 1978). This program has been proven very e f f e c t i v e , and e n t a i l s v i r t u a l l y no p r o v i n c i a l expenditure except for the c a p i t a l cost of the vehicles and equipment. A l l the dentists need are t h e i r own instruments. The f e a s i b i l i t y of u t i l i z i n g mobile or portable units for providing other services i n these situations should be thoroughly explored. Another solution to improving the a c c e s s i b i l i t y of i s o l a t e d communities to health care services i s u t i l i z a t i o n of s a t e l l i t e services whereby health personnel located i n certain towns or c i t i e s provide services to outlying communities or settlements. In Ontario a number of examples of such arrangements already exist (Ontario Council of Health, 1974). These include periodic supportive and consultative v i s i t s to smaller communities from major centres within a d i s t r i c t . Such arrangements would be most applicable to primary health care of a more spe c i a l i z e d nature such as p e d i a t r i c , o b s t e t r i c and p s y c h i a t r i c services. In Manitoba, a recent medical manpower study recommended the exploration of the p o t e n t i a l of t e l e v i s i o n or radio consultation for remote areas (Manitoba Medical Manpower 6 The physical configuration of a mobile unit should be t a i l o r e d to meet s p e c i f i c needs. For example, to serve the coastal communities of the Mid Coast Region, f l y i n g (or other-wise) ferry units are advisable. Inland areas can be served by equipped vans. For general consultation and diagnosis, basic G.P. instruments and an examining table would be adequate. Committee Report, 1978). A l l i e d health personnel p a r t i c u l a r l y nurse p r a c t i t i o n e r s can and should provide valuable services to small i s o l a t e d communities where the use of a full-time physician cannot be j u s t i f i e d . Despite these potentials for intervention and improve-ment, the p r a c t i c a l i t y of each of these solutions needs to be further explored. For example, quite apart from the e t h i c a l issue of whether government should have the r i g h t to control professional services, the setting of requirement standards, the determination of the appropriate number and the mix of personnel required for each region or geographic area, and similar kinds of technical considerations are exceedingly complex. As regional requirements are dependent upon the c h a r a c t e r i s t i c s of the population, the resources available, the r e f e r r a l patterns of patients and regional epidemiologies -- a l l of which are subject of change over time, i t i s obvious that no one single "master" model can be u n i v e r s a l l y applied. Better understanding of the needs of the population at the sub-provincial l e v e l i s an es s e n t i a l step toward r e a l i z i n g the intervention or improvement potentials. Also, the p r a c t i c a l i t y of any of these solutions i s depen-dent upon economic constraints. To be r e a l i s t i c , ensuring equal access to every i n d i v i d u a l i s s o c i a l l y , p o l i t i c a l l y and t h e o r e t i c a l l y sound, but may not be economically viable: some settlements are so dispersed and have such 5a.small/population base that providing the same standard of services as :' for>urban centres may be u n j u s t i f i a b l y costly. Thus, to be 117 implementable, solutions must also observe cost r e a l i t y . Furthermore, the various alternatives must be evaluated against the o v e r a l l manpower po l i c y of the province. Is equity the fundamental goal of a health care delivery system? Or i s free enterprise the s o c i a l p r i n c i p l e behind the o v e r a l l manpower policy? What are the p r i o r i t i e s i f there are c o n f l i c -ting goals? No solutions can be evaluated and selected without a sound o v e r a l l p olicy, and a strategy that spells out such a p o l i c y . In countries such as. Sweden, Soviet Russia and B r i t a i n where health care i s p u b l i c l y funded, health care p o l i c i e s r e f l e c t an e g a l i t a r i a n philosophy and a b e l i e f i n l o c a l p a r t i c i p a t i o n . For example, i n Br i t a i n ' s National Health Service System, the basic unit of health care delivery i s the d i s t r i c t which encompasses a geographic area with a population of 100,000. A l l health care providers are funded by and report to the d i s t r i c t . Its p r i n c i p a l r e s p o n s i b i l i t y i s projecting l o c a l manpower requirements and preparation of annual operating: plans for the d i s t r i c t . The d i s t r i c t i s d i r e c t l y responsible to the region, which i n turn reports to the national health department (Hilleboe, Barkhuus and Thomas, 1972; Shannon and Denver, 1974; Department of Health and Social Security, U.K., 1976). The essense of this approach i s to emphasize meeting the needs of a geographic area rather than managing i n d i v i d u a l i n s t i t u t i o n s (such as hospitals) or programs. Decentralization also enables c r u c i a l decisions about health care delivery to be made at the regional or community l e v e l , thereby ensuring more equitable delivery of care according to 118 needs. In Canada, the concept of decentralization or r e g i o n a l i -zation of health care delivery has received increasing, . . . interests, and more and more public policy-makers have advocated i t s adoption. Regionalization Canada's experience with r e g i o n a l i z a t i o n i s best repre-sented by Quebec and Ontario.(Ontario Council of Health, 1975 and 1977; Bennett and Krasny, 1977). Quebec established i t s f i r s t twelve regional councils i n 1971, as a r e s u l t of the Castonguay report. The councils are charged with planning r e s p o n s i b i l i t y but have no budgetary authority. In Ontario, the regional body i s c a l l e d the D i s t r i c t Health Council, with a population base of 100,000, and d i f f e r s from Quebec's regional council i n that the council members are volunteers rather than appointed o f f i c i a l s . But the D i s t r i c t Health Councils.: are . only charged with planning and advisory respon-s i b i l i t y and have no r e a l decision-making power. Since both re g i o n a l i z a t i o n schemes are s t i l l i n t h e i r infancy, evaluation at this stage may be pre-mature. Nevertheless, c r i t i c s have already expressed pessimism.. Many mistrust the government's a b i l i t y to design an e f f e c t i v e regional structure to "do the job". It has been argued that parochial and c o n f l i c t i n g interests are too many, and incentives for co-operation are too few. Also, there i s a fear that by creating a new l e v e l of government the system would be prone to over-bureaucratization -- some suggest that B r i t a i n ' s NHS has already shown signs of this problem. 119 I t i s no s u r p r i s e t h a t t h e p r o c e s s o f r e g i o n a l i z a t i o n i s a l o n g and p a i n f u l one. Many o f t h e s e b a r r i e r s and p o t e n t i a l dangers a r e pe rhaps u n a v o i d a b l e . But t h e y need n o t o u t w e i g h t he m e r i t s o f t h i s a p p r o a c h . R e g i o n a l i z a t i o n p r o v i d e s t h e n e c e s s a r y s t r u c t u r a l f ramework w i t h o u t w h i c h many o f t he improvements i n h e a l t h c a r e d e l i v e r y wou l d n o t be p o s s i b l e : (1) b e t t e r i d e n t i f i c a t i o n o f l o c a l needs as l o c a l commun i t i e s and r e g i o n s a r e more a b l e t o a r t i c u l a t e t h e i r p rob lems and needs ; (2) more r a t i o n a l d i s t r i b u t i o n o f r e s o u r c e s , as p rog rams , s e r v i c e s , f a c i l i t i e s , money and manpower a r e a p p r o p r i a t e l y c h a n n e l l e d t o needy a r e a s ; (3) b e t t e r c o - o r d i n a t i o n as r e g i o n a l c o u n c i l s .set.- o v e r a l l d i r e c t i o n f o r p rog rams , thus a v o i d i n g d u p l i c a t i o n o r d e p r i v a t i o n o f s e r v i c e s ) - and -(4) o p p o r t u n i t y f o r i n n o v a t i o n as l o c a l a r e a s g a i n autonomy t o d e s i g n t h e i r own programs t o meet s p e c i f i c needs w h i c h wou l d n o t be p o s s i b l e o t h e r w i s e . From t h e manpower p l a n n i n g p e r s p e c t i v e , r e g i o n a l i z a t i o n a l s o p r o v i d e s t he n e c e s s a r y f ramework f o r i m p r o v i n g a c c e s s i -b i l i t y i n - u n d e r - s e r v i c e d a r e a s . As d i s c u s s e d i n t h e e a r l i e r s e c t i o n , many d e p r i v e d a r ea s need s p e c i a l a r rangement s f o r d e l i v e r y , i n c l u d i n g u t i l i z a t i o n o f m o b i l e u n i t s t o r e a c h i s o l a t e d a r e a s , c o n s u l t i n g s e r v i c e s a t t he s u b - s p e c i a l t y l e v e l f r om r e g i o n a l h e a l t h c e n t r e s t o t h e o u t l y i n g c o m m u n i t i e s , g roup p r a c t i c e w h i c h r e q u i r e s an e f f e c t i v e and e f f i c i e n t ne twork o f commun i ca t i on and s p e c i a l appo i n tmen t s w h i c h r e q u i r e s a l o c a l o r r e g i o n a l manpower r e c r u i t i n g c e n t r e - - a l o c a l manpower r e c r u i t i n g c e n t r e i s more e f f i c i e n t t h a n a p r o v i n c i a l one as i t can d e a l w i t h u r g e n t manpower i s s u e s o r l o c a l p l a cement d i r e c t l y and i m m e d i a t e l y . The i m p l e m e n t a t i o n o f t h e s e programs r e q u i r e s a r e g i o n a l body w i t h p l a n n i n g , a d m i n i s t r a t i o n ; and r e s o u r c e a l l o c a t i o n power. 