Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Alternative care delivery systems : an empirical study and commentary Ratsoy, M. Bernadet 1981

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1981_A6_7 R28.pdf [ 7.1MB ]
Metadata
JSON: 831-1.0095070.json
JSON-LD: 831-1.0095070-ld.json
RDF/XML (Pretty): 831-1.0095070-rdf.xml
RDF/JSON: 831-1.0095070-rdf.json
Turtle: 831-1.0095070-turtle.txt
N-Triples: 831-1.0095070-rdf-ntriples.txt
Original Record: 831-1.0095070-source.json
Full Text
831-1.0095070-fulltext.txt
Citation
831-1.0095070.ris

Full Text

ALTERNATIVE CARE DELIVERY SYSTEMS: AN EMPIRICAL STUDY AND COMMENTARY by M. BERNADET RATSOY B.Sc.N., The U n i v e r s i t y o f B r i t i s h C o lumbia, 1968 A T h e s i s S u b m i t t e d i n P a r t i a l F u l f i l m e n t o f the Requirements F o r the Degree o f Mast e r o f S c i e n c e i n The F a c u l t y o f Graduate S t u d i e s Department o f H e a l t h Care and E p i d e m i o l o g y H e a l t h S e r v i c e s P l a n n i n g We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA AUGUST 19 81 © M . BERNADET RATSOY 19 81 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C o lumbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my de-partment o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s under-s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f H e a l t h Care and E p i d e m i o l o g y U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, B r i t i s h Columbia V6T 1W5 ABSTRACT The r i s i n g c o s t s o f h e a l t h care'and the l a c k o f i n t e -g r a t i o n between p a r t s o f the d e l i v e r y system has l e d t o d i s c u s s i o n and e x p e r i m e n t s on new forms o f d e l i v e r i n g c a r e . Governments have i n c l u d e d the development o f ambulat o r y c a r e i n new st a t e m e n t s o f o b j e c t i v e s and g o a l s i n the hope t h a t e x p e n d i t u r e s might be reduced t h r o u g h the reduced use p f a c u t e c a r e h o s p i t a l beds. T h i s i s a s t u d y o f the e x p e r i e n c e s u r r o u n d i n g an acut e c a r e h o s p i t a l ' s a t t e m p t s t o have a M e d i c a l Day Care Program a c c e p t e d by the government as an a d j u n c t t o the e x i s t i n g Ambulatory Care S e r v i c e s o f t h e h o s p i t a l . As D i r e c t o r o f N u r s i n g a t the h o s p i t a l i t was p o s s i b l e t o f o l l o w the sequence o f e v e n t s , c o n c e p t development, p r o p o s a l d e s i g n , m i n i s t r y i n v o l v e m e n t , i m p l e m e n t a t i o n and e v a l u a t i o n . A d i a r y was k e p t f o r one y e a r f o l l o w i n g im-p l e m e n t a t i o n o f t h e program as a p i l o t p r o j e c t and p r o j e c t documents have c o n t r i b u t e d t o the a n a l y s i s o f e v e n t s . What was not r e a d i l y a p p a r e n t were the many f o r c e s o u t s i d e the h o s p i t a l w h i c h were i m p a c t i n g on the l i k e l i h o o d o f the p r o p o s a l ' s a c c e p t a n c e . S i n c e Ambulatory Care was the h e a l t h p o l i c y o f the 1970's i t was p u z z l i n g t o f i n d the M i n i s t r y o f H e a l t h u n r e s p o n s i v e t o a p r o p o s a l which seemed most a p p r o p r i a t e . i i I n a t t e m p t s t o r e s o l v e the p u z z l e r e g a r d i n g the l a c k o f i n t e r e s t i n ambulatory c a r e a t the h o s p i