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Implications of physician manpower planning in Canada for the family physicians of British Columbia Varley, John Charles 1980

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el  IMPLICATIONS OF PHYSICIAN MANPOWER PLANNING FOR THE FAMILY  IN CANADA  PHYSICIANS OF B R I T I S H COLUMBIA  by JOHN CHARLES M.D.,  The  VARLEY  UNIVERSITY'of  A THESIS SUBMITTED  TORONTO,  1953  IN PARTIAL FULFILMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRADUATE DEPARTMENT OF HEALTH CARE AND FACULTY OF  We  accept  this  STUDIES EPIDEMIOLOGY  MEDICINE  thesis  to the required  as  conforming  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA SEPTEMBER,  ©John  1980  Charles Varley,  1980  In presenting this thesis  in partial  fulfilment of the requirements f o r  an advanced degree at the University of B r i t i s h C o l u m b i a , I agree that the Library shall make it freely available for r e f e r e n c e and s t u d y . I further agree that permission for extensive copying o f t h i s  thesis  for scholarly purposes may be granted by the Head o f my Department or by his representatives.  It  i s understood that c o p y i n g o r p u b l i c a t i o n  o f this thesis for financial gain shall not be allowed w i t h o u t my w r i t t e n permission.  Department of The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5  ABSTRACT  The  work  physicians the  content  in British  second  world  reassessment  of  underway, b o t h health in  care  the  point  since  the  despite  co  provinces,  required health local  to  nstitutional  What  community has  operation.  as  an was  sponsored  now  become  national  changed  the  because  both  a  health  subject  of  years  has a  is  private care  care  to  were  system  of  enterprise  and  system  the  in  government-funded in  particularly insurance  the  of  apparent  funding  nationwide  doctors  been  series  health  and  complex  to  family  become  involvement  r e l a t i o n s h i p of became  had  deeding  health  payment schemes, f o r d o c t o r s of  r e s u l t of It  joint  Primary  of  system  incentives  a  been  a practitioner.  appropriate  Government  series  a  a  recognition  twenty  care  agreements.  develop  care.  thirties,  forties,  federal  greater  development  health  since  has  States.  last  family  sixties,  physicians  given  the  of  evolving  late  United  of view of  the  the  the  the  been  in  been  family  The  tasks  federal-provincial that,  of  recently  Canada,  changing  role  practice  has  Since  i n Canada and  practitioners*  In  Columbia  America.  reviewed from  s t y l e of  war.  the  has  North  and  third (the  party  last  programs),  to new  their  of  a  has  patients,  rules  of  the  iii  Medical  C a r e A c t o f 1967.  Government led  to  questions  Subsequently, especially  the prospects  manpower  important  considered regarding  for  spending.  for better  planning,  planning,  i n the early  Commission  on H e a l t h  which  began  t o be  sixties.  At that  Services  examined  s e r v i c e s t o a l l Canadians.  attempts  British  accountability  o f b r i n g i n g p h y s i c i a n s * s e r v i c e s and a l l i e d  h e a l t h manpower  and  i n payment f o r s e r v i c e s h a s  l e d t o t h e need  health  the Royal  The  about  this  considered very time,  involvement  to plan  Columbia and  i n the s i x t i e s  criticized.  the prospects  primary  care  to  British  Columbia.  p h y s i c i a n manpower  be  and  i n Canada  seventies are  Conclusions  are  drawn  f o r f u t u r e manpower p l a n n i n g f o r  given  by  family  practitioners  in  iv  TABLE OF CONTENTS  TITLE PAGE ABSTRACT TABLE OF CONTENTS ACKNOWLEDGEMENTS CHAPTER 1. INTRODUCTION CHAPTER 2. DEVELOPMENTS IN THE WORK OF PRIMARY CARE PHYSICIANS IN BRITISH COLUMBIA 1. THE BROAD BACKGROUND 2. PRIMARY PHYSICIAN'S PERSPECTIVE ON TODAY'S MEDICAL TRIAD a. THE PUBLIC/MEDICAL PROFESSION EQUATION b. THE CHANGING REFERRAL SYSTEM C.SOCIAL LABELLING ACTIVITY BY PHYSICIANS AND ITS APPROPRIATENESS d. PUBLIC EXPECTANCY: THE TWENTY-FOUR HOUR MAN e. PERSONAL RESPONSIBILITY OF PATIENTS f . THE TEAM APPROACH TO HEALTH CARE g. MEDICINE AND SOCIETY IN RECIPROCITY h. REDEFINITION OF THE FAMILY PHYSICIAN CHAPTER 3. THE CANADIAN HEALTH CARE SYSTEM 1. THE EVOLUTION OF THE FEDERAL-PROVINCIAL SYSTEM OF HEALTH CARE 2. DOCTORS' ATTITUDES TO THE HEALTH CARE SYSTEM 3. ACCOUNTABILITY AND CONTROLS 4. MANPOWER DEVELOPMENTS  i i i iv vi 1 8 8 14  16  19 23 27 29 33 37 41 41 42 45 52  V  TABLE OF CONTENTS (CONT.)  CHAPTER 4. HEALTH PLANNING ACTIVITIES 1. ENTREPRENEURIAL "PLANNING", OR THE "NON-SYSTEM" 2. EMERGENCE OF GOVERNMENT PLANNING PROCESSES IN CANADA AND BRITISH COLUMBIA 3. EMERGENCE OF MEDICAL MANPOWER PLANNING PROCESSES: AN INTERNATIONAL MOVEMENT 4. RATIONAL, BUREAUCRATIC, AND ADVOCACY PLANNING CHAPTER 5. A CRITICAL EVALUATION OF THE PLANNING PROCESS 1. IDEOLOGICAL DIFFERENCES AND THEIR EFFECT ON PLANNING a. ENTREPRENEURIAL ATTITUDES AND PROBLEMS b. CORPORATE OR RATIONAL PLANNERS' ATTITUDES C.CONSUMER ADVOCACY 2. RATIONAL PLANNING AND POLICIES CHAPTER 6. ANALYSIS OF CANADA'S MAJOR HEALTH PLANNING PROJECT TO DATE 1. INTRODUCTION 2. BACKGROUND 3. PROBLEM DEFINITION 4. METHODOLOGY 5. TOTAL METHOD COMMENTS AND CRITICISMS 6. DEFINITION OF FAMILY PRACTICE 7. CONCLUSIONS AND POSSIBLE SOLUTIONS CHAPTER 7. CONCLUSIONS FOR HEALTH PLANNING BIBLIOGRAPHY APPENDIX  53 53  59  64 72 80 80 80 83 91 94 97 97 97 98 99 102 108 116 119 128 13 9  vi  ACKNOWLEDGEMENT  I  take  stimulus,  and  considerable Without  this  completion. Anderson Manpower like  help. Stevens  Dr.  I  would  t o thank Anne  i n moving me  effort I  would  my  t o complete not  have  thank  f o r h i s guidance  when  he  was  a t U.B.C.  Dr. Annette  Research Finally,  Unit, a  special  word  present  of  head  head  and c o p i e s .  i t s  D.  0.  of the I  would  of the  Hsu, f o r t h e i r  thanks  and d i l i g e n t  of the manuscript  Dr.  In a d d i t i o n ,  and D r . D a v i d  f o r h i s strenuous  preparation  Stark,  thesis.  achieved  to  Unit  f o r her  this  like  Research  professor,  Crichton,  also  t o thank  Manpower  friend,  help  her  opportunity  to  effort  Robert i n the  1  CHAPTER  ONE  Introduction  T h e r e has primary  care  physicians  twenty y e a r s . only  be  been a demand t o  The  by  developments.  These  Two,  also  pressures the  is  and  social  world  first  war.  to  pay  doctors'  upon t h e  health  by  third  these  e x a m i n e d , and The explored the  The  care party  the  into  fees,  has  which  health  in  can  Chapter the  pressures in  has  of  later  i n C h a p t e r T h r e e as of  the  work  from  medicine  legislated scheme  since  government third  the  payment  had. p r o f o u n d  effects  points  Pressures  of view  had  this  a preliminary  manpower  into  monies,  exerted  practising physicians  has  and  party  d e l i v e r y system.  legislation  development  to  injection  physicians'  last  family practitioners in  insurance  p a y e r s on  of  multiphasic  examining  Canada  health  i n t o h o s p i t a l s and  schemes  with  the  complex, and  explored  developments  them,  national  are  numbers  in  overview of  addition  to  the  America  are  concerned  In  responses a  an  reasons  technological  existence last  taking  ambiguous r o l e s o f  seventies.  manifold  North  reasons for t h i s  appreciated  which  in  increase  to  planning  are  explained. impact  is  discussing activities  2 in  Canada,  Chapter  and  Royal  commissioned  in  which  world  general  had been  generally,  reported  proposed  of  in  1964,  i n the f o r t i e s  that  of  by  care  (Heagarty,  Saskatchewan  the i n t r o d u c t i o n  funded  before  the medical  i n the province  schemes  in  on M e d i c a l Manpower  acceptance  I t was r e a l i z e d  payment  which  study  and i m p l e m e n t e d  1962.  party  western  Commission,  a special  reccommending  1943),  the  Four.  A  plan  in  of t h i r d  governments  would  n e c e s s i t a t e manpower p l a n n i n g , s i n c e q u e s t i o n s o f r i g h t s to  health  right have Royal  care  i s now  had begun  taken  t o be  f o r granted  not y e t reached Commissioners  on t h i s  for increasing  suggested  t h a t more m e d i c a l  medical  time,  since  Butter,  The  about  the  supplies,  and  s c h o o l s s h o u l d be opened and  now  subsided,  factor  a  f o r Canada a t  staging  post  migrants  inflow  and  but  i t  control  i n threats  creating  potential  t o move  physicians  on t o o t h e r  problems  of medical  1  of  services.  even Even  i n an  (McGregor, outflow  has  i n m e d i c a l manpower p l a n n i n g ,  resulted  distribution  problem  of p r o f e s s i o n a l The  problematic  to  became  1972).  has  attempt  Canada  flow  physicians  any  Americans  s c h o o l s expanded.  international 1971;  this  principle.  manpower  However, t h e r e was a s p e c i a l this  the  recommendations  necessity  existing  Although  i n Canada,  agreement made  raised.  of  been  a  because  activities  has  countries,  thus  more though  uneven attempts  3 were  made  chosen  in British  by  new  achieving  immigrant  better  the  province,  of  Physicians  declared  Columbia  and  to  govern  physicians,  more  even  practice  in  distribution  the r e g u l a t i o n s promulgated and  illegal  Surgeons  by  a  the  of  challenge  hope  the  College  Columbia  carried  of  throughout  by  British  sites  to  were  the  Human  1975 Rights  f  Commission,  physician  manpower  according capacity  to to  Other  problems,  their  and  The  emigration  increase  in  Canada  i n t h e monies pumped the post-war  sixties,  federal  special  the grants  facilities necessity  for  but  recognized  t o be  called  commissions  on t h e d i s t r i b u t i o n questions  surface,  e.g.  a l ).  together  of  and mix  had  planning  by  the  to  provide  care.  began and  The  to  committees, t o work  of h e a l t h p r o f e s s i o n a l s .  getting value  be  provincial  sixties  were  the  for medical  standing  i n the l a t e  of  in  for building  only  Federal  vast  education  agreed  manpower,  and  Health  the middle  not  of  1975).  i n health  accountability  were C a n a d i a n s  of  institutions  a l l health  ad hoc  patterns  manpower  By  teachingrresearch  for  their  tertiary  years.  government  (Robertson,et  conferences,  well,  into  to educational and  systems,  affected  for considering planning  manpower,  began  also  had  differ  Bureau  health  was  also  issues  their  Petersdorf,  of  Canada d u r i n g  and  (U.S.  1974;  development  activities  payment  physicians,  R e s o u r c e s Development,  have  a l t h o u g h the  particular  produce  immigration  countries  beginning  As to  f o r money i n  4  their  health  services,  properly  organized  Costs  Health  are  of  reviewed While  tackle  The  to  agreements, rather,  a  Four.  there  been  has  planning  care  service  hospitals  government. payment  by  their system  is  by  changes  evoke too  public  as  well  i n the  as  the  on  financial  concessions  yearly  the  who  defensive  are  budgets  medical  now that  are  of  partnership  between  institutions agencies,  means o f  do  forces  terms  the  of  which  to  with  i f they  not,  i n the  of  by  federal of  in  desire  medicare  with  their  federal  to  costs. funds  respective withdraw There  provinces  general are  -  the  same  percentage  health  care.  with  the  payment  of  because  of  the  open-ended  sponsorship  have been v a r i o u s  trade-offs,  channeled  from  so  bargaining  for  responsibility  in  Doctors  rising  consumed  and  control  assumption medicare  limited.  It i s ,  involved  more  they  governments.  These p r o v i n c i a l g o v e r n m e n t s have been of  to  present  governments  aware  effort  under  profession. in  from  not,  clout  system,  the  reports  i s quite  health  many r e a c t i o n a r y  currently  governments  the  on  groups,  community  voluntary  has  Various  power  being  Force  these  renegotiated  or  Task  1969.  However, g o v e r n m e n t , by  doing,  of  A  services  considerable  providers,  mechanisms,  institute  a  controlled  continually  as  in  issues  that  closely  the  controlled?  i n Chapter  health  professional  were  reported  recognize  Canadian  such  Care  manpower  have had  and  and  into  provincial coffers  to  5  meet  medicare  costs  now  assumed  by  However, p r o v i n c i a l g o v e r n m e n t s t e n d as  part  of  their  subject  to  the  departments innate  demands  for  care  to  fee  This  medical  i s being  as  such,  cabinet is  are  portfolios  and  thus  developed  p r o v i n c i a l funding is  an for  seen  in  p r o v i n c i a l governments  and  associations More  created  participation  funds  they  resistance  various  provinces.  to view these  and  There  increases.  confrontation cooperative  other  open-ended  between  respective of  of  costs.  negotiations their  revenue,  dollars.  resistance  health  terms  general  the  and  in  more,  in place  atmosphere  discussing a  of  spirit  the  in  of  previous  health  care  involved  with  delivery. The  medical  profession  defensive  posturing  financial  status,  effectiveness would  in  appear  to  planned  excluded control input  from of  technological priority  since  the  physicians'  without  logical  times  for Cost  as  planning^ of  to  its little  Crichton).  when  This  well,  organizations  strong  control  were  profession  costs  i s the  health  was  Governmental  medical  controlling  as  profession  Medicare  meetings.  regards  of  have  particularly  days  preliminary  advances.  ( A»  erosion  to exclude the  the  i n these  c o n t r o l of  government  the  seem  seem  planning  and  planning  would  they^  more t e n d e d  participation  being  The  that  suit  so  prevent further now  health  t h e y have more and from  to  is  of  new  number  one  care  course^ d o v e t a i l s  budgets.  nicely  with  6  policy,  which  itself  factors  distinct  medical  care  service as  a  just  guard  is  reporting feels  third  by  the  and  high  their  Physicians  have  effect  their  their the  introduced  introduction  new  of  an  and  immutable  values, be  to  service work  ensure  adversely.  s t r u c t u r e s of  substitute  there  groups.  Because  of  these  physician easily  manpower  service for  the  medical  planning  eighties  do  not from  organization  personnel,  The  any  Apart  i t  medical  that  organizations  Within  effective  doctors  economic s t a t u s .  group.  interest  media  the p u b l i c  f o r the  not  sectorial  of  inappropriate.  rivalries.  monolithic  more for  intra-professional a  in  pre-eminence  evidenced  attempted  c o n d i t i o n s of  were  more and  because  even  slipping  into  r e s i s t a n c e to  as  Rather,  p u b l i c support  taking  schemes  terms, but  may  The  f o r involvement  a t t i t u d e s and  salaries  risk  payment  upon  political  costs.  complete  Financial  public.  when t h e y b e w a i l  changes  own  many and  to bargain  looked  changing  is little  were  action.  longer  by  needs  party  their  no  that  There  until  p r o v i s i o n on  fact  medical  have c o n t i n u e d  rear  doctors  from  determined  p r o v i d e r s , who  entrepreneurs introduced,  is  there  are  profession i s  for  i s not  and  are  many  rivalries, a  primary  likely  to  be  achieved. A  critique  of  process  i n Canada  and  Chapter  Five.  The  the  medical  British  manpower  Columbia  difficulties  of  planning  i s presented  applying  in  planning  7 techniques health  care  Conclusions planning chapter.  to  the  organization  service  are  regarding  to primary  care  of  an  considered  the  improved in  Chapter  application  s e r v i c e s are  primary  drawn  of  Six.  manpower  i n the  last  8  CHAPTER  Developments  TWO  i n t h e Work o f P r i m a r y C a r e P h y s i c i a n s i n  B r i t i s h Columbia  1.  The B r o a d  Background  British primary  care  (Clute).  Columbia  has  physicians  than  T h e r e h a s been  of  the Canadian  of  departments  faculties.  Physicians  view  the r e s t  an t r e n d  physician  family  percentage of the  t o upgrade with  medicine  continuing  served  t o improve  and  of  higher  the  can o n l y  medical  t h e same primary be  establishment  care  by  and  of  The  services  and  school  programs  purpose.  understood  education  provinces  i n medical  education  of  the status  programs o f t h e Canadian C o l l e g e  have  wanting  complex,  of  The  certification  for  family  a  Family reasons  are quite  taking  health  a  long  service  organization. Canada's p h y s i c i a n s are  strongly  States.  Frinkerstein  development occurred  influenced  of  United  i n response  and t h e i r by  has  proximity traced  States to  service  that  to  four  medical  organization the  stages education  society's  concern  United i n the which about  9 their  medical  followed Canada.  services.  quite The  These  closely  by  similar  f o u r p e r i o d s he  beginnings  of  medical  nineteenth  century;  1910,  when  the  their  standards  Foundation  schools in a  the  post-Flexmer  report  (movement  was  to  then  of  specialist  training  period, beginning  to  be  made  development of m e d i c a l medicine one  to  specialization  the  holistic  Canada has  population unit  The  specialist  has  resulted  same  t h e mid  way  training  has  the  which,  because  in  the  of  same  1925,  when  the  community  s i x t i e s , which less  the  was  technical of  more  care physicians States  absence  to of  time, select  general  Canada  in quite  Canadian  general  were social  country.  of  having  in their  of the d i f f e r e n t  (Clute).  course  affect  specialists  populated  the  time.  (although  thinly  the  d.,  citizens  same  a widespread,  c.  increased  United  were n o t downgraded  r e g a r d e d ) , because  the  the  more p r i m a r y  practitioners effect  of  Carnegie  improve  provision  (Stevens), d i d not at  from  to  for  the  i n most A m e r i c a n  practitioners the  than  specialists  period  health care.  a l w a y s had  per  the  about  and  the  in  the  to  respond  demand for  a.  practitioners);  technology;  and  comprehensive  own  to  e r a , b e g i n n i n g about  answer  their  general  in  criticism  by  made  training  began  the  published  scientific  attempts  were:  development  responded  were  developments  distinguished  school  b.  developments  status to more  the  highly  conditions in  Although  Canada  10 had  grown  from  Confederation not  until  1971.  As  urban  and  were well,  the  rural  which  In  immediate  centres.  demand  for  America  National  were was  Canada s e r v e d  how  Australia.  i n the  Health  hostile  the  major  Consequently, practitioners negative  numbers  of  early  was  between and  seventies. less  for  demand general  internists isolated  the  to  and  in  sixties  began  as  fifties set  to  the  that  a  and  a  emerge  an  entry point for large  the with  views  alternatively,  the  up  was  fleeing in  establishment  about  influx  from  1948.  of  were made t o  immigrants bad  an  North  the  of  British  Eckstein  the g e n e r a l p r a c t i t i o n e r s  concessions  the  evolved.  There  Service  by  metropolitan  the  than  relatively  system  o t h e r s have e x p l a i n e d how quite  by  general  really  was  changed,  the  there  until  it  population  inhabit  not  War,  population  gradually  by  between  immigrant p h y s i c i a n s l e a v i n g Europe f o r  and  physicians  It  that  of  years,  up  who  referral  As w e l l ,  large  specialists  subspecialists  more complex  that  predominant  postwar  backed  larger  World  double  to  become  surgeons  numbers o f  began  people  Second  years to  million  distribution  care  practitioners,  the  settlements  had  tertiary  general  and  admitted  centres  for  eleven  postwar  populations  the  to  i n 1867  the  immigrants  larger  three  that the  were  experiences  socialized  immigrants,  i f young  were  service  and  specialists.  often  with,  and  and  general strongly  medicine. doctors,  Or would  (  11 be  those  cuts  with  dimmed  introduced  reality  of  from  1951  prospects  onwards.  f i n a n c i n g c o s t s of the  began  to  strike  began  to  move more  intent,  educational  in  home t o  the  slowly  providing  At  that  British  government. than  had  to  cost  time,  Health The  been  specialist  due  the  Service  government  their  training  original  posts  for  ex-servicemen. But?ter a  "parking  they  has  l o t " f o r new  became  joined  those  Canadian  in  United  the  and  North  sought  having  had  landed  (the  centres  of  the  United  Canada,  and  many  British seemed  Columbia, more  of  to  further training  in  where  and  s l o w e d down c o n s i d e r a b l y  at the  time of  not  physicians  called  because  up,  but  the  existence  the  two In  affected  young  because of  the  of  the  border  and  the  or  the  warmer  course,  stayed  Ontario  and  conditions  through  Canada  the Vietnam  were  growing  provinces  Maritimes),  social  movement  operate  the  to  The  only  attractive.  and  moved  working  to  from the  Some, o f  these  then  aspired  population  States. of  who  as  until  Some  l e a r n t how  Prairies  used  years  America.  graduates  who  Others,  larger  climates in  in  often  f o r a few  a f e e - f o r - s e r v i c e s y s t e m , moved on  where t h e y to  Canada was  medical  careers  States.  how  immigrants  established  subspecialist the  explained  liable  war,  to  be  consciousness  of  differences  between  countries. summary, by  the  it  appears  general  that trends  Canada  was  identified  also by  12 Frinkerstein, Canadian  but with  circumstances,  British-trained the  American  nature to  time  general  lags,  and  adjustments  a  strong  practitioners  influences  with  their  who  input  important  and d e c i d e d  own.  factor  in  to stay  British  of  counteracted The  o f t h e p r o f e s s i o n a l i m m i g r a n t s who were  the country  to f i t  there  special  attracted  h a s been  Columbian  an  medical  decision-making. In  the  federal  chapter  and  in  for  scheme  was t h a t o f M e d i c a l  their  developing  The l a s t  funding  Care,  The  payment  scheme  supported  accepted  in  by  In  doctors  introducing  and  carrier.  Medical  Services Incorporated  of  various  union  prepaid  provincial  provide p o r t a b i l i t y  considered scheme  a  third  party  funds  had  been  doctors  in  1943  instrumental  many  to  prepaid  in  medical  including  British  S e r v i c e s A s s o c i a t i o n was t h e  largest  credit  were  provinces,  C o l u m b i a , where t h e M e d i c a l There  of  Canadian  establishing various  health  for service to  government  (Heagarty).  the  national be  by  assume  i n which governments agreed  by  the  to  era w i l l  introduction  fact,  decision  of t h e programs i n t h i s  principle  in  a  t o meet p h y s i c i a n s ' f e e s  patients.  schemes  the  governments  i n the postwar  some d e t a i l .  provide  follows,  provincial  responsibility insurance  which  were  several  f o r smaller  scheme, plans  others,  C.U.&  across  including  e m p l o y e r s , and  C. the  The  linking  country  was done by t h e e s t a b l i s h m e n t  to  of the  13 Trans  Canada  deduction  for  portion  or  accepting all  their  a l l of a  Patients  health  care,  the  medical  prepaid  government  much  of  their  that  fee  British  -  for  health  care  doctors  were j u s t  had  their in  a  tight  To  feel  they  role  in  the  to  did the  of people  the and  i n the  programs  program,  service like  gradually.  attention,  the  position  than  uncertain  of  government  Care  doctors they  their  had role  own  of  Columbia,  the  budget, only  so  50%  of  physicians  in  do  not  get  of  scoffers  their  did  not  due  prepaid  claim  the  incomes).  The  time t o cover  By  (or were  the  time  in a in  the  far  to  the  to  the to  stronger  inherent  but  Health  introduce  that  began  1943,  introduce  National  proposed  Medicare)  been and  offer  the B r i t i s h  postwar p e r i o d , but  Medical  method  province.  f e d e r a l government  a comprehensive  doctors  Assistance  establishment (the  a  schedule,  and  accept  not  to secure  i n the  and  Social on  day,  province  out  rein  payroll paying  In B r i t i s h  had  this  a  fee  ideology  g r a d u a l l y been expanded o v e r  The  Service  their  care.  often  schedule.  Columbia  majority  with  doctors  credit  plans  fee,  e s t a b l i s h e d S.A.M.S. -  Services  so,  medical  paying  employers  plan  c e r t a i n percentage  party  Medical  four  Plan.  became i n d o c t r i n a t e d i n t o t h e  third the  Medical  last  receive economic  they  were  i m p l i c a t i o n s of  involvement.  The Saskatchewan  first (in  province 1962,  by  to the  introduce New  Medicare,  Democratic  Party  14  [Socialist]), and  Wolfe) ,  that  suffered a bitter and  the  manifestation  the R o y a l Commission  felt  it  had  determine  to  its  doctors'  on  Health  negotiate  with  attitude  wary  when  refused  even  as  to  observers,  the  at  establishment  the of  experience  and  plans.  would wonder  it  One  would be  be  an  national  2.  Medicare  a  expertise i f the  medicare  effect scheme  of in  Columbia,  the  1968  let  this in  to  regarding became more  them  appear, leading  despite  prepaid  their medical  f e d e r a l government involve doctors  scheme  that  might  felt  in  the  turn  out  them. decision  upon  the  i s considered  Primary Physician's  1961-1964,  conferences  -  was  profession  later  to  planning  income b o n a n z a f o r  The  British  of  strike  Services,  doctors  p o l i t i c a l l y unwise t o  establishment to  growing  this  (Badgley  intentions  The  government  of  the  and  Medicare's establishment. the  strike  to  proceed  primary  with  a  physicians  of  now.  Perspective  on  Today's  Medical  Triad  a.  The  Public/Medical In  the  shift  Profession from  a  relatively  simplistic  between t h e  p h y s i c i a n and  group t r i a d  i n v o l v i n g p a t i e n t , p h y s i c i a n , and  as  third  party  payer,  the  Equation  the  p a t i e n t , t o a more  public  dyad  complex  government  concept  of  the  15  physician  and  changed.  A bureaucratic  the  the p h y s i c i a n ' s  sensitivity  when  conflict  about such  which as  of  the  the  third  the  with  party  original  that  third  medical  fee  concept  of  p r e s e n c e can  dyadic  party  and  has  shrink  relationship,  arises  profession  structure  the p u b l i c  over  i s most  pattern  issues  sensitive,  of  practice  surveillance. Eric analysis,  Berne, defines  transaction.  we  find  unit  a  two-way  practice  of  agency.  when  that  a  blanket  of  that  i n the  there  services,  is  a  reasoning.  This  a challenge  t o , and  strong  their  suspect  entrepreneurship  of to  a  giving  and The  party, or  its  often  to  act  rules  and  policies,  and  seem  using  force  i s inherently  practitioner -  sanctity  of  however,  by, t h e f r e e - w h e e l i n g  the  the  party  an  payments.  motivations,  third  a  government,  authoritarianism,  which cover  manner  is a  and  as  is  the a d d i t i o n of a t h i r d  departments  regulations  accustomed  intercourse  transaction  much  party  Governmental  transactional  of e l e c t r o n s h i f t s ,  information,  i s compounded by  of  social a  flow,  i n medical  especially  become  in  Instead  equation  of  of  reaction.  receiving  under  the  originator  Inherent  equilibrium: chemical  the  of  a  one  private  spirit who  had  dyadic  relationship. For degree to  the  of  that  relationship,  the  r e s p o n s i b i l i t y manifested  payment  of  the  physician's  patient by  carried  a  his contribution  fee.  Under  present  16 c o n d i t i o n s , the g e n e r a l p u b l i c f e e l s t h a t the s e r v i c e i s free,  and,  take set  as  such,  tends  i t f o r granted. that  to  those  applying  in  who  need  attitudinal  utilization  i t most:  Aday).  Columbia  a utilization  f e e , and  elderly  a l l utilization i n the  the  However,  British  substantially the  the  as  fee seems  they s t a t e , i t denies access to the  (Wildavsky,  government  as w e l l  Opponents of u t i l i z a t i o n fees decry the use  of the same because,  elderly  P h y s i c i a n s miss  the payment of a fee or  to i n s t i l l .  system  to abuse s e r v i c e  extended  has  poor the  no  and  the  provincial  hesitation  in  r e c e n t l y , has i n c r e a s e d  fees, care  including  those  institutions.  f e e s have been noted by J u s t i c e H a l l i n h i s 1980  of  These report^  (Canada, 1 9 8 0 ) . b. The Changing R e f e r r a l System As  the  public  has  grown  more  accustomed  to  medicine, more knowledgeable about medical developments, more secure i n t h e i r medical comcomitant s h i f t  i n the nature of t h e i r a t t i t u d e to the  general p r a c t i t i o n e r often  the  instrument  family  " r i g h t s ' , t h e r e has been a  and  also  practitioner  to the is  specialist.  viewed  not  More as  of the f a m i l y ' s h e a l i n g p r o c e s s e s , but  the as  a  stepping-stone to t h e i r u l t i m a t e s e r v i c e instrument, the specialist.  Because  patient often arrives the  accuracy  judgemental  of as  of  these  i n the o f f i c e  his/her to  attitudinal  the  firmly  shifts,  the  convinced  of  self-diagnosis,  unwittingly  inadequacy  the  of  family  17  practitioner his/her  to  handle  demand f o r and r i g h t  Attitudinal confined guilty when  his/her  to  changes  the  outside  public.  The  customary leads  and  The p r o c e s s  definition  in  control  well  emphasis  There  finds  its  often  physician  f o r problems care.  This of  referral  ultimate  hospital,  status,  no  the system  medical  staff  care  professional  where  consultants.  on c o m p l i c a t e d  referral of  constructed while  with  the  family  position,  and no  The d e f i c i e n c i e s  programs, w i t h  treatment  that  bearing  i n disarray. and  often system  referral  their  medicine, are  akin  brought  truth  which  i s that  t o be  into  by  suspicion.  perhaps  to subterfuge,  as a c o r n e r s t o n e I t needs  with  understood,  own m y s t i q u e  plain  approached  mechanisms a r e p o w e r f u l  poorly  their  The  is  care  elements  i n Canada,  adjusted,  health  often  penetrate.  system  system  the  i s a feeling  instruments,  is  of  just  recognized.  observers  to  in  of the stature of the family  closed  h a s no  are  short-circuiting  of the p a t i e n t ' s  The  the  the  such h o s p i t a l - b a s e d  natural  patient  professionally-approved  physician.  are not  specialists  area  to further diminution  practitioner  above,  for a  own  strong  of the attending  consultations  their  and  specialist.  as noted  specialist-to-specialist  of  to a  o f t h e same b y p a s s i n g  seeking  case,  the  policy  a l l  is difficult the  referral  of Medicare,  redefined, reality  and  of  modified, today's  18  practices.  The  practitioner's specialists greater the is  leap-frogging  status  alike,  erosion  and  services  totally own  on w h i c h  logical  system  appointments  phone  our p r e s e n t  ultimate  step  with  In f a c t ,  or  appear  the  and  produce,  even  Medicare  program  the  United  this  i s now  requesting  States,  sophisticated general  patients  i s to  and a f f l u e n t  and g o i n g  interesting Medical  to  Services  their  without  a  thin  families referral. edge  unlimited  straight  their  Is t h i s  referral  as  t o make  care?  "The  tends  to a  What  care  more  provisional  specialist status  valid  The  Will  public  judgements  are the ensuing  or  care really  non-referred,  i s f o r the  provider.  the  to physicians  totally  the  It i s  Columbia,  system?  Will  In  t o bypass the  own  seek  special  changes  appropriate?  consultant  that  British  to  own  Patients  to the expert...".  the r i g h t  own t e r t i a r y  their  for  has r e c e n t l y g r a n t e d  these  their  or even p a s t .  his  in  o f t h e wedge  of  sophisticated their  notes  consultant-access  extrapolation  really  Plan  pending  American  that  of  commonplace.  