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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 IN CANADA FOR THE FAMILY PHYSICIANS OF BRITISH COLUMBIA by JOHN CHARLES VARLEY M . D . , T h e U N I V E R S I T Y ' o f T O R O N T O , 1953 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY FACULTY OF MEDICINE We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA SEPTEMBER, 1980 © J o h n Charles V a r l e y , 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 Columbia, I agree that the Library shall make it freely available for re ference and study. I further agree that permission for extensive copying o f t h i s t h e s i s for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or p u b l i c a t i o n o f this thesis for financial gain shall not be allowed wi thout my w r i t t e n permission. Department of The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 ABSTRACT The work content and s t y l e of p r a c t i c e of f a m i l y p h y s i c i a n s i n B r i t i s h Columbia has been e v o l v i n g s i n c e the second world war. Since the l a t e s i x t i e s , a reassessment of the r o l e of f a m i l y p h y s i c i a n s has been underway, both i n Canada and the United S t a t e s . Primary h e a l t h care has r e c e n t l y been given g r e a t e r r e c o g n i t i o n i n North America. The development of f a m i l y p r a c t i t i o n e r s * tasks i n the l a s t twenty years i s reviewed from the p o i n t of view of a p r a c t i t i o n e r . In Canada, the h e a l t h care system has been changing s i n c e the f o r t i e s , as a r e s u l t of a s e r i e s of f e d e r a l - p r o v i n c i a l agreements. I t had become apparent t h a t , d e s p i t e co n s t i t u t i o n a l deeding of h e a l t h care to the p r o v i n c e s , f e d e r a l i n c e n t i v e s and funding were r e q u i r e d to develop an a p p r o p r i a t e nationwide system of h e a l t h c a r e . What was a j o i n t p r i v a t e e n t e r p r i s e and l o c a l community sponsored h e a l t h care system i n the t h i r t i e s , has now become a complex government-funded o p e r a t i o n . Government involvement i n t h i r d p a r t y payment schemes, f o r d o c t o r s p a r t i c u l a r l y (the l a s t of a s e r i e s of n a t i o n a l h e a l t h insurance programs), has changed the r e l a t i o n s h i p of d o c t o r s to t h e i r p a t i e n t s , because both became s u b j e c t to the new r u l e s of the i i i M e d i cal Care Act of 1967. Government involvement i n payment f o r s e r v i c e s has l e d to qu e s t i o n s about a c c o u n t a b i l i t y f o r spending. Subsequently, t h i s l e d to the need f o r b e t t e r p l a n n i n g , e s p e c i a l l y h e a l t h manpower p l a n n i n g , which began to be con s i d e r e d very important i n the e a r l y s i x t i e s . At t h a t time, the Royal Commission on Health S e r v i c e s examined the prospects of b r i n g i n g p h y s i c i a n s * services and a l l i e d h e a l t h manpower s e r v i c e s to a l l Canadians. The attempts to plan p h y s i c i a n manpower i n Canada and B r i t i s h Columbia i n the s i x t i e s and s e v e n t i e s are con s i d e r e d and c r i t i c i z e d . C o n c l u s i o n s are drawn re g a r d i n g the pr o s p e c t s f o r f u t u r e manpower p l a n n i n g f o r primary care to be given by f a m i l y p r a c t i t i o n e r s i n B r i t i s h Columbia. iv TABLE OF CONTENTS TITLE PAGE i ABSTRACT i i TABLE OF CONTENTS iv ACKNOWLEDGEMENTS v i CHAPTER 1. INTRODUCTION 1 CHAPTER 2. DEVELOPMENTS IN THE WORK OF PRIMARY CARE PHYSICIANS IN BRITISH COLUMBIA 8 1. THE BROAD BACKGROUND 8 2. PRIMARY PHYSICIAN'S PERSPECTIVE ON TODAY'S MEDICAL TRIAD 14 a. THE PUBLIC/MEDICAL PROFESSION EQUATION b. THE CHANGING REFERRAL SYSTEM 16 C.SOCIAL LABELLING ACTIVITY BY PHYSICIANS AND ITS APPROPRIATE-NESS 19 d. PUBLIC EXPECTANCY: THE TWENTY-FOUR HOUR MAN 23 e. PERSONAL RESPONSIBILITY OF PATIENTS 27 f. THE TEAM APPROACH TO HEALTH CARE 29 g. MEDICINE AND SOCIETY IN RECIPROCITY 33 h. REDEFINITION OF THE FAMILY PHYSICIAN 37 CHAPTER 3. THE CANADIAN HEALTH CARE SYSTEM 41 1. THE EVOLUTION OF THE FEDERAL-PROVINCIAL SYSTEM OF HEALTH CARE 41 2. DOCTORS' ATTITUDES TO THE HEALTH CARE SYSTEM 42 3. ACCOUNTABILITY AND CONTROLS 45 4. MANPOWER DEVELOPMENTS 52 V TABLE OF CONTENTS (CONT.) CHAPTER 4. HEALTH PLANNING ACTIVITIES 53 1. ENTREPRENEURIAL "PLANNING", OR THE "NON-SYSTEM" 53 2. EMERGENCE OF GOVERNMENT PLANNING PROCESSES IN CANADA AND BRITISH COLUMBIA 59 3. EMERGENCE OF MEDICAL MANPOWER PLANNING PROCESSES: AN INTERNAT-IONAL MOVEMENT 6 4 4. RATIONAL, BUREAUCRATIC, AND ADVOCACY PLANNING 7 2 CHAPTER 5. A CRITICAL EVALUATION OF THE PLANNING PROCESS 80 1. IDEOLOGICAL DIFFERENCES AND THEIR EFFECT ON PLANNING 80 a. ENTREPRENEURIAL ATTITUDES AND PROBLEMS 80 b. CORPORATE OR RATIONAL PLANNERS' ATTITUDES 83 C.CONSUMER ADVOCACY 91 2. RATIONAL PLANNING AND POLICIES 94 CHAPTER 6. ANALYSIS OF CANADA'S MAJOR HEALTH PLANNING PROJECT TO DATE 97 1. INTRODUCTION 97 2. BACKGROUND 97 3. PROBLEM DEFINITION 98 4. METHODOLOGY 99 5. TOTAL METHOD COMMENTS AND CRITICISMS 102 6. DEFINITION OF FAMILY PRACTICE 108 7. CONCLUSIONS AND POSSIBLE SOLUTIONS 116 CHAPTER 7. CONCLUSIONS FOR HEALTH PLANNING 119 BIBLIOGRAPHY 128 APPENDIX 13 9 v i ACKNOWLEDGEMENT I take t h i s o p p o r t u n i t y to thank my p r o f e s s o r , s t i m u l u s , and f r i e n d , Dr. Anne C r i c h t o n , f o r her c o n s i d e r a b l e help i n moving me to complete t h i s t h e s i s . Without her e f f o r t I would not have achieved i t s completion. I would a l s o l i k e to thank Dr. D. 0 . Anderson f o r h i s guidance when he was head of the Manpower Research U n i t at U.B.C. In a d d i t i o n , I would l i k e to thank Dr. Annette Stark, present head of the Manpower Research U n i t , and Dr. David Hsu, f o r t h e i r h e l p . F i n a l l y , a s p e c i a l word of thanks to Robert Stevens f o r h i s strenuous and d i l i g e n t e f f o r t i n the p r e p a r a t i o n of the manuscript and c o p i e s . 1 CHAPTER ONE  I n t r o d u c t i o n There has been a demand to i n c r e a s e the numbers of primary care p h y s i c i a n s i n North America i n the l a s t twenty years. The reasons fo r t h i s are complex, and can only be a p p r e c i a t e d by t a k i n g an overview of m u l t i p h a s i c developments. These reasons are explored i n Chapter Two, which i s a l s o concerned with examining the work press u r e s and ambiguous r o l e s of f a m i l y p r a c t i t i o n e r s i n the s e v e n t i e s . In a d d i t i o n to the p r e s s u r e s from manifold t e c h n o l o g i c a l developments i n medicine and s o c i a l responses to them, Canada has l e g i s l a t e d i n t o e x i s t e n c e a n a t i o n a l h e a l t h insurance scheme s i n c e the l a s t world war. The i n j e c t i o n of government monies, f i r s t i n t o h o s p i t a l s and l a t e r i n t o t h i r d p a r t y payment schemes to pay d o c t o r s ' f e e s , has had. profound e f f e c t s upon the h e a l t h care d e l i v e r y system. Pressures exerted by these t h i r d p a r t y payers on p r a c t i s i n g p h y s i c i a n s are examined, and the p h y s i c i a n s ' p o i n t s of view e x p l a i n e d . The l e g i s l a t i o n which has had t h i s impact i s e x p l o r e d i n Chapter Three as a p r e l i m i n a r y to d i s c u s s i n g the development of h e a l t h manpower pl a n n i n g a c t i v i t i e s 2 i n Canada, and i n the western world g e n e r a l l y , i n Chapter Four. A Royal Commission, which re p o r t e d i n 1964, commissioned a s p e c i a l study on Medical Manpower bef o r e reccommending g e n e r a l acceptance of the medical care p l a n which had been proposed i n the f o r t i e s (Heagarty, 1943), and implemented i n the p r o v i n c e of Saskatchewan i n 1962. I t was r e a l i z e d t h a t the i n t r o d u c t i o n of t h i r d p a r t y payment schemes funded by 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 of r i g h t s t o h e a l t h care had begun to be r a i s e d . Although t h i s r i g h t i s now taken f o r granted i n Canada, the Americans have not yet reached agreement on t h i s p r i n c i p l e . The Royal Commissioners made recommendations about the n e c e s s i t y for i n c r e a s i n g medical manpower s u p p l i e s , and suggested t h a t more medical s c h o o l s should be opened and e x i s t i n g s c h o o l s expanded. However, th e r e was a s p e c i a l problem f o r Canada at t h i s time, s i n c e Canada became a s t a g i n g post i n an i n t e r n a t i o n a l flow of p r o f e s s i o n a l migrants (McGregor, 1971; B u t t e r , 1972). The i n f l o w and outflow of p h y s i c i a n s has now subsided, but i t has been a pro b l e m a t i c f a c t o r i n medical manpower p l a n n i n g , because any attempt to c o n t r o l p h y s i c i a n s 1 a c t i v i t i e s has r e s u l t e d i n t h r e a t s to move on to other c o u n t r i e s , thus c r e a t i n g p o t e n t i a l problems of even more uneven d i s t r i b u t i o n of medical s e r v i c e s . Even though attempts 3 were made i n B r i t i s h Columbia to govern p r a c t i c e s i t e s chosen by new immigrant p h y s i c i a n s , i n the hope of a c h i e v i n g b e t t e r and more even d i s t r i b u t i o n throughout the p r o v i n c e , the r e g u l a t i o n s promulgated by the C o l l e g e of P h y s i c i a n s and Surgeons of B r i t i s h Columbia were d e c l a r e d i l l e g a l by a c h a l l e n g e c a r r i e d to the Human 1975 R i g h t s Commission, f Other c o u n t r i e s have a l s o had p h y s i c i a n manpower problems, although the i s s u e s d i f f e r a c c o r d i n g to t h e i r p a r t i c u l a r payment systems, t h e i r c a p a c i t y to produce p h y s i c i a n s , and t h e i r p a t t e r n s of immigration and e m i g r a t i o n (U.S. Bureau of Health Resources Development, 1974; P e t e r s d o r f , 1975). The development of h e a l t h manpower pl a n n i n g a c t i v i t i e s i n Canada was a l s o a f f e c t e d by the v a s t i n c r e a s e i n the monies pumped i n t o t e r t i a r y e d u c a t i o n i n Canada duri n g the post-war y e a r s . By the middle of the s i x t i e s , the f e d e r a l government had agreed to p r o v i d e s p e c i a l g r a nts to e d u c a t i o n a l i n s t i t u t i o n s f o r b u i l d i n g and f a c i l i t i e s f o r t e a c h i n g r r e s e a r c h i n h e a l t h c a r e . The n e c e s s i t y for c o n s i d e r i n g p l a n n i n g not only f o r medical manpower, but f o r a l l h e a l t h manpower, began to be re c o g n i z e d (Robertson,et a l ). F e d e r a l and p r o v i n c i a l conferences, ad hoc commissions and standing committees, began to be c a l l e d together i n the l a t e s i x t i e s to work on the d i s t r i b u t i o n and mix of h e a l t h p r o f e s s i o n a l s . As w e l l , q u e s t i o n s of a c c o u n t a b i l i t y were beginning to s u r f a c e , e.g. were Canadians g e t t i n g value f o r money i n 4 t h e i r h e a l t h s e r v i c e s , and were the s e r v i c e s being p r o p e r l y organized and c o n t r o l l e d ? A Task Force on the Costs of Health Care r e p o r t e d i n 1969. V a r i o u s r e p o r t s are reviewed i n Chapter Four. While there has been a c o n s i d e r a b l e e f f o r t to t a c k l e manpower pl a n n i n g i s s u e s by these groups, they have had to recognize t h a t t h e i r power i s q u i t e l i m i t e d . The Canadian h e a l t h care system i s not, under present agreements, c l o s e l y c o n t r o l l e d by governments. I t i s , r a t h e r , a c o n t i n u a l l y r e n e g o t i a t e d p a r t n e r s h i p between p r o f e s s i o n a l s e r v i c e p r o v i d e r s , community i n s t i t u t i o n s such as h o s p i t a l s or v o l u n t a r y h e a l t h agencies, and government. However, government, by means of c o n t r o l of payment mechanisms, has the c l o u t with which to i n s t i t u t e changes i n the system, i f they do not, i n so doing, evoke too many r e a c t i o n a r y f o r c e s i n the g e n e r a l p u b l i c as w e l l as the medical p r o f e s s i o n . Doctors are c u r r e n t l y on the d e f e n s i v e i n terms of bargaining f i n a n c i a l concessions from governments - the same governments who are now aware of the r i s i n g percentage of y e a r l y budgets t h a t are consumed by h e a l t h c a r e . These p r o v i n c i a l governments have been i n v o l v e d with the assumption of more r e s p o n s i b i l i t y f o r payment of medicare i n t h e i r r e s p e c t i v e p r o v i n c e s because of the f e d e r a l d e s i r e to withdraw from open-ended sponsorship of medicare c o s t s . There have been v a r i o u s t r a d e - o f f s , with f e d e r a l funds channeled i n t o p r o v i n c i a l c o f f e r s to 5 meet medicare c o s t s now assumed by the p r o v i n c e s . However, p r o v i n c i a l governments tend to view these funds as p a r t of t h e i r g e n e r a l revenue, and as such, they are s u b j e c t to the demands of other c a b i n e t p o r t f o l i o s and departments f o r d o l l a r s . There i s thus developed an innate r e s i s t a n c e to open-ended p r o v i n c i a l funding f o r h e a l t h care c o s t s . T h i s r e s i s t a n c e i s seen i n n e g o t i a t i o n s between v a r i o u s p r o v i n c i a l governments and t h e i r r e s p e c t i v e medical a s s o c i a t i o n s i n d i s c u s s i n g terms of fee i n c r e a s e s . More and more, a s p i r i t of c o n f r o n t a t i o n i s being c r e a t e d i n p l a c e of the p r e v i o u s c o o p e r a t i v e p a r t i c i p a t i o n atmosphere i n h e a l t h care d e l i v e r y . The medical p r o f e s s i o n i s so i n v o l v e d with d e f e n s i v e p o s t u r i n g to prevent f u r t h e r e r o s i o n of i t s now f i n a n c i a l s t a t u s , t h a t t h e y ^ seem to have l i t t l e e f f e c t i v e n e s s i n h e a l t h p l a n n i n g ( A» C r i c h t o n ) . T h i s would appear to s u i t government p a r t i c u l a r l y w e l l , as they have more and more tended to exclude the p r o f e s s i o n from p a r t i c i p a t i o n s i n c e the days when Medicare was being planned and the p h y s i c i a n s ' o r g a n i z a t i o n s were excluded from the p r e l i m i n a r y meetings. Governmental c o n t r o l of p l a n n i n g without s t r o n g medical p r o f e s s i o n input would seem l o g i c a l f o r c o n t r o l l i n g c o s t s of new t e c h n o l o g i c a l advances. Cost c o n t r o l i s the number one p r i o r i t y i n these times as regards h e a l t h care budgets. The c o n t r o l of planning^ of course^ d o v e t a i l s n i c e l y with 6 p o l i c y , which i t s e l f i s determined by many p o l i t i c a l f a c t o r s d i s t i n c t from medical needs and c o s t s . The medical care p r o v i d e r s , who were complete r i s k t a k i n g entrepreneurs u n t i l t h i r d p a r t y payment schemes were in t r o d u c e d , have continued to b a r g a i n f o r involvement i n s e r v i c e p r o v i s i o n on t h e i r own terms, but more and more as a rear guard a c t i o n . F i n a n c i a l pre-eminence f o r d o c t o r s i s no longer looked upon as an immutable and j u s t f a c t by the p u b l i c . Rather, because of media r e p o r t i n g and changing a t t i t u d e s and v a l u e s , the p u b l i c f e e l s t h a t high s a l a r i e s may even be i n a p p r o p r i a t e . There i s l i t t l e p u b l i c support evidenced f o r the doctors when they bewail t h e i r s l i p p i n g economic s t a t u s . P h y s i c i a n s have attempted to ensure t h a t any changes i n t r o d u c e d i n t o s e r v i c e o r g a n i z a t i o n s do not e f f e c t t h e i r c o n d i t i o n s of work a d v e r s e l y . Apart from t h e i r r e s i s t a n c e to new s t r u c t u r e s of o r g a n i z a t i o n and the i n t r o d u c t i o n of s u b s t i t u t e p e r s o n n e l , there are i n t r a - p r o f e s s i o n a l r i v a l r i e s . The medical p r o f e s s i o n i s not a m o n o l i t h i c group. W i t h i n i t t h e r e are many s e c t o r i a l i n t e r e s t groups. Because of these r i v a l r i e s , e f f e c t i v e medical manpower pl a n n i n g f o r a primary p h y s i c i a n s e r v i c e f o r the e i g h t i e s i s not l i k e l y to be e a s i l y achieved. A c r i t i q u e of the medical manpower pl a n n i n g process i n Canada and B r i t i s h Columbia i s presented i n Chapter F i v e . The d i f f i c u l t i e s of a p p l y i n g p l a n n i n g 7 techniques to the o r g a n i z a t i o n of an improved primary h e a l t h care s e r v i c e are c o n s i d e r e d i n Chapter S i x . Conclusions r e g a r d i n g the a p p l i c a t i o n of manpower pla n n i n g to primary care s e r v i c e s are drawn i n the l a s t chapter. 8 CHAPTER TWO Developments i n the Work of Primary Care P h y s i c i a n s i n British Columbia 1. The Broad Background B r i t i s h Columbia has a higher percentage of primary care p h y s i c i a n s than the r e s t of the pr o v i n c e s ( C l u t e ) . There has been an trend to upgrade the s t a t u s of the Canadian f a m i l y p h y s i c i a n with the establishment of departments of f a m i l y medicine i n medical school f a c u l t i e s . The c o n t i n u i n g education programs and c e r t i f i c a t i o n programs of the Canadian C o l l e g e of Family P h y s i c i a n s have served the same purpose. The reasons f o r wanting to improve primary care s e r v i c e s are q u i t e complex, and can only be understood by t a k i n g a long view of medical education and h e a l t h s e r v i c e o r g a n i z a t i o n . Canada's p h y s i c i a n s and t h e i r s e r v i c e o r g a n i z a t i o n are s t r o n g l y i n f l u e n c e d by p r o x i m i t y to the United S t a t e s . F r i n k e r s t e i n has t r a c e d four stages i n the development of United S t a t e s medical education which occu r r e d i n response to t h a t s o c i e t y ' s concern about 9 t h e i r medical s e r v i c e s . These developments were f o l l o w e d q u i t e c l o s e l y by s i m i l a r developments i n Canada. The four p e r i o d s he d i s t i n g u i s h e d were: a. the beginnings of medical school development i n the n i n e t e e n t h century; b. the post-Flexmer p e r i o d from 1910, when the s c h o o l s responded to the c r i t i c i s m of t h e i r standards i n a r e p o r t p u b l i s h e d by the Carnegie Foundation (movement was then made to improve the s c i e n t i f i c t r a i n i n g of g e n e r a l p r a c t i t i o n e r s ) ; c. the s p e c i a l i s t t r a i n i n g p e r i o d , beginning about 1925, when attempts began to be made to respond to the i n c r e a s e d development of medical technology; and d., the community medicine era, beginning about the mid s i x t i e s , which was one answer to the demand f o r l e s s t e c h n i c a l s p e c i a l i z a t i o n and f o r the p r o v i s i o n of more comprehensive h o l i s t i c h e a l t h c a r e . Canada has always had more primary care p h y s i c i a n s per p o p u l a t i o n u n i t than has the U n i t e d S t a t e s ( C l u t e ) . The s p e c i a l i s t t r a i n i n g which, i n the course of time, has r e s u l t e d i n most American c i t i z e n s having to s e l e c t t h e i r own s p e c i a l i s t s because of the absence of g e n e r a l p r a c t i t i o n e r s (Stevens), d i d not a f f e c t Canada i n q u i t e the same way at the same time. Canadian g e n e r a l p r a c t i t i o n e r s were not downgraded i n t h e i r s t a t u s to the same e f f e c t (although s p e c i a l i s t s were more h i g h l y regarded), because of the d i f f e r e n t s o c i a l c o n d i t i o n s i n a widespread, t h i n l y populated country. Although Canada 10 had grown from three to eleven m i l l i o n people between Co n f e d e r a t i o n i n 1867 and the Second World War, i t was not u n t i l the postwar years t h a t l a r g e numbers of immigrants were admitted to double t h a t p o p u l a t i o n by 1971. As w e l l , the d i s t r i b u t i o n of p o p u l a t i o n between urban and r u r a l s e t t l e m e n t s g r a d u a l l y changed, and l a r g e r p o p u l a t i o n s began to i n h a b i t the m e t r o p o l i t a n c e n t r e s which had become predominant by the s e v e n t i e s . In the immediate postwar y e a r s , there was l e s s demand f o r t e r t i a r y care s p e c i a l i s t s than f o r g e n e r a l p r a c t i t i o n e r s , backed up by g e n e r a l i n t e r n i s t s and g e n e r a l surgeons who were r e l a t i v e l y i s o l a t e d i n the ( l a r g e r c e n t r e s . I t was not u n t i l the s i x t i e s t h a t a demand f o r s u b s p e c i a l i s t s r e a l l y began to emerge and a more complex r e f e r r a l system evolved. As w e l l , Canada served as an e n t r y p o i n t f o r l a r g e numbers of immigrant p h y s i c i a n s l e a v i n g Europe f o r North America and A u s t r a l i a . There was an i n f l u x of p h y s i c i a n s i n the e a r l y f i f t i e s f l e e i n g from the B r i t i s h N a t i o n a l Health S e r v i c e s e t up i n 1948. E c k s t e i n and o t h e r s have e x p l a i n e d how the g e n e r a l p r a c t i t i o n e r s were q u i t e h o s t i l e to the establishment of t h a t s e r v i c e and how the major concessions were made to the s p e c i a l i s t s . Consequently, the immigrants were o f t e n g e n e r a l p r a c t i t i o n e r s with bad experiences with, and s t r o n g l y n e g a t i v e views about s o c i a l i z e d medicine. Or a l t e r n a t i v e l y , the immigrants, i f young d o c t o r s , would 11 be those with dimmed e d u c a t i o n a l prospects due to c o s t cuts i n t r o d u c e d from 1951 onwards. At t h a t time, the r e a l i t y of f i n a n c i n g c o s t s of the B r i t i s h Health S e r v i c e began to s t r i k e home to the government. The government began to move more slo w l y than had been t h e i r o r i g i n a l i n t e n t , i n p r o v i d i n g s p e c i a l i s t t r a i n i n g p o s t s f o r ex-servicemen. But?ter has e x p l a i n e d how Canada was o f t e n used as a "parking l o t " f o r new immigrants f o r a few years u n t i l they became e s t a b l i s h e d i n North America. Some then j o i n e d those Canadian medical graduates who a s p i r e d to s u b s p e c i a l i s t c a r e e r s and who sought f u r t h e r t r a i n i n g i n the United S t a t e s . Others, having l e a r n t how to operate i n a f e e - f o r - s e r v i c e system, moved on from the p r o v i n c e s where they had landed (the P r a i r i e s and the M a r i t i m e s ) , to the l a r g e r c e n t r e s of p o p u l a t i o n or the warmer c l i m a t e s of the United S t a t e s . Some, of course, stayed i n Canada, and many of these moved to O n t a r i o and B r i t i s h Columbia, where working and s o c i a l c o n d i t i o n s seemed more a t t r a c t i v e . The movement through Canada slowed down c o n s i d e r a b l y at the time of the Vietnam war, not only because young p h y s i c i a n s were l i a b l e to be c a l l e d up, but because of the growing consciousness of the e x i s t e n c e of the border and the d i f f e r e n c e s between the two c o u n t r i e s . In summary, i t appears t h a t Canada was a l s o a f f e c t e d by the g e n e r a l trends i d e n t i f i e d by 12 F r i n k e r s t e i n , but with time l a g s , adjustments to f i t Canadian circumstances, and a str o n g input of B r i t i s h - t r a i n e d g e n e r a l p r a c t i t i o n e r s who counteracted the American i n f l u e n c e s with t h e i r own. The s p e c i a l nature of the p r o f e s s i o n a l immigrants who were a t t r a c t e d to the country and decided to stay there has been an important f a c t o r i n B r i t i s h Columbian medical decision-making. In the chapter which f o l l o w s , the d e c i s i o n by f e d e r a l and p r o v i n c i a l governments to assume r e s p o n s i b i l i t y f o r developing a n a t i o n a l h e a l t h insurance scheme i n the postwar era w i l l be c o n s i d e r e d i n some d e t a i l . The l a s t of the programs i n t h i s scheme was t h a t of Medical Care, i n which governments agreed to pr o v i d e funding to meet p h y s i c i a n s ' fees f o r s e r v i c e to t h e i r p a t i e n t s . The i n t r o d u c t i o n of a t h i r d p a r t y payment scheme supported by government funds had been accepted i n p r i n c i p l e by Canadian d o c t o r s i n 1943 (Heagarty). In f a c t , d o c t o r s were i n s t r u m e n t a l i n i n t r o d u c i n g and e s t a b l i s h i n g many p r e p a i d medical schemes i n the v a r i o u s p r o v i n c e s , i n c l u d i n g B r i t i s h Columbia, where the Medical S e r v i c e s A s s o c i a t i o n was the l a r g e s t c a r r i e r . There were s e v e r a l o t h e r s , i n c l u d i n g Medical S e r v i c e s Incorporated f o r smal l e r employers, and the c r e d i t union p r e p a i d scheme, C.U.& C. The l i n k i n g of v a r i o u s p r o v i n c i a l p lans across the country to pr o v i d e p o r t a b i l i t y was done by the establishment of the 13 Trans Canada Medical Plan. P a t i e n t s paying a p a y r o l l d e duction f o r t h e i r h e a l t h c a r e , employers paying a p o r t i o n or a l l of the medical p l a n f e e , and d o c t o r s a c c e p t i n g a c e r t a i n percentage of t h e i r fee schedule, a l l became i n d o c t r i n a t e d i n t o the ideology and method of t h i r d p a r t y p r e p a i d medical c a r e . In B r i t i s h Columbia, the government e s t a b l i s h e d S.A.M.S. - S o c i a l A s s i s t a n c e Medical S e r v i c e s - with a t i g h t r e i n on the budget, so much so, t h a t d o c t o r s o f t e n had to accept only 50% of t h e i r fee schedule. To t h i s day, the p h y s i c i a n s i n B r i t i s h Columbia f e e l they d i d not and do not get due c r e d i t f o r t h e i r r o l e i n the establishment of p r e p a i d h e a l t h care i n the p r o v i n c e (the s c o f f e r s c l a i m the d o c t o r s were j u s t out to secure t h e i r own incomes). The plans had g r a d u a l l y been expanded over time to cover the m a j o r i t y of people i n the p r o v i n c e . The f e d e r a l government d i d not o f f e r to i n t r o d u c e a comprehensive s e r v i c e l i k e the B r i t i s h N a t i o n a l Health S e r v i c e i n the postwar p e r i o d , but proposed to i n t r o d u c e f o u r programs g r a d u a l l y . By the time t h a t the l a s t program, Medical Care (or Medicare) began to r e c e i v e a t t e n t i o n , the d o c t o r s were i n a f a r stronger economic p o s i t i o n than they had been i n 1943, but they were u n c e r t a i n of t h e i r r o l e and the i n h e r e n t i m p l i c a t i o n s of government involvement. The f i r s t p r o v i n c e to i n t r o d u c e Medicare, Saskatchewan ( i n 1962, by the New Democratic Party 14 [ S o c i a l i s t ] ) , s u f f e r e d a b i t t e r d o c t o r s ' s t r i k e (Badgley and Wolfe) , and the m a n i f e s t a t i o n of t h i s s t r i k e was t h a t the Royal Commission on Health S e r v i c e s , 1 9 6 1 - 1 9 6 4 , f e l t i t had to n e g o t i a t e with the p r o f e s s i o n to determine i t s a t t i t u d e and i n t e n t i o n s r e g a r d i n g Medicare's establishment. The d o c t o r s l a t e r became more wary when the government r e f u s e d to l e t them appear, even as observers, at the p l a n n i n g conferences l e a d i n g to the establishment of Medicare - t h i s d e s p i t e t h e i r experience and growing e x p e r t i s e i n p r e p a i d medical p l a n s . One would wonder i f the f e d e r a l government f e l t i t would be p o l i t i c a l l y unwise to i n v o l v e d o c t o r s i n the establishment of a medicare scheme t h a t might t u r n out to be an income bonanza for them. The e f f e c t of the d e c i s i o n to proceed with a n a t i o n a l scheme i n 1968 upon the primary p h y s i c i a n s of B r i t i s h Columbia, i s c o n s i d e r e d now. 2. Primary P h y s i c i a n ' s P e r s p e c t i v e on Today's Medical T r i a d a. The P u b l i c / M e d i c a l P r o f e s s i o n Equation In the s h i f t from a r e l a t i v e l y s i m p l i s t i c dyad between the p h y s i c i a n and the p a t i e n t , to a more complex 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 government as t h i r d p a r t y payer, the p u b l i c concept of the 15 p h y s i c i a n and the p h y s i c i a n ' s concept of the p u b l i c has changed. A b u r e a u c r a t i c t h i r d p a r t y presence can shr i n k the s e n s i t i v i t y of the o r i g i n a l dyadic r e l a t i o n s h i p , when c o n f l i c t with t h a t t h i r d p a r t y a r i s e s over i s s u e s about which the medical p r o f e s s i o n i s most s e n s i t i v e , such as the fee s t r u c t u r e and p a t t e r n of p r a c t i c e s u r v e i l l a n c e . E r i c Berne, the o r i g i n a t o r of t r a n s a c t i o n a l a n a l y s i s , d e f i n e s the u n i t of s o c i a l i n t e r c o u r s e as a t r a n s a c t i o n . Inherent i n a t r a n s a c t i o n i s an e q u i l i b r i u m : a two-way flow, much i n the manner of a chemical r e a c t i o n . Instead of e l e c t r o n s h i f t s , however, we f i n d i n medical p r a c t i c e t h a t there i s a g i v i n g and r e c e i v i n g of i n f o r m a t i o n , s e r v i c e s , and payments. The equation i s compounded by the a d d i t i o n of a t h i r d p a r t y , e s p e c i a l l y when t h a t p a r t y i s a government, or i t s agency. Governmental departments o f t e n seem to a c t under a b l a n k e t of a u t h o r i t a r i a n i s m , u s i n g r u l e s and r e g u l a t i o n s which cover t h e i r m o t i v a t i o n s , p o l i c i e s , and reas o n i n g . T h i s strong t h i r d p a r t y f o r c e i s i n h e r e n t l y a c h a l l e n g e t o , and suspect by, the free-wheeling s p i r i t of e n t r e p r e n e u r s h i p of the p r a c t i t i o n e r - one who had become accustomed to the s a n c t i t y of a p r i v a t e dyadic r e l a t i o n s h i p . For t h a t r e l a t i o n s h i p , the p a t i e n t c a r r i e d a degree of r e s p o n s i b i l i t y manifested by h i s c o n t r i b u t i o n to the payment of the p h y s i c i a n ' s f e e . Under present 16 conditions, the general public f e e l s that the service i s free, and, as such, tends to abuse service as well as take