120 Regionalization of health care delivery i n B.C. can and should allow more r a t i o n a l and e f f e c t i v e use of the manpower resource. At present, the only form of l o c a l management of health care i n the province i s the regional hospital board. There are also public health units and dental units, but neither three correspond with one another (in both geographic and functional terms). The l a t t e r two, i n fact, are l o c a l o f f i c e branches of the Ministry, and therefore not true l o c a l organizations. Only the hos p i t a l boards have l o c a l represen-tation. But even the l o c a l h ospital boards do not function t r u l y as automous dee-is ion-making, bodies. .. Their functions are limited to those of general hospital administration. They do not look at the t o t a l health needs of the regions or the appropriate balance of programs to meet these needs .. In other words, there i s no l o c a l health care planning function i n the province. Regional d i s t r i c t planning has. t r a d i t i o n a l l y excluded health care planning, even though i t i s a v i t a l part of the' l o c a l system, and health care services are just as essential to the well-being of people as are schools, roads, waste disposal, parks, etc., i f not more so. As an i n i t i a l step, the concept can be experimented with a small scale (using one or two regions). Time, knowledge, experience and public acceptance are a l l necessary for the success of the endeavour, and can only be achieved through careful staged planning. While no perfect prescriptions can be forwarded, i t seems that at least three areas of concern deserve careful consideration: Local Representation The regional planning and management body, here c a l l e d the Regional Health Council, should be made up of l o c a l residents, with reasonable representation from'deliverers, consumers, l o c a l health i n s t i t u t i o n s (e.g. hospital) and municipal or regional government. Such a mix ensures the council represents the general health needs of the region rather than those of any p a r t i c u l a r interest group. Regional Boundaries There already have existed i n B.C. numerous functional d i s t r i c t s and regions. It i s , therefore, important that the new regional organization not create another set of unrelated boundaries. E f f o r t s hould be made to ensure the boundaries coincide with other major functional units such as education, s o c i a l services, municipal planning, etc A regional health unit should contain a va r i e t y of health services and a reasonable number of people. From the experiences of Ontario and B r i t a i n , a population of 100,000 i s a minimum size for e f f e c t i v e program planning and manage ment. A smaller population would create situations where program and resource u t i l i z a t i o n could not be j u s t i f i e d . Planning Functions Instead of trying to resolve c o n f l i c t s or cope with small group intere s t s , the Regional Health Council should focus i t s e f f o r t and attention ton- a comprehensive analysis of health care needs of the regional population as a s t a r t i n g point. The analysis w i l l provide the most c r u c i a l piece of data for r a t i o n a l decision-making, and i s a prerequisite 122 to the establishment of a resource recruitment and a l l o c a t i o n process. The existence of a factual basis i s also es s e n t i a l for meaningful dialogue from which mutual agreement on the who, how and what questions can be reached. As the Council gains experience, maturity, confidence and acceptance, i t s scope of a c t i v i t i e s should also be broadened. The ultimate r e s p o n s i b i l i t y of a regional body i s more than data surveys, projecting manpower and resource requirements or establishing a l l o c a t i o n mechanisms. It must also be responsible for on-going monitoring and evalu-ation of programs and a c t i v i t i e s , and modifying them when required, l i a i s o n with other sectors (such as education and s o c i a l services) of the regional system and p a r t i c i -pation i n p r o v i n c i a l l e v e l planning at an advisory capacity. In sum, r e g i o n a l i z a t i o n i s a long, d i f f i c u l t process and there are many formidable barriers to i t s success, but the pote n t i a l benefits make i t worthwhile for the p r o v i n c i a l govern-ment to put more effort:, and talent to overcoming them, or even forgoing some immediate cost-saving schemes for the long-term gains. 123 BIBLIOGRAPHY A. BOOKS Arasteh, J.D., Factors Influencing Practice Location of Professional Health Manpower: A Rewiew of Lit e r a t u r e , 1974. Blalock, Hubert M., Measurement i n the Social Sciences: Theories and~Strategies, Chicago: Aldine Pub. Co., _ , Social S t a t i s t i c s , N.Y.: McGraw-Hill, 1972. Bryant, John H., A l l e n S. Ginsberg, Seth B. Goldsmith, Margaret C. Olendzki, and Nora Piore, Community  Hospitals and Primary Care Centre for Community Health Systems, Faculty of Medicine, Columbia University, Ballinger Publishing Company, Cambridge, Massachusetts, 1976. de Vise, Pierre, Misused and Misplaced Hospitals and Doctors:  A Locational Analysis of the Urban Health Cafe C r i s i s , Commission on College Georgraphy Resource Paper No. 22, Association of American Geographers, Washington, D.C. 1973. McGlashan; N.D., ed., Medical Geography: Techniques and F i e l d  Studies, London: Methuen and Co. Ltd., 1972. Reinke, W.A.., And K.N. Williams, ed. , Health Planning, Qualitative Aspects and Quantitative Techniques, John Hopkins University, School of Hygiene and Public Health, Dept. of International Health, Baltimore, 1972. Shannon, G.W. , and G.E. Alan Dever, Health Care•-Delivery:  Spatial Perspectives, McGraw-Hill Problems Series i n Geography, 1974. 124 B. PERIODICALS Bass, Martin, and William J. Copeman, "An Ontario Solution to Medically Unerserviced Areas: Evaluation of an On-going Program," Canadian Medical Journal, September 6, 1975, Vol. 113, pp. 403-407. Davidoff, Paul, and Thomas A. Reiner, "A Choice of Planning," Journal of the American Inst i t u t e of Planners, Vol. 28, May, 1962. p p . 103-115. Evans, R.G., "Does Canada Have Too Many Doctors? - Why Nobody Loves an Immigrant Physician," Canadian Public Policy, Spring 1976, pp. 147-161. Ross, Maralow, M. Ganmont, and J.M. Horne, "The Impact of the Physician Surplus on the D i s t r i b u t i o n of Physicians Across Canada," Canadian Public Policy, Spring 1976, pp. 169-191. C. PUBLICATION OF GOVERNMENT, UNIVERSITIES AND OTHER ORGANIZATIONS Anderson, D.O., Report to the Federal/Provincial Health Manpower Committee: B.C. Health Manpower Planning  A c t i v i t i e s , November 1974-April 1975, Health Manpower Working Group, Vancouver: O f f i c e of the Co-ordinator, Health Sciences Centre, U.B.C, 1975. Aziz, J., Supply Projections to 1981: Selected Health Manpower  Categories, 1974. Bennett, James E., and Jacques Krasny, "Health Care i n Canada: A Series on the Nation's Health," The F i n a n c i a l Post, March 26-May 7, 1977. B r i t i s h Columbia College of Physicians and Surgeons, Medical  Directory, 1975-76 and 1977-78. B r i t i s h Columbia Department of Economic Development, The  Central Report, I.P.A. Series, 1976. , The Kootenay Report, I.P.A.Series, 1976. , The Mid Coast Report, I.P.A. Series, 1976. 125 , The North West Report, I.P.A. Series, 1977. B r i t i s h Columbia Ministry of Health, B.C. Department of  Health Annual Report, 1976. B r i t i s h Columbia Ministry of Municipal A f f a i r s and Housing, S t a t i s t i c s Relating to Regional and Municipal  Governments i n B r i t i s h Columbia, June 1977. Canada, Health Manpower Studies: A Selected Bibliography  1964-75, 1976. , Report of the E l e c t o r a l Boundaries Commission for the Province of B r i t i s h Columbia, 1976. , Royal Commission on Health Services Report 1964-65, 196T! Canada, Health and Welfare, Physician Manpower Supply '. Proj ection, 1974. , National Committee on Physician Manpower Requirements for Physicians i n Canada, 1975. Canadian Medical Association, Department of Research and  Development Quickbase, Ottawa, 1974. Community Health Centre Project, The Community Health Centre  i n Canada, Report of the Community Health Centre Project to the Conference of Health Ministers, Ottawa, 1972, Vol. 1-4. Foulkes, Richard G., Health Security for B r i t i s h Columbians, Report to the Minister of Health, Province of B.C., Voctoria, 1974. Hacon, William S., The Health Manpower Situation i n Canada, Paper prepared for presentation on Health Planning, Ottawa, September 10-14, 1973. Hilleboe, H.E., A. Barkbuss, and W.C. Thomas, J r . , Approaches  to National Health Planning, Public Health Papers No. 46, World Health Organization, Geneva, 1972. LaLonde, Marc, A New Perspective on the Health of Canadians, A Working Document, Ottawa, Department of National Health and Welfare, 1974. Manitoba, Cabinet Committee on Health, Education and Social Policy, White Paper on Health Policy, July 1972. "Manitoba Medical Manpower Committee Report," A p r i l 1978. Ontario, Ontario Health Planning Task Force Report, 1974. 126 Ontario Council of Health, D i c t r i c t Health Councils, A Report of the Ontario Council of Health, Toronto, 1975. , Evaluation of Primary Health Care Services, A Report of the Ontario Council of Health, Toronto, 1976. , Health Services for New Towns and Major Developments or Redevelopments i n E x i s t i n g Communities and i n  Underserviced Areas, A.Report of the Ontario Council of Health, 1974. , Physician Manpower, A Report of the Ontario Council of Health, 1974. , The Planning Function of D i s t r i c t Health Councils, A Report of the Ontario Council of Health, 1977. Quebec, Commission of Inquiry on Health and Social Welfare, Health, 1970. R o l l c a l l 75, A Status Report of Health Personnel i n the Province of B r i t i s h Columbia, Report R:l, D i v i s i o n of Health Services Research and Development, Health Sciences Centre, U.B.C, 1976. R o l l c a l l 77, A Status Report of Health Personnel i n the Province of B r i t i s h Columbia, Report R:5, D i v i s i o n of Health Services Research and Development, Health Sciences Centre, U.B.C, 1978. Scarrow, Hart, Medical Manpower Survey: 1968-69, Province of B r i t i s h Columbia, B.C. Health Resources Council, Technical Report M-l, 1969. Taylor, J. A l l y n , "The Joint Advisory Committee of Government of Ontario and the Ontario Medical Association on Methods to Control Health Care Costs," Toronto, January,1978. United Kingdom, Department of Health and Social Security, "The NHS Planning System," June 1976. Vancouver Sun; "Finding Canadian Externs Like P u l l i n g Teeth," July 7, 1978, p. A9. , "Lone P s y c h i a t r i s t i n North Quits for Lucrative Toronto," November 29, 1977, p. A l . , " P s y c h i a t r i s t Shortage Worst," November 30, 1977, p. A14. 