t a l l e v e l , o t h e r developments i n the p r o v i n c e were r e v i e w e d . P l a n n i n g models were e x p l o r e d s e e k i n g e x p l a n a t i o n f o r i n c o n s i s t e n -c i e s o b s e r v e d between s t a t e d government o b j e c t i v e s and government b e h a v i o r i n r e l a t i o n t o the development o f h o s p i t a l a m b u l a t o r y c a r e . More s a t i s f a c t o r y e x p l a n a t i o n s were found i n a p o l i t i c a l model th a n i n p l a n n i n g models, i n the l i g h t o f a c t u a l developments. Some c o n c l u s i o n s a r e drawn about the impact o f p o l i t i c a l r e a l i t i e s on management f u n c t i o n s i n h e a l t h c a r e i n s t i t u t i o n s . CONTENTS I INTRODUCTION 1 I I HISTORICAL CONTEXT OF AMBULATORY 7 CARE IN CANADA I I I PROVINCIAL ACTIVITY IN AMBULATORY CARE 16 IV MEDICAL DAY CARE PROGRAM AT ST. PAUL'S HOSPITAL 47 V INCONSISTENCIES IN BEHAVIOR ON THE PART OF GOVERNMENT 64 VI PLANNING : A POLITICAL PROCESS 72 V I I PROPOSALS AND THE POLITICAL SYSTEM 87 V I I I CONCLUSIONS 113 IX APPENDICES 125 X SOURCES CONSULTED 148 I v ACKNOWLE DGEMENT I would l i k e t o t a k e t h i s o p p o r t u n i t y t o thank Dr. A. C r i c h t o n f o r h e r generous and k i n d l y s u p p o r t t h r o u g h o u t the c o n c e p t i o n and w r i t i n g o f t h i s t h e s i s . Her sense o f my d i r e c t i o n e l i m i n a t e d some unn e c e s s a r y s i d e t r i p s and i s g r e a t l y a p p r e c i a t e d . The a s t u t e c r i t i q u e o f the work by t h e s i s committee members, Dr. C. McKenzie and Mr. B. Weisman, has w i t h o u t doubt improved the q u a l i t y o f the work. A l s o , I would w i s h t o thank Dr. H. McDonald f o r h i s s u p p o r t and f o r h i s a u t h o r i z a t i o n t o use h o s p i t a l documents and t o Anne Waters and A n i t a Greenaway f o r t h e i r p a t i e n c e and t y p i n g s k i l l s . v ' CHAPTER I INTRODUCTION T h i s i s the s t u d y o f the development o f a M e d i c a l Day Care Program a t S t . P a u l ' s H o s p i t a l , Vancouver, BC, e s p e c i a l l y as the development r e l a t e s t o the M i n i s t r y o f H e a l t h ' s i n v o l v e m e n t . As D i r e c t o r o f N u r s i n g a t the h o s p i t a l , and member o f the E x e c u t i v e Committee, i t was p o s s i b l e t o f o l l o w the d e c i s i o n s t a k e n about i n t r o d u c t i o n , development, and i m p l e m e n t a t i o n o f the program on t h e p a r t o f the h o s p i t a l . A d i a r y was k e p t f o r one y e a r f o l l o w i n g the i n i t i a t i o n o f what f i n a l l y was t o be a p i l o t p r o j e c t , and s u p p o r t i n g documents have been b r o u g h t t o -g e t h e r t o form a b a s i s f o r . a n a l y s i s o f e v e n t s . What was n o t i m m e d i a t e l y v i s i b l e t o a D i r e c t o r o f N u r s i n g were the s h i f t s i n power and the changes i n government p o l i c y w h i c h were n e c e s s a r y t o e x p l o r e t o answer the q u e s t i o n o f t h i s t h e s i s : S i n c e ambulatory c a r e was the d e s i r e d  h e a l t h p o l i c y o f the 1 9 7 0 ' s i n Canada, why has an a p p a r e n t l y  s u c c e s s f u l program f a i l e d t o r e c e i v e c o n t i n u i n g g o v e r n -ment s u p p o r t ? The C o n t e x t Chapter I I s e t s the scene. The