making  note  and t o make  referrals  Fox  practitioner,  diagnosis  define  for  specialist  appointments which a r e a l r e a d y  be  public  i n Canada, one o f  bypass the f a m i l y p r a c t i t i o n e r  choosing.  the  by  family  based. The  and  the  has l e d t o , and w i l l  of the r e f e r r a l  underpinnings  of  logical public this  ever  be  to ever so  i n defining costs  apt to  19 be?  The  r e - d e f i n i t i o n of  question  underlying  the  the  referral  need  for  a  system  was  Health  one  Services  Review '7 9, (Canada, 1980).  c.  Social  Labelling  Activity  by  Physicians  and  its  Appropriateness Patients  have  than  been  about  more  social  c o n t r o l , Watkins  physicians, society.  as He  controller  physical  central of  functions  specific  doctrines.  i. ii. iii. iv.  The  to  an  only  for  adherents he  and  role to  his  for  their  poses  the  c h a r a c t e r i s t i c s of a p r o f e s s i o n a l :  code  his discussion  body o f  knowledge,  community,  of e t h i c s . culture.  o f t h e s e c o n d c h a r a c t e r i s t i c , he  the r o l e of p r o f e s s i o n a l of  as  He q u o t e s Greenwood's d e f i n i t i o n as  professional  certification  from  interpreter  peripheral  of the  on  such  on  priest  the  more  The  elaborates  book  of  a  authority,  In  his  controllers for  as  Professional  v . The  doctors  social  command o f a s y s t e m a t i c  A regulative  In  In the p r i e s t ' s p l a c e  distinct  sanction  consult  professionals,  and  passing  but  profession.  to the f i v e  discusses  role  society,  similar  medical  the  to  symptoms.  gatekeepers  notes  pre-eminent  accustomed  illness  as  a  authority  social  i n the  function,  by  20 labelling His  activity,  i . e . 'what  i n t e r p r e t a t i o n of  this  area  more a p p l i c a b l e t o B r i t a i n , appropriate a  i n Canada, as  multitude  role  of  the  well  be  of  of  a  of  doctors  physician's  that  Britain)  i s no  an  this  task  as  -  an  an  t r a i n i n g with  likely  Medical  physicians  of  than  by  as  insurance  These  five a  do  not  not  to  days.  companies  Many to  hammered bargaining  physician  as  their  out  of  the  time,  dispatching  room  In  as  Canada,  onerous  paperwork part  of  should  is  -  slips  sick  the the  fact,  directive for  are  absence used  by  benefits,  or  time unions use  payment. and  the  of  the  inappropriate.  delegate  and  their  In  a  by  medical  undertake  sick  but  of  (in  slips  between  policeman  employers  sick  the  Institution,  issued  sick  abuse  providing  at  the  issue  part  office  and  desirable  may  discussion  regarded  red-tape  The  from  chits.  Association  deterrent  items are  and  official  or  employers  unions  in a  s o r t i n g and  physicians  advising  employers  likely  a Political  be  with  important  practitioner's  to  is  illness  a view to becoming a b u r e a u c r a t .  Canadian  less  a  outcome o f  Most  as  to  an  not  Mackenzie,  for  important  operation  requirements.  as  but  Service  point  illness'.  i s becoming i n c r e a s i n g l y  in testifying  general  i s most  practice.  the  'chits'  more t h a n  issuing  physicians not  the  social  conditional  function,  Health  suggests  and  but  as  sick benefits proliferate  perspective.  National  count  of  significance in Britain  physician's the  varying  i s to  to  The  themselves  21  t h i s watchdog The  function.  constraints  certifies  an  illness  a  fait  often  an  required for  their  sick  leave the  should  have  illness  not and  -  sought,  sometimes  i s hard pressed t o  or v a l i d i t y ,  and may a l s o  because  appear  or e m p l o y e r ,  of the p u b l i c  or o t h e r  system  they  the  to  as t h e and n o t  counsellor.  members  payments, t h a t  he  documentation  attention,  accuracy  as  render  of t h e i r  The p h y s i c i a n  parental,  to  present  f o r t h e i n s u r a n c e company  Those  as  they  medical  document's  physician  such  the f a c t  which  at a l l .  as o n e ' s m e d i c a l  how  for  so he may appear  advocate  after  received  no i l l n e s s  query do  or  a  Many p a t i e n t s  accompli, illness  on  are often  process meaningless. as  placed  health  operates  who  benefits and  their  they a r e , i n e f f e c t ,  decide to a v a i l  have  accumulated  a r e so aware rights their  themselves  to  own  as t o  certain  labellers,  of t h e i r  accrued  benefits. Thus,  sick  leave  benefits  actual  illness  by w o r k e r s ,  salary  payment  that  inherent  right.  is  really  He  i s used  municipal One to  b u t a r e viewed  The p h y s i c i a n ' s i n terms  as a m e d i c a l clerk to obtain  the medical  n o t used f o r as a  fringe  c a n , and s h o u l d , come t o them  insignificant  would  are often  also  position  of h i s t o t a l  b u r e a u c r a t , much a building  query  profession  i n this  area  function.  a s one u s e s  a  permit.  the pre-eminence by  a s an  the author  attributed  i n terms  of  22  social the  labelling  priestly  more  and  gatekeeping,  function.  peripherally  function,  so  from  has  the  g o v e r n m e n t s moved t h e strictly from  service  to  says,  of  the  medical and  care  likely  to  with  be  the  a  change  technology  resultant  ability  learning  shifted away  the  from  technical  and  from  its  adviser  and  in a  built  with a  the  as  and  and  the  friend,  both  the  art  of  with  its  to the  art  disease, the to  has  physician that  before; o'er,  fits  on  to the  performer:  The danger requited;  the  function  opposed  of  power  i s more  emphasis  endure  of  technical  "God and d o c t o r we l i k e a d o r e , But o n l y when i n d a n g e r , n o t alike  an  at  role  knowledge,  perspective  sage  [and]  opposed  of  it  responsibility  medical on  comes  into  utilitarian  of  away  principles  allocation  disease,  cope  well  decision  physician's  century  to cure  of  is  p r a c t i c e , as  emphasis that  by  "Government,"  periphery,  perspective  to  moved  planning  care,  of  and  the  explosion  how  for  control  institutional  resource  shift,  of medical The  health  burden  power  in this  medicine.  has  social  making.  there  for  viewed  Such  the  the  service,  this  priest  health  policy  i n a c t i o n a t the  With  function.  of  and  responsibility  centre".  of  of  ethical  between  the  replacement  central  advent  " i s where  health  antiphony  a  component  r e s t . . . g i v e n the  as  a  p h y s i c i a n more p e r i p h e r a l l y i n t o a  c e n t r a l planning  Mackenzie  Just  as  are  of  a  23 God is slighted.  doctor  forgotten Robert  As  such,  his  circumscribed Again, of  when  function,  reality, 1975.  even The  clinics  stress  with  hospital  a  Along  idea  of  repugnance  achieving  one's  a  fixed  viewed  with  was  terms of  an  important  was  with  today's  written  only i n  mental to  health  avoid  mental  outdated  h i s i d e a s by  p r e v e n t i v e community  c l i n i c s , the  someone  took  of i n d i v i d u a l i s m  not consistent  Thus  a v e r y shrunken  on  with  mental role  the  health  certain  the idea  of  of patients  or i l l n e s s  with  a  i n t h e 1960's.  The s t e r e o t y p i n g  o f development  dislike  more  the area  touch  function,  inconsistent  of t h e i r  is  into  as  community-based  identity.  self-realization. essence,  on  by p h y s i c i a n s ,  stage  as  of  his article  with the r i s e people  at  i s out  'labelling'  Labelling  enters  illness  preventive  committal  decade.  very  though  Epigram"  function  author  mental he  the  realizes.  t h e same of  Owen,  control  than Watkins  certification  labelling  a  social  and  came  t o be  process  of  labelling  is, in  for practitioners,  both i n  f o r such a f u n c t i o n ,  and i n t e r m s  i t s importance.  d. P u b l i c  Expectancy:  There  is  a  The 24 Hour Man  dichotomy  in  the  public  attitude  24  towards p h y s i c i a n s ^ w i t h a t r a d i t i o n a l organized  medicine,  doctor as w e l l of  linger  as  along  a fallible  a comprehensive  Health  man.  Care  the  health  of  state  benevolent  what  desirable  for  economics, such  seVices,  principle  a  or  except  weakens  the  physician  seven  of  a  care of  outside  such  the  bypassed.  definer  as  made  a of  providers  of  service. such  for  The  full  time  specific  time  emergency office  what  Such  i s made  departments hours  and, the  Increasingly, to  available  week.  give  because  of  substantiating  the  accessibility,  d o c t o r / p a t i e n t dyad,  definitions  mention  or  of  Health),  the  week  can  hospital  of  mention  a  of,  areas  Primary  of  and  being  No  days  of  beneficial  for  days  attitude  in isolated  i s often  become  need  practitioner  non-emergent  delete  given.  seven  Utilization  spin-off  a  province  These is  services  the  no  or  care,  of the e v e r - p r e s e n t ,  feel They  day, as  hour,  natural  has  those  hours  i s that  spans. for  with  on,  twenty-four  coverage  public.  i s taken  effect  reality  the  the  operation  and  Council  figure.  proponents  practicability,  twenty-four  the  the  medical  of  primary  of  "Evaluation  Ontario  individual  concepts  care p l a n f o r the  the  towards  paternalistic  development  embrace some o f t h e c h a r a c t e r i s t i c s old-time  a  newer  Report:  Services,  one's  Definitions  f o r the  Mustard  (the  Remnants  with  as p r i n c i p l e s  Ontario  viewing  favourably.  practitioner thinking  whilst  antagonism  as  is  a  such,  attending the  public  constitutes  an  25  emergency.  This  is a  natural  development  in  a  'free'  system. Let  us  work week  therein  definition  Does  the  What  other  word  many  because  are  not  a  is  by  more  have  and  services,  it  valid?  hour  a  day  care?  such  an  of  public  extensive  is  service  system  in  responsibility the person (as  the  public  i n Canada),  evening  or  even  not by  by  of  patients  abuses after  minor  or  the a p p l i c a t i o n  unusual.  Thus, under  unconsciously  Medicare  treated  cast  on t h e p r i m a r y c a r e p r o v i d e r ,  requesting care.  departments  they  midnight  of doses  their  own  and  on  system defines  in  the  of  as the  none  'free'  arrival  i n the  emergency  afflictions common  to greater  health.  a l l  The  non-recent  not  such  incorrectly  appear.  I t does n o t l e a d for  and  a  and  do  these  that  postal  stores,  All-embracing statements  deficient  i n the  courts,  p r o v i d e such coverage. are  an  defining  services,  department  the  for  Banking,  social  supermarkets,  components  prescription  i s not u t i l i z e d the  This  Is  liberally.  offices,  subtleties  understandable  noted,  more  government  a role  on  day  obvious.  Miner.  available is  seven  there are  twenty-four  service  we  hour,  readily  t h e word emergency  As  other  theory  require  service  definition.  legal  role  public  Such  service,  that  in  emergency, b u t  the  twenty-four  of primary care i s r e a l l y  described  basis?  this  reccommendation,  included  as  examine  best  sense,  is  responsibility  Rather,  i t leads  to  26  an  o v e r - d e p e n d e n c y on m e d i c a l  Illich.  The e x i s t e n c e  leads  to  the  out-patient best  be  laboratory the  departments,  do  as  not  could  The  same  apply  form  service. happen  the  Is medical  higher  do l e a d  Patient  psychological (Kastner). in  preventing  human  services  devaluation are provided  utilitarian  mechanistic  Howard  Strauss  and  or  co-insurance  into  that  Patient  care;  be  the  when  technical  discuss  convenience  but  this  rather  t o abuses o f  one  i f one w i l l ,  form  c a n be  a r e viewed  service well  force  provided:  humans who  they  of  commitment  a positive  services  by f e l l o w  objects  i t should  p r i n c i p l e s do n o t  is  will  of  at a  i n terms o f e f f o r t t o  scheduling,  made  of care  volume and l i k e l y  contributions  effectively  i n the daytime.  quasi-governmental  of medical  co-insurance,  Such  or  as a c c e s s i b i l i t y  appropriate  services  does n o t happen i n any  so s a c r o s a n c t  quality  into  his responsibilities  delivery?  to a higher  system.  obtain  care  care  interpreted  to a  they  governmental  i n health  factors lead  of  Often  t o be c a l l e d  t o perform  from  can  Cadillac  containment.  have  This  that  trivia.  delivered  i s free  coverage  style  to the d e l i v e r y  t h e end o f t h e work-day.  other  cost  be more e f f i c i e n t l y arguments  with  as p h y s i c i a n s ,  t i m e when t h e p a t i e n t at  dealing to  hour  twenty-four-hour-a-day  technicians  h o s p i t a l , as w e l l  that  of  and a p r a c t i c e  lead  and x - r a y  a s e n u n c i a t e d by I v a n  of free twenty-four  evolution  described  services  care  in  as  components. Humanizing  27 Health  Care  (see a l s o S c h a e f f e r ) .  I f we a l s o examine t h e s e v e n d a y week p r o p o s a l , find  that  week  reality.  social  i t flies  preclude seven  Hospitals  fabric  unionized,  of  program:  cases;  such,  of  their  operating  bookings  occupancy  the  general  staffs  rooms  and  rates  operating  a r e open  fall  o f f on weekends.  The  the  for  twenty-four  hour day u s a g e .  on  the f u l f i l l m e n t  by  the p u b l i c  provided  rise  always  means  Personal  in  on  Law:  available.  option  does  the  i t i s a paraphrase  to the l e v e l The  services  sought  of those  freely  Parkinson-style  use o f f a c i l i t i e s  at  or e c o n o m i c a l ,  t h e one hand  and " b e t t e r "  processes  As s u c h ,  as  staff  R e s p o n s i b i l i t y of P a t i e n t s  While "more"  day week  abuse  the inordinate  times not necessary e.  seven  of Parkinson's  will  and  proposition  basis  on  on weekends; many  is  same  on a  only f o r  t e s t s are not a v a i l a b l e ; a d m i n i s t r a t i v e  provides  are  are closed  laboratory mostly  work  o f h o s p i t a l management  o f t h e h o s p i t a l from  for elective  emergency  As  as p a r t  t h e economics  areas  day week  of the contemporary  exist  today.  so t h a t  many  weekends  i n the face  we  described  response  to  access above,  Illich*s  independence  for  freedom  professional  from  health  there  are attempts  to medical there call and  care  h a s been for to  through the  another  greater  increase  dominance.  to get  This  been e n c o u r a g e d by t h e L a l o n d e R e p o r t , A New  trend  personal patients' trend  has  Perspective  28  on t h e H e a l t h o f C a n a d i a n s sponsored  1974.  f  by t h e F e d e r a l M i n i s t e r  (Xalonde) , responsibility  and  encouraged  for their  The  report  of Health  Canadians  own l i f e s t y l e s  was  and W e l f a r e  to  and  take  more  environment:  " B e t t e r t o hunt i n f i e l d s , f o r unbought Than fee the doctor for a nauseous draught The wise, for cure, on e x e r c i s e depend; God n e v e r made h i s work f o r man t o mend." health  ( J o h n D r y d e n 17 00) The 1  response  to  Participaction  has  this  While  independence with sports  and  t o t a k e more  some  from  physicians,  think  t h e need others  by  promotion  setting  and  may  noted  called  e n t h u s i a s t i c , and in their  lead  for continual  have  up  have  practices  preventive  the  to  own  greater  consultation increase  care,  responded  focussing such  as  B.C.,  management  as  c a r e , now  a  where  emphasis  preventive  the  an ' i n ' c o n c e p t ,  care physicians.  perspective crisis  of  i s not r e a l l y  The f a m i l y  time-comprehensive a  in  this  health Western  i n North on  stress  Holistic  health  new  f o r primary  doctors are able to obtain and  patient  treatment  i s placed  function.  to  on  f o r P r e v e n t i v e and B e h a v i o r a l M e d i c i n e  Vancouver,  care  program  injuries.  movement  a  a  interest  this  Some g e n e r a l p r a c t i t i o n e r s  Centre  to  has been u n e x p e c t e d l y  1  l e d many p e o p l e  fitness.  report  which  focus.  family-comprehensive goes A  beyond  more  fully  the  acute  holistic  29 approach the  i s possible  services  now b e c a u s e  o f many a l l i e d  physiotherapists,  health  e t c . (College  Canada:  Health  Martin). of  f.  The argument  a comprehensive  will  now be  there can of  approach  merit  i s , because  to a patient's  specialist  likely  relate?  interaction  as  health  care  To what  essence  i n the Identity  uncertainties t o move  that  team as h i s  is a  group  in  of  his  intimate  of health  care  the patient  most  the  intimate  medical  discussion  Society,  the patient  of a primary  will  There  are  relationships  t o seek  care,  is  personal Reality  involvement inherent that  would  o u t one t h e r a p i s t o f  relating care,  human  of  emphasizes  principle.  tend  likely  of i n t e r a c t i o n  by a warm, f r i e n d l y ,  i n one-to-team  system  kind  f o r rewarding  Glasser,  Quite  by d e f i n i t i o n ,  or team member The  first  the area  of the  (The Random House D i c t i o n a r y o f  involvement - given  the  present  a pair  required  therapist. Therapy  director  discussion  and t h e d o c t o r ?  which,  Language) .  person,  called  M.  Care  essentially  a dyad,  two, a c o u p l e , English  i s the l o g i c a l  i n the foregoing  of the p a t i e n t  be t e r m e d  the  also  of  considered.  there  interaction  Physicians  p r o f e s s i o n a l ' s Role?  a b o u t who  such as  optometrists,  of Family  The Team A p p r o a c h t o H e a l t h Is  professionals  dietitians,  accupuncturists, Allied  of the a v a i l a b i l i t y of  and  contact. i n the  Under o u r forseeable  30  future, to  the  be  the  usual  physician.  nature, working person is  we  of  envisage  unit,  need  as  as  one  approach today. will one  is in  being may  not  stay. who  by  deny  of  the  i s no  a  i s involved,  is  the f a m i l y The  under  services put  forward.  practitioner, training and/or 19739 program  in  a  doctor  more In a  fable  the  team  cases  seen  necessity  team  of  i s here  the  team  available,  crisis  and  and  i t  should  be  confidante  i n dialogue  situation. and  likely  of  problem  the  The  trained  with  person  for  that  f o r the next g e n e r a t i o n ,  Canada  the  this  registered  a  of  or  Imai) .  experiences  provision  idea  family  mixed  providers  economic  nurse  medicine  Dugas,  been  local  in  reasonable  outpost  Witt er,  favourable  old  the  the  educated  t u t e l a g e under  has  as  men.  for adjunctive medical  family at  team  practitioner.  case  the  f o r the  I f the  of the  the  the s e v e r a l b l i n d  empathetic,  a t p r e s e n t , and  program  role.  reminded  component  best  continue  satisfactory  continuing i n h i s care  suitable,  position  the  complex  t h e p a t i e n t , w e l l p a s t any most  training  argument:  However,  nature,  be  will  therefore define  eminently  well  to  many  There  to  fulfilling  t h e e l e p h a n t as v i e w e d This  in  We  p h i l o s o p h y , and  represented  contact  intimate contact person  cost,  hinged who  in  of  on  So  success  the  community  far,  been nurse  further medicine  (Boudreau,  t h i s type of a n d Roemer)  (RoemerT,  (Spitzer).  primary has  received  practitioner  working  despite  31 The The as  reasons  doctors a  viewed  threat  economic  for this t h e new  to their  t o t h e Second H a l l  Review  -  should  be p l a c e d  fee-for-service of  t h e expanded  practitioner  the nurses  principle; role  with  would  be  Services  that  doctors  abandonment own  of the  elaboration  wherein taken  were Nursing  - Health  and by t h e i r  their  fears  stated  of the nurse,  functions  to  of the Canadian  Inquiry  on s a l a r i e s ,  a r e many.  certainly Their  by t h e s u b m i s s i o n  wherein  success  r o l e f o r the nurse  and  (Spitzer).  Association '7 9  of  expanded  security  position  substantiated  lack  many  over  family by  the  nurses. Family allied  nurse  doctor  of  health  could  general, from  practitioners'  be  been  having  such  so  profession  allied  dental  doctors,  practitioners  'mini-team', to preclude  the advantageous There  i s no by  with  have,  the  that  the  the case  of l o s i n g p r o f e s s i o n a l status  tapping  this  in  possibilities  doubt  In  a  doctors  the u t i l i z a t i o n  professionals.  reason  of of have  p o t e n t i a l l y e c o n o m i c and  would  f o r the apparent be  prescription  reassuringly  as  perhaps  these  resource.  Another  role  a  has p r o s p e r e d  fears  against  functional  negative  health  their  mitigated  considered  arrangement.  dental  towards  p r a c t i t i o n e r s , who,  insight into  an  attitudes  advocated  the lack  for by  them, a  of  failure a  well  of  nurse  documented  energetically  government  interested  and in  32  instituting  a  major  change  the p u b l i c i s b a s i c a l l y health  care  changing opinion  on  which  when a d v o c a t i n g of  of  of h o s p i t a l  practitioners Nurse Canada  nearby  m i d w i v e s , we to  Nurse  Medical this  only  category seen  of  later,  in  Committee  Report  Manpower  Planning,  submission the  numbers  of  have  reveals  that  gained  from  discussion growth  of  new  of  the  assumptions  numbers medical  not  exist  practice  States.  appearing  isolated  the  worker  National review  in that  that  the  development of and Roemer)  the  As  will  Requirements  Committee  on  of  obstetrical  depend  the of  the  on  the  methods. obstetrical of  be  midwifery.  (Roeme^.  of  development  the  to  outpost  resisted  boundaries for  t h e r e were  compared  payment  analyzing  Trial  o f them i n Canada as  nurse/obstetrician will  development  depend  allied  who  discussion  a  could  consider  care  the  public  When we  for  a  of  practitioner.  exception  health  of  of  against  r e d u c t i o n of the  a n e s t h e t i s t s do  few  Program  specialists  groundswell  use  i n the United  the  Britain,  Northern  d a y s by  large  very  are  planner  As  method  B u r l i n g t o n Randomized  the  find  present  doctors  or  as t h e n u r s e  the  the  system.  (Spitzer) indicated  practitioner  despite  specialty  bed  with such  large  The  present  the  politician  change.  admissions  as  no  the Nurse P r a c t i t i o n e r  savings  be  and  is  a  the  happy w i t h  delivery,  i t , there  in  new  The  role  inferences  report  are  of  concomitant  obstetrics,  specialty,  Medical  in and  that  a of  they  33  envisage role of  the  at  the  development  the  expense  family  Medicine  and  planners  medical  the  would  care  care  society."(  seem  fact,  may  they  changes,  same f u n c t i o n .  individual,; around In  Blishen  i s an  it  is  is  as  his  role Not  not  a  as  health  care  introduction  states:  integral part  them  are  society of are  in  "Since  of  for  to the  society,  the  changes  in  structure  of  reciprocal;  are or  -  very  organization.  not  as  has  be  more  the  maintain as  than  generally  of  radical  groups - d e f i n e d  immune  more  to  spite  such  organization  any  apt  organizations Association  not  their  to  often  and  have r e p e r c u s s i o n s  organizations  are  the  the  p.3).  in  factions,  considerably  practice!  infer.  r  between  because  level,  nurse/obstetrician's  in Reciprocity  to  system  Physicians concepts  family  society  Doctrines  relationship medical  for  organized  from  D o c t o r s and  shrinking  Society  Medicine, insulated  the  p r a c t i t i o n e r in that  rewarding prospect  g.  of  of  the  to  the  any  other  higher  power  British  without  to  induce  Conflict  these  of  their Medical  Columbia  Medical  so-called  The  rebel  effect  of  stay  within  change.  e f f e c t i v e instruments  to  base.  their  elements.  In  intelligence  constraints a  group.  sensitive  d i s s i d e n t s when t h e y been  developing  of  such  Indeed, change  i n e v i t a b l y r e s u l t s , but  the they  in  the  the  sum  34  effect and  i s that  attuned  such  to the  Physicians  changes i n the  flow  everyone  else,  greatest  difficulty  of  and  in  often  around  mainstream  i t i s the  of  public  them.  life  that  with  has  the  reality  a d o c t o r , w i t h more f r e q u e n t weekends o f f and  shorter  weeks  with  a l l the  and  avocations. problems  inordinately  from  In  the  general  existing  reciprocity  to  recreational,  for  maturation  early  bank,  his  knows, portions sustain  his  He  or  career  status  should his  him  for  professional with  i s now  suffer  consequences  have total  and  moves  to  a  is  more  culture,  physical hours  economic  made  is  are  social  or  mental  medical base,  not  in data  but  that  he  these  enough  dedication.  maturation  not  initially  aware,  of  his socio-familial  mast  children's  h i s mental  years  career  exists.  Blishen again  medical  his  existence  endless  medical  the  his  been  also  the  aware t h a t e x c e s s i v e l y  excessive  developing  that  work e t h i c  his  for  work  of  by  society  marriage,  may  of  phasically  collide  to  weeks  physician  earlier  before  phases  or  appear  work  weakened  He  toiling  processes,  well-being.  and  the  contemporary  hours  healthy  personnel  dysfunctional  enjoys,  so does t h e p h y s i c i a n . prolonged  life  shortened  alluded  As  hedonistic,  of  social  population  applicable.  Medical  p s y c h i a t r i c illness i n Physicians).  (short:  the  the  society  sensitive  i n a c c e p t i n g the present-day  work  The  o r g a n i z a t i o n s r e m a i n more  to His  imbricates  development.  35  The  thermodynamic  applied  to  physicians  as  they  lives.  That  is  professional equals to  the  work  amount  in  available career,  be  the  energy  of  the  grid  l e v e l ^ say  As  over  represent  the  energy  physician's  One  time,  serves  social  norm  tag,  a  for  falls  due  to  in  enhance effect the  the  the  disincentive  otherwise,  productivity.  lives  his  be  to  work  off  the  a  work  seen in  to his  change  summation care  his  on  weaken and  medical and  work  in  forces  integrated  a p p e a r s t o be  as  from  and  The  versus  vector  strengthen  physician  time  week, would  various  plateaus  a  plotted  career  per  their  if  their entropy  system. any  be  would energy.  earlier  confluence  in of  forces.  income-levelling desirable  in  usually-applied  force  and  time  his  professional  medical  price  years  their from  at  vector,  can  through  say,  delivery  i n hours  output  to  physician  the  entropy  progress  entropy  of  many p r e s e n t - d a y  which  a  of  available  care  these v e c t o r s  direction  This  of  summation  life.  energy  health  i.e.  activity  of  the  coordinate  concept  to  terms income  of  socialist  working  under  the  ratios,  spending  other  curve excessive  of  in  working  status.  beyond The  income  of  would  rather  hours  in  the  tax, as  so its  professional use  pursuits,  decreasing  tax  strong  has,  part  business of  income  professionals,  viewpoint,  Many p r o f e s s i o n a l s or  many  progressive  suppression  recreation  progressive  their  than  be  cost/benefit patient  care.  36 Income t a x own  p r o s c r i p t i o n of m e d i c a l m o t i v a t i o n  diseconomies. The  than  n a t u r a l h i s t o r y of  those  engaged  result  of  stress  level  many  commercial  be  and  as  the  red  not  meld  easily  characterized  as  diagnoses  and  mystique  from  de-emphasis  are  on  a  on  p u b l i c , but  second in  the  manner  professionals.  high, a  the  has  may  The  armed  made  to  sixty. careers  a  the  is  bureaucratic, party  in  the  bureaucratic demands  for  appearances;  as that  suggests  qualities  that  personality for  that  with as  a  has  patients'  Removing  the  the  the  services  foreshortening  moral, not  itself.  status,  i n the personnel  and only  Shrinkage  development  of  lives, medical  i t s repercussions  social  been  associated  cultural,  for medical personnel of  is  portrayal  profession  auger  the  public  satisfactions,  incomes  careers  on  of  court  common  physician  respect,  professional  relative  with  and  physicians,  f i g u r e to  of  too  be  a t age  increased  decision-maker  the  could  medical  treatments.  social the  a  likely  Submission to  to  documentation  incomes  retire  shorter  doubt,  insensitive third  tape;  of  no  comparison who  is  areas,  which,  intervention and  acceptance  doctors'  of  relationship.  medico-legal well  medical  affecting  unyielding  doctor/patient  A  pilots,  force  to  generally  other  involved.  airline  perceived  rules  in  s u r g i c a l careers  f a c t o r s , one  Another  do  wreaks i t s  of  and later  f u t u r e , much and  medical  other careers  37 would from  lead  to a  their  lesser  investment  economic  return  f o r the p u b l i c ,  i n the education  and t r a i n i n g o f  physicians. Another physicians called:  force  •entropy"  -  the  new  authority-figure Watergate.  fallibility  as  have  medical  shown  a  better  Industrial  intern  resident  and  greater  dimension  alone.  As f o r t h o s e  shared-call  desire  for  of  governmental  and  graduates,  interns  and  as much  hours  and  Revolution  time  of  The  approach  no d o u b t  than  that  to  succumb t o of a  of medicine  i n p r a c t i c e , group p r a c t i c e  systems a r e the l o g i c a l  more  pay.  to the existence  lives  already  strength  as p o s s i b l e t o  better  type  physicians  to their  and  Vietnam  training, will  awareness of these  usually  of i n d i v i d u a l i s m ,  s u r p r i s i n g l y organized  working  indentured  more  following  practicing self-determination  achieve  or  perhaps,  awareness  Recent  residents  the  or  when c a l c u l a t i n g a  h i s p r o d u c t i v i t y - i s the r i s e  paralleling  in  t o be c o n s i d e r e d  off  for  outcome o f  family  and  their  leisure  pursuits.  h.  R e d e f i n i t i o n of the Family It  i s not altogether  physician  is  physician,  with  training, as  a mere  confused  Physician surprising  about  h i s years  of  his  that role  scientific  the  today. and  does n o t t a k e r e a d i l y t o h a v i n g h i m s e l f booking  agent  or c h i t  signer.  family  There  A  clinical viewed appears  38 to  be  some  necessity  primary  care  training  programs.  A Report  for a  physician,  definition  of  of the Health  Report).  clearer  definition  his function,  primary  care  Planning  and  was  Task  of the  attendant  given  Force  i n the  (the Mustard  I t states: "Primary c a r e i n c l u d e s not only those services that are provided at f i r s t c o n t a c t between t h e p a t i e n t and t h e health professional but also responsibility for promotion and maintenance of health care and f o r c o m p l e t e and c o n t i n u o u s care f o r the individual including referral when required...The functions of health personnel i n the primary care group i n c l u d e prevention, health promotion, health maintenance, consultation, education, diagnosis, treatment and r e h a b i l i t a t i o n . . . ."  The Force  above  on  1976,  Evaluation  by  the  interesting procedural health  items  personnel.  the Minority of Primary  Dr.  Glazier.  Edward  full-time committee:  have  been  that  was  Health  Council there  It  of  by Care  i s no of  functions  is  also  Care  He  there  practising felt  l e d t o 'predetermined established prior  the  made  of  was  composition  conclusions  to  on t h e  written  physician  to the f i r s t  is  primary  Force  Services  that  of  It  interesting  Health notes  Task  Services,  mention  o f t h e Task  He  the  Health.  Report  fee-for-service himself.  accepted  Primary  i n the l i s t  Evaluation  committee  of  Ontario  t o note  care  consider  definition  by  only  one  on  the  of the  [that] could  meeting'.  