127 Warner, Morton M., ed., A Annotated Bibliography of Health  Care Teamwork and Health Centre Development, Department of Health Care and Epidemiology, C B / C , 1975. White, K.L., D.0. .Anderson, E. Kalimo, B.M. Kleczkowiski, T. Purola, and C. Vukmomovic, Health Services: Concepts  and Information for National Planning and Management, Public Health Paper No. 67, World Health Organization, Geneva, 1977. D. THESES AND OTHER PAPERS Evans, R.G., "Beyond the Medical Market Place, Expenditure, U t i l i z a t i o n and Cost of Insured Health Care i n Canada)' Department of Economic Discussion Paper, U.B.C, 1974. , and A.D. Wolfson, "Moving the Target to Hit the Bullet : Generation of U t i l i z a t i o n by Physicians i n Canada," Paper prepared for the National Bureau of Economic Research Conference on the Economics of Physician and Patient Behaviour, Stanford, C a l i f o r n i a , January 1978. (Preliminary) Herdman John, Patterns of Practice of General Surgeons i n  Non-metropolitan B r i t i s h Columbia, M. Sc. Thesis, Department of Health Care and Epidemiology, U.B.C., 1975. Schultz, George P., " F a c i l i t y Patterns for a Regional Health Care System," RSRI Discussion Paper Series No. 34, Regional Science Research I n s t i t u t e , P h i l a . , October 1969. "Selected S t a t i s t i c s and Projections: Physician Manpower Supply i n B r i t i s h Columbia," Health Manpower Research Unit, Health Services Research and Development, U.B.C, September 1976. APPENDIX A RURALITY RANKING BY STUDY REGION (A) METRO CENTRES: VANCOUVER & VICTORIA (a) R RURALITY SCORE (b) a -b b (c) RANK( j 5 r^->.2) P N C K I 0 s V M 566 529 298 277 261 185 47 42 .01 .070 .437 .070 .058 .291 .746 .106 .999 4 4 4 6 (B),METRO CENTRES: VANCOUVER, VICTORIA, CALGARY & EDMONTON (aO . p = R = Study Region (a) R N C P K I 0 S V M RURALITY SCORE (b) 529 298 285 269 261 185 47 42 .01 a -b b (c) .432 .044 .056 .030 .291 .746 .106 .999 RANK ( ^ > . 2) 3k 3k 3k 6 7k 7k 9 K = Kootenays 0 = Okanagan C = C e n t r a l I n t e r i o r s = South-West M = M e t r o p o l i t a n V = South Vancouver I s l a n d I = Mid Coast N = North-West P = Peace R i v e r (b) (c) From Table 2. e . g . 566-529 529 = .070 OO APPENDIX B ESTIMATES OF POPULATION BY COMMUNITY AND SUB-REGION, 1976 * ALBERNI-CLAYOQUOT 32,174 1. Bamf i e l d 200 2 . Long Beach 100 3. P o r t A l b e r n i 26,300 4 . P o r t A l b i o n 100 5. S p r o a t Lake 300 6 . To f i n o 600 7. U c l u e l e t 1 , 200 8. IR (Ahousat) . 300 9 . IR (P.ort A l b e r n i ) 300 10. IR ( T o r i n o ) 200 11 . IR ( U c l u e l e t ) 200 12 . IR ( Z a r l u s ) 100 13 . SR ( P o r t A l b e r n i ) 1 , 500 14 . SR ( T o r i n o ) 400 15. SR ( U c l u e l e t ) 300 BULKLEY-NECHAKO 32,617 16 . B u r n s Lake ; 2,700 17. Co1leymount 100 18 . D a n s k i n 100 19 . D e c k e r Lake 200 20. Endako 300 21 . F o r t F r a s e r 500 22 . F o r t S t . James 3,200 23 . F r a n c o i s Lake • 100 24 . F r a s e r Lake 2,000 25. G r a n i s l e 1 , 200 26. G r a s s y P l a i n 100 27. H o u s t o n 3 , 000 28. O o t s a Lake • 100 29 . Perow 100 30 . S m i t h e r s 4,800 31. South" Bank 200 32 . T a t a l r o s e 100 33 . T a y s i e Lake 100 34 . T c h e s i n k u t Lake 200 35. Telkwa 1 , 500 36 . T i n t a g e l 100 37 . T o p l e y 100 38 . T o p l e y L a n d i n g 100 39 . V a n d e r h o o f 2 , 800 40. IR (Burns Lake) 500 APPENDIX B (CONT.) 41 . IR ( F o r t B a b i n e ) 100 42 . IR ( F o r t S t . James) 500 43 . IR ( F r a s e r .Lake) 400 44 . IR (Nechako 300 45 . IR ( T a c h i e + P i n c h i ) 300 46. IR ( T a k l a L a n d i n g ) • 200 47 . SR (Burns Lake) 1 , 000 48 . SR ( F o r t S t . James) 2 , 000 49 . SR ( F r a s e r Lake) 600 50 . SR ( S m i t h e r s ) 1 , 000 51 . SR ( V a n d e r h o o f ) 2 , 000 CAPITAL 230 , 592 52 . G a l i a n o I s . 500 53 . Mayne I s l a n d 300 54 . Pender I s l a n d 500 55. P o r t Renfrew 400 56. R i v e r J o r d a n 200 57 . S a l t s p r i n g I s l a n d 3 , 600 58 . S a t u r n a I s l a n d 200 59 . Sooke 4 , 300 60 . V i c t o r i a 219 , 000 61. IR ( V i c t o r i a ) 1 , 500 CARIBOO 51 , 616 62 . A l e x a n d r i a 300 63 . A l e x i s Creek 200 64. B i g C r e e k 100 65. B u f f a l o .Creek 1 400 66. C a s t l e Rock 100 67 . Canim Lake 400 68 . E a g l e C r e e k 400 69. F o r e s t Grove 800 70 . H a n c e v i l l e 7 200 71 . H e n d r i x Lake 600 72 . H o r s e f l y 700 73. K e r s l e y 200 74 . K l e e n a K l e e n e 100 75. Lac La Hache 1 ,000 76. L i k e l y 100 77 . M a c a l i s t e r 100 78 . McLeese Lake 500 79 . M a r g u e r i t e 500 80. Meldrum House 100 131 APPENDIX B (CONT.) 81 . 100 M i l e House 2 , 500 82 . 150 M i l e House 700 83 . Q u e s n e l 14,800 84. R i s k e C r e e k 100 85 . Soda C r e e k 600 86 . S p r i n g h o u s e 10 0. 87 . S t r a t h n a v e r 200 88 . W e l l s 700 89 . W i l l i a m s Lake 16,000 90 . IR ( A l e x i s C r eek) 500 91 . IR ( A l k a l i Lake) 600 92 . IR ( A n i h i m Lake) 100 93 . IR ( E a g l e C reek) 400 94 . IR ( M a r g u e r i t e ) 100 95 . IR (Nazko) 200 96. IR ( R i s k e C r e e k ) 100 97 . IR ( W i l l i a m s Lake).. 300 98 . SR ( A l k a l i Lake) 1 , 000 99 . SR (100 M i l e House) 1,400 100. SR ( Q u e s n e l ) 3 , 600 101. SR ( W i l l i a m s Lake) 800 CENTRAL COAST 4,184 102 . B e l l a C o o l a 500 103 . F i r v a l e 100 104 . H a g e n s b o r g 300 105. Ocean F a l l s 1,400 106 . IR ( B e l l a B e l l a ) 800 107 . IR ( B e l l a C o o l a ) 500 108 . SR (Ocean F a l l s ) 400 CENTRAL FRASER VALLEY 87,927 109 . C e n t r a l F r a s e r : - V a l l e y 87,900 CENTRAL KOOTENAY 48,962 110. A i n s w o r t h Hot S p r i n g 100 I l l . A r g e n t a 100 112 . B a l f o u r 200 113 . Bo swe11 100 114. B u r t o n 100 115. Canyon 100 116 . Cas t l . e g a r 11,100 117 . C r a w f o r d Bay 300 118. Cre s t o n 7,200 119.. - Edgewopd.'. 100 120 . E r i e 100 APPENDIX B (CONT.) 121. F a u q u i e r 200 122 . G l a d e 100 123 . Gray C r e e k 200 124 . H a r r o p 2.0 0 125 . H i l l s 200 126 . J o h n s o n s 100 127 . K a s l o 800 128 . K i t c h e n e r 100 129 . K o o t e n e y Bay 100 130 . L i s t e r 1 100 131. M i r r o r Lake 100 132 . Nakusp 2 , 000 133 . N e e d l e s 100 134 . Nelson.. 13,800 135. New Denver 800 136 . P r o c t e r 200 137. Remac 100 138 . R i o n d e l .600 139 . Robson 1,100 140 . Salmo 1, 500 141 . S h o r e a c r e s . 400 142 . S h u t t y Beach 100 143 . S i l v e r t o n 300 144 . S l o c a n 400 145 . S l o c a n P a r k 400 146. S o u t h S l o c a n 300 147 . Taghum 200 148. Thrums 400 149. W i l l o w P o i n t 100 150 . Winlaw 400 151 . Wynnde1 600 152 . Yahk 200 153 . Ymir 300 154 . SR ( C r e s t o n ) 1,400 155 . SR ( K a s l o ) 800 156 . SR (Nakusp) 700 CENTRAL OKANAGAN 71,254 157. Kelowna 60,400 158 . Okanagan C e n t r e 400 159 . Oyama 600 160 . P e a c h l a n d 4,400 161. We s t b a n k 1, 100 162 . W i n f i e l d 3 , 800 163 . IR (Kelowna) 500 APPENDIX B (CONT.) COLUMBIA-SHUSWAP 35,569 164 . B a l m o r a l 100 165. B l i n d Bay 300 166. C a s t l e d a l e 100 167. C e l i s t a 200 168 . C r a i g e l l a c h i e 100 169. D o n a l d S t a t i o n 300 170 . E a g l e Bay 200 171. F a l k l a n d 500 172 . F i e l d 500 173 . G o l d e n 4 , 600 174 . H a r r o g a t e 100 175. Malakwa 200 176. Mara 100 177 . M i c a C r e e k 900 178 . P a r s o n 400 179. R e v e l s t o k e 7,600 180 . Salmon Arm 14,400 181 . S c o t c h C r e e k 200 182 . S icamous 1, 500 183 . S o r r e n t o 400 184. T r o u t Lake 100 185. IR ( B l i n d Bay) 300 186 . IR (Salmon Arm) 300 187 . SR ( R e v e l s t o k e ) 2,000 COMOX -STRATHCONA 57 , 186 188 . B l a c k C r e e k 200 189 . B l o e d e l 200 190 . C a m p b e l l R i v e r 17,500 191. Cumberland 2,200 192 . Cour tenay-Comox 25,300 193 . Denman I s l a n d 100 194. Drew H a r b o u r 100 195 . E s p e r a n z a 100 196 . Fanny Bay 100 197. George H a r b o u r 100 198 . G o l d R i v e r 2,000 199 . H e r i o t Bay..:. 300 200 . Hornby I s l a n d 200 201 . H y a c i n t h e Bay 100 202 . K e l s e y Bay 200 203 . Kyuquot 100 204 . Mansons L a n d i n g 200 205 . M e r v i l l e • • 300 APPENDIX B (CONT.) 206 . O y s t e r R i v e r 200 207 . Q u a t h i a s k i Cove 200 208 . Rock Bay 200 209 . R o y s t o n 700 210 . Sayward 400 211. T a h s i s 1,700 212 . U n i o n Bay 600 213 . Whaletown 500 214 . Z e b a l i o s 400 215 . IR (Campbell: R i v e r ) 300 216 . IR ( G o l d R i v e r ) 100 217 . IR (Kyuquot) 100 218 . IR ( U n i o n Bay) 100 219 . SR ( C a m p b e l l R i v e r ) 1,800 220 . SR ( T a h s i s ) 400 COWICHAN VALLEY 47,100 221 . Bamberton 100 222 . C a y c u s e 400 223 . Duncan 32,300 224 . Honeymoon Bay 800 225. Lady s m i t h 4,700 226. Lake Cowichan 3,100 227. N i t i n a t 200 228 . S a l t a i r 1,400 229 . Shawnigan Lake 300 230 . T h e t i s I s l a n d 200 231. Youbou 1 , 500 232 . IR (Duncan) 1,400 233 . IR ( N i t i n a t ) 100 234 . IR ( S a l t a i r - T h e t i s I s . ) 600 DEWDNEY-ALOUETTE 52,430 235 . D e w d n e y - A l o u e t t e 52,400 EAST KOOTENAY 46,450 236 . A t h e l m e r 300 237 . B r i s c o 100 238 . C a n a l F l a t s 1,100 239 . C r a n b r o o k 16,100 240. E dgewater 500 241. E l f o r d 1 , 900 242 ., E l k o 300 243 . F a i r m o n t S p r i n g s 100 244 . F e r n i e 5,300 245 . G a l l o w a y 200 APPENDIX B (CONT.) 246 . Grasmere 100 247. Ho smer 200 248 . I n v e r m e r e 2,200 249. J a f f r a y 300 250. K i m b e r l e y 7 , 600 251. Moy i e 200 252 . Radium H o t s p r i n g s 600 253 . Shookumchuck 100 254 . Sparwood 4,100 255 . S p i l l i a m a c h e e n 100 256 . Ta Ta C r e e k 100 257 . Wardner 200 258 . Wasa 500 259. Windermere 500 260. IR ( F l a g s t o n e ) 100 261 . IR ( F o r t S t e e l e ) 100 262 . IR (Wilmer) 100 263 . SR ( K i m b e r l e y ) 1, 400 264 . SR ( I n v e r m e r e ) 1,200 265 . SR (Sparwood) 800 FRASER-CHEAM 51,430 266 . B o s t o n Bar 700 267 . C h i l l i w a c k 43,200 268 . Hope. 5,200 269. N o r t h Bend 500 270. Spuzzum 100 271. Y a l e 300 272 . IR ( B o s t o n Bar) 100 273 . IR ( C h i l l i w a c k ) 1, 100 274. IR ( N o r t h Bend) 100 FRASER - FORT GEORGE 79,616 275. A l b r e d a 100 276. A l e g a Lake 100 277 . B e a r Lake 400 278 . C r e s c e n t Spur 100 279 . Dome C r e e k 100 280 . D u n s t e r 100 281 . Giscome 500 282 . Lamming M i l l s 100 283 . Mackenz i e 5,400 284 . McLeod Lake 100 285 . M c B r i d e 1,100 APPENDIX B (CONT.) 286. Penny 100 287 . P r i n c e George 68,000 288 . Red Rock 200 289. R e i d Lake 200 290 . S h e l l e y 200 291. S i n c l a i r M i l l s 100 292 . Summit Lake 100 293 . T e t e Taune Cache 100 294 . Upper F r a s e r 500 295 . Valemou n t 1,300 296 . W i l l o w R i v e r 600 297 . Woodpecker 100 GREATER VANCOUVER 1,085,242 298. G r e a t e r V a n c o u v e r 1, 085, 200 KITIMAT-STIKINE 38,718 299 . B r a u n s I s . 