Canadian H e a l t h I n s u r a n c e program was d e v e l o p e d between the mid 1 9 4 0 ' s and the l a t e 1 9 6 0 ' s . The f e d e r a l government o f f e r e d a s e r i e s o f matching g r a n t s t o the p r o v i n c e s t o d e v e l o p 1 p u b l i c l y funded h e a l t h c a r e programs. B r i t i s h Columbia responded, a c c e p t i n g the f e d e r a l o f f e r s . By the mid-s i x t i e s , however, co n c e r n s had begun t o be e x p r e s s e d about the e x t e n t o f the commitment t o p r o v i d e s e r v i c e s and the methods f o r d o i n g so. The e x t e n s i v e use o f i n p a t i e n t c a r e i n a c u t e c a r e h o s p i t a l s began t o be q u e s t i o n e d and a l t e r -n a t i v e methods o f f u n d i n g c a r e and d e l i v e r y o f s e r v i c e s were s u g g e s t e d . How the p r o v i n c e o f B r i t i s h Columbia has responded t o i t s h e a l t h c a r e r e s p o n s i b i l i t i e s i n the a r e a o f a m b u l a t o r y c a r e i s the c o n t e n t o f Chapter I I I . The Ambulatory Care Program Once Ambulatory Care had been d e c l a r e d a 'good t h i n g ' s e v e r a l groups p i c k e d up the i n i t i a t i v e t o d e v e l o p a v a r i e t y o f s e r v i c e s which f i t under the u m b r e l l a o f a m b u l a t o r y c a r e . Some o f the groups implemented p r o -grams, o t h e r groups atte m p t e d t o f a c i l i t a t e development. A t t h a t t i m e , the main p r o v i n c i a l a c t i v i t y i n t h i s f i e l d seemed t o be o r i e n t e d toward h o s p i t a l - b a s e d programs. The s h o r t - l i v e d B r i t i s h Columbia M e d i c a l C e n t r e and the G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t were two b o d i e s i n B.C. which have p l a y e d the r o l e o f f a c i l i t a t o r s o f h o s p i t a l a m b u l a t o r y c a r e programs. As i n d i v i d u a l i n s t i t u t i o n s were m o t i v a t e d t o d e v e l o p programs, the f i e l d expanded. Government f u n d i n g / s u p p o r t was, and remains r e s t r i c t e d t o a s h o r t l i s t o f p r o c e d u r a l i t e m s and, more r e c e n t l y , b l o c k f u n d i n g was p r o v i d e d f o r a 2 l i m i t e d number o f programs a t one h o s p i t a l . However, the p r o v i n c i a l P u b l i c H e a l t h S e r v i c e had d e v e l o p e d a Home Care Program o v e r many y e a r s and i n 1971 r e s o u r c e s were d i r e c t e d i n t o a h o s p i t a l r e p l a c e m e n t program. I t was aimed a t d i r e c t s u b s t i t u t i o n o f expen-s i v e a c u t e c a r e h o s p i t a l time w i t h c a r e p r o v i d e d i n the p a t i e n t ' s own home i n s t e a d . F i v e Community Human Resources and H e a l t h C e n t r e s were e s t a b l i s h e d d u r i n g the NDP government o f 19 72-76 bu t f u r t h e r a c t i o n i n t h i s a r e a o f development was abandoned when a S o c i a l C r e d i t government was r e - e l e c t e d i n 1976. The f o u r c e n t r e s w h i c h c o n t i n u e t o e x i s t have met i n i t i a l e x p e c t a t i o n s f o r l e s s h o s p i t a l usage, b e t t e r a c c e s s i b i l i t y and l e s s c o s t s . (See C h a p t e r I I I ) Reasons f o r not p u r s u i n g t h i s s u c c e s s f u l o p t i o n remain a m a t t e r o f s p e c u l a t i o n . One manpower s u b s t i t u t i