In  39 other  words,  function, just as  a  he  as  felt  given  specialty  is  as  are  left  in  staffs,  intimate  medical  trenches; the  Royal  on  the  often  their  the  seeking  by  the  reports  P h y s i c i a n Manpower -  the  for  the  as  t o who  of  is  the  care: nearly  totally academia, in  the  umbrella  borders  their  National  the  so  that  requests Committee  (as on  Planning);  authoritarian  physicians, of  from  and  under  expanded  f a m i l y p r a c t i c e becomes a r e s i d u u m evidenced  functions  happenings  clustered specialists, College,  "have each  i v o r y tower o f  of  and,  Roemer).  with  knowledge  was  that  feasible  problem  i n the  groups  ground  its  work  (Roemer and  biases,  study  the  care  committee,  particular  of  schools,  primary  the  defining  scope  of  group to d e f i n e primary  without  -  on  Specialist  then with  medical  specialist  own  'incestuous'  the  most a p p r o p r i a t e -  others  their  practitioner."  We  the  the  biased  underestimates general  of  definition  appropriate.  been c r i t i c i z e d  of  by  reflection  such, not  the  secluded  health  away  in  planners,  the  who  are  administrative  not  branch  government; -  inherent while  the  family  difficulties  engrossed  practice  p a c t i t i o n e r s themselves,  in  of  the  b o u n d a r i e s and  There  are  many  viewing  dilemma  a  of  wider defending  with  the  perspective shrinking  prestige.  problems  in  a  redefinition.  The  40  problem  touches  It w i l l  be  The primary  most  of  the  other  reassessed i n d e t a i l selection care  of  i n Chapter  candidates  physicians  with  resistance  to s o c i a l disease; with  the  social  sciences; with  as  elaborated  medical the  schools  needs  of  by of  a broader  Glasser; more  today;  branches  with  realistic -  manpower p l a n n i n g p r o c e s s .  a l l  of  medicine.  Six.  for  training  hopefully a wider  the  of  on  germane the  in  identity,  introduction  curricula  impinge  greater  background  concept  as  in to  medical  41  CHAPTER THREE  The  Canadian Health  Care  System  1. The E v o l u t i o n o f t h e F e d e r a l - P r o v i n c i a l S y s t e m o f Health  Care For  health  Canada,  care  roughly 70's.  the  development  may  be v i e w e d  system  comparable The  social  to a  forties  saw  planning.  hospitals  from  phase  introduction  from  fifties  Services  the  the f e d e r a l  of the f i f t i e s of  Care  Act  a  of  saw  Commission  health  the  the  government was  comprehensive  1957), The  spurred  sixties  insurance  embracing on  Health  concerned care  with system,  responsibilities,  the  Services the  by t h e hospital  Saskatchewan  of, a  of  nation-wide  (the Medical  the  Hall  The  rationalizing  accentuation  This  c h a r a c t e r i z e d by  i n 1964.  alterations  of  and D i a g n o s t i c  i n 1967  concepts  of  costs for  i n 1949.  the  c a n be  system  ideas  growth  national  by  each  to the  strengthened  f o r , and t h e i n s t i t u t i o n  health  Act) ,  were  of  o f 1949.  planning  Medicare  stages,  t h e 40's  i n s u r a n c e program ( t h e H o s p i t a l I n s u r a n c e  example  integrative  i n four  the beginning  The  an  by means o f t h e g r a n t i n g o f c a p i t a l  construction hospital  decade,  of  of  in of  Royal  seventies the  the  whole funding  personal  42 responsibility  f o r h e a l t h by  over  containment.  cost  cost-shared  programs  Book,  this  and  are  Lalonde's  report,  The  worry  Federal-Provincial  described  description  and  in  is  the  Canada  reproduced  Year  in  the  Appendix, i .  2. D o c t o r s A t t i t u d e s As  a  Association national  Heagarty,  in  federal  of  1943.  out  funding  to  introduced (Medical passed 1943 all  and  they  of  services; great  was  were  Canadians  aware  a  for  times  the  income  the  scheme, a l l  the  By  the  had  debts  i n the of  which  insecurity.  Now  enquiry  which  supported  a long time  to  complexities to r a i s e  time  to  the  such  programs,  of  in  at  and  for  the  ian people  the  pay  c o u l d not i n the  sufficient  last  twenty  the  of  these  the  were  program  years  had  physicians.  In  hard  thirties.  cash  John  involved  nearly  conscious  Dr.  Canad  i t took  changed  shortage  o f bad  for  started,  had  very had  become  constitutional  gradually. Care)  to  Because  by  of  fully  Canadian  the p l a n n i n g  scheme  C M . A.  move  such  pay  into  committee  services  the  operationalizing  the The  i n time.  bought  insurance  of  health  point  partly  health  government's  funding  sort  was  chairman  reported  that  System  d e s c r i b e d i n the p r e v i o u s chapter, the  Medical of  t o the H e a l t h Care  times  They for be  early  which  were  also  professional collected;  of  sixties,  the  43  privately medical  organized care,  supported these The  their  had  were  doctors  Medical  introduced  then,  plans  now  i n the  assured  run  The  coverage  of  had  grown s t e a d i l y of  the  war  fifties, to  the  but  not  of  to  increase  better by  Canada  service.  these  f o l l o w i n g the  hospital  well  Most  Trans  i n order  provided  years  and  organizations.  the  provide  population  hospital  established.  promoted  and  prepaid  for  non-profit  had  over  the  well  by  early  incomes  schemes  before  become  themselves  Plans  growth  prepayment  insurance  plans earlier  (Taylor,  Shillington). While profession health  there for  province  of  and  was  w h i c h has  persisted  agreements Medicare  have  to  to  of  the  been  i.e. national grants,  for years  proceed  these  and  of  doctors  of  agreements  that  events  of  by  Wolfe,  McTaggart),  them  and here.  several  What  s u s p i c i o n and  the  Equally  the  introduce  The  s i n c e then,  with  p h y s i c i a n s were  and  described  recount  atmosphere  medical  c o n f r o n t a t i o n between and  Badgley  programs.  ambiguities whether  the  the  government's d e c i s i o n t o  proposed  important  programs,  C a r e Scheme i n 1962.  (Tollefson,  i t i s not  a  Saskatchewan  confrontation  analysts  from  construction  grants,  Medical  support  three  hospital  f o l l o w e d the  a provincial  strong  first  operating  government  this  the  grants,  hospital  was  mistrust  despite  formal  operationalizing important which  never  was  were  of the  clarified  subsidized entrepreneurs,  or  in  44  contract  with  the  Agreement" m o d i f i e d that any  they  could  governments.  The  "Saskatoon  t h e payment mechanism f o r d o c t o r s  define  their  own  method  of  so  payment  in  o f f o u r ways: a. D i r e c t b.  C o m m i s s i o n payment t o t h e  Payment o f t h e d o c t o r  c . Payment o f then  reimbursed  doctor fee  the d o c t o r  may  by  by  an  by  t h e p a t i e n t , who  the  approved  Commission.  c h a r g e more t h a n  schedule,  the  important  care  legalized as  is  The  official re-  T h i s i s the  payment method g r a n t e d ,  terms of subsequent developments i n health  agency.  w i t h ,the p a t i e n t b e i n g  s p o n s i b l e f o r the d i f f e r e n c e . most  doctor.  in  the  s y s t e m o f Canada, b e c a u s e i t  balance  billing,  and  thus  served  a model f o r f u t u r e a g r e e m e n t s between  the p r o v i n c e s The  and  agreement thus  the medical guaranteed  profession. freedom  in  t h e money a r r a n g e m e n t s between p a t i e n t s and  doctors  doctor (This  issue  point  of  billing  The  in  in  the the  referred of  bill their  and t  S a l a r y payments t o  the  Commission.  to  doctors  to balance  entrenched  the  come  principle  w h i c h was  •7 9) . rights  has  by  d.  to  surface  again  controversy the  Health  Saskatchewan t o opt  original  out  as  over  a  balanced  Services  felt  of the  agreement  major  that  Review their  system  were  with  the  45  government model  for  of  Saskatchewan,  other  such  agreement  p r o v i n c i a l governments  serving  and  for  as  a  Medicare  nationally. The one  issue  could  is  argue over  organization  of  other  who  groups mechanism  clinical services have  which  is  the  use  of  buffer  as  the  use  of  insurance  the  of  regional  planning  of  hospital  facilities  3.  Accountability pointed  involvement  in  out the  led  to  and  costs.  the  professionals,  hospital influence the  in  at  have  used  to  the  and  to  and  complete  provide  the  argued  by  bodies.  prevent the  open  governments  anonymity,  felt  to  do  such  in  Saskatoon Agreement),  control  community  no  such the  as  the  the or use  development  level.  Controls i n the  previous chapter, of of  quality  various  services  has  accountability control  has  voluntary  programs  in-hospital data  While  funding  differences  boards  accreditation  extensive  the  of  issues  Because  on  to  funding  concern with  as  c a r r i e r s was  resolutions  and  such  professions  established  negotiate  should  arguable,  been  groups  to  As  is  has  autonomy.  decision-making,  power,  between  (as  medical  doctors  confrontion  sixties  of  that  discretion  One  that  accumulated  in  inevitably for  quality  be  left  to  such  as  exert  an  Because  of  mechanisms  have  quality  to  government  arisen  control. the  to  Medicare  tapes,  46 quantity  data  performance particular group of area If  similarly  of  two  of  Patterns  of  in  intermeshed  with  physician  are  surveillance Medicare  produced  regard  in  Although  (as  the  Columbia  in  the  United  pp.  9^)to  and  for of  the  to  and  the  periodic  relicensing i s the  new  at  control  new  in  the  Canada  the any  Medical  quality  a  is  of  is a  is  Surgeons  for  quality  control),  present  the  mechanism  force  is  the  education.  voluntary trend  in  emerging  ( Roemer and  or  practice, province. on  the  for physicians. effort  of  the  by  the  This  Roemer, a  licensing trend  will  appropriateness Continuing College  a  quality  review  medical  there  stress  major  from  amount o f c o n t i n u i n g e d u c a t i o n  state  with  group).  P h y s i c i a n s and a  large  c o n s t r a i n t s of  from  quality  are  of  a  answerable  is  continuing  continued  dovetail  of  Canada,  States  time  a  more,  Because  there  Finally,  on  swing  Committee  on  designated  i s then  emerges  College  make a c e r t a i n  requirement  he  quality  programs  British  education  that  opposed  on  a peer  or  Columbia.  third  emphasis  such  authority  Practice  ethics.  performance upsurge  A  by  statistical  considered,  by  to  a  on  q u a n t i t y when t h e  data.  data  physicians in a  his practice,  mechanism  physician's  to data  deviations  British  a  The  compared  i s decided  shows  facet  Association  in  be  standard  of  available.  practising  performance  the  that  readily  p h y s i c i a n can  particular to  are  a l l aspects  (a norm o f p r a c t i c e  his  norm  governing  of  of  medical Family  47 Physicians status  o f Canada  and  Appendix  performance  re d e f i n i t i o n  Continued  education College  credits  in  per  requires  they  Royal College  productive  family  physicians  (see the  Family  College  minimum  to  pass  qualifying  efforts  quality  practice  they  the  set  of  specialists f o r the  The e f f e c t o f  i s apt than  emphasize  by  a  examinations  and S u r g e o n s .  the  medical  Certification  educational  because  Physician).  of continuing  applicant  the  requires  i n t h e manner o f would-be the  of  mechanisms  both  the  of P h y s i c i a n s  various  t o upgrade  year.  the  write  effort  of a C e r t i f i e d  of a defined  e x a m i n a t i o n s , much  these  of  membership  performance  when  i n an  to  be  more  surveillance  a positive  parameter  to p r o f e s s i o n a l performance. As  regards  governments after  to  1949  regarding  cost c o n t r o l , the f a i l u r e control  led  to  rigid  hospital  Hospital  Insurance  Despite  these  hospital  construction  rules  operation  being  Services  hospital  costs  planning  established  cost-sharing  and D i a g n o s t i c  rules,  of p r o v i n c i a l  in  the  A c t o f 1957. continued  to  escalate. The agreed  provincial  to  come  mid-sixties  p r o f e s s i o n a l medical  into  following they  Medical the  must  Royal  decided  that  controls  over  scrutiny  and t o e n c o u r a g e p r o p e r  members,  Care  set  i n order  up  groups,  programs  having in  the  Commission  enquiry,  their  economic  t o escape  own  bureaucratic  p r a c t i c e methods.  They  48 have e s t a b l i s h e d of  practice,  careful  to  their  as  own  mentioned  keep  group  i n response  government  data  much  more  successful  than  other p r o f e s s i o n a l  data  Society bank  from  Force  (which data  Report  not  containment United 1979). but  control  their  where  there  or  by  as  the  is  no  which  other  i n t h e 1970's, f o l l o w i n g the  to  practice  grown.  data  only,  because  the  emphasis  Similar  health  Task  of  available) ,  care  Force  important  Health  the F e d e r a l  Costs  Care  problems  system  produced  new  Medicare on  May  cost  in  the  28th.,  recommendations,  1972)  and  tioners  (Boudreau,  organization  t h e use  open-  structures (Hastings  of nurse  practi-  1973).  c . T r e a t more p a t i e n t s funding of  an  system.  as Community H e a l t h C e n t r e s  Report,  i n the  1969  o f t h e s e were:  b. C o n s i d e r p o s s i b l e such  in  exist  (Time,  many  ended t o a c l o s e - e n d e d  change  been  members  such  statistics  from  have  a . Amend t h e f u n d i n g a r r a n g e m e n t s f r o m  The  been  clinical  groups,  lawyers, for  they  of  over-servicing  on  then  States  t h e most  members'  manner,  surveillance  hospital  has  The  have  t h e norm.  reviewed was  patterns  information collected  the  over  They  over  this  resource  Nevertheless, Task  in  possible  deviations  In  been  backup  demonstrate  t o the  banks.  have  earlier.  control  activities  Law  methods o f e x a m i n i n g  o u t s i d e of  services  was  hospitals. brought  about  in  1977  with  Financing  Act.  passing  of  The  incomes,  keeping  t o more c o n f r o n t a t i o n medical  associations  came  to  global  so t h a t  to fight  led  experience  to  between  some  care  o f funds  readily  prominence  and  attackable.  on  most  items  when  makes  but,  as  and s p e c i a l i s t s and a c e r t a i n consensus should  be.  target  physicians' the t o t a l  of t h e i r  physicians'  The  incomes  as  where incomes  budgetary  and p r o v i n c i a l  I t i s the f a c t  groups  t o i r o n out  physicians*  i s that  of  on t h e d i f f e r e n c e s  visible  for national  that  made  differentials  be e x e r t e d ,  i s considered.  public  to obtain  t h e emphasis  one o f t h e s m a l l e r  allocation  were  and g e n e r a l i s t s  ultimate  should  had  divided.  inequities,  E x p e r i e n t i a l data  appropriate  are  p r o f e s s i o n a l medical  attempts  as  controls  Governments  (as Saskatchewan  differential  were r e v i e w e d  the  This l e d  between p r o v i n c i a l  increases.  budgeting  accumulated,  with  on  i n pace  of the seventies.  fee  specialists,  difficulty  rising  i t o u t a s t o how t h e p i e was  specialists  t o what  from  pressure  i n t h e a l l o c a t i o n o f an i n c r e a s e  inequalities.  being  i n the  and p r o v i n c i a l g o v e r n m e n t s when t h e  medical d o l l a r s , the various were l e f t  them  i n the dialogue  renegotiate  towards  initiated),  This  Programs  are given  outcome o f a . was t o e x e r t  the i n f l a t i o n a r y trends  tended  Establi  D e t a i l s o f t h e changes  natural  physicians'  time  the  ^X.  Appendix  with  the  health  m e d i a and incomes  so  50  New  organization  structures  above, were p r o m o t e d v i g o r o u s l y However, There  they  was  have  naturally  from  the  medical  been  moved  central  implementation Centres  (see  perform  medical  whole,  to of  such  as  even in  lay  total  by  were  in  centre's  board and  cost  c.  of  p.  above has  containment  out-patient  services.  saved, with  the  themselves  what  experience  the  when en  masse,  oriented  practice  to  use date  or  the  considered  The  as  ensued,  centre  of  directors.  to  manager  resigned  they  Health  employees  1973,  health  a  the  taken  naturally  doctors  in  and  as  centre  in  principles  that  from  physicians  country,  health  had  centred  employees,  community  of  need  Regina of  profession  Community  squabbles  in  their  to e a r l i e r ,  Item  a  Many  efforts  service  i n the  regard  because  practitioners  for  to  success.  r e a d i l y overlooked  as  b.  areas.  earlier,  more  Anderson)  complement  they  interference  alluded  and  control  philosophy,  health  been  directors.  though  a  of  these  the  Hastings Report.  confrontation  centre's  to  functions  not  to  as  in  i n many  modicum  mentioned  s e t of p h y s i c i a n s  has  subject  as  r e s i s t a n c e was the  tried  a  but  role  Crichton  psychological  board  profession,  of  mentioned  resistance  peripherally,  their  and  achieved  some  authoritarian  function,  a  only  as  was  by  the  of  nurse  has  been  30. been as  new  Many  attendant  the  most  funds  e f f e c t i v e measure were  h o s p i t a l bed  cost  reduction,  provided  for  d a y s have  been  by  the  use  of  51 day  care  had  t o be p u s h e d  care  surgery.  surgery  reducing  Even  initially  by  i t s " waiting  can  still  technology  (with  difficulty  in  approval  of  offices This  of  out-patient extending the  offices  and  how  governmental  earlier  procedures medical to  and  Columbia. times  for  services  the r e s i s t a n c e to in  radiologists*  would  be  to  applied. new  This  technology,  u n p r e d i c t a b l e c o s t s , i s s o f t e n e d by  overwhelming  system, with  acceptance  by t h e a d j a c e n t the r e s u l t a n t  of  many  United  new  States  information  flow  Canada. Community  and  Long  Columbia Their by  i n the  o f how much c o s t would be  resistance  and t e c h n i q u e s  care  government  diagnostic  services  controls  and  equipment  No d o u b t  new  Witness the  waiting  ultra-sound  such  when  in British  despite  on t h e p r o b l e m  because of attendant the  diagnostic  t o s e v e r a l weeks.  generated,  areas  of  radiologists  of  o f day  procedures.  arises.  establishment  hospital  centred  natural  spotty  costs)  existed  establishment  for elective  some  ultra-sound  resistance  t h e scope  t o o u t - p a t i e n t or o u t - o f - h o s p i t a l  attendant  private  government  p r o f e s s i o n , a s a method o f  lists  have  the  the p r o v i n c i a l  t o broaden  the medical  Government committment care  then,  Term by  cost  giving  health Care  health  care home  merit care  care have and  programs  such  been  developed  social  service  arises  from  to patients  a s Home in  would  British  departments.  the savings who  Care  attained  othwerwise  52  require  (Crane).  a bed i n a h o s p i t a l ^  4 . Manpower D e v e l o p m e n t s Since initially most  i n those  attractive  areas As  physicians  have  generally  and fanned  has  entrepreneurial effective  manpower made.  to  The  amenities,  medically  congested  areas,  major  the c i t i e s  felt,  and these  first.  primary  specialties  care have  to the middle  however, may  not  skills.  f o r paying  distribution  to consider next  facilities  climatic  the  development  responsible  and  themselves  and  Columbia.  been  control  t h e most  i n those  use o f p r o f e s s i o n a l  become  wanted  in  out from  north of B r i t i s h It  has  and  t o become  those  distributed  with  o p p o r t u n i t i e s decreased  physicians  far  areas  social  tended  have  where  chapter  is  be Since  the  and  that  concerned  most  government i t has  of physician  substitutions  d e v e l o p m e n t o f h e a l t h manpower p l a n n i n g  the  bills,  mix  this  might with  activities.  be the  53  CHAPTER FOUR  Health Planning  1.  Entrepreneurial With  certain or  to  situation worked  of professional  associations,  o f c o n d u c t were a g r e e d upon.  professional  attempt  " P l a n n i n g " , o r t h e "Non-System"  the formation  rules  Activities  ethics,  bring  in  order  which  without  can  be  any  regarded  in® a  individual controls  free  a  as  situation were a b l e  for  of  groups  of  information,  this  s e r v i c e began t o e v o l v e .  used  as p l a n n i n g ,  today,  establishing suit  medicine. dyadic  professional  they  practitioners (1958)  E.C. Hughes  :  patient  of fees,  organized  had  and As a  patterns  as t h a t the  of  concept  word i s  effect  c a r e w h i c h was  of  how,  century  in a  'free  of  regulated  nineteenth  has>described  the  the  A l t h o u g h t h e s e m i g h t n o t be  a system of h e a l t h  relationship,  t o compete  for physicians. more  which  of services,  i n t h e same s e n s e  nevertheless,  the  the  the s p l i t t i n g  code,  first  in  the c o n f i d e n t i a l i t y of  of behaviour  of enforcing  regarded  to  patients,  a mode  code  the advertising  and p r e v e n t e d  established  of  ethical  has r e g u l a t e d  referral  result  The  a  practitioners  'quacks' and o t h e r m e d i c a l d e v i a n t s patients.  rules,  entrepreneurial  medical  -  These  simple  choice  of  54  doctors' was  working  thought  pactitioners a  health  to  should  would  be  be  rules  the  associations  room it  and for  has  the  were  procedures,  when  patients, nurses  and  that  mistakes  were  these  relationships  be  to  organization.  Catholic  to  exploiters  of  voluntary to  of  the  to  force. public  'the  more  American  some o f  more  order  turn,  too  much  more beds  hospital  College  more  was  accreditation Gradually, were b r o u g h t  the of  obvious hospital  instrumental  procedures to strong  obliged  and  surgical  into  gave  as  accreditation  the  Bradley  Association  in  is  As  Roemer's Law,  control  L.O.  professional  E a c h e r n went f r o m  accreditation  Hospital  gained  to  i t became  adequate.  the  the  conform  the  there  that  Hospital  development,  hospitals  states  Mc  Canada,  introduction  out,  performed'.  bring  In  by  available,  i n order  century,  entrepreneurs.  called,  develop  and  concept  illnesses,  themselves,  pointed  surgeons  Surgeons P to  This  over  or  twentieth  in  have  Vancouver G e n e r a l in 1918  the  way  established  d i s c r e t i o n by  more  the  control  treat  in,  ensure  the  i n the  not,  others  operations w i l l  in  to  out  controls  come t o be  abuses  to  called  set  code,  conducted.  that  Fuchs  used  able  However, e a r l y clear  was  be  ethical  sufficient  In more s e v e r e  team  would  The  professional  provide  care  pharmacists  the  behaviour.  1  consultants  caught.  within  the  support. municipal  standards the into  which  most line  as  the  obvious through  55 peer  reviews,  where  or they  controls  communities  were  were  were d r i v e n less  glad  into  strict  the r u r a l  and  where  areas,  the  to get professional help  small on any  terms. In to  North  gain  could  hospital  guide  illness.  This  privileges  committees  became  tertiary began set  level,  to feel  do  their  safeguards However,  strongly  exclude generally itself,  some  and  these,  out as  t o have  general  or  hospital  Ontario,  general  when  conditions of  under doctors  privileges  public attempts  an i n s u f f i c i e n t  'free  choice  control  were  surgery  might  practitioners.  that  or  practitioners  they  three  through  some  a t the secondary  operations  having  for  credentials  Gradually,  certain  restricted,  recognized  general  and c r e d e n t i a l s  e . g . t h e amount  fought  of  European  applying  hospitals'  centres  in  as  the right  records  the  surgical  such  Saskatchewan  by  be  they  episodes  the  physicians  accepted.  referral  work,  would  conduct  being  and  that  some  where  their by  squeezed  for their  could  The  had  before  to  sought  h i s patients to the s p e c i a l i s t s  care.  approved  so  complete  contrast  Britain,  handed o v e r  and  hospitals  in  as  usually  reviewed  was  was  in-patient  privileges,  p a t i e n t s through  such  practitioner  a l lphysicians gradually  admitting  their  countries  for  America,  they  have  to  certain present. for  a l l  inquiries  in  were  to  It  made was  now  of doctor'  was,  - that  p a t i e n t s were  56 not  able  given have  -  to  assess  and  that  not  been  hospital some  the peer  become  study  only  about  the  also Clute  the  by  observers  proposed  pursue such  of  joint  continuing  endeavours.  have  helped  reords, and  federal  Insurance  specialized  of  The  only  inventories,  to  forty percent  standards  office  set  procedures.  should  be  medical  remedied education.  established  been  and  began  competence.  to  left the  provincial  develop  medical  sixty  was  Surgeons  to  of  curriculum  that  s t a n d a r d - s e t t i n g has  programs.  professional  Hospital  their  educational  medical  Provincial  of  is  of  minimum  situation  P h y s i c i a n s and  associations  some  this  there  analysis  basic  showed  the  at  to  leaders  maintenance  Physicians  general, of  about  Family  accreditation  on  that  the  i n Nova S c o t i a and  look  improvement  College  Colleges  to  from  These  solely  earlier,  academic  i n O n t a r i o met  sent  but  were  practices.  others  doctors  doctors  In  and  they  essential.  development  not  the  The  the  concerned,  of  through  office  that  of  Clute  on  that  work  mentioned  rapid  but  care  office  accruing  1950's,  was  by  percent  to  so  planning, A  were  component  the  technology  reviews  As  quantity Medicare data By  of  extended  activities.  quality  quality  to  to  the  hospital hospital  c o n s u l t i n g programs bookkeeping,  etc.  g o v e r n m e n t s have a l s o e s t a b l i s h e d  consultancy  activities  departments. committees  In  within  British  also exist,  their  Columbia,  consisting  of  a  57 varied  group  government  medical  representatives  representative,  government for  of  on t e c h n i c a l  such  as  the  in  matters  renal  order  to  plus  advise  and e q u i p m e n t  and  a  continuing  the  purchases  cardiac  care  committees. One has  provided  many of  cannot  deny  day  outstanding  health  events,  care  achievements  delivery.  daily  newsworthy. seeking  the  them. is  well  delivery  hand, by  expectancy, that  Health  with  to  other  "non-system".  as  we  own  i s t h a t most o f t h e p u b l i c  as  of health  per  is  care  as  o f t h e s y s t e m , on of  mortality  position  countries,  entrepreneurs,  with  understand  health  care  rates,  life  m o r t a l i t y and m o r b i d i t y ,  inferior  often  adequate  of t h e i r  the q u a l i t y  O r g a n i z a t i o n . Annual The  systems  The o b s e r v e r s  such  peri-natal  or  care,  too  granting  boundaries  at  i s not  health  system,  the delivery  look  indices  Canada's  relative  and  constituted.  other  component  tasks  of  system  of the matter  satisfied  presently the  existing  linkages  usual  without  a r e undoubtedly  The f a c t  as  i n r e p o r t i n g news  i n the  due  ill-defined  of  changes  the d e f i c i e n c i e s  "Non-systems"  i n the s e r v i c e  appraisers  accentuate to  as w e l l  t h e c a l a m i t i e s , a s r e p o r t i n g on t h e  performance  invoke  individualism  services,  The m e d i a ,  Similarly,  to  enterprising  t o day m e d i c a l  often accent  hum-drum  that  and f e e l  these  indices  undesirable  (World  Statistics).  with  a long  history  of  dyadic  58  doctor/patient viewpoints,  have  high  standard  with  social  and  costs  As J u d g e  has  funding  but  In right  from  the  became  was  if  M e d i c a r e was  implemented  which  has  mechanism.  There  remedies.  The  professional academic  the  Force  until had  health  postwar  just  on  years  funding,  what  the  1969,  been  their  Costs  after  of  a l l the  leglislated  implemented  into  (Quebec  i n 1970) .  t o be  developed  institutions  to  funding  of  extensive  realize  leads  groups'  about  the  to  costs  always  planning  and  attitudes  concern  until  to  up  provide  services,  their  completely  are  question.  establishment  Task  set  not  was  time  existence,  planning,  for better  into  provide  committed  insurance  about  push  care  processes.  not  The  not  health  Concern  who  between  i t was  meant.  Care  major  a  than  of  i t i s governments t h a t  of  them a l o n g  commit ments  national  out,  beginning  governments  patients  distribution  s e r v i c e s came  there  that  Health  The  while  institutions,  i t took  the  service rationing  care  and  health  distinction  Canada,  providing  individual  to  professionals  and  with  their  s e c t o r s came f r o m g o v e r n m e n t s when  pointed  a  financial  for their  two  dominating  concerned  a l l citizens.  c o s t s of  is  more  issues relating  i n these  rising  there  been  of care  for  planning the  relationships  to  time  concern into lags  mechanisms  hospital d i d not  about  an in  operational implementing  developed  associations  seem  to  the  social  by and  government  the the to  59 be  adequate  to  (Abel-Smith),  the  various  they  became  they  with of  social  British  health  British  examples.  care. the cope  the  in  service than  funding,  for  of  the  lines  mentally with  by  to  planning Health  when  the  problem.  governments  after  the  latter  involved  had  to  i n Canada  in  planning  nineteenth  century  was,  at  Act,  1875,  had  first,  had or  became  municipal  joint  they  laid  health  care  for  could  not  were  more  models. twentieth  century,  involved  in  p r e v i o u s l y been  respond  social  provide  this  heavily  which  committees  second decade of the government  to  local In  the American  which  voluntary  became  governments  that  authorizing  their  f o r Canadian development of  Saskatchewan  obliged  of  of  Processes  following  Public  ill,  In the  Canada  This  Similarly,  planning  they  integration  because  were  with  Certainly,  c o o r d i n a t i o n and  services  by  influenced  coping  Columbia  public  down t h e  be  f o r money  needs.  Governments  influenced  value  (Cochrane).  individuals, involved  or  might  Emergence o f Government P l a n n i n g  and  for  efficiency  standards  parts  in  consider  2.  or  concerned  interest  with  although  effectiveness were l e s s  deal  to  effort.  considered The  demands  participation  of  hospital a  matter  government  for two  the  was  legislation or  more  60 municipalities.  Gradually,  became more and more improve  health  program, doctors  the  Federation) 1944,  health  i n 1916  t o low-income  When  in  involved  services,  started  as  as  social  rural  was  i t had  a  for  mandate  to  to  i n health  planners  (1944) , had  basis, this,  Swift when  national  health  The were  i t was  described  agreement governments,  ends,  applied grants and  health  the  social logics  public services  in  Saskatchewan comprehensive i t s campaign  the  United  moved  States  The  to  Sigerist  on  a regional  region  chosen f o r  federal  planning  for  i n 1948. national  the the  chapter  federal  the  Sigerist The  in  and  i n the  reaching provincial  Plan  s e e n as  across  a  their  were  national  h e a l t h program  construction  evenly  also  as w e l l as h a v i n g  level.  mental  hospital  and  insurance  s e r v i c e s were  security of  health  complexities  health  national  more  Roemer).  h i s cabinet  first by  for  of  f o r p u b l i c and  for  the  attract  Commonwealth  implemented  overtaken  and b e c a u s e  the  at  from  i n the previous  means t o g r e a t e r own  being  between  and  to  doctor  to  and  leg islate  t o be  plans  A p p e n d i x , 1. B e c a u s e  power  Douglas  insurance  federal  lever  f o r the p r o v i n c e .  begun  Current  municipal  accordance with  T.C.  program  legislation  (Roemer  elected to  a l l , in  develop a s o c i a l  Saskatchewan  (Cooperative  (Lipset).  Plan  a  the  areas  platform bring  of  i n seeking  such  C.C.F.  