300 300 . C e d a r v a l e 100 301 . E d d o n t e n a j on 200 302 . H a z e l t o n 1,300 303 . I s k u t 100 304 . Kemano 400 305 . K i t i m a t 12,600 306. K i t s a u l t 400 307 . K i t w a n g a 300 308 . L a k u s e Lake 200 309 . Nas s 300 310. S t e w a r t 1,40 0 311. T e l e g r a p h C r e e k 300 312 . T e r r a c e 15,000 313 . Usk 100 314 . IR ( A i y a n s h ) 700 315 . IR ( G r e e n v i l l e ) 500 316. IR ( H a r t h y Bay) 200 317 . IR ( H a z e l t o n ) 700 318 . IR ( K i n c o l i t h ) 500 319. IR ( K i t i m a t ) 800 320 . IR (Klemtu) 200 321 . IR ( M o r i c e t o w n ) 300 322 . IR ( N u c h a t l a h t ) 800 323 . IR ( S p i c e I s l a n d ) 500 324. IR ( T e l e g r a p h C reek) 100 325. IR ( T e r r a c e ) 100 326 . SR ( K i t i m a t ) 300 A P P E N D I X B ( C O N T . ) KOOTENAY BOUNDARY 31,706 327. B e a v e r d e l l 200 328 . C h i n a C r e e k 100 329. C h r i s t i n a Lake 300 330. F r u i t v a l e 1,500 331. Grand F o r k s 4,500 332 . Greenwood 1,100 333 . K e t t l e V a l l e y 200 334. Midway 600 335. Montros e 1,200 336. P a t e r s o n 100 337 . Rock C r e e k 200 338. Ro s s l a n d 5 , 000 339 . T r a i l 14,700 340 . W e s t b r i d g e 100 341. SR (Grand F o r k s ) 900 342 . SR (Greenwood) 1,000 MOUNT WADDINGTON 12,476 343 . A l e r t Bay 700 344 . B e a v e r Cove 100 345 . C o a l H a r b o u r 400 346. H o l b e r g 400 347 . K a l e v a 100 348 . K n i g h t I n l e t 100 349 . K o k i s h 300 350. Nimpki sh 300 351. P o r t A l i c e 1,500 352 . P o r t Hardy 3,700 353. P o r t M c N e i l 1,500 354 . S h o a l H a r b o u r 100 355. S o i n t u l a 800 356. T e l e g r a p h Cove 100 357 . V e r n o n Lake 200 358 . W i n t e r H a r b o u r 200 359. Was s 500 360. IR (Kingcome I n l e t ) 600 361. IR ( P o r t Hardy) 300 362 . IR ( Q u a t s i n o ) 300 363 . SR ( P o r t Hardy) 200 APPENDIX B (CONT.) NANAIMO 61,879 364 . Nana imo 61,800 NORTH OKANAGAN 46,860 365. A r m s t r o n g 5,600 366 . C h e r r y v i i 1 e 400 367 . E n d e r b y 2,600 368. Gr i n d r o d 500 369 . Lumby 1,100 370 . Okanagan L a n d i n g 900 371 . Ver n o n 29,900 372 . IR (Spalumcheen) 300 373 . IR (Vernon) 200 374 . SR (Enderby) 1,200 375 . SR (Vernon) 4,000 OKANAGAN-SIMILKAMEEN 51,520 376. Cawston 800 3 77. H e d l e y 500 378 . K a l e d e n 900 379 . Keremeo s 900 380 . Naramata 600 381 . Okanagan F a l l s 800 382 . O l a l l a 200 383 . O l i v e r 5,300 384 . Osoyoos 4 , 500 385 . P e n t i o t o n 2 3,900 386 . P r i n c e t o n 4 , 100 387 . Summerland 7,200 388 . West Bench 1,000 389 . IR ( P e n t i c t o n ) 400 390 . IR ( S i m i l k a m e e n ) 300 PEACE RIVER - LIARD 44,842 391 . B a l d o n n e l 100 392 . C h a r l i e Lake 200 393 . Chetwynd 1,500 394 . Couce Coupe 800 395 . Dawson Cre e k 15,900 396 . F e l l e r s H e i g h t s 100 397 . F o r t N e l s o n 3,200 398. F o r t S t . John 12,600 399 . Hudson Hope 1,300 400. Lone P r a i r i e . ' 100 APPENDIX B (CONT.) 401 . Lower P o s t 200 402 . M i l e 54 100 403 . M i l e 285 100 404 . M i l e 293 100 405 . M i l e 295 2 00 406. R o l l a 100 407 . T a y l o r 700 408 . Tupper 100 409 . Upper Cutbank 100 410 . Wonowon 200 411. IR ( M o b e r l y Lake) 200 412 . IR ( F o r t N e l s o n ) 500 413 . IR (Ware) 100 414 . SR (Dawson Creek) 1,300 415. SR ( F o r t N e l s o n ) 600 416. SR ( F o r t S t . John) 4,400 POWELL RIVER 19,648 417 . Bubber Bay 200 418 . G i l l i e s Bay 700 419. Lang Bay 500 420 . L a s q u e t i 100 421. Lund 200 422 . P o w e l l R i v e r 14,600 423 . S a l t e r y Bay 200 424 . Vananda 600 425. IR ( P o w e l l R i v e r ) 400 426 . SR ( P o w e l l R i v e r ) 2,100 SKEENA-QUEEN CHARLOTTE 22,662 427 . J u s k a t l a 200 428. Mas s e t 1, 600 429. Oona R i v e r 100 4 3.0 . P o r t C l e m e n t s 400 431 . P o r t Edward 1, 200 432 . P o r t Simpson 100 433. P r i n c e R u p e r t 15,000 434. Queen C h a r l o t t e 700 435 . S a n d s p i t 500 APPENDIX B (CONT.) 436. S e w e l l 100 437. S k i d e g a t e 100 438. IR (Masset) 700 439. IR ( M e t l a k a t l a ) 100 440. IR ( P o r t Simpson) 700 441. IR ( S k i d e g a t e ) 300 442. SR ( P r i n c e R u p e r t ) 800 SQUAMISH-LILLOOET 15,769 443. B r a l o r n e 400 444. G o l d B r i d g e 200 445. L i l l o o e t 2,300 446. Pemberton 300 447. S e t o n P o r t a g e 100 448. S h e l a t h 200 449. Squamish 9,100 450. W h i s t l e r 500 451. IR ( L i l l o o e t ) 900 452. IR (Pemberton) 800 453. IR (Squamish) 200 454. SR (Squamish) 800 STIKINE 1,545 455. A t l i n 300 456. C a s s i a r ' : . M 1,100 457. IR (Dease Lake) 100 SUNSHINE COAST 12,508 458. Egmont 300 459. Gambler I s l a n d 100 460. Garden Bay 200 461. G i b s o n s 3,700 462. Halfmoon Bay 100 463. I r v i n e s L a n d i n g 200 464. L a n g d a l e 200 465. M a d e i r a P a r k 700 466. P o r t M e l l o n 200 467. S e c h e l t 3,000 468. W i l s o n C r e e k 700 469. IR ( W i l s o n C reek) 400 470. SR ( G i b s o n s ) 1,200 471. SR ( S e c h e l t ) 1,300 APPENDIX B (CONT.) THOMPSON - NICOLA 92,126 472 . Anglemont 100 473 . A s h c r o f t 4,000 474. Aspen Grove 100 475 . A v o l a 300 4 76. B a r r i e r e 1 , 000 477 . B i g Bar C r e e k 100 478 . B i r c h I s l a n d 300 479 . B l a c k p o o l 100 480 . B l u e R i v e r 600 481. Chache C r e e k 1 , 600 482 . Chase 1 , 900 483 . Chu Chua 200 484 . C l e a r w a t e r 700 485 . C l i n t o n 800 486 . D o u g l a s Lake 100 487 . H e f f l e y 700 488 . Kamloop s 58,300 489 . Logan Lake 1,400 490 . L o u i s C r e e k 300 491. Lower N i c o l a 400 492 . L y t t o n 1, 800 493 . McLure 200 494 . Magna Bay 200 495 . M e r r i t t 7,700 496 . Monte Cr e e k 100 497 . Monte Lake 200 498 . N i c o l a 100 499 . Q u i l c h e n a 100 500 . R a y l e i g h 800 501 . S avona 800 502 . 70 M i l e House 300 503 . Spences B r i d g e 200 504. Vavenby 400 505 . V i n s u l l a 100 506 . W a l h a c h i n ' 100 507 . Westwold 500 508 . IR ( A s H c r o f t ) 100 509. IR (Chase) 300 510 . IR ( C l i n t o n ) 300 APPENDIX B (CONT.) 511 . IR ( D a r f i e l d ) 200 512. IR ( D o u g l a s Lake) 100 513 . IR (Kamloops) 600 514 . IR ( L y t t o n ) 500 515. IR ( N i c o l a ) 700 516. IR ( S p e n c e r B r i d g e ) 300 517 . SR ( C l i n t o n 1 ) 900 518 . SR (Kamloops) 1,500 SOURCE: S t a t i s t i c s Canada, 1971 and 1976 Census A b b r e v i a t i o n s : IR = I n d i a n R e s e r v e SR = S u b - r e g i o n E x p l a n a t i o n o f E s t i m a t i o n ; - P o p u l a t i o n e s t i m a t e s o f I n c o r p o r a t e d c o m m u n i t i e s a r e b a s e d on 1976 C e n s u s . P o p u l a t i o n o f t h e i n c o r p o r a t e d a r e a s and t h e s u r r o u n d i n g e n u m e r a t i o n a r e a s o f t h e community a r e i n c l u d e d . - P o p u l a t i o n e s t i m a t e s o f U n i n c o r p o r a t e d c o m m u n i t i e s a r e b a s e d on 1971 C e n s u s , and a r e p r o - r a t e d u s i n g 1971-76 growth r a t e s o f i n d i v i d u a l Census D i v i s i o n s . - A l l f i g u r e s a r e g i v e n t o t h e n e a r e s t 100 p e r s o n s . - S u b - r e g i o n s a r e used t o a c c o u n t f o r p o p u l a t i o n s c a t t e r e d a r o u n d a majo r p o p u l a t i o n c e n t r e . The p r e c i s e l o c a t i o n s o f such p o p u l a t i o n a r e u n i d e n t i f i a b l e . - L o c a t i o n s o f I n d i a n R e s e r v e s a r e g i v e n i n terms o f t h e i r a p p r o x i m a t i o n t o t h e n e a r e s t m a j o r p o p u l a t i o n c e n t r e s . APPENDIX C . l POPULATION BY TRAVEL DISTANCE TO THE NEAREST GENERAL PRACTITIONERS OR FAMILY PHYSICIANS BY CATCHMENT. AREA LOCATION OF G . P . / F . P . - NO-. OF - G . P . / F . P . POPULATION BY TRAVEL DISTANCE POP PER PHYSICIAN < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL KOOTENAYS Cranbrook 18 16,200 900 17,100 950 F e r n i e 8 5,500 500 500 6,500 813 Invermere 5 3,800 1,700 1,200 6,700 1,340 K imber ley 8 7,600 100 100 1,400 9,200 1,150 Sparwood 2 6,000 800 6,800 3,400 C a s t l e g a r 7 13,000 13,000 1,857 Creston 9 8,000 400 1,400 9,800 1,089 K a s l o 2 1,100 100 100 800 2,100 1,050 Nakusp 3 2,000 100 300 200 700 3,300 1,100 Nelson 16 14,200 600 14,800 925 New Denver 3 1,300 400 1,700 567 R i o n d e l . 1 1,000 200 1,200 1,200 Salmo 3 2,000 2,000 667 S locan 1 1,100 1,100 1,100 F r u i t v a l e 2 2,700 2,700 1,350 Grand Forks 5 4,800 900 5,700 1,140 Greenwood 1 1,700 1,000 2,700 2,700 Rock Creek 1 500 200 700 700 Rossland 6 5,100 5,100 850 T r a i l 18 14,800 14,800 822 STUDY- REGION 119 112,400 5,200 1,000 200 8,200 127,100 1,068 OKANAGAN Keremeos 1 2,200 500 2,700 2,700 O l i v e r 4 5,300 5,300 1,325 Osoyoos 5 4,500 4,500 900 P e n t i c t o n 25 26,600 26,600 1,064 P r i n c e t o n 4 4,100 4,100 1,025 Summerland 5 8,200 8,200 1,640 APPENDIX C . l (CONT.) LOCATION OF G . P . / F . P . NO. OF G . P . / F . P . POPULATION BY TRAVEL DISTANCE POP PER PHYSICIAN < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL Armstrong 4 5,900 500 6,400 1,600 Enderby 3 3,100 1,200 4,300 1,433 Lumby 2 1,500 1,500 750 Vernon 25 31,000 4,000 35,000 1,400 Kelowna 46 60,900 60,900 1,324 Oyama .1 600 600 600 Rut land 6 4,200 4,200 700 Westbank 4 5,500 5,500 1,375 STUDY REGION 135 163,600 500 5,200 169,600 1,256 CENTRAL INTERIOR B l i n d Bay 2 1,300 1,300 650 Golden 5 4,900 600 500 6,000 1,200 Mica Creek 1 900 900 900 Reve ls toke 5 7,600 2,000 9,600 1,920 Salmon Arm 18 14,700 14,700 817 Sicamous 2 1,800 100 1,900 950 A s h c r o f t 6 5,700 5,700 950 Chase 1 2,600 300 2,900 2,900 C learwater 3 1,100 800 1,000 900 3,800 933 C l i n t o n 1 1,100 400 900 2,400 2,400 Kamloops 55 60,400 1,500 800 1,500 64,200 1,167 Logan Lake 2 1,400 1,400 700 L y t t o n 3 2,300 1,900 4,200 1,400 M e r r i t t 7 9,000 200 100 9,300 1,329 Kleena Kleene 1 100 100 800 1,000 1,000 1 0 0 - M i l e House 6 4,700 800 600 1,400 7,500 1,250 Quesnel 12 15,000 500 800 900 3,600 20,800 1,733 W i l l i a m s Lake 8 17,000 1,100 400 2,800 1,000 22,300 2,788 L i l l o o e t 4 3,200 300 600 4,100 1,025 Fo r t S t . James 5 3,700 500 2,000 6,200 1,240 F raser Lake 2 3,200 600 3,800 1,900 Vanderhoof 4 2,800 300 2,000 5,100 1,275 Mackenzie 3 5,400 100 5,500 1,833 McBride 3 1,200 200 100 1,500 3,000 •.'11,000 APPENDIX C . l (CONT.) LOCATION OF G . P . / F . P . P r i n c e George STUDY REGION SOUTH-WEST Pemberton Squamish C h i l l i w a c k Hope C. F r a s e r V a l l e y Dewdney-Alouette Gibsons Seche l t STUDY REGION METROPOLITAN Greater Vancouver Sooke Pender I s . S a l t s p r i n g I s . V i c t o r i a STUDY REGION NO. OF G . P . / F . P . 