i t for granted. Physicians miss the a t t i t u d i n a l set that the payment of a fee or u t i l i z a t i o n fee seems to i n s t i l l . Opponents of u t i l i z a t i o n fees decry the use of the same because, they state, i t denies access to the system to those who need i t most: the poor and the eld e r l y (Wildavsky, Aday). However, the p r o v i n c i a l government i n B r i t i s h Columbia has no hesita t i o n i n applying a u t i l i z a t i o n fee, and recently, has increased substantially a l l u t i l i z a t i o n fees, including those of the elderly in the extended care i n s t i t u t i o n s . These fees have been noted by Justice H a l l in his 1980 report^ (Canada, 1980) . b. The Changing Referral System As the public has grown more accustomed to medicine, more knowledgeable about medical developments, more secure in their medical "rights', there has been a comcomitant s h i f t in the nature of their attitude to the general p r a c t i t i o n e r and also to the s p e c i a l i s t . More often the family p r a c t i t i o n e r i s viewed not as the instrument of the family's healing processes, but as a stepping-stone to their ultimate service instrument, the s p e c i a l i s t . Because of these a t t i t u d i n a l s h i f t s , the patient often arrives i n the o f f i c e firmly convinced of the accuracy of his/her self-diagnosis, unwittingly judgemental as to the inadequacy of the family 1 7 p r a c t i t i o n e r to handle h i s / h e r case, and str o n g i n h i s / h e r demand f o r and r i g h t to a s p e c i a l i s t . A t t i t u d i n a l changes as noted above, are not j u s t c o n f i n e d to the p u b l i c . The s p e c i a l i s t s are o f t e n g u i l t y of the same bypassing of the a t t e n d i n g p h y s i c i a n when seeking c o n s u l t a t i o n s f o r a p a t i e n t f o r problems o u t s i d e t h e i r own area of ca r e . T h i s s p e c i a l i s t - t o - s p e c i a l i s t s h o r t - c i r c u i t i n g of the customary and p r o f e s s i o n a l l y - a p p r o v e d r e f e r r a l system leads to f u r t h e r d i m i n u t i o n of the s t a t u r e of the f a m i l y p h y s i c i a n . The process f i n d s i t s u l t i m a t e p r o f e s s i o n a l d e f i n i t i o n i n the c l o s e d h o s p i t a l , where the f a m i l y p r a c t i t i o n e r has no s t a t u s , no s t a f f p o s i t i o n , and no c o n t r o l of the p a t i e n t ' s c o n s u l t a n t s . The d e f i c i e n c i e s of such h o s p i t a l - b a s e d medical care programs, with t h e i r n a t u r a l emphasis on complicated treatment medicine, are w e l l r e c o g n i z e d . The r e f e r r a l system i s o f t e n approached by observers of the h e a l t h care system with s u s p i c i o n . There i s a f e e l i n g t h a t r e f e r r a l mechanisms are powerful instruments, o f t e n p o o r l y understood, perhaps c o n s t r u c t e d with elements a k i n to subte r f u g e , and a l l the while b e a r i n g t h e i r own mystique which i s d i f f i c u l t to p e n e t r a t e . The p l a i n t r u t h i s t h a t the r e f e r r a l system i n Canada, as a cornerstone p o l i c y of Medicare, i s i n d i s a r r a y . I t needs to be r e d e f i n e d , m o d i f i e d , a d j u s t e d , and brought i n t o the r e a l i t y of today's 1 8 p r a c t i c e s . The l e a p - f r o g g i n g of the f a m i l y p r a c t i t i o n e r ' s s t a t u s and s e r v i c e s by p u b l i c and s p e c i a l i s t s a l i k e , has l e d t o , and w i l l produce, even g r e a t e r e r o s i o n of the r e f e r r a l system i n Canada, one of the underpinnings on which our present Medicare program i s based. The l o g i c a l u l t i m a t e step f o r p a t i e n t s i s to t o t a l l y bypass the f a m i l y p r a c t i t i o n e r and to make t h e i r own appointments with the s p e c i a l i s t of t h e i r own choosing. In f a c t , t h i s i s now commonplace. P a t i e n t s phone or appear r e q u e s t i n g r e f e r r a l s f o r c o n s u l t a n t appointments which are al r e a d y pending or even pa s t . In the United S t a t e s , Fox notes t h a t "The more s o p h i s t i c a t e d and a f f l u e n t American tends to bypass the gen e r a l p r a c t i t i o n e r , making h i s own p r o v i s i o n a l d i a g n o s i s and going s t r a i g h t to the ex p e r t . . . " . I t i s i n t e r e s t i n g to note t h a t i n B r i t i s h Columbia, the Medical S e r v i c e s Plan has r e c e n t l y granted to p h y s i c i a n s and t h e i r f a m i l i e s the r i g h t to seek s p e c i a l i s t care without a r e f e r r a l . Is t h i s s p e c i a l s t a t u s or r e a l l y the t h i n edge of the wedge to a t o t a l l y n o n - r e f e r r e d , u n l i m i t e d c o n s u l t a n t - a c c e s s system? The l o g i c a l e x t r a p o l a t i o n of these changes i s f o r the p u b l i c to d e f i n e t h e i r own t e r t i a r y care p r o v i d e r . W i l l t h i s ever be r e a l l y a p p r o p r i a t e ? W i l l the p u b l i c ever be so s o p h i s t i c a t e d as to make v a l i d judgements i n d e f i n i n g t h e i r r e f e r r a l care? What are the ensuing c o s t s apt to 19 be? The r e - d e f i n i t i o n of the r e f e r r a l system was one q u e s t i o n u n d e r l y i n g the need f o r a Health S e r v i c e s Review '7 9, (Canada, 1980). c. S o c i a l L a b e l l i n g A c t i v i t y by P h y s i c i a n s and i t s Appropriateness P a t i e n t s have been accustomed to c o n s u l t d o c t o r s about more than p h y s i c a l symptoms. In h i s book on s o c i a l c o n t r o l , Watkins d i s c u s s e s p r o f e s s i o n a l s , such as p h y s i c i a n s , as gatekeepers and s o c i a l c o n t r o l l e r s f o r s o c i e t y . He notes the p a s s i n g of the p r i e s t from h i s pre-eminent c e n t r a l r o l e as an i n t e r p r e t e r and c o n t r o l l e r of s o c i e t y , to a more p e r i p h e r a l r o l e f o r s i m i l a r f u n c t i o n s but only f o r adherents to t h e i r s p e c i f i c d o c t r i n e s . In the p r i e s t ' s p l a c e he poses the medical p r o f e s s i o n . He quotes Greenwood's d e f i n i t i o n as to the f i v e d i s t i n c t 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 : i . The command of a systematic body of knowledge, i i . P r o f e s s i o n a l a u t h o r i t y , i i i . The s a n c t i o n of the community, i v . A r e g u l a t i v e code of e t h i c s . v. The p r o f e s s i o n a l c u l t u r e . In h i s d i s c u s s i o n of the second c h a r a c t e r i s t i c , he e l a b o r a t e s on the r o l e of p r o f e s s i o n a l a u t h o r i t y i n the c e r t i f i c a t i o n of i l l n e s s as a s o c i a l f u n c t i o n , by 20 l a b e l l i n g a c t i v i t y , i . e . 'what i s to count as i l l n e s s ' . H is i n t e r p r e t a t i o n of t h i s area of s o c i a l o p e r a t i o n i s more a p p l i c a b l e to B r i t a i n , but i s becoming i n c r e a s i n g l y a p p r o p r i a t e i n Canada, as s i c k b e n e f i t s p r o l i f e r a t e with a m u l t i t u d e of v a r y i n g c o n d i t i o n a l requirements. The r o l e of the d o c t o r s ' c h i t s ' i n t e s t i f y i n g to i l l n e s s may w e l l be of s i g n i f i c a n c e i n B r i t a i n as an important p a r t of a p h y s i c i a n ' s f u n c t i o n , but not l i k e l y from the p h y s i c i a n ' s p e r s p e c t i v e . Mackenzie, i n a d i s c u s s i o n of the N a t i o n a l Health S e r v i c e as a P o l i t i c a l I n s t i t u t i o n , suggests t h a t the g e n e r a l p r a c t i t i o n e r ' s o f f i c e ( i n B r i t a i n ) i s no more than a s o r t i n g and d i s p a t c h i n g room and an i s s u i n g p o i n t f o r o f f i c i a l c h i t s . In Canada, t h i s task i s most l i k e l y to be regarded as onerous by p h y s i c i a n s - an outcome of red-tape and paperwork - and not as an important or d e s i r a b l e p a r t of medical p r a c t i c e . Most p h y s i c i a n s do not undertake t h e i r t r a i n i n g with a view to becoming a bureaucrat. In f a c t , the Canadian Medical A s s o c i a t i o n i s s u e d a d i r e c t i v e a d v i s i n g p h y s i c i a n s not to i s s u e s i c k s l i p s f o r absence of l e s s than f i v e days. Many s i c k s l i p s are used by employers as a d e t e r r e n t to abuse of s i c k b e n e f i t s , or by insurance companies p r o v i d i n g the s i c k time payment. These items are hammered out between the unions and the employers at b a r g a i n i n g time, but the use of the p h y s i c i a n as t h e i r policeman i s i n a p p r o p r i a t e . The unions and the employers should delegate to themselves 21 t h i s watchdog f u n c t i o n . The c o n s t r a i n t s p l a c e d on a p h y s i c i a n as he c e r t i f i e s an i l l n e s s are o f t e n such as to render the process meaningless. Many p a t i e n t s present documentation as a f a i t accompli, a f t e r the f a c t of t h e i r i l l n e s s -o f t e n an i l l n e s s f o r which they have not sought, r e q u i r e d or r e c e i v e d medical a t t e n t i o n , and sometimes f o r no i l l n e s s at a l l . The p h y s i c i a n i s hard pressed to query t h e i r document's accuracy or v a l i d i t y , because to do so he may appear p a r e n t a l , and may a l s o appear as the advocate f o r the insurance company or employer, and not as one's medical c o u n s e l l o r . Those members of the p u b l i c who have accumulated s i c k l e a v e or other h e a l t h b e n e f i t s are so aware as to how the system operates and t h e i r r i g h t s to c e r t a i n payments, t h a t they are, i n e f f e c t , t h e i r own l a b e l l e r s , should they decide to a v a i l themselves of t h e i r accrued b e n e f i t s . Thus, s i c k leave b e n e f i t s are o f t e n not used f o r a c t u a l i l l n e s s by workers, but are viewed as a f r i n g e s a l a r y payment t h a t can, and should, come to them as an in h e r e n t r i g h t . The p h y s i c i a n ' s p o s i t i o n i n t h i s area i s r e a l l y i n s i g n i f i c a n t i n terms of h i s t o t a l f u n c t i o n . He i s used as a medical bureaucrat, much as one uses a mu n i c i p a l c l e r k to o b t a i n a b u i l d i n g permit. One would a l s o query the pre-eminence a t t r i b u t e d to the medical p r o f e s s i o n by the author i n terms of 22 s o c i a l l a b e l l i n g and gatekeeping, as a replacement f o r the p r i e s t l y f u n c t i o n . J u s t as the p r i e s t has moved more p e r i p h e r a l l y from a c e n t r a l s o c i a l c o n t r o l f u n c t i o n , so has the advent of h e a l t h p l a n n i n g by governments moved the 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 s t r i c t l y s e r v i c e component of h e a l t h care, w e l l away from c e n t r a l p l a n n i n g and p o l i c y making. "Government," Mackenzie says, " i s where the burden of d e c i s i o n comes to r e s t . . . g i v e n the e t h i c a l and i n s t i t u t i o n a l p r i n c i p l e s of the h e a l t h s e r v i c e , there i s b u i l t i n t o i t an antiphony between the power and r e s p o n s i b i l i t y of medical care i n a c t i o n a t the p e r i p h e r y , [and] the power and r e s p o n s i b i l i t y f o r resource a l l o c a t i o n at the c e n t r e " . With t h i s s h i f t , the p h y s i c i a n ' s r o l e i s more l i k e l y t o be viewed from i t s u t i l i t a r i a n t e c h n i c a l f u n c t i o n . Such a p e r s p e c t i v e of medical f u n c t i o n f i t s w i th the change i n t h i s century on the emphasis on the technology of medical p r a c t i c e , as opposed to the a r t of medicine. The e x p l o s i o n of knowledge, with i t s r e s u l t a n t a b i l i t y to cure d i s e a s e , as opposed to the a r t of l e a r n i n g how to cope with and endure d i s e a s e , has s h i f t e d the emphasis i n a p e r s p e c t i v e of the p h y s i c i a n away from t h a t of a sage and f r i e n d , to t h a t of a t e c h n i c a l a d v i s e r and performer: "God and doctor we l i k e adore, But only when i n danger, not b e f o r e ; The danger o'er, both are a l i k e r e q u i t e d ; 23 God i s f o r g o t t e n and the doctor s l i g h t e d . Robert Owen, Epigram" As such, h i s s o c i a l c o n t r o l f u n c t i o n i s more c i r c u m s c r i b e d than Watkins r e a l i z e s . Again, when the same author e n t e r s i n t o the area of c e r t i f i c a t i o n of mental i l l n e s s as an important l a b e l l i n g f u n c t i o n , he i s out of touch with today's r e a l i t y , even though h i s a r t i c l e was w r i t t e n only i n 1975. The s t r e s s on community-based mental h e a l t h c l i n i c s with a p r e v e n t i v e f u n c t i o n , to avoid mental h o s p i t a l committal by p h y s i c i a n s , outdated h i s ideas by a decade. Along with p r e v e n t i v e community c l i n i c s , the very idea of ' l a b e l l i n g ' someone took on a c e r t a i n repugnance with the r i s e of i n d i v i d u a l i s m i n the 1960's. L a b e l l i n g people was not c o n s i s t e n t with the i d e a of a c h i e v i n g one's i d e n t i t y . The s t e r e o t y p i n g of p a t i e n t s a t a f i x e d stage of development or i l l n e s s came to be viewed as i n c o n s i s t e n t with the process of s e l f - r e a l i z a t i o n . Thus mental h e a l t h l a b e l l i n g i s , i n essence, a very shrunken r o l e f o r p r a c t i t i o n e r s , both i n terms of t h e i r d i s l i k e f o r such a f u n c t i o n , and i n terms of i t s importance. d. P u b l i c Expectancy: The 24 Hour Man There i s a dichotomy i n the p u b l i c a t t i t u d e 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 antagonism towards organized medicine, w h i l s t viewing one's i n d i v i d u a l p r a c t i t i o n e r f a v o u r a b l y . Remnants of a p a t e r n a l i s t i c t h i n k i n g l i n g e r along with the newer concepts of the doctor as a f a l l i b l e man. D e f i n i t i o n s of p r i m a r y c a r e , as w e l l as p r i n c i p l e s f o r the d e v e l o p m e n t and o p e r a t i o n of a comprehensive h e a l t h care plan f o r the p r o v i n c e of O n t a r i o (the M u s t a r d R e p o r t : " E v a l u a t i o n of P r i m a r y Health Care S e r v i c e s , the O n t a r i o C o u n c i l of H e a l t h ) , embrace some of the c h a r a c t e r i s t i c s of the ever-present, old-time benevolent medical f i g u r e . These d e f i n i t i o n s s t a t e what the proponents f e e l i s b e n e f i c i a l and d e s i r a b l e f o r the p u b l i c . They d e l e t e mention of the economics, p r a c t i c a b i l i t y , or need f o r s u b s t a n t i a t i n g such s e V i c e s , with those s e r v i c e s being made a v a i l a b l e twenty-four hours a day, seven days a week. Such a p r i n c i p l e i s taken as a g i v e n . No mention i s made of the e f f e c t on, or the a t t i t u d e o f , the p r o v i d e r s of twenty-four hour, seven days a week s e r v i c e . The r e a l i t y i s t h a t no p r a c t i t i o n e r can g i v e such f u l l time coverage except i n i s o l a t e d areas or f o r s p e c i f i c time spans. U t i l i z a t i o n of h o s p i t a l emergency departments f o r non-emergent care o u t s i d e of o f f i c e hours i s a n a t u r a l s p i n - o f f of such a c c e s s i b i l i t y , and, as such, weakens the d o c t o r / p a t i e n t dyad, because the a t t e n d i n g p h y s i c i a n i s o f t e n bypassed. I n c r e a s i n g l y , the p u b l i c has become the d e f i n e r as to what c o n s t i t u t e s an 25 emergency. T h i s i s a n a t u r a l development i n a ' f r e e ' system. Let us examine t h i s twenty-four hour, seven day work week reccommendation, because there are s u b t l e t i e s i n c l u d e d t h e r e i n t h a t are not r e a d i l y obvious. T h i s d e f i n i t i o n of primary care i s r e a l l y a r o l e p r e s c r i p t i o n as d e s c r i b e d i n r o l e theory by Miner. Is i t v a l i d ? Does the p u b l i c r e q u i r e twenty-four hour a day care? What other s e r v i c e i s a v a i l a b l e on such an e x t e n s i v e b a s i s ? Such a s e r v i c e i s understandable f o r an emergency, but the word emergency i s not u t i l i z e d i n the d e f i n i t i o n . As we have noted, the p u b l i c i s d e f i n i n g the word more and more l i b e r a l l y . Banking, p o s t a l s e r v i c e , government o f f i c e s , s o c i a l s e r v i c e s , c o u r t s , l e g a l s e r v i c e s , supermarkets, department s t o r e s , and many other components of the s e r v i c e system do not p r o v i d e such coverage. A l l - e m b r a c i n g statements such as these are d e f i c i e n t i n t h a t they c a s t a l l the r e s p o n s i b i l i t y on the primary care p r o v i d e r , and none on the person r e q u e s t i n g c a r e . Thus, under a ' f r e e ' system (as the p u b l i c u n c o n s c i o u s l y and i n c o r r e c t l y d e f i n e s Medicare i n Canada), abuses appear. The a r r i v a l i n the evening or even a f t e r midnight i n the emergency departments of minor or non-recent a f f l i c t i o n s best t r e a t e d by the a p p l i c a t i o n of doses of common sense, i s not unusual. I t does not l e a d to g r e a t e r r e s p o n s i b i l i t y by p a t i e n t s f o r t h e i r own h e a l t h . Rather, i t leads to 2 6 an over-dependency on medical care as enunciated by Ivan I l l i c h . The e x i s t e n c e of f r e e twenty-four hour coverage leads to the e v o l u t i o n of twenty-four-hour-a-day o u t - p a t i e n t departments, and a p r a c t i c e s t y l e t h a t can best be d e s c r i b e d as d e a l i n g with t r i v i a . C a d i l l a c s e r v i c e s do not l e a d to co s t containment. Often l a b o r a t o r y and x-ray t e c h n i c i a n s have to be c a l l e d i n t o the h o s p i t a l , as w e l l as p h y s i c i a n s , to perform s e r v i c e s t h a t could be more e f f i c i e n t l y d e l i v e r e d i n the daytime. The same arguments apply to the d e l i v e r y of care a t a time when the p a t i e n t i s f r e e from h i s r e s p o n s i b i l i t i e s a t the end of the work-day. T h i s does not happen i n any other form of governmental or quasi-governmental s e r v i c e . Is medical care so sacro s a n c t t h a t i t should happen i n h e a l t h care d e l i v e r y ? P a t i e n t convenience f a c t o r s i n t e r p r e t e d as a c c e s s i b i l i t y p r i n c i p l e s do not le a d to a higher q u a l i t y of medical care; but r a t h e r they do l e a d to a higher volume and l i k e l y to abuses of the system. P a t i e n t c o n t r i b u t i o n s i n terms of e f f o r t to o b t a i n a p p r o p r i a t e s c h e d u l i n g , i s one form of p s y c h o l o g i c a l c o - i n s u r a n c e , or i f one w i l l , commitment ( K a s t n e r ) . Such co-insurance w i l l be a p o s i t i v e f o r c e i n p r e v e n t i n g d e v a l u a t i o n of the s e r v i c e s p r o v i d e d : human s e r v i c e s are pr o v i d e d by f e l l o w humans who can be e f f e c t i v e l y made i n t o o b j e c t s when they are viewed as u t i l i t a r i a n m e c h a n i s t i c t e c h n i c a l s e r v i c e components. Howard and Strauss d i s c u s s t h i s w e l l i n 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 the seven day week p r o p o s a l , we f i n d t h a t i t f l i e s i n the face of the contemporary work week r e a l i t y . H o s p i t a l s e x i s t as p a r t of the g e n e r a l s o c i a l f a b r i c of today. As such, t h e i r s t a f f s are un i o n i z e d , so t h a t the economics of h o s p i t a l management pr e c l u d e many areas of the h o s p i t a l from o p e r a t i n g on a seven day week program: o p e r a t i n g rooms are c l o s e d on weekends f o r e l e c t i v e bookings and are open only f o r emergency cases; occupancy r a t e s f a l l on weekends; many l a b o r a t o r y 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 s t a f f i s mostly o f f on weekends. The seven day week o p t i o n p r o v i d e s the same b a s i s f o r abuse as does the twenty-four hour day usage. As such, i t i s a paraphrase on the f u l f i l l m e n t of Parkinson's Law: s e r v i c e s sought by the p u b l i c w i l l r i s e to the l e v e l of those f r e e l y p r o v i d e d and always a v a i l a b l e . The P a r k i n s o n - s t y l e p r o p o s i t i o n means the i n o r d i n a t e use of f a c i l i t i e s at times not necessary or economical, e. Personal R e s p o n s i b i l i t y of P a t i e n t s While on the one hand there are attempts to get "more" and " b e t t e r " access to medical care through the processes d e s c r i b e d above, there has been another trend i n response to I l l i c h * s c a l l f o r g r e a t e r p e r s o n a l independence f o r h e a l t h and to i n c r e a s e p a t i e n t s ' freedom from p r o f e s s i o n a l dominance. T h i s trend has been encouraged by the Lalonde Report, A New P e r s p e c t i v e 28 on the He a l t h of Canadians f 1974. The r e p o r t was sponsored by the F e d e r a l M i n i s t e r of Health and Welfare (Xalonde) , and encouraged Canadians to take more r e s p o n s i b i l i t y f o r t h e i r own l i f e s t y l e s and environment: "Bett e r to hunt i n f i e l d s , f o r h e a l t h unbought Than fee the doctor f o r a nauseous draught The wise, f o r cure, on e x e r c i s e depend; God never made h i s work f o r man to mend." (John Dryden 17 00) The response to t h i s r e p o r t and to a program c a l l e d 1 P a r t i c i p a c t i o n 1 has been unexpectedly e n t h u s i a s t i c , and has l e d many people to take more i n t e r e s t i n t h e i r own f i t n e s s . While some thin k t h i s may l e a d to g r e a t e r independence from the need f o r c o n t i n u a l c o n s u l t a t i o n with p h y s i c i a n s , o t hers have noted the i n c r e a s e i n s p o r t s i n j u r i e s . Some gen e r a l p r a c t i t i o n e r s have responded to t h i s movement by s e t t i n g up p r a c t i c e s f o c u s s i n g on h e a l t h promotion and p r e v e n t i v e care, such as the Western Centre f o r P r e v e n t i v e and B e h a v i o r a l Medicine i n North Vancouver, B.C., where emphasis i s p l a c e d on s t r e s s management as a p r e v e n t i v e f u n c t i o n . H o l i s t i c h e a l t h care, now an ' i n ' concept, i s not r e a l l y new f o r primary care p h y s i c i a n s . The f a m i l y d o c t o r s are ab l e to o b t a i n a time-comprehensive and family-comprehensive p e r s p e c t i v e of a p a t i e n t which goes beyond the acute care c r i s i s treatment f o c u s . A more f u l l y h o l i s t i c 29 approach i s p o s s i b l e now because of the a v a i l a b i l i t y of the s e r v i c e s of many a l l i e d h e a l t h p r o f e s s i o n a l s such as p h y s i o t h e r a p i s t s , d i e t i t i a n s , o p t o m e t r i s t s , a c c u p u n c t u r i s t s , e t c . ( C o l l e g e of Family P h y s i c i a n s of Canada: A l l i e d H ealth p r o f e s s i o n a l ' s Role? a l s o M. M a r t i n ) . The argument about who i s the l o g i c a l d i r e c t o r of a comprehensive approach to a p a t i e n t ' s h e a l t h care w i l l now be co n s i d e r e d . f . The Team Approach to Health Care Is there merit i n the f o r e g o i n g d i s c u s s i o n of the i n t e r a c t i o n of the p a t i e n t and the doctor? Quite l i k e l y t h ere i s , because e s s e n t i a l l y the area of i n t e r a c t i o n can be termed a dyad, which, by d e f i n i t i o n , i s a group of two, a couple, a p a i r (The Random House D i c t i o n a r y of the E n g l i s h Language) . To what kind of a primary care person, s p e c i a l i s t or team member w i l l the p a t i e n t most l i k e l y r e l a t e ? The essence of the i n t i m a t e human i n t e r a c t i o n r e q u i r e d f o r rewarding medical c a r e , i s c a l l e d involvement - giv e n by a warm, f r i e n d l y , p e r s o n a l t h e r a p i s t . G l a s s e r , i n h i s d i s c u s s i o n of R e a l i t y Therapy i n the I d e n t i t y S o c i e t y , emphasizes involvement as the f i r s t p r i n c i p l e . There are in h e r e n t u n c e r t a i n t i e s i n one-to-team r e l a t i o n s h i p s t h a t would tend to move the p a t i e n t to seek out one t h e r a p i s t of tha t team as h i s i n t i m a t e r e l a t i n g c o n t a c t . Under our present system of h e a l t h care, and i n the f o r s e e a b l e 3 0 f u t u r e , the usual i n t i m a t e c o n t a c t person w i l l continue to be the p h y s i c i a n . We need to t h e r e f o r e d e f i n e the nature, working p h i l o s o p h y , and t r a i n i n g program fo r the person we envisage as f u l f i l l i n g the r o l e . I f the team i s represented as being eminently s a t i s f a c t o r y as the co n t a c t u n i t , one may w e l l be reminded of the o l d f a b l e of the elephant as viewed by the s e v e r a l b l i n d men. T h i s i s not to deny the n e c e s s i t y of the team approach i n many of the complex problem cases seen today. There i s no argument: the team i s here and i t w i l l s t a y . However, a component of the team should be one who i s i n v o l v e d , empathetic, a v a i l a b l e , c o n f i d a n t e i n nature, c o n t i n u i n g i n h i s care and i n d i a l o g u e with the p a t i e n t , w e l l past any c r i s i s s i t u a t i o n . The person most s u i t a b l e , best educated and t r a i n e d f o r t h a t p o s i t i o n at present, and l i k e l y f o r the next g e n e r a t i o n , i s the f a m i l y p r a c t i t i o n e r . The case f o r a d j u n c t i v e medical p r o v i d e r s working under the f a m i l y doctor i n the p r o v i s i o n of primary s e r v i c e s at a more reasonable economic c o s t , has been put forward. In Canada t h i s i d e a hinged on the nurse p r a c t i t i o n e r , a r e g i s t e r e d nurse who r e c e i v e d f u r t h e r t r a i n i n g i n outpost medicine or i n community medicine and/or t u t e l a g e under a f a m i l y p r a c t i t i o n e r (Boudreau, 19739 W i t t e r , Dugas, Imai) . So f a r , t h i s type of and Roemer) program has been of mixed success (RoemerT, d e s p i t e f a v o u r a b l e l o c a l experiences ( S p i t z e r ) . 31 The reasons f o r t h i s l a c k of success are many. The d o c t o r s viewed the new expanded r o l e f o r the nurse as a t h r e a t to t h e i r s e c u r i t y and c e r t a i n l y to t h e i r economic p o s i t i o n ( S p i t z e r ) . T h e i r f e a r s were s u b s t a n t i a t e d by the submission of the Canadian Nursing A s s o c i a t i o n to the Second H a l l I n q u i r y - Health S e r v i c e s Review '7 9 - wherein the nurses s t a t e d t h a t d o c t o r s should be pl a c e d on s a l a r i e s , with abandonment of the f e e - f o r - s e r v i c e p r i n c i p l e ; and by t h e i r own e l a b o r a t i o n of the expanded r o l e of the nurse, wherein many f a m i l y p r a c t i t i o n e r f u n c t i o n s would be taken over by the nurses. Family p r a c t i t i o n e r s ' a t t i t u d e s towards these a l l i e d nurse h e a l t h p r a c t i t i o n e r s , who, perhaps with a doctor could be co n s i d e r e d a 'mini-team', have, i n g e n e r a l , been so neg a t i v e as to pr e c l u d e the d o c t o r s from having i n s i g h t i n t o the advantageous p o s s i b i l i t i e s of such an arrangement. There i s no doubt t h a t the d e n t a l p r o f e s s i o n has prospered by the u t i l i z a t i o n of a l l i e d d e n t a l h e a l t h p r o f e s s i o n a l s . In the case of d o c t o r s , t h e i r f e a r s of l o s i n g p r o f e s s i o n a l s t a t u s have m i t i g a t e d a g a i n s t tapping t h i s p o t e n t i a l l y economic and f u n c t i o n a l resource. Another reason f o r the apparent f a i l u r e of nurse p r a c t i t i o n e r s would be the l a c k of a w e l l documented r o l e p r e s c r i p t i o n f o r them, e n e r g e t i c a l l y and r e a s s u r i n g l y advocated by a government i n t e r e s t e d i n 32 i n s t i t u t i n g a major change i n the present system. As the p u b l i c i s b a s i c a l l y happy with the present method of h e a l t h care d e l i v e r y , and as the d o c t o r s are a g a i n s t changing i t , there i s no l a r g e groundswell of p u b l i c o p i n i o n on which a p o l i t i c i a n or planner could depend when advocating change. The B u r l i n g t o n Randomized T r i a l of the Nurse P r a c t i t i o n e r ( S p i t z e r ) i n d i c a t e d t h e r e were savings of h o s p i t a l bed days by r e d u c t i o n of the numbers of admissions with the use of a l l i e d medical p r a c t i t i o n e r s such as the nurse p r a c t i t i o n e r . Nurse p r a c t i t i o n e r a n e s t h e t i s t s do not e x i s t i n Canada d e s p i t e the l a r g e numbers who p r a c t i c e t h a t s p e c i a l t y nearby i n the United S t a t e s . When we c o n s i d e r midwives, we f i n d very few of them i n Canada as compared to B r i t a i n , the only e x c e p t i o n appearing to be the Northern Nurse Program f o r i s o l a t e d outpost midwifery. Medical s p e c i a l i s t s have r e s i s t e d the development of and Roemer) t h i s category of h e a l t h care worker (Roeme^. As w i l l be seen l a t e r , i n a d i s c u s s i o n of the Requirements Committee Report of the N a t i o n a l Committee on Medical Manpower Planning, a review of the o b s t e t r i c a l submission r e v e a l s t h a t development of the new r o l e of the n u r s e / o b s t e t r i c i a n w i l l depend on the concomitant development of new payment methods. The i n f e r e n c e s gained from a n a l y z i n g the o b s t e t r i c a l r e p o r t i n a d i s c u s s i o n of the boundaries of o b s t e t r i c s , and of growth assumptions f o r t h a t s p e c i a l t y , are t h a t they 33 envisage the development of the n u r s e / o b s t e t r i c i a n ' s r o l e at the expense of s h r i n k i n g c o n s i d e r a b l y the r o l e of the f a m i l y p r a c t i t i o n e r i n t h a t same f u n c t i o n . Not a rewarding prospect f o r f a m i l y p r a c t i c e ! g. Medicine and S o c i e t y i n R e c i p r o c i t y Medicine, or g a n i z e d and i n d i v i d u a l , ; i s not as i n s u l a t e d from the s o c i e t y around i t as h e a l t h care p l a n n e r s would seem to i n f e r . In h i s i n t r o d u c t i o n to Doctors and D o c t r i n e s r B l i s h e n s t a t e s : "Since the medical care system i s an i n t e g r a l p a r t of s o c i e t y , the r e l a t i o n s h i p between them i s r e c i p r o c a l ; changes i n medical care may have r e p e r c u s s i o n s f o r the s t r u c t u r e of s o c i e t y . " ( p . 