Party  care  the c i t i z e n s  not  health  development  (1949) , Canada,  spread created  61 numerous  jobs,  and  seen  were  unity,  health  A.  servants  health  Hamilton  to follow  some t i m e l a t e r  later  f o r government  planning  services  hospital  districts  hospital  facility  Democratic  health  of p r o v i n c i a l  in  t o meet  these  by  needs.  doctors'  terms,  and  p o s i t i o n , that  When  were  these  no  civil  not u n t i l  d e p a r t m e n t was funding.  Many  became  a  The need  f o r proper  accepted.  Regional  of  Dr.  1966  to  control  British  R.G.  residents, This  was  a  province  planning  in  so  Columbia  Fouikes  into the  and h i s p r o p o s e d  i n q u i r y was  1973, b u t t h e r e p o r t was c o u c h e d  philosophical  George  I n 1972 t h e N.D.P. (New  government  inquiry  Columbia  t o prepare  and i t was  s e t up  an  plans  there  gradually  commissioned  own  1949).  to consider.  were  their  f o r the  manpower  developments.  Party)  needs  plan  h o s p i t a l operating  was  do  Minnesota  through,  health  (1969),  the  i n 1952, i t had  that a h o s p i t a l insurance  to deal with  time,  plan  to Minnesota,  plan.  Minister,  and A s s o c i a t e s ,  returned  able  developed  manpower  care  British  Deputy  from  for national  this  to  While  i t s Associate  and  consultants  matter  at  unable  effectively.  i n consultants  hospital  years  that  were  businesses,  sound h e a l t h  to prepare a p u b l i c health  bring  (James  recognized,  governments  commissioned  to  be  planning  Elliott,  community  than a t e c h n i c a l l y  must  provincial  small  t o be an i n t e g r a t i n g f a c t o r  rather It  stimulated  i n such  completed  socialistic  antagonistic  the Minister  of Health  to the had t o  62 call  i t an  than  a  'advisory'  policy  placate  the  for  other  Quebec  the  Arts,  1974).  Nova  develop  government,  influenced  Ontario  by  a  governments  Scotia  consultant  and  had  for  such help  and  also  studies  1971)  plan  in  rather  order  to  engaged  the  a  health  federal  (White of  council,  professions (Mustard,  consultants  and  Edward  of  series  health  private  Breton,  Prince  from  the  those  Manitoba  received  on  written  regionalization  Cape  as  plans  particularly  1970)  had  the  p r o v i n c i a l advisory  commissioned  (Healing  government,  providers.  been  made by  had  other  Island,  Maritime  had  government  to  sought  to  develop  plans. The  issues  the  p r o v i n c i a l governments,  1972).  studies  better  had  of  (Castonguay/Nepveu,  Paper,  and  document  service  Foulkes  document t o t h e  conflict  and  those  head  i n the  and  financers  gluttonous national  between t h o s e interested  seventies  product,  containment  of  that  of  and  health  "cost"  issues  (Baker, Cochrane).  worry  consumer  in  interested in "quality"  the  health  an  increasing  must  therefore  care'  are  The  the  a  economists  machine  share be  came t o  of  the  is  a  gross  c u r t a i l e d . 'Cost  key  words  from  the  seventies. There advances  is  no  i n medicine  tomography  doubt are  installations,  750,000 d o l l a r s .  The  that  the  expensive. for  savings  newer  Computerized  example,  accrued  technical  from  average the  axial about  avoidance  63 of  invasive  to  be  one  estimated  can  so  to  much  changed  a  bypass  added  not  and  obtain  Coronary has  techniques  true  to  their  any  indicators  quality  of  evaluation  of  medicine's  through  those  when  they  biases. the  reporting.  in  the  newer  adequate  n o t made.  adequately  Can  and  e c o n o m i c s o f any for  with  The  we  cannot  live  cannot  m e d i a do  we  the  live from  turn  to  particular  of  media  to a v a i l political  to  live  field.  themselves action  if  advancements  bureaucrat  cost/benefit  such  the  technological  m e d i c a l advance?  analyzers  as  both  without  to p r o c u r e such  the  of  decry  regard  n o t a l l o w us  administrative  the  attained  without  aspects  f o r chances  evaluate  retrospective  by  awareness  knowledge i n t h e m e d i c a l  attempts any  the  in  easily  what  negative  technologies w i l l  feel  on  quality  critics  is  if  statistical  Patient  negatives evolving  i n medicine.  these  those  the  news  we  demand o f t h e p u b l i c  they are  and  patients,  viewed  Are  that  r e p r e s e n t a t i v e s whom we  the  a vacuum r e a d v a n c i n g  The of  and  devices.  procedure  as  than by  such  have  before  Valuations  system?  i s that  Similarly,  positives advances  used  media  of  sheet  many  derive.  valid  medical  fact  positive  of  capabilities  same  report The  to  present  modern  life  existence  less  the  balance  longevity.  difficult  operations  expensive  of  their  considerations  a  appraisal  i s an  quality  of  on  cost  the  are  unnecessary  entered  surgery  quality  patients,  and  as  predict  ratio  and  I t i s easy Cochrane  64 ( E f f e c t i v e n e s s and deficiencies fields not  of  in  uncertain was  of  on  the  of  advantages  of  prepared been an in  by  the  of  the  and  money  -  costs  off).  Planners  their  priorities  costs  of  health  we  for  the  in  order  care  cannot  medicine  less  to  than  to  or  economics of  Emergence o f M e d i c a l Movement  the  became  advances.  ad  the the  to  system  be  the being  always  and  write review  increased unpleasant  care  system.  adjusted  i s the  Manpower P l a n n i n g  hoc,  have  have t o  face  an  explorations  accept  of a second-rate health person  1976.  Explorations  accommodate  delivery,  maneuvering  in  M e d i c i n e has  so  of  Research  without  science.  willing  obvious  sake  we  new  have  f i n g e r a t as  We  costs.  no  the  International  point  error  Unfortunately,  3.  system  in  the  are  the  where  will  We  National  o f g o v e r n m e n t b u d g e t s may  prospects  the  the  care.  advances  trial  o i l (which  medicine.  entrepreneurial,  health  evolving, cost  technologies  point  States  on  Pervasive  Trudeau government  to  some o f  political  for  the  to bear  medicine  for  funding  "non-system",  method  Illich.  i n Canada, when, f o r  United  inadequate  Ivan  s t a t e of  same s y s t e m we  a  pontificate  newer m e d i c a l  curtailed  i s the  example  this  to  of  i n the  curtailed  was  this  re  economies,  dependent Yet  fashion  advances  ample e v i d e n c e  Research  the  negativism  produce  Council  Efficiency)  in  doctor.  Processes:  an  65 Medical science;  manpower p l a n n i n g  rather,  relatively planning  i t is  recent  were  introduced  emerging  origin.  noted  as  compulsory  m o t i v a t i o n was  an  i s neither  as  two-fold.  unrest  he  t o promote e c o n o m i c and  dualism sought so  of  is  developments  country,  must  a l w a y s be  idealistic  conscience,  political  expediency  control,  sensitive This either  is  say  counterpoised  or  in  a  official  organization, Saskatchewan day,  the  were  used  as  duality in  of  the  resistant-to-change (Badgi&y and  that  the  context justice  the  and  the  more  of  Wolfe).  crisis  in  by  both  in  the  pragmatic  was  government's  They  groups  as  as  in  in  are the  of  any  In  the  Bismarck's Both  against the  are  are  goals  evident. stand  to  legislation  Miner.  1962,  any  of  processes  operative  of  purpose  power  two  relationship,  the  the  i t s population.  synchronized.  enunciated  Medicare  i.e.  system  development  complicated goals  This  self-preservation,  emerging a s p i r a t i o n s of  not  defuse  of a government a t t e m p t i n g  the  to  intermeshed formal  route  His  Secondly,  today,  social  from  of such  equality.  care  from  of  and  through  to the  health  viewed  maturation  national  retain  the  wanted t o  us  a  Bismarck  empire.  a l t r u i s m and  in  of  when  social  with  movement  f o r Germany.  he  h i s new  still  f o r g o a l s of both  that  an  threatening  purpose  1883,  Primarily,  a r t nor  beginnings  health insurance  political wanted  social  Scattered early  an  goals strong  population  66 Developments proceed  apart  similar  social  communication in  i n health  from  planning  changes  planning  i n other  principles  processes  i n Canada d i d n o t  between  countries  with  and i n t e r e s t s .  The  c o u n t r i e s were  enhanced  t h e p o s t W o r l d War I I p e r i o d by a p r o l i f e r a t i n g  literature by  the  on s o c i a l  and h e a l t h  development  of  planning,  computerized  and  world  latterly  libraries,  with  immense s e a r c h p o t e n t i a l s f o r r e l e v a n t i n f o r m a t i o n . process as  a  o f t h e emergence o f a h e a l t h  part  evident  by  /American Ottawa a  of a  Conference  i n 1973.  especially  resources  i n five  international  of  t h e Pan  Planning  held i n  Organization  and  common  of  was a l s o planning, employed  characteristics, and t e c h n i q u e . in a  have  been  in  their  Nys  features  Methodologies  existing  was  as  application  system  health  emphasized book  the health  care by  on  the  insurance  and  European c o u n t r i e s . drew  attention  issues i n medical  of the migration  Chapter  have  elements  welfare  and  do  in local  common  Abel-Smith  study  nations.  countries  Delesie  development  Health  planning,  such  Manpower  conscience,  f o r c e i n the promotion of health  social  Blanpain,  conferences  The W o r l d  despite variations These  of social  on H e a l t h  i n emerging  various  and  system  international  substantial  in  total  system  The  to  the  pressing  manpower p l a n n i n g  in his  of physicians.  As e x p l a i n e d i n  Two, Canada i s g r e a t l y a f f e c t e d  by t h e m i g r a t i o n  doctors  not only  i n and  out of  the country,  but  67 within  its  own  jurisdictions century  which  (Anderson  physicians  and  registers  between set  At  up  in  were  controlling  practitioners,  the  proper  the  t h a t time,  surgeons for  of  over  were  et a l ) .  responsibility  powers  borders,  provincial  the  nineteenth  the  c o l l e g e s of  delegated  admissions  along  professional  with  the  to  the  disciplinary  behaviour  of  their  peers. Apart  from  the  comments  and  suggestions  manpower w h i c h were made i n t h e p r o v i n c i a l -  p l a n s w h i c h were n o t  lack  of  planners  delivery  system  by  b e e n done u n t i l Commission  on  and  well followed  the  situation  Health  special  19JL4_,  p h y s i c i a n manpower  The  on  report,  rec< ommendations  Commission education  to  manpower  the  little  because  (Hall  over  seems  reviewed  by  Report),  the  to  the  of  have Royal  1961-1964.  M e d i c a l Manpower i n C a n a d a . has  1  this  further  issue  planning,  universities  physicians. called  through  a l r e a d y been  mentioned.  report  the  led  development  of  Royal medical  i n Canada.  numbers o f a l l i e d the  in  propose  1969,  By  was  Services  Judek's  -  1949  p l a n s of  administrative control  governments  about  in  discussion,  A 1969 and  as  had  become  educators  that  became  of  aware  health of  h e a l t h p r o f e s s i o n a l s being produced and  community  National in  colleges,  Health  Ottawa  a follow-up  to  Manpower  bring  out  conference  in addition Conference the  was  issues  held  in  the by to was for 1971  68  (Second N a t i o n a l H e a l t h Health  Manpower  Manpower C o n f e r e n c e ,  D i r e c t o r a t e was  the development of a H e a l t h A  National  Requirements 1971, The  submitted analyzed  of  in detail  Canada  meetings  of  began  formed  which  thesis  into  the  i t t o be r e g a r d e d  in  t o be h e l d .  mentioned  this  input  enabled  with  Manpower  was  Committee  Committee  as p a r t  physician  Committee R e p o r t  in  Physician  Requirements  to the National  Considerable  on  Physicians  the  A  Manpower B i b l i o g r a p h y .  and f e d e r a l - p r o v i n c i a l Report  e s t a b l i s h e d , along  Committee  for  Ottawa).  was  above, i s submission.  Requirements as a v a l u a b l e  b a c k u p document. Dr.  D.O.  Columbia, 1959,  who  was  National Planning  had been  invited  Health Unit  Coordinator British  Anderson,  was  of  As  i n health  represent  Committee.  established  Health  the  in  planning  province A  Health  the  Sciences  at  subsidized  by  British  office  the  since  on  the  Manpower of  the  U n i v e r s i t y of  government,  but  independent.  mentioned  Health  Manpower  1973,  and  important  the U n i v e r s i t y of  active  Manpower  Columbia,  academically  to  of  the  above,  Planning report  documentation  there  was  Conference of  that  a  held  Pan  American  i n Ottawa  conference  in  provides  on t h e s t a t e o f t h e a r t a t t h a t  time. Meanwhile, which  had been  i n 1972, t h e S o c i a l i n power  f o r years  Credit  in British  government Columbia,  69 was  replaced  make the of  some  by  new  an  moves  province.  in  Among  the B r i t i s h  primary  N.D.P.  government  health  these  moves  develop  new  hospital.  However,  h e a l t h manpower p l a n n i n g  professionals The in  1975,  and  the  Committee,  stock.  continues are  to  data-providing who  Anderson  left  Department has  National In health  in  officials  i t s own  Dr.  as  the  of Dr.  health  1976  a  now,  planning  time  Columbia  unit  the  basis. one  but  these  unit by The other  and  Dr. -  A. Dr.  Health province on  the  Planning.  government to  down  had  planning.  Manpower  seems  slowed  consulted  plus  to  research,  for  regular  provincial  was  officials  than  the  Planning  contracts,  is  by  continued  British  responsible  on  repealed  back-up  rather  election  National  government  Committee f o r H e a l t h  manpower  on  i n the  planning  U n i v e r s i t y of  representative  1975,  care  objective  Anderson the  evaluation,  is  was  government  functions,  now  Act  on  new  given  to  banks  defeated  manpower  the  The  be  geared  Stark,  While  province  until  secondary  data  B.C.M.C.  provincial  temporarily  tertiary  province.  Socreds.  represent  take  the  a  teaching  s o o n became p r e d o m i n a n t ,  N.D.P. g o v e r n m e n t was  returning  to  the  develop  i n the  (B.C.M.C.), whose  to  teaching  in  establishment  existing  and  to  the  Centre  to  organization  coordinate  activities  started  was  decided  to  hospital  Anderson  service  Columbia M e d i c a l  o b j e c t i v e s were  which  have  concern passed  about to  the  70 Ministry  of  University 197 8  Education, of  an  British  advisory  commissioned committee Minister  of  widespread  Columbia  a  Health  under  the  Health,  on  by  the  Dr.  P a t r i c k McGeer,  neurology  committee  by  was  headed  on  Black.  committee, w i t h  Dr.  executive  Association,  British this  Columbia  committee  public  director  for  and  reported  and  the government, because own  increase  medical  argued  broad  that  physicians should  be  in cut  collection by  the  Health  policy  head Dr.  Columbia of  the  However,  when  n o t made  quickly buried  namely:  Black's more  and  by  f i t i n with  direction,  already  Columbia,  in British  report  than  that  largest  data,  entitled of  Health  Columbia. Personnel  Columbia,  activities  Division  Development, British  were  The of  was  was  to had  enough  recruitment  back.  planning  regularly.  British  Whittmore  enrollment.  British  Presently health  school  there  the  Bolton,  i t s f i n d i n g s d i d not  general  ex-Socred  i t s r e p o r t was  then  This  government,  Association.  i n 1979,  s i x months,  McGeer's  of  Phyllis  Hospitals  an  David  F.N.  Medical  was  Representation  r e p r e s e n t i n g the p r o v i n c i a l  y,  manpower  of  of Medicare, Rigb  In  report.  chairmanship  Wesley  professor.  health  Department  a  The  are and  Services subtitle  gathering  still  carried  most  Rollcall  Health  i n the  data  Services  i s : *A  Province  of  on  comprehensive  '79.  Centre,  and  i s published Research  University Status  British  Report  and of of  Columbia'.  71 The  report  describes  groups, d e t a i l i n g  numbers,  e a c h g r o u p ' s manpower such It  report, i s used  Group  the reports by  registration  bodies  This  examining  health  Planning  Health  discussing  each  western  and  twice  by  Group  in  and  Group,  which  meets  a  i s attended  Regional data.  out  by  meets  two  the  monthly,  group.  year  by  and  Columbia,  each  manpower  twice  Working  professional  for British  carried  health  years.  the l i c e n s i n g  provincial  to  The  discuss  provincial  as w e l l as by D r . A. S t a r k , head o f t h e  Development also  health  Unit,  have  as  an  a manpower  professionals,  and  observer.  The  d i s c u s s i o n group they  also  discrepancies exist  sectors of the country  manpower require  prefer  Manpower  as  two  meet  a year.  various  hand,  Health  are  On t h e n a t i o n a l s c e n e ,  flow  every  consistent, standardized  allied  provinces  allied  '79 i s t h e f o u r t h  planning  Working  Working  representatives,  for  with  personnel  issued  i s specific  manpower  manpower,  Research  well  activities  Provincial  medical  being  of various  report  Hospital District  National  Rollcall  the p r o v i n c i a l as  health  r a t e s , and r a t e s o f change i n  stock.  f o r planning,  groups.  twenty-eight  needs  and  more d o c t o r s  of  qualified  personnel.  d o e s n o t want to  have  i n terms o f t h e i r  policies. and l o o k  or  need  immigration  between  The  Maritimes  f o r continued The more of  medical  west,  on  doctors,  physicians  still  immigration the  other  and  would  to  Canada  72 restricted. position  This,  i n t u r n , would  f o r the various  funding  and e x p a n s i o n .  consensus  or  Department colleges  tacit  of  the  medical  federal  t o a more  faculties  At the present  agreement  of physicians  lead  i n terms o f  time  between  government  secure  there  the  i s no  Immigration  and  the  various  and s u r g e o n s o f t h e p r o v i n c e s .  4. Rationalr Bureaucratic, and Advocacy planning The  national  influenced  by  rationality of  Aspen  on p h y s i c i a n s attempts  to  the planning  process.  A  was  Systems  accumulating  Corporation  on  the  Health  bring large  was more  volume  subject.  Manpower  Methods and T e c h n o l o g y . S e r i e s I d e f i n e d planning  manpower  international  into  literature  committee  The  Planning  health  manpower  i n t h e f o l l o w i n g way: "...a process whereby goals, o b j e c t i v e s , p r i o r i t i e s , and a c t i v i t i e s for h e a l t h manpower d e v e l o p m e n t a r e determined i n a systematic f a s h i o n , i n o r d e r t o e n s u r e t h a t h e a l t h manpower resources, both current and f u t u r e , a r e a d e q u a t e t o meet t h e r e q u i r e m e n t s for the d e l i v e r y of heal th services to a population."  This  definition  is  encompassing,  explicit,  appropriate.  D e f i n i t i o n s by t h e m s e l v e s , however,  stand  as  alone  planning. fails and  beacon  The d e f i c i t  t o take how  a  illustrated  i n such  i n t o account  they  impinge  above  with  determining  on  the  a definition  the p o l i t i c a l the  B.C.'s"  planning action  and cannot  course  i s that i t  policy  factors  process, on  of  the  as  Black  73  Report. In Health  Confrey's  Manpower  Conference  paper,  Planning",  on H e a l t h  "The  Political  presented  Manpower  Aspects  of  t o t h e Pan A m e r i c a n  Planning,  he s a i d :  "Virtually a l l activities associated w i t h h e a l t h manpower p l a n n i n g program a d m i n i s t r a t i o n a r e conducted w i t h i n a political setting and pervaded by political f o r c e s . . . . Improvement o f h e a l t h manpower r e p r e s e n t s a p r o p o s a l for social change, and engenders political debate, compromise, and accommodation, the r e c o n c i l i a t i o n of divergent viewpoints." This of  outcome  i s the penultimate  which p l a n n e r s  planning  should  efforts  of  a l w a y s be c o n s c i o u s ,  eventually  government p o l i c y .  end p o i n t  meet  T.L. H a l l s a i d  the  planning, when  their  reality  of  i n 1972:  "The planner's desire to disassociate himself from the p o l i t i c a l process reflects a misunderstanding of h i s primary responsibilities, which have been s u c c i n t l y d e f i n e d , as f i r s t , " t h e illumination of choices for the p o l i t i c a l d e c i s i o n - m a k e r , " and s e c o n d , as a n a t u r a l c o n s e q u e n c e o f t h e f i r s t , the "persistant restraint and prevention of the foolish, the w a s t e f u l , and t h e c y n i c a l " . " Confrey  later  primarily the  basis  judgements  states  i n terms of  that  of value  scientific  are  "political  more  judgements,  criteria.".  global  particular  issue  under  inevitably  encompass  more  particular  issue.  When  decisions  in  rather  B.C.'s  than  Political  perspective  discussion, than  a r e made  actions  value  than  because  the parochialism  on  any they  of that  in filing  the  74 Black  Report  are  better  able  opposed  to the  when  one  to  attempts  to care.  number  of  developing serve  the  did  above  seem  a  of  mark  the  Economic health  individuals b.  then  the  This  method  in  the  perhaps  document.  one  So  always  needs  has  was  outcome  United  planning. the  of  States, involved  Hall's  study  for  planning  e f f e c t i v e n e s s of  become  method, w h i c h  of  estimating  a in  efforts health health  and  i s concerned with  the  much  and  how  to  are  made by  converted  defined t o The  determination  health to  i n 1941  Doctor's  governments  pay.  needs method: t h e  are  rational  and  had  methods  are w i l l i n g  needs  preface  is  are:  services  Health  population's  the  rational  the  for  four  manpower r e q u i r e m e n t s  of  in  manpower  His  a  efficiency  planners  land  methodologies.  costs  one  though  planning,  be  Particularly  models  a.  context,  even  comments,  to  the  health  as  them,  rationality  improve  health  above  rationality?".  from  methodologies  the  understand  of  "whose  Apart  in  a c t u a l d e c i s i o n to bury  talks  t o ask,  viewed  of  the  professionals  and  manpower by  requirements.  George Bernard  Shaw  Dilemma:  "...make up your minds how many d o c t o r s t h e community needs t o keep i t well. Do n o t r e g i s t e r more or less t h a n t h i s number; and l e t r e g i s t r a t i o n c o n s t i t u t e the doctor a c i v i l servant w i t h a d i g n i f i e d l i v i n g wage p a i d o u t of p u b l i c funds." c.  Health  manpower:  population  ratio  method  75 hinges  on what  needed  t o meet t h e p o p u l a t i o n ' s d.  certain  ratio  Service  targets  o f manpower  targets and  to population  health  Firstly,  that  analysis, in  then  two  i n any  and  balance  the  stressed  defining  those  methodology  health  adopted  f o r i t s unique  than  method  Hall's  methods  A p p e n d i x , 1. need  f o r accurate,  definitions. paper,  Planning", better  1976.  an  study  tapes*  early  Data  of  halth  Committee  of  Secondly,  has  that  be  to  often  be more  h i s table  study  method  data,  based  on  Needs  this  feature  fortunately  because  was  was of  the  standardized  f o r Health  States  i n the  i n her Manpower  in  a  much  for obtaining the  copious  Definition standardization developed  manpower the  needs  National  f o r the by  Committee  the on  Manpower.  Levine of  of  of the c r i t e r i a  Canadian  Requirements Physician  data  factors.  and  data,  should  any  was  information.  portion  factors  country  stressed  Canada  utilization  Medicare  role  reprint  Altenderfer  the  For d e t a i l e d a n a l y s i s o f  p o s i t i o n than the United  accurate  was  any  situation,  reliable  " A n a l y t i c a l and  study,  f o r supply  Underlying  subsequent  in his analysis.  manpower  for  the  the  points  i s required. see  needs.  targets.  f o r t h e demand  specific one  major  projections  with  be  methods: r e l a t e s t o d e f i n i n g  manpower r e q u i r e m e n t s t o meet t h o s e Hall  care  will  and Kahn  operations  i n the United  research  States  in their  wrote  paper  on  of the health  76 manpower  models.  operations  They  research  listed  when  four  applied  constraints  to  health  on  manpower  studies:  It  a.  fragmented  studies  b.  fragmented  funding  c.  limited  d.  inadequate a t t e n t i o n to p s y c h o s o c i a l  i s apropos  factors  to  concerning  scope o f s t u d i e s  t o compare comments  t h e human  policy-making  of  their  made  remarks  earlier  factor  of  government  on  psychosocial  in  this  physicians  discussed  factors.  thesis  and  to the  previously.  To  quote: "... t h e h e a l t h f i e l d i s a v e r y human i n d u s t r y . . . i t i s s u r p r i s i n g t o s e e how often operations research studies i n h e a l t h manpower p r o c e e d as i f t h e y a r e dealing with i n a n i m a t e o b j e c t s whose behaviour is standardized and predictable." In health  h i s paper  on c o n d i t i o n s  models, T e s t a a.  stressed  the m u l t i p l i c i t y  f o r the development of  two p o i n t s : of health  decision  makers,  and b. afflicting Among  the  epidemiology  the population  American  approaches Lave,  the  to  the  and R e i n h a r d t  reader  of a  authors study  m o d e l s have a l s o been  disease  of  processes  country.  developing  developed  i s referred  of  medical varying  f o r more  employed.  methodological manpower, methods,  detail.  Nathan, t o which  Mathematical  77 Chorney, Conference  i n h i s presentation  on  "Mathematical four  simplify be  health  Health  reducing  only  causal  The  weakness  future  They  models,  which  relationships  of these  the  attempt  have  had  in certain specialized  analyses  repeating  ignoring  models  them t o e q u a t i o n s  system, then develop h i s t o r i c a l cross-setional  described  to which  limited areas  of  study.  Econometric  validate  entitled  Manpower",  mathematically.  manpower  Planning,  models:  and t h e n  b.  and  problems,  handled  American  Manpower  Analytical-algebraic  real  success,  to  Models  mathematical a.  can  Health  t o t h e Pan  the past,  social  on  i n the  statistics  health  care  l o n g i t u d i n a l analyses  t o attempt models  rely  to verify  hypotheses.  i s the uncertainty  and i n t h e e c o n o m i c  components  of  the  or  of the  analysis  health  care  problem. c.  Simulation  systems,  employing  computers  as a b a s i c  model, in  models  are abstractions  probability tool  to  However,  they  that  t h e computer  and  that  the  itself.  projections using  t o o have  inherent  program  real  may  world  and  'run' experiments  i n s t e a d o f on t h e s y s t e m  m a k i n g manpower  techniques  may  defined  using on t h e  variables. defects,  undetected not  real  They a r e u s e f u l  possible  have  of  be  in  errors,  accurately  quantifiable. d.  Numerical  experimentation  i s a variation  of  78 simulation using the of  models  equations  computer. one  avoiding  probability  d e r i v e d from e x p l i c i t These m o d e l s a r e  of  several  techniques  but  hypotheses to  feed  useful  courses  of  i n the  selection  action  for  the  tried  to  decision-maker. As propose began by  the  Canadian  n a t i o n a l s o l u t i o n s to  to  recognize  bureaucrats, system.  who  had  (e.g.  planning  having to  were  the  members  constraints  imposed  as d e s c r i b e d a b o v e ) ,  to  manage  groups  reviewing has  and  by  the  continuity  of  the  their  in  the  the  also  had  positions  there,  and  different  of  the  has  which  to  parties  argued  and  basic  and  planning  attention  change'.  planners,  reconcile,  health  drawn  'dynamics w i t h o u t corporate  problems,  say  Podair).  York,  ideological  Committee  the  there  (such  Advocacy  Alford, New  that  the p o l i t i c i a n s  matter  National  He  that  activities the  identified  community  has  in  the  led  to  entrepreneurs,  health  i d e o l o g i e s which resulted  different  involved this  in  advocates  were  in failure  as  difficult  to  agree  on  plans. Before  going  the  ideological  and  their  consider  further,  position  of the  r e s i s t a n c e to the  i t may  the  feasibility  corporate  planners;  and  expressions  o f demand, or  how  be  u s e f u l to  entrepreneurs  planning of to  i n Canada,  process;  rational examine  consider  to  also  planning  by  consumers'  consumer p l a n n i n g  could  be  79 developed.  80  CHAPTER F I V E  A Critical  Evaluation  of the Planning  1. I d e o l o g i c a l D i f f e r e n c e s  a.  Entrepreneurial  inherent  changes in  of  Planning  for  are well  the  Health  systems a r e  positions  bias  of  present  Task  Care  future  illustrated  Force  on  the  Services,  by  Dr.  and o t h e r s  have  examined  international  care  was  mainstream developments  of  grow  accustomed  their of  in  perceptions  of  profession  of  made  proprietary medical  profession  emerging  health,  social,  the health as  a  role  of  planners. whole  maintenance of the s t a t u s  was  physicians that  jurisdiction.  the  and  interested  the  economic  to typecast  public  quo and t h e i r  This  from  reactionaries, The  of  medical  to the c o n v i c t i o n  i n each c o u n t r y , has h e l p e d  profession  the process  phenomena  a process which f o r generations  semi-isolation  the  Report  Primary  scientists  health  advocacy  of advocacy  transcendant  elitism, and  on  Glazier). Friedson  the  i n viewing  in their  Minority  Evaluation Edward  biases  (problems  the  Effect  Attitudes  Ideological also  and T h e i r  Process  in view  more  incomes,  the the that  i n the rather  81 than  in  the  delivery  expediting  system,  has  of  been  p u b l i c against organized T h i s r e a c t i o n was the  doctors'  conviction  critical  observers  (Badgley  contradict provided they  this  course, union  approach.  medical  ethics,  Hippocratic  national  The  services, their  oath,  that  social  asserting and  that  that, to  apparent  was  event  and  strike.  the  public  self-evident  they  to  had  view,  This,  of  even  trade  of  their  abandonment  in  was  medical  in their  e n t r e p r e n e u r i a l or  epitomized  The  s t r i k i n g d o c t o r s would  rights  the  1962.  international  of  abandoned t h e i r  The  the  surrounding  in  and  aftermath  c o n c l u s i o n by  with  care  in prejudicing  Saskatchewan  and W o l f e ) .  within  fits  in  i n the  emergency  were  factor  health  medicine.  of  t h a t the doctors had ethics  a  improved  emphasized by events  strike  general  an  eye  by  the  most  of  the  population. The clear.  abandonment of  The  criteria  their  social  surrounding  ethic  f  Choice, and C o n f l i c t i n S o c i a l These  the  feasibility,  Saskatchewan proposing  a  course,  and  the  government provincial  support aspect. of  criteria  The  fanatic  focus  support met  on for  all  medicare  not  Policy. the l e g i t i m a c y , an  these  plan,  and Webb, i n  issue.  The  criteria  in  except  for  n o i s y r e s i s t a n c e of the media pressure  so  'Emerging P r o p o s i t i o n s *  have been e l a b o r a t e d by H a l l , Land, Parker Change  was  groups,  created  a  the and,  false  82 atmosphere majority The  of non-support;  was  sympathetic  government's  stake.  of  to  process  educated  the  a  remove the  much  medical  sympathy the  introduction view  with  physicians  the  resistance,  American  of of  medical  in  Medical  Blanpain  such  status,  Medicare  when  i n 1970  organized  militant  and  paternalistic  enjoying  seemed  to  concept  of  was  n o t much  they  resisted  (Taylor).  medicine,  our  American  care  i s not as  system  as  The  contrasted  East.  a  i n the United  characteristic and  (given  the right  doctor  produced  were  of  loaned  would  arising  setting) , that by  the  our s o c i e t y  of a  approach  to  limited  to  States.  trait  t o Arab  seem  the  States.  