52 211 1 8 38 7 59 40 4 7 164 1,086 4 2 8 231 1,331 POPULATION BY TRAVEL DISTANCE < 25 Km. 25-49 Km. 50-74 Km. SOUTH VANCOUVER ISLAND Duncan 23 Ladysmith 6 Lake Cowichan 4 Nanaimo 48 P o r t A l b e r n i 19 To f ino 1 U c l u e t e t 1 "STUDY REGION 102 MID COAST P o w e l l R i v e r 18 Taxada I s . 2 68,600 239,700 1,100 9,300 44,300 5,200 87,900 52,400 4,800 3,500 208,500 1,085,200 4,300 500 3,600 220,500 1,314,100 33,700 4,700 5,400 61,800 26,600 800 1,500 134,500 15,700 1,500 ^ 75 Km. SCATTERED 1,200 8,800 500 400 100 1,100 3,500 200 300 500 2,600 700 100 300 3,600 200 700 5,700 600 TOTAL 71,100 300 300 400 500 900 POP PER PHYSICIAN 1,367 7,900 15,800 277,900 1,317 1,600 1,600 800 10,100 1,263 44,300 1,166 5,600 800 87,900 1,490 52,400 1,310 1,200 6,100 1,525 1,300 6,200 886 3,300 216,100 1,318 1,085,200 999 4,900 1,225 200 1,500 750 3,600 450 220,500 955 . 200 1,315,800 989 36,300 1,578 4,700 783 6,100 1,525 61,900 1,290 300 1,500 28,700 1,511 .. 700 1,500 1,500 400 1,900 1,900 300 2,600 141,200 1,384 2,100 18,000 1,000 1,500 750 APPENDIX C . l (CONT.) LOCATION OF G . P . / F . P . NO. OF G . P . / F . P . POPULATION BY TRAVEL DISTANCE POP PER PHYSICIAN < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL A l e r t Bay 2 1,500 600 2,100 1,050 P o r t A l i c e 1 1,500 1,500 1,500 P o r t Hardy 3 4,400 500 4,900 1,633 Por t M c N e i l 3 1,600 700 700 300 3,300_ 1,100 B e l l a C o l l a 2 1,300 100 1,400 700 Ocean F a l l s 1 1,400 1,200 2,600 2,600 Masset 4 2,300 400 200 100 3,000 750 Queen C h a r l o t t e 2 1,100 500 :1,600 800 Campbell R i v e r 19 18,700 700 800 2,100 22,300 1,174 Courtenay-Comox 24 25,800 25,800 1,075 Cumberland 4 3,700 3,700 925 Gold R i v e r 2 2,100 2,100 1,050 Hornby I s . 1 300 300 300 Tahs is 1 2 ,100 700 2,800 2,800 STUDY REGION 90 85,600 : 1 , 4 0 0 1,500 1,600 7,500 98,100 1,090 NORTH-WEST P r i n c e Rupert 21 . 16,300 900 800 18,000 857 Haze l ton 4 2,000 ,300 300 900 3,500 875 K i t i m a t 14 13,400 1,900 15,300 1,093 Stewart 1 1,400 1,000 2,400 2,400 Terrace 15 15,200 200 2,100 17,500 1,167 Burns Lake 6 3,200 800 300 300 1,000 5,600 933 Houston 2 3,100 100 100 1,200 100 4,600 2,300 Smithers 9 6,300 1,000 7,300 811 C a s s i a r 1 1,100 100 300 1,500 1,500 STUDY REGION 73 62,000 1,400 700 3,400 8,200 75,900 1,040 PEACE RIVER Chetwynd 3 1,800 1,800 600 Dawson Creek 11 16,700 300 100 1,300 18,400 1,673 Hudson Hpoe 1 1,300 1,300 1,300 Por t Nelson 3 3,600 1,300 4,900 1,633 Fo r t S t . John 9 13,700 200 4,500 18,400 2,044 STUDY REGION 27 37,100 300 100 200 7,100 44,800 1,659 B.C. 2,252 2 ,357 ,400 25,200 10,200 13,800 57,900 2 ,466,500 1,095 APPENDIC C.2 POPULATION BY TRAVEL DISTANCE TO THE NEAREST PHARMACISTS BY CATCHMENT AREA LOCATION OF NO. OF POPULATION BY TRAVEL DISTANCE POP PER PHARMACISTS < PHA' < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL • PHA KOOTENAYS Cranbrook 8 16,200 900 1,700 2,138 F e r n i e 7 5,500 500 500 6,500 929 Invermere 3 3,800 1,700 1,200 6,700 2,233 K imber ley 5 7,600 100 100 1,400 9,200 1,840 Sparwood 4 6,000 800 6,800 1,700 C a s t l e g a r 8 13,300 800 400 1,300 15,800 1,975 Creston 6 8,000 400 200 1,000 1,400 11,000 1,833 K a s l o 1 1,100 100 100 800 2,100 2,100 Nakusp 1 2,000 100 300 200 700 3,300 3,300 Nelson 6 14,200 600 100 14,900 2,483 Salmo 1 1,900 1,900 1,900 F r u i t v a l e 1 2,700 2,700 2,700 Grand Forks 4 4,800 900 5,700 1,425 Greenwood 1 1,700 1,000 2,700 2,700 Rossland 3 5,100 5,100 1,700 T r a i l 9 14,800 14,800 1,644 STUDY REGION 68 108,700 5,700 1,800 2,500 8,200 127,100 1,869 OKANAGAN Keremeos 2 2,200 500 2,700 1,350 O l i v e r 2 . 5,300 5,300 2,650 Osoyoos 2 4,500 500 5,000 2,500 P e n t i c t o n 20 26,600 26,600 1,330 P r i n c e t o n 4 4,100 4,100 1,025 Summerland 2 8,200 8,200 4,100 Armstrong 3 5,900 500 6,400 2,133 Enderby 2 3,100 1,200 4,300 2,150 Lumby 1 1,500 1,500 1,500 Vernon 20 31,000 4,000 35,000 1,750 Kelowna 29 60,900 600 200 61,700 2,128 APPENDIX C.2 (CONT.) LOCATION OF PHARMACISTS NO. OF PHA POPULATION BY TRAVEL DISTANCE POP- PER ••. PHA ; < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL Rut land 7 4,200 4,200 600 Westbank 5 5 ,500 5,500 1,100 STUDY REGION 99 163,000 1,100 5,200 169,600 1,713 CENTRAL INTERIOR Golden 2 4,900 600 500 6,000 3,000 Reve ls toke 3 7,600 if, ooo 2,000 10,600 3,533 Salmon Arm 8 14,700 14,700 1,838 Sicamous 1 1,800 100 1,900 1,900 A s h c r o f t 1 5 ,700 5,700 5,700 Chase 2 3,700 500 4,200 2,100 C learwater 1 1,100 800 1,000 900 3,800 3,800 C l i n t o n 1 1,100 400 900 2,400 2,400 Kamloops 46" 60,400 1,500 800 1,500 64,200 1,396 M e r r i t t 5 9,000 1,600 600 2,300 13,500 2,700 1 0 0 - M i l e House 6 4,700 800 600 1,400 7,500 1,250 Quesnel 7 15,000 500 800 900 3,600 20,800 2,971 W i l l i a m s Lake 8 17,000 1,100 400 2,800 2,000 23,300 2,913 L i l l o o e t 1 3 ,200 300 600 4,100 4,100 For t S t . James 1 3 ,700 500 2,000 6,200 6,200 F raser Lake 1 3 ,200 600 3,800 3,800 Vanderhoof 1 2,800 300 2,000 5,100 5,100 Dunster 1 200 1,300 100 1,600 1,600 Mackenzie 1 5 ,400 100 5,500 5,500 McBride 1 1,200 100 100 1,400 1,400 P r i n c e George 30- 68,600 1,200 700 600 71,100 2,370 STUDY REGION 128 235,000 11,100 6,100 9,700 16,000 277,900 2,171 SOUTH-WEST Pemberton 2 1,100 500 1,600 800 Squamish 4 9,300 800 10,100 2,525 C h i l l i w a c k 27 44,300 44,300 1,641 Hope 5 5,200 400 800 600 7,000 1,400 C. F r a s e r V a l l e y 46 87,900 87,900 1,911 Dewdney-Aloue 11 e 25 52,400 52,400 2,096 Gibsons 5 4 ,800 100 1,200 6,100 1,220 APPENDIX C.2 (CONT.) LOCATION OF PHARMACISTS NO. OF PHA ~ POPULATION BY TRAVEL DISTANCE POP • PER r -PHA . < 25 Km. 25-49 Km. 50-74 Km. t 75 Km. SCATTERED TOTAL Mader ia Park 2 1,100 300 1,400 700 Seche l t 5 3 ,500 1,300 4,800 960 STUDY REGION 121 209,600 1,300 800 600 3,300 216,100 1,786 METROPOLITAN Greater Vancouver 889 1 ,085,200 1,085,200 1,221 S a l t s p r i n g I s . 4 3 ,600 3,600 900 Sooke 2 4,300 200 400 4,900 2,450 V i c t o r i a 179 220,500 500 300 700 222,000 1,240 STUDY REGION 1,074 1,313,600 700 700 700 1,315,800 1,225 SOUTH VANCOUVER ISLAND Duncan 16 33,700 2,600 36,300 2,269 Ladysmith 2 4,700 4,700 2,350 Lake Cowichan 1 5 ,400 700 6,100 6,100 Nanaimo 41 61,800 100 61,900 1,510 Por t A l b e r n i 19 26,600 300 300 1,500 28,700 1,511 U c l u e l e t 2 1,500 800 1,100 3,400 1,700 STUDY REGION 81 133,700 4,400 300 2,600 141,200 1,743 MID COAST P o w e l l R i v e r 10 15,700 1,700 2,100 19,500 1,950 A l e r t Bay 1 1,500 600 2,100 2,100 Por t Hardy 2 4,400 •-.. 2-,'000 2,100 1,000 4,800 14,300 7,150 Masset 2 2,300 400 200 1,700 4,600 2,300 Campbell R i v e r 10 18,700 700 800 2,100 22,300 2,230 Courtenay-COmox 15 25,800 100 200 26,100 1,740 Cumberland 1 3 ,700 3,700 3,700 Gold R i v e r 1 2 ,100 2,100 2,100 Tahs is 1 2 ,100 700 2,800 2,800 STUDY REGION 43 76,300 4,300 3,200 3,500 10,300 98,100 2,281 NORTH-WEST P r i n c e Rupert 10 16,300 900 800 18,000 1,800 K i t i m a t 5 13,400 1,900 15,300 -3,060 Stewart 1 1,400 . : . ' 2,500 3,900 3,900 APPENDIX C.2 (CONT.) LOCATION OF NO. OF POPULATION BY TRAVEL DISTANCE POP. PER PHARMACISTS PHA . < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL PHA Ter race 8 15,200 200 400 2,100 17,900 2,238 Houston 1 3 ,100 100 100 1,200 100 4,600 4,600 Smithers 5 6,300 300 1,300 700 1,800 10,400 2,080 STUDY REGION 31 58,900 1,400 1,700 3,500 10,200 75,900 2,448 PEACE RIVER Chetwynd 1 1,800 1,800 1,800 Dawson Creek 4 16,700 300 100 1,300 18,400 4,600 F o r t Nelson 2 3,600 1,300 4,900 2,450 F o r t S t . John 6 13,700 1,500 4,500 19,700 3,283 STUDY REGION 13 35,800 300 100 1,500 7,100 44,800 3,446 B .C . 1,658 2 ,334,600 30,300 14,400 22,300 , 62,900 2,466,500 1,487 o APPENDIX C.3 POPULATION BY TRAVEL DISTANCE TO THE NEAREST DENTISTS BY CATCHMENT AREA LOCATION OF DENTISTS NO. OF DENTISTS POPULATION BY TRAVEL DISTANCE POP PER . DENTIST < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL KOOTENAYS 2,443 Cranbrook 7 16,200 900 17,100 F e r n i e 1 5,500 500 500 6,500 6,500 Invermere 1 3 ,800 1,700 1,200 6,700 6,700 K imber ley 4 7,600 100 100 1,400 9,200 2,300 Sparwood 1 6,000 800 6,800 6,800 C a s t l e g a r 2 13,300 800 400 1,300 15,800 7,900 Creston 5 8,000 400 200 1,000 1,400 11,000 2,200 Nelson 9 14,200 2,500 1,100 200 800 19,700 2,189 Grand Forks 3 4 ,800 1,700 1,900. 8,400 2,800 Ross land 1 5,100 5,100 5,100 T r a i l 7 17,500 100 17,600 2,514 STUDY REGION 41 102,000 9,200 2,600 4,900 8,200 127,100 3,100 OKANAGAN O l i v e r 4 5,300 5,300 1,325 Osoyoos 2 4,500 1,300 300 6,100 3,050 P e n t i c t o n 11 26,600 1,100 27,700 2,518 P r i n c e t o n 1 4,100 500 5,600 5,600 Summerland 3 8,200 8,200 2,733 Armstrong 2 9,000 500 1,200 10,700 5,350 Vernon 19 31,000 1,500 .• 500 4,000 37,000 1,947 Kelowna 21 60,900 600 200 61,700 2,938 Rut land 4 4,200 4,200 1,050 Westbank 2 5,500 5,500 2,750 STUDY REGION 69 159,300 4,500 300 5,200 169,600 2,458 CENTRAL INTERIOR Golden 2 4,900 600 600 6,100 3,050 Reve ls toke 2 7,600 3,000 2,700 13,300 6,650 Salmon Arm 8 14,700 14,700 1,838 Sicamous 1 1,800 100 1,900 1,900 APPENDIX C.3 (CONT.) LOCATION OF DENTISTS NO. OF DENTISTS POPULATION BY TRAVEL DISTANCE POP PER DENTIST < 25 Km. 25-49 Km. 50-74 Km. > 75 Km. SCATTERED TOTAL U c l u e l e t 1 1,500 800 1,100 3,400 3,400 STUDY REGION 58 133,700 4,400 300 2,600 141,200 2,434 MID COAST 2,167 P o w e l l R i v e r 9 15,700 1,700 2,100 19,500 P o r t Hardy 2 . 5 , 0 0 0 1,100 6,100 3,050 P o r t M c N e i l 1 . 