3 ) . P h y s i c i a n s are not immune to the d e v e l o p i n g concepts i n s o c i e t y any more than any other group. In f a c t , because of t h e i r g e n e r a l l y higher i n t e l l i g e n c e l e v e l , they are apt to be more s e n s i t i v e to these changes, i n s p i t e of the c o n s t r a i n t s of t h e i r o r g a n i z a t i o n s to m a i ntain a power base. Medical o r g a n i z a t i o n s such as the B r i t i s h Columbia Medical A s s o c i a t i o n are not without t h e i r s o - c a l l e d r e b e l f a c t i o n s , or r a d i c a l elements. The e f f e c t of such groups - d e f i n e d as d i s s i d e n t s when they stay w i t h i n the o r g a n i z a t i o n - has been to induce change. Indeed, they are o f t e n very e f f e c t i v e instruments of change i n the o r g a n i z a t i o n . C o n f l i c t i n e v i t a b l y r e s u l t s , but the sum 34 e f f e c t i s t h a t such o r g a n i z a t i o n s remain more s e n s i t i v e and attuned to the changes i n the s o c i e t y around them. P h y s i c i a n s flow i n the mainstream of l i f e with everyone e l s e , and o f t e n i t i s the p u b l i c t h a t has the g r e a t e s t d i f f i c u l t y i n a c c e p t i n g the present-day r e a l i t y of a d o c t o r , with more frequent weekends o f f and s h o r t e r work weeks and a v o c a t i o n s . Medical personnel c o l l i d e with a l l the problems of l i f e and appear to s u f f e r i n o r d i n a t e l y from s o c i a l d y s f u n c t i o n a l consequences ( s h o r t : p s y c h i a t r i c illness i n P h y s i c i a n s ) . In the e x i s t i n g shortened work weeks t h a t the g e n e r a l p o p u l a t i o n enjoys, the p h y s i c i a n a l s o e x i s t s . The r e c i p r o c i t y a l l u d e d to e a r l i e r by B l i s h e n again i s a p p l i c a b l e . As contemporary s o c i e t y moves to a more h e d o n i s t i c , r e c r e a t i o n a l , weakened work e t h i c c u l t u r e , so does the p h y s i c i a n . He i s now aware t h a t e x c e s s i v e l y prolonged hours t o i l i n g b e f o r e the medical mast i s not h e a l t h y f o r h i s marriage, h i s c h i l d r e n ' s s o c i a l m aturation processes, or f o r h i s p h y s i c a l or mental w e l l - b e i n g . He may work e x c e s s i v e hours i n i t i a l l y i n the e a r l y phases of developing h i s mental medical data bank, h i s career s t a t u s and h i s economic base, but he knows, or should have been made aware, t h a t these p o r t i o n s of h i s t o t a l e x i s t e n c e are not enough to s u s t a i n him f o r endless years of d e d i c a t i o n . His p r o f e s s i o n a l medical c a r e e r maturation i m b r i c a t e s p h a s i c a l l y with h i s s o c i o - f a m i l i a l development. 35 The thermodynamic concept of entropy can be a p p l i e d to p h y s i c i a n s as they progress through t h e i r p r o f e s s i o n a l l i v e s . That i s to say, t h e i r entropy equals the amount of energy a v a i l a b l e from a p h y s i c i a n to work i n the h e a l t h care d e l i v e r y system. The work a v a i l a b l e energy of a p h y s i c i a n at any time i n h i s c a r e e r , i . e . the entropy v e c t o r , i f p l o t t e d on a c o o r d i n a t e g r i d of years i n h i s career versus h i s work a c t i v i t y l e v e l ^ say i n hours per week, would be seen to be the summation of the v a r i o u s v e c t o r f o r c e s i n h i s l i f e . As these v e c t o r s strengthen and weaken and change d i r e c t i o n over time, t h e i r i n t e g r a t e d summation would re p r e s e n t the u s u a l l y - a p p l i e d medical care work energy. T h i s energy output p l a t e a u s and f a l l s o f f e a r l i e r i n p h y s i c i a n ' s p r o f e s s i o n a l l i v e s due to the c o nfluence of many present-day f o r c e s . One f o r c e appears to be the p r o g r e s s i v e income tax which serves as a d i s i n c e n t i v e to many p r o f e s s i o n a l s , medical and otherwise, i n terms of working beyond the s o c i a l norm to enhance income s t a t u s . The s t r o n g i n c o m e - l e v e l l i n g e f f e c t of p r o g r e s s i v e income tax, so d e s i r a b l e from the s o c i a l i s t viewpoint, has, as i t s p r i c e tag, the s u p p r e s s i o n i n p a r t of p r o f e s s i o n a l p r o d u c t i v i t y . Many p r o f e s s i o n a l s would ra t h e r use t h e i r time f o r r e c r e a t i o n or other business p u r s u i t s , than be working under the curve of d e c r e a s i n g c o s t / b e n e f i t r a t i o s , spending e x c e s s i v e hours i n p a t i e n t c a r e . 36 Income tax p r o s c r i p t i o n of medical m o t i v a t i o n wreaks i t s own diseconomies. The n a t u r a l h i s t o r y of s u r g i c a l c a r e e r s i s s h o r t e r than those engaged i n other medical areas, l i k e l y the r e s u l t of many f a c t o r s , one of which, no doubt, i s the s t r e s s l e v e l i n v o l v e d . A comparison could be made to commercial a i r l i n e p i l o t s , who r e t i r e a t age s i x t y . Another f o r c e a f f e c t i n g medical c a r e e r s i s p e r c e i v e d to be the i n t e r v e n t i o n of a b u r e a u c r a t i c , g e n e r a l l y u n y i e l d i n g and i n s e n s i t i v e t h i r d p a r t y i n the d o c t o r / p a t i e n t r e l a t i o n s h i p . Submission to b u r e a u c r a t i c r u l e s and red tape; to i n c r e a s e d demands f o r m e d i c o - l e g a l documentation and c o u r t appearances; as w e l l as acceptance of a common p u b l i c p o r t r a y a l t h a t d o c t o r s ' incomes are too high, suggests q u a l i t i e s t h a t do not meld e a s i l y with a p e r s o n a l i t y t h a t has been c h a r a c t e r i z e d as a decision-maker f o r p a t i e n t s ' l i v e s , diagnoses and treatments. Removing the medical mystique from p h y s i c i a n s , with the a s s o c i a t e d de-emphasis on the p h y s i c i a n as a c u l t u r a l , moral, and s o c i a l f i g u r e to r e s p e c t , has i t s r e p e r c u s s i o n s not only on the p u b l i c , but on the p r o f e s s i o n i t s e l f . Shrinkage of p r o f e s s i o n a l s a t i s f a c t i o n s , s o c i a l s t a t u s , and r e l a t i v e incomes may auger the development of l a t e r second c a r e e r s f o r medical personnel i n the f u t u r e , much i n the manner of armed s e r v i c e s personnel and other p r o f e s s i o n a l s . The f o r e s h o r t e n i n g of medical c a r e e r s 37 would l e a d to a l e s s e r economic r e t u r n f o r the p u b l i c , from t h e i r investment i n the educa t i o n and t r a i n i n g of p h y s i c i a n s . Another f o r c e to be con s i d e r e d when c a l c u l a t i n g a p h y s i c i a n s •entropy" - or perhaps, as more u s u a l l y c a l l e d : h i s p r o d u c t i v i t y - i s the r i s e of i n d i v i d u a l i s m , p a r a l l e l i n g the new awareness of governmental and a u t h o r i t y - f i g u r e f a l l i b i l i t y f o l l o w i n g Vietnam and Watergate. Recent medical graduates, i n t e r n s and r e s i d e n t s have shown a s u r p r i s i n g l y organized s t r e n g t h i n p r a c t i c i n g s e l f - d e t e r m i n a t i o n as much as p o s s i b l e to achieve b e t t e r working hours and b e t t e r pay. The indentured I n d u s t r i a l R e v o l u t i o n type of approach to i n t e r n and r e s i d e n t t r a i n i n g , w i l l no doubt succumb to the awareness of these p h y s i c i a n s to the e x i s t e n c e of a g r e a t e r dimension to t h e i r l i v e s than t h a t of medicine alone. As f o r those al r e a d y i n p r a c t i c e , group p r a c t i c e or s h a r e d - c a l l systems are the l o g i c a l outcome of t h e i r d e s i r e f o r more time o f f f o r f a m i l y and l e i s u r e p u r s u i t s . h. R e d e f i n i t i o n of the Family P h y s i c i a n I t i s not a l t o g e t h e r s u r p r i s i n g t h a t the f a m i l y p h y s i c i a n i s confused about h i s r o l e today. A p h y s i c i a n , with h i s years of s c i e n t i f i c and c l i n i c a l t r a i n i n g , does not take r e a d i l y to having h i m s e l f viewed as a mere booking agent or c h i t s i g n e r . There appears 38 to be some n e c e s s i t y f o r a c l e a r e r d e f i n i t i o n of the primary care p h y s i c i a n , h i s f u n c t i o n , and attendant t r a i n i n g programs. A d e f i n i t i o n of primary care was given i n the Report of the H e a l t h Planning Task Force (the Mustard R e p o r t ) . I t s t a t e s : "Primary care i n c l u d e s not only those s e r v i c e s t h a t are pro v i d e d a t f i r s t c o n t a c t between the p a t i e n t and the h e a l t h p r o f e s s i o n a l but a l s o r e s p o n s i b i l i t y f o r promotion and maintenance of h e a l t h care and f o r complete and continuous care f o r the i n d i v i d u a l i n c l u d i n g r e f e r r a l when required...The f u n c t i o n s of h e a l t h personnel i n the primary care group i n c l u d e p r e v e n t i o n , h e a l t h promotion, h e a l t h maintenance, c o n s u l t a t i o n , education, d i a g n o s i s , treatment and r e h a b i l i t a t i o n . . . ." The above d e f i n i t i o n was accepted by the Task Force on E v a l u a t i o n of Primary Health Care S e r v i c e s , 1976, by the On t a r i o C o u n c i l of He a l t h . I t i s i n t e r e s t i n g to note t h a t there i s no mention made of p r o c e d u r a l items i n the l i s t of f u n c t i o n s of primary h e a l t h care p e r s o n n e l . I t i s a l s o i n t e r e s t i n g to co n s i d e r the M i n o r i t y Report of the Task Force on the E v a l u a t i o n of Primary Health Care S e r v i c e s w r i t t e n by Dr. Edward G l a z i e r . He notes t h a t there was only one f u l l - t i m e f e e - f o r - s e r v i c e p r a c t i s i n g p h y s i c i a n on the committee: h i m s e l f . He f e l t the composition of the committee l e d to 'predetermined c o n c l u s i o n s [that] could have been e s t a b l i s h e d p r i o r to the f i r s t meeting'. In 39 other words, he f e l t the d e f i n i t i o n of primary care f u n c t i o n , as given by the others on the committee, was j u s t a r e f l e c t i o n of t h e i r own p a r t i c u l a r b i a s e s , and, as such, not a p p r o p r i a t e . S p e c i a l i s t study groups "have been c r i t i c i z e d as 'incestuous' on the ground t h a t each s p e c i a l t y i s b i a s e d i n d e f i n i n g i t s f u n c t i o n s and underestimates the scope of work f e a s i b l e f o r the g e n e r a l p r a c t i t i o n e r . " (Roemer and Roemer). We are l e f t then with the problem as to who i s the most a p p r o p r i a t e group to d e f i n e primary c a r e : - medical s c h o o l s , with t h e i r n e a r l y t o t a l l y s p e c i a l i s t s t a f f s , o f t e n i n the i v o r y tower of academia, without i n t i m a t e knowledge of the happenings i n the medical trenches; - the c l u s t e r e d s p e c i a l i s t s , under the umbrella of the Royal C o l l e g e , seeking expanded borders so t h a t f a m i l y p r a c t i c e becomes a residuum of t h e i r requests (as evidenced by the r e p o r t s from the N a t i o n a l Committee on P h y s i c i a n Manpower P l a n n i n g ) ; - a u t h o r i t a r i a n h e a l t h p l a n n e r s , who are not p h y s i c i a n s , secluded away i n the a d m i n i s t r a t i v e branch of government; - the f a m i l y p a c t i t i o n e r s themselves, with the i n h e r e n t d i f f i c u l t i e s of viewing a wider p e r s p e c t i v e w h i l e engrossed i n the dilemma of defending s h r i n k i n g p r a c t i c e boundaries and p r e s t i g e . There are many problems i n a r e d e f i n i t i o n . The 40 problem touches most of the other branches of medicine. I t w i l l be reassessed i n d e t a i l i n Chapter S i x . The s e l e c t i o n of candidates f o r t r a i n i n g as primary care p h y s i c i a n s with h o p e f u l l y g r e a t e r r e s i s t a n c e to s o c i a l d i s e a s e ; with a wider background i n the s o c i a l s c i e n c e s ; with a broader concept of i d e n t i t y , as e l a b o r a t e d by G l a s s e r ; with the i n t r o d u c t i o n i n medical s c h o o l s of more r e a l i s t i c c u r r i c u l a germane to the needs of today; - a l l impinge on the medical manpower pl a n n i n g p r o c e s s . 41 CHAPTER THREE The Canadian Health Care System 1. The E v o l u t i o n of the F e d e r a l - P r o v i n c i a l System of  Health Care For Canada, the development of an i n t e g r a t i v e h e a l t h care system may be viewed i n four stages, each roughly comparable to a decade, from the 40's to the 70's. The f o r t i e s saw the beginning of the ideas of s o c i a l p l a n n i n g . The f i f t i e s saw the growth of h o s p i t a l s by means of the g r a n t i n g of c a p i t a l c o s t s f o r c o n s t r u c t i o n from the f e d e r a l government i n 1949. T h i s h o s p i t a l phase of the f i f t i e s was strengthened by the i n t r o d u c t i o n of a comprehensive n a t i o n a l h o s p i t a l insurance program (the H o s p i t a l Insurance and D i a g n o s t i c S e r v i c e s Act of 1957), spurred by the Saskatchewan example of 1949. The s i x t i e s can be c h a r a c t e r i z e d by the p l a n n i n g f o r , and the i n s t i t u t i o n o f , a nation-wide Medicare h e a l t h insurance system i n 1967 (the Medical Care Act) , embracing the concepts of the H a l l Royal Commission on Health S e r v i c e s i n 1964. The s e v e n t i e s were concerned with the r a t i o n a l i z i n g of the whole h e a l t h care system, a l t e r a t i o n s i n the funding r e s p o n s i b i l i t i e s , a c c e n t u a t i o n of p e r s o n a l 42 r e s p o n s i b i l i t y f o r h e a l t h by Lalonde's r e p o r t , and worry over c o s t containment. The F e d e r a l - P r o v i n c i a l c o s t - s h a r e d programs are d e s c r i b e d i n the Canada Year  Book, and t h i s d e s c r i p t i o n i s reproduced i n the Appendix, i . 2. Doctors A t t i t u d e s to the Health Care System As d e s c r i b e d i n the p r e v i o u s chapter, the Canadian Medical A s s o c i a t i o n was p a r t l y bought i n t o the p l a n n i n g of a n a t i o n a l h e a l t h insurance scheme by Dr. John Heagarty, chairman of the committee of enquiry which re p o r t e d i n 1943. The CM. A. f u l l y supported the f e d e r a l government's move to become i n v o l v e d i n the funding of h e a l t h s e r v i c e s f o r the Canad i a n people at t h a t p o i n t i n time. Because i t took such a long time to s o r t out the c o n s t i t u t i o n a l c o m p l e x i t i e s of o p e r a t i o n a l i z i n g such a scheme, and to r a i s e s u f f i c i e n t f u n d i n g to pay f o r a l l the programs, these were in t r o d u c e d g r a d u a l l y . By the time the l a s t program (Medical Care) was s t a r t e d , n e a r l y twenty years had passed and times had changed f o r the p h y s i c i a n s . In 1943 they were very conscious of the hard times which a l l Canadians had had i n the t h i r t i e s . They were a l s o aware of the shortage of cash to pay f o r p r o f e s s i o n a l s e r v i c e s ; of bad debts which could not be c o l l e c t e d ; of g r e a t income i n s e c u r i t y . Now i n the e a r l y s i x t i e s , the 43 p r i v a t e l y o rganized prepayment schemes f o r h o s p i t a l and medical care, i n t r o d u c e d b e f o r e the war but not w e l l supported then, had become w e l l e s t a b l i s h e d . Most of these plans were now run by n o n - p r o f i t o r g a n i z a t i o n s . The d o c t o r s themselves had promoted the Trans Canada Medical Plans i n the e a r l y f i f t i e s , i n order to i n c r e a s e t h e i r assured incomes and to p r o v i d e b e t t e r s e r v i c e . The coverage of the p o p u l a t i o n p r o v i d e d by these p l a n s had grown s t e a d i l y over the years f o l l o w i n g the e a r l i e r growth of p r e p a i d h o s p i t a l insurance ( T a y l o r , S h i l l i n g t o n ) . While there was strong support from the medical p r o f e s s i o n f o r the f i r s t t h ree programs, i . e . n a t i o n a l h e a l t h g r a n t s , h o s p i t a l c o n s t r u c t i o n g r a n t s , and h o s p i t a l o p e r a t i n g g r a n t s , a c o n f r o n t a t i o n between the government of Saskatchewan and the d o c t o r s of t h a t p r o v i n c e f o l l o w e d the government's d e c i s i o n to i n t r o d u c e a p r o v i n c i a l Medical Care Scheme i n 1962. The events of t h i s c o n f r o n t a t i o n have been d e s c r i b e d by s e v e r a l a n a l y s t s ( T o l l e f s o n , Badgley and Wolfe, and McTaggart), and i t i s not proposed to recount them here. What was important was the atmosphere of s u s p i c i o n and m i s t r u s t which has p e r s i s t e d f o r years s i n c e then, d e s p i t e formal agreements to proceed with the o p e r a t i o n a l i z i n g of Medicare programs. E q u a l l y important were the a m b i g u i t i e s of these agreements which never c l a r i f i e d whether p h y s i c i a n s were s u b s i d i z e d entrepreneurs, or i n 44 c o n t r a c t with the governments. The "Saskatoon Agreement" m o d i f i e d the payment mechanism f o r d o c t o r s so t h a t they c o u l d d e f i n e t h e i r own method of payment i n any of four ways: a. D i r e c t Commission payment to the d o c t o r . b. Payment of the doctor by an approved agency. c. Payment of the doctor by the p a t i e n t , who i s then reimbursed by the Commission. The doctor may charge more than the o f f i c i a l fee schedule, with ,the p a t i e n t being r e -s p o n s i b l e f o r the d i f f e r e n c e . T h i s i s the most important payment method granted, i n terms of subsequent developments i n the h e a l t h care system of Canada, because i t l e g a l i z e d balance b i l l i n g , and thus served as a model for f u t u r e agreements between the p r o v i n c e s and the medical p r o f e s s i o n . The agreement thus guaranteed freedom i n the money arrangements between p a t i e n t s and d o c t o r s d. S a l a r y payments to the doctor by the Commission. ( T h i s i s s u e has come to the s u r f a c e again as a major p o i n t of p r i n c i p l e i n the c o n t r o v e r s y over balanced b i l l i n g which was r e f e r r e d to the Health S e r v i c e s Review •7 9) . The d o c t o r s of Saskatchewan f e l t t h a t t h e i r r i g h t s to balance b i l l and to opt out of the system were entrenched i n t h e i r t o r i g i n a l agreement with the 45 government of Saskatchewan, such agreement s e r v i n g as a model for other p r o v i n c i a l governments and f o r Medicare n a t i o n a l l y . The i s s u e i s t h a t of medical autonomy. While no one could argue t h a t d o c t o r s should have complete d i s c r e t i o n over c l i n i c a l decision-making, the o r g a n i z a t i o n of s e r v i c e s i s arguable, and argued by other groups who have power, such as funding b o d i e s . One mechanism which has been used to prevent open c o n f r o n t i o n between the p r o f e s s i o n s and the governments i s the use of b u f f e r groups to p r o v i d e anonymity, such as the use of insurance c a r r i e r s was f e l t to do i n the s i x t i e s (as e s t a b l i s h e d i n the Saskatoon Agreement), or to n e g o t i a t e r e s o l u t i o n s of d i f f e r e n c e s such as the use of r e g i o n a l p l a n n i n g boards to c o n t r o l the development of h o s p i t a l f a c i l i t i e s a t the community l e v e l . 3 . A c c o u n t a b i l i t y and C o n t r o l s As p o i n t e d out i n the p r e v i o u s chapter, government involvement i n the funding of s e r v i c e s has i n e v i t a b l y l e d to concern with i s s u e s of a c c o u n t a b i l i t y f o r q u a l i t y and c o s t s . Because q u a l i t y c o n t r o l has to be l e f t to the p r o f e s s i o n a l s , v a r i o u s v o l u n t a r y mechanisms such as h o s p i t a l a c c r e d i t a t i o n programs have a r i s e n to e x e r t an i n f l u e n c e on i n - h o s p i t a l q u a l i t y c o n t r o l . Because of the e x t e n s i v e data accumulated i n the Medicare tapes, 46 q u a n t i t y data governing a l l aspects of a p h y s i c i a n ' s performance are r e a d i l y a v a i l a b l e . The data on a p a r t i c u l a r p h y s i c i a n can be compared to data on a l a r g e group of s i m i l a r l y p r a c t i s i n g p h y s i c i a n s i n a designated area (a norm of p r a c t i c e i s decided on by a peer group). I f h i s performance shows a s t a t i s t i c a l swing from the norm of two standard d e v i a t i o n s or more, i n any p a r t i c u l a r f a c e t of h i s p r a c t i c e , he i s then answerable to the P a t t e r n s of P r a c t i c e Committee of the Medical A s s o c i a t i o n i n B r i t i s h Columbia. Because q u a l i t y i s intermeshed with q u a n t i t y when the time c o n s t r a i n t s of a p h y s i c i a n are c o n s i d e r e d , there i s a q u a l i t y s u r v e i l l a n c e mechanism t h a t emerges from review of the Medicare data. A t h i r d q u a l i t y c o n t r o l mechanism i s t h a t produced by the C o l l e g e of P h y s i c i a n s and Surgeons i n regard to e t h i c s . F i n a l l y , a new f o r c e f o r q u a l i t y performance (as opposed to q u a l i t y c o n t r o l ) , i s the upsurge i n emphasis on c o n t i n u i n g medical e d u c a t i o n . Although such programs are a t present v o l u n t a r y i n B r i t i s h Columbia and Canada, there i s a trend emerging i n the United S t a t e s and Canada ( Roemer and Roemer, pp. 9^)to make a c e r t a i n amount of c o n t i n u i n g education a requirement f o r continued p r a c t i c e , by the l i c e n s i n g a u t h o r i t y of the s t a t e or p r o v i n c e . T h i s trend w i l l d o v e t a i l with the new s t r e s s on the a p p r o p r i a t e n e s s of p e r i o d i c r e l i c e n s i n g f o r p h y s i c i a n s . C o n t i n u i n g medical education i s the major e f f o r t of the C o l l e g e of Family 47 P h y s i c i a n s of Canada i n an e f f o r t to upgrade both the s t a t u s and performance of f a m i l y p h y s i c i a n s (see the Appendix re d e f i n i t i o n of a C e r t i f i e d Family P h y s i c i a n ) . Continued membership i n the C o l l e g e r e q u i r e s the performance of a d e f i n e d minimum of c o n t i n u i n g medical education c r e d i t s per year. C e r t i f i c a t i o n by the C o l l e g e r e q u i r e s the a p p l i c a n t t o pass a s e t of examinations, much i n the manner of would-be s p e c i a l i s t s when they w r i t e the q u a l i f y i n g examinations f o r the Royal C o l l e g e of P h y s i c i a n s and Surgeons. The e f f e c t of these v a r i o u s e d u c a t i o n a l e f f o r t s i s apt to be more p r o d u c t i v e of q u a l i t y p r a c t i c e than s u r v e i l l a n c e mechanisms because they emphasize a p o s i t i v e parameter to p r o f e s s i o n a l performance. As regards c o s t c o n t r o l , the f a i l u r e of p r o v i n c i a l governments to c o n t r o l h o s p i t a l c o n s t r u c t i o n p l a n n i n g a f t e r 1949 l e d to r i g i d r u l e s being e s t a b l i s h e d r e g a r d i n g h o s p i t a l o p e r a t i o n c o s t - s h a r i n g i n the H o s p i t a l Insurance and D i a g n o s t i c S e r v i c e s A c t of 1957. Des p i t e these r u l e s , h o s p i t a l c o s t s continued to e s c a l a t e . The p r o v i n c i a l p r o f e s s i o n a l medical groups, having agreed to come i n t o Medical Care programs i n the m i d - s i x t i e s f o l l o w i n g the Royal Commission enquiry, decided t h a t they must s e t up t h e i r own economic c o n t r o l s over members, i n order to escape b u r e a u c r a t i c s c r u t i n y and to encourage proper p r a c t i c e methods. They 48 have e s t a b l i s h e d t h e i r own methods of examining p a t t e r n s of p r a c t i c e , as mentioned e a r l i e r . They have been c a r e f u l to keep group c o n t r o l over members' c l i n i c a l a c t i v i t i e s i n response to the i n f o r m a t i o n c o l l e c t e d from government data banks. In t h i s manner, they have been much more s u c c e s s f u l i n the c o n t r o l of t h e i r members than other p r o f e s s i o n a l s u r v e i l l a n c e groups, such as the Law S o c i e t y have been over lawyers, where t h e r e i s no data bank backup resource f o r s t a t i s t i c s by which to demonstrate p o s s i b l e o v e r - s e r v i c i n g or other p r a c t i c e d e v i a t i o n s from the norm. Ne v e r t h e l e s s , i n the 1970's, f o l l o w i n g the F e d e r a l Task Force Report on the Costs of Health Care i n 1969 (which reviewed h o s p i t a l data o n l y , because Medicare data was not then a v a i l a b l e ) , the emphasis on c o s t containment has grown. S i m i l a r problems e x i s t i n the United S t a t e s h e a l t h care system (Time, May 28th., 1979). The Task Force produced many recommendations, but the most important of these were: a. Amend the funding arrangements from an open-ended to a close-ended system. b. Consider p o s s i b l e new o r g a n i z a t i o n s t r u c t u r e s such as Community Health Centres (Hastings Report, 1972) and the use of nurse p r a c t i -t i o n e r s (Boudreau, 1973). c. T r e a t more p a t i e n t s o u t s i d e of h o s p i t a l s . The change i n the funding of s e r v i c e s was brought about i n 1977 with the pa s s i n g of the E s t a b l i Programs F i n a n c i n g A c t . D e t a i l s of the changes are given i n the Appendix ^X. The n a t u r a l outcome of a. was to exert pressure on p h y s i c i a n s ' incomes, keeping them from r i s i n g i n pace with the i n f l a t i o n a r y trends of the s e v e n t i e s . T h i s l e d to more c o n f r o n t a t i o n i n the di a l o g u e between p r o v i n c i a l medical a s s o c i a t i o n s and p r o v i n c i a l governments when the time came to r e n e g o t i a t e fee i n c r e a s e s . Governments tended towards g l o b a l budgeting (as Saskatchewan had i n i t i a t e d ) , so t h a t i n the a l l o c a t i o n of an i n c r e a s e of medical d o l l a r s , the v a r i o u s p r o f e s s i o n a l medical groups were l e f t to f i g h t i t out as to how the p i e was d i v i d e d . T h i s l e d to some d i f f e r e n t i a l i n e q u i t i e s , but, as experience accumulated, attempts were made to i r o n out i n e q u a l i t i e s . E x p e r i e n t i a l data on the d i f f e r e n c e s between s p e c i a l i s t s and g e n e r a l i s t s and s p e c i a l i s t s and s p e c i a l i s t s , were reviewed to o b t a i n a c e r t a i n consensus as to what a p p r o p r i a t e d i f f e r e n t i a l s should be. The d i f f i c u l t y with the emphasis on physicians* incomes as being the u l t i m a t e and most v i s i b l e t a r g e t where c o n t r o l s should be exerted, i s t h a t p h y s i c i a n s ' incomes are one of the smaller items when the t o t a l budgetary a l l o c a t i o n of funds f o r n a t i o n a l and p r o v i n c i a l h e a l t h care i s c o n s i d e r e d . I t i s the f a c t of t h e i r media and p u b l i c prominence t h a t makes p h y s i c i a n s ' incomes so r e a d i l y a t t a c k a b l e . 50 New o r g a n i z a t i o n s t r u c t u r e s as mentioned i n b. above, were promoted v i g o r o u s l y and t r i e d i n many areas. However, they have only achieved a modicum of success. There was n a t u r a l l y some r e s i s t a n c e to these e f f o r t s from the medical p r o f e s s i o n , but as the p r o f e s s i o n had been moved p e r i p h e r a l l y , as mentioned e a r l i e r , from a c e n t r a l a u t h o r i t a r i a n r o l e to a more s e r v i c e centred f u n c t i o n , t h e i r r e s i s t a n c e was r e a d i l y overlooked i n the implementation of the Hastings Report. Community Health Centres (see C r i c h t o n and Anderson) need p h y s i c i a n s to perform medical f u n c t i o n s as employees, and the p s y c h o l o g i c a l s e t of p h y s i c i a n s i n the country, taken as a whole, has not been to regard themselves as employees s u b j e c t to l a y c o n t r o l by a h e a l t h c e n t r e manager or board of d i r e c t o r s . Many squabbles n a t u r a l l y ensued, such as c o n f r o n t a t i o n i n Regina i n 1973, when the c e n t r e ' s t o t a l complement of d o c t o r s r e s i g n e d en masse, even though they were community h e a l t h c e n t r e o r i e n t e d i n p h i l o s o p h y , because of what they c o n s i d e r e d was i n t e r f e r e n c e i n t h e i r p r i n c i p l e s of p r a c t i c e by the h e a l t h c e n t r e ' s board of d i r e c t o r s . The use of nurse p r a c t i t i o n e r s and t h a t experience to date has been a l l u d e d to e a r l i e r , p. 3 0 . Item c. above has been the most e f f e c t i v e measure f o r c o s t containment as new funds were pro v i d e d f o r o u t - p a t i e n t s e r v i c e s . Many h o s p i t a l bed days have been saved, with the attendant c o s t r e d u c t i o n , by the use of 51 day care surgery. Even then, the p r o v i n c i a l government had to be pushed i n i t i a l l y to broaden the scope of day care surgery by the medical p r o f e s s i o n , as a method of reducing i t s " w a i t i n g l i s t s f o r e l e c t i v e procedures. Government committment to o u t - p a t i e n t or o u t - o f - h o s p i t a l care can s t i l l have some s p o t t y areas when new technology (with attendant costs) a r i s e s . Witness the d i f f i c u l t y i n the establishment of and government approval of u l t r a - s o u n d d i a g n o s t i c equipment i n the o f f i c e s of p r i v a t e r a d i o l o g i s t s i n B r i t i s h Columbia. T h i s r e s i s t a n c e e x i s t e d d e s p i t e w a i t i n g times f o r o u t - p a t i e n t h o s p i t a l u l t r a - s o u n d d i a g n o s t i c s e r v i c e s extending to s e v e r a l weeks. No doubt the r e s i s t a n c e to the establishment of such s e r v i c e s i n r a d i o l o g i s t s * o f f i c e s c e n t r e d on the problem of how much co s t would be generated, and how c o n t r o l s would be a p p l i e d . T h i s n a t u r a l governmental r e s i s t a n c e to new technology, because of attendant u n p r e d i c t a b l e c o s t s , i s soften e d by the e a r l i e r and overwhelming acceptance of many new procedures and techniques by the adjacent U n i t e d S t a t e s medical care system, with the r e s u l t a n t i n f o r m a t i o n flow to Canada. Community h e a l t h care programs such as Home Care and Long Term Care have been developed i n B r i t i s h Columbia by h e a l t h and s o c i a l s e r v i c e departments. T h e i r c o s t care merit a r i s e s from the savings a t t a i n e d by g i v i n g home care to p a t i e n t s who would othwerwise 52 r e q u i r e a bed i n a h o s p i t a l ^ ( C r a n e ) . 