United this  by  of  t h e development  emergence  There  attitude  neighbour,  jurisdictional  Canada  the  to  c h a r a c t e r i s t i c s of medical  developmental  funds  specialists  feldschers  the Middle  innate  organized,  social  Association  reports  Soviet-trained in  at  Saskatchewan  S i m i l a r l y , there  entrepreneurial practice  countries  never  as i n d i v i d u a l s , h a s been a c c e n t u a t e d  comprehensive h e a l t h The  an  by p u b l i c  of the o l d s t y l e  f o r t h e Quebec  present-day  by  wealthy  profession.  position.  were in  public  The d e n i a l o f t h e l e g i t i m a c y  group of d o c t o r s , of  government  medicine  fact.  the parliamentary  the s i l e n t  criteria  organized  to that  benefits  the  legitimacy  However,  seemed b l i n d  actually,  when  countries  t o be  certain  p r a c t i t i o n e r s , plus  during  intern  results (Coker).  a  training  i n the type of Sigerist,  in  83 The  Physician's  Profession  Through the  Ages,  states:  "...the physician's position in society i s never determined by the p h y s i c i a n h i m s e l f b u t by t h e s o c i e t y he i s s e r v i n g . " Mc  Keown  states: " I t i s widely recognized that doctors a c q u i r e t h e i r concept of p r a c t i c e from t h e i r c l i n i c a l t e a c h e r s and t h a t when they leave the t e a c h i n g h o s p i t a l they a r e d e t e r m i n e d t o do t h e k i n d o f work t h e y saw as students.".  The  basic  the  personality  characteristics frequently  obsessive-compulsive  individuals (Parlow,  who  are  of  The  an  sub-specialists expert  endurance  Rothman).  production  of  and  a  higher finite  body  rewards, are  Ostow,  Petersdorf,  Unfortunately, school  he  model  of  Macgraw  [the m e d i c a l the  identify...  .'.  in  the  spite  as  of  resurgence  of  undergraduates turning  b.  Corporate  or  and  in a  1978  and  an  to family  Rational  with  noted  r o l e model,  an the and  others). in  medical  readily available  practitioner  Perkoff,  interest  no  status,  (Hiestand  'Ordinarily  s t u d e n t ] has  of  known  the and  t r a i n i n g , and  Relman,  says,  general  lack  of  well  on  specialists  professional  in  oriented  influences of  of  Miles)  achievement  setting  attendant material Magraw,  (Myckatyn,  abundance  seeking  knowledge  type  are  that  there  increasing  which  to  latterly, has  been  number  a of  practice training.  Planners'  Attitudes  and  84  Problems The  corporate  assumption for  physicians  present is  that  or  rational  i t i s possible and t o p r o j e c t  maldistribution  planners  make  to calculate plans  the  t h e needs  f o r c o r r e c t i n g the  of physicians.  Maldistribution  o f two t y p e s : i.  geographical.  concerning  factors  professional Arasteh's  review  influencing  health  report  A  manpower  t o t h e U.S.  of  the  practice is  location  given  Department  literature  in  of  Josephine  of Health  and  Welfare. ii. service  s p e c i a l i z a t i o n . The mix o f d i f f e r e n t k i n d s o f  providers  (see Their  and  Berliner,  Colwill,  Relman). Rational  planners  physicians  should  majority capacity  of  It and  problems 'health' on  people  also  they  able  to  can c a l c u l a t e provide  i n accordance now  with  how  care  f o r the  the  financial  and i n t h e f u t u r e .  take account of r i s i n g  many  health  Their  care  costs  and a s a p e r c e n t a g e o f t h e G.N.P. i s recognized  projections  certain  be  of the country  plans w i l l absolute,  believe  that  solutions concern  definitions  manpower  assessments  t h e r e a r e methodology problems, but are  fuzzy  and 'needs'  the perception  i n health  proposed.  The  definitions.  are variably  and h a s been  s e t of  Topics  interpreted  of the observer.  i s desirable  first  such  as  depending  Standardization attempted  of  (Katz).  85  The  World  Health  promulgated  and  Organization  definition  g e n e r a l l y accepted.  of  I t i s as  "a s t a t e o f c o m p l e t e p h y s i c a l , and s o c i a l w e l l - b e i n g and n o t the absence of d i s e a s e " . Health  has  personal  also  fitness  (Cushman). or  The  care.  technician,  care  demand  of  the  can  itself  be  derived. of  In  living'  either  true  population  in for  requires  careful  or  or  nurse  country  to  country  another,  various  lab  in  the  categories  definition  of  difficulties.  g r o u p , s u c h as p h y s i c i a n s , once  there  the  are  definition  three  or  has  possible  can been  listings  physicians: i.  licensing  It  difficult Canada,  of  cause  Enumeration of a s p e c i f i c in  that  to  'optimal  population  physician  qualifications  workers  a  that  country  the  as  of  of  definition  that  of  and  needs  follows:  creative  categorized  V a r i a t i o n s from  part  functions health  is  etc.  one  been  the  as  fruitful,  was  mental merely  elsewhere  perceived  Another  standardization  from  full,  have  approximate  health  defined  for  Needs  perceived.  fact  been  health  The from  colleges the  of  various  physicians  provinces  ii.  The  Canadian Medical  iii.  The  Medicare u t i l i z a t i o n  is  important  to  t h e most a c c u r a t e A experts  second in  the  know  and  which  surgeons'  totalled,  Directory. tapes.  listing  comprehensive data  methodology field.  are  and  problem  Hopefully,  is likely  be  lack  of  passage  of  source.  concerns with  to  the  the  86  t i m e , and will  be  with  is  literature.  so.  the  Health  nations,  more  experience,  this  deficit  rectified.  Third  for  more a c c u m u l a t e d  planning  with  A  problem  health  body  of  world  i n a p a r t i c u l a r country,  the  application  b e e n honed by  Fourthly, methodologies  is  the  method  or  problems  hand.  The  projecting enunciated i.  physician by  Hall,  The  as  the  four  which  require  have  not  yet.  of  of  multiple  devising of  methods  manpower  even  accumulated,  problems  problem  combination  the  venture  being  has  solutions, as  of  new  planning  health  difficulty  appropriate at  the  experiences  there  and  is a relatively  literature  specific  previous  limitations  manpower  but  of  of  the  methods for  most  for  the  assessing  and  requirements  are  those  follows:  e c o n o m i c demand method: "The v a r i o u s needs e x p r e s s e d both by individuals and societies are so numerous t h a t i t i s i m p o s s i b l e t o meet them a l l . T h i s omnipresent d u a l i t y 'numerous needs - few resources' dictates that choices must be made. The purpose of economics is precisely to find the mechanisims governing these choices." (Sackett).  ii. iii. of  The  health  Physician/population  the Requirements iv.  needs method  The  (Schonfeld)  ratios  (Canada.  Report  Committee)  service  targets  approach  (see  the  87 Appendix^for Often  no  one  demanded  by  addition, the  method  the  the  problems  tenor  fifth  good  will  method  political The  of  H a l l ' s t a b l e d e t a i l i n g each method).  of  of  the  interwoven  with  quantity  treatment.  The  previously  target  that  i s not  Organization international were r a t e d  year  of  The  In with  on  lack  assessment  planners in  of  of  of  data,  adequate  of  definition  of  aiming  for  World  for  only  is  results  The  that  lack  Quality  are  focus.  the  use  Health in  three  a  the  indices  comprehensive:  expectation  of  life  at  birth  and  at  one  age, the  crude death  iii.  the  proportional  indices,  comparisons, conditions Canada.  assessing  although are  The  and  mortality  health of  health.  of  ratio.  adequate  the  of m o r t a l i t y  effectiveness  population's  in  W.H.O. a l s o  the  rate,  relatively  applying  unambiguity  the  compatible  centres  a  concluded  ii.  These  be  country.  mentioned f u z z y  clearly  sufficiently  i.  is  in  comparison  requirements  effectiveness.  health  (W.H.O.)  to  problem  measuring  that  the  particular  has  There  for  all  country  methodology  parameters  implies  a  adopted  indicators.  health  meet  health  for  insensitive services  concluded  that,  statistics, a  But  again,  to  the  industry  in  because  of  the  t h e y were u s e f u l  population  measures used  international  to  and  in  help  mortality  in  evaluating  improve  that  statistics  88  are,  at best, A  with  crude i n d i c a t o r s of health.  sixth  methodology  i t s inherent  assessment other  weakness  u n p r e d i c t a b i l i t y when r e l a t i n g  of diagnostic  or  f a c e t of the health  measure  of  Difficulty  treatment  service  reduplication  results  or any  requiring a  personal  of  to the  measures  operation  non-quantifiable  of  i s t h e human f a c t o r ,  judgement. reflects  this  weakness. The  seventh p o i n t  methodology  weaknesses  application their  In t h i s  and  d e f i n i t i o n s often  the  inherent  output  the  lack  differences  obtainable  adequate  for  inappropriate input/output  evaluation Finally,  or  of  above, as  in  and  the  market  F o r example,  First, both  using their  the  h i s demand  health choice  an  of  of  resources.  make  economic has  and s u p p l y  criteria  often  economic  physician  system  data  inadequacies  t o make  h i s actions  is Because  data  use  input  The  purposes  the  as  because o f  indices.  efficient and  rules  because of  care  quality.  i t i s impossible to  feel  study  the  s e r v i c e s and  inoperable  conditions.  in  economic  i n the health  poor  vagueness  to control  physicians  t o be  economic  difficult.  Second,  care  standard  measurement  the physician  analysis  difficulty  f a c t o r s are not r e a d i l y d e f i n a b l e of  mentioned  the  area,  seem  t o normal market  and  ability  is  i n the evaluation of  o f economic laws t o h e a l t h  planning.  opposed  to consider  resources,  the  curves. many  and t h e f i n a n c i a l  89 resources  available  to  them  a t t i t u d e means t h e v a l u e s by  p h y s i c i a n s overwhelm  considerations.  The  analysis  an  health  i n such  care  monopolist the and  those  values  difficulties  were d e s c r i b e d by  care  and  the  system,  inconclusive.  alternative  models  limitless.  given  of  to  supply  Klarman.  use  and  The  demand  physician's  of b a r r i e r s  render  economic  p e r p l e x i n g i n d u s t r y as  analysis  Reinhardt's  of  This  ascribed to medical o b j e c t i v e s  economically  position  health  are  to  more  table  physician pricing  entry  to  difficult describing  is  included  as  problems i n d e v e l o p i n g  an  the Appendix, 5 » Given effective solutions  the  aforementioned  health  care  system  have been o f f e r e d  methodology,  nonetheless  t o the v a r i o u s weaknesses  as  follows: Definitions standardized certain  by  and  consensus  world-wide  definitions  health  determining  the  other  thing  of  allied the  nationwide numbers  will  professional annual  care  exact  by  linkages. be  to  and  fields  trans-Canadian  for  Use  our  own  inadequacies  medical  of  the  work  computer  upgrading  possible i f information  relicensing.  of  of  force  i s h o p e f u l l y becoming  Annual  activities  largely for  The  i n the  be  international  specifics  system.  means  could  groups,  the  numbers  health  past,  of  applications,  pertaining  particular  and  terminology  was of the  a  of  its  physician  concerning  requirement social  with  a  of  insurance  the their  numbers  90 of  physicians  counting system  of  to  a  in  programs  when  excessive  or  required  it  terms  required  for  A  similar  be  used  residents.  changes  in  numbers  a  keeping  Such  an  reduce  that  of  computer  medical  evident  double  for  considerably  became  of  the  •reasonable*  and  sufficient (Requirements  that  up the  training  there  were  particular  group  of  health  the  for  funding,  the  provincial  information  as  sought  19,  lack  of  in  to  our of  do  the so, for  for  Part  So  in dealing care  that a  we  is  provide  to  facie  system.  should  and  move  prima  care  which  1).  arises!  health to  be  quality  experts  as  a the  should  health  country  that  The  adequate be  jointly  federal.  Literature declining  Page  analyzing  responsibility  and  be  i t i s suggested  need f o r r a t i o n a l i z a t i o n requirement  proposed  fuzzy d e f i n i t i o n s  relative  experts  physicians  'reasonable'  Report:  requirements,  such  care  that  the problem of  methodologies  been  of  numbers o f p h y s i c i a n s  Committee  the  numbers  i t has  provide  Regarding  physician  total  country,  to  soon a g a i n  the  quality  population,  basic  and  would  inadequate  preventing  move. could  interns  effecting  in  t o meet c h a n g i n g demands f o r s e r v i c e s .  In  develop  the  basis  assessment  lag-time  with  of  useful  on  national  tallies  date  be  physicians  on  accurate  would  limitations the  world  accumulate  on  and  i n computer  methodology  national retrieval  bodies  are of  libraries.  91 The  total  time  so  short,  of  existence  relatively,  collection  of  sufficient  t o meet our  In problem  with  solutions  the  were  assumptions, i.  i t  planning  is  against  a  mitigates  sources  and  data  needs.  of  the  lack  of  Requirements good by  Committee's  indicators,  stating  several  several  general  follows:  large  base y e a r s of d a t a  Marc  health care  background  profferred  as No  ii.  that  comprehensive  analysis  of  areas  existed  in  the  collection.  Perceived  Lalonde's  o f unmet needs  need  equals  statement  in  demand  A New  (compare  with  P e r s p e c t i v e on  the  H e a l t h o f Canadians , p. ^1). iii.  The  deficit  of  equals the unnecessary iv. The  The  it.  A  but  experience  c . Consumer As shown  indicates  assumptions  consensus  statement  application  data  of  are  applies  h o p e f u l l y , we to  services  laws will  real  need.  self-evident.  of u n p r e d i c t a b i l i t y  i s that  economic  necessary  rendered.  t h e human f a c t o r  the  similar  analysis, our  utilization  regards  methodology,  the  services  weaknesses i n such As  unrendered  we  to  have  the  to gain  to  live  with  inadequacies  health  care  some b e n e f i t  in  in  system from  date.  Advocacy  pointed  out  considerable  above,  consumers  ambivalence  in  in their  Canada  have  attitudes  92 towards they  planning respond  satisfactions trustful 29, a  of  of  1980.  to  organized  of groups  people,  about  traditional  medicine As  followed  or  the  make  whole,  planning  Research Council) body,  but  it  critical  of e x i s t i n g  society  and  find more  the  ways  points  out  ways  system whereby  attain  good  monthly  p u b l i c a t i o n , has  on  health  health  care,  or  going  some  been an  on  to  voluntary  Planning  has  to  But,  organized  and  active  omissions  r a t h e r than  to  responsive  employees.  American  and  setting  offices.  of  Etzioni  the  Podair,  as  or  being  too  that  our  care.  personal in  by  The  one  his  the  consumer  numerous  including  large  elaborates  seen  the  stated  make  to  Consumer's G u i d e t o Good H e a l t h , of  women  service organization.  larger perspective,  organizations  sixties,  in protesting  well  focus  p r o v i s i o n of c a r e ,  must  consumers  to  less  September  P  as  (Social  Columbia  patient  services,  been  hand,  become  alternatives,  existence  tended  one  the  such  care  S.P.A.R.C.  has  i n the  a  the  of B r i t i s h  deficits  On  health other  of  i n s t e a d of d o c t o r s '  despite  agencies.  end  radicals  c o n s u m e r s have n o t  demands,  they  Macleans  the  American  the  about  population,  primary  health collectives  (see  w e l l , at  i n the  emergency d e p a r t m e n t s on  On  questionnaires  Page 4 6 ) .  number  services.  i n a p o s i t i v e manner, b u t  young  up  health  needs book  the  and to  Consumer R e p o r t s ,  a  how  be  The  deficits  consumer,  can  of  sure  high on  social  quality to  articles  select  and  93  evaluate 1972  a doctor.  formulated  suggested the  Patient's B i l l Consumer modern  a  i t be  acceptance  TV  American  'bill  posted of  of in  Hospital  rights' every  i t s concepts.  philosophy  medical  hero, spoke  University,  May  at  for  This  i s most Alan  to  and  on  a  Appendix^6.  summated  (Hawkeye  in  encourage  "Statement  aptly  Alda  as  patients,  i n the  a physicians'  1979,  Association  hospital  of R i g h t s " i s i n c l u d e d  M*A*S*H*) when he Columbia  The  by  Pierce  commencement  follows:  "Be s k i l l e d , be l e a r n e d , be aware o f the dignity of your calling. But p l e a s e don't ever l o s e s i g h t of your own simple humanity... . Put p e o p l e first. And I i n c l u d e i n t h a t n o t j u s t p e o p l e , but t h a t which e x i s t s between people. L e t me c h a l l e n g e y o u . With a l l y o u r s t u d y , you can r e a d my x - r a y s l i k e a telegram. But can you r e a d my i n v o l u n t a r y muscles? Can you s e e t h e f e a r and u n c e r t a i n t y i n my f a c e ? Will you t e l l me when you d o n ' t know what t o do? Can you f a c e y o u r own fear, y o u r own u n c e r t a i n t y ? When i n d o u b t , can you c a l l i n h e l p ? W i l l you be t h e k i n d o f d o c t o r who c a r e s more a b o u t t h e c a s e t h a n a b o u t t h e p e r s o n ? ("Nurse, c a l l t h e g a s t r i c u l c e r and have him come i n a t t h r e e . " ) Y o u ' l l know y o u ' r e i n t r o u b l e i f you f i n d y o u r s e l f w i s h i n g t h e y would m a i l in their liver in a plain brown envelope. Where d o e s money come on y o u r l i s t ? W i l l i t be t h e s o l e s t a n d a r d a g a i n s t which to reckon your success? Where w i l l y o u r f a m i l y come on y o u r list? How many d a y s and n i g h t s , weeks and months, will you separate yourself f r o m them, b u r i e d i n y o u r work, b e f o r e you realize that you've removed yourself from an important part of your life? And i f you're a male d o c t o r , how w i l l you r e l a t e t o women? Women as patients, as nurses, as  a of at  94 fellow doctors and later as students? Thank you for taking on the enormous r e s p o n s i b i l i t y t h a t you have - and f o r h a v i n g t h e s t r e n g t h t o have made i t t o t h i s day. I d o n ' t know how y o u ' v e managed t o l e a r n i t a l l . But t h e r e i s one more t h i n g you can l e a r n a b o u t t h e body t h a t o n l y a n o n - d o c t o r would t e l l you - and I hope y o u ' l l a l w a y s remember t h i s : t h e head bone i s c o n n e c t e d t o t h e h e a r t bone. Don't l e t them come a p a r t . "  2.  Rational Planning In  1976  the  a p r o j e c t of special  was  to  He  British  Group  of  summarized  the  b i a s e s w h i c h were i n h e r e n t and  reviewed  surgery  responsible  requirements for p h y s i c i a n s  Working  Columbia.  Policies  author  reference  Manpower  and  the  examples.  a.  few  the  i n Canada, for  Province  boundaries,  developing  the of  using  Amongst  British  assumptions  general  other  with  Health  i n e a c h Task C o m m i t t e e  reports,  as  Columbia,  for  report  practice  comments,  and  and  he  noted  defined  their  that:  field  or  medical  s e t l i m i t s on b.  few  groups  adequately  t h e i r boundaries,  accepted  the  need  and  for  allied  health  professionals. He  reviewed  workloads.  in  detail  The  method  f i n d i n g s were  Manpower  Working  that  times  the  the  to  Group. perform  In  used  discussed  with  discussion,  various  to  calculate the  Health  was  noted  it  activities  might  be  95 inappropriate,  substitution  been c o n s i d e r e d , number o f He which  then  compared  presently  there  projection  there  the  Columbia, could  The Columbia  an  Physician  showed  adhering but  in  including  increase  patterns  their  and  be  of  would  services.  with  those  to  required.  At  -  an  ratios, a  very  the  of crude  rate  of  Province  of  that,  by  practice  practice ratios a in  British  were  1981,  in  fees which  meet of  in  this  may  British be  fallacy that,  and  quite in  the  since  the  Columbia  busy  were  the  summary  in  indicated  of  to  the  1,000.  there  continue  by  annual  in  the  in  British  practice  estimated  of  and  practice  A  1975  methodology  in  in  using  current  ratios  clearly  an  to  Province  productive,  busy  total  a p p l i e d then  observed  i t also  the  optimum  By  that to  were  generous  doctors  Requirements'  physicians  the  not  upon  proposed  doctors  1974  oversupply  inappropriate,  exceeded  had  of  3,744 d o c t o r s  actually  4,760  Province  1981  very  i t might  be  data of  for  4,484  from  proposed  ratios  doctors.  i n doctors  or  the  the  the  700  of  Province,  if  were  by  approximately  British  workers  l i d placed  ratios  t h e r e would be  oversupply,  change  no  in  Subcommittee  Province, time,  the  existed  Overall,  Requirements  the  t h e r e was  other  activities.  Columbia.  the  and  of  already  financially  alternative or  an  alteration  physicians  could  i n c r e a s i n g demands  these  ways  f i n d i n g s form  in be for  part  96 of  the  Appendix^. Also  general/family  included are  practice  R e q u i r e m e n t s Committee While its  Health  activities,  there  planning  guidelines into  office  activities were for  for  of  discussed Wesley  buried  education  took  been  above. set  since  the  stock  of  The up  of  from  the  more  the  the  Dr.  that  than  rough came  situation.  Education, of  continues  government  the  Health  f i t i n with  which  Group  conviction  new  report by  i t d i d not  policies  less  provide  Minister  Black,  because  has  action,  the  taken  Manpower W o r k i n g  will  and  surgery,  tables for  Report.  the  rational  and  workload  Dr.  The  McGeer,  Working  Party  Department,  was  the t e c h n o l o g i c a l  McGeer  had  decided  to  pursue. Some hope f o r r a t i o n a l David  Donnison,  government  are  trade-offs  most  should  exist,  influence engaged  in  the  who  has  likely of  to  the  there  trading-off,  agreed be  a of  inputs i s given that  incremental  time,  is  thinking  planning  but  if  a  likelihood the  i n the  by  decisions  by  and  on  based  standing  plan  that  it  will  politicians  who  are  absence  of  other  strong  persuasions. A in  the  detailed  a n a l y s i s of  Requirements  N a t i o n a l Committee on next  chapter.  the  Committee  planning  Report  of  process 1975  P h y s i c i a n Manpower i s g i v e n  to in  used the the  97  C H A P T E R  Analysis  S I X  o f Canada's M a j o r H e a l t h  Planning  Project to  Date  1. i n t r o d u c t i o n  The  utilization  resources  combined  Requirements document  health  shortcomings,  be  in  study by  1975  as  a  state  basis  developed  in  consultant  Report  Despite  a  With  and  the  planning.  p h y s i c i a n manpower n e e d s . analysis  data  make  i t serves can  time,  to  Committee  for  strategies  of  the a r t  the  Report's  which  made s u b s e q u e n t  out f o r the Health  Manpower W o r k i n g  the author  (see the Appendix),  will  equivalent term  'family  o f , and  'general  practice  i s used  of  t h a t i n mind, a d e t a i l e d  and q u e r y o f t h e R e p o r t ,  analysis,  new  assessment  carried  this  the  of  from  the  of  1  to the Group  now be g i v e n .  is  considered  interchangeably  with,  In the the  practice".  2. Background  The  National  Committee  on  Physician  Manpower i n  98 1972  undertook  to  "develop  recommendations  regarding  physicians  various  project  i n the  was  various  to  ensure  medical  1973,  Manpower.  disciplines more  disciplines  Accordingly, April,  future  a  C a n a d i a n p e o p l e t h a n had the  the The  resource  Health  and  whereby  Welfare,  optimum  discipline working remained total, to  be  appraise  instituted. the  the  various  p a r t i e s , how  considering one  by  on  the  of  the  future Once  of  purpose  National  methodology  a l l the  in  individually  of  filed, and  i f they  this  study,  the  medical  each  individual  were  effect  of  supplemented  needs  discipline them  Physician  creation  Department  cumulative  following  the  it in  were  then,  is  problem:  Definition  Given working  The  of  place.  establish a  and  to a s c e r t a i n t h e i r  Problem  would  to  to  i n each  mix  needs  discipline,  estimated.  reports  then  to consider  3.  be  This  Committee  the  sought  present  could  party  from  i n Canada.".  taken  committee,  personnel  for  Committee e s t a b l i s h e d i n  Requirements  latter  make  requirements  the  heretofore  National  and  appropriate for  working p a r t i e s i n each medical by  criteria  the  deal  reports  would  assumptions with  the  one and  overlap  of  evaluate the of  their  manpower findings,  methodology?  How  group boundaries  to  99 arrive  at a r a t i o n a l  discipline?  If  implemented,  what  Columbia  prediction  the  i n terms  o f f u t u r e needs  working  would  party  be  the  o f numbers and  f o r each  proposals  impact  on  were  British  cost?  4. Methodology  The group  of  problem  approach  utilized  physicians of  in  manpower  disciplines  on  knowledgeable  a  was  to  each  specialty  planning  in  national  physicians  initially  help  of  each  ensure  the  utilization needs.  group  from  Welfare.  A  the  calculation  of  the  planning  assumptions  available  methods,  in this and  assisted  of  manual  developed  way  to  interpreting  projections  was  was  Detailed  practice  i n assessing  party  Experienced,  Department  of  by  National to  future  resource  Health  and  assist  the  work. utilized  calculation  of  involved health  physician/manpower  difficulties was  made  the  respective  recruited.  i n making  methodology  approaches:  of  the  working  in their The  and  working  personnel  groups  accuracy  data,  Each  was  study  their  knowledge o f t h e t e c h n o l o g y , t r a i n i n g , etc.,  to  level.  were  organize a  evident presented  inherent by  the  in  needs,  ratios. the  I  of  the  of  basic and  the  Realization  field  discussion  i n Part  two  of  health  problems  Report  of  and the  100 Requirements course,  Committee.  preclude  outside  the  in  review  this  Such  comment  program.  and  The  i s presented  i n an  of the  if  r e c o m m e n d a t i o n s were  The  r e p o r t s and  Method  Variations  were  Delphinian  Method  the  collection  and  the  employed  i s a weighted  physician  workload  data  available  in  not,  of  from  others  comment  offered  to evaluate  their  total  the  impact  implemented.  by  utilized  of  c o n s i s t e d of workload  certain  informed  consensus  effort  physician  i s that  of  and  to assess  methodology a c t u a l l y  Delphinian  criticism  criticism  validity their  d i s c u s s i o n does  the  method.  disciplines.  garnering  a  consensus  by  opinions.  The  judgement of p r o b a b i l i t i e s .  The  method  experienced  The  capitalizes  Canada  by  virtue  on  of  the two  abundant fortuitous  circumstances: a. u n i v e r s a l b.  the  prepaid medical  fee  for  service  coverage, payment  and  method  for  physicians. The  prepaid  utilization specifics in  a  medical data,  for  given  selected  each  can  The  available  projection  year  for  the  next  chosen  census,  e v a l u a t i o n of  analyzed  the  type  base  the  generally  with  be  insurance  particular  year.  because  care  from was and  to of  years  utilization that 1981, because  claims, determine  service of data  time  the  rendered  1971-72  were  was  first  period.  because  The  i t coincides  i t represents  predictions that  i.e.  i s not  a  time  too  far  101  removed. The as  details  follows.  physicians to  help  The  disciplines  stated from  year  by  the  utilization  can  be  or  of  of  a  of  the  for that  unit  type  that  etc.  the  fourteen  categories.  workload  per  year  specialty,  in  selected  work  general  a  assumption  overworked  in  An  optional  46  weeks  optimal  for  here  terms  hours  work week o f  was  adopted  number  of  to  render  available  of  is  by  48  physicians the  up  the  total in  per  a l l  and  groups which  house year's  the  per  for total  year  year.  they  are work.  work week y e a r calculate  should given  in  or The  doctors  that  to  a  year  spent  is  week  week  services  their  (available  time  hours  of  by  total  This  per  time  performed  the  that  hours  most  by  Their  of  week  unit  i n performing  each  per  groups  country.  i n hours  i s available  per  the  specialty  workload  adding  by  performance  time  workload  hours  by  rendered  rendered  specialty  visits,  are  a  reasonable  specific  doctors  office  assigned  the  method  fourteen  across  service  data),  calculated  calls  the  multiplying  services  data  then  for  type  By  of  services  u n i f o r m i t y of  specific  number  of  standardized into  i n minutes  specialty.  p h y s i c i a n workload  types  first  ensure  various  each  the  The  were  (average)  of  of the  have  been  the  base  years.  base  Using  these  years  and  optimum taking  numbers into  of  physicians in  consideration  the  population  102 trends,  as  well  calculation for  each  of  The  for  projected  projected  number  of  the p r o j e c t e d  1981  optimum  excesses  of  Necessary  5. T o t a l  The  optimum  each  o f new  annual a  in  This demand  each  f o r 1981, to  optimums. graduates  measure  training  in  the  program  measures  By  could  the  i n a formula  graduates  at  to  a  needed  comparing each  required of  and  arrive  annual  number  specialty,  factors,  Formula)  1981  levels,  Method Comments and  availability the  i s that  of  the  specialty attain  shortcomings  the or  can  be  estimated.  then  be  undertaken  Criticisms  large  intriguing  to u t i l i z e  future physician method  1981.  imbalances.  raises  qualified  required  combine t h e p r e s e n t number  required  annual  corrective  to correct  for  an  attrition  Cheung  with  data  and  o f t h e number  the  present  at  practitioners  o p t i m a l number  Manseau-Mo  meet  physicians  a  1981.  factors  calculation  of  developments,  developed  arrives  medical  immigration  to  be  supply c a l c u l a t i o n s  active  (the  future  numbers  can  thus  calculation  likely  optimum  specialty  methodology  of  as  question  such d a t a  needs.  The  physicians  amounts as  of to  utilization who  i n making p r o j e c t i o n s f o r  unstated assumption  are  i s best  the  best  of  qualified.  this Let  103  us  now examine t h a t Should  planning  physicians  at  all?  form of peer has  engage  Manpower  review.  planning  hospitals,  medical about  manpower  i s , after  sixty  surgical  of  Physician review  processes  reviewers  that  unique  relationship  with  the  control  t h e demand  Fein).  If this  medical  care  despite  their  placed  i s true,  total  that  strong  he  planning  physicians  on  i n Canada  been  less  physicians  health  by  power b a s e .  i n the present  effectively  future remove  sole  Does health  their  consumer,  services  a r e a major  be  planning?  care  their  than  should  physicians,  group f o r doing  for  after  hospitals are  (Sorkin,  a r e t h e same m e d i c a l  i s accorded  of  the a c c r e d i t a t i o n  health  physicians  audit,  quality  personnel  own  manpower  part  system, but a r e not determinants  the physician  apropos  committees  i n p h y s i c i a n manpower  hold  Presently,  the  thus  that  theorists  planning?  r e v i e w by  f o r and a c c e p t a n c e o f  has  the  most a p p r o p r i a t e  of  enthusiasm  Is i t l o g i c a l  Economic  a l l , a  medical  50% o f C a n a d i a n  overwhelming. prime peer  in  The r e c o r d  operation  l e s s than  of  tissue,  improvement  rendered.  years  i s that  peer  as  etc., for  accredited. such  to the establishment  such  services  program  of  health  The h o s p i t a l a c c r e d i t a t i o n p r o g r a m  leading  infection,  the  in  been t h e c a t a l y s t i n t h e p r o m o t i o n o f p e e r  physicians, in  assumption.  of the  in total,  the p a r t i a l system  role  make i t  participant status i n  physician their  numbers?  