1 , 6 0 0 2,200 2,200 300 6,300 6,300 B e l l a Coola 1 1,300 100 200 800 2,400 2,400 Ocean F a l l s 1 1,400 1,200 2,600 2,600 Masset 2 2,300 400 200 100 3,000 1,500 Queen C h a r l o t t e 1 1,100 500 1,600 1,600 Campbell R i v e r 7 18,700 700 2,900 4,900 27,200 3,886 Courtenay^Comox 12 29,400 200 200 29,800 2,483 STUDY REGION 36 76,500 4,600 1,700 5,200 9,600 98,100 2,725 NORTH-WEST P r i n c e Rupert 3 16,300 900 800 18,000 6,000 Haze l ton 1 2,000 300 300 900 3,500 3,500 K i t i m a t 4 13,400 1,900 15,300 3,825 Ter race 4 15,200 200 6,000 21,400 5,350 Burns Lake 1 3 ,200 800 300 300 1,000 5,600 5,600 Houston 1 3 ,100 100 100 1,200 100 4,600 4,600 Smithers 3 6,300 1,000 7,300 2,433 STUDY REGION 17 59,500 1,400 700 3,300 10,800 75,900 4,465 PEACE RIVER 2,525 Dawson Creek 8 .16,700 300 100 1,800 1,300 20,200 Fo r t Nelson 2 3 ,600 1,300 4,900 2,450 F o r t S t . John 3 13,700 1,500 4,500 19,700 6,567 STUDY REGION 13 34,000 300 100 3,300 7,100 44,800 3,446 B .C . 1,208 2 ,298 ,600 39,000 17,700 46,600 62,600 2 ,446,500 2,042 APPENDIX C.3 (CONT.) LOCATION OF NO. OF DENTISTS DENTISTS Chase 1 C learwater 1 Kamloops 27 M e r r i t t 3 Quesnel 8 W i l l i a m s Lake 7 F r a s e r Lake 1 Vanderhoof 2 M a c k e n z i e . 1 McBride 1 P r i n c e George 34 STUDY REGION 99 SOUTH-WEST Squamish 4 C h i l l i w a c k 19 Hope 1 C. F raser V a l l e y 28 Dewdney-Aloutte 17 Gibsons 2 Seche l t 2 STUDY REGION 73 METROPOLITAN Greater Vancouver 678 S a l t s p r i n g I s . 1 Pender I s . 1 V i c t o r i a 122 STUDY REGION 802 SOUTH VANCOUVER ISLAND Duncan 14 Ladysmith 1 Lake Cowichan 1 Nanaimo 30 P o r t A l b e r n i 11 POPULATION BY TRAVEL DISTANCE POP PER DENTIST < 25 Km. 25-49 Km. 50-74 Km. , > 75 Km. SCATTERED TOTAL 3,700 500 4,200 4,200 ' 1,100 800 1,000 900 3,800 3,800 60,400 1,500 800 6,900 2,400 , 72,000 2,667 9,000 1,600 600 ' 6,400 17,600 5,867 • 15,000 500 800 900 3,600 20,800 2,600 17,000 1,100 1,400 8,200 2,400 30,100 4,300 3,200 600 3,800 3,800 2,800 300 3,700 500 4,000 11,300 5,650 5,400 100 5,500 5,500 1,200 200 100 1,500 3,000 3,000 3,000 68,600 1,200 700 600 71 ,100 : 2,091 216,400 8,400 10,200 27,100 15,800 277,900 2,807 9,300 500 1,100 800 11,700 2,925 44,300 44,300 2,332 5,200 400 800 600 7,000 7,000 87,900 87,900 3,139 52,400 52,400 3,082 4,800 100 1,200 6,100 3,050 3,500 1,100 300 1,300 6,200 3,100 207,400 1,600 1,600 1,700 3,300 216,100 2,960 .1 ,085,200 3,600 500 220,500 1,309,800 300 4,300 4,400 500 500 200 600 800 1,085,200 3,600 1,500 225,400 1,315,800 1,601 3,600 1,500 1,848 1,640 33,700 2,600 4 ,700 5 ,400 700 61,800 100 26,600 300 300 1,500 36,300 2,593 4,700 4,700 6,100 6,100 61,900 2,063 28,700 2,609 154 APPENDIX C.4 POPULATION BY TRAVEL DISTANCE TO THE NEAREST GENERAL SURGEONS BY CATCHMENT AREA LOCATION OF NO. OF POPULATION BY TRAVEL DISTANCE POP PER GENERAL SURGEONS G. s v < 75 Km. > 75 Km. TOTAL ( G r . ' S . KOOTENAYS Cranbrook 3 17,100 17,100 5,700 F e r n i e 1 13,300 13,300 13,300 Invermere 2 6,800 5,6u0 12,400 6,200 Kimber ley 1 9,200 9,200 9,200 Creston 1 8,600 2,400 11,000 11,000 Nakusp 1 2,200 2,10.0 4,300 4,300 Nelson 2 18,800 1,500 20,400 10,200 F r u i t v a l e 1 2,800 2,800 2,800 T r a i l 3 32,900 32,900 10,967 C h r i s t i n a Lake 1 7,400 7,400 7,400 STUDY REGION 16 119,900 7,200 127,100 7,944 OKANAGAN O l i v e r 1 11,400 "1 ,000 12,400 12,400 P e n t i c t o n 4 36,400 4,100 40,500 10,125 Vernon 7 42,000 5,200 47,200 6,743 Kelowna 6 71,400 71,400 11,900 STUDY REGION 18 160,300 9,300 169,600 9,422 CENTRAL INTERIOR Reve ls toke 1 7,600 3,200 10,800 10,800 Salmon Arm 1 20,800 20,800 20,800 Kamloops 9 65,100 28,200 93,800 10,367 Quesnel 3 16,300 4,500 20,800 6,933 W i l l i a m s Lake 2 19,500 11,600 31,100 15,550 P r i n c e George 6 70,500 9,100 79,600 13,258 Vanderhoof 1 10,000 15,300 25,300 25,300 STUDY REGION 23 210,400 67,500 277,900 12,083 SOUTH-WEST • C h i l l i w a c k 2 49,800 1,500 51,300 25,650 C. F r a s e r V a l l e y 5 87,900 87,900 17,580 Dewdey-Alouette 2 52,400 52,400 26,200 Seche l t 1 9,800 2,500 12,300 12,300 STUDY REGION 10 209,700 6,400 216,100 9,065 METROPOLITAN Greater Vancouver 126 1,094,500 2,400 1,096,900 8,706 V i c t o r i a 33 229,900 600 230,500 6,985 STUDY REGION 159 1,315,200 600 1,315,800 9,065 SOUTH VANCOUVER ISLAND Duncan 2 47,100 47,100 23,550 Nanaimo 6 61,900 61,900 10,317 Por t A l b e r n i 3 28,400 3,700 32,100 10,700 STUDY REGION 11 137,500 3,700 141,200 12,836 APPENDIX C.4 (CONT.) 15 LOCATION OF GNERAL SURGEONS MID COAST Cour t enay-Gomox Campbell R i v e r P o w e l l R i v e r STUDY REGION NORTH-WEST P r i n c e Rupert K i t i m a t Terrace STUDY REGION PEACE RIVER Dawson Creek Fo r t S t . John STUDY REGION B.C . NO. OF POPULATION BY TRAVEL DISTANCE POP PER . G.S. < 75 Km. > 75 Km. TOTAL ' C.S. 1 2 3 6 29,800< 19,400 17,400 67,200 24,200 2,100 30,900 29,800 43,600 19,500 98,100 29,800 21,800 6,500 16,350 16,300 13,400 15,400 45,300 6,300 1,900 16,800 30,600 22,600 15,300 32,200 75,900 7,533 15,300 16,100 12,650 17,100 13,700 30,800 3,100 10,900 14,000 20,200 24,600 44,800 10,100 24,600 14,933 252 2 ,296,300 170,200 2 ,446,500 9,788 156 APPENDIX C.5 POPULATION BY TRAVEL DISTANCE TO THE NEAREST PSYCHIATRISTS BY CATCHMENT AREA LOCATION OF NO. OF POPULATION BY TRAVEL DISTANCE POP PER PSYCHIATRISTS PSY ' ' < 75 Km. > 75 Km. TOTAL ' PSY KOOTENAYS Nelson T r a i l STUDY REGION 2 1 3 18,800 41,400 60,600 62,800 1,700 66,500 81,600 43,100 127,100 40,800 43,100 42,367 OKANAGAN P e n t i c t o n Kelowna Vernon STUDY REGION 3 3 1 7 47,300 71,400 63,500 160,300 5,600 17,400 9,300 52,900 71,400 80,900 169,600 14,300 23,800 80,900 24,229 CENTRAL INTERIOR Kamloops Quesnel P r i n c e George STUDY REGION 2 1 1 4 65,100 16,300 70,500 151,900 40,200 27,800 149,300 126,000 105,300 44,100 219,800 227,900 52,650 44,100 219,800 99,650 SOUTH-WEST C. F r a s e r V a l l e y Dewdney-Alouette STUDY REGION 6 1 7 132,200 52,400 194,400 7,000 21,700 139,200 52,400 216,100 23,200 52,400 8,655 METROPOLITAN Greater Vancouver V i c t o r i a STUDY REGION 146 24 170 1,094,500 229,900 1,315,200 12,000 600 600 1,106,500 230,500 1,315,800 7,579 9,604 8,655 SOUTH VANCOUVER.- ISLAND Duncan 3 Nanaimo 3 P o r t A l b e r n i 1 STUDY REGION 7 47,100 61,900 28,400 137,500 3,700 3,700 47,100 61,900 32,100 141,200 15,700 20,633 32,100 20,171 MID COAST Courtenay-Comox P o w e l l R i v e r STUDY REGION 2 1 3 48,500 17,400 66,500 24,900 4,800 31,600 73,400 22,200 98,100 36,700 22,200 32,700 NORTH-WEST STUDY REGION 0 0 75,900 75,900 99,650 PEACE RIVER STUDY REGION 0 0 44,800 44,800 99,650 B .C . 201 2 ,086,400 380,100 2 ,446,500 12,271 APPENDIX C.6 POPULATION BY TRAVEL DISTANCE TO THE NEAREST PEDIATRICIANS. BY CATCHMENT AREA LOCATION OF PEDIATRICIANS NO. OF PED POPULATION BY TRAVEL DISTANCE <.75 Km. > 7 5 Km. TOTAL POP" PER PED. KOOTENAYS Cranbrook Nelson T r a i l STUDY REGION 1 1 2 4 27,200 18,800 41,400 87,800 19,100 16,500 1,700 39,300 46,300 35,300 43,100 127,100 46,300 35,300 21,550 31,775 OKANAGAN P e n t i c t o n Kelowna Vernon STUDY REGION 47,300 71,400 63,500 160,300 5,600 17,400 9,300 52,900 71,400 80,900 169,600 26,450 35,700 80,900 33,920 CENTRAL INTERIOR Kamloops W i l l i a m s Lake P r i n c e George STUDY REGION 65,100 19,600 70,500 155,200 32,400 32,300 79,200 122,700 97,500 51,900 149,700 277,900 19,500 51,900 149,700 46,100 SOUTH-WEST C h i l l i w a c k STUDY REGION 49,800 199,900 1,500 16,200 51,300 216,100 51,300 15,019 METROPOLITAN Greater Vancouver 89 V i c t o r i a 12 STUDY REGION 101 1,234,800 263,000 1,314,200 12,000 7,700 1,600 1,246,800 270,700 1,315,800 14,009 22,558 15,019 SOUTH VANCOUVER ISLAND Nanaimo 2 STUDY REGION 2 68,800 103,000 32,100 38,200 100,900 141,200 50,450 70,600 MID COAST Courtenay-Comox P o w e l l R i v e r STUDY REGION 1 1 2 48,500 17,400 66,500 24,900 4,800 31,600 73,400 22,200 98,100 73,400 22,200 49,050 NORTH-WEST Ter race STUDY REGION 28,800 29,000 41,300 46,900 70,100 75,900 70,100 75,900 PEACE RIVER STUDY REGION B.C. 0 123 2 ,115,900 44,800 44,800 350,600 2 ,446,500 46,100 20,053 158 APPENDIX C.7 POPULATION BY TRAVEL DISTANCE TO THE NEAREST OBSTETRICIANS OR GYNAECOLOGISTS BY CATCHMENT AREA LOCATION OF OBSTET/GYNAECO NO. OF OBS /GYN •' POPULATION < 75 Km. BY TRAVEL > 75 Km. DISTANCE TOTAL POP PER OBS 7GYN KOOTENAYS T r a i l 2 43,000 8.1,700 124,700 62,350 STUDY REGION 2 43,400 83,700 127,100 63,550 OKANAGAN P e n t i c t o n 2 47,300 5,600 52,900 26,450 Kelowna 3 71,400 71,400 23,800 Vernon 1 63,500 17,400 80,900 80,900 STUDY REGION 6 160,300 9,300 169,600 28,267 CENTRAL INTERIOR Kamloops 5 65,100 32,400 97,500 19,500 W i l l i a m s Lake 1 19,600 32,300 51,900 51,900 P r i n c e George 3 70,500 34,400 104,900 34,967 STUDY REGION 9 155,200 122,700 277,900 30,878 SOUTH-WEST C h i l l i w a c k 1 49,800 1,500 .51 ,300 51,300 STUDY REGION 1 199,900 16,200 216,100 15,957 METROPOLITAN Greater Vancouver 77 1 ,234,800 12,000 11 ,246,800 16,192 V i c t o r i a 18 228,900 2,000 230,900 12,828 STUDY REGION 95 1,314,200 1,600 1 ,315,800 15,957 SOUTH VANCOUVER ISLAND Nanaimo 5 61,900 32,100 94,000 18,800 Ladysmith 1 44,500 2,200 46,700 46,700 STUDY REGION 6 106,500 34,700 141,200 23,533 MID COAST Whaletown 1 1,200 1,200 1,200 C o ur t en ay-Comox 1 48,000 24,200 72,200 72,200 P o w e l l R i v e r 1 17,400 4,800 22,200 22,200 STUDY REGION 3 67,200 30,900 98,100 32,700 NORTH-WEST Terrace 1 28,800 41,300 70,100 70,100 STUDY REGION i - 29,000 46,900 75,900 ' 75,900 PEACE RIVER Dawson Creek l 17,100 3,100 20,200 20,200 F o r t S t . John l 13,700 10,900 24,600 24,600 STUDY REGION 2 30,800 14,000 44,800 22,400 B.C. 125 2 ,106,500 360,000 2 ,446,500 19,732 APPENDIX D TEST OF SAMPLE VARIANCE BETWEEN TWO TEST SAMPLES FOR  URGENT WAITING TIME ANALYSIS (WAITING TIME IN DAYS) SAMPLE 1 .5 .5 .5 3 .0 .5 0 1.5 .5 . 5 2 .0 SAMPLE 2 .5 .5 . 5 1.0 0 .5 4 . 5 . 5 .5 .5 mean .95 .90 s 2 .8583 1.6556 F = s^/s j = 1.165 The c r i t i c a l v a l u e of F at .05 l e v e l of s i g n i f i c a n c e i s 3 . 4 4 . S ince the F v a l u e f a l l s i n the acceptance r e g i o n , i t can be concluded that the v a r i a b i l i t y of the t e s t samples i s not s i g n i f i c a n t l y d i f f e r e n t from each o t h e r . In Test Sample 1 , the i n t e r v i e w e r posed as a p a t i e n t to o b t a i n the i n f o r m a t i o n . In Test Sample 2 , the purpose of the survey and the i d e n t i t y of the i n t e r v i e w e r was r e v e a l e d to the respondent . APPENDIX E WAITING IT IME'F.OR AN;;JAPP6INTMENT^WITH' A' .GENERAL" PRACTITIONER-(a) COMMUNITY TYPE NO. OF G .P . ' s WAITING TIME (DAYS) " URGENT NON-URGENT KOOTENAYS Cranbrook 2 17 .5 .5 Nelson 2 15 .5 .5 C a s t l e g a r 2 6 .5 . 