4. Manpower Developments Since p h y s i c i a n s have d i s t r i b u t e d themselves i n i t i a l l y i n those areas with the most f a c i l i t i e s and most a t t r a c t i v e s o c i a l and c l i m a t i c a m e n i t i e s , these areas have tended to become m e d i c a l l y congested f i r s t . As o p p o r t u n i t i e s decreased i n those areas, primary care p h y s i c i a n s and those i n the major s p e c i a l t i e s have g e n e r a l l y fanned out from the c i t i e s to the middle and f a r n orth of B r i t i s h Columbia. I t has been f e l t , however, t h a t t h i s e n t r e p r e n e u r i a l development may not be the most e f f e c t i v e use of p r o f e s s i o n a l s k i l l s . Since government has become r e s p o n s i b l e f o r paying the b i l l s , i t has wanted to c o n t r o l d i s t r i b u t i o n and mix of p h y s i c i a n manpower and to co n s i d e r where s u b s t i t u t i o n s might be made. The next chapter i s concerned with the development of h e a l t h manpower plann i n g a c t i v i t i e s . 53 CHAPTER FOUR Health Planning A c t i v i t i e s 1. E n t r e p r e n e u r i a l " Planning", or the "Non-System" With the formation of p r o f e s s i o n a l a s s o c i a t i o n s , c e r t a i n r u l e s of conduct were agreed upon. These r u l e s , or p r o f e s s i o n a l e t h i c s , can be regarded as a f i r s t attempt to b r i n g order in® a f r e e e n t r e p r e n e u r i a l s i t u a t i o n i n which i n d i v i d u a l medical p r a c t i t i o n e r s worked without any c o n t r o l s - a s i t u a t i o n i n which 'quacks' and other medical d e v i a n t s were ab l e to compete f o r p a t i e n t s . The e t h i c a l code of the p r o f e s s i o n a l groups has r e g u l a t e d the a d v e r t i s i n g of s e r v i c e s , the r e f e r r a l of p a t i e n t s , the c o n f i d e n t i a l i t y of p a t i e n t i n f o r m a t i o n , and prevented the s p l i t t i n g of f e e s , and e s t a b l i s h e d a mode of behaviour f o r p h y s i c i a n s . As a r e s u l t of e n f o r c i n g t h i s code, more or g a n i z e d p a t t e r n s of s e r v i c e began to evolve. Although these might not be regarded as p l a n n i n g , i n the same sense as t h a t word i s used today, n e v e r t h e l e s s , they had the e f f e c t of e s t a b l i s h i n g a system of h e a l t h care which was r e g u l a t e d to s u i t the p r a c t i t i o n e r s of n i n e t e e n t h century (1958) medicine. E.C. Hughes : has>described how, i n a simple dyadic r e l a t i o n s h i p , the concept of ' f r e e c h o i c e of 54 d o c t o r s ' working w i t h i n the p r o f e s s i o n a l e t h i c a l code, was thought to p r o v i d e s u f f i c i e n t c o n t r o l over p a c t i t i o n e r s 1 behaviour. In more severe i l l n e s s e s , when a h e a l t h care team was used to t r e a t p a t i e n t s , c o n s u l t a n t s would be c a l l e d i n , or nurses and pharmacists would be a b l e to ensure t h a t mistakes were caught. The r u l e s s e t out the way these r e l a t i o n s h i p s should be conducted. However, e a r l y i n the t w e n t i e t h century, i t became c l e a r t h a t the c o n t r o l s e s t a b l i s h e d by the p r o f e s s i o n a l a s s o c i a t i o n s were not, i n themselves, adequate. As Fuchs and o t h e r s have p o i n t e d out, there i s too much room f o r d i s c r e t i o n by entrepreneurs. Roemer's Law, as i t has come to be c a l l e d , s t a t e s t h a t 'the more beds and the more surgeons a v a i l a b l e , the more s u r g i c a l o p e r a t i o n s w i l l be performed'. Mc Eachern went from the Vancouver General H o s p i t a l to the American C o l l e g e of i n 1918 Surgeons P to develop v o l u n t a r y h o s p i t a l a c c r e d i t a t i o n procedures, i n order to c o n t r o l some of the more obvious abuses and to b r i n g more order i n t o h o s p i t a l o r g a n i z a t i o n . In Canada, L.O. Bradley was i n s t r u m e n t a l i n the i n t r o d u c t i o n of a c c r e d i t a t i o n procedures to which the C a t h o l i c H o s p i t a l A s s o c i a t i o n gave str o n g support. T h i s development, i n t u r n , o b l i g e d the m u n i c i p a l h o s p i t a l s to conform to a c c r e d i t a t i o n standards as the concept gained f o r c e . G r a d u a l l y , the most obvious e x p l o i t e r s of the p u b l i c were brought i n t o l i n e through 55 peer reviews, or they were d r i v e n i n t o the r u r a l areas, where c o n t r o l s were l e s s s t r i c t and where the small communities were g l a d to get p r o f e s s i o n a l h e l p on any terms. In North America, a l l p h y s i c i a n s g r a d u a l l y sought to g a i n h o s p i t a l a d m i t t i n g p r i v i l e g e s , so t h a t they could guide t h e i r p a t i e n t s through complete episodes of i l l n e s s . T h i s was i n c o n t r a s t to some European c o u n t r i e s such as B r i t a i n , where the g e n e r a l p r a c t i t i o n e r handed over h i s p a t i e n t s to the s p e c i a l i s t s f o r i n - p a t i e n t c a r e . The p h y s i c i a n s a p p l y i n g f o r p r i v i l e g e s u s u a l l y had t h e i r records and c r e d e n t i a l s reviewed and approved by the h o s p i t a l s ' c r e d e n t i a l s committees be f o r e being accepted. G r a d u a l l y , some h o s p i t a l s became r e f e r r a l c e n t r e s at the secondary or t e r t i a r y l e v e l , and i n these, g e n e r a l p r a c t i t i o n e r s began to f e e l squeezed out as c e r t a i n c o n d i t i o n s were s e t f o r t h e i r work, e.g. the amount of surgery they c o u l d do would be r e s t r i c t e d , or they might have to conduct t h e i r s u r g i c a l o p e r a t i o n s under c e r t a i n safeguards such as having three d o c t o r s p r e s e n t . However, the r i g h t to have h o s p i t a l p r i v i l e g e s f o r a l l was s t r o n g l y fought through p u b l i c i n q u i r i e s i n Saskatchewan and O n t a r i o , when attempts were made to exclude some gen e r a l p r a c t i t i o n e r s . I t was now g e n e r a l l y recognized t h a t ' f r e e c h o ice of doctor ' was, by i t s e l f , an i n s u f f i c i e n t c o n t r o l - t h a t p a t i e n t s were 56 not a b l e to assess the q u a l i t y of care t h a t they were given - and t h a t peer reviews were e s s e n t i a l . These have not been extended to o f f i c e work but s o l e l y to h o s p i t a l a c t i v i t i e s . As mentioned e a r l i e r , there i s some q u a l i t y component a c c r u i n g from the a n a l y s i s of q u a n t i t y Medicare data on o f f i c e p r a c t i c e s . By the 1950's, the development of medical technology was so r a p i d t h a t academic l e a d e r s began to become concerned, not only about b a s i c c u r r i c u l u m p l a n n i n g , but a l s o about the maintenance of competence. A study by C l u t e and o t h e r s showed t h a t only f o r t y percent of the d o c t o r s i n Nova S c o t i a and s i x t y percent of the d o c t o r s i n O n t a r i o met the minimum standards s e t by observers sent to look a t t h e i r o f f i c e procedures. C l u t e proposed t h a t t h i s s i t u a t i o n should be remedied through improvement of c o n t i n u i n g medical e d u c a t i o n . The C o l l e g e of Family P h y s i c i a n s was e s t a b l i s h e d to pursue such e d u c a t i o n a l endeavours. In g e n e r a l , s t a n d a r d - s e t t i n g has been l e f t to the C o l l e g e s of P h y s i c i a n s and Surgeons and to the h o s p i t a l a c c r e d i t a t i o n programs. The p r o v i n c i a l h o s p i t a l a s s o c i a t i o n s have helped to develop c o n s u l t i n g programs on medical reords, i n v e n t o r i e s , bookkeeping, e t c . P r o v i n c i a l and f e d e r a l governments have a l s o e s t a b l i s h e d some p r o f e s s i o n a l consultancy a c t i v i t i e s w i t h i n t h e i r H o s p i t a l Insurance departments. In B r i t i s h Columbia, j o i n t s p e c i a l i z e d committees a l s o e x i s t , c o n s i s t i n g of a 57 v a r i e d group of medical r e p r e s e n t a t i v e s p l u s a government r e p r e s e n t a t i v e , i n order to advise the government on t e c h n i c a l matters and equipment purchases f o r such as the r e n a l and c o n t i n u i n g c a r d i a c care committees. One cannot deny t h a t e n t e r p r i s i n g i n d i v i d u a l i s m has p r o v i d e d day to day medical s e r v i c e s , as w e l l as many outsta n d i n g achievements i n the s e r v i c e component of h e a l t h care d e l i v e r y . The media, i n r e p o r t i n g news events, o f t e n accent the c a l a m i t i e s , as r e p o r t i n g on the hum-drum d a i l y performance of usual tasks i s not newsworthy. S i m i l a r l y , a p p r a i s e r s of h e a l t h care, seeking to invoke changes i n the system, too o f t e n accentuate the d e f i c i e n c i e s without g r a n t i n g adequate due to the e x i s t i n g system or "non-system". "Non-systems" are undoubtedly systems of t h e i r own with i l l - d e f i n e d l i n k a g e s and boundaries as we understand them. The f a c t of the matter i s t h a t most of the p u b l i c i s w e l l s a t i s f i e d with the d e l i v e r y of h e a l t h care as p r e s e n t l y c o n s t i t u t e d . The observers of the system, on the other hand, look a t the q u a l i t y of h e a l t h care d e l i v e r y by i n d i c e s such as m o r t a l i t y r a t e s , l i f e expectancy, p e r i - n a t a l m o r t a l i t y and m o r b i d i t y , and f e e l t h a t Canada's i n f e r i o r p o s i t i o n per these i n d i c e s r e l a t i v e to other c o u n t r i e s , i s u n d e s i r a b l e (World Health O r g a n i z a t i o n . Annual S t a t i s t i c s ) . The entrepreneurs, with a long h i s t o r y of dyadic 58 d o c t o r / p a t i e n t r e l a t i o n s h i p s dominating t h e i r v i e w p o i n t s , have been more concerned with p r o v i d i n g a high standard of care f o r t h e i r i n d i v i d u a l p a t i e n t s than with s o c i a l i s s u e s r e l a t i n g to the d i s t r i b u t i o n of care and c o s t s f o r a l l c i t i z e n s . The major push for b e t t e r p l a n n i n g i n these two s e c t o r s came from governments when the r i s i n g c o s t s of h e a l t h s e r v i c e s came i n t o q u e s t i o n . As Judge has p o i n t e d out, i t i s governments t h a t p r o v i d e funding but p r o f e s s i o n a l s who p r o v i d e s e r v i c e s , and t h e r e i s a d i s t i n c t i o n between t h e i r a t t i t u d e s to f i n a n c i a l and s e r v i c e r a t i o n i n g p r o c e s s e s . In Canada, while there was concern about funding r i g h t from the beginning of the establishment of h e a l t h care i n s t i t u t i o n s , i t was not u n t i l the postwar years t h a t governments became committed to e x t e n s i v e funding, and i t took them a long time to r e a l i z e j u s t what t h e i r commit ments meant. The Task Force on the Costs of Health Care was not s e t up u n t i l 1969, a f t e r a l l the n a t i o n a l h e a l t h insurance had been l e g l i s l a t e d i n t o e x i s t e n c e , i f not completely implemented (Quebec Medicare was implemented i n 1970) . Concern about c o s t s leads to concern about s o c i a l p l a n n i n g , which has to be developed i n t o an o p e r a t i o n a l mechanism. There are always time l a g s i n implementing remedies. The p l a n n i n g mechanisms developed by the p r o f e s s i o n a l groups' h o s p i t a l a s s o c i a t i o n s and the academic i n s t i t u t i o n s d i d not seem to the government to 59 be adequate to d e a l with e f f i c i e n c y or value f o r money (Abel-Smith), although they might be coping with e f f e c t i v e n e s s or standards (Cochrane). C e r t a i n l y , they were l e s s concerned with c o o r d i n a t i o n and i n t e g r a t i o n of the v a r i o u s p a r t s of the s e r v i c e because of t h e i r i n t e r e s t i n i n d i v i d u a l s , than were governments a f t e r they became i n v o l v e d i n funding, f o r the l a t t e r had to co n s i d e r s o c i a l needs. 2. Emergence of Government Planning Processes i n Canada  and B r i t i s h Columbia Governments of Canada became i n v o l v e d i n p l a n n i n g p u b l i c h e a l t h s e r v i c e s f o l l o w i n g n i n e t e e n t h century B r i t i s h examples. T h i s p l a n n i n g was, at f i r s t , h e a v i l y i n f l u e n c e d by the P u b l i c Health Act, 1875, which l a i d down the l i n e s f o r Canadian development of s o c i a l h e a l t h c a r e . S i m i l a r l y , governments had to p r o v i d e care f o r the m e n t a l l y i l l , when the l o c a l committees could not cope with t h a t problem. In t h i s they were more i n f l u e n c e d by the American models. In the second decade of the t w e n t i e t h century, the Saskatchewan government became i n v o l v e d i n h o s p i t a l p l a n n i n g which had p r e v i o u s l y been c o n s i d e r e d a matter f o r v o l u n t a r y or m u n i c i p a l e f f o r t . The government was o b l i g e d t o respond to demands f o r l e g i s l a t i o n a u t h o r i z i n g j o i n t p a r t i c i p a t i o n of two or more 60 m u n i c i p a l i t i e s . G r a d u a l l y , the c i t i z e n s of Saskatchewan became more and more i n v o l v e d i n seeking l e g i s l a t i o n to improve h e a l t h s e r v i c e s , such as the m u n i c i p a l doctor program, s t a r t e d i n 1916 as a s o c i a l l e v e r to a t t r a c t d o c t o r s to low-income r u r a l areas (Roemer and Roemer). When the C.C.F. (Cooperative Commonwealth Federation) Party was e l e c t e d to power i n Saskatchewan i n 1944, i t had a mandate to l e g i s l a t e comprehensive h e a l t h care f o r a l l , i n accordance with i t s campaign p l a t f o r m ( L i p s e t ) . T.C. Douglas and h i s c a b i n e t moved to b r i n g i n h e a l t h p l a n n e r s from the U n i t e d S t a t e s to develop a s o c i a l program f o r the p r o v i n c e . The S i g e r i s t Plan (1944) , had begun to be implemented on a r e g i o n a l b a s i s , S w i f t Current being the f i r s t r e g i o n chosen f o r t h i s , when i t was overtaken by f e d e r a l p l a n n i n g f o r n a t i o n a l h e a l t h insurance i n 1948. The f e d e r a l plans f o r n a t i o n a l h e a l t h insurance were d e s c r i b e d i n the p r e v i o u s chapter and a l s o i n the Appendix, 1. Because of the c o m p l e x i t i e s i n reaching agreement between the f e d e r a l and p r o v i n c i a l governments, and because h e a l t h s e r v i c e s were seen as a means to g r e a t e r s o c i a l s e c u r i t y as w e l l as having t h e i r own ends, the l o g i c s of the S i g e r i s t Plan were not a p p l i e d a t the n a t i o n a l l e v e l . The n a t i o n a l h e a l t h grants f o r p u b l i c and mental h e a l t h program development and f o r p u b l i c h o s p i t a l c o n s t r u c t i o n (1949) , spread h e a l t h s e r v i c e s more evenly across Canada, c r e a t e d 61 numerous jobs, s t i m u l a t e d s m a l l community bu s i n e s s e s , and were seen to be an i n t e g r a t i n g f a c t o r f o r n a t i o n a l u n i t y , r a t h e r than a t e c h n i c a l l y sound h e a l t h care p l a n . I t must be reco g n i z e d , t h a t a t t h i s time, the p r o v i n c i a l governments were unable to do t h e i r own he a l t h p l a n n i n g e f f e c t i v e l y . While B r i t i s h Columbia commissioned i t s A s s o c i a t e Deputy M i n i s t e r , George E l l i o t t , to prepare a p u b l i c h e a l t h plan i n 1952, i t had to b r i n g i n c o n s u l t a n t s from Minnesota to prepare a h o s p i t a l and h e a l t h manpower plan f o r the p r o v i n c e (James A. Hamilton and A s s o c i a t e s , 1949). When these c o n s u l t a n t s returned to Minnesota, t h e r e were no c i v i l s e r vants a b l e to f o l l o w through, and i t was not u n t i l some time l a t e r t h a t a h o s p i t a l insurance department was developed to de a l with h o s p i t a l o p e r a t i n g f u n d i n g . Many years l a t e r ( 1 9 6 9 ) , h e a l t h manpower p l a n n i n g became a matter f o r government to c o n s i d e r . The need f o r proper p l a n n i n g s e r v i c e s was g r a d u a l l y accepted. Regional h o s p i t a l d i s t r i c t s were s e t up i n 1966 to c o n t r o l h o s p i t a l f a c i l i t y developments. In 1972 the N.D.P. (New Democratic Party) government of B r i t i s h Columbia commissioned an i n q u i r y by Dr. R.G. Fouikes i n t o the h e a l t h needs of p r o v i n c i a l r e s i d e n t s , and h i s proposed pl a n s to meet these needs. T h i s i n q u i r y was completed i n 1973, but the r e p o r t was couched i n such s o c i a l i s t i c p h i l o s o p h i c a l terms, and was so a n t a g o n i s t i c to the do c t o r s ' p o s i t i o n , t h a t the M i n i s t e r of Health had to 62 c a l l i t an ' a d v i s o r y ' document to the government, r a t h e r than a p o l i c y document of the government, i n order to p l a c a t e the s e r v i c e p r o v i d e r s . Foulkes had been i n f l u e n c e d by the p l a n s w r i t t e n f o r other p r o v i n c i a l governments, p a r t i c u l a r l y those of Quebec (Castonguay/Nepveu, 1970) and Manitoba (White Paper, 1972). O n t a r i o had a l s o r e c e i v e d a s e r i e s of s t u d i e s made by the p r o v i n c i a l a d v i s o r y h e a l t h c o u n c i l , and had commissioned s t u d i e s on the h e a l t h p r o f e s s i o n s (Healing A r t s , 1971) and r e g i o n a l i z a t i o n (Mustard, 1974). Nova S c o t i a had engaged p r i v a t e c o n s u l t a n t s to develop a plan f o r Cape Breton, and other Maritime governments such as P r i n c e Edward I s l a n d , had sought c o n s u l t a n t help from the f e d e r a l government to develop b e t t e r p l a n s . The c o n f l i c t between those i n t e r e s t e d i n " q u a l i t y " i s s u e s and those i n t e r e s t e d i n " c o s t " i s s u e s came to a head i n the s e v e n t i e s (Baker, Cochrane). The economists and f i n a n c e r s worry t h a t the h e a l t h machine i s a g l u t t o n o u s consumer of an i n c r e a s i n g share of the gross n a t i o n a l product, and must t h e r e f o r e be c u r t a i l e d . 'Cost containment of h e a l t h care' are the key words from the s e v e n t i e s . There i s no doubt t h a t the newer t e c h n i c a l advances i n medicine are expensive. Computerized a x i a l tomography i n s t a l l a t i o n s , f o r example, average about 750,000 d o l l a r s . The savings accrued from the avoidance 63 of i n v a s i v e techniques and unnecessary o p e r a t i o n s have to be estimated and entered on a balance sheet b e f o r e one can o b t a i n a true c o s t a p p r a i s a l of such d e v i c e s . Coronary bypass surgery i s an expensive procedure t h a t has added to the q u a l i t y of l i f e of many p a t i e n t s , i f not so much to t h e i r l o n g e v i t y . V a l u a t i o n s on the changed q u a l i t y of t h e i r e x i s t e n c e as viewed by the p a t i e n t s , are d i f f i c u l t to d e r i v e . Are these q u a l i t y c o n s i d e r a t i o n s any l e s s v a l i d than those s t a t i s t i c a l i n d i c a t o r s of q u a l i t y used by the c r i t i c s i n the e v a l u a t i o n of the present system? P a t i e n t awareness of modern medicine's c a p a b i l i t i e s i s e a s i l y a t t a i n e d through those same media r e p r e s e n t a t i v e s whom we decry when they r e p o r t medical news with what we regard as b i a s e s . The f a c t i s t h a t we cannot l i v e without both the p o s i t i v e and the negative aspects of media r e p o r t i n g . S i m i l a r l y , we cannot l i v e without the p o s i t i v e s and the n e g a t i v e s e v o l v i n g from t e c h n o l o g i c a l advances i n medicine. The media do not allow us to l i v e i n a vacuum re advancing knowledge i n the medical f i e l d . The demand of the p u b l i c f o r chances to a v a i l themselves of newer t e c h n o l o g i e s w i l l t u r n to p o l i t i c a l a c t i o n i f they f e e l adequate attempts to procure such advancements are not made. Can any a d m i n i s t r a t i v e bureaucrat p r e d i c t adequately and e v a l u a t e the c o s t / b e n e f i t r a t i o and economics of any p a r t i c u l a r medical advance? I t i s easy f o r r e t r o s p e c t i v e a n a l y z e r s such as Cochrane 64 ( E f f e c t i v e n e s s and E f f i c i e n c y ) to p o n t i f i c a t e on d e f i c i e n c i e s i n the f a s h i o n of Ivan I l l i c h . P e r v a s i v e f i e l d s of n e g a t i v i s m re newer medical t e c h n o l o g i e s w i l l not produce advances i n the s t a t e of medicine. We have ample evidence of t h i s i n Canada, when, f o r the sake of u n c e r t a i n economies, funding f o r the N a t i o n a l Research C o u n c i l was c u r t a i l e d by the Trudeau government i n 1976. Research was c u r t a i l e d to the p o i n t where we became dependent on the United S t a t e s system f o r new advances. Yet t h i s i s the same system we p o i n t the f i n g e r at as an example of a "non-system", e n t r e p r e n e u r i a l , ad hoc, inadequate method of h e a l t h care. We cannot have the advantages of the advances i n medicine without being prepared to bear some of the c o s t s . Medicine has always been an e v o l v i n g , t r i a l and e r r o r s c i e n c e . E x p l o r a t i o n s i n medicine c o s t money - no l e s s so than e x p l o r a t i o n s f o r o i l (which c o s t s we are w i l l i n g to accept and w r i t e o f f ) . Planners of government budgets may have to review t h e i r p r i o r i t i e s i n order to accommodate the i n c r e a s e d c o s t s of h e a l t h care d e l i v e r y , or face the unpleasant p o l i t i c a l p r o s p ects of a second-rate h e a l t h care system. U n f o r t u n a t e l y , the obvious person to be a d j u s t e d i n maneuvering the economics of the system i s the d o c t o r . 3. Emergence of Medical Manpower Planning Processes: an  I n t e r n a t i o n a l Movement 65 Medical manpower p l a n n i n g i s n e i t h e r an a r t nor a s c i e n c e ; r a t h e r , i t i s an emerging s o c i a l movement of r e l a t i v e l y recent o r i g i n . S c a t t e r e d beginnings of such p l a n n i n g were noted as e a r l y as 1883, when Bismarck i n t r o d u c e d compulsory h e a l t h insurance f o r Germany. His m o t i v a t i o n was t w o - f o l d . P r i m a r i l y , he wanted to defuse p o l i t i c a l u n rest t h r e a t e n i n g h i s new empire. Secondly, he wanted to promote economic and s o c i a l e q u a l i t y . T h i s dualism of purpose i s s t i l l with us today, i . e . the sought f o r g o a l s of both a l t r u i s m and s e l f - p r e s e r v a t i o n , so t h a t developments i n the h e a l t h care system i n any country, must always be viewed from the context of both an i d e a l i s t i c maturation of s o c i a l j u s t i c e i n the n a t i o n a l conscience, and from the more pragmatic p o l i t i c a l expediency route of a government attempting to r e t a i n c o n t r o l , through the development of l e g i s l a t i o n s e n s i t i v e to the emerging a s p i r a t i o n s of i t s p o p u l a t i o n . T h i s i s not to say t h a t the two processes are e i t h e r c o u n t e r p o i s e d or synchronized. They are intermeshed i n a complicated r e l a t i o n s h i p , as are the formal o f f i c i a l g o a l s and the o p e r a t i v e goals of any o r g a n i z a t i o n , as enunciated by Miner. In the Saskatchewan Medicare c r i s i s of 1962, as i n Bismarck's day, the d u a l i t y of purpose was e v i d e n t . Both g o a l s were used i n the government's stand a g a i n s t s t r o n g r e s i s t a n t - t o - c h a n g e power groups i n the p o p u l a t i o n (Badgi&y and W o l f e ) . 66 Developments i n h e a l t h p l a n n i n g i n Canada d i d not proceed a p a r t from changes i n other c o u n t r i e s with s i m i l a r s o c i a l p l a n n i n g p r i n c i p l e s and i n t e r e s t s . The communication processes between c o u n t r i e s were enhanced i n the post World War II p e r i o d by a p r o l i f e r a t i n g world l i t e r a t u r e on s o c i a l and h e a l t h p l a n n i n g , and l a t t e r l y by the development of computerized l i b r a r i e s , with immense search 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 . The process of the emergence of a h e a l t h system conscience, as a p a r t of a t o t a l system of s o c i a l p l a n n i n g , was evid e n t by i n t e r n a t i o n a l conferences such as the Pan /American Conference on Health Manpower Planning h e l d i n Ottawa i n 1973. The World Health O r g a n i z a t i o n was a l s o a s u b s t a n t i a l f o r c e i n the promotion of h e a l t h p l a n n i n g , e s p e c i a l l y i n emerging n a t i o n s . Methodologies employed i n v a r i o u s c o u n t r i e s do have common c h a r a c t e r i s t i c s , d e s p i t e v a r i a t i o n s i n l o c a l a p p l i c a t i o n and technique. These common elements e x i s t i n g i n a h e a l t h care and s o c i a l w e l f a r e system have been emphasized by Bla n p a i n , D e l e s i e and Nys i n t h e i r book on the development and f e a t u r e s of the h e a l t h insurance and resources i n f i v e European c o u n t r i e s . Abel-Smith drew a t t e n t i o n to the p r e s s i n g i n t e r n a t i o n a l i s s u e s i n medical manpower plann i n g i n h i s study of the m i g r a t i o n of p h y s i c i a n s . As e x p l a i n e d i n Chapter Two, Canada i s g r e a t l y a f f e c t e d by the m i g r a t i o n of d o c t o r s not only i n and out of the country, but 67 w i t h i n i t s own borders, between the p r o v i n c i a l j u r i s d i c t i o n s which were s e t up i n the n i n e t e e n t h century (Anderson et a l ) . At t h a t time, the c o l l e g e s of p h y s i c i a n s and surgeons were delegated the r e s p o n s i b i l i t y f o r c o n t r o l l i n g admissions to the r e g i s t e r s of p r a c t i t i o n e r s , along with d i s c i p l i n a r y powers over the proper p r o f e s s i o n a l behaviour of t h e i r p eers. Apart from the comments and suggestions about manpower which were made i n the p r o v i n c i a l p lans of 1949 - p l a n s which were not w e l l f o l l o w e d through because of lack of planners and a d m i n i s t r a t i v e c o n t r o l over the d e l i v e r y system by governments - l i t t l e seems to have been done u n t i l the s i t u a t i o n was reviewed by the Royal Commission on Health S e r v i c e s ( H a l l R e p o r t ) , 1 9 6 1 - 1 9 6 4 . Judek's s p e c i a l r e p o r t , Medical Manpower i n Canada. 19JL4_, on p h y s i c i a n manpower has 1 a l r e a d y been mentioned. The rec< ommendations i n t h i s r e p o r t l e d the Royal Commission to propose f u r t h e r development of medical education i n Canada. By 1 9 6 9 , the i s s u e had become t h a t of h e a l t h manpower p l a n n i n g , as educators became aware of the numbers of a l l i e d h e a l t h p r o f e s s i o n a l s being produced by the u n i v e r s i t i e s and community c o l l e g e s , i n a d d i t i o n to p h y s i c i a n s . A N a t i o n a l Health Manpower Conference was c a l l e d i n 1969 i n Ottawa to b r i n g out the i s s u e s f o r d i s c u s s i o n , and a f o l l o w - u p conference was h e l d i n 1971 68 (Second N a t i o n a l Health Manpower Conference, Ottawa). A Health Manpower D i r e c t o r a t e was e s t a b l i s h e d , along with the development of a Health Manpower B i b l i o g r a p h y . 