biases  against  Can new,  104 alternative unbiased types such  forms  planners?  of  health  Can  participants  planning  and  of  care  they  delivery  effectively  i n the rendering  threatens  their  status  to  plan of  become f o r new  care  quo  when  r  economically  otherwise? On t h e o t h e r  the  extreme  manpower  opposite  planners?  statistics citizen  hand, w o u l d  In  be more group,  in  methodology  assumptions  be  valid  and  and  Would  legitimized  by t h e m e d i c a l  physician  total  needs  of  group  would  by  be  profession?  be  an  an  same expert  assumptions Would  of  in their  medical  existence  bureaucratic  physician the  by  conclusions?  acceptable  t o move t o  would  own  t h e mere  determinant  of  words,  their  non-medical  spectre  selection  other  making  specialties?  the  appropriately utilized  determining  and  i t be l o g i c a l  groups such  a  recognized  and  Not l i k e l y .  The  control  anathema  of  future  to  organized  alternatives?  Another  medicine. What possibility  then, would  determination medical  are  the  be  one  i n medical  profession  of  manpower  and  role  boards  justified  and  f o r both the  medical  have  r e p r e s e n t a t i o n on t h e i r Is  such  an  technical  insular  for physician  i t s inherent widespread  Would  partial  Physicians  and a p p r o p r i a t e , e s p e c i a l l y  t h e community?  of  planning  associations.  manpower p l a n n i n g , w i t h in  role  the c i t i z e n s .  been slow t o i n c o r p o r a t e c i t i z e n various  a  linkages  advice  lead  105 t o more l o g i c a l a  non-medically  balanced  planning  expert  dominate the  Would  or  committee,  an  in  physician  of  the  in  rendered  permeable a  seems in  i t not  by  of  reality over  and  factors. of  anachronistic. Requirements of  be  context  of  Health  In an  to  care  have  been  Welfare.  effective medically  payment  of  care  methods  costs,  these  and  permeating  planning input  seems  health  more  health  as  medicine  more  party  with  input  granted,  and  other  but  r o l e of  of  Committee and  logical  citizen  all-medical  Granted,  to  membranes  light  all  lead  input  today's  advent  third  planning  to more  leg. i s l a t i v e l y  the  of  citizen-dominated  informed  educated  public,  selection  Department  care  physicians;  physician  governments, b a l l o o n i n g  the  a  take  uncertainty  closed-system  better  sophisticated  factors,  of  all  self-determination  the  Formerly  other  to  into  strong  measure  system.  many  Would  health  types  i.e.  Would  although  inappropriate  involving  apt  three  enough  solitary  past,  media,  of  p a r t i c i p a t i o n type  be  input  them a l l .  appropriate The  input  the  a committee with  well?  total  s u c h a c o m m i t t e e be  above,  raises  rejection design  of  mentioned  citizen;  committee?  the  joint  context  committee?  Consideration committees  in a  medical  i n t o the  planning  considering  more l i k e l y  committee?  would  when p u t  dominant  conclusions,  s y s t e m , be  or  conclusions  was  project However,  process present  from this  the was  106  more a s t e c h n i c a l a d v i s o r s , of  and n o t a t a l l i n t h e r o l e  representatives of the p u b l i c i n t e r e s t In  conclusion,  documents and t h e i r they  represent  physicians, defensive picture  a  major  validity,  the views  who,  by  posture,  of a  their  private very  some  these  the fact  interest  to give  needs  that  group,  a  balanced  of the country  complementary  of the general  of  status-maintaining  are not l i k e l y  without  representatives  criticism  a r i s e s from  of the future medical  whole,  and n e e d .  as a  input  public health  from  consumers.  a Having planning,  thus  let  participation medical is  activity  by  the  consider the  health  funding care  residency  programs,  payments, The  hospital  is  mechanisms  and  problem of  field.  programs.  North  day s i t u a t i o n  programs,  of  Admittedly,  America  sectors  from  and  medicare  public  health,  involvement of  part the  by  funding of  the  inadequacies  A c t as i t a p p l i e s  i n the d e l i v e r y  fund  intern  integration  stems  i s usually  governments  payments,  of  input  government  in specific  programs,  characteristic  of  determining  of  This  Thus,  research  lack  medical  status  in  levels  mechanisms  of non-integration  the B r i t i s h  present  care  insurance  the  into  By and l a r g e , c i t i z e n  training  dominant  government  public  system.  medical  input present  various  i n the health by  the  general  through  university  etc.  for citizen  planning.  only  accomplished of  us  manpower  achieved  pXimped  of health  to the care.  107 The  Act allocates  provinces, federal  but the r e a l i t y  Physician  provides health  an  care d e l i v e r y It  public  demand  of  involvement public  health etc.  alternative  care,  how  considers initiating satisfied  Would  their valid with  informed  concentration  more  the  still  be n e c e s s a r y  appropriate obvious  surveys?  Is  in  the public  so  planning?  manpower  h a s been or  the  their  planning. groundswell  family  thirty on  a  t h e p u b l i c may t o what  years  type  of  of  specialties.  t o be a  n o t be so w e l l desires  Over  are i n  the l a s t  of p u b l i c practice  post  one  problems  manpower  as  to  could  when  i n medical  sure  to the  participation  the  Is  informed  answer  as t o p r e f e r  so  public  process?  system  the general after  be  and  reliable  of medical there  Given  surveys  the s p e c i a l t i e s , or  physician  the present  non-participant For  delivery  t o be a p p r o p r i a t e ,  for public  expense  not  planning  i s y e s , i t would  consensus  reached.  was  for this  enough?  programs,  immigration,  then  of the  i s national i n  services,  interested  determine  facet  training  deemed  questions  lives,  demands  Committee  university  Why  solicited  f o r one  The c o n c e p t  participation  enough,  for  to  for health  distribution,  years,  to the  economics  Requirements  approach  system.  relates  mechanisms  terms  of today's  Manpower  integrative  scope.  be  for health care  participation.  The  above  responsibility  support in  World  Could  few  the  their  War  II  public  108  wants be  ascertained i n regard  of  the  family  practitioner  general  public  be  nature  of  the  family  specialty  groups,  interest,  that  programs.  How  considered  far  be  should  give  their the  should from  allowed  to  primary  in  practitioner  with  see  the  role  Would  the  determining  the  encompassing?  reliable  dominate  apart  public  more  t o what t h e y  than  own  specific  medical  the  wants  economic  determine care?  the  various areas  schools  and  of  public  the  reality? for  Is  the  their  Should  themselves public  be the  just  aware  of  who  of  the  n a t i o n ' s h e a l t h needs as o p p o s e d t o t h e p u b l i c ' s demands on  the  health  premium  for  by  vs. Can  same  the  Should  primary care  country  care  questions  to  a l l  hinge,  primary  by  care  institute  as  Committee's  of  in  the  may  the  of Family  have  carrying  results  labours.  Definition  well,  on  the  a by  general delivered the  These medical  process.  participation  strength  pay  delivered  delivered  afford  t h e R e q u i r e m e n t s Committee, b u t  6.  public  i n the e l a b o r a t i o n of a p p r o p r i a t e answers.  Public  the  the  These q u e s t i o n s demand some r o l e by  manpower p l a n n i n g  idea  a  primary  specialists?  public  system?  selecting  specialists practice?  care  Practice  been  out  of  i t s very of  a the  difficult tasks  of  a b s e n c e weakens  the  Requirements  109  The to  second  the  major  definition  flaw  of  i n the methodology  family  Requirements  Committee  Report  formulated,  just  the  reported. in  Nonetheless,  the reports  practice  is  pre-empt  i t  does,  when  such  a  necessarily health  role  of  a great  practice  came f r o m  organization was  the lack  Family  practice  half  of  determinants are i.e.  Even the  they  Is  practice  to f i l l  the  practice?  fuzziness  of  strong  national  facts  are that  t o have weak  assumed  power  base.  of the medical  power  practitioners  physician a r e and how  l a r g e l y i n t h e hands o f o t h e r the s p e c i a l t i e s .  a  be  has surrounded  The  of  best  family  family  practice  to  practice  could  of t h i s  practice.  national  o f who  of  of a p o l i t i c a l l y  family  proper  are reviewed.  of r o l e ambiguity Some  general  by g o v e r n m e n t .  for  a t t h e bottom  though  data  appropriate  i n the face  was  prevailing  and  functions  Canada  f o r general  leadership  structure.  most  for general  strong  had  general  definition  of  deal  new  i n Canada.  difficult  that  procedures  or  needs  specialties  appropriate  these  role  was  attitude  the u t i l i z a t i o n  the best  care  Admittedly family  is  a  Practice  s p e c i a l t i e s bordering  to expropriation method  Granted,  Family  various  functions  s t y l e of gaining  compared  it  that  on  t h e common  of those  certain  obviously The  as  practice.  relates  constitute  workforce, they  medical  will power  the  function groups,  110 Thus  we  sub-groups  is  find the  family  practice,  public  i n t e r e s t or  curious group  (in  sprung  to  needed  to  practitioners practice  were  one  incongruous part  that the  slow  of  a  nation's general  practice?  medical  training  against  medical of of  the  s c h o o l s of  hospitals, family  specialty general  such of  practice.  practice  are as  At  medicine  expanding  role  would  i t not  numbers  in have  were family  Departments of  family  of  so. the  faculties  British Did  it  medical  have  had  the  a  the  not  seem  training half  facts  need  in  Columbia  of  department  power  obviated  to  of  of the of the  defend  incongruities. specialty  for  the  the  same  nibbling it  to  the  representing  not  rise  of  groups  u n i v e r s i t i e s and  determines,  groups  do  Obviously, grounds  the  practitioners  University  and  parallel  predicting  i n medical  physicians  power  Why  1981?  in  of  practitioners  required  involved  maintaining  Thus,  family  family  to  role  internal  report)  of  evolving  the  physicians,  the  numbers i n t h e  for  medical  s i t u a t i o n gives  as  larger  of  necessarily  party  last  be  group  the  more  in  the  to  of  schools.  predicted  of  determiner  numbers  universities,  being  the  such  medical  train  of  This  t h e i r own  mind  power  not  desire.  larger  university  many  does  working  more o f  training  the  and  their  the  largest  circumstances,  need f o r of  that  is  on  the  most  at  presently  control  active  part,  time, the  in  the  the  in  staffs nature  organized  boundaries  of  constituted,  to  Ill further  restrict  specialty can  a  working  party  summation  boundaries,  general  of  these  adequately practice  constantly approach  i t s role.  reports  subtracted  delivery,  one  and m o d i f y  on  same  from  specialty  t o what  wonder  physician  the whole  of  roles  and  medical  care  practice?  Is  residuum  surrounded  by  This  negative  constitutes general  i f general  manpower,  general  s h r i n k i n g boundaries?  as  the v a r i o u s  committees*  describe  a  Given  type  practice  practice  is  viable  graduate  in  medicine  of  makes  under  such  has  been  circumstances. The moulded  present in  the  envisages.  Does  new image  the  t h i s new  malfit  portrayed  the u t i l i z a t i o n  model o f f a m i l y p r a c t i c e a  vestigial  embodied the of  are of  model  practice  asking  i s who  general  outmoded virtue  members  medical to  produced  should  be  exclusively schools  with  outmoded.  specialist  but s t i l l of  of  medical  be  data?  to various their The  for family practice  lingering  educator  appropriate  In e f f e c t ,  of  graduate  On  model than  what  of the  interest  of  groups i n position  presently  concerned  we  model  function  specialty  vested  i s one  the  as  clauses  practice?  the a r c h i t e c t  Allocation  as  utilization  grandfather family  family  practice  Is t h i s  a p t t o be any more  practice?  making  family  data?  d i s p l a y e d by u t i l i z a t i o n  seems  of  hand, i s t h e u n i v e r s i t y  general  model the  by  i n the older  other  that  remnant,  school  image o f t h e g r a d u a t i n g  practitioner by  the  medical  more  being with  112 ambulatory  care,  medical  practice  non-procedural model  in  public  had  items  any  input  that  the  would  public the  such  of  care,  starting  committees school.  for  more  of  public  powers  be  record  entry  utilized  been  date?  in  most  McMaster  of candidates  achievement future  of  academia in  doctors? for  choosing  their  and a  by  medical  The  the  has  been  medical  lead  academic  such  medical  and  track method  solely  the  types  preoccupation  achievement Are  of  academic  to appropriate and  on  candidate.  does c h o i c e  of  method.  in  exceptions  based  but  have  bodies  the  pre-medical  predilection  selection  of  notable  expediency  with  selection  selection  few  most  Should  modus o p e r a n d i  is difficult,  process,  The  enter  hands  with  the  the  selection  of  them  on  model.  the  to  other  the  University,  Selection  based  in  schools,  achievement  method  on  extent  of f u t u r e d o c t o r s  Basically,  academic  a  be  seeking  than  some  for decision-making.  solely  What has  to  as  sacrosanct  vested  educator?  such  candidates  to  seem  come a b o u t ?  would  Committees f o r s e l e c t i o n  even  terms  point  a  to  the d e t e r m i n a t i o n of the g e n e r a l p r a c t i c e  appropriate  such  i t would  participated  participation  of  the  As  in  c o u l d such  Has  a  appropriate?  fitting  been  public  interest?  i n p u t be  on  Is such  determination  health  of  emphasis  be  How  the  more  aspects  preventive medicine.  into  consumer  psycho-social with  and  with  indeed,  ultimate  the  and  keeping  m o d e l , and the  with  such  biases closed  113 system  biases  Again,  i s this  public?  apt then  Would  in  the  not  best  public  a proper  area  for entry  more in  from  been  doctor-technicians  who,  their  product  spite  ultimate  indeed,  the  economics  of  a f f o r d more o f s u c h  a medical  product?  considered  here.  applications  for  recruits  a  concerns  medical t o be  candidate  of  Is  i t a p p r o p r i a t e when  to  have n e a r l y f i f t y  branch almost Is  an  out  percent  of  outcome  such  a  less  as  health  The  intellect selected of  a medical a  proper training  well  a service?  care  trained  to  be  more  arise  than  process  achievement.  finally  graduate,  doctors  enter  a  become  reduced  referral  worker?  of  talents?  health  I f the s p i r i t  system  Many  exploitation and  and  remains  and  may  triage  medical  selection  t h e new  that  period  economics,  positions  filled.  profession  role  our  school  those  practitioner's  turn  deliver  their  to the  such  family not  of  the  original  their  wastefulness.  high  our  restructuring  of t h i s whole p r o c e s s  It  there are p o s i t i o n s  their  emergence  Can  aspect  of  excellent  attitudinal  (Blanpain).  Another  the  participation  during  entrepreneurs should  the  of  out of  undergo, an  of  track record, previously turn  is  training,  to  medical  to  orientation,  medical  view  greater public The  interest?  balanced  the  process?  has  leading  the  desired  selection  motivational  in  a  schools result  mentioned,  of  be  not  characteristics medical  to  care  the  new  Could  we  worker  to  of f u t u r e general  114 practice triage  i s captured  referral  by  a description  worker',  would  not a  such  playing  practice well  can o n l y  down  grading  ultimately  lead  the trend  should care  along  the medical cling  to  evidenced  in  parties?  several  Are  several  of  there  of  aspect the  the reports  of  lessen  the  described  of  i n discussion  boundaries, maintain report  role  yet,  the  of  on  right  to  example.  new  nurse-obstetrician possibility  majority unto the  In t h e i r  o f normal  themselves family  mentioned. a valid It  of  and  of  seem  hand,  primary  role,  deliveries.  then,  to  an  of oversight  seek  tasks  as and  seek Take  working  to the  party  discussion  of  a  t h e g r o u p can s e e  group  a  worker then  deliveries.  i n such  both  they  care.  such  The  voiced  giving  they  gynecology  allocating  working  attitudes  specific  (midwife)  kind  the  as  practitioner  limited  d e s c r i p t i o n of f a m i l y would  own  primary  tenaciously,  family  other  a l l abnormal  Is that  a r e moving,  groups  rather  practitioner  If this i s  On t h e one l e v e l ,  give  the o b s t e t r i c s  for  the  so  those  of t h e i r  family  rendering  reports  the  the  of  schools  not c o n t r a d i c t o r y  p r i m a r y and s e c o n d a r y c a r e ? to  role  deliverer.  s p e c i a l t i e s also role  of  t o t h e need f o r a l e s s  which medical  that  form  and e c o n o m i c a l ?  the  t r a i n e d primary medical care  indeed  in  and  'medical  surrogate  m e d i c a l p r a c t i t i o n e r be more a p p r o p r i a t e Down  as  The  renders role  arrangement likely  the  of  i s not  to lead  to  practice?  i n s p i t e of i t s l e s s e r  status  115 in  the medical  groups, focal that  that  point  schools  general  country.  General  nearly  half  be  exclusive  practice training  a  What  on t h e p a r t  processed and  are  practice severly  attainable,  the  frustration ultimately program. that  lead  not  general  universities'  this  problem  medical  is  school  process.  and  products  of  our  Those  who  opt  for  to linger  long  economic created  opting  for  a  one's  a  easily  feeling talents,  specialty  o f economics w i l l  lead  t h e more to greater  same p r i m a r y  working p a r t i e s s t i l l  will  members  the  market  competition  services  espouse.  of  training  the percentage of p h y s i c i a n status,  with  Although  security by  of  family  in a field  and l i m i t e d d u t i e s .  misapplication  specialist  sense  specialists  unrest  the d e l i v e r y of those  specialist  groups  are  makes  to  general  They  horizons  The h i g h e r  achieve  principles in  and  of  inputs?  practitioners.  practice  the  part  outcomes  school  shrinking  in  of  Common  has  of the s p e c i a l i s t  are not l i k e l y  general  role  of the  specialty  then  the t r a i n i n g  the  medical  family  Why  doubt,  after a l l ,  the destiny  i n t e r e s t or i n p u t ?  No  e d u c a t o r who c o n t r o l s  do,  or  planning  manpower  of assorted  larger  programs?  attitudinal  that  otherwise.  held  manpower  practitioners  i n t h e hands  us  the linkstone  of the medical  of the p u b l i c  tell  of the s p e c i a l t y  remains  of health  Is i t appropriate  practice  would  practice  i n any p r o g r a m  i s valid.  constitute  and i n t h e e y e s  that the  Can we a f f o r d  116 Cadillac  delivery  Extrapolation wherein  all  delivering care,  of  medical  the  trio  worker.  effectively outcome health  What  specialists be  doctor  to  that  a we  but  primary provide  more  a lesser  care,  would  schema.  best  Is  be this  i n t e r e s t s of  i t logical,  given  the the  physician?  Could  the  competently than  will  restrict  to  ensure  his  eventually  and  rewarding,  the  public?  likely  cope  seems  consultants?  secondary  mechanisms were  encourage  d e l i v e r y with  Is  role  of  specialists,  Solutions  to  role  future  tertiary  alternatives?  efficient  himself,  adequately  only?  Could  more  prividing  payment  such  a  and  a  the  family  trained  to  practitioner  public?  Possible  lead  become  such  in  rewarding  Only  future.  not  and  the  be  more  in  services?  secondary,  family  of the  and  are  practitioner  role  The  place  Conclusions  the  primary,  eliminated  traditional  could  primary care  care-consuming  present?  trends  health  graduates  of  appropriate  larger,  primary  present  whilst sharing  health  7.  of  for and  survival  in  not  not  only  to  act  as  such to  of a the  reasons, care?  altered appropriately,  specialists  role  specialist,  economic  tertiary  a at  the  a  with  possible  Would  Can  family  could  If we  consultants  117 University practice  streaming  specialties  after  engineering and  training  years for four  such  are being  medicine turning opted  Would  result  early  style  result  deadweight  retain  and  tenure  the  the  of  would-be  allocation  their  eliminate  be d i s c l o s e d  after as  benefit  from  the four-year  a specialist Returning  curricula two y e a r s ,  much  of  unnecessary  medical  by v i r t u e  such  school  of t r a d i t i o n  The  particular  or r e q u i s i t e f o r  specialist.  many  The  inefficiencies cost/benefit  proper  specialist that  program,  portion  i n h i s own  no  would  analyses f o r  The f a m i l y p r a c t i t i o n e r a  have  specialized  the basic of  in  while  who  school  appropriate  i f proper  finally  another  saving,  area of  teachers.  graduate  c o u r s e s were c o n s t r u c t e d . also  economic  items  positions  program  streaming  unloading Many  two  earlier  o f such c o u r s e s t o t h e a p p r o p r i a t e  p r o g r a m s would likely  the l a s t  A streamed  of medical  courses are not necessarily every  during  own p a r t i c u l a r  their  metallurgical,  specialist-consultants  learning.  curricula  various  take  programs a f t e r  in  so t h a t  into  however,  this  Restructuring  optional  could  trained  engineers  splitting  civil,  program.  would,  not  for their  knowledge?  as  i n considerable  out w e l l  for  developed  specialties  years.  for  the second b a s i c y e a r ,  of the undergraduate  medical  into  techniques  specialties,  mechanical,  programs  doubt  o f streamed program  would  emerging learning  right.  to  the  concept  of  physician  118 manpower in  allocation  Canada,  ultimate  and t h e r e q u i r e m e n t s  i t would  experience  seem of  logical  to eventually  the working  parties  appropriate methodologies  for insertion  streaming  the  years.  process  Here  resources  be  products,  then  after could  made.  including the  second  rational  The  changing  the  two  care  basic  o f manpower  specialty  practitioners,  their  the medical  allocation  health  use t h e  and  into  of  resulting  family  for physicians  medical  would  attuned  to  needs  Canadian  p e o p l e , and more i n k e e p i n g w i t h t h e i r  be more of  the  economic  capabilities. Having manpower  planning  Committee linkages we  will  considered the broader  Report, such  now  as  raised  and  having  a program turn  by  issues  of physician  the  Requirements  demonstrated  has i n t h e h e a l t h  care  to the conclusions of t h i s  m e d i c a l manpower p l a n n i n g , i n C h a p t e r  the  Seven.  many  system,  thesis  on  119  CHAPTER SEVEN  Conclusions  f o r Health  Planning  1. General  a. The  premise  of health  maldistribution  of  manpower  physicians,  planning both  i s that  by  numbers  and by mix, l e a d s  to the d e p r i v a t i o n of access  health  as  care,  injustice  and  which  such,  requires  planners  and g o v e r n m e n t s .  Health  resource  manpower p l a n n i n g or and  technique, error,  must be p a r t of  constitutes early  planning, i s a part,  and t h e r e f o r e financial  of  social  remedies  which  by  health  i s not a refined a r t i s subject  responsibility  o f t h e government  the system.  a  to  to  trial  for  which  r o l e as a m o u l d e r  120  c. Medical with  manpower p l a n n i n g  the s p i r i t  can p r o c e e d  o f freedom  of choice  a p r o f e s s i o n a l c a r e e r , such the  fabric  and c o e x i s t  of a democratic  i n choosing  freedom b e i n g  p a r t of  society.  d. Intervention p o l i c i e s , in  the  advance  health  t o invoke  changes  system,  require  careful  care  evaluation  evoke n e g a t i v e  designed  to  ensure  that  they  do n o t  changes.  e. Health the be  manpower  allocation remembered  factors,  planning  i s an  integral  part of  of health resources, but i t should that personnel  not  resources  inanimate  a r e human  technical  resource  components.  f. Governments accruing general  from public  prepared else  enjoying  face  to  a  the  health  approval  adequately  the p o l i t i c a l  political  care  system  advantages which  and a c c e p t a n c e , fund  such  a  consequences  has  must  be  system,  or  inherent i n  121 the  provision  of  a  second-rate  method  of  health  care.  g. Just  as  acceptance  not  in  agreement  part  of  the  necessary  health  2.  political planning  planner's  mandate,  the  acceptance reality  position  care,  policy  with  socio-medical opposing  of  the  of  by  of  conclusions so  also  planners  the  the  decisions  prime  may  is be  of  the  resistance  and  deliverers  of  physicians.  Canada  a. Planning of  for  Canada  the is  rationality  a l l o c a t i o n of  necessary in  an  in  larger portion  Product  the  A  corollary  patients  to  of  of  Appendix ^  our  health  order  industry  increasingly (see  health  belief  care  in  to  resources achieve  consuming  the  Gross  in  the  an  National  7).  Canada,  is  right  of  that  the  122 health as.  care  one  bureaucracy  of  its  thus  created  underlying  should  have  principles,  the  humanizing  of h e a l t h care d e l i v e r y ( S c h a e f f e r ) .  Physician  manpower  c.  total  health  present  personnel  such  for  the  changes  portion  but  within  o f our h e a l t h  planning  of  is  the care  likely  to  item.  health personnel  efficient  one  planning,  physician  r e m a i n t h e key  the  is  and f o r s e e a b l e c o n t e x t  system,  Allied  planning  planning  allocation  institution  of  i s necessary for  of these any  resources,  contemplated  and role  i n the f u t u r e f u n c t i o n s of v a r i o u s h e a l t h  personnel.  e. Under  our p r e s e n t  constitution,  projected  constitutional  and  remain,  that  will  a  pluralism will  decision-making  for  and l i k e l y  change,  provincial continue the  to  health  i n any  care i s ,  jurisdiction, be  allocation  a  factor of  so in  health  123  personnel  resources.  Education  of medical  item  medical  f.  in  university should  departments  is  manpower  training  be  better  personnel  the  ensure t h a t  i n balance  to  that  for  provincial  health  governments  of health  t h e demands  the  physicians  appropriate  the supply  with  a central  planning,  programs  seconded of  i s such  to  personnel  generated  by t h e  system.  g. Evolutionary system than  changes  i n Canada the  use  (* r e v o l u t i o n a r y • )  i n the health  should of  be  care  delivery  encouraged,  disruptive  total  rather system  changes.  h. Canada, develop achieved process  or  any  the kind by  other  of doctor  using  an  are not l i k e l y  necessarily  nation,  appropriate.  will  ultimately  i t wants;  the r e s u l t s  unplanned t o be  evolutionary  efficient  or  even  124  3.  Fee-For-Service  System  a. Despite  the  negative  fee-for-service  system  there  panaceas  are  "no  payment mechanism"  effects  o f payment leading  of  of  the  physicians,  to  a  perfect  ( W o l f e and B a d g e l y ) .  b. Two  overlooked  payment  mechanism  detailed  data  utilization the care  present system  method  benefits  that  alternative  are  of the  the  enormous  generated  tapes f o r health existence that  evolved  i s often being  of a  fee-for-service  by  amounts  the  of  medicare  s y s t e m a n a l y s i s , and high-quality  under  reproached  medical  a fee-for-service without  a viable  offered.  c. Changes as  i n t h e f e e - f o r - s e r v i c e payment  advocated  by  Justice  report,  constitute  concepts  of  our  a  present  Hall  shift health  in from  mechanism  his the  service  second basic system,  125 and,  as  such,  medical  will  manpower  create  spin-offs  planning  process  i n the that  are  indefinable.  4. F a m i l y  Physicians  a. The  family  group,  accounts  medical  for nearly  manpower  personnel is  practitioner/general  resource  a key i s s u e  fifty  personnel planning  of  practitioner percent  Canada,  for this  f o r any p l a n n i n g  of the so  that  component,  venture.  b. Ascribing being  the d e f i n i t i o n  that  residuum  expropriation boundaries not  of  such, w i l l  lead  family  practice  resulting  functions  of various  a creative  of  by  specialty  or i n t e g r a t i v e  after the  the  expanding  disciplines,  approach,  t o debasement o f f a m i l y  to  is  and, a s pratice.  c. Given  the costs,  train  family  time,  physicians,  and  resources  needed  the p r e s c r i p t i o n  to  o f an  126  abbreviated  role  practitioners  will  physicians  function lead  seeking  elaboration  the  of  specialists,  to  an  for  fewer  role,  numbers  and  also  increasing  themselves doing  . family  to  of the  number  of  primary health  care  delivery.  5. B r i t i s h  Columbia  British  Columbia,  geography,  and  exemplified  by  western-style a  large  point  a  of  social  less  spirit,  of physicians,  physician  and  for British  allied  health  due c o n s i d e r a t i o n  interwoven  national  i n a free  freer,  i n turn, i s  ratios  the t o t a l be  society.  to the  number o f  necessary.  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Spitzer,  Walter  0.:  A strategy  in Jan  for evaluation  of  137 new h e a l t h p r o f e s s i o n a l s . B e t h e s d a , M a r y l a n d : John E. F o g a r t y I n t e r n a t i o n a l C e n t r e . N a t i o n a l I n s t i t u t e s o f H e a l t h , 1973. S p i t z e r , W a l t e r 0., R u s s e l l , W. A. M. [and] H a c k e t t , B. C.: F i n a n c i a l consequences of employing a nurse p r a c t i t i o n e r , i n O n t a r i o  Medical Review, F e b 1973, pp.96-100.  S t e v e n s , Rosemary: A m e r i c a n m e d i c i n e and t h e public interest. New Haven, Conn.: Y a l e U n i v e r s i t y P r . , 1971. S t u d i e s i n e c o n o m i c p l a n n i n g o v e r s p a c e and t i m e . E d i t e d by G. G. J u d g e . New Y o r k : N o r t h H o l l a n d Pub. Co., 1973. Saskatchewan. H e a l t h S e r v i c e s P l a n n i n g Commission ( M a l c o l m G. T a y l o r C h a i r m a n ) : The S a s k a t c h e w a n hospital services plan. Regina, 1949. T a y l o r , M a l c o l m G.: H e a l t h i n s u r a n c e and C a n a d i a n public policy. M o n t r e a l : Queen's U n i v e r s i t y P r . , 1978. T h i e r , S. 0. [and] B e r l i n e r * R. W.: Manpower p o l i c y : b a s e i t on f a c t s , n o t o p i n i o n s , i n New England J o u r n a l o f M e d i c i n e , v.299, ppl305-1307. Testa, Mario: Health models: c o n d i t i o n s f o r t h e i r development. ( p a p e r p r e s e n t e d a t t h e Pan A m e r i c a n C o n f e r e n c e on H e a l t h Manpower P l a n n i n g ) O t t a w a : 1973 Time M a g a z i n e ( E d i t o r s ) : H e a l t h c o s t s : what 1imir? ( c o v e r s t o r y ) May 28, 1 9 7 9 . P P . - 5 8 - 6 5 . T o l l e f s o n , E . A.: B i t t e r Modern P r . , 1 9 6 4 .  medicine.  Regina:  U.S. B u r e a u o f H e a l t h R e s o u r c e s D e v e l o p m e n t : H e a l t h manpower - s u p p l y and d i s t r i b u t i o n . W a s h i n g t o n : 1974. U n i v e r s i t y of B r i t i s h Columbia. O f f i c e of the Coordinator, Health Sciences Centre. D i v i s i o n of H e a l t h S e r v i c e s R e s e a r c h and D e v e l o p m e n t : R o l l c a l l '75: A s t a t u s r e p o r t o f h e a l t h p e r s o n n e l i n the P r o v i n c e o f B r i t i s h Columbia Vancouver: 1 9 7 7 . ( r e p o r t R:5, 1977) U n i v e r s i t y of B r i t i s h Columbia. O f f i c e of the Coordinator, Health Sciences Centre. D i v i s i o n of  138 H e a l t h S e r v i c e s R e s e a r c h and D e v e l o p m e n t : R o l l c a l l '79: A s t a t u s r e p o r t o f h e a l t h p e r s o n n e l i n t h e Province o f B r i t i s h Columbia Vancouver: 1979. ( r e p o r t R:12, 1979) W a t k i n s , C. K e n : S o c i a l Longman, 1 9 7 5 .  