o n p r o j e c t d e m o n s t r a t i n g the e f f e c t i v e n e s s o f the n u rse p r a c t i t i o n e r was the o n l y p r o v i n c i a l a c t i v i t y i n t h i s a r e a o f p o t e n t i a l c o s t r e d u c t i o n . F i n d i n g s were s i m i l a r t o t h o s e o f o t h e r p r o j e c t s , (See C h apter I I ) , c o n ducted a c r o s s the c o u n t r y . D e s p i t e p o s i t i v e r e s u l t s , t h i s development has d i e d f o r r e a s o n s w h i c h p r o b a b l y r e l a t e t o the m e d i c a l c o n t r o l o f h e a l t h c a r e d e l i v e r y . 3 A r r i v i n g on the scene a t a much l a t e r d a t e , b u t h a v i n g a s t r o n g i n f l u e n c e on f u r t h e r Ambulatory Care developments i n c l u d i n g h o s p i t a l based programs, was the Long Term Care Program (LTC) i n t r o d u c e d J a n u a r y , 1978. I n t r o d u c t i o n o f the program r e c o g n i z e d t h e need f o r c h r o n i c c a r e i n t h e p r o v i n c e . I t was e x p e c t e d t o r e l i e v e the problem o f f a m i l i e s c a r i n g f o r t h e i r e l d e r l y members and t o p l a c e p e o p l e r e q u i r i n g i n s t i t u t i o n a l c a r e i n t o more a p p r o p r i a t e , i . e . , n o t ac u t e c a r e , e n v i r o n m e n t s . The program was e x p e c t e d t o consume 15% o f the h e a l t h c a r e budget. Even so, i t has n o t met the demonstrated need. Presumably the expense o f t h i s program, as well-.as: main-t a i n i n g o t h e r s e r v i c e s , has b r o u g h t about the government's i n t e n s e c o n c e r n about f i s c a l c o n t r o l . Most m i n i s t r y a c t i v i t y i s now f o c u s s e d on t i g h t e r c o n t r o l ; w i t h c u t -backs i n i n p a t i e n t and a m b u l a t o r y c a r e , 19 81 a l l o c a t i o n s t o h o s p i t a l s a r e l e s s t han the i n f l a t i o n r a t e . I n v e s t i -g a t i o n s o f f i n a n c i a l management o f the l a r g e r h o s p i t a l s a r e o n g o i n g . The LTC program has o r i e n t e d the p u b l i c toward i n s t i t u t i o n a l c a r e a l t h o u g h the s t a t e d prime purpose o f the program was t o a s s i s t p e o p l e i n t h e i r homes. The P i l o t Program a t S t . P a u l ' s D e s c r i b e d C hapter IV i s an acc o u n t o f the e v o l u t i o n o f the M e d i c a l Day Care Program a t S t . P a u l ' s H o s p i t a l . 4 I n response t o an i n t e r n a l need and a B r i t i s h Columbia M e d i c a l C e n t r e commitment, the h o s p i t a l sought government s u p p o r t o f a new a m b u l a t o r y c a r e program i n 19 76. The program was d e s i g n e d t o a l l e v i a t e the h o s p i t a l ' s h i g h occupancy problem as w e l l as t o c o n t r i b u t e a l e s s expen-s i v e c a r e d e l i v e r y o p t i o n t o the community. The p r o p o s a l was a c c e p t e d as a one y e a r p i l o t p r o j e c t o n l y , b u t t h r e e y e a r s l a t e r no government e v a l u a t i o n has o c c u r r e d . The Q u e s t i o n Chapter V r a i s e s the q u e s t i o n o f the i n c o n s i s t e n c i e s between s t a t e d government o b j e c t i v e s and a c t u a l b e h a v i o r , i n r e l a t i o n t o a m b u l a t o r y c a r e g e n e r a l l y . Why d i d the government appear t o s u p p o r t the development o f amb u l a t o r y c a r e