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 was formed i n 1971, and f e d e r a l - p r o v i n c i a l meetings began to be h e l d . The Report of the Requirements Committee which was submitted to the N a t i o n a l Committee mentioned above, i s analyzed i n d e t a i l as p a r t of t h i s t h e s i s submission. C o n s i d e r a b l e p h y s i c i a n input i n t o the Requirements Committee Report enabled i t to be regarded as a v a l u a b l e backup document. Dr. D.O. Anderson, of the U n i v e r s i t y of B r i t i s h Columbia, who had been a c t i v e i n h e a l t h p l a n n i n g s i n c e 1959, was i n v i t e d to r e p r e s e n t the p r o v i n c e on the N a t i o n a l Health Manpower Committee. A Health Manpower Planning U n i t was e s t a b l i s h e d i n the o f f i c e of the Coordinator of Health Sciences at the U n i v e r s i t y of B r i t i s h Columbia, s u b s i d i z e d by government, but ac a d e m i c a l l y independent. As mentioned above, there was a Pan American Health Manpower Planning Conference h e l d i n Ottawa i n 1973, and the r e p o r t of t h a t conference p r o v i d e s important documentation on the s t a t e of the a r t at t h a t time. Meanwhile, i n 1972, the S o c i a l C r e d i t government which had been i n power f o r years i n B r i t i s h Columbia, 69 was r e p l a c e d by an N.D.P. government which decided to make some new moves i n h e a l t h s e r v i c e o r g a n i z a t i o n i n the p r o v i n c e . Among these moves was the establishment of the B r i t i s h Columbia Medical Centre (B.C.M.C.), whose primary o b j e c t i v e s were to c o o r d i n a t e e x i s t i n g t e a c h i n g h o s p i t a l a c t i v i t i e s and to develop a new t e r t i a r y care t e a c h i n g h o s p i t a l . However, the secondary o b j e c t i v e of h e a l t h manpower pl a n n i n g soon became predominant, as Dr. Anderson s t a r t e d to develop data banks on the h e a l t h p r o f e s s i o n a l s i n the p r o v i n c e . The N.D.P. government was defeated i n the e l e c t i o n i n 1975, and the B.C.M.C. Act was repealed by the r e t u r n i n g Socreds. While Dr. Anderson continued to r e p r e s e n t the p r o v i n c e on the N a t i o n a l Planning Committee, p r o v i n c i a l manpower pl a n n i n g was slowed down t e m p o r a r i l y u n t i l the new government o f f i c i a l s had time to take s t o c k . The U n i v e r s i t y of B r i t i s h Columbia u n i t continues to be g i v e n government c o n t r a c t s , but these are geared to e v a l u a t i o n , back-up r e s e a r c h , and d a t a - p r o v i d i n g f u n c t i o n s , r a t h e r than p l a n n i n g . Dr. A. Stark, who now i s r e s p o n s i b l e f o r the u n i t - Dr. Anderson l e f t i n 1976 - i s c o n s u l t e d by Health Department o f f i c i a l s on a r e g u l a r b a s i s . The p r o v i n c e has i t s own r e p r e s e n t a t i v e now, p l u s one other on the N a t i o n a l Committee f o r Health Manpower Pl a n n i n g . In 1975, p r o v i n c i a l government concern about h e a l t h manpower p l a n n i n g seems to have passed to the 70 M i n i s t r y of Education, headed by Dr. P a t r i c k McGeer, a U n i v e r s i t y of B r i t i s h Columbia neurology p r o f e s s o r . In 197 8 an a d v i s o r y committee on h e a l t h manpower was commissioned by a Health Department r e p o r t . T h i s committee was under the chairmanship of an ex-Socred M i n i s t e r of Health, Wesley Black. R e p r e s e n t a t i o n was widespread on the committee, with Dr. David B o l t o n , head of Medicare, r e p r e s e n t i n g the p r o v i n c i a l government, Dr. F.N. Rigb y, e x e c u t i v e d i r e c t o r of the B r i t i s h Columbia Medical A s s o c i a t i o n , and P h y l l i s Whittmore of the B r i t i s h Columbia H o s p i t a l s A s s o c i a t i o n . However, when t h i s committee rep o r t e d i n 1979, i t s r e p o r t was not made p u b l i c f o r s i x months, and then was q u i c k l y b u r i e d by the government, because i t s f i n d i n g s d i d not f i t i n with McGeer's own broad g e n e r a l p o l i c y d i r e c t i o n , namely: to i n c r e a s e medical school enrollment. B l a c k ' s r e p o r t had argued t h a t there were a l r e a d y more than enough p h y s i c i a n s i n B r i t i s h Columbia, and t h a t r e c r u i t m e n t should be cut back. P r e s e n t l y i n B r i t i s h Columbia, data g a t h e r i n g and h e a l t h p l a n n i n g a c t i v i t i e s are s t i l l c a r r i e d on r e g u l a r l y . The l a r g e s t and most comprehensive c o l l e c t i o n of data, e n t i t l e d R o l l c a l l '79. i s p u b l i s h e d by the D i v i s i o n of Health S e r v i c e s Research and Development, Health S e r v i c e s Centre, U n i v e r s i t y of B r i t i s h Columbia. The s u b t i t l e i s : *A Status Report of Health Personnel i n the Province of B r i t i s h Columbia'. 71 The r e p o r t d e s c r i b e s twenty-eight h e a l t h personnel groups, d e t a i l i n g numbers, r a t e s , and r a t e s of change i n each group's manpower sto c k . R o l l c a l l '79 i s the f o u r t h such r e p o r t , the r e p o r t s being i s s u e d every two y e a r s . I t i s used by the p r o v i n c i a l Health Manpower Working Group f o r p l a n n i n g , as w e l l as by the l i c e n s i n g and r e g i s t r a t i o n bodies of v a r i o u s p r o v i n c i a l p r o f e s s i o n a l groups. T h i s r e p o r t i s s p e c i f i c f o r B r i t i s h Columbia, examining h e a l t h manpower pl a n n i n g i n each Regional H o s p i t a l D i s t r i c t with c o n s i s t e n t , s t a n d a r d i z e d data. Planning a c t i v i t i e s are c a r r i e d out by the P r o v i n c i a l Health Working Group, which meets monthly, d i s c u s s i n g each a l l i e d h e a l t h manpower group. The N a t i o n a l Working Group meets twice a year to d i s c u s s medical manpower, and i s attended by two p r o v i n c i a l r e p r e s e n t a t i v e s , as w e l l as by Dr. A. Stark, head of the Research and Development U n i t , as an observer. The western p r o v i n c e s a l s o have a manpower d i s c u s s i o n group f o r a l l i e d h e a l t h p r o f e s s i o n a l s , and they a l s o meet twice a year. On the n a t i o n a l scene, d i s c r e p a n c i e s e x i s t between v a r i o u s s e c t o r s of the country i n terms of t h e i r medical manpower needs and p o l i c i e s . The Maritimes s t i l l r e q u i r e more doc t o r s and look f o r continued immigration flow of q u a l i f i e d p e r s o n n e l . The west, on the other hand, does not want or need more d o c t o r s , and would p r e f e r to have immigration of p h y s i c i a n s to Canada 72 r e s t r i c t e d . T h i s , i n t u r n , would l e a d to a more secure p o s i t i o n f o r the v a r i o u s medical f a c u l t i e s i n terms of funding and expansion. At the presen t time there i s no consensus or t a c i t agreement between the Immigration Department of the f e d e r a l government and the v a r i o u s c o l l e g e s of p h y s i c i a n s and surgeons of the p r o v i n c e s . 4. Rationalr Bureaucratic, and Advocacy planning The n a t i o n a l committee on p h y s i c i a n s manpower was i n f l u e n c e d by i n t e r n a t i o n a l attempts to b r i n g more r a t i o n a l i t y i n t o the pl a n n i n g p r o c e s s . A l a r g e volume of l i t e r a t u r e was accumulating on the s u b j e c t . The Aspen Systems C o r p o r a t i o n Health Manpower Planning Methods and Technology. S e r i e s I d e f i n e d h e a l t h manpower pl a n n i n g i n the f o l l o w i n g way: "...a process whereby g o a l s , 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 f o r h e a l t h manpower development are determined i n a syste m a t i c f a s h i o n , i n order to ensure t h a t h e a l t h manpower reso u r c e s , both c u r r e n t and f u t u r e , are adequate to meet the requirements f o r the d e l i v e r y of hea l th s e r v i c e s to a p o p u l a t i o n . " T h i s d e f i n i t i o n i s encompassing, e x p l i c i t , and a p p r o p r i a t e . D e f i n i t i o n s by themselves, however, cannot stand alone as a beacon determining the course of p l a n n i n g . The d e f i c i t i n such a d e f i n i t i o n i s t h a t i t f a i l s to take i n t o account the p o l i t i c a l p o l i c y f a c t o r s and how they impinge on the p l a n n i n g p r o c e s s , as i l l u s t r a t e d above with B.C.'s" a c t i o n on the Black 73 Report. In Confrey's paper, "The P o l i t i c a l Aspects of Health Manpower Pl a n n i n g " , presented to the Pan American Conference on Health Manpower Plan n i n g , he s a i d : " V i r t u a l l y a l l a c t i v i t i e s a s s o c i a t e d with h e a l t h manpower pl a n n i n g program a d m i n i s t r a t i o n are conducted w i t h i n a p o l i t i c a l s e t t i n g and pervaded by p o l i t i c a l f o r c e s . . . . Improvement of h e a l t h manpower re p r e s e n t s a pro p o s a l f o r s o c i a l change, and engenders p o l i t i c a l debate, compromise, and accommodation, the r e c o n c i l i a t i o n of d i v e r g e n t v i e w p o i n t s . " T h i s outcome i s the penultimate end p o i n t of p l a n n i n g , of which planners should always be consc i o u s , when t h e i r p l a n n i n g e f f o r t s e v e n t u a l l y meet the r e a l i t y of government p o l i c y . T.L. H a l l s a i d i n 1972: "The planner's d e s i r e to d i s a s s o c i a t e h i m s e l f from the p o l i t i c a l process r e f l e c t s a misunderstanding of h i s primary r e s p o n s i b i l i t i e s , 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 , "the i l l u m i n a t i o n of cho i c e s f o r the p o l i t i c a l decision-maker," and second, as a n a t u r a l consequence of the f i r s t , the " p e r s i s t a n t r e s t r a i n t and pr e v e n t i o n of the f o o l i s h , the w a s t e f u l , and the c y n i c a l " . " Confrey l a t e r s t a t e s t h a t " p o l i t i c a l d e c i s i o n s are made p r i m a r i l y i n terms of value judgements, r a t h e r than on the b a s i s of s c i e n t i f i c c r i t e r i a . " . P o l i t i c a l v alue judgements are more g l o b a l i n p e r s p e c t i v e than any p a r t i c u l a r i s s u e under d i s c u s s i o n , because they i n e v i t a b l y encompass more than the p a r o c h i a l i s m of t h a t p a r t i c u l a r i s s u e . When B.C.'s a c t i o n s i n f i l i n g the 74 Black Report are viewed i n the above context, one i s b e t t e r a b l e to understand them, even though perhaps opposed to the a c t u a l d e c i s i o n to bury the document. So when one t a l k s of r a t i o n a l i t y p l a n n i n g , one always has to ask, "whose r a t i o n a l i t y ? " . Apart from the above comments, r a t i o n a l p l a n n i n g methodologies d i d seem to be a r a t i o n a l outcome of attempts to improve the e f f i c i e n c y and e f f e c t i v e n e s s of h e a l t h c a r e . P a r t i c u l a r l y i n the United S t a t e s , a number of h e a l t h p l a n n e r s had become i n v o l v e d i n d e v e l o p i n g models of manpower p l a n n i n g . H a l l ' s e f f o r t s serve as a land mark f o r the study of h e a l t h methodologies. His four methods f o r e s t i m a t i n g h e a l t h manpower requirements are: a. Economic method, which i s concerned with the c o s t s of h e a l t h s e r v i c e s and how much governments and the i n d i v i d u a l s are w i l l i n g to pay. b. Health needs method: the d e t e r m i n a t i o n of the p o p u l a t i o n ' s needs are made by h e a l t h p r o f e s s i o n a l s and then the needs are converted to manpower requirements. T h i s method was d e f i n e d i n 1941 by George Bernard Shaw i n the p r e f a c e to The Doctor's Dilemma: "...make up your minds how many doct o r s the community needs to keep i t w e l l . Do not r e g i s t e r more or l e s s than 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 with a d i g n i f i e d l i v i n g wage p a i d out of p u b l i c funds." c. Health manpower: p o p u l a t i o n r a t i o method 75 hinges on what r a t i o of manpower to p o p u l a t i o n w i l l be needed to meet the p o p u l a t i o n ' s h e a l t h care needs. d. S e r v i c e t a r g e t s methods: r e l a t e s to d e f i n i n g c e r t a i n t a r g e t s and then d e f i n i n g the subsequent manpower requirements to meet those t a r g e t s . H a l l s t r e s s e d two major p o i n t s i n h i s a n a l y s i s . F i r s t l y , t h a t i n any h e a l t h manpower study, the data, a n a l y s i s , and p r o j e c t i o n s f o r supply f a c t o r s should be i n balance with those f o r the demand f a c t o r s . Secondly, the methodology adopted f o r any country has to be s p e c i f i c f o r i t s unique s i t u a t i o n , and t h a t o f t e n more than one method i s r e q u i r e d . For d e t a i l e d a n a l y s i s of H a l l ' s methods see the r e p r i n t of h i s t a b l e i n the Appendix, 1. U n d e r l y i n g any study method was the need f o r ac c u r a t e , r e l i a b l e data, based on s t a n d a r d i z e d d e f i n i t i o n s . A l t e n d e r f e r s t r e s s e d t h i s f e a t u r e i n her paper, " A n a l y t i c a l and Data Needs f o r Health Manpower Pl a n n i n g " , 1976. Canada was f o r t u n a t e l y i n a much b e t t e r p o s i t i o n than the United S t a t e s was f o r o b t a i n i n g a c c u r a t e u t i l i z a t i o n data because of the copious Medicare tapes* i n f o r m a t i o n . D e f i n i t i o n s t a n d a r d i z a t i o n was an e a r l y p o r t i o n of the c r i t e r i a developed f o r the study of Canadian h a l t h manpower needs by the Requirements Committee of the N a t i o n a l Committee on P h y s i c i a n Manpower. Levine and Kahn i n the United S t a t e s wrote of the r o l e of o p e r a t i o n s r e s e a r c h i n t h e i r paper on h e a l t h 76 manpower models. They l i s t e d four c o n s t r a i n t s on o p e r a t i o n s r e s e a r c h when a p p l i e d to h e a l t h manpower s t u d i e s : a. fragmented s t u d i e s b. fragmented funding c. l i m i t e d scope of s t u d i e s d. inadequate a t t e n t i o n to p s y c h o s o c i a l f a c t o r s . I t i s apropos to compare t h e i r remarks on p s y c h o s o c i a l f a c t o r s to comments made e a r l i e r i n t h i s t h e s i s concerning the human f a c t o r of p h y s i c i a n s and to the policy-making of government d i s c u s s e d p r e v i o u s l y . To quote: "... the h e a l t h f i e l d i s a very human i n d u s t r y . . . i t i s s u r p r i s i n g to see how o f t e n o p e r a t i o n s r e s e a r c h s t u d i e s i n h e a l t h manpower proceed as i f they are d e a l i n g with inanimate o b j e c t s whose behaviour i s s t a n d a r d i z e d and p r e d i c t a b l e . " In h i s paper on c o n d i t i o n s f o r the development of h e a l t h models, Testa s t r e s s e d two p o i n t s : a. the m u l t i p l i c i t y of h e a l t h d e c i s i o n makers, and b. the epidemiology of d i s e a s e processes a f f l i c t i n g the p o p u l a t i o n of a country. Among American authors d e v e l o p i n g methodological approaches to the study of medical manpower, Nathan, Lave, and Reinhardt developed v a r y i n g methods, to which the reader i s r e f e r r e d f o r more d e t a i l . Mathematical models have a l s o been employed. 77 Chorney, i n h i s p r e s e n t a t i o n to the Pan American Conference on Health Manpower Planning, e n t i t l e d "Mathematical Models and Health Manpower", d e s c r i b e d four mathematical models: a. A n a l y t i c a l - a l g e b r a i c models attempt to s i m p l i f y r e a l problems, reducing them to equations which can be handled mathematically. They have had l i m i t e d success, and then only i n c e r t a i n s p e c i a l i z e d areas of h e a l t h manpower study. b. Econometric models, which r e l y on s t a t i s t i c s to v a l i d a t e c a u s a l r e l a t i o n s h i p s i n the h e a l t h care system, then develop h i s t o r i c a l l o n g i t u d i n a l analyses or c r o s s - s e t i o n a l analyses to attempt to v e r i f y hypotheses. The weakness of these models i s the u n c e r t a i n t y of the f u t u r e r e p e a t i n g the past , and i n the economic a n a l y s i s i g n o r i n g the s o c i a l components of the h e a l t h care problem. c. S i m u l a t i o n models are a b s t r a c t i o n s of r e a l systems, employing p r o b a b i l i t y techniques and us i n g computers as a b a s i c t o o l to 'run' experiments on the model, i n s t e a d of on the system i t s e l f . They are u s e f u l i n making manpower p r o j e c t i o n s u s i n g d e f i n e d v a r i a b l e s . However, they too have inh e r e n t p o s s i b l e d e f e c t s , i n t h a t the computer program may have undetected e r r o r s , and t h a t the r e a l world may not be a c c u r a t e l y q u a n t i f i a b l e . d. Numerical experimentation i s a v a r i a t i o n of 78 s i m u l a t i o n models a v o i d i n g p r o b a b i l i t y techniques but u s i n g equations d e r i v e d from e x p l i c i t hypotheses to feed the computer. These models are u s e f u l i n the s e l e c t i o n of one of s e v e r a l courses of a c t i o n f o r the decision-maker. As the Canadian N a t i o n a l Committee t r i e d to propose n a t i o n a l s o l u t i o n s to the problems, the members began to recognize t h a t there were c o n s t r a i n t s imposed by the p o l i t i c i a n s (such as d e s c r i b e d above), and by the b u r e a u c r a t s , who had to manage the c o n t i n u i t y of the system. Advocacy groups a l s o had t h e i r say i n the matter (e.g. P o d a i r ) . A l f o r d , reviewing h e a l t h p l a n n i n g a c t i v i t i e s i n New York, has drawn a t t e n t i o n to the d i f f e r e n t i d e o l o g i c a l p o s i t i o n s of the p a r t i e s i n v o l v e d i n the p l a n n i n g t h e r e , and has argued t h a t t h i s has l e d to 'dynamics without change'. He i d e n t i f i e d e n trepreneurs, c o r p o r a t e p l a n n e r s , and community h e a l t h advocates as having d i f f e r e n t b a s i c i d e o l o g i e s which were d i f f i c u l t to r e c o n c i l e , and which r e s u l t e d i n f a i l u r e to agree on p l a n s . Before going f u r t h e r , i t may be u s e f u l to c o n s i d e r the i d e o l o g i c a l p o s i t i o n of the entrepreneurs i n Canada, and t h e i r r e s i s t a n c e to the p l a n n i n g process; to a l s o c o n s i d e r the f e a s i b i l i t y of r a t i o n a l p l a n n i n g by c o r p o r a t e p l a n n e r s ; and to examine consumers' e x p r e s s i o n s of demand, or how consumer p l a n n i n g could be 79 developed. 80 CHAPTER FIVE  A C r i t i c a l E v a l u a t i o n of the Planning Process 1. I d e o l o g i c a l D i f f e r e n c e s and T h e i r E f f e c t on Planning a. E n t r e p r e n e u r i a l A t t i t u d e s I d e o l o g i c a l b i a s e s i n viewing present systems are a l s o i n h e r e n t i n t h e i r advocacy p o s i t i o n s f o r f u t u r e changes (problems of advocacy b i a s are w e l l i l l u s t r a t e d i n the M i n o r i t y Report of the Task Force on the E v a l u a t i o n of Primary Health Care S e r v i c e s , by Dr. Edward G l a z i e r ) . F r i e d s o n and ot h e r s have examined the process of the transcendant i n t e r n a t i o n a l phenomena of medical e l i t i s m , a process which f o r ge n e r a t i o n s made p h y s i c i a n s and s c i e n t i s t s grow accustomed to the c o n v i c t i o n t h a t h e a l t h care was t h e i r p r o p r i e t a r y j u r i s d i c t i o n . T h i s s e m i - i s o l a t i o n of the medical p r o f e s s i o n from the mainstream of emerging h e a l t h , s o c i a l , and economic developments i n each country, has helped to t y p e c a s t the p r o f e s s i o n i n the r o l e of r e a c t i o n a r i e s , i n the p e r c e p t i o n s of h e a l t h p l a n n e r s . The p u b l i c view t h a t the p r o f e s s i o n as a whole was i n t e r e s t e d more i n the maintenance of the s t a t u s quo and t h e i r incomes, r a t h e r 81 than i n the expediting of an improved health care delivery system, has been a factor i n prejudicing the public against organized medicine. This reaction was emphasized by events surrounding the doctors' s t r i k e i n Saskatchewan i n 1962. The general conviction of national and international c r i t i c a l observers in the aftermath of that event was that the doctors had abandoned the i r s o c i a l and medical ethics (Badgley and Wolfe). The s t r i k i n g doctors would contradict t h i s conclusion by asserting that they had provided emergency services, and that, in th e i r view, they were within th e i r rights to s t r i k e . This, of course, f i t s with the entrepreneurial or even trade union approach. The apparent abandonment of their medical ethics, epitomized in the public eye by the Hippocratic oath, was self-evident to most of the population. The abandonment of their s o c i a l ethic was not so cl e a r . The c r i t e r i a surrounding 'Emerging Propositions* have been elaborated by H a l l , Land, Parker and Webb, in Changef Choice, and C o n f l i c t in Social Policy. These c r i t e r i a focus on the legitimacy, the f e a s i b i l i t y , and the support for an issue. The Saskatchewan government met a l l these c r i t e r i a i n proposing a p r o v i n c i a l medicare plan, except for the support aspect. The noisy resistance of the media and, of course, fanatic pressure groups, created a fal s e 82 atmosphere of non-support; a c t u a l l y , the s i l e n t p u b l i c m a j o r i t y was sympathetic t o the government p o s i t i o n . The government's l e g i t i m a c y c r i t e r i a were never at stake. However, org a n i z e d medicine i n Saskatchewan seemed b l i n d to t h a t f a c t . The d e n i a l of the l e g i t i m a c y of the pa r l i a m e n t a r y process by an organized, m i l i t a n t group of d o c t o r s , educated by p u b l i c funds and e n j o y i n g the b e n e f i t s of a wealthy s o c i a l s t a t u s , seemed to remove much of the o l d s t y l e p a t e r n a l i s t i c concept of the medical p r o f e s s i o n . S i m i l a r l y , there was not much sympathy f o r the Quebec s p e c i a l i s t s when they r e s i s t e d the i n t r o d u c t i o n o f Medicare i n 1970 ( T a y l o r ) . The present-day view of orga n i z e d medicine, as c o n t r a s t e d with p h y s i c i a n s as i n d i v i d u a l s , has been accentuated by the r e s i s t a n c e , i n our American neighbour, of the American Medical A s s o c i a t i o n to the development of a comprehensive h e a l t h care system i n the United S t a t e s . The e n t r e p r e n e u r i a l j u r i s d i c t i o n a l approach to medical p r a c t i c e i s not a c h a r a c t e r i s t i c l i m i t e d to c o u n t r i e s such as Canada and the United S t a t e s . B l a n p a i n r e p o r t s the emergence of t h i s t r a i t when S o v i e t - t r a i n e d f e l d s c h e r s were loaned to Arab c o u n t r i e s i n the Middle E a s t . There would seem to be c e r t a i n i n n a t e c h a r a c t e r i s t i c s of medical p r a c t i t i o n e r s , p l u s a developmental a t t i t u d e a r i s i n g d u r i n g i n t e r n t r a i n i n g (given the r i g h t s e t t i n g ) , t h a t r e s u l t s i n the type of doctor produced by our s o c i e t y (Coker). S i g e r i s t , i n 83 The P h y s i c i a n ' s P r o f e s s i o n Through the Ages, s t a t e s : "...the p h y s i c i a n ' s p o s i t i o n i n s o c i e t y i s never determined by the p h y s i c i a n h i m s e l f but by the s o c i e t y he i s s e r v i n g . " Mc Keown s t a t e s : " I t i s widely recognized t h a t d o c t o r s 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 are determined to do the kind of work they saw as s t u d e n t s . " . The b a s i c p e r s o n a l i t y c h a r a c t e r i s t i c s f r e q u e n t l y are of the obsessive-compulsive type (Myckatyn, Miles) i n i n d i v i d u a l s who are endurance and achievement o r i e n t e d (Parlow, Rothman). The s e t t i n g i n f l u e n c e s on the p r o d u c t i o n of an abundance of s p e c i a l i s t s and s u b - s p e c i a l i s t s seeking higher p r o f e s s i o n a l s t a t u s , an expert knowledge of a f i n i t e body of t r a i n i n g , and the attendant m a t e r i a l rewards, are w e l l known (Hiestand and Ostow, Magraw, P e t e r s d o r f , Relman, and o t h e r s ) . U n f o r t u n a t e l y , as Macgraw says, ' O r d i n a r i l y i n medical sc h o o l he [the medical student] has no r e a d i l y a v a i l a b l e model of the g e n e r a l p r a c t i t i o n e r with which to i d e n t i f y . . . .'. P e r k o f f , i n 1978 noted t h a t l a t t e r l y , i n s p i t e of the lack of a r o l e model, th e r e has been a resurgence of i n t e r e s t and an i n c r e a s i n g number of undergraduates t u r n i n g to f a m i l y p r a c t i c e t r a i n i n g . b. Corporate or R a t i o n a l Planners' A t t i t u d e s and 84 Problems The c o r p o r a t e or r a t i o n a l planners make the assumption t h a t i t i s p o s s i b l e to c a l c u l a t e the needs f o r p h y s i c i a n s and to p r o j e c t p l a n s f o r c o r r e c t i n g the present m a l d i s t r i b u t i o n of p h y s i c i a n s . M a l d i s t r i b u t i o n i s of two types: i . g e o g r a p h i c a l . A review of the l i t e r a t u r e c oncerning f a c t o r s i n f l u e n c i n g p r a c t i c e l o c a t i o n of p r o f e s s i o n a l h e a l t h manpower i s giv e n i n Josephine A r a s t e h ' s r e p o r t t o the U.S. Department of Health and Welfare. i i . s p e c i a l i z a t i o n . The mix of d i f f e r e n t kinds of s e r v i c e p r o v i d e r s (see T h e i r and B e r l i n e r , C o l w i l l , Relman). R a t i o n a l planners b e l i e v e they can c a l c u l a t e how many p h y s i c i a n s should be abl e to p r o v i d e care f o r the m a j o r i t y of people i n accordance with the f i n a n c i a l c a p a c i t y of the country now and i n the f u t u r e . T h e i r p l a n s w i l l a l s o take account of r i s i n g h e a l t h care c o s t s a b s o l u t e , and as a percentage of the G.N.P. I t i s recog n i z e d i n h e a l t h manpower assessments and p r o j e c t i o n s t h a t there are methodology problems, but c e r t a i n s o l u t i o n s are proposed. The f i r s t s e t of problems concern f u z z y d e f i n i t i o n s . Topics such as 'h e a l t h ' and 'needs' are v a r i a b l y i n t e r p r e t e d depending on the p e r c e p t i o n of the observer. S t a n d a r d i z a t i o n of d e f i n i t i o n s i s d e s i r a b l e and has been attempted ( K a t z ) . 85 The World Health O r g a n i z a t i o n d e f i n i t i o n of h e a l t h was promulgated and g e n e r a l l y accepted. I t i s as f o l l o w s : "a s t a t e of complete p h y s i c a l , mental and s o c i a l w e l l - b e i n g and not merely the absence of d i s e a s e " . Health has a l s o been d e f i n e d elsewhere as the 'optimal p e r s o n a l f i t n e s s f o r f u l l , f r u i t f u l , c r e a t i v e l i v i n g ' (Cushman). Needs have been c a t e g o r i z e d as e i t h e r true or p e r c e i v e d . The p e r c e i v e d needs of a p o p u l a t i o n i n f a c t approximate the demand of t h a t p o p u l a t i o n f o r h e a l t h c are. Another d e f i n i t i o n t h a t r e q u i r e s c a r e f u l s t a n d a r d i z a t i o n i s t h a t of p h y s i c i a n or nurse or l a b t e c h n i c i a n , e t c . V a r i a t i o n s from country to country or from one p a r t of the country to another, i n the f u n c t i o n s and q u a l i f i c a t i o n s of v a r i o u s c a t e g o r i e s of h e a l t h care workers can cause d e f i n i t i o n d i f f i c u l t i e s . Enumeration of a s p e c i f i c group, such as p h y s i c i a n s , can i n i t s e l f be d i f f i c u l t once the d e f i n i t i o n has been d e r i v e d . In Canada, there are three p o s s i b l e l i s t i n g s of p h y s i c i a n s : i . The c o l l e g e s of p h y s i c i a n s and surgeons' l i c e n s i n g from the v a r i o u s p r o v i n c e s are t o t a l l e d , i i . The Canadian Medical D i r e c t o r y . i i i . The Medicare u t i l i z a t i o n tapes. I t i s important to know which l i s t i n g i s l i k e l y to be the most ac c u r a t e and comprehensive data source. A second methodology problem concerns the l a c k of experts i n the f i e l d . H o p e f u l l y , with the passage of 86 time, and with more accumulated experience, t h i s d e f i c i t w i l l be r e c t i f i e d . T h i r d i s the problem of l i m i t a t i o n s of the l i t e r a t u r e . Health p l a n n i n g i s a r e l a t i v e l y new venture f o r n a t i o n s , with h e a l t h manpower p l a n n i n g being even more so. A body of world l i t e r a t u r e has accumulated, but i n a p a r t i c u l a r country, the h e a l t h problems r e q u i r e the a p p l i c a t i o n of s p e c i f i c s o l u t i o n s , which have not been honed by p r e v i o u s experiences as y e t . F o u r t h l y , t h e r e i s the problem of m u l t i p l e methodologies and the d i f f i c u l t y of d e v i s i n g the most a p p r o p r i a t e method or combination of methods f o r the problems at hand. The four methods f o r a s s e s s i n g and p r o j e c t i n g p h y s i c i a n manpower requirements are those enunciated by H a l l , as f o l l o w s : i . The economic demand method: "The v a r i o u s needs expressed both by i n d i v i d u a l s and s o c i e t i e s are so numerous t h a t i t i s i m p o s s i b l e to meet them a l l . T h i s omnipresent d u a l i t y 'numerous needs - few r e s o u r c e s ' d i c t a t e s t h a t c h o i c e s must be made. The purpose of economics i s p r e c i s e l y to f i n d the mechanisims governing these c h o i c e s . " ( S a c k e t t ) . i i . The h e a l t h needs method (Schonfeld) i i i . P h y s i c i a n / p o p u l a t i o n r a t i o s (Canada. Report of the Requirements Committee) i v . The s e r v i c e t a r g e t s approach (see the 87 Appendix^for H a l l ' s t a b l e d e t a i l i n g each method). Often no one method w i l l meet a l l the requirements demanded by the problems of a p a r t i c u l a r country. In a d d i t i o n , the method adopted has to be compatible with the p o l i t i c a l tenor of the country The f i f t h methodology problem c e n t r e s on the lack of good i n d i c a t o r s . There i s a lack of adequate parameters f o r measuring e f f e c t i v e n e s s . Q u a l i t y i s interwoven with q u a n t i t y i n assessment of r e s u l t s of treatment. The p r e v i o u s l y mentioned f u z z y d e f i n i t i o n of h e a l t h i m p l i e s t h a t h e a l t h p l a n n e r s are aiming f o r a t a r g e t t h a t i s not c l e a r l y i n f o c u s . The World Health O r g a n i z a t i o n (W.H.O.) concluded t h a t f o r use i n the i n t e r n a t i o n a l comparison of data, only three i n d i c e s were r a t e d s u f f i c i e n t l y comprehensive: i . The e x p e c t a t i o n of l i f e at b i r t h and at one year of age, i i . the crude death r a t e , and i i i . the p r o p o r t i o n a l m o r t a l i t y r a t i o . These i n d i c e s , although adequate for i n t e r n a t i o n a l comparisons, are r e l a t i v e l y i n s e n s i t i v e to the c o n d i t i o n s a p p l y i n g i n the h e a l t h s e r v i c e s i n d u s t r y i n Canada. The W.H.O. a l s o concluded t h a t , because of the unambiguity of m o r t a l i t y s t a t i s t i c s , they were u s e f u l i n a s s e s s i n g the h e a l t h of a p o p u l a t i o n and i n e v a l u a t i n g the e f f e c t i v e n e s s of measures used to help improve t h a t p o p u l a t i o n ' s h e a l t h . But again, m o r t a l i t y s t a t i s t i c s 88 are, at best, crude i n d i c a t o r s of h e a l t h . A s i x t h methodology weakness i s the human f a c t o r , with i t s i n h e r e n t 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 to the assessment of d i a g n o s t i c or treatment measures or any other f a c e t of the h e a l t h s e r v i c e o p e r a t i o n r e q u i r i n g a measure of n o n - q u a n t i f i a b l e p e r s o n a l judgement. D i f f i c u l t y of r e d u p l i c a t i o n of r e s u l t s r e f l e c t s t h i s weakness. The