control.  London:  Wildavsky, Aaron: D o i n g b e t t e r and f e e l i n g worse: t h e p o l i t i c a l p a t h o l o g y o f h e a l t h p o l i c y , in Health i n the United States E d i t e d by J o h n H. Knowles. New Y o r k : N o r t o n , 1977. W i t t e r , Dogas [and] W i t t e r , B e v e r l y : Nursing's expanded r o l e i n Canada; i m p l i c a t i o n s o f t h e J o i n t CM.A./C.N.A. s t a t e m e n t o f p o l i c y , i n N u r s i n g c l i n i c s o f N o r t h A m e r i c a , v . 9 , #3, September, 197 4. r  W o l f e , Samuel [and] B a d g e l y , R o b i n F.: How much i s enough? The payment o f d o c t o r s - i m p l i c a t i o n s f o r h e a l t h p o l i c y i n Canada, i n I n t e r n a t i o n a l J o u r n a l o f H e a l t h S e r v i c e s , v . 4 , S p r i n g , 1974, pp.245-264. W o r l d H e a l t h O r g a n i s a t i o n : The f i r s t t e n y e a r s o f the World H e a l t h O r g a n i s a t i o n . G e n e v a : 1958. World Health O r g a n i s a t i o n : World H e a l t h O r g a n i s a t i o n t e c h n i c a l r e p o r t : s e r i e s 137. Geneva: 1957. World Health O r g a n i s a t i o n : World Health O r g a n i s a t i o n t e c h n i c a l r e p o r t : s e r i e s 440. Geneva: 1970. World Health O r g a n i s a t i o n : s t a t i s t i c s r e p o r t . 1968-.  World h e a l t h G e n e v a : 1968-.  ADDENDUM Anderson, D. 0.: Canada: Epidemiology i n t h e P l a n n i n g Process i n B r i t i s h Columbia: D e s c r i p t i o n of an E x p e r i e n c e w i t h a New Model, Epidemiology as a Fundamental S c i e n c e , e d i t e d by K. L. White and Maureen M. Henderson, New York, O x f o r d , 1976. B r i t i s h Columbia M i n i s t r y o f H e a l t h ; Report o f the A d v i s o r y Committee on M e d i c a l Manpower, V i c t o r i a , Queen's P r i n t e r , 1979. (Black Report) Canada, Report Ottawa,  Department o f  o f  N a t i o n a l  t h e Committee  Queen's  P r i n t e r ,  H e a l t h  on Nurse 1973.  a n d  Welfare  P r a c t i t i o n e r s , (Boudreau)  138 Canadian Nurses H e a l t h Services Crane,  Oct.  H o s p i t a l  1975, V .  Basic  Books,  H a l l ,  E.:  Program  R.:  Who S h a l l  Canada's Health  E. C : 1958.  L i v e  ?,  N a t i o n a l  i n  B r i t i s h  i n  New  -  Canada,  York,  P r o v i n c i a l  Commitment  Services  Review  Men and T h e i r  K e n : R a t i o n i n g  Heinemann,  Programs  1975.  f o r t h e 1980's:  Saskatoon: Hughes, Press,  Care  A d m i n i s t r a t i o n  p p . 26-31.  Fuch,  Judge,  A s s o c i a t i o n : Submission t o Review '79, O t t a w a , C.N.A.,1979-  L . M . : Home  Columbia,  A  S o c i a l  Work,  H e a l t h  f o r RenewaTT '79,  1980.  Glencoe  S e r v i c e s ,  Free  London,  1978.  O n t a r i o : Commission on H o s p i t a l P r i v i l e g e s Report: Toronto, Queen's P r i n t e r , 1972.  ^  Ontario C o u n c i l o f H e a l t h : E v a l u a t i o n o f Primary Care Services, Toronto, Government P r i n t e r , 1976. (Mustard Report) Quebec: Commission o f I n q u i r y on H e a l t h and S o c i a l Medicine: Report, 1970. 1970. (CastonguayNepvev) Saskatchewan: Commission o f I n q u i r y H o s p i t a l P r i v i l e g e s : Report. Regina, P r i n t e r , 1963.  i n t o Queen's  139  APPENDIX  1.  Canada  Year  1978-79.  Book  r e s p o n s i b i l i t i e s  2.  Summary,  Report  N a t i o n a l  Committee  Requirements S p e c i a l H e a l t h  f o r  Manpower  John  V a r l e y ,  i+.  Major  Requirements P h y s i c i a n  to  i n  B r i t i s h  of  Canada  U n i t ,  B r i t i s h  H e a l t h  Sciences  Columbia,  137S.  M.D  147  F a m i l y  Methods  f o r  A s s e s s i n g  and  Requirements.  Thomas  Conference  Ottawa,  A l t e r n a t i v e  w i t h  Columbia.  C e r t i f i e d  American  Committee,  Manpower.  the  P l a n n i n g ,  Uwe  on  11+0  f i e l d  of  Manpower Pan  the  h e a l t h  Research  U n i v e r s i t y  C.  the  P h y s i c i a n s  Centre,  D e f i n i t i o n  6.  of  Reference  3.  5.  i n  C o n s t i t u t i o n a l  on  P h y s i c i a n  P r o j e c t i n g H a l l .  H e a l t h  Manpower  1973  Methods  of  161  P h y s i c i a n  P r i c i n g ,  Reinhardt  Statement  on  A f f i r m e d  by  November  17,  160  162  a the  P a t i e n t ' s Board  1972,  of  B i l l  of  R i g h t s .  T r u s t e e s  American  H o s p i t a l  A s s o c i a t i o n .  163 7.  Government Canadian Issue  No.  Spending.  I m p e r i a l 1,  1979  Bank  Commercial of  L e t t e r ,  Commerce,  Toronto, 165  140 APPENDIX  199  1  Canada Year Book 1978-79  Constitutional responsibilities in the health field  5.2  Government involvement in health care services in 1867, al Confederation, was minimal. For the most part the individual was compelled to rely on his own resources and those of his family group, and hospitals were administered and financed by private charities and religious organizations. The only specific references to health in the distribution of legislative powers under the British North America Act allocate to Parliament jurisdiction over quarantine and the establishment and maintenance of marine hospitals, and to provincial legislatures jurisdiction over the establishment, maintenance and management of hospitals, asylums, charities and charitable institutions in and for the province, other than marine hospitals. In 1867 this latter reference probably was meant to cover most health care services. Since the provinces were assigned jurisdiction over generally all matters of a merely local or private nature in the province, it is probable that this power was deemed to cover health care, while the provincial power over municipal institutions provided a convenient means for dealing with such matters. Thus provision of health care services has been traditionally acknowledged as primarily a provincial responsibility. But a measure of responsibility in health matters has been expressed over the years in many federal programs and policies.  Federal-provincial co-operation Since the federal and provincial governments share responsibility for dealing with health matters, a formal structure has been established for federal-provincial co-operation. It comprises the following: conference of ministers of health; conference of deputy ministers of health; federal-provincial advisory committees on institutional care services, community care services, health promotion and lifestyle, environmental and occupational health and health manpower. The conferences of ministers and deputy ministers of health involve matters of promotion, protection, maintenance and restoration of the health of the Canadian people. Normally, the conference of ministers meets annually and the conference of deputy ministers twice a year. The five advisory committees facilitate the work of the ministers and deputy ministers, and assist them in achieving objectives, identifying major issues and solving problems. They may set up groups to deal with particular subjects requiring more detailed study.  1.  Reproduced by permission of the Minister of Supply and Services Canada  5.3  141 200  5.4  Canada Year Book 1978-79  Federal health services The national health and welfare department is the principal federal agency in health matters. It is responsible for the overall promotion, preservation, and restoration of the health of Canadians, and for their social security and social welfare. The department acts in conjunction with other federal agencies and with provincial and local services. The provincial governments actually administer health services. Although the patterns of health services are similar, their organization and administration vary from province to province. Other federal agencies which carry out specialized health functions include, for example, the health division. Statistics Canada, which gathers health and vital statistics, the veterans affairs department, which administers hospitals and health services for war veterans, and the agriculture department, which has certain responsibilities for health aspects of food production. Branches of the national health and welfare department are responsible for health protection, medical services, health programs, long-range health planning and fitness and amateur sport. The Medical Research Council supports research in health sciences in Canadian universities and affiliated institutions. In the health and welfare department, an integrated program protects the public against unsafe foods, drugs, cosmetics, medical and radiation-emitting devices, harmful microbial agents and technological and social environments, environmental pollutants and contaminants of all kinds, and fraudulent drugs and devices. Medical services include health care and public health services for registered Indians, Inuit and all residents of the Yukon Territory and Northwest Territories, as well as quarantine and regulatory services, immigration medical services, public service health, a national prosthetics service, civil aviation medicine, disability assessment and emergency health and welfare services. Long-range health planning assesses the orientation of health services and the organization of resources. The fitness and amateur sport branch encourages excellence in Canada's athletes and participation of all Canadians in activities oriented toward fitness and recreation. The health programs branch administers federal aspects of Canada's two major health programs, hospital and medical insurance; supports health care delivery system and resource development; undertakes health promotion; and both supports and conducts research.  5.4.1  Health care Medical care. Before the establishment of government-administered medical insurance, voluntary prepayment arrangements to cover the cost of physicians' services had developed in public and private sectors. By the end of 1968, basic medical or surgical coverage, or both, were being provided to about 17.2 million Canadians, 82% of the population. Voluntary plans in the private sector covered about 10.9 million, or 52%, and public plans covered 6.3 million, or 30%. By 1972 all 10 provinces and the two territories had met the criteria stipulated under the Medical Care Act as conditions for federal cost-sharing, and virtually the entire eligible population was insured for all required medical services plus a limited range of oral surgery. Members of the Canadian Armed Forces, the Royal Canadian Mounted Police, and inmates of federal penitentiaries whose medical care requirements are met under alternative provisions are excluded. Services by physicians that are not medically required, such as examinations for life insurance, services covered under other legislation, such as immunization where available through organized public health services, and services to treat work-related conditions already covered by worker compensation legislation are not covered. Comprehensive coverage must be provided for all medically required services rendered by a physician or surgeon. There can be no dollar limit or exclusion except on the ground that the service was not medically required. The federal program includes not only those services that have been traditionally covered as benefits by the health insurance industry, but also those preventive and curative services that have been traditionally covered through the public sector in each province, such as medical care of  142 Health patients in mental and tuberculosis hospitals and services of a preventive nature provided to individuals by physicians in public health agencies. The plan must be universally available to all eligible residents and cover al least 95% of the total eligible provincial population (in fact the plans cover over 99%). A uniform terms and conditions clause is intended to ensure that all residents have access to coverage and to prevent discrimination in premiums because of previous health, age, non-membership in a group, or other considerations. If a premium system of financing is.selected, subsidization in whole or in part for low-income groups is permitted. It has been left to the individual province to determine whether its residents should be insured on a voluntary or compulsory basis. Utilization charges at the time of service are not precluded by the federal legislation if they do not impede, either by their amount or by the manner of their applications, reasonable access to necessary medical care, particularly for low-income groups. The plan must provide portability of benefit coverage when the insured resident is temporarily absent from the province and when moving residence to another participating province. The provincial medical care insurance plan must be administered on a non-profit basis by a public authority that is accountable to the provincial government for its financial transactions. It is permissible for provinces to assign certain administrative functions to private agencies. These criteria leave flexibility with each province to determine its own administrative arrangements for the operation of its medical care insurance plan and to choose the way in which it will be financed, that is, through premiums, sales tax, other provincial revenues, or by combination of methods. Federal financial contributions to the provinces prior to April 1977 were based on half of the national per capita cost of the insured services of the national program, excluding administration, multiplied by the number of insured persons in each province. A 1976 amendment to the act established a ceiling of 113% on the per capita increase of the federal contribution for the fiscal year 1976-77. Hospital insurance. The Hospital Insurance and Diagnostic Services Act which took effect on July 1, 1958, was designed to make available to all eligible residents a wide range of hospital and diagnostic services, subject to medical necessity, at little or no direct cost to the patient, thereby removing financial barriers to adequate care which existed for many residents prior to the introduction of the program. Under the act, contributions by the federal government are authorized for programs administered by the provinces providing hospital insurance and laboratory and other services in aid of diagnosis. The program incorporates five general principles: comprehensiveness of services; universal availability of coverage to all eligible residents; no barriers to reasonable accessibility of care; portability of benefits; and public administration of the provincial programs. Facilities covered under the program include general, rehabilitation (convalescent), and extended care (chronic) hospitals together with specialized hospitals such as those providing maternity or pediatric care. The program may also cover diagnostic services in non-hospital facilities. Specifically excluded under the program are tuberculosis hospitals and sanatoria, hospitals or institutions for the mentally ill, and nursing homes, homes for the aged, infirmaries or other institutions whose purpose is to provide custodial care. In development of hospital insurance legislation, existing traditions were maintained as far as possible. The pattern of hospital ownership and operation that existed before the act came into force was retained and provincial autonomy was not infringed. Consequently, even 20 years later, almost 90% of the beds covered by hospital insurance are located in facilities owned and operated by voluntary bodies and municipalities. The policy of provincial autonomy allows each province to decide on methods of administration and of financing its share of program costs while still ensuring a basic uniformity of coverage throughout the country. All provinces and territories have participated since 1961. Details of services provided are in Section 5.5.1, Provincial health insurance plans.  201  143 202  Canada Year Book 1978-79  Insured in-patient services must include accommodation, meals, necessary nursing service, diagnostic procedures, most pharmaceuticals, the use of operating rooms, case rooms, anesthesia facilities, and radiotherapy and physiotherapy if available. Similar out-patient services may be included in provincial plans and authorized for contribution under the act. All provinces include a fairly comprehensive range of out-patient services. The individual may select the hospital in which he will be treated provided his physician has admitting privileges, and the only limit to the duration of insured services is the extent of medical necessity. Moreover, during a temporary absence, coverage is portable anywhere in the world for in-patient services, and in the case of most provinces for out-patient services also, although such benefits are subject to provincially regulated maxima for rates of payment and length of hospital stay as set out in the summary of provincial programs. Provinces may include additional benefits in their plans without affecting the federal-provincial agreements. Some provincial hospital plans provide additional services such as nursing home care and these are also mentioned in the provincial program summaries. These additional services are not cost-shared under hospital insurance. The principles of universal availability of benefits to all eligible residents and portability of benefits are reflected in provisions of each provincial program. For many years, about 99% of all eligible residents have been insured persons. Although provincial plans in general stipulate a waiting period of three months, coverage may continue from the province of previous residence. First-day coverage is generally provided for the newborn, immigrants, and certain other categories of persons without prior coverage in other provinces. A health insurance supplementary fund has been established for residents who have been unable to obtain coverage or who have lost coverage through no fault of their own. Until March 31, 1977 the federal government contributed approximately half the cost of insured in-patient and out-patient services for Canada as a whole. This included payments to Quebec under the Established Programs (Interim Arrangements) Act effective January 1965. The formula provided proportionately larger contributions in those provinces where per capita costs were below the national average and vice-versa. Provinces may raise their portion of insurable costs as they wish, provided that access to services is not impaired. All provinces finance their share in whole or part from general revenue. Established programs financing. Late in 1976, following several years of negotiations, the provinces and the federal government agreed to new financial arrangements for medical care and hospital insurance, among other fiscal matters. This led to the FederalProvincial Fiscal Arrangements and Established Programs Financing Act, 1977, assented to on March 31, 1977, containing consequential amendments to the Medical Care Act and the Hospital Insurance and Diagnostic Services Act. Commencing April 1, 1977, federal contributions to the established programs of hospital insurance, medical care and post-secondary education are no longer directly related to provincial costs, but take the form of the transfer of a predetermined number of tax points, and related equalization and cash payments. Total federal contributions, in general terms, are now based on the current escalated value of the 1975-76 federal contributions for the programs in question. The tax room vacated by the federal government permitted the provinces to increase their tax rates so as to collect additional revenue without necessarily increasing the total tax burden on Canadians. The yield from the new provincial taxes will normally increase faster than the rate of growth of the Gross National Product (GNP). The cash payments are conditional upon the provincial health insurance plans meeting the criteria of the federal health insurance legislation. At the outset, the cash payments will approximate the value of the tax room transferred, and be in the form of per capita payments calculated in accordance with the FederalProvincial Fiscal Arrangements and Established Programs Financing Act, 1977. These per capita payments will be escalated yearly in accordance with changes in the GNP, and adjusted gradually over time so that all provinces at the end of five years will be receiving equal per capita cash contributions.  144 Health Also under the act as of April 1, 1977, the federal government is making additional equal per capita cash contributions yearly to the provinces to contribute toward the costs of certain extended health care services. Health resources fund. The Health Resources Fund Act of 1966 provided $500 million over 15 years (1966-80) for financial assistance in planning, acquisition, construction, renovation, and equipping health training and research facilities. Up to 50% of eligible costs of approved projects are supported by federal contributions. Of this total, $400 million is allocated to provinces on a per capita basis, $25 million is further allocated to the Atlantic provinces for joint projects, and $75 million for health training and research projects of national significance. Professional training program. This program provides about $2.3 million a year to the provinces for training health and hospital personnel. Two types of training are funded by the federal government: bursaries for one academic year or longer, and short courses for up to three months. Assistance may also be given to the holding of, and attendance at, provincial and national conferences with emphasis on health manpower planning and development. Health services for specific groups. Through medical services branch, the national health and welfare department provides or arranges health services for persons whose care is by custom or legislation a federal responsibility. Indians and Inuit, as residents of a province or territory, are entitled to benefits of medical care and hospital insurance. These insured benefits are supplemented by the branch, which helps in arranging transportation and obtaining drugs and prostheses. A comprehensive public health program provides dental care for children, immunization, school health services, health education, and prenatal, postnatal and well-baby clinics. A native alcohol abuse program funds locally-run programs. Since Indians and Inuit comprise only 1.0% of the population and are distributed widely throughout Canada, a network of specially designed health facilities operates in almost 200 communities. Increasing numbers of Indians and Inuit are being trained and employed in public health and medical care programs to facilitate understanding and health activities in the communities. With the exception of insured hospital and medical care programs, administered by the governments of the Yukon Territory and Northwest Territories, the national health and welfare department has for many years managed health services for all residents of the two northern territories. These comprise a comprehensive public health program, special arrangements to facilitate interstation communication, and the transportation of patients from isolated communities to referral medical centres. Several university groups provide, on a rotation basis for specified zones, medical personnel and students. Their activities arefinancedthrough government contracts and medical care insurance. As of January .1978, departmental facilities included six hospitals, three health stations and nine health centres in the Yukon Territory and four hospitals, 39 nursing stations, six health stations and eight health centres in the Northwest Territories. Under the Quarantine Act, all vessels, aircraft, and other conveyances and their crews and passengers arriving in Canada from foreign countries are subject to inspection to detect and correct conditions that could introduce such diseases as smallpox, cholera, plague and yellow fever. Quarantine stations are located at major seaports and airports. The branch enforces standards of hygiene on federal property including ports and terminals, interprovincial means of transport, and Canadian ships and aircraft. Medical services branch determines the health status of all persons referred by the employment and immigration commission for Canadian immigration purposes. It also provides or arranges health care services for certain persons after arrival in Canada; including immigrants who become ill en route or while seeking employment. The branch is responsible for a comprehensive occupational health program for federal employees in Canada and abroad. This includes health counselling, surveillance of the occupational and working environment, pre-employment, periodic and special examinations, first aid and emergency treatment, advisory services and special health programs. Increased attention is given to pre-retirement and stress.  203  145 204 Canada Year Book 1978-79 The department advises the ministry of transport on health and safety in Canadian civil aviation. Regional and headquarters aviation medical officers review medical examinations, participate in aviation safety programs, and assist in air accident investigations. There is close liaison with authorities in foreign aviation medicine, with standards usually based on international agreements. Prosthetic services assists in prosthetic and corrective rehabilitation under agreements with most provinces and with the veterans affairs department, and provides a national focal point for related expertise. Discussions have been held on a plan to transfer this activity to provincial control. Medical services physicians provide an assessment and advisory service to the employment and immigration commission on claims for benefits under the sickness and maternity benefit plan. The Canada Pension Plan maintains its own disability assessment service. Emergency welfare services is responsible for a national capability, embracing government and welfare related non-government agencies of essential welfare services in any type of emergency in Canada. In an effort to improve communication through new technology, the branch has participated in telemedicine experiments, with Moose Factory and Kashechewan, Ont. receiving direct consultation on medical and surgical matters through television. The magnitude of health problems posed by environmental pollution has resulted in a number of activities. The environmental contaminants program is studying effects of mercury pollution from coast to coast. Other environmental contaminants such as cadmium, arsenic and mirex are of growing concern.  Provincial and local health services Regulation of health care, operation of health insurance programs and direct provision of some specialized services rest with the provincial governments; some health responsibilities are delegated to local authorities. Although provinces generally assign primary responsibility for health to one department, the distribution of function varies from one province to another. Some provinces have combined health and social services within the same department. Others maintain liaison between departments responsible for these related services.  In a number of provinces, health insurance programs are administered by semiautonomous boards or commissions, or by a separate department. Some report directly to a minister of health; others are under the jurisdiction of a deputy minister. Several provincial health insurance programs are operated directly by health departments. In each province both institutional and ambulatory care for tuberculosis and mental illness are provided by an agency of the department responsible for health, with increasing attention to preventive services. Programs related to other particular health problems such as cancer, alcoholism and drug addiction, venereal diseases and dental conditions have been developed by government agencies, often in co-operation with voluntary associations. A number of provincial programs serve specific population groups such as mothers and children, the aged, the needy and those requiring rehabilitation. Environmental health, involving education, inspection and enforcement of standards, is frequently shared by health departments and other agencies. Public health or community health units are among the most decentralized. Some are responsible for local health education, school health and organized home care. Although local and regional involvement in health services has been concentrated in hospital planning and some public health aspects, several provinces have inaugurated district and regional boards.  5.5  146 210  Canada Year Book 1978-79  5.5.1 Provincial health insurance plans Following is a summary of provincial health insurance plans. These cover benefits provided in accordance with the program criteria of the federal Hospital Insurance and Diagnostic Services Act and the Medical Care Act. Additional benefits are provided generally on a limited basis. Some such features of certain plans are: dental care for - children, prescribed drugs for the elderly and persons with some particular illnesses, some services of health professionals other than physicians, some sight and hearing aids and rehabilitation services. The federal government is not contributing under federal health insurance legislation toward the costs of these additional benefits. However, it contributes toward the costs of certain health services under the extended health care services program such as nursing home and adult residential care, home care (health aspects) and ambulatory health care services. This summary gives only the highlights of provincial plans and refers to the programs which were in effect on January 1, 1977. Standard medical and hospital benefits are listed, together with additional benefits. Information on details of the plans and on recent changes in coverage, premiums and authorized charges, if any, may be obtained from the provincial agencies responsible. Except as otherwise indicated, there were no premiums or authorized charges. The provisions for assistance vary from province to province. The summary does not include many services which are provided by provincial health departments on a universal basis (such as health unit services, institutional care for tuberculosis and mental patients, venereal disease control, some home care programs), nor does it include details of programs for social service recipients.  British C o l u m b i a . Medical care benefits: all medically required services of medical practitioners and certain surgical-dental procedures undertaken by dental surgeons in hospitals. Additional benefits: optometry, chiropractic, naturopathy, physiotherapy, podiatry, orthoptic treatment and services o f Red Cross nurses, special nurses and the Victorian Order of Nurses, orthodontic services for harelip and cleft palate.. Free prescription drug program for residents 65 and over, and a universal pharmacare plan effective June 1, 1977 which protects individuals from financial hardship as a result of high prescription drug expenses. Premium per month: single, S7.50; two persons, $15.00; family of three or more. SI 8.75. T h e premiums are those for persons who do not qualify for premium assistance on account o f limited income. Hospital in-patient benefits: standard ward and all approved available services. Out-patient: emergency services, minor surgical procedures, day care surgical services, out-patient cancer therapy, psychiatric day care and night care services, day care rehabilitation services, narcotic addiction services, physiotherapy services, diabetic day care, and specified out-patient psychiatric services in designated hospitals, dietetic counselling services; cytology services operated by B C Cancer Institute and renal dialysis treatments in designated hospitals. Out-of-province benefits: (in-patient) during a temporary period o f absence that ends at midnight on the last day o f the 12th month following the month o f departure from province; maximum stay of 12 months unless otherwise approved; referral, if approved by deputy minister.  APPENDIX  147  2 .  HEALTH MANPOWER RESEARCH UNIT  4th FLOOR I.R.C. BUILDING THE UNIVERSITY OF BRITISH COLUMBIA VANCOUVER, B.C., CANADA V6T 1W5  C/O OFFICE OF THE COORDINATOR HEALTH SCIENCES CENTRE  F i l e : 36.80.02  SUMMARY  Report of the Requirements Committee National Committee on Physician Manpower  REQUIREMENTS FOR PHYSICIANS IN CANADA WITH SPECIAL REFERENCE TO BRITISH COLUMBIA  May 10th, 1976  John C. Varley, M.D.  A Research Unit for the Health Manpower Working Croup, Ministry of Health, British Columbia  BOUNDARIES PRESENT General/Family Practice (G.P./F.P.)  1• Primary Care 2. 23# o f major f r a c t u r e repairs 3. 1056 o f v a r i c o s e v e i n surgery 4. 1£$ o f appendectomies 5. 30$ o f t o n s i l l e c t o m i e s 6. 