5 T r a i l 2 18 .5 .5 F e r n i e 3 8 .5 .5 Sparwood 3 2 0 ' 0 R i o n d e l 3 1 0 0 Ross land 3 6 .5 .5 Greenwood 3 1 .5 "• .5 OKANAGAN P e n t i c t o n 2 24 .5 .5 . Vernon 2 24 .5 .5 Kelowna ^ 2 45 .5 3 .5 W i n f i e l d 2 1 0 0 Rut land 2 5 0 2 .0 Osoyoos 3 5 .5 .5 Keremeos 3 1 1.5 1.5 Armstrong 3 4 0 0 Lumby 3 2 .5 .5 CENTRAL INTERIOR Salmon Arm 2 18 .5 .5 Kamloops 2 53 0 0 Quesnel 2 12 0 .5 P r i n c e George 2 52 0 2 .0 Golden 3 5 0 0 B l i n d Bay 3 1 (doctor r e t i r e d ) M e r r i t t ^ 3 7 0 1.5 Logan Lake 3 1 0 0 1 0 0 - M i l e House 3 6 0 .5 K leena Kleene* 3 1 (part t ime doctor not L i l l o o e t 3 4 1.0 1.5 Vanderhoof 3 4 2 .0 2 .0 F r a s e r Lake 3 2 . 5 .5 Mackenzie 3 3 0 0 McBride 3 3 .5 .5 SOUTH-WEST C h i l l i w a c k 2 38 0 5 . 0 C h i l l i w a c k 2 38 (no response) Abbots fo rd 2 59 0 .5 Langley 2 59 . 5 .5 Maple Ridge 2 40 1.0 1.0 M i s s i o n 2 40 0 2 .0 P i t t Meadows 2 40 (on h o l i d a y ) Seche l t 3 7 0 0 APPENDIX E (CONT.) COMMUNITY (a) TYPE NO. OF G.P. 's WAITING TIME (DAYS) URGENT NON-URGENT 161 Gibsons Squamish Pemberton Hope METROPOLITAN Burnaby Burnaby Coqui t lam D e l t a New Westmin is te r North Vancouver Por t Coqui t lam Por t Moody Richmond Surrey Vancouver Vancouver Vancouver Vancouver 0: •" . Vancouver Vancouver Vancouver Vancouver West Vancouver Whiterock V i c t o r i a V i c t o r i a V i c t o r i a V i c t o r i a V i c t o r i a Sooke S a l t s p r i n g I s . * (downtown) (downtown) (downtown) 4 8 1 7 1,331 0 0 0 0 .5 .5 .5 1.0 1.0 0 1.0 1.0 1.0 4 . 5 2 .0 2 .0 .5 .5 . 5 .5 .5 .5 1.0 .5 0 .5 .5 .5 0 2 .5 0 0 0 1.0 .5 .5 .5 1.0 (no response) 1.0 0 1.0 1.0 2 .0 4 . 5 2 .0 >.0 .5 .5 .5 : . 0 .5 .5 0 0 0 0 0 0 0 5 SOUTH VANCOUVER ISLAND Duncan 2 Nanaimo 2 P o r t A l b e r n i 2 Lake Cowichan 3 Tof ino 3 23 48 19 4 1 .5 .5 .0 .5 0 .5 .5 1.0 .5 0 MID COAST P o w e l l R i v e r 2 18 0 0 Campbell R i v e r 2 18 .5 .5 Comox 2 10 . 5 . 5 Taxada I s . 3 2 0 0 P o r t Hardy 3 3 . 5 1.0 A l e r t Bay* 3 2 0 .5 Por t A l i c e .3 1 (now no doctor ) B e l l a Coola 3 2 0 2 .0 Ocean F a l l s 3 1 1.5 2 . 0 Queen C h a r l o t t e I s . 3 6 1.5 2 .0 APPENDIX E (CONT.) COMMUNITY; (a) TYPE NO. OF G . P l s WAITING TIME (DAYS) URGENT NON-URGENT Masset Tahs is 4 1 0 1.0 0 1.0 NORTH-WEST P r i n c e Rupert Terrace Haze l ton Stewart Smithers 2 2 3 3 3 17 15 4 1 8 .5 0 2 .0 0 .5 1.0 0 2 .0 0 .5 PEACE RIVER Dawson Creek Chetwynd Hudson Hope 2 3 3 10 3 1 1.5 1.5 1.5 1.5 (permanent doctor l e f t , on ly temporary doctor ) Community Type: 1 = M e t r o p o l i t a n cent re w i t h a p o p u l a t i o n of 100,000 and over . 2 = Urban cent re w i t h a p o p u l a t i o n of 10,000 to 9 9 , 9 9 9 . 3 = R u r a l community w i t h a p o p u l a t i o n of l e s s than 10 ,000 , and not adjacent to ( i . e . 25 Km.) an u rban .cent re . . .- . G .P . i s p a r t - t i m e . 163 APPENDIX F * *'* YEAR OF GRADUATION AND PLACE OF GRADUATION^ (GENERAL PRACTITIONER AND FAMILY PHYSICIAN) (a) 1975 - 1976 1977 - 1978 COMMUNITY TYPE YEAR PLACE YEAR PLACE (19 _) (19__) KOOTENAYS Sparwood 3 55 3 59 2 S locan Park 3 72 2 72 2 Greenwood 3 59 1 59 1 T r a i l 2 54 2 48 2 Grand Forks 3 72 3 72 2 Creston 3 70 3 69 3 Salmo 3 58 3 60 3 Invermere 3 67 2 75 2 Cranbrook 2 67 2 76 2 Cranbrook 2 70 2 65 2 OKANAGAN Armstrong 3 53 4 57 2 Vernon 2 66 2 58 1 Osoyoos 3 38 4 51 2 Peachland 3 73 1 73 1 Westbank 3 57 1 68 2 Kelowna 2 59 2 70 1 Kelowna' 2 61 2 41 2 Kelowna 2 67 2 50 2 P e n t i c t o n 2 38 2 54 2 2 71 2 52 2 CENTRAL INTERIOR Salmon Arm Reve ls toke C learwater Chase Golden F r a s e r Lake W i l l i a m s Lake Vanderhoof Sicamous K leena Kleene Quesnel Quesnel Kamloops Kamloops P r i n c e George P r i n c e George P r i n c e George 2 54 3 64 3 72 3 54 3 72 3 69 2 57 3 57 3 43 3 60 2 50 2 69 2 52 2 64 2 64 2 72 2 39 3 60 2 2 64 2 2 7 1 2 3 54 3 3 7 1 3 3 70 3 3 69 3 2 70 2 3 43 3 3 60 3 2 71 3 3 72 3 2 72 2 3 48 3 1 55 1 2 39 2 3 56 3 APPENDIX F (CONT.) 164 COMMUNITY P r i n c e George P r i n c e George P r i n c e George SOUTH-WEST, ; Abbots ford Seche l t Gibsons Hope F t . Langley Pemberton P i t t Meadows M i s s i o n C h i l l i w a c k (a) TYPE 2 3 3 3 2 3 2 2 2 2 1975 - 1976 YEAR PLACE (19__) 64 3 66 1 68 1 1977 - 1978  YEAR PLACE (19 ) 65 68 71 73 69 63 66 62 72 58 2 3 1 2 2 2 3 1 1 1 64 69 39 66 73 71 67 54 63 73 52 75 66 2 2 2 2 3 2 2 2 1 3 METROPOLITAN Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Vancouver Burnaby Burnaby White Rock West Vancouver D e l t a Richmond Coqui t lam New Westminster Por t Coqui t lam Por t Moody North Vancouver 52 71 54 54 61 69 66 36 43 60 64 48 62 55 49 73 38 49 65 70 67 49 56 70 55 47 54 65 58 2 3 2 2 1 2 2 2 2 4 2 2 4 4 3 3 3 1 2 3 3 2 2 2 66 67 69 75 76 49 69 44 60 72 71 55 69 64 45 39 71 55 71 67 42 54 68 61 67 76 74 72 59 1 2 3 1 1 2 2 4 1 1 2 2 1 1 2 2 4 2 3 2 2 3 3 3 2 2 2 2 2 APPENDIX F (CONT.) COMMUNITY (a) TYPE 1975 - 1976  YEAR" PLACE (19 . ) 1977 - 1978  YEAR PLACE (19 ) Surrey V i c t o r i a V i c t o r i a V i c t o r i a V i c t o r i a V i c t o r i a V i c t o r i a V i c t o r i a Soode S a l t s p r i n g I s . Sidney SOUTH VANCOUVER ISLAND Duncan Tof ino Lake Cowichan Ladysmith Por t A l b e r n i P o r t A l b e r n i Nanaimo Nanaimo Nanaimo Nanaimo 57 70 60 64 71 40 58 56 43 71 66 49 69 57 73 65 54 71 54 38 70 3 3 3 1 1 4 3 1 2 2 4 2 3 3 2 2 1 1 1 3 2 67 68 75 73 67 57 31 44 51 60 59 57 66 74 59 44 55 41 58 63 72 2 1 2 1 4 3 2 3 3 1 MID COAST A l e r t Bay B e l l a Coola Ocean F a l l s U c l u e t e t Queen C h a r l o t t e Comox Por t McNe i l Hornby I s . P o w e l l R i v e r P o w e l l R i v e r 3 3 3 3 3 2 3 3 2 2 61 44 73 69 72 52 70 69 70 62 3 2 2 3 1 2 3 3 3 2 42 44 73 65 72 75 70 70 43 69 NORTH-WEST' - : Haze l ton Stewart Smithers P r i n c e Rupert Ter race Ter race Burns Lake Burns Lake K i t i m a t K i t i m a t 3 3 3 2 2 2 3 3 2 2 37 63 72 73 50 62 70 71 66 63 74 53 66 67 71 73 75 73 66 44 1 3 2 2 2 2 2 2 2 2 166 APPENDIX F (CONT.) (a) 1975 - 7 6 . 1977 - 78 COMMUNITY TYPE YEAR PLACE YEAR PLACE (19__) (19__) PEACE RIVER Hudson Hope F t . Nelson Chetwynd Dawson Creek Dawson Creek F t . S t . John F t . S t . John 3 3 3 2 2 2 2 68 58 66 71 57 72 67 3 3 3 1 2 3 3 68 68 66 72 58 76 58 3 3 3 3 2 2 3 To avo id i n c l u s i o n of s e m i - r e t i r e d p h y s i c i a n s , those graduated before 1934 ( fo r 1975-76) and those graduated before 1936 ( fo r 1977-78) are exc luded from the sample. P l a c e of G r a d u a t i o n : (1) B . C . , (2) Other p r o v i n c e s , (3) E u r o p e / U . S . A . , (4) Other c o u n t r i e s . l^ Community Type: 1 = M e t r o p o l i t a n cent re w i t h a p o p u l a t i o n of 100,000 and ove r . 2 = Urban cen t re w i t h a p o p u l a t i o n of 10,000 to 9 9 , 9 9 9 . 3 = R u r a l community w i t h a p o p u l a t i o n l e s s than 10,000 and not ad jacent to ( i . e . w i t h i n 25 Km.) an urban c e n t r e . APPENDIX G. .1. I. ACCESSIBILITY RANKING BY TRAVEL DISTANCE (INDEX A) BY STUDY REGION GENERAL PRACTITIONER '(a) (b) R SCORE V 45 0 48 S 49 M 56 K 65 I 77 C 109 N 184 P 270 •00 a-b/b .067 .021 , 143 .161 .185 .416 .688 .467 RANK ( ^ > . 0 1 ) ih V 44 ih 0 47 4*2 M 60 4% S 61 4% K •74 4% I 84 7 C 101 8 N 220 9 P 252 PHARMACIST (a) (b) (d) R SCORE a-b/b .068 .277 .017 .213 .135 .202 1.178 .145 RANK ( ^ > . 2 ) ih 0 44 ih V 44 3h M 51 3h S 65 5h K 85 5k I 108 7 C 128 8h P 236 8h N 245 DENTIST (a) .(b) (d). R SCORE a-b/b .227 .275 .308 .271 .185 .843 .038 RANK (^>.2) GENERAL SURGEON PSYCHIATRIST PEDIATRICIAN (a) (b) : R SCORE M .01 S 3 V 3 0 5 K 6 C 24 I 31 P 31 N 40 (d) i-b/b .999 .667 .200 3.000 .292 .290 RANK ( ^ > - 3 ) 6 7h 7h 9 (a) R SCORE M .01 V 3 0 J5. S 10 I 32. C 45 ' K -•52 P 1-00 N 100 (b) (d): a-b/b .999 .667 1.000 2.200 .406 .155 .923 RANK (^>.5) (a) (b) SCORE 1 M .01 2 0 5 3 S 7 4 V 27 6 K 31 6 I 32 6 C 44 81s N 62 81s P 100 (d) (. a-b/b v .999 .040 2.857 .148 .032 .038 .409 .613 RANK a-b 1 2 3 4 6 6 6 8 9 APPENDIX G . l (CONT.) OBSTETRICIAN/GYNAECOLOGIST OVERALL (a) •(b) R SCORE M .01 0 5 S 7 V 25 I 31 p 31 C 44 N 62 K 62 (d) i -b/b .999 .400 2.571 .240 .419 .409 .065 RANK (c) <a-b>.2) (a) R RANK SUM 1 M 15 2 0 16 3 V 17 4 s 24.5 5k K 40 5k I 41 .5 7 C 52 .5 8k P 5 5 . 5 8k N 59 (d) a-b/b .067 ,063 ,412 .667 .038 .265 .057 .063 RANK <^>.2) ^ R = Study Region K = Kootenays 0 = Okanagan C = C e n t r a l I n t e r i o r s = South-West M = M e t r o p o l i t a n V = South Vancouver I s l a n d I = Mid Coast N = North-West P = Peace R i v e r ( b )F rom Table 8 . 1 (°)Rank sum of a l l seven groups of personne l See foo tnote (c) of Appendix A. APPENDIX G. 1,,(C0NT. ) I I . RANK CORRELATION BETWEEN TRAVEL DISTANCE (INDEX A) AND RURALITY Spearman Rank C o r r e l a t i o n C o e f f i c i e n t = r £ 1 -6 l d 2 n ( n z - l ) R X y 3 M 9 3 S ih 4 V ih ih 0 6 ik K 4 5 I 4 6h C 4 eh P ih 8k N ih 8h where = x = Y l = y 2 = y 3 = Y4 = Y 5 = Y6 = Y7 = ?8 = x - y±; R u r a l i t y Rank T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , T r a v e l D i s t a n c e , ( i n Rank) G . P . Pha ; ... Den. _ C . S . Psy •'• Ped Obs/Gyn-O v e r a l l ^4 ^5 ye R • X y i A2 d l Y2 j 2 d 2 M 9 4*5 20.25 3h 42.25 S ih Qi 9.00 3h 16 V ih ik 36 ih 36 0 • 6 ik 20.25 ih 20.25 K 4 kk .25 5h .25 I 4 4*2 .25 5h .25 C 4 7 9 7 9 P ik 9 56.25 8h 49 N ih 8 42.25 8h 49 193.50 223.00 r s = - . 6 1 3 r s = - . 8 5 8 2 2 2 d 6 y7 d 7 ys d 8 36 1 64 r 64 1 64 1 64 2 49 6.25 21s 25 4 12.25 3 12.25 3 12.25 4 12.25 36 2*2 25 2 30.25 4 12.25 4 12.25 •2 30.25 20.25 41s 2.25 3 9; • 2 16 2 16. 2 16 1 kh .25 6 4 6 '4 8*5 12. 25 '5*5 .25 2.25 7h 6.25 6 4 6 4 • - 5h .25 5% 2.25 2.25 6 4 6 4 6 7 ,9, 8 16 49 7h 36 8h '49 . ; i 9 56.25 5 k 16 ~: 8 42.25 49 9 56.25 8h 49 . 8 42,25 8% 49 8 42.25 202.00 219.00 225.5.0 215.00 191.0.0 210.50 - . 6 8 3 r s = - . 8 2 5 .= - . 8 7 9 r s = -.7r92 r s = - , 5 9 2s r s = - . 7 5 4 LO ;_.\.: :;. r: • •. APPENDIX G .2,.• I . ACCESSIBILITY RANKING BY P OP ULATION/HEALTH PERSONNEL RATIO (INDEX B) BY STUDY REGION GENERAL PRACTITIONER (a) R SCORE M 989 N 1040 K 1068 I 1090 0 1256 C 1317 S 1318 V 1384 P 1659 a-b/b .052 .012 .012 .152 .049 .050 .417 RANK , a - b . W (rrr>.05) PHARMACIST (a) .