seventh p o i n t to c o n s i d e r i n the e v a l u a t i o n of methodology weaknesses i s the d i f f i c u l t y i n the a p p l i c a t i o n of economic laws to h e a l t h care s e r v i c e s and t h e i r p l a n n i n g . In t h i s area, standard economic r u l e s and d e f i n i t i o n s o f t e n seem to be in o p e r a b l e because of the i n h e r e n t d i f f e r e n c e s i n the h e a l t h care market as opposed to normal market c o n d i t i o n s . For example, input and output 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 because of the la c k of adequate measurement i n d i c e s . The data o b t a i n a b l e f o r economic study purposes i s o f t e n i n a p p r o p r i a t e or of poor q u a l i t y . Because of input/output vagueness and the data inadequacies mentioned above, i t i s im p o s s i b l e to make an economic e v a l u a t i o n as to the e f f i c i e n t use of re s o u r c e s . F i n a l l y , the p h y s i c i a n and h i s a c t i o n s make economic a n a l y s i s d i f f i c u l t . F i r s t , the p h y s i c i a n has the a b i l i t y to c o n t r o l both h i s demand and supply curves. Second, i n us i n g h e a l t h system r e s o u r c e s , many p h y s i c i a n s f e e l t h e i r c h o i c e c r i t e r i a and the f i n a n c i a l 89 resources a v a i l a b l e to them are l i m i t l e s s . T h i s a t t i t u d e means the values a s c r i b e d to medical o b j e c t i v e s by p h y s i c i a n s overwhelm those v a l u e s g i v e n to economic c o n s i d e r a t i o n s . The d i f f i c u l t i e s of supply and demand a n a l y s i s i n such an economically p e r p l e x i n g i n d u s t r y as h e a l t h care were d e s c r i b e d by Klarman. The p h y s i c i a n ' s monopolist p o s i t i o n and the use of b a r r i e r s to e n t r y to the h e a l t h care system, render a n a l y s i s more d i f f i c u l t and i n c o n c l u s i v e . Reinhardt's t a b l e d e s c r i b i n g a l t e r n a t i v e models of p h y s i c i a n p r i c i n g i s i n c l u d e d as the Appendix, 5 » Given the aforementioned problems i n d e v e l o p i n g an e f f e c t i v e h e a l t h care system methodology, nonetheless s o l u t i o n s have been o f f e r e d to the v a r i o u s weaknesses as f o l l o w s : D e f i n i t i o n s and terminology could be l a r g e l y s t a n d a r d i z e d by consensus of groups, i n t e r n a t i o n a l f o r c e r t a i n world-wide a p p l i c a t i o n s , and trans-Canadian f o r d e f i n i t i o n s p e r t a i n i n g to the s p e c i f i c s of our own p a r t i c u l a r h e a l t h care system. The inadequacies of determining the exact numbers i n the medical work f o r c e and other a l l i e d h e a l t h f i e l d s i s h o p e f u l l y becoming a t h i n g of the p a s t , by means of the computer with i t s nationwide l i n k a g e s . Annual upgrading of p h y s i c i a n numbers w i l l be p o s s i b l e i f i n f o r m a t i o n concerning the p r o f e s s i o n a l a c t i v i t i e s was a requirement of t h e i r annual r e l i c e n s i n g . Use of the s o c i a l insurance numbers 90 of p h y s i c i a n s would be u s e f u l i n p r e v e n t i n g double counting of p h y s i c i a n s on the move. A s i m i l a r computer system on a n a t i o n a l b a s i s c o u l d be used f o r keeping ac c u r a t e t a l l i e s of i n t e r n s and r e s i d e n t s . Such an up to date assessment would c o n s i d e r a b l y reduce the lag-time i n e f f e c t i n g changes i n medical t r a i n i n g programs when i t became e v i d e n t t h a t t h e r e were e x c e s s i v e or inadequate numbers of a p a r t i c u l a r group r e q u i r e d to meet changing demands f o r s e r v i c e s . In terms of the t o t a l numbers of p h y s i c i a n s r e q u i r e d f o r the country, i t has been proposed t h a t a •reasonable* q u a l i t y of h e a l t h care be sought f o r the p o p u l a t i o n , and t h a t the numbers of p h y s i c i a n s should be s u f f i c i e n t to p r o v i d e t h a t 'reasonable' q u a l i t y (Requirements Committee Report: Page 19, P a r t 1 ) . So soon again the problem of f u z z y d e f i n i t i o n s a r i s e s ! Regarding the r e l a t i v e l a c k of experts i n d e a l i n g with methodologies for a n a l y z i n g h e a l t h care and p h y s i c i a n requirements, i t i s suggested t h a t we move to develop such experts i n our country as a prima f a c i e need f o r r a t i o n a l i z a t i o n of the h e a l t h care system. The b a s i c requirement to do so, i s to p r o v i d e adequate fu n d i n g , the r e s p o n s i b i l i t y f o r which should be j o i n t l y p r o v i n c i a l and f e d e r a l . L i t e r a t u r e l i m i t a t i o n s on methodology are d e c l i n i n g as the world and n a t i o n a l bodies of i n f o r m a t i o n accumulate i n computer r e t r i e v a l l i b r a r i e s . 91 The t o t a l time of e x i s t e n c e of h e a l t h care p l a n n i n g i s so s h o r t , r e l a t i v e l y , t h a t i t m i t i g a t e s a g a i n s t a c o l l e c t i o n of comprehensive background sources and data s u f f i c i e n t t o meet our needs. In a n a l y s i s of the Requirements Committee's problem with the lack of good i n d i c a t o r s , s e v e r a l s o l u t i o n s were p r o f f e r r e d by s t a t i n g s e v e r a l g e n e r a l assumptions, as f o l l o w s : i . No l a r g e areas of unmet needs e x i s t e d i n the base years of data c o l l e c t i o n . i i . P e r c e i v e d need equals demand (compare with Marc Lalonde's statement i n A New P e r s p e c t i v e on the Health of Canadians , p. ^1). i i i . The d e f i c i t of unrendered necessary s e r v i c e s equals the unnecessary s e r v i c e s rendered. i v . The u t i l i z a t i o n data i n d i c a t e s r e a l need. The weaknesses i n such assumptions are s e l f - e v i d e n t . As regards the human f a c t o r of u n p r e d i c t a b i l i t y i n methodology, the consensus i s t h a t we have to l i v e with i t . A s i m i l a r statement a p p l i e s to the inadequacies i n the a p p l i c a t i o n of economic laws to h e a l t h care system a n a l y s i s , but h o p e f u l l y , we w i l l g a i n some b e n e f i t from our experience to date. c. Consumer Advocacy As p o i n t e d out above, consumers i n Canada have shown c o n s i d e r a b l e ambivalence i n t h e i r a t t i t u d e s 92 towards p l a n n i n g of h e a l t h s e r v i c e s . On the one hand, they respond to q u e s t i o n n a i r e s about p a t i e n t s a t i s f a c t i o n s i n a p o s i t i v e manner, but they become l e s s t r u s t f u l of organized medicine (see Macleans P September 29, 1980. Page 46). As w e l l , at the end of the s i x t i e s , a number of groups i n the p o p u l a t i o n , such as women and young people, f o l l o w e d American r a d i c a l s i n p r o t e s t i n g about t r a d i t i o n a l primary h e a l t h care s e r v i c e s , s e t t i n g up h e a l t h c o l l e c t i v e s or other a l t e r n a t i v e s , or going to emergency departments i n s t e a d of d o c t o r s ' o f f i c e s . But, on the whole, consumers have not been w e l l organized to make demands, d e s p i t e the e x i s t e n c e of some v o l u n t a r y p l a n n i n g agencies. S.P.A.R.C. ( S o c i a l P lanning and Research Co u n c i l ) of B r i t i s h Columbia has been an a c t i v e body, but i t has tended to focus on omissions or d e f i c i t s i n the p r o v i s i o n of care, r a t h e r than being too c r i t i c a l of e x i s t i n g s e r v i c e o r g a n i z a t i o n . On a l a r g e r p e r s p e c t i v e , E t z i o n i s t a t e d t h a t our s o c i e t y must f i n d ways to make l a r g e s o c i a l o r g a n i z a t i o n s more responsive to the p e r s o n a l needs of consumers and employees. P o d a i r , i n h i s book The  Consumer's Guide to Good Health, e l a b o r a t e s the d e f i c i t s of the American system as seen by the consumer, and p o i n t s out ways whereby the consumer can be sure to a t t a i n good h e a l t h c a r e . The Consumer Reports, a monthly p u b l i c a t i o n , has numerous high q u a l i t y a r t i c l e s on h e a l t h c a r e , i n c l u d i n g one on how to s e l e c t and 93 e v a l u a t e a d o c t o r . The American H o s p i t a l A s s o c i a t i o n i n 1972 formulated a ' b i l l of r i g h t s ' f o r p a t i e n t s , and suggested i t be posted i n every h o s p i t a l to encourage the acceptance of i t s concepts. T h i s "Statement on a P a t i e n t ' s B i l l of R i g h t s " i s i n c l u d e d i n the Appendix ^ 6 . Consumer p h i l o s o p h y i s most a p t l y summated by a modern TV medical hero, Alan A l d a (Hawkeye P i e r c e of M*A*S*H*) when he spoke at a p h y s i c i a n s ' commencement at Columbia U n i v e r s i t y , May 1979, as f o l l o w s : "Be s k i l l e d , be l e a r n e d , be aware of the d i g n i t y of your c a l l i n g . But please don't ever l o s e s i g h t of your own simple humanity... . Put people f i r s t . And I i n c l u d e i n t h a t not j u s t people, but t h a t which e x i s t s between people. Let me c h a l l e n g e you. With a l l your study, you can read my x-rays l i k e a telegram. But can you read my i n v o l u n t a r y muscles? Can you see the f e a r and u n c e r t a i n t y i n my face? W i l l you t e l l me when you don't know what to do? Can you face your own f e a r , your own u n c e r t a i n t y ? When i n doubt, can you c a l l i n help? W i l l you be the k i n d of doctor who cares more about the case than about the person? ("Nurse, c a l l the g a s t r i c u l c e r and have him come i n at three.") Y o u ' l l know you're i n t r o u b l e i f you f i n d y o u r s e l f wishing they would m a i l i n t h e i r l i v e r i n a p l a i n brown envelope. Where does money come on your l i s t ? W i l l i t be the s o l e standard a g a i n s t which to reckon your success? Where w i l l your f a m i l y come on your l i s t ? How many days and n i g h t s , weeks and months, w i l l you separate y o u r s e l f from them, b u r i e d i n your work, b e f o r e you r e a l i z e t h a t you've removed y o u r s e l f from an important p a r t of your l i f e ? 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 to women? Women as p a t i e n t s , as nurses, as 94 f e l l o w d o c t o r s - and l a t e r as students? Thank you f o r t a k i n g 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 having the s t r e n g t h to have made i t to t h i s day. I don't know how you've managed to 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 about the body t h a t only a non-doctor would t e l l you - and I hope y o u ' l l always remember t h i s : the head bone i s connected to the h e a r t bone. Don't l e t them come a p a r t . " 2. R a t i o n a l Planning and P o l i c i e s In 1976 the author was r e s p o n s i b l e f o r d e v e l o p i n g a p r o j e c t of requirements fo r p h y s i c i a n s i n Canada, with s p e c i a l r e f e r e n c e to B r i t i s h Columbia, f o r the Health Manpower Working Group of the Province of B r i t i s h Columbia. He summarized the boundaries, assumptions and b i a s e s which were i n h e r e n t i n each Task Committee r e p o r t and reviewed the r e p o r t s , u s i n g g e n e r a l p r a c t i c e and surgery as examples. Amongst other comments, he noted t h a t : a. few medical groups adequately d e f i n e d t h e i r f i e l d or s e t l i m i t s on t h e i r boundaries, and b. few accepted the need f o r a l l i e d h e a l t h p r o f e s s i o n a l s . He reviewed i n d e t a i l the method used to c a l c u l a t e workloads. The f i n d i n g s were d i s c u s s e d with the Health Manpower Working Group. In d i s c u s s i o n , i t was noted t h a t the times to perform v a r i o u s a c t i v i t i e s might be 95 i n a p p r o p r i a t e , s u b s t i t u t i o n of other workers had not been c o n s i d e r e d , and t h e r e was no l i d p l a c e d upon t o t a l number of a c t i v i t i e s . He then compared the r a t i o s proposed with those which p r e s e n t l y e x i s t e d i n the Province of B r i t i s h Columbia. O v e r a l l , i f the r a t i o s proposed by the Requirements Subcommittee for 1981 were a p p l i e d then to the P r o v i n c e , there would be 3,744 d o c t o r s r e q u i r e d . At the time, there were 4,484 d o c t o r s i n p r a c t i c e - an oversupply, by the very generous r a t i o s , of approximately 700 d o c t o r s . By u s i n g a very crude p r o j e c t i o n of the a c t u a l l y observed annual r a t e of change i n d o c t o r s from 1974 to 1975 i n the P r o v i n c e of B r i t i s h Columbia, i t might be estimated t h a t , by 1981, there c o u l d be 4,760 d o c t o r s i n p r a c t i c e i n t h i s P r o v i n c e , or an oversupply of 1,000. The data showed t h a t the p r a c t i c e i n B r i t i s h Columbia of adhering to c u r r e n t r a t i o s may be q u i t e i n a p p r o p r i a t e , but i t a l s o i n d i c a t e d a f a l l a c y i n the P h y s i c i a n Requirements' methodology i n t h a t , s i n c e the p h y s i c i a n s i n the P r o v i n c e of B r i t i s h Columbia al r e a d y exceeded optimum r a t i o s and were busy and f i n a n c i a l l y p r o d u c t i v e , c l e a r l y there were a l t e r n a t i v e ways i n c l u d i n g an i n c r e a s e i n the fees or an a l t e r a t i o n i n the p a t t e r n s of p r a c t i c e i n which p h y s i c i a n s could be busy and would continue to meet i n c r e a s i n g demands f o r t h e i r s e r v i c e s . A summary of these f i n d i n g s form p a r t 96 of the A p p e n d i x ^ . A l s o i n c l u d e d are workload t a b l e s f o r g e n e r a l / f a m i l y p r a c t i c e and surgery, taken from the Requirements Committee Report. While the Health Manpower Working Group continues i t s a c t i v i t i e s , t here has been l e s s c o n v i c t i o n t h a t r a t i o n a l p l a n n i n g w i l l p r o v i d e more than rough g u i d e l i n e s f o r a c t i o n , s i n c e the new government came i n t o o f f i c e and took stock of the s i t u a t i o n . The a c t i v i t i e s of the M i n i s t e r of Education, Dr. McGeer, were d i s c u s s e d above. The r e p o r t of the Working Party f o r Wesley Black, s e t up by the Health Department, was b u r i e d because i t d i d not f i t i n with the t e c h n o l o g i c a l education p o l i c i e s which Dr. McGeer had decided to pursue. Some hope for r a t i o n a l p l a n n i n g i n p u t s i s given by David Donnison, who has agreed t h a t d e c i s i o n s by government are l i k e l y t o be incremental and based on t r a d e - o f f s most of the time, but i f a s t a n d i n g p l a n should e x i s t , t here i s a l i k e l i h o o d t h a t i t w i l l i n f l u e n c e the t h i n k i n g of the p o l i t i c i a n s who are engaged i n t r a d i n g - o f f , i n the absence of other strong p e r s u a s i o n s . A d e t a i l e d a n a l y s i s of the p l a n n i n g process used i n the Requirements Committee Report of 1975 to the N a t i o n a l Committee on P h y s i c i a n Manpower i s g i v e n i n the next chapter. 97 C H A P T E R S I X A n a l y s i s of Canada's Major Health Planning P r o j e c t to Date 1. i n t r o d u c t i o n The u t i l i z a t i o n of time, data and c o n s u l t a n t resources combined t o make the Report of the Requirements Committee i n 1975 a s t a t e of the a r t document f o r h e a l t h p l a n n i n g . D e s p i t e the Report's shortcomings, i t serves as a b a s i s from which new s t r a t e g i e s can be developed i n the assessment of p h y s i c i a n manpower needs. With t h a t i n mind, a d e t a i l e d a n a l y s i s and query of the Report, made subsequent to the study c a r r i e d out f o r the Health Manpower Working Group by the author (see the Appendix), w i l l now be g i v e n . In t h i s a n a l y s i s , ' f a m i l y p r a c t i c e 1 i s c o n s i d e r e d the e q u i v a l e n t o f , and i s used i n t e r c h a n g e a b l y w i t h , the term 'general p r a c t i c e " . 2. Background The N a t i o n a l Committee on P h y s i c i a n Manpower i n 98 1972 undertook to "develop c r i t e r i a and make recommendations r e g a r d i n g f u t u r e requirements f o r p h y s i c i a n s i n the v a r i o u s d i s c i p l i n e s i n Canada.". T h i s p r o j e c t was to ensure a more a p p r o p r i a t e mix of the v a r i o u s medical d i s c i p l i n e s f o r the needs of the Canadian people than had h e r e t o f o r e taken p l a c e . A c c o r d i n g l y , the N a t i o n a l Committee e s t a b l i s h e d i n A p r i l , 1973, the Requirements Committee on P h y s i c i a n Manpower. The l a t t e r committee, by the c r e a t i o n of working p a r t i e s i n each medical d i s c i p l i n e , supplemented by resource personnel from the Department of N a t i o n a l Health and Welfare, sought to e s t a b l i s h a methodology whereby optimum present and f u t u r e needs i n each d i s c i p l i n e c ould be estimated. Once a l l the i n d i v i d u a l working p a r t y r e p o r t s i n each d i s c i p l i n e were f i l e d , i t remained then to appraise them i n d i v i d u a l l y and i n t o t a l , to a s c e r t a i n t h e i r cumulative e f f e c t i f they were to be i n s t i t u t e d . The purpose of t h i s study, then, i s to c o n s i d e r the f o l l o w i n g problem: 3. Problem D e f i n i t i o n Given the v a r i o u s r e p o r t s of the medical manpower working p a r t i e s , how would one evaluate t h e i r f i n d i n g s , c o n s i d e r i n g the assumptions and the methodology? How would one d e a l with the o v e r l a p of group boundaries to 99 a r r i v e at a r a t i o n a l p r e d i c t i o n of f u t u r e needs f o r each d i s c i p l i n e ? I f the working par t y p r o p o s a l s were implemented, what would be the impact on B r i t i s h Columbia i n terms of numbers and cost? 4. Methodology The approach u t i l i z e d was to i n i t i a l l y o r ganize a group of p h y s i c i a n s i n each s p e c i a l t y t o study the problem of manpower p l a n n i n g i n t h e i r r e s p e c t i v e d i s c i p l i n e s on a n a t i o n a l l e v e l . Experienced, knowledgeable p h y s i c i a n s were r e c r u i t e d . D e t a i l e d knowledge of the technology, t r a i n i n g , p r a c t i c e methods, e t c . , of each group was made a v a i l a b l e i n t h i s way to h e l p ensure the accuracy i n a s s e s s i n g and i n t e r p r e t i n g u t i l i z a t i o n d ata, and i n making p r o j e c t i o n s of f u t u r e needs. Each working p a r t y was a s s i s t e d by resource personnel from the Department of N a t i o n a l Health and Welfare. A working manual was developed to a s s i s t the groups i n t h e i r work. The methodology u t i l i z e d i n v o l v e d two b a s i c approaches: the c a l c u l a t i o n of h e a l t h needs, and the c a l c u l a t i o n of physician/manpower r a t i o s . R e a l i z a t i o n of the d i f f i c u l t i e s i n h e r e n t i n the f i e l d of h e a l t h p l a n n i n g was e v i d e n t by the d i s c u s s i o n of problems and assumptions presented i n P a r t I of the Report of the 100 Requirements Committee. Such d i s c u s s i o n does not, of course, p r e c l u d e comment and c r i t i c i s m from o t h e r s o u t s i d e the program. The c r i t i c i s m and comment o f f e r e d i n t h i s review i s presented i n an e f f o r t t o evaluate the v a l i d i t y of the r e p o r t s and to assess t h e i r t o t a l impact i f t h e i r recommendations were implemented. The methodology a c t u a l l y u t i l i z e d c o n s i s t e d of the D e l p h i n i a n Method and the p h y s i c i a n workload method. V a r i a t i o n s were employed by c e r t a i n d i s c i p l i n e s . The D e l p h i n i a n Method i s t h a t of g a r n e r i n g a consensus by the c o l l e c t i o n of informed experienced o p i n i o n s . The consensus i s a weighted judgement of p r o b a b i l i t i e s . The p h y s i c i a n workload method c a p i t a l i z e s on the abundant data a v a i l a b l e i n Canada by v i r t u e of two f o r t u i t o u s circumstances: a. u n i v e r s a l p r e p a i d medical coverage, and b. the fee f o r s e r v i c e payment method f o r p h y s i c i a n s . The p r e p a i d medical care insurance c l a i m s , i . e . u t i l i z a t i o n data, can be analyzed to determine the s p e c i f i c s f o r each p a r t i c u l a r type of s e r v i c e rendered i n a g i v e n year. The base years of 1971-72 were s e l e c t e d because the u t i l i z a t i o n data was f i r s t g e n e r a l l y a v a i l a b l e from t h a t time p e r i o d . The p r o j e c t i o n year chosen was 1981, because i t c o i n c i d e s with the next census, and because i t r e p r e s e n t s a time f o r e v a l u a t i o n of the p r e d i c t i o n s t h a t i s not too f a r 101 removed. The d e t a i l s of the p h y s i c i a n workload method are as f o l l o w s . The types of s e r v i c e s rendered by p h y s i c i a n s were f i r s t s t a n d a r d i z e d i n t o f o u r t e e n groups to h e l p ensure u n i f o r m i t y of data across the country. The v a r i o u s d i s c i p l i n e s then assigned a u n i t time (average) i n minutes f o r the reasonable performance of each s p e c i f i c type of s e r v i c e rendered by t h e i r s p e c i a l t y . By m u l t i p l y i n g the u n i t time by the t o t a l number of s e r v i c e s of a s p e c i f i c type performed i n a s t a t e d year by the d o c t o r s of t h a t s p e c i a l t y ( a v a i l a b l e from u t i l i z a t i o n d a t a ) , the workload i n hours per year can be c a l c u l a t e d f o r t h a t s p e c i a l t y i n performing house c a l l s or o f f i c e v i s i t s , e t c . T h e i r t o t a l year's workload i s a v a i l a b l e by adding up the time spent f o r each of the f o u r t e e n c a t e g o r i e s . T h i s i s the t o t a l workload per year per s p e c i a l t y , i n hours per year or hours per week f o r a s e l e c t e d work week year. The g e n e r a l assumption here i s t h a t a l l d o c t o r s are overworked i n terms of hours per week t h a t they work. An o p t i o n a l work week of 48 hours and work week year of 46 weeks was adopted by most groups to c a l c u l a t e the optimal number of p h y s i c i a n s which should have been a v a i l a b l e t o render the s e r v i c e s g i v e n i n the base y e a r s . Using these optimum numbers of p h y s i c i a n s i n the base years and t a k i n g i n t o c o n s i d e r a t i o n p o p u l a t i o n 102 trend s , as w e l l as l i k e l y f u t u r e developments, a c a l c u l a t i o n of optimum numbers of p h y s i c i a n s r e q u i r e d f o r each s p e c i a l t y can be developed f o r 1981. T h i s methodology thus a r r i v e s at an optimum demand c a l c u l a t i o n f o r 1981. The supply c a l c u l a t i o n s combine the p r e s e n t number of a c t i v e medical p r a c t i t i o n e r s i n each s p e c i a l t y , immigration f a c t o r s and a t t r i t i o n f a c t o r s , and the p r o j e c t e d optimal number r e q u i r e d f o r 1981, i n a formula (the Manseau-Mo Cheung Formula) to a r r i v e a t a c a l c u l a t i o n of the number of new annual graduates needed to meet the p r o j e c t e d 1981 optimums. By comparing the present number of annual graduates i n each s p e c i a l t y with the p r o j e c t e d annual number r e q u i r e d to a t t a i n the 1981 optimum l e v e l s , a measure of the shortcomings or excesses of each t r a i n i n g program can be estimated. Necessary c o r r e c t i v e measures could then be undertaken to c o r r e c t imbalances. 5. T o t a l Method Comments and C r i t i c i s m s The a v a i l a b i l i t y of l a r g e amounts of u t i l i z a t i o n data r a i s e s the i n t r i g u i n g q u e s t i o n as to who i s best q u a l i f i e d to u t i l i z e such data i n making p r o j e c t i o n s f o r f u t u r e p h y s i c i a n needs. The unstated assumption of t h i s method i s t h a t p h y s i c i a n s are the best q u a l i f i e d . Let 103 us now examine t h a t assumption. Should p h y s i c i a n s engage i n h e a l t h manpower pla n n i n g a t a l l ? Manpower plann i n g i s , a f t e r a l l , a form of peer review. The h o s p i t a l a c c r e d i t a t i o n program has been the c a t a l y s t i n the promotion of peer review by p h y s i c i a n s , l e a d i n g to the establishment of committees i n h o s p i t a l s , such as s u r g i c a l t i s s u e , medical a u d i t , i n f e c t i o n , e t c . , f o r improvement i n the q u a l i t y of medical s e r v i c e s rendered. The rec o r d i n Canada a f t e r about s i x t y y ears of o p e r a t i o n of the a c c r e d i t a t i o n program i s t h a t l e s s than 50% of Canadian h o s p i t a l s are a c c r e d i t e d . P h y s i c i a n enthusiasm f o r and acceptance of such peer review processes has thus been l e s s than overwhelming. Is i t l o g i c a l t h a t p h y s i c i a n s should be the prime peer reviewers i n p h y s i c i a n manpower planning? Economic t h e o r i s t s hold t h a t p h y s i c i a n s , by t h e i r unique r e l a t i o n s h i p with the h e a l t h care consumer, c o n t r o l the demand p l a c e d on h e a l t h s e r v i c e s ( S o r k i n , F e i n ) . I f t h i s i s t r u e , are the same medical personnel the most a p p r o p r i a t e group f o r doing t h e i r own manpower planning? P r e s e n t l y , p h y s i c i a n s are a major p a r t of the medical care system, but are not determinants i n t o t a l , d e s p i t e t h e i r strong power base. Does the p a r t i a l r o l e of the p h y s i c i a n i n the present h e a l t h system make i t apropos t h a t he i s accorded s o l e p a r t i c i p a n t s t a t u s i n t o t a l p l a n n i n g f o r f u t u r e p h y s i c i a n numbers? Can p h y s i c i a n s e f f e c t i v e l y remove t h e i r b i a s e s a g a i n s t new, 104 a l t e r n a t i v e forms of h e a l t h care d e l i v e r y to become unbiased p l a n n e r s ? Can they e f f e c t i v e l y p l a n f o r new types of p a r t i c i p a n t s i n the rendering of c a r e r when such p l a n n i n g t h r e a t e n s t h e i r s t a t u s quo economically and otherwise? On the other hand, would i t be l o g i c a l to move to the extreme op p o s i t e i n the s e l e c t i o n of p h y s i c i a n manpower planners? In other words, would the same s t a t i s t i c s be more a p p r o p r i a t e l y u t i l i z e d by an expert c i t i z e n group, making t h e i r own assumptions i n determining methodology and c o n c l u s i o n s ? Would t h e i r assumptions be v a l i d and a c c e p t a b l e by medical groups and s p e c i a l t i e s ? Would the mere e x i s t e n c e of such a non-medical determinant group be recognized and l e g i t i m i z e d by the medical p r o f e s s i o n ? Not l i k e l y . The sp e c t r e of t o t a l b u r e a u c r a t i c c o n t r o l of f u t u r e p h y s i c i a n needs would be an anathema to organized medicine. What then, are the a l t e r n a t i v e s ? Another p o s s i b i l i t y would be one of a r o l e of p a r t i a l d e t e r m i n a t i o n i n medical manpower pl a n n i n g f o r both the medical p r o f e s s i o n and the c i t i z e n s . P h y s i c i a n s have been slow to i n c o r p o r a t e c i t i z e n r e p r e s e n t a t i o n on t h e i r v a r i o u s boards and a s s o c i a t i o n s . Is such an i n s u l a r r o l e j u s t i f i e d and a p p r o p r i a t e , e s p e c i a l l y for p h y s i c i a n manpower p l a n n i n g , with i t s i n h e r e n t widespread l i n k a g e s i n the community? Would medical t e c h n i c a l advice l e a d 105 to more l o g i c a l c o n c l u s i o n s when put i n t o the context of a non-medically dominant p l a n n i n g committee? Would balanced c o n c l u s i o n s , c o n s i d e r i n g the t o t a l h e a l t h care system, be more l i k e l y i n a j o i n t p a r t i c i p a t i o n type of p l a n n i n g committee? Would such a committee be a r e a l i t y or would expert medical input be apt to take over and dominate the committee? C o n s i d e r a t i o n of the three types of p l a n n i n g committees mentioned above, i . e . a l l p h y s i c i a n s ; a l l c i t i z e n ; or p h y s i c i a n input i n t o c i t i z e n - d o m i n a t e d committee, r a i s e s enough u n c e r t a i n t y to l e a d to r e j e c t i o n of them a l l . Would i t not be more l o g i c a l to design a committee with s t r o n g p h y s i c i a n input but with an a p p r o p r i a t e measure of informed c i t i z e n input as w e l l ? The s o l i t a r y s e l f - d e t e r m i n a t i o n r o l e of medicine i n the p a s t , although leg. i s l a t i v e l y granted, seems i n a p p r o p r i a t e i n the context of today's h e a l t h care system. Formerly closed-system membranes have been rendered permeable by the advent of more e f f e c t i v e media, a b e t t e r educated and more m e d i c a l l y s o p h i s t i c a t e d p u b l i c , t h i r d p a r t y payment methods i n v o l v i n g governments, b a l l o o n i n g h e a l t h care c o s t s , and many other f a c t o r s . In l i g h t of these permeating f a c t o r s , s e l e c t i o n of an a l l - m e d i c a l p l a n n i n g process seems a n a c h r o n i s t i c . Granted, other input was p r e s e n t i n the Requirements Committee p r o j e c t from the Department of Health and Welfare. However, t h i s was 106 more as t e c h n i c a l a d v i s o r s , and not at a l l i n the r o l e of r e p r e s e n t a t i v e s of the p u b l i c i n t e r e s t and need. In c o n c l u s i o n , a major c r i t i c i s m of these documents and t h e i r v a l i d i t y , a r i s e s from the f a c t t h a t they r e p r e s e n t the views of a p r i v a t e i n t e r e s t group, p h y s i c i a n s , who, by t h e i r very s t a t u s - m a i n t a i n i n g d e f e n s i v e p o s t u r e , are not l i k e l y t o g i v e a balanced p i c t u r e of the f u t u r e medical needs of the country as a whole, without some complementary input from r e p r e s e n t a t i v e s of the g e n e r a l p u b l i c h e a l t h consumers. a Having thus pXimped f o r c i t i z e n input i n t o medical p l a n n i n g , l e t us c o n s i d e r the presen t s t a t u s of p a r t i c i p a t i o n by the g e n e r a l p u b l i c i n determining medical manpower p l a n n i n g . By and l a r g e , c i t i z e n input i s achieved only through v a r i o u s l e v e l s of government a c t i v i t y i n the h e a l t h care f i e l d . T h i s i s u s u a l l y accomplished by funding mechanisms i n s p e c i f i c s e c t o r s of the h e a l t h care system. Thus, governments fund u n i v e r s i t y medical t r a i n i n g programs, i n t e r n and res i d e n c y programs, r e s e a r c h programs, medicare payments, h o s p i t a l insurance payments, p u b l i c h e a l t h , e t c . The dominant c h a r a c t e r i s t i c of involvement by government i s the lack of i n t e g r a t i o n of funding mechanisms and programs. Admittedly, p a r t of the problem of n o n - i n t e g r a t i o n stems from the inadequacies of the B r i t i s h North America A c t as i t a p p l i e s to the present day s i t u a t i o n i n the d e l i v e r y of h e a l t h c a r e . 