63$ o f confinements 7. \\% of C a e s a r i a n s e c t i o n s 8. 32$ o f a n a e s t h e t i c s 9. ECG, X-ray i n t e r p r e t a t i o n  Internal Medicine  G l o b a l term i n c l u d i n g a l l s u b s p e c i a l t i e s except Neurology and Dermatology  ANTICIPATED E n v i s i o n a l l Primary Care as i d e a l l y the exclusive r e s p o n s i b i l i t i e s of General/ Family P r a c t i c e A n t i c i p a t e more and more of primary contact s e r v i c e s w i l l be p r o v i d e d by FP/GP's Increased t e a c h i n g r e s e a r c h and a d m i n i s t r a tion  1. 85$ on a r e f e r r a l b a s i s . 2. 15$ d i r e c t access by patients 3. Take over o f s e r i o u s l y i l l p a t i e n t s as GP/FP's move more t o care o f ambulatory p a t i e n t s 4. I n t e r n a l o v e r l a p between g e n e r a l i n t e r n i s t s and subspecialists 5. More i n t e r n i s t s i n education o f c e r t i f i e d family physicians  ROLE SHARED WITH  CONFLICTS  I n t e r n a l Medicine General Surgery Pediatrics O b s t e t r i c s gynecology Anaesthesia Nurse p r a c t i t i o n e r  C o n s u l t a n t s t o no l o n g e r g i v e primary care. Restriction of p r e s e n t l y p e r formed s u r g i c a l obstetricalanaesthetic s e r v i c e s .  General P r a c t i c e Other I n t e r n i s t s Pediatrics  L C D . Care Seriously i l l care P r a c t i s i n g both as c o n s u l t a n t s and general p r a c t i tioners  BOUNDARIES  Pediatrics  ObstetricsGynecology  General Surgery  PRESENT  ANTICIPATED  ROLE SHARED WITH  1. Conception to Adolescence. 2. Primary care - a) 10$ of 0 to 17 year age primary care, b) 50$ of work done i s i n primary care. 3. Secondary care. 4. Tertiary care. 5. Long term chronic d i s abilities  1. More consultation. 2. Less primary care, but a continuing primary care function 3. More subspecialization with internal overlap e.g. neonatology 4. No surgical services. 5. More genetic counselling 6. More community pediatricians  General/family practice  Primary Health Care of women: a) early detection of cancer b) family planning c) genetic counselling d) sex counselling e) marital counselling  A l l high-risk obstetr i c a l patients 2. Obstetrical exclusive domain procedural l i s t including abortions Gynecologic procedures Continue as primary or f i r s t contact care physicians for women  General/family practice General surgeons Urology New a l l i e d health personnel: e.g. midwife Womens Health Cooperative Groups  1. 10$ of income i s from general practice 2. Procedures: 77$ appendectomies 91% of cholecystectomies 81$ of hernia repairs 3. Other major surgery 4. Minor surgery  1. Transfer of a l l G.P. major surgery to surgeons 2. Maintain some primary care contact with public 3. Non-urban orthopaedics 4. Intensive care of trauma patients 5. Psychotherapy - n i l  General practice Orthopaedics Urology Surgical subspecialties Pediatric surgery Internal medicine  Obstetricians Internists New a l l i e d health personnel - e.g. pediatric nurse practitioner  CONFLICTS Primary care of children Perinatology Adolescents  Pediatric primary care.  High r i s k obstetr i c a l cases Procedural items Bladder conditions Normal obstetrics Pap smears, infections, sex and contraceptive counselling  Major/minor surgery Fractures Hernia e.g. Head and neck surgery Children Intensive care  -P-  BOUNDARIES Anaesthesia  ANTICIPATED PRESENT 1. I n t e n s i v i s t s .1. Nerve b l o c k s - 20$ 2. S u r g i c a l a n a e s t h e s i a 1 ... 2. I d e a l l y a l l a n a e s t h e t i c s should be given by 3. O b s t e t r i c a l anaesthesia} * anaesthetists 4. Care o f unconscious patients 3. Acupuncture - f o r e s e e l i t t l e role 5. P a i n r e l i e f problems 6. R e s u s c i t a t i o n 4. No v a r i c o s e v e i n o r allergy infections 7. V a r i c o s e v e i n i n j e c t i o n s 8. H y p o s e n s i t i z a t i o n 9. Teaching, Research, Administration Psychoses 1. T r a v e l l i n g teams t o Neuroses r u r a l areas 2. P s y c h o g e r i a t r i c s e r P e r s o n a l i t y problems vices Psychogenic r e a c t i o n s Mental R e t a r d a t i o n 3. Sub s p e c i a l i z a t i o n A d m i n i s t r a t i o n , Research, 4. Community c e n t r e work Teaching 5. Reduced mental h o s p i t a l work-load 1. Orthopedic s e r v i c e s 1. J o i n t replacement s u r g e r y O n t a r i o , A p r i l '72 - 40$ 2. More f r a c t u r e work ob(23$ - s u r g i c a l t a i n e d by l e s s e r r o l e o f specialists) G.P.'s and g e n e r a l (38$ - f a m i l y p h y s i c i a n s ) surgeons 2. A l b e r t a 1970 - 21* o f orthopaedic s p e c i a l i s t s time spent on s u r g e r y outside t h e i r s p e c i a l t y b B  Psychiatry  Orthopaedic Surgery  Urology  1. Care o f a d r e n a l s , u r i n a r y t r a c t , male r e p r o d u c t i v e tract 2. Teaching, a d m i n i s t r a t i o n  1. E x c l u s i v e care o f a d r e n a l s u r i n a r y t r a c t , male r e p r o ductive tract 2. Shared procedures l i s t e.g. r e n a l t r a n s p l a n t a t i o n 3. More treatment teams 4. More s e x u a l i t y workload  ROLE SHARED WITH 1. General p r a c t i c e 'practitioners' 2. A l l i e d h e a l t h personnel - a n a e s t h e t i c technicians 3. I n t e r n i s t s 4. General surgeons  CONFLICTS Anaesthetics Nerve b l o c k s  General p r a c t i c e Nurses S o c i a l workers Psychologists  M e d i c a l model v s . P s y c h o - s o c i a l model of team treatment programs  General surgeons) I n t e r n i s t s , surgeons P l a s t i c surgeons Orthopaedic t e c h nicians  Neurologists V a s c u l a r surgeons Endocrinologists Gynecologists Family p h y s i c i a n s Nurses, gu. t e c h n i c i a n s General surgeon urologists  Anaesthetics I n t e n s i v e care Anaesthesia  Fractures Trauma management Tendon, hand s u r g e r y Fractures  Renal f a i l u r e p a t i e n t s , C o n f l i c t reduced by team approach  General  urology  O  BOUNDARIES Otolaryngology  Dermatology  A l l e r g y and Clinical Immunology  Plastic  Surgery  ROLE SHARED WITH Neurology  CONFLICTS Audiology and v e s t i b u l a r problems Cancer o f head and neck  PRESENT 1. Problems o f ear, nose, throat larynx, plus neck, b r o n c h i , oesophagus, a l s o m a x i l l o facial 2 . 2 5 $ n o n - r e f e r r e d work i . e . primary c o n t a c t  ANTICIPATED 1. C o n t i n u i n g primary contact 2. Implantable h e a r i n g aids 3. G r e a t e r share o f T. & A. 's  1. S k i n Mucous membranes Venereal disease 2. E x c l u s i v e treatment l i s t a) h o s p i t a l i z e d p a t i e n t s b) l i f e - t h r e a t e n i n g eruptions c) C h r o n i c d i s a b l i n g s k i n diseases d) systemic therapy r e quired e) a l l o c c u p a t i o n a l dermatoses w i t h 1 week l o s s of work 1. D i a g n o s t i c and treatment allergy services 2. A l l e r g y treatment 1972-3 a ) B.P./F.P.'s 77$ b) I n t e r n i s t s 11$ c) P e d i a t r i c i a n s 9% 3. C l i n i c a l Immunology - one competent t o d i r e c t a service or research immunology l a b o r a t o r y Surgical restoration of appearance and f u n c t i o n - head and neck - hand - skin  1. 5 0 $ o f p a t i e n t s nonr e f e r r e d , i . e . have primary access 2. E x c l u s i v e treatment list  General p r a c t i c e Internists Surgeons Allergists  1. 20-30$ work primary contact (non-referred) 2. Continued s i m i l a r r o l e  General P r a c t i c e Internists Pediatricians  Not much c o n t a c t  Increase i n hand s u r g e r y . Decrease i n head and neck s u r g e r y f o r carcinoma. Decrease i n hypospadias r e p a i r s . Increased microv a s c u l a r s u r g e r y and t i s s u e transplantation  Otolaryngology Orthopaedic s u r g e r y General s u r g e r y Urology  -  General and p l a s t i c surgeons A l l i e d h e a l t h personnel - A u d i o l o g i s t s general/Family prac-  T. & A. 's General dermatology Systemic dermatoses Surgical lesions  Head and neck s u r g e r y Hand s u r g e r y Breast r e c o n s t r u c t i o n Congenital G e n i t a l i a Anomalies  DATA SUMMARY. FEE-FOR-SERVICE WORKLOAD , FULL-TIME FEE-FOR-SERVICE PHYSICIANS. DISCIPLINE OF GENERAL/FAMILY PRACTICE  Services/year per total physician  S e r v i c e times (minutes) direct  indirect  total  A c t u a l workload (hours/year) per physician total  Distribution o f workload physician/year %  148,192  16  30  15  45  111,144  12  0.5  5,338,132  560  30  IS  45  4,003,599  420  18.6  3. O f f i c e v i s i t s  38,817,352  4,071  12  4  16  10.351,291  1,086  48.0  4. H o s p i t a l  11,323,948  1,188  5  5  10  1.887,324  198  8.8  3,559,822  373  10  25  35  2,076,563  218  9.6  6. Major surgery  190,767  20  60  190,767  20  0.9  7. Minor surgery  1,159,393  122  25  483,080  51  2.3  8. S u r g i c a l assistance  334,966  35  60  334,966  35  1.5  9. O b s t e t r i c services  193,329  20  180  579.987  60  2.7  675,158  71  75  843,947  88  3.9  8,358,487  877  5  696,541  73  3.2  70.099,546  7,353  1. C o n s u l t a t i o n s 2. Complete examinations  visits  ~S. Home v i s i t s  10. A n a e s t h e s i a 13. Other d i a g n o s t i c / therapeutic services  15  10  14. M i s c e l l a n e o u s services TOTALS  21,559,209 •  (a) Based on s e r v i c e times a t t r i b u t e d by the working p a r t y on p h y s i c i a n manpower requirements discipline.  100.0  DATA SUMMARY, FEE-FOR-SERVICE WORKLOAD , FULL-TIME FEE-FOR-SERVICE PHYSICIANS, SPECIALTY OF GENERAL SURGERY  total  A c t u a l workload (hours/year)  S e r v i c e times (minutes)  Services/year per physician  direct  indirect  total  total  per physician  Distribution o f workload physician/year %  1. C o n s u l t a t i o n s  446,258  265  35  15  50  371,882  221  8.1  2. Complete examinations  492.641  293  30  10  40  328,427  195  7.2  2,134,864  1,268  15  5  20  711,621  423  15.S  1,045,798  621  5  5  10  174,300  103  3.8  5. Home v i s i t s  134,639  80  20  15  35  78,539  47  1.7  6. Major surgery  486,677  289  200  85  285 2,311,716  1,373  50.5  7. Minor s u r g e r y  226,651  135  60  30  90  339,977  202  7.4  57,243  34  95  30  125  119,256  71  2.6  6,574  4  7,477  4  880,786  523  10  146,797  87  3.2  7,779  5  5,927,387  3.S21  4,582,515  2,722  100.0  3. O f f i c e  visits  4. H o s p i t a l  visits  8. S u r g i c a l assistance 9. O b s t e t r i c services10. A n a e s t h e s i a 13. Other d i a g n o s t i c / therapeutic services 14. M i s c e l l a n e o u s services TOTALS  (a) Based on s e r v i c e times a t t r i b u t e d by the working p a r t y on p h y s i c i a n manpower requirements f o r the specialty.  VJ1 ^1  154  PROJECTIONS TOR PHYSICIAN MANPOWER FOR CANADA FOR 1981 WORKING PARTY PROPOSALS COMPARED TO REQUIREMENTS COMMITTEE RECOMMENDATIONS.  Specialty  Working Par•ty Proposed Optimal Req uirements f o r 1981 Number o f ^ D e f i c i t o r P h y s i c i a n s Surplus from base (W.P.) years  General/ Family Practice  Requirement s Committee> Recommendat i o n s f o r 1981 Physician: Population Ratio  Annual Supply to meet 1981 Requirements  Number o f P h y s i c i a n : Percentage Present Physicians Population Difference Ratio (R.C.) (WP-RC) ( WP ) °  Needed  x l 0  -  n  -1,930  1:1,440  3,193 375 288 1,340 U984 to 2,497  -823  -86 -335 -370 t o -883  1:7,700 1:65,300 1:85,0OO 1:18,20O 1:12,300/ 9,800  2,987 375 272 1.224 2,225  1:8,200 1:65,300 1:90,000 1:20,000 1 :11,000  -6.5 0 -5.6 -8.7 12.2 t o -10.9  2,234  -156  1:11,000  2,234  1:11,000  0  85  210 147  -35 -11  1:117,000 1:166,700  1:117,000 1:166,700  0 0  15-20 11  7 4-5  1,577  -402  1:15,500  1,398  1:17,500  -11.4  55-60  63  887  r-107  1:27,600  874  1:28,000  -1.5  35  24  490  -75  1:50,000.OC  490  1:50,000  0  14-28  26  186  -261  1:30,000  805  1:30,400  40-50  45  245 489  -73 -94  1:100,000 1:50,000  245 489  1:100,000 1:50,000  15 23  29  16,937  16,937  1:1440  0  N.A.  713  183 12 N.A. 80-85 80  182 24 18 62 141  Medical Specialties Internal Medicine Dermatology Neurology Paediatrics Psychiatry  -125  Surgical Specialties General Surgery Cardiovascular: Thoracic Neurosurgery Obstetrics: Gynecology Ophthamology Otolaryngology Orthopaedic Surgery Plastic Surgery Urology  210 147  -1.3 0 0  96  13  Other Specialties Anaesthesia Totals  1.781 -477 1:13.742 82 1.781 1:13.742 0 105 1552 32,993 - -5,360 -22.8 t o 32,693 33,506 5,873 -45.9 A.. N a t i o n a l Committee on P h y s i c i a n Manpower, Requirements f o r P h y s i c i a n s i n Canada, P a r t I I I March 1, 1976. B. F e e - F o r - S e r v i c e P h y s i c i a n s . C. N.A. = Not A v a i l a b l e  155  (CURRENT B.C. POPULATION - 2,409,515)  Hollcall 7 ^ Data (B.C. P o p u l a t i o n 2.409.515) C Ratio Number  Specialty  1:1068  2254  9259  260  62500 83333 19231 12048  125 201  General/Family P r a c t i c e Medical S p e c i a l t i e s I n t e r n a l Medicine Dermatology Neurology Paediatrics Psychiatry  1 1 1 1 1  Surgical Specialties General Surgery Cardiovascular:Thoracic Neurosurgery Obstetrics:Gynecology Opthalmology Otolaryngology Orthopaedic Surgery P l a s t i c Surgery Urology  1:9524 1:200000 1:111111 1:19232 1:20408 1:45455 1:29412 1:100000 1:45455  Other S p e c i a l t i e s Anaesthesia '  1:13514  39 25  252 13 22  125 118  55  82 25  53 178 3827  Totals  Working P a r t y Proposed Present Optimal R a t i o s A p p l i e d to C u r r e n t B.C. P o p u l a t i o n Ratio  Number^  1:1440  1673  1:8000 1:89000 1:85000 1:18260 1:12300/9800  301 27 28 132 196/246  1:10630 1:124000 1:166700 1:15900 1:28000 1:50000 1:30400 1:104800 1:50000  227 19 14 152 86 48 79 23 48  1:3742  175 3228/3278  R o l l c a l l 75, Report R:1, D i v i s i o n o f H e a l t h S e r v i c e s Research and Development, H e a l t h S c i e n c e s Centre, U n i v e r s i t y o f B r i t i s h Columbia N a t i o n a l Committee on P h y s i c i a n Manpower, Report o f the Requirements Committee, P a r t I I I , March 1, 1976 C.  Non Post-Graduate  D.  Number o f P h y s i c i a n s e x c l u d i n g I n t e r n s and R e s i d e n t s ,  Physicians i n B r i t i s h  15$ o f P h y s i c i a n s i n 1974).  Columbia ( i n t e r n s and R e s i d e n t s =  156  PROJECTED PHYSICIAN MANPOWER RATIOS APPLIED TO B.C. FOR 1981 (PROJECTED 1981 B.C. POPULATION =2,821,700) R o l l c a l l 75 Data  Specialty  General/Family  Practice  Ratios 1:1068  Nos. 2642  Working P a r t y F u t u r e Optimal Proposals Nos. Ratios I960 1:1440  Medical S p e c i a l t i e s I n t e r n a l Medicine Dermatology Neurology Paediatrics Psychiatry  1:9259 1:62500 1:83333 1:19231 1:12048  305 45 34 147 234  1:7700 1:65300 1:85000 1; 18260 1 12300 t o ,1 9800  Surgical Specialties General Surgery Cardi ovascular:Thoracic Neurosurgery Obstetrics:Gynecology Ophthalmology Otolaryngology Orthopaedic Surgery P l a s t i c Surgery Urology  1:9524 1:200000 1:111111 1:19231 1:20408 1:45455 1:29412 1:100000 1:45455  296 14 25 147 138 62 96 28 62  Other S p e c i a l t i e s Anaesthesia  1:13514  209  Totals  4484  Requirements Committee Recommendations Ratios 1:1440  Nos. 1960  366 43 33 155 229 288  1:8200 1:65300. 1:90000 1:20000  344 43 31 141  1:11000  257  1 11000 1 .117000 1 : 166700 1 : 15500 1 :27600 1 :50000 1 :30000 1 :100000 1 :50000  257 24 17 182 102 56 94 28 56  1:11000 1:117000 1:166700 1:17500 1:28000 1:50000 1:30400 1:100000 1:50000  257 24 17 161 101 56 93 28 56  1:13742  205  1:13742  205  3807 3866  3774  157  PROJECTIONS FOR PHYSICIAN MANPOWER FOR B.C. C a l c u l a t e d from Data from " R o l l c a l l 75" Specialty  Non Post-Graduate Physicians  Non Post-Graduate Physicians per Demi-Million  E s t i m a t e d Annual Rate o f Change  1974-1975  Annual Rate X 6 years  to 1981-$  Simple P r o jection 'Annual Rate '74,-  •75 x 6  t o 1981  1975  from  Numbers o f Physicians General/Family Practice  2254  468  4.38$  26.28$  Medical S p e c i a l t i e s I n t e r n a l Medicine Dermatology Neurology Paediatrics Psychiatry  260 39  25  125 201  54 8 5 26 42.  5.26 14.71 19.05 5.04 5-24  31-56 88.26 114.3 30.24 31.44  342 73 53 163 264  52.5  -1.56  -9.36  228  2.5 4.5  8.33 -4.35  Surgical Specialties General Surgery Cardiovascular: Thoracic Neurosurgery Obstetrics: Gynecology Ophthalmology Otolaryneology Orthopaedic  Surgery P l a s t i c Surgery Urology _  - 252 13  22  125  26  55  24.5 11.5  82  17  118  25 53  3.31 4.42  3.92  5  VI  5.13 8.70 -3.64  37  2.30  50 -26.1  Totals  178 3827  19-5 16  26.52 23.52  19.86  150 149 68  30.78 52.2 • -21.84  107 38 41  13.8  202.5  Other Specialties Anaesthesia  2846  4760  158 ASSUMPTIONS DEFINITION A55UXITI0H3  GtMnl or  TOMART  SERVICE PATTKHN AIWUMWIOMJ AflD DATA CARE OR CONTACT SERVICE TIMES >*ULL TIME PEE OPTIMUM AVERAGE AND SPECIFICS FOR 5KRVXCK WORK YEAR  OPTIMUM AVERAGE WORK WEEK  rmrrucniw:  OPTIMAL HONK FORCE FHrJICXAN/POIVUTlOR  um  Definition l i Ideal ayatcn haa primary n o n e x c l u s i v e . eara aa exclusive r e Applicable to a p o n a l b i l i t y of CP/FP i n t e r n i s t s also  Coanaelling a n d Ona who r e paychotherapy eoived ovar aarvicoa cannot ba 120,000.00 averaged f o r a unit of aaxrlea. Micro arrora i n 9395 93.8* average aarvlea t l M estlmetea oauao l a r f a man* powar dlatortiona when applied to high volume eervicea auch aa offlot T i a i t a .  46 working vecktf  Internal Medicine  Global term Diseases and disorders of Internal structurea of adult body exclude3 dermatology * neurology  15* of i n t e r n i s t ' a new patients seen on a p r i a a r y b a s i s . 85* referred casea. Subs p e c i a l t i e s : nearly 100* r e f e r r e d .  Presently popul a t i o n i a underserviced by 10*  93.5*  46 working  Pediatrics  Health care from concept i o n to adolescence  70* of paediatricians accept non-referred cases. There i a a strong demand f o r p r i a a r y care f r o a paediatricians  D i f f i c u l t y separating priaary from secondary service  693  94*  46 veeks  48 hours  1:16260  Obstetrics and Gynecology  T o t a l health care of women r e l a t e d to reproduction and reproductive organs  Consultations c o n s t i tute 10Z of workload Public should maintain primary care a b i l i t y  More o r leas atandard  992 96.5* (84*)  46 weeks  48 houra  1:15900  General Surgery  S u r g i c a l and non-surgical treatment of potentially surgical conditions  Ontario - 10* of income of Direct va Indirect general surgeona comes service time com- . ponents. Times from general practice tended to ba on lew aide  1664  96*  Aaaeatheaia  Prevention of pain and l i f e support. Hot an i n s t i t u tional aerrica  Rone  Quebec average of 61 minutes average anaeathstio time l n community hosp i t a l s (76 minutes l n teaching hospitals)  1570  Workload 45 weeks split with Practitioner Anaesthetists  Psychiatry  Diagnosis and Ro assumptions made treatment of paychoaea. neuroses, peraonality problems, psycho-* genie reactlona  Lack of hard data  Orthopedic Surgery  Diagnosis and treatment of Musculos k e l e t a l system conditions  Alberta 1970: 76* of time on orthopod i c a , 21* on surgery outaide their specialty  Family >raetice  Majority should be r e referred except f o r emergencies  1616  45 weak*  49 houra ( i d e a l - 40 houra)  55 hours  1:10630  54 hours i n community hosp i t a l . 57 hours i n a teaching hospital  1:13742  Only 50* of 45 vseka psychiatrists are F.T.F.f.S, remainder on aalary o r aesaional basis  48 hours (35 houra c l i n i c a l )  1:12336 to 1:9800  490  46 weeks  45 hours  Approximately 1:30000  46 weeks  52 hours  1)48585  96*  Ontario 1972i  Orthopedic aur» geona d i d 40* o f orthopedic s e r vices Urology  Moos or l i t t l e Diaeaeee o f adrenals, the urinary t r a c t and the male reproductive tract  Data inadequate because Ontario and Quobeo omitted from surg i c a l workload tables. Ron* standardised coding  357 96*  159  GROWTH ASSUMPTTflws  I9a1 TAKUhT J«J«E» or CHAOUATK TO ATTAIN TAP.OCT  B  / " *  M  ••rttflwj  o  r  *  o  f  p  r  l  -  * V f l i * U  ~ r y s.nrlcs.  should bo uoad  Population growth 11.4* *« I population Kopo group pracln  tltt  Only u cooplo••ntary r o l o , not as cub— o t i ration  Mo changoo oxeopt fop » n prlnary contact  0  C  T  0  E  I  10755 ( A l l PT, foo-for •oryies)  452  IN);  71)  (Foo-foraorrica)  Intornal Xodicina  Moro aub•pooioliuUOB  Podia t r i c o  Dopands on t r a i n i n g of OP/FP  Kov oubMnlntalnod opocialtiaa loonatology gonotics t i e . idoloacont •odicino Mora subH apoeialtias. Half of ppooont output 55-40 pop yoar, •PO fopoign nod l e a l grsduataa  Otatotpioa Gynoeology  Ono t h i r d of no» o a r t i f l easts apa P.M. • • • a . Subspealally training w i l l  Gonoral Surgory  P r i o a r l l y mo consultants  11.771 population (Tooth 3-47» lneroasod utlliutlon Ineraaaing tacfan o l o g i c a l ooaploxlty  Band fop ppisary aocondapy)eapa tariiary ,  11.77* population growth. Kov hoalth capo d o l i v o r y pattorna - eoasunity cowtpoo  Againat paadlatpie aurao-prsctitionapa azeapt for raoots apoaa and noonatal i n tanaiva capo  Minor. Ilo s u r g i c a l polo i n auturo  Consultant r o l a Tariaa with  12.3% population growth. Kola of isaigratlon r e strictions will dofioit.  Hot Corssaon boforo 1981. No* rolo f o r nursoobatatpician d a ponds on nov paysnnt aothoda  a l l high r i s k obs t e t r i c s patiants. Exclusive obstocr i c a procoduro l i s t . Escluairo gynecology pro— oodupa l i s t  Population growth of 11.7*. S h i f t O.P. aurgery to gonoral aurgoona  Sugpeet opora t i n g rooa tochniciana fop s u r g i c a l assistance  alio of  Minlsiss, o i - . 1 . p r i s . n l , capt fop group conaultanta coverage, but maintain aoca prisary capo contact 0  lacraasn  If reatricHone t l o n on f o p •iga n o d i c a l grsduatee, than leeasp q u a l i t y of aoaaathatlc oaro w i l l p o sult '.B.B. - 7 5 * l i k e l y s o n . of new c o p t i - but p r i n a r i l y fieanta a—n raforral. n u a l l y . Xoro aubapocialitatloo  Anaoothosia  Psychiatry  Opthopodio Supgory  Urology  D  n  0  W  ,  d  Ooaand e p e eifle urological training f o r laatigrant swrglcal•rologlats  1 , 0  i  n  c  r  — •  Ao conaultanta only  Mora asbulatr y caro, laaa inetltucionIsatloa  0  A . Conaultanta  > Consultants  Porhapa ooro priamry contact f o p gonoral i n t o r n l a t s i f Unltad S t a t . a tronda adopts*  Asauae C P . a u r «opy. Haalth capa d a l i r a r y patterae w i l l not eauao change i n futuro r » — Jllli Tenant Population growth Low p r i o r i t y tor A l l anaosthotica of \ A % . Xneroaaod training of anaaa- and anaosthatlc aso.es •intenthotle techniclaoB.aorvicea ahould siTists' Profar r.M.C.'a to bo provided by AeupuBoturo t r a i n in ansossnaoathatlata thoaia rathar than upgrading anaeethatlc p r a c t l t l o n e r a ronulation growth Utilise a i l ' ^oroua boundaries " Aging of populacatagorios t i o n . Lack of r u r a l aarvleoo. -  Population gpo.th Opon to poo1 * . Roduca wait- a i b i l i t y l u g period f o r appolntaonts. I n eroaaad dooand fop olnor conditions. Aging populaclono.  , . mcroaood ronal tranaplanto 2. Ihoroaaod a s bulatopy eara •oana sore i n offlcloney and laepoaaod nood f o r aopo upologlota  Mopv uao a n t i c ! patad, oapoclally in clinica  Loea orthopedic. by gonoral aup( . o n . and by O.P.'a  Consolidation of ppooont boundapioa  3193  1577  1984-2497  giT  rr-rr°~  i 0  160  EDUCATIONAL  The  OBJECTIVES FOR CERTIFICATION. IN FAMILY • MEDICINE College  of Family  Part The  particular  physician  has been  Physicians  I , 1974.  function  of  the  certified  described  by  the C o l l e g e  of  Physicians:  "A C e r t i f i e d F a m i l y P h y s i c i a n s h a l l be skilled in establishing and maintaining relationships with patients and asociates which f a c i l i t a t e maximally, the p r o v i s i o n of h e a l t h care.. He s h a l l be s k i l l e d i n sensing and f o r m u l a t i n g a l l health problems and investigating and managing common h e a l t h p r o b l e m s . He shall be able to arrange through consultation and delegation, the provision to patients of those elements of health care which a r e better provided by other health professionals. He shall be technically competent at those procedures commonly required in primary care. He s h a l l p r o v i d e f o r a constantly available health service to persons regardless of their age o r problem. He shall select for patients, those preventative and screening procedures, as well as methods of investigation and management, w h i c h a r e e s t a b l i s h e d as worthwhile. He shall continuously r e v i e w and u p - d a t e h i s competency and be capable of assessing pertinent research."  family Family  Table 8-1 Major Methods for Assessing and Projecting Manpower Requirements Prerequisites and  Appropriate  Method  Advantages  Disadvantages  Country  Professional standards  Fullfills health ethic o f providing services according to need provides ultimate or m a x i m u m goal for the provision o f services  Continued wide divergence among experts on " b e s t " methods to treat many disease conditions;  Requires sophisticated data and  A p t to result in costly projections o f service requirements; Far in excess o f ability to provide  them Physician-population talio  Easy lo use and interpret; Data requirements usually modest and not very sensitive to errors  Easy to select unrealistic ratios resulting in major errors in economic and manpower policies; Provides little insight into the d y n a m ics of demand;  Situations  technical expertise; O f greatest use in countries with large public sector and active government commitment to improving and shaping health services delivery O f greatest use in countries with public or private sectors, reasonably adequate health services delivery system, and limited planning resources  With primary emphasis on manpower, little attention may be given to health services  Ti O M X  Economic-demographic  May be complicated and costly, and  realistic projections;  requires sophisticated data;  technical expertise in tome areas;  Does not necessarily take into account the quality o f services or their relevance to the health problems o f the country;  O f greatest use in countries with  Probably provides a g o o d estimate o f m i n i m u m growth in demand and ensures that the level o f future satisfaction at least equals present satisfaction  Service targets  Requires sophisticated data and  T e n d s to produce economically  Permits a disagreed approach in which the most suitable methods a n d standards are used f o r each . component activity o f the sector; With primary emphasis on "ser-  large private sector; L i m i t e d government involvement in the provision o f health services  May neglect consideration o f ways to improve manpower productivity Prone to having standards based more o n desires than o n reality, leading to major policy errors; High degree o f statistical expertise may be required to sue successfully  vices," not " m a n p o w e r , " attention focused o n productivity and efficient resource utilization; Facilitates closer adjustment to  Modest data and planning capability requirements; O f greatest use in countries with activist government policies toward development and provision o f health services; Adequate governmental c o n t r o l over health services delivery system  delivery ID needs and demands Source: T h o m w Hall. "Estimating Requirements and S u p p l y : Where D o We S t a n d ? " inPan A merican Conference Scientific Publication N o , 279 (WWhington. p . C : Pan A m e r i c a n Health Organization, 1974). pp. 6 4 - 6 5 .  on Health Manpower  Planning.  162  APPENDIX 5.  ALTERNATIVE MODELS OF  Physicians Are P r i c e Takers  II Physicians Are Price Setters  PHYSICTAN PRICING  Fees c l e a r the the market f o r physician services  B F e e s do not c l e a r the market for physician services  The p h y s i c i a n s e l l s his services in a competitive local market and reacts to market-determined . l o c a l fee schedules  There are price ceilings, which a r e s e t by third p a r t y p a y e r s , and the individual physician reacts to these fees  The p h y s i c i a n e n j o y s a monopoly i n the the market for his services and sets h i s f e e s as a s i n g l e ( f i x e d fee schedule) or p r i c e d i s c r i m i n ating (sliding-scale -fee-schedule) monopolost.  The physician takes whatever cases he likes, organizes his p r a c t i c e to suit his tastes, and sets h i s fees so as t o g e n e r a t e a given target income, related, presumably, to the locality.  R e i n h a r d t , . Uwe: H e a l t h manpower p l a n n i n g i n a m a r k e t c o n t e x t : t h e c a s e o f p h y s i c i a n manpower, i n Systems a s p e c t s o f h e a l t h p l a n n i n g , N. B a i l e y and M. Thompson e d s . P r o c e e d i n g s o f the I I ASA C o n f e r e n c e , Baden, A u s t r i a , A u g u s t 20-22, 1974. New Y o r k : N o r t h H o l l a n d , 1975, p.146.  APPENDIX  163  6. STATEMENT ON A PATIENT'S Bill OF RIGHTS Affirmed by the Board of Trustees November 17, 1972  The American Hospital Association presents a Patient's Bill of Rights with the expectation that observance of these rights will contribute to more effective patient ' care and greater satisfaction for the patient, his physician, and the hospital organization. Further, the Association presents these rights in the expectation that they will be supported by the hospital on behalf of its patients, as an integral part of the healing process. It is^  recognized that a personal relationship between the physician and the patient is essential for the provision of proper medical care. The traditional physician-patient relationship takes on a new dimension when care is rendered within an organizational structure. Legal precedent has established that the institution itself also has a responsibility to the patient. It is in recognition of these factors that these rights are affirmed. 1. The patient has the right to considerate and respectful care. 2. The patient has the right to obtain from bis physician complete current information concerning his diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate person in bis behalf. He has the right to know by name, the physician responsible fox coordinating his care. 3. The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and/ or treatment. Except in emergencies, such information for informed consent, should include but not necessarily be limited to the specific procedure and/or treatment, the medically significant risks involved, and the probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information. The patient also has the right to know the name of the person responsible for the procedures and/or treatment. 4. The patient has the right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of his action. 5. The patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Those not directly in-  volved in his care must have the permission of the patient to be present. 6. The patient has therightto expect that all communications and records pertaining to his care should be treated as confidential. 7. The patient has the right to expect that within its capacity a hospital must make reasonable responsetothe request of a patient for services. The hospital must provide evaluation, service, and/ or referral as indicated by the urgency of the case. When medically permissible a patient may be transferred to another facility only after he has received complete information and explanation concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must first have accepted the patient for transfer. 8. The patient has the right to obtain information as to any relationship of his hospital to other health care and educational institutions insofar as his care is concerned. The patient has the right • to obtain information as to the existence of any professional relationships among individuals, by name, who are treating him. 9. The patient has the right to be advised if the hospital proposes to engage in or perform human experimentation affecting his care or treatment. The patient has the right to refuse to participate in such research projects. 10. The patient has the right to expect reasonable continuity of care. He has the right to know in advance what appointment times and physicians are available and where. The patient has the right to expect that the hospital will provide a mechanism whereby he is informed by his physician or a delegate of the physician of the patient's continuing health care requirements following discharge. 1L The patient has the right to examine and receive an explanation of his bill regardless of source of payment 12. The patient has therightto know what hospital rules and regulations apply to his conduct as a patient.  165 APPENDIX 7 .  Distribution of Total Government Spending Data source: Consolidated Government Finance. Statistics Canada  

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