(b) (e) R SCORE" a-b/b .046 .337 .018 .025 .047 .161 .128 .408 M 1225 I 1281 0 1713 V 1743 s 1786 K 1869 C 2170 N 2448 P 3446 RANK ( ^ > . D ik M 1641 ik V 2434 hk 0 2458 kk I 2725 kk c 2807 hk s 2960 7 K 3100 8 P 3346 9 N 4465 DENTIST (a) (b) (c). R SCORE" a-b/b .483 .010 .109 .030 .055 .047 .079 .334 RANK ( ^ > . D 6 6 6 6 6 9 GENERAL SURGEON (a) (b) R SCORE K 7944 M 9065 S 9065 0 9422 C 12083 N 12650 V 12836 P 14933 I 16350 -b/b .141 .039 .282 .047 .015 .163 .095 RANK , a - b ^ (e) 09) PSYCHIATRIST (a) .(b) R SCORE M 8655 S 8655 V 20171 0 24229 I 32700 K 42367 C 99650 P 99650 N 99650 i - b / b 1.331 .201 .350 .296 1.352 RANK a - b . ( ^ > . 5 ) ik M 15019 ik S 15019 hk K 31775 kk 0 33920 hk C 46100 hk P 46100 8 I 49050 8 V 70600 8 N 75900 PEDIATRICIAN (a) (b) (e), R SCORE a-b/b 1.116 .068 .359 .064 .439 .075 RANK (^>.3) 3^  31 6 6 6 o APPENDIX G . 2 , (CONT.) OBSTETRICIAN/GYNAECOLOGIST RANK OVERALL INDICES A, B COMBINED (a) R (b) SCORE M 15957 S 15957 P 22400 V 23533 0 28267 c 30878 I 32700 K 63550 N 75900 i -b/b .404 .051 .201 .092 .059 .943 .194 (e) ( ^ > . 2 ) J.-2 ik 3k 3k 6 6 6 8k 8k . ( c ) (a) RANK R SUM M 11 S 24 .5 0 29 K 31 I 36 V 37.5 C 45 .5 P 49 .5 N 51 (e) i -b/b * .227 .184 .069 .161 .042 .213 .088 .020 RANK 1) R =(d) RANK SUM 1 M 3 2 0 5 .5 3k S 6 3k V 7.5 5k K 9 5k I 11 8 C 16 8 N 16 8 P 16 a-b/b .888 .090 .250 .200 .222 .455 RANK <^>.3) 5 5 5 8 8 ( a?R= Study Region K = Kootenays 0 = Okanagan C = C e n t r a l I n t e r i o r S = South-West M = M e t r o p o l i t a n V = South Vancouver I s l a n d I = Mid Coast N = North-West P = Peace R i v e r ( t ) ' From Table 8 .2 ^ "Rank sum of a l l seven groups of personne l ^ Rank sum of Index A and Index B i n terms of the OVERALL rank (V • " V ~ . . : > ^ See f o o t n o t e (c) of Appenix A. ,_, APPENDIX G.2 (CONT.) II. ..RANK CORRELATION BETWEEN POPULATION-HEALTH PERSONNEL RATIO (INDEX B) AND RURALITY Spearman Rank Correlation Coefficient = r g = 1 -6 l d t x n(n^-l) where = x = y i = y 2 = y 3 = y4 = ys = y6 = y 7 = ys = y 9 = x - y.; Rurality Rank Ratio, G.P. Ratio, Pha Ratio, Den.'-. Ratio, G.S. Ratio, Psy Ratio, Ped, \ Ratio, Obs/Gyn Ratio, Overall Combined Indices A and B. (in Rank) R X y i 4 y2 4 y3 A2 d3 M 9 l 64 ih 56.25 1 64 S ih 6h 1 Qi 9 . 6 2.25 V ih 8 .25 Qi 9 - :. 2h 25 0 6 5 1 4*5 2.25 2h 12.25 K 4 3 1 Qi .25 6 4 I 4 3 1 ih 6.25 6 4 C 4 eh 6.25 1 9 6 4 P \h 9 56.25 9 56.25 6 20.25 N ih 3 2.25 8 42.25 9 56.25 133.00 190.50 192.00 -.108 rs= -.588 rs= -.600 ?4 2 d4 ^5 2 d5 ye 2 d6 ?7 2 d7 ^8 2 d8 y 9 2 d 9 R X 3 36 Ih 56.25 ih 56.25 ik 56.25 1 64 1 64 M 9 3 20.25 ih 36 ih 36 ik 36 2 30.25 2k 25 S Ik 6 2.25 Qi 9 8h 2.25 3k 16 5k 4 5 6.25 V ik 3 9 Qi 2.25 3k 6.25 6 0 3k 6.25 2k 12.25 0 6 1 9- Qi .25 3k 2.25 8k 12.25 3k .25 5 1 K 4 9 25 Qi .25 6 4 6 4 5k 2.25 5 1 I 4 6 4.. " 8 16 6 4 6 4 8 16 8 16 C 4 8 ,42.25 8 42.25 6 20.25 3k 4 8 42.25 8 42.25 P Ik 6 "20.25 8 42.25 8k 49 8k 49 8 42.25 8 42.25 N ik 168.00 204.50 180.25 171.50 207.50 210.00 rs= -.400 r s = -.700 -.502 rs= -.429 -.729 rs= -.750 APPENDIX H I. WAITING TIME RANKING BY STUDY REGION URGENT RANK R<"> XIME<">,-b/b(C) NON-URGENT R (a) RANK , a - b (b) , (c) ( i i > . l ) TIME a-b/b K b ' S C K I 0 V N+P M ,15 ,35 ,39 ,41 ,44 .50 ,86 ,88 1.330 .1:14" .051 .073 .136 .720 .023 8 K .39 7 V .50 5 C .73 5 I .86 5 N+P .93 3 0 1.00 ik S 1.00 ik M 1.21 .282 .460 .178 .081 .075 .210 8 7 6 4 4 4 I I . RANK CORRELATION BETWEEN WAITING TIME AND RURALITY Spearman Rank C o r r e l a t i o n C o e f f i c i e n t = r s r s = 1 " thl-is » where d = x - y ; d L = x - y i ; d 2= x - y 2 ; n K n ' x = R u r a l i t y Rank; y^= W a i t i n g Time (Urgent) Rank; y 2 = W a i t i n g Time (Non-urgent) Rank: R(a) x n d 2 y 2 d | M 8 1% 42.25 ik 42.25 S 6k 8 2.25 ik 25 V 6% 3 , 1 2 . 2 5 1 .25 0 5 5 0 4 1 K 3 5 4 8 25 I 3 5 4 4 1 C 3 7 16 6 9 N+P 1 ik .25 4 9 81.00 112.50 r s = .036 r s = - . 3 3 9 (a) See foo tnote (a) of Appendix A. ( b ) From Table 11. (c) See f o o t n o t e (c) of Appendix A. APPENDIX I RESULTS OF STATISTICAL TESTS I. WAITING TIME 1. To t e s t the s i g n i f i c a n t d i f f e r e n c e of mean w a i t i n g t ime — u rgent , by study reg ion Group • Okan. • M e t r o . ' Met ro . N-W.+Peace R. Okan. ... N-W.+Peace R. 2 . To t e s t the s i g n i f i c a n t d i f f e r e n c e of mean w a i t i n g time — u rgent , by community type ( s i ze ) mean S t . dev. F. v a l u e T/z va lue s i g n , d i f f . 0.879 0.389 0.389 0.432 0.879 0.432 n mean S t . dev. F v a l u e T/z v a l u e s i g n , d i f f -<9 0.4 44 0 . 4 P 4 3.79 - 1 . 3 8 29 0.879 0.903 (3 .09) ( -1 .645) 29 0.879 0.903 1.27 0.06 7 0.857 0.802 (3. 81) (1.645) No .9 0.444 0 . 4i64 2.99 - 1 . 3 0 7 0.857 0.802 (3 .58) ( -1 .771) No Group n Metro 29 Urban 27 _- .Urban 27 R u r a l 37 Metro 29 R u r a l 37 t . v . v l  v l  0 .903 5.78 2.62 0.376 (.1.91) (1.645) 0.376 2.48 - 0 . 3 4 0.591 (1 -86 ) ( -1 .645) 0.903 2.33 2.42 0.591 (1.88) (1.645) - A l l t e s t s use .05 as the s i g n i f i c a n c e l e v e l . - F v a l u e measures sample v a r i a n c e . I f the v a l u e i s g reater than the c r i t i c a l v a l u e , sample means would not be compared. - F i g u r e s g i ven i n b r a c k e t s under F v a l u e and T/z va lue i n d i c a t e the c r i t i a l va lues of the r e s p e c t i v e c a t e g o r i e s , - A l l t e s t s are o n e - t a i l t e s t s . - F o r the C h i - s q u a r e t e s t s , the s i g n i f i c a n c e l e v e l i s . 1 0 . APPENDIX I (CONT.) To t e s t the s i g n i f i c a n t d i f f e r e n c e of mean w a i t i n g t ime — non -u rgent , by community type ( s i z Group n mean S t . dev. F va lue T/z va lue s i g n , d i f f Metro 29 1. 207 1. 130 .1 .01 0. .81 Urban 27 0 . 963 1. 126 (1-.•91.) (1. .645) No Urban 27 0 . 963 1. 126 2 .46 1, .30 R u r a l 37 0 . 662 0 . 717 (1. •-79) (1. .645) Metro 29 1. 207 1. 130 2 .48 2, .38 R u r a l 37 0 . 662 0 . 717 (1-.88) (1 .645) — . YEAR OF GRADUATION To t e s t the s i g n i f i c a n t d i f f e r e n c e of mean year of g raduat ion by study reg ion Group n mean S t . dev. F va lue T/z va lue s i g n . d i f f . Okan... 10 57.40 10.11' 1.16 - 1 .27 No Metro;-, ". * . ; - 40 62, 23 1-0.87 (2.84) (-1.645.) Met ro . 40 62.23 10.87 1.59 - 1 . 3 9 N-W.+Peace R. 17 66.35 8 .63 (2.16) ( -1 .645) No Okan.-' .. - ' . ." \ 10 57.40 10 .11 1.3,7 - 2 . 4 4 . N-W.+Peace R. 17 66.35 8.63 (2.54) ( -1 .711) Yes To t e s t the sis. ; n i f i c a n t d i f f e r e n c e of mean year of g raduat ion by community type ( s i z e ) Group n mean S t . dev. F v a l u e T/z v a l u e s i g n . d i f f . Metro 40 62.23 10.87 1.08 0.78 Urban 46 60.35 11.30 (1.68) (1.645) No Urban 46 60.35 11.30 1.61 - - 2 . 1 7 R u r a l 41 65.12 8.89 (1.65) ( -1 .645) Yes Metro 40 62 .23 10.87 1.49 - 1 . 3 1 R u r a l 41 65.12 8.89 (1.70) ( -1 .645) No APPENDIX I (CONT.) I I I . PLACE OF GRADUATION 1. To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) B .C . ve rsus (B) n o n - B . C . g raduates , 1977-78 by study r e g i o n 2 Group n of (A) n of (B) Ch i va lue s i g n , d i f f . Okan.+ S . Van.. I s . 6 14 3.49 N-W.+Peace R. 1 16 (2.71) Yes 2. To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) n o n - B . C . Canadian versus (B) European/U.S>A. graduates between p e r i o d s 1975-76 and 1977-78 f o r Kootenays, Mid Coast , C e n t r a l I n t e r i o r , North-West and Peace R i v e r as a group 2 Group n of (A) n of (B) Ch i va lue s i g n , d i f f . 1975-76 20 31 3.18 1977-78 29 22 (2.71) Yes 3 . To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) n o n - B . C . Canadian versus (B) European/U.S ; A . graduates between p e r i o d s 1975-76 and 1977-78 f o r North-West and Peace R i v e r as a. group- -,\ 2 Group n of (A) n of (B) Ch i va lue s i g n , d i f f . 1975-76 10 6 3 .14 1977-78 5 11 (2.71) Yes 4. To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) B.C. versus (B) n o n - B . C . g raduates , 1977-78 by community type ( s i z e ) 2 Group n of (A) n of (B) Ch i va lue s i g n , d i f f . Metro 9 31 1.31 Urban 6 40 (2.71) No Metro R u r a l 9 31 0.38 7 34 (2.71) No Urban 6 40 0.29 R u r a l 7 34 (2.71) No APPENDIX I (CONT.) To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) n o n - B . C . Canadian versus (B) European/U.S.A. g raduates , 1977-78 by community type ( s i z e ) Group n of (A) n of (B) Ch i v a l u e s i g n . Metro 18 10 0.05 Urban 24 15 (2.71) No Metro 18 10 0 R u r a l 22 12 (2.71) No Urban 24 15 0.09 R u r a l 22 12 (2.71) No To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) B .C . versus (B) n o n - B . C . graduates between p e r i o d s 1975-76 and 1977-78 f o r each of the community types 2 Group n of (A) n of (B) Ch i va lue s i g n , d i f f . 1975-76 9 31 0 1977-78 10 30 (2.71) No 1975-76 6 40 1.22 1977-78 10 , 36 (2.71) No 1975-76 7 34 0.40 1977-78 5 36 (2.71) No To t e s t the s i g n i f i c a n t d i f f e r e n c e of p r o p o r t i o n s of (A) n o n - B . C . Canadian versus (B) European/U.S.A. graduates between p e r i o d s 1975-76 and 1977-78 f o r each of the community types 2 Group n of (A) n of (B) Ch i va lue s i g n , d i f f . 1975-76 18 10 0 .11 1977-78 15 10 (2.71) No 1975-76 1977-78 Urban 24 23 15 13 0.04 (2.71) No 1975-76 1977-78 R u r a l 22 11 12 23 7.12 (2.71) Yes APPENDIX J I. PLACE AND YEAR OF GRADUATION RANKING BY STUDY REGION PLACE OF GRADUATION YEAR OF GRADUATION R (a) (b) ,W PLACE a-b/b . 107 .032 .125 111 V 70 0 70; M 77.5 I 80 K 90 C 90 S 90 N 90 P 100 RANK (a) , A ( R_ YEAR ih 0 5.7.4 ih V 58.9 3h C 60.9 3h M 62.1 • bh I 62.2 bh K 65.5 bh S 66.0 bh N 66.1 9 P 66.6 a-b/b .026 .034 .020 .002 .053 .008 .002 .008 RANK (d) ( a z b > . 0 2 ) . RANK CORRELATION BETWEEN PLACE AND YEAR OF GRADUATION AND RURALITY Spearman Rank C o r r e l a t i o n C o e f f i c i e n t = r g 6 7 d 2 , , r s = 1 ( 2 - l T ' w h e r e d = X - Y » d l = x " Y l 5 d 2 = x - y2 , l U n } x = R u r a l i t y Rank; y^= P l a c e of Graduat ion Rank; Y2= Year of Graduat ion Rank; X y i 4 y2 4 M 9 3h 30.25 45g 30.25 S ih bh 1 71s 0 V ih Ih. 36.00 2 30.25 0 6 ih 20.25 1 25 K 4 • bh 6.25 ih 12.25 I 4 3h .25 hh .25 c 4 bh 6.25 3 1 p ih 9 56.25 ih 36 N ih bh2 25.00 ih 36 181.50 171.00 r s = -.508 r s = -.425 (a.) v See foo tnote (a) of Appendix A. ( b ) i From Table - 15. (c) - - • "' \ From Table 13. ^ See footnote (c) of Appendix A. 

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