107 The Act a l l o c a t e s r e s p o n s i b i l i t y f o r h e a l t h care to the p r o v i n c e s , but the r e a l i t y of today's economics demands f e d e r a l p a r t i c i p a t i o n . The P h y s i c i a n Manpower Requirements Committee provi d e s an i n t e g r a t i v e approach f o r one f a c e t of the h e a l t h care d e l i v e r y system. The concept i s n a t i o n a l i n scope. I t r e l a t e s to u n i v e r s i t y t r a i n i n g programs, p u b l i c demand f o r h e a l t h s e r v i c e s , a l t e r n a t i v e d e l i v e r y mechanisms of h e a l t h c a r e , immigration, p h y s i c i a n d i s t r i b u t i o n , e t c . Why then was not more p u b l i c involvement s o l i c i t e d f o r t h i s p l a n n i n g process? Is p u b l i c p a r t i c i p a t i o n deemed to be a p p r o p r i a t e , informed enough, i n t e r e s t e d enough? Given the answer t o the above q u e s t i o n s i s yes, i t would s t i l l be necessary to determine how consensus f o r p u b l i c p a r t i c i p a t i o n c o u l d be reached. Would surveys be a p p r o p r i a t e when one c o n s i d e r s t h e i r expense and the obvious problems i n i n i t i a t i n g v a l i d r e l i a b l e surveys? Is the p u b l i c so s a t i s f i e d with the prese n t system as to p r e f e r to be a n o n - p a r t i c i p a n t i n medical manpower planning? For the s p e c i a l t i e s , the p u b l i c may not be so w e l l informed or so sure as to what t h e i r d e s i r e s are i n terms of medical manpower p l a n n i n g . Over the l a s t few y e a r s , t h e r e has been a groundswell of p u b l i c support f o r the g e n e r a l or f a m i l y type of p r a c t i c e i n t h e i r l i v e s , a f t e r t h i r t y years of post World War II c o n c e n t r a t i o n on the s p e c i a l t i e s . Could the p u b l i c 108 wants be a s c e r t a i n e d i n regard to what they see the r o l e of the f a m i l y p r a c t i t i o n e r encompassing? Would the g e n e r a l p u b l i c be more r e l i a b l e i n determining the nature of the f a m i l y p r a c t i t i o n e r than the v a r i o u s s p e c i a l t y groups, with t h e i r own s p e c i f i c areas of i n t e r e s t , t h a t dominate the medical s c h o o l s and t h e i r programs. How f a r should the wants of the p u b l i c be c o n s i d e r e d a p a r t from economic r e a l i t y ? Should the p u b l i c be allowed to determine f o r themselves j u s t who should g i v e primary care? Is the p u b l i c aware of the n a t i o n ' s h e a l t h needs as opposed to the p u b l i c ' s demands on the h e a l t h care system? Should the p u b l i c pay a premium f o r s e l e c t i n g a primary care d e l i v e r e d by s p e c i a l i s t s vs. primary care d e l i v e r e d by g e n e r a l p r a c t i c e ? Can the country a f f o r d primary care d e l i v e r e d by s p e c i a l i s t s ? These q u e s t i o n s demand some r o l e by the p u b l i c 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. These same q u e s t i o n s a l l hinge, as w e l l , on the medical manpower p l a n n i n g process. P u b l i c p a r t i c i p a t i o n may have been a d i f f i c u l t i d e a to i n s t i t u t e i n the c a r r y i n g out of the tasks of the Requirements Committee, but i t s very absence weakens the s t r e n g t h of the r e s u l t s of the Requirements Committee's l a b o u r s . 6. D e f i n i t i o n of Family P r a c t i c e 109 The second major flaw i n the methodology r e l a t e s to the d e f i n i t i o n of f a m i l y p r a c t i c e . Granted, a Requirements Committee Report on Family P r a c t i c e was formulated, j u s t as the v a r i o u s s p e c i a l t i e s had re p o r t e d . Nonetheless, the common a t t i t u d e p r e v a i l i n g i n the r e p o r t s of those s p e c i a l t i e s b o r d e r i n g g e n e r a l p r a c t i c e i s t h a t i t i s a p p r o p r i a t e and proper to pre-empt c e r t a i n f u n c t i o n s t h a t g e n e r a l p r a c t i c e o b v i o u s l y does, when the u t i l i z a t i o n data are reviewed. The s t y l e of g a i n i n g these new f u n c t i o n s could best be compared to e x p r o p r i a t i o n procedures by government. Is such a method of r o l e d e f i n i t i o n of f a m i l y p r a c t i c e n e c e s s a r i l y the best or most a p p r o p r i a t e to f i l l the h e a l t h care needs of Canada f o r f a m i l y p r a c t i c e ? Admittedly a gre a t d e a l of r o l e ambiguity has surrounded f a m i l y p r a c t i c e i n Canada. Some of t h i s f u z z i n e s s of r o l e came from the lack of a p o l i t i c a l l y s trong n a t i o n a l o r g a n i z a t i o n for ge n e r a l p r a c t i c e . The f a c t s are t h a t i t was d i f f i c u l t f o r g e n e r a l p r a c t i c e to have assumed strong l e a d e r s h i p i n the fa c e of a weak power base. Family p r a c t i c e was at the bottom of the medical power s t r u c t u r e . Even though f a m i l y p r a c t i t i o n e r s c o n s t i t u t e h a l f of the n a t i o n a l p h y s i c i a n workforce, the determinants of who they are and how they w i l l f u n c t i o n are l a r g e l y i n the hands of other medical power groups, i . e . the s p e c i a l t i e s . 110 Thus we f i n d t h a t the power of the medical sub-groups i s the l a r g e s t determiner of the r o l e of f a m i l y p r a c t i c e , and does not n e c e s s a r i l y p a r a l l e l the p u b l i c i n t e r e s t or d e s i r e . T h i s s i t u a t i o n g i v e s r i s e to c u r i o u s circumstances, such as the i n t e r n a l medicine group ( i n t h e i r working p a r t y r e p o r t ) p r e d i c t i n g the need f o r more of t h e i r own numbers i n the expanding r o l e of t r a i n i n g l a r g e r numbers of f a m i l y p r a c t i t i o n e r s i n the u n i v e r s i t y medical s c h o o l s . Why would i t not have sprung to mind t h a t more f a m i l y p r a c t i t i o n e r s were needed to t r a i n the l a r g e r r e q u i r e d numbers of f a m i l y p r a c t i t i o n e r s p r e d i c t e d f o r 1981? Departments of f a m i l y p r a c t i c e were slow i n e v o l v i n g i n medical f a c u l t i e s i n many u n i v e r s i t i e s , the U n i v e r s i t y of B r i t i s h Columbia being one of the l a s t to do so. Did i t not seem incongruous to be i n v o l v e d i n the medical t r a i n i n g of p a r t of a group of p h y s i c i a n s r e p r e s e n t i n g h a l f of the n a t i o n ' s p h y s i c i a n s , and not have had a department of g e n e r a l p r a c t i c e ? O b v i o u s l y , the power f a c t s of the medical t r a i n i n g grounds o b v i a t e d the need to defend a g a i n s t m a i n t a i n i n g such i n c o n g r u i t i e s . Thus, the power of s p e c i a l t y groups i n c o n t r o l i n medical s c h o o l s of u n i v e r s i t i e s and on the a c t i v e s t a f f s of h o s p i t a l s , determines, f o r the most p a r t , the nature of f a m i l y p r a c t i c e . At the same time, the o rganized s p e c i a l t y groups are n i b b l i n g at the boundaries of g e n e r a l p r a c t i c e as i t i s p r e s e n t l y c o n s t i t u t e d , to I l l f u r t h e r r e s t r i c t and modify i t s r o l e . Given the v a r i o u s s p e c i a l t y working p a r t y r e p o r t s on p h y s i c i a n manpower, can a summation of these same committees* r o l e s and boundaries, s u b t r a c t e d from the whole of medical care d e l i v e r y , adequately d e s c r i b e g e n e r a l p r a c t i c e ? Is gen e r a l p r a c t i c e a s p e c i a l t y residuum surrounded by c o n s t a n t l y s h r i n k i n g boundaries? T h i s negative type of approach as to what c o n s t i t u t e s g e n e r a l p r a c t i c e makes one wonder i f g e n e r a l p r a c t i c e i s v i a b l e under such circumstances. The prese n t new graduate i n medicine has been moulded i n the image the medical s c h o o l s p e c i a l i s t e nvisages. Does t h i s new image of the gr a d u a t i n g f a m i l y p r a c t i t i o n e r m a l f i t the model of f a m i l y p r a c t i c e as p o r t r a y e d by the u t i l i z a t i o n data? Is t h i s u t i l i z a t i o n model of f a m i l y p r a c t i c e outmoded but s t i l l l i n g e r i n g as a v e s t i g i a l remnant, by v i r t u e of grandfather c l a u s e s embodied i n the o l d e r members of f a m i l y p r a c t i c e ? On the other hand, i s the u n i v e r s i t y medical educator model of g e n e r a l p r a c t i c e apt to be any more a p p r o p r i a t e than t h a t d i s p l a y e d by u t i l i z a t i o n data? In e f f e c t , what we are asking i s who should be the a r c h i t e c t of the model of g e n e r a l p r a c t i c e ? A l l o c a t i o n of the f u n c t i o n of model making e x c l u s i v e l y t o v a r i o u s s p e c i a l t y groups i n the medical schools with t h e i r vested i n t e r e s t p o s i t i o n seems to be outmoded. The graduate p r e s e n t l y being produced f o r f a m i l y p r a c t i c e i s one concerned more with 112 ambulatory care, with the p s y c h o - s o c i a l aspects of medical p r a c t i c e and with more emphasis on non-procedural items and p r e v e n t i v e medicine. Is such a model i n keeping with the p u b l i c i n t e r e s t ? Has the p u b l i c had any input i n t o the d e t e r m i n a t i o n of such a model, and indeed, would such input be a p p r o p r i a t e ? As the u l t i m a t e consumer of h e a l t h c a r e , i t would seem to be f i t t i n g t h a t the p u b l i c p a r t i c i p a t e d to some extent i n 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 model. How c o u l d such p a r t i c i p a t i o n come about? The most a p p r o p r i a t e s t a r t i n g p o i n t would be on the s e l e c t i o n committees f o r candidates seeking to enter medical s c h o o l . Committees for s e l e c t i o n of f u t u r e d o c t o r s have been even more sa c r o s a n c t than other medical bodies i n terms of p u b l i c e ntry f o r decision-making. Should such powers be vested s o l e l y i n the hands of the medical educator? What has been t h e i r modus operandi and t r a c k r e c o r d t o date? B a s i c a l l y , the s e l e c t i o n method u t i l i z e d i n most sc h o o l s , with few n o t a b l e exceptions such as McMaster U n i v e r s i t y , has been based s o l e l y on academic achievement by the pre-medical c a n d i d a t e . S e l e c t i o n of candidates i s d i f f i c u l t , but does c h o i c e of a method based on the expediency of the academic achievement s e l e c t i o n process, l e a d t o a p p r o p r i a t e types of f u t u r e d o c t o r s ? The p r e d i l e c t i o n and p r e o c c u p a t i o n of academia f o r and with academic achievement b i a s e s them i n choosing a s e l e c t i o n method. Are such c l o s e d 113 system b i a s e s apt to be i n the best p u b l i c i n t e r e s t ? Again, i s t h i s then not a proper area f o r e n t r y of the p u b l i c ? Would not a more balanced view of the c h a r a c t e r i s t i c s d e s i r e d i n the medical product of our medical s c h o o l s r e s u l t from g r e a t e r p u b l i c p a r t i c i p a t i o n i n the s e l e c t i o n process? The t r a c k r e c o r d , p r e v i o u s l y mentioned, has been to t u r n out e x c e l l e n t d o c t o r - t e c h n i c i a n s who, i s s p i t e of t h e i r o r i g i n a l m o t i v a t i o n a l o r i e n t a t i o n , undergo, d u r i n g t h e i r p e r i o d of medical t r a i n i n g , an a t t i t u d i n a l r e s t r u c t u r i n g l e a d i n g t o t h e i r u l t i m a t e emergence as medical entrepreneurs ( B l a n p a i n ) . Can the economics, and indeed, should the economics of our h e a l t h care system a f f o r d more of such a medical product? Another aspect of t h i s whole process remains to be c o n s i d e r e d here. I t concerns w a s t e f u l n e s s . Many more a p p l i c a t i o n s f o r medical school p o s i t i o n s a r i s e than t h e r e are p o s i t i o n s to be f i l l e d . The s e l e c t i o n process r e c r u i t s a candidate of high i n t e l l e c t and achievement. Is i t a p p r o p r i a t e when those s e l e c t e d f i n a l l y graduate, to have n e a r l y f i f t y percent of the new d o c t o r s enter a branch of t h e i r p r o f e s s i o n t h a t may become reduced almost to the r o l e of a medical t r i a g e r e f e r r a l worker? Is such an outcome a proper e x p l o i t a t i o n of the new f a m i l y p r a c t i t i o n e r ' s t r a i n i n g and t a l e n t s ? Could we not t u r n out a l e s s w e l l t r a i n e d h e a l t h care worker to d e l i v e r such a s e r v i c e ? I f the s p i r i t of f u t u r e g e n e r a l 114 p r a c t i c e i s captured by a d e s c r i p t i o n such as 'medical t r i a g e r e f e r r a l worker', would not a surrogate form of medical 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 and economical? Down p l a y i n g and down grading the r o l e of f a m i l y p r a c t i c e can only u l t i m a t e l y l e a d to the need f o r a l e s s w e l l t r a i n e d primary medical care d e l i v e r e r . I f t h i s i s indeed the trend along which medical s c h o o l s are moving, should the medical s p e c i a l t i e s a l s o r e n d e r i n g primary care c l i n g to t h a t r o l e aspect so t e n a c i o u s l y , as evidenced i n s e v e r a l of the r e p o r t s of the working p a r t i e s ? Are there not c o n t r a d i c t o r y a t t i t u d e s v o i c e d i n s e v e r a l of the r e p o r t s of those groups g i v i n g both primary and secondary care? On the one l e v e l , they seek to l e s s e n the r o l e of the f a m i l y p r a c t i t i o n e r as d e s c r i b e d i n d i s c u s s i o n of t h e i r own s p e c i f i c tasks and boundaries, y e t , on the other hand, they seek to mai n t a i n the r i g h t to g i v e primary c a r e . Take the r e p o r t of the o b s t e t r i c s and gynecology working p a r t y f o r example. In t h e i r r a t h e r l i m i t e d d i s c u s s i o n of a new n u r s e - o b s t e t r i c i a n (midwife) r o l e , the group can see the p o s s i b i l i t y of a l l o c a t i n g to such a worker the m a j o r i t y of normal d e l i v e r i e s . The group then renders unto themselves a l l abnormal d e l i v e r i e s . The r o l e of the f a m i l y p r a c t i t i o n e r i n such an arrangement i s not mentioned. Is t h a t kind of o v e r s i g h t l i k e l y to l e a d to a v a l i d d e s c r i p t i o n of f a m i l y p r a c t i c e ? I t would seem then, i n s p i t e of i t s l e s s e r s t a t u s 115 i n the medical schools and i n the eyes of the s p e c i a l t y groups, t h a t general p r a c t i c e remains the l i n k s t o n e or f o c a l p o i n t i n any program of h e a l t h manpower p l a n n i n g t h a t i s v a l i d . General p r a c t i t i o n e r s do, a f t e r a l l , c o n s t i t u t e n e a r l y h a l f of the medical manpower of the country. Is i t a p p r o p r i a t e t h a t the d e s t i n y of g e n e r a l p r a c t i c e be i n the hands of a s s o r t e d s p e c i a l t y groups e x c l u s i v e of the p u b l i c i n t e r e s t or input? Common sense would t e l l us otherwise. Why then has not g e n e r a l p r a c t i c e h e l d a l a r g e r r o l e i n the u n i v e r s i t i e s ' t r a i n i n g programs? No doubt, p a r t of t h i s problem i s a t t i t u d i n a l on the p a r t of the s p e c i a l i s t medical s c h o o l educator who c o n t r o l s the t r a i n i n g p r o c e s s . What are the outcomes and products of our processed medical s c h o o l inputs? They are s p e c i a l i s t s and f a m i l y p r a c t i t i o n e r s . Those who opt f o r f a m i l y p r a c t i c e are not l i k e l y to l i n g e r long i n a f i e l d with s e v e r l y s h r i n k i n g h o r i z o n s and l i m i t e d d u t i e s . Although g e n e r a l p r a c t i c e makes economic s e c u r i t y e a s i l y a t t a i n a b l e , the unrest c r e a t e d by a f e e l i n g of f r u s t r a t i o n and m i s a p p l i c a t i o n of one's t a l e n t s , w i l l u l t i m a t e l y l e a d to o p t i n g f o r a s p e c i a l t y t r a i n i n g program. The higher the percentage of p h y s i c i a n members t h a t achieve s p e c i a l i s t s t a t u s , the more the market p r i n c i p l e s of economics w i l l l e a d to g r e a t e r c o m p e t i t i o n i n the d e l i v e r y of those same primary s e r v i c e s t h a t the s p e c i a l i s t working p a r t i e s s t i l l espouse. Can we a f f o r d 116 C a d i l l a c d e l i v e r y of primary h e a l t h s e r v i c e s ? E x t r a p o l a t i o n of p r e s e n t trends could l e a d to a f u t u r e wherein a l l medical graduates become s p e c i a l i s t s , d e l i v e r i n g the t r i o of primary, secondary, and t e r t i a r y c a re, w h i l s t s h a r i n g primary care d e l i v e r y with a l e s s e r h e a l t h worker. The f a m i l y p r a c t i t i o n e r would be e f f e c t i v e l y e l i m i n a t e d i n such a schema. Is t h i s outcome a p p r o p r i a t e and i n the b e s t i n t e r e s t s of the h e a l t h care-consuming p u b l i c ? Is i t l o g i c a l , given the t r a d i t i o n a l p l a c e of the f a m i l y p h y s i c i a n ? 7. C o n c l u s i o n s and P o s s i b l e S o l u t i o n s What are the a l t e r n a t i v e s ? Could the f a m i l y p r a c t i t i o n e r be t r a i n e d to competently cope with a l a r g e r , more rewarding r o l e than seems p o s s i b l e a t present? Only such a r o l e w i l l ensure h i s s u r v i v a l i n the f u t u r e . Could we r e s t r i c t e v e n t u a l l y the r o l e of s p e c i a l i s t s to t h a t of c o n s u l t a n t s ? Would not such a r o l e be more e f f i c i e n t and rewarding, not only to the doctor h i m s e l f , but to the p u b l i c ? Can a s p e c i a l i s t , p r i v i d i n g primary care, l i k e l y f o r economic reasons, adequately p r o v i d e secondary and t e r t i a r y care? I f payment mechanisms were a l t e r e d a p p r o p r i a t e l y , could we not encourage more s p e c i a l i s t s to act as c o n s u l t a n t s only? 117 U n i v e r s i t y t r a i n i n g programs f o r engineers p r a c t i c e streaming techniques f o r s p l i t t i n g i n t o s p e c i a l t i e s a f t e r the second b a s i c year, so t h a t v a r i o u s e n g i n e e r i n g s p e c i a l t i e s , such as c i v i l , m e t a l l u r g i c a l , and mechanical, are being developed d u r i n g the l a s t two yea r s of the undergraduate program. A streamed program f o r medical s p e c i a l t i e s would, however, take another four y e a r s . Would not t h i s e a r l i e r streaming i n medicine r e s u l t i n c o n s i d e r a b l e economic s a v i n g , w h i l e t u r n i n g out w e l l t r a i n e d s p e c i a l i s t - c o n s u l t a n t s who have opted e a r l y f o r t h e i r own p a r t i c u l a r area of s p e c i a l i z e d knowledge? R e s t r u c t u r i n g of medical school c u r r i c u l a i n t o o p t i o n a l s t y l e programs a f t e r the b a s i c two y e a r s , could r e s u l t i n the unloading of much unnecessary deadweight l e a r n i n g . Many items of medical s c h o o l c u r r i c u l a r e t a i n t h e i r p o s i t i o n s by v i r t u e of t r a d i t i o n and the tenure of t h e i r t e a c h e r s . The p a r t i c u l a r courses are not n e c e s s a r i l y a p p r o p r i a t e or r e q u i s i t e f o r every would-be graduate s p e c i a l i s t . The proper a l l o c a t i o n of such courses to the a p p r o p r i a t e s p e c i a l i s t programs would e l i m i n a t e many i n e f f i c i e n c i e s t h a t would l i k e l y be d i s c l o s e d i f proper c o s t / b e n e f i t analyses f o r courses were c o n s t r u c t e d . The f a m i l y p r a c t i t i o n e r would a l s o b e n e f i t from such a program, no doubt emerging a f t e r the four-year p o r t i o n of streamed program l e a r n i n g as a s p e c i a l i s t i n h i s own r i g h t . Returning f i n a l l y to the concept of p h y s i c i a n 118 manpower a l l o c a t i o n and the requirements f o r p h y s i c i a n s i n Canada, i t would seem l o g i c a l to e v e n t u a l l y use the u l t i m a t e experience of the working p a r t i e s and t h e i r a p p r o p r i a t e methodologies f o r i n s e r t i o n i n t o the medical streaming process a f t e r the second of the two b a s i c y e a r s . Here then c o u l d r a t i o n a l a l l o c a t i o n of manpower resources be made. The r e s u l t i n g s p e c i a l t y medical products, i n c l u d i n g f a m i l y p r a c t i t i o n e r s , would be more attuned t o the changing h e a l t h c a r e needs of the Canadian people, and more i n keeping with t h e i r economic c a p a b i l i t i e s . Having c o n s i d e r e d the broader i s s u e s of p h y s i c i a n manpower pl a n n i n g as r a i s e d by the Requirements Committee Report, and having demonstrated the many l i n k a g e s such a program has i n the h e a l t h care system, we w i l l now turn to the c o n c l u s i o n s of t h i s t h e s i s on medical manpower p l a n n i n g , i n Chapter Seven. 119 CHAPTER SEVEN  Conclusi o n s f o r Health Planning 1. General a. The premise of h e a l t h manpower p l a n n i n g i s t h a t m a l d i s t r i b u t i o n of p h y s i c i a n s , both by numbers and by mix, leads to the d e p r i v a t i o n of access t o h e a l t h care, and as such, c o n s t i t u t e s a s o c i a l i n j u s t i c e which r e q u i r e s e a r l y remedies by plann e r s and governments. Health resource p l a n n i n g , of which h e a l t h manpower p l a n n i n g i s a p a r t , i s not a r e f i n e d a r t or technique, and t h e r e f o r e i s s u b j e c t to t r i a l and e r r o r , f i n a n c i a l r e s p o n s i b i l i t y f o r which must be p a r t of the government r o l e as a moulder of the system. c. 120 Medical manpower plann i n g can proceed and c o e x i s t with the s p i r i t of freedom of ch o i c e i n choosing a p r o f e s s i o n a l c a r e e r , such freedom being p a r t of the f a b r i c of a democratic s o c i e t y . d. I n t e r v e n t i o n p o l i c i e s , designed to invoke changes i n the h e a l t h care system, r e q u i r e c a r e f u l advance e v a l u a t i o n to ensure t h a t they do not evoke negative changes. e. Health manpower pl a n n i n g i s an i n t e g r a l p a r t of the a l l o c a t i o n of h e a l t h r e s o u r c e s , but i t should be remembered t h a t personnel resources are human f a c t o r s , not inanimate t e c h n i c a l resource components. f . Governments e n j o y i n g the p o l i t i c a l advantages a c c r u i n g from a h e a l t h care system which has ge n e r a l p u b l i c approval and acceptance, must be prepared to adequately fund such a system, or e l s e face the p o l i t i c a l consequences i n h e r e n t i n 121 the p r o v i s i o n of a second-rate method of h e a l t h c a r e . g. J u s t as acceptance of p o l i t i c a l p o l i c y d e c i s i o n s not i n agreement with p l a n n i n g c o n c l u s i o n s i s p a r t of the p l a n n e r ' s mandate, so a l s o may be necessary the acceptance by planners of the s o c i o - m e d i c a l r e a l i t y of the r e s i s t a n c e and opposing p o s i t i o n of the prime d e l i v e r e r s of h e a l t h care, the p h y s i c i a n s . 2. Canada a. Planning f o r the a l l o c a t i o n of h e a l t h resources of Canada i s necessary i n order to achieve r a t i o n a l i t y i n an i n d u s t r y consuming an i n c r e a s i n g l y l a r g e r p o r t i o n of the Gross N a t i o n a l Product (see the Appendix ^ 7 ) . A c o r o l l a r y of our b e l i e f i n the r i g h t of p a t i e n t s to h e a l t h care i n Canada, i s t h a t the 122 h e a l t h care bureaucracy thus c r e a t e d should have as. one of i t s u n d e r l y i n g p r i n c i p l e s , 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 ) . c. P h y s i c i a n manpower pl a n n i n g i s one p o r t i o n of t o t a l h e a l t h personnel p l a n n i n g , but w i t h i n the prese n t and f o r s e e a b l e context of our h e a l t h care system, such p h y s i c i a n p l a n n i n g i s l i k e l y to remain the key item. A l l i e d h e a l t h personnel p l a n n i n g i s necessary f o r the e f f i c i e n t a l l o c a t i o n of these r e s o u r c e s , and f o r the i n s t i t u t i o n of any contemplated r o l e changes 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 p e r s o n n e l . e. Under our present c o n s t i t u t i o n , and l i k e l y i n any p r o j e c t e d c o n s t i t u t i o n a l change, h e a l t h care i s , and w i l l remain, a p r o v i n c i a l j u r i s d i c t i o n , so t h a t p l u r a l i s m w i l l continue to be a f a c t o r i n decision-making f o r the a l l o c a t i o n of h e a l t h 123 personnel r e s o u r c e s . f . Education of medical personnel i s such a c e n t r a l item i n medical manpower p l a n n i n g , t h a t the u n i v e r s i t y t r a i n i n g programs f o r p h y s i c i a n s should be seconded to a p p r o p r i a t e h e a l t h departments of the p r o v i n c i a l governments to b e t t e r ensure t h a t the supply of h e a l t h personnel i s i n balance with the demands generated by the system. g. E v o l u t i o n a r y changes i n the h e a l t h care d e l i v e r y system i n Canada should be encouraged, r a t h e r than the use of d i s r u p t i v e t o t a l system (* r e v o l u t i o n a r y • ) changes. h. Canada, or any other n a t i o n , w i l l u l t i m a t e l y develop the kind of doctor i t wants; the r e s u l t s achieved by us i n g an unplanned e v o l u t i o n a r y process are not l i k e l y to be e f f i c i e n t or even n e c e s s a r i l y a p p r o p r i a t e . 124 3. F e e - F o r - S e r v i c e System a. D e s p i t e the negative e f f e c t s of the f e e - f o r - s e r v i c e system of payment of p h y s i c i a n s , t h e r e are "no panaceas l e a d i n g to a p e r f e c t payment mechanism" (Wolfe and Ba d g e l y ) . b. Two overlooked b e n e f i t s of the f e e - f o r - s e r v i c e payment mechanism are the enormous amounts of d e t a i l e d data generated by the medicare u t i l i z a t i o n tapes f o r h e a l t h system a n a l y s i s , and the present e x i s t e n c e of a h i g h - q u a l i t y medical care system t h a t evolved under a f e e - f o r - s e r v i c e method t h a t i s o f t e n reproached without a v i a b l e a l t e r n a t i v e being o f f e r e d . c. Changes i n the f e e - f o r - s e r v i c e payment mechanism as advocated by J u s t i c e H a l l i n h i s second r e p o r t , c o n s t i t u t e a s h i f t from the b a s i c concepts of our present h e a l t h s e r v i c e system, 125 and, as such, w i l l c r e a t e s p i n - o f f s i n the medical manpower pl a n n i n g process t h a t are i n d e f i n a b l e . 4. Family P h y s i c i a n s a. The f a m i l y p r a c t i t i o n e r / g e n e r a l p r a c t i t i o n e r group, accounts f o r n e a r l y f i f t y percent of the medical manpower personnel of Canada, so t h a t personnel resource p l a n n i n g f o r t h i s component, i s a key i s s u e f o r any pl a n n i n g venture. b. A s c r i b i n g the d e f i n i t i o n of f a m i l y p r a c t i c e to being t h a t residuum r e s u l t i n g a f t e r the e x p r o p r i a t i o n of f u n c t i o n s by the expanding boundaries of v a r i o u s s p e c i a l t y d i s c i p l i n e s , i s not a c r e a t i v e or i n t e g r a t i v e approach, and, as such, w i l l l e a d to debasement of f a m i l y p r a t i c e . c. Given the c o s t s , time, and resources needed to t r a i n f a m i l y p h y s i c i a n s , the p r e s c r i p t i o n of an 1 2 6 a b b r e v i a t e d r o l e f u n c t i o n f o r . f a m i l y p r a c t i t i o n e r s w i l l l e a d t o fewer numbers of p h y s i c i a n s seeking the r o l e , and a l s o to the e l a b o r a t i o n of an i n c r e a s i n g number of s p e c i a l i s t s , themselves doing primary h e a l t h care d e l i v e r y . 5. B r i t i s h Columbia B r i t i s h Columbia, by v i r t u e of i t s c l i m a t e , i t s geography, and i t s s o c i a l amenities, as e x e m p l i f i e d by a l e s s t r a d i t i o n a l , f r e e r , w e s t e r n - s t y l e p r o f e s s i o n a l s p i r i t , i s a t t r a c t i n g a l a r g e number of p h y s i c i a n s , which, i n t u r n , i s a l t e r i n g the p h y s i c i a n / p o p u l a t i o n r a t i o s to the p o i n t where some c o n t r o l over the t o t a l number of p h y s i c i a n s p r a c t i c i n g here w i l l be necessary. 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S u m m a r y , R e p o r t o f t h e R e q u i r e m e n t s C o m m i t t e e , N a t i o n a l C o m m i t t e e o n P h y s i c i a n M a n p o w e r . R e q u i r e m e n t s f o r P h y s i c i a n s i n C a n a d a w i t h S p e c i a l R e f e r e n c e t o B r i t i s h C o l u m b i a . H e a l t h M a n p o w e r R e s e a r c h U n i t , H e a l t h S c i e n c e s C e n t r e , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 137S. J o h n C . V a r l e y , M . D 1 4 7 3 . D e f i n i t i o n o f t h e C e r t i f i e d F a m i l y P h y s i c i a n 160 i+. M a j o r M e t h o d s f o r A s s e s s i n g a n d P r o j e c t i n g M a n p o w e r R e q u i r e m e n t s . T h o m a s H a l l . P a n A m e r i c a n C o n f e r e n c e o n H e a l t h M a n p o w e r P l a n n i n g , O t t a w a , 1 9 7 3 161 5. A l t e r n a t i v e M e t h o d s o f P h y s i c i a n P r i c i n g , U w e R e i n h a r d t 1 6 2 6. S t a t e m e n t o n a P a t i e n t ' s B i l l o f R i g h t s . A f f i r m e d b y t h e B o a r d o f T r u s t e e s N o v e m b e r 1 7 , 1 9 7 2 , A m e r i c a n H o s p i t a l A s s o c i a t i o n . 163 7 . G o v e r n m e n t S p e n d i n g . C o m m e r c i a l L e t t e r , C a n a d i a n I m p e r i a l B a n k o f C o m m e r c e , T o r o n t o , I s s u e N o . 1 , 1 9 7 9 165 140 A P P E N D I X 1 199 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 5.3 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 141 200 Canada Year Book 1978-79 5.4 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 201 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. 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 Federal-Provincial 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 Federal-Provincial 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 203 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 are financed through 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 examina-tions, first aid and emergency treatment, advisory services and special health programs. Increased attention is given to pre-retirement and stress. 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 5.5 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 semi-autonomous 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. 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 Columbia. 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 of 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, $15.00; family of three or more. SI 8.75. The premiums are those for persons who do not qualify for premium assistance on account of limited income. Hospital in-patient benefits: standard ward and all approved available services. Out-patient: emergency services, minor surgical procedures, day care surgical services, out-patient cancer therapy, psychiatric day care and night care services, day care rehabilitation services, narcotic addiction services, physiotherapy services, diabetic day care, and specified out-patient psychiatric services in designated hospitals, dietetic counselling services; cytology services operated by BC Cancer Institute and renal dialysis treatments in designated hospitals. Out-of-province benefits: (in-patient) during a temporary period of absence that ends at midnight on the last day of the 12th month following the month of departure from province; maximum stay of 12 months unless otherwise approved; referral, if approved by deputy minister. A P P E N D I X 2 . HEALTH MANPOWER RESEARCH UNIT 147 C/O OFFICE OF THE COORDINATOR HEALTH SCIENCES CENTRE 4th FLOOR I.R.C. BUILDING THE UNIVERSITY OF BRITISH COLUMBIA VANCOUVER, B.C., CANADA V6T 1W5 F i l e : 36.80.02 SUMMARY Report of the Requirements Committee National Committee on Physician Manpower REQUIREMENTS FOR PHYSICIANS IN CANADA WITH SPECIAL REFERENCE TO BRITISH COLUMBIA May 10th, 1976 John C. Varley, M.D. A Research Unit for the Health Manpower Working Croup, Ministry of Health, British Columbia BOUNDARIES PRESENT ANTICIPATED ROLE SHARED WITH CONFLICTS General/Family Practice (G.P./F.P.) 1• Primary Care 2. 23# of major fracture repairs 3. 1056 of varicose vein surgery 4. 1£$ of appendectomies 5. 30$ of tonsillectomies 6. 63$ of confinements 7. \\% of Caesarian sections 8. 32$ of anaesthetics 9. ECG, X-ray i n t e r p r e t a t i o n Envision 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 Practice Anticipate more and more of primary contact ser-vices w i l l be provided by FP/GP's Increased teaching r e -search and administra-tion Internal Medicine General Surgery Pediatrics Obstetrics gynecology Anaesthesia Nurse p r a c t i t i o n e r Consultants to no longer give primary care. R e s t r i c t i o n of presently per-formed s u r g i c a l -o b s t e t r i c a l -anaesthetic s e r v i c e s . Internal Global term in c l u d i n g a l l Medicine subspecialties except Neurology and Dermatology 1. 85$ on a r e f e r r a l basis. 2. 15$ d i r e c t access by patients 3. Take over of ser i o u s l y i l l patients as GP/FP's move more to care of ambulatory patients 4. Internal overlap between general 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 of c e r t i f i e d family physicians General Practice Other Internists Pediatrics L C D . Care Seriously i l l care P r a c t i s i n g both as consultants and general p r a c t i -tioners BOUNDARIES PRESENT ANTICIPATED ROLE SHARED WITH CONFLICTS Pediatrics 1. Conception to Adolescence. 2. Primary care - a) 10$ of 0 to 17 year age primary care, b) 50$ of work done is in primary care. 3. Secondary care. 4. Tertiary care. 5. Long term chronic dis-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 coun-selling 6. More community pedia-tricians General/family practice Obstetricians Internists New allied health personnel - e.g. pediatric nurse practitioner Primary care of children Perinatology Adolescents Pediatric primary care. Obstetrics- Primary Health Care Gynecology of women: a) early detection of cancer b) family planning c) genetic counselling d) sex counselling e) marital counselling 2. A l l high-risk obstet-ri c a l patients 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 allied health personnel: e.g. midwife Womens Health Co-operative Groups High risk obstet-rical cases Procedural items Bladder conditions Normal obstetrics Pap smears, infec-tions, sex and contraceptive counselling General Surgery 1. 2. 3. 4. 10$ of income is from general practice Procedures: 77$ appendectomies 91% of cholecystectomies 81$ of hernia repairs Other major surgery Minor surgery 1. Transfer of a l l G.P. major surgery to sur-geons 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 sub-specialties Pediatric surgery Internal medicine Major/minor surgery Fractures Hernia e.g. Head and neck surgery Children Intensive care -P-BOUNDARIES PRESENT ANTICIPATED ROLE SHARED WITH CONFLICTS Anaesthesia .1. Nerve blocks - 20$ 1. Intensivists 1. General practice Anaesthetics 2. Surgical anaesthesia 1 ... 3. O b s t e t r i c a l anaesthesia} b B * 2. Ideally a l l anaesthetics 'practitioners' Nerve blocks should be given by 2. A l l i e d health per-4. Care of unconscious anaesthetists sonnel - anaesthetic patients 3. Acupuncture - foresee technicians Anaesthetics 5. Pain r e l i e f problems l i t t l e role 3. Internists Intensive care 6. Resuscitation 4. No varicose vein or 4. General surgeons Anaesthesia 7. Varicose vein i n j e c t i o n s a l l e r g y infections 8. H y p o s e n s i t i z a t i o n 9. Teaching, Research, Administration Psychiatry Psychoses 1. T r a v e l l i n g teams to General practice Medical model vs. Neuroses r u r a l areas Nurses Psycho-social model Personality problems 2. Psychogeriatric ser- S o c i a l workers of team treatment Psychogenic reactions vices Psychologists programs Mental Retardation 3. Sub s p e c i a l i z a t i o n Administration, Research, 4. Community centre work Teaching 5. Reduced mental ho s p i t a l work-load Orthopaedic 1. Orthopedic services Surgery Ontario, A p r i l '72 - 40$ (23$ - s u r g i c a l s p e c i a l i s t s ) (38$ - family physicians) 2. Alberta 1970 - 21* of orthopaedic s p e c i a l i s t s time spent on surgery outside t h e i r s p e c i a l t y 1. Joint replacement surgery 2. More fracture work ob-tained by lesser role of G.P.'s and general surgeons General surgeons) Internists, surgeons P l a s t i c surgeons Orthopaedic tech-nicians Fractures Trauma management Tendon, hand surgery Fractures Urology 1. Care of adrenals, urinary t r a c t , male reproductive t r a c t 2. Teaching, administration 1. Exclusive care of adrenals Neurologists urinary t r a c t , male repro- Vascular surgeons ductive t r a c t Endocrinologists 2. Shared procedures l i s t Gynecologists e.g. renal transplantation Family physicians 3. More treatment teams Nurses, gu. technicians 4. More sexuality workload General surgeon -urologists Renal f a i l u r e patients, C o n f l i c t reduced by team approach General urology O BOUNDARIES PRESENT ANTICIPATED ROLE SHARED WITH CONFLICTS Otolaryngology Dermatology All e r g y and C l i n i c a l Immunology 1. Problems of ear, nose, throat larynx, plus neck, bronchi, oeso-phagus, also maxillo-f a c i a l 2 . 2 5 $ non-referred work i . e . primary contact 1. Continuing primary con- Neurology tact 2. Implantable hearing aids 3. Greater share of T. & A. 's 1. Skin Mucous membranes Venereal disease 2. Exclusive treatment l i s t a) h o s p i t a l i z e d patients b) l i f e - t h r e a t e n i n g eruptions c) Chronic d i s a b l i n g skin diseases d) systemic therapy re-quired e) a l l occupational derma-toses with 1 week loss of work 1. 5 0 $ of patients non-referred, i . e . have primary access 2. Exclusive treatment l i s t General and p l a s t i c surgeons A l l i e d health per-sonnel - Audiologists general/Family prac-Audiology and vestibular problems Cancer of head and neck T. & A. 's General practice Internists Surgeons A l l e r g i s t s General dermatology Systemic dermatoses Surgical lesions 1. Diagnostic and treatment a l l e r g y services 2. A l l e r g y treatment 1972-3 a) B.P./F.P.'s 77$ b) In t e r n i s t s 11$ c) Pediatricians 9% 3. C l i n i c a l Immunology - one competent to d i r e c t a service or research immunology laboratory 1. 20-30$ work primary contact (non-referred) 2. Continued s i m i l a r role General Practice Internists Pediatricians Not much contact P l a s t i c Surgery S u r g i c a l r e s t o r a t i o n of appearance and function - head and neck - hand - skin Increase i n hand surgery. Decrease i n head and neck surgery f o r carcinoma. Decrease i n hypospadias repa i r s . Increased micro-vascular surgery and tissue transplantation Otolaryngology Orthopaedic surgery General surgery Urology - Head and neck surgery - Hand surgery - Breast reconstruction - 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 Service times (minutes) Actual workload (hours/year) Di s t r i b u t i o n t o t a l per physician d i r e c t i n d i r e c t t o t a l t o t a l per physician of workload physician/year % 1. Consultations 148,192 16 30 15 45 111,144 12 0.5 2. Complete examinations 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. Hospital v i s i t s 11,323,948 1,188 5 5 10 1.887,324 198 8.8 ~S. Home v i s i t s 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 15 10 25 483,080 51 2.3 8. Surgical assistance 334,966 35 60 334,966 35 1.5 9. Obstetric services 193,329 20 180 579.987 60 2.7 10. Anaesthesia 675,158 71 75 843,947 88 3.9 13. Other diagnostic/ therapeutic services 8,358,487 877 5 696,541 73 3.2 14. Miscellaneous services TOTALS 70.099,546 7,353 21,559,209 • 100.0 (a) Based on service times attributed by the working party on physician manpower requirements d i s c i p l i n e . DATA SUMMARY, FEE-FOR-SERVICE WORKLOAD , FULL-TIME FEE-FOR-SERVICE PHYSICIANS, SPECIALTY OF GENERAL SURGERY Services/year Service times (minutes) Actual workload (hours/year) Distribution of workload t o t a l per physician d i r e c t i n d i r e c t t o t a l t o t a l per physician physician/year % 1. Consultations 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 3. Offi c e v i s i t s 2,134,864 1,268 15 5 20 711,621 423 15.S 4. Hospital v i s i t 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 surgery 226,651 135 60 30 90 339,977 202 7.4 8. Surgical assistance 57,243 34 95 30 125 119,256 71 2.6 9. Obstetric services- 6,574 4 10. Anaesthesia 7,477 4 13. Other diagnostic/ therapeutic services 880,786 523 10 146,797 87 3.2 14. Miscellaneous services 7,779 5 TOTALS 5,927,387 3.S21 4,582,515 2,722 100.0 (a) Based on service times attributed by the working party on specialty. physician manpower requirements for the VJ1 ^ 1 154 PROJECTIONS TOR PHYSICIAN MANPOWER FOR CANADA FOR 1981 WORKING PARTY PROPOSALS COMPARED TO REQUIREMENTS COMMITTEE RECOMMENDATIONS. Specialty Working Par Optimal Req f o r 1981 •ty Proposed uirements Requirement Recommendat f o r 1981 s Committee ions > Annual Supply to meet 1981 Requirements Number of^ Physicians (W.P.) D e f i c i t or Surplus from base years Physician: Population Ratio Number of Physicians (R.C.) Physician: Population Ratio Percentage Difference (WP-RC) ( WP ) x l 0 ° Present Needed General/ Family - n Practice 16,937 -1,930 1:1,440 16,937 1:1440 0 N.A. 713 Medical S p e c i a l t i e s Internal Medicine 3,193 -823 1:7,700 2,987 1:8,200 -6.5 183 182 Dermatology 375 -125 1:65,300 375 1:65,300 0 12 24 Neurology 288 -86 1:85,0OO 272 1:90,000 -5.6 N.A. 18 Paediatrics 1,340 -335 1:18,20O 1.224 1:20,000 -8.7 80-85 62 Psychiatry U984 to -370 to 1:12,300/ 2,225 1 :11,000 12.2 to 80 141 2,497 -883 9,800 -10.9 Surgical S p e c i a l t i e s General Surgery 2,234 -156 1:11,000 2,234 1:11,000 0 85 96 Cardio-vascular: Thoracic 210 -35 1:117,000 210 1:117,000 0 15-20 7 Neurosurgery 147 -11 1:166,700 147 1:166,700 0 11 4-5 Obstetrics: Gynecology 1,577 -402 1:15,500 1,398 1:17,500 -11.4 55-60 63 Ophtha-mology 887 r-107 1:27,600 874 1:28,000 -1.5 35 24 Otolaryn-gology 490 -75 1:50,000.OC 490 1:50,000 0 14-28 26 Orthopaedic Surgery 186 -261 1:30,000 805 1:30,400 -1.3 40-50 45 P l a s t i c Surgery 245 -73 1:100,000 245 1:100,000 0 15 13 Urology 489 -94 1:50,000 489 1:50,000 0 23 29 Other Spe c i a l t i e s Anaesthesia 1.781 -477 1:13.742 1.781 1:13.742 0 82 105 Totals 32,993 -33,506 -5,360 -5,873 32,693 -22.8 to -45.9 1552 A.. National Committee on Physician Manpower, Requirements f o r Physicians i n Canada, Part I I I March 1, 1976. B. Fee-For-Service Physicians. C. N.A. = Not Available 155 (CURRENT B.C. POPULATION - 2,409,515) Specialty H o l l c a l l 7 ^ Data (B.C. Population 2.409.515) Working Party Proposed Present Optimal Ratios Applied to Current B.C. Population C Ratio Number Ratio Number^ General/Family Practice 1:1068 2254 1:1440 1673 9259 62500 83333 19231 12048 Medical S p e c i a l t i e s Internal Medicine 1 Dermatology 1 Neurology 1 Paediatrics 1 Psychiatry 1 Surgical S p e c i a l t i e s General Surgery 1:9524 Cardiovascular:Thoracic 1:200000 Neurosurgery 1:111111 Obstetrics:Gynecology 1:19232 Opthalmology 1:20408 Otolaryngology 1:45455 Orthopaedic Surgery 1:29412 P l a s t i c Surgery 1:100000 Urology 1:45455 Other S p e c i a l t i e s Anaesthesia ' 1:13514 260 39 25 125 201 252 13 22 125 118 55 82 25 53 178 1:8000 1:89000 1:85000 1:18260 1:12300/9800 1:10630 1:124000 1:166700 1:15900 1:28000 1:50000 1:30400 1:104800 1:50000 1:3742 301 27 28 132 196/246 227 19 14 152 86 48 79 23 48 175 Totals 3827 3228/3278 C. D. R o l l c a l l 75, Report R:1, D i v i s i o n of Health Services Research and Development, Health Sciences Centre, University of B r i t i s h Columbia National Committee on Physician Manpower, Report of the Requirements Committee, Part I I I , March 1, 1976 Non Post-Graduate Physicians i n B r i t i s h Columbia Number of Physicians excluding Interns and Residents, (interns and Residents = 15$ of Physicians i n 1974). 156 PROJECTED PHYSICIAN MANPOWER RATIOS APPLIED TO B.C. FOR 1981 (PROJECTED 1981 B.C. POPULATION =2,821,700) Specialty R o l l c a l l 75 Data Working Party Future Optimal Requirements Committee Recommendations General/Family Practice Medical S p e c i a l t i e s Internal Medicine Dermatology Neurology Paediatrics Psychiatry Surgical S p e c i a l t i e s General Surgery Cardi ovascular:Thoracic Neurosurgery Obstetrics:Gynecology Ophthalmology Otolaryngology Orthopaedic Surgery P l a s t i c Surgery Urology Other S p e c i a l t i e s Anaesthesia Proposals Ratios Nos. Ratios Nos. Ratios Nos. 1:1068 2642 1:1440 I960 1:1440 1960 1:9259 305 1: 7700 366 1:8200 344 1:62500 45 1: 65300 43 1:65300. 43 1:83333 34 1: 85000 33 1:90000 31 1:19231 147 1; 18260 155 1:20000 141 1:12048 234 1 12300 to 229 -,1 9800 288 1:11000 257 1:9524 296 1 11000 257 1:11000 257 1:200000 14 1 .117000 24 1:117000 24 1:111111 25 1 : 166700 17 1:166700 17 1:19231 147 1 : 15500 182 1:17500 161 1:20408 138 1 :27600 102 1:28000 101 1:45455 62 1 :50000 56 1:50000 56 1:29412 96 1 :30000 94 1:30400 93 1:100000 28 1 :100000 28 1:100000 28 1:45455 62 1 :50000 56 1:50000 56 1:13514 209 1:13742 205 1:13742 205 Totals 4484 3807 -3866 3774 157 PROJECTIONS FOR PHYSICIAN MANPOWER FOR B.C. Calculated from Data from " R o l l c a l l 75" Specialty Non Post-Graduate Physicians Non Post-Graduate Physicians per Demi-Million Estimated Annual Rate of Change 1974-1975 Annual Rate X 6 years to 1981-$ Simple Pro-j e c t i o n 'Annual Rate '74,-•75 x 6 to 1981 from 1975 Numbers of Physicians General/Family Practice Medical S p e c i a l t i e s Internal Medicine Dermatology Neurology Paediatrics Psychiatry Surgical  S p e c i a l t i e s General Surgery Cardiovascular: Thoracic Neurosurgery Obstetrics: Gynecology Ophthalmology Otolaryneology Orthopaedic Surgery P l a s t i c Surgery Urology Other _ S p e c i a l t i e s Anaesthesia 2254 260 39 25 125 201 - 252 13 22 125 118 55 82 25 53 178 468 54 8 5 26 42. 52.5 2.5 4.5 26 24.5 11.5 17 5 VI 37 4.38$ 5.26 14.71 19.05 5.04 5-24 -1.56 8.33 -4.35 3.31 4.42 3.92 5.13 8.70 -3.64 2.30 26.28$ 31-56 88.26 114.3 30.24 31.44 -9.36 50 -26.1 19.86 26.52 23.52 30.78 52.2 • -21.84 13.8 2846 342 73 53 163 264 228 19-5 16 150 149 68 107 38 41 202.5 Totals 3827 4760 158 ASSUMPTIONS DEFINITION SERVICE PATTKHN AIWUMWIOMJ AflD DATA A55UXITI0H3 TOMART CARE OR CONTACT SERVICE TIMES >*ULL TIME PEE AND SPECIFICS FOR 5KRVXCK rmrrucniw: OPTIMUM AVERAGE WORK YEAR OPTIMUM AVERAGE WORK WEEK OPTIMAL HONK FORCE FHrJICXAN/POIVUTlOR um GtMnl or Family >raetice Definition li nonexclusive. Applicable to internists also Ideal ayatcn haa primary eara aa exclusive re-aponalbility of CP/FP 9395 93.8* Coanaelling a n d Ona who re- 46 working 49 houra paychotherapy eoived ovar vecktf (ideal - 40 aarvicoa cannot ba 120,000.00 houra) averaged for a unit of aaxrlea. Micro arrora i n average aarvlea t l M estlmetea oauao larfa man* powar dlatortiona when applied to high volume eer-vicea auch aa offl o t T i a i t a . Internal Medicine Global term Diseases and disorders of Internal struc-turea of adult body exclude3 dermatology * neurology 15* of internist'a new patients seen on a priaary basis. 85* referred casea. Sub-specialties: nearly 100* referred. Presently popu-lation i a under-serviced by 10* 1616 93.5* 46 working Pediatrics Health care 70* of paediatricians Di f f i c u l t y sep- 693 94* 46 veeks 48 hours 1:16260 from concep- accept non-referred arating priaary tion to cases. There i a a from secondary adolescence strong demand for service priaary care froa paediatricians Obstetrics Total health Consultations consti- More or leas 992 96.5* 46 weeks 48 houra 1:15900 and care of women tute 10Z of workload atandard (84*) Gynecology related to re- Public should maintain production and primary care a b i l i t y reproductive organs General Surgical and Ontario - 10* of income of Direct va Indirect 1664 96* 45 weak* 55 hours 1:10630 Surgery non-surgical general surgeona comes service time com- . treatment of from general practice ponents. Times potentially tended to ba on surgical lew aide conditions Aaaeatheaia Prevention of Rone Quebec average of 1570 Workload 45 weeks 54 hours i n 1:13742 pain and l i f e 61 minutes average s p l i t community hos-support. Hot anaeathstio time with p i t a l . 57 an i n s t i t u - l n community hos- Practi- hours i n a tional aerrica pitals (76 minutes tioner teaching l n teaching hospi- Anaes- hospital tals) thetists Psychiatry Diagnosis and Ro assumptions made Lack of hard data Only 50* of 45 vseka 48 hours (35 1:12336 to treatment of psychiatrists houra c l i n i c a l ) 1:9800 paychoaea. are F.T.F.f.S, neuroses, per- remainder on aonality pro- aalary or blems, psycho-* aesaional genie reactlona basis Orthopedic Diagnosis and Majority should be re- Alberta 1970: 76* 490 96* 46 weeks 45 hours Approximately Surgery treatment of referred except for of time on ortho- 1:30000 Musculo- emergencies pod ica, 21* on skeletal sys- surgery outaide tem conditions their specialty Ontario 1972i Orthopedic aur» geona did 40* of orthopedic ser-vices Urology Diaeaeee of adrenals, the urinary tract and the male reproductive tract Moos or l i t t l e Data inadequate because Ontario and Quobeo omitted from sur-gical workload tables. Ron* standardised coding 357 96* 46 weeks 52 hours 1)48585 159 GROWTH ASSUMPTTflws / " *  M o r *  o f p r l - * V f l i * U ••rttflwj ~ r y s.nrlcs. should bo uoad Population growth 11.4* *«lnI population Kopo group prac-tltt Only u cooplo-••ntary rolo, not as cub— o t i ration I9a1 TAKUhT J«J«E» or CHAOUATK TO B 0 C T 0 E I ATTAIN TAP.OCT Mo changoo oxeopt fop » n prlnary contact 10755 (Al l PT, foo-for •oryies) I N ) ; (Foo-for-aorrica) 452 71) Intornal Xodicina Moro aub-• p o o i o l i u -UOB Dopands on training of OP/FP Pr ioar l ly mo consultants 11.771 population (Tooth 3-47» lneroasod u t l l i u t l o n Ineraaaing tacfa-nological ooa-ploxlty Porhapa ooro priamry contact fop gonoral intornlats i f Unltad Stat.a tronda adopts* 3193 Podia tr ico Otatotpioa Gynoeology Gonoral Surgory Anaoothosia Psychiatry Kov oub-opocialtiaa loonatology gonotics t i e . idoloacont •odicino Mora sub- H apoeialt ias. Half of ppo-oont output 55-40 pop yoar, •PO fopoign nod lea l grsduataa Mnlntalnod Band fop ppisary aocondapy)eapa tar i i a ry , Consultant rola Tariaa with alio of 11.77* population growth. Kov hoalth capo do-l ivory pattorna - eoasunity cowtpoo 12.3% population growth. Kola of isaigratlon r e -str ict ions w i l l do f io i t . Againat paadla-tpie aurao-prsc-titionapa azeapt for raoots apoaa and noonatal i n -tanaiva capo Hot Corssaon bo-foro 1981. No* rolo for nurso-obatatpician da-ponds on nov pay-snnt aothoda Minor. Ilo surgical polo i n auturo a l l high r i sk ob-stetr ics patiants. Exclusive obstoc-r i ca procoduro l i s t . Escluairo gynecology pro— oodupa l i s t 1577 Ono third of Minlsiss, o i - . 0 1 . p r i s . n l , no» o a r t i f l - capt fop group conaultanta easts apa P.M. coverage, but •••a. Sub- maintain aoca spealal ly prisary capo training w i l l contact lacraasn Population growth of 11.7*. Shi f t O.P. aurgery to gonoral aurgoona Sugpeet opor-ating rooa tochniciana fop surgical assistance If rea t r i c -tlon on fop-•iga nodical grsduatee, than leeasp qual i ty of aoaaathatlc oaro w i l l po-sult Hone Ao conaultanta only Population growth of \ A % . Xneroaaod aso.es •inten-siTists' AeupuBoturo Asauae C P . aur-«opy. Haalth capa da l i rary patterae w i l l not eauao change i n futuro r»— Jllli Tenant fieanta an-nually. Xoro aubapocialita-tloo '.B.B. - 75* l i k e l y son. Mora asbulat-of new c o p t i - but pr inar i ly 0 r y caro, laaa — ra fo r ra l . inet ltucion-Isatloa ronulation growth Aging of popula-t ion. Lack of rura l aarvleoo. Low pr ior i ty tor A l l anaosthotica training of anaaa- and anaosthatlc thotle techniclaoB.aorvicea ahould Profar r.M.C.'a to bo provided by tra in in ansos- snaoathatlata thoaia rathar than upgrading anaee-thatlc practltlonera Ut i l i se a i l ' catagorios ^oroua boundaries -" 1984-2497 Opthopodio D n 0 W , d 1 , 0 i n c r — • A. Conaultanta Population gpo.th Opon to poo- Loea orthopedic. giT rr-rr-Supgory 1 * . Roduca wait- a i b i l i t y by gonoral aup- ° ~ i 0 lug period for (.on. and by appolntaonts. In- O.P.'a eroaaad dooand fop olnor conditions. Aging populaclono. Urology Ooaand epe-e i f l e uro-logical training for laatigrant swrglcal-•rologlats > Consultants , . mcroaood ronal tranaplanto 2. Ihoroaaod as -bulatopy eara •oana sore i n -offlcloney and laepoaaod nood for aopo upologlota Mopv uao an-t i c ! patad, oapoclally in c l in i ca Consolidation of ppooont boundapioa 160 EDUCATIONAL OBJECTIVES FOR CERTIFICATION. IN FAMILY • MEDICINE The C o l l e g e of Family P h y s i c i a n s Part I, 1974. The p a r t i c u l a r f u n c t i o n o f the c e r t i f i e d f a m i l y p h y s i c i a n has been d e s c r i b e d by the C o l l e g e of Family P h y s i c i a n s : "A C e r t i f i e d Family P h y s i c i a n s h a l l be s k i l l e d i n e s t a b l i s h i n g and mai n t a i n i n g r e l a t i o n s h i p s with p a t i e n t s and a s o c i a t e s which f a c i l i t a t e maximally, the p r o v i s i o n of he 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 h e a l t h problems and i n v e s t i g a t i n g and managing common h e a l t h problems. He s h a l l be able to arrange through c o n s u l t a t i o n and d e l e g a t i o n , the p r o v i s i o n to p a t i e n t s of those elements of h e a l t h care which are b e t t e r provided by other h e a l t h p r o f e s s i o n a l s . He s h a l l be t e c h n i c a l l y competent at those procedures commonly re q u i r e d i n primary care. He s h a l l provide for a c o n s t a n t l y a v a i l a b l e h e a l t h s e r v i c e to persons r e g a r d l e s s of t h e i r age or problem. He s h a l l s e l e c t f o r p a t i e n t s , those p r e v e n t a t i v e and screening procedures, as w e l l as methods of i n v e s t i g a t i o n and management, which are e s t a b l i s h e d as worthwhile. He s h a l l c o n t i n u o u s l y review and up-date h i s competency and be capable of a s s e s s i n g p e r t i n e n t research." Table 8-1 Major Methods for Assessing and Projecting Manpower Requirements Method Advantages Disadvantages Prerequisites and Appropriate Country Situations Professional standards Physician-population talio Economic-demographic Service targets Fullfills health ethic of providing services according to need provides ultimate or maximum goal for the provision of services Easy lo use and interpret; Data requirements usually modest and not very sensitive to errors Tends to produce economically realistic projections; Probably provides a good estimate of minimum growth in demand and ensures that the level of future satisfaction at least equals present satisfaction Permits a disagreed approach in which the most suitable methods and standards are used for each . component activity of the sector; With primary emphasis on "ser-vices," not "manpower," attention focused on productivity and effi-cient resource utilization; Facilitates closer adjustment to delivery ID needs and demands Continued wide divergence among experts on "best" methods to treat many disease conditions; Apt to result in costly projections of service requirements; Far in excess of ability to provide them Easy to select unrealistic ratios resulting in major errors in economic and manpower policies; Provides little insight into the dynam-ics of demand; With primary emphasis on manpower, little attention may be given to health services May be complicated and costly, and requires sophisticated data; Does not necessarily take into account the quality o f services or their relevance to the health prob-lems of the country; May neglect consideration of ways to improve manpower productivity Prone to having standards based more on desires than on reality, leading to major policy errors; High degree of statistical expertise may be required to sue successfully Requires sophisticated data and 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, reason-ably adequate health services delivery system, and limited plan-ning resources Requires sophisticated data and technical expertise in tome areas; O f greatest use in countries with large private sector; Limited government involvement in the provision o f health services Modest data and planning capa-bility requirements; O f greatest use in countries with activist government policies toward development and provi-sion of health services; Adequate governmental control over health services delivery system Source: T h o m w Hall. "Estimating Requirements and Supply: Where Do We Stand?" inPan A merican Conference on Health Manpower Planning. Scientific Publication No, 279 (WWhington. p . C : Pan American Health Organization, 1974). pp. 64-65. Ti O M X APPENDIX 5. ALTERNATIVE MODELS OF PHYSICTAN PRICING 162 P h y s i c i a n s Are P r i c e Takers Fees c l e a r the the market f o r p h y s i c i a n s e r v i c e s The p h y s i c i a n s e l l s h i s s e r v i c e s i n a competitive l o c a l market and r e a c t s to market-deter-mined . l o c a l fee schedules B Fees do not c l e a r the market f o r p h y s i c i a n s e r v i c e s There are p r i c e c e i l i n g s , which are s e t by t h i r d p a r t y payers, and the i n d i v i d u a l p h y s i c i a n r e a c t s to these fees II P h y s i c i a n s Are P r i c e S e t t e r s The p h y s i c i a n enjoys a monopoly i n the the market for h i s s e r v i c e s and s e t s h i s fees 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 -a t i n g ( s l i d i n g - s c a l e -fee-schedule) mon-o p o l o s t . The p h y s i c i a n takes whatever cases he l i k e s , organizes h i s p r a c t i c e to s u i t h i s t a s t e s , and sets h i s fees so as to generate a given t a r g e t i n -come, r e l a t e d , presumably, to the l o c a l i t y . Reinhardt,. Uwe: Health manpower planning i n a market context: the case of p h y s i c i a n manpower, i n Systems aspects of h e a l t h p l a n n i n g , N. B a i l e y and M. Thompson eds. Proceedings of the II ASA Conference, Baden, A u s t r i a , August 20-22, 1974. New York: North Holland, 1975, p.146. APPENDIX 6 . 163 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 physi-cian, and the hospital organization. Further, the Associ-ation presents these rights in the expectation that they will be supported by the hospital on behalf of its pa-tients, as an integral part of the healing process. It is^ recognized that a personal relationship between the phy-sician 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 prec-edent 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 re-spectful care. 2. The patient has the right to obtain from bis physician complete current information concern-ing 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 in-formation should be made available to an ap-propriate 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 in-formation for informed consent, should include but not necessarily be limited to the specific pro-cedure and/or treatment, the medically signifi-cant risks involved, and the probable duration of incapacitation. Where medically significant al-ternatives for care or treatment exist, or when the patient requests information concerning med-ical 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 in-formed 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, exami-nation, 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 the right to expect that all com-munications 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 res-ponse to the 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 explana-tion concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must first have ac-cepted 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 phy-sician or a delegate of the physician of the pa-tient's continuing health care requirements fol-lowing discharge. 1L The patient has the right to examine and re-ceive an explanation of his bill regardless of source of payment 12. The patient has the right to 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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