programs and then w i t h h o l d s u p p o r t f o r two y e a r s from S t . P a u l ' s p r o p o s a l , a c c e p t i n g , i n the end, o n l y a p i l o t p r o j e c t ? A n a l y s i s P l a n n i n g models a r e c o n s i d e r e d i n C h a p t e r V I . They proved i n a d e q u a t e t o e x p l a i n the S t . P a u l ' s s i t u a t i o n . D e c i s i o n s are c o n s t a n t l y made on the b a s i s o f m i s i n f o r -m a t i o n , f a l s e images o f t h e w o r l d and, i n the absence o f c r u c i a l i n f o r m a t i o n w h i c h may o r may n o t e x i s t . O p t i o n s s t u d i e d are n o t a l l t h o s e p o s s i b l e b u t a s e l e c t e d few t h a t d e c i s i o n - m a k e r s choose on p o l i t i c a l .5 grounds. P l a n n i n g i s a p r o c e s s used t o c o n t r o l d e v e l o p -ment i n the manner d e s i r e d by tho s e w i t h power. Ad hoc and i n c o n s i s t e n t purposes i n government encourage 'game p l a y i n g ' and c o m p e t i t i o n between i n s t i t u -t i o n s and a g e n c i e s w h i c h r e l y on government f o r f u n d i n g . T r a c i n g the p r o g r e s s o f i s s u e s t h r o u g h the p o l i t i c a l system p r o v i d e s more s a t i s f a c t o r y e x p l a n a t i o n s f o r the c i r c u m s t a n c e s o b s e r v e d i n B r i t i s h C o l umbia. T h i s p r o c e s s i s d e s c r i b e d i n Chapter V I I u s i n g the H a l l e t a l model which o r g a n i z e s the p r o c e s s i n t o the a r e a s o f l e g i t i m a c y , f e a s i b i l i t y , and s u p p o r t . A l t h o u g h each i s s u e t r a v e l s an i d i o s y n c r a t i c r o u t e , the c h a r a c t e r i s t i c s d e s c r i b e d do a p p l y t o each i s s u e i n a l e s s e r o r g r e a t e r degree. Chapter V I I I p r o v i d e s a summary o f the con-c l u s i o n s w h i c h have been drawn from p e r s o n a l e x p e r i e n c e s as a h e a l t h c a r e a d m i n i s t r a t o r i n B.C.,at the h o s p i t a l l e v e l , e x p l o r a t i o n o f e v e n t s r e l a t e d t o the development o f ambulatory c a r e i n B.C. and, from a t t e m p t s t o a p p l y p l a n n i n g and p o l i t i c a l models t o e x p l a i n the s i t u a t i o n . T h i s p a r t l y e n t r e p r e n e u r i a l , p a r t l y government c o n t r o l l e d h e a l t h c a r e b u s i n e s s demands t h a t a s u c c e s s -f u l manager u n d e r s t a n d and l e a r n how t o n e g o t i a t e the maze r e s u l t i n g from c o n f l i c t i n g i d e o l o g i e s , f i s c a l c o n s t r a i n t s , and power b r o k e r i n g . 6 CHAPTER I I THE HISTORICAL CONTEXT OF AMBULATORY CARE IN CANADA The B r i t i s h N o r t h A m e r i c a A c t o f 1867 makes l i t t l e s p e c i f i c r e f e r e n c e t o h e a l t h c a r e , w h i c h i s u n d e r s t a n d a b l e , s i n c e the A c t was w r i t t e n i n a time when government i n -volvement was r e s t r i c t e d t o r e s p o n s e s t o emergencies. F o r the most p a r t , i n d i v i d u a l s r e l i e d on t h e i r own r e -s o u r c e s o r t h o s e o f t h e i r f a m i l y . H o s p i t a l s o f the day were a d m i n i s t e r e d and f i n a n c e d by c h a r i t i e s , v o l u n t a r y and r e l i g i o u s o r g a n i z a t i o n s , t o c a r r y out t h e i r p h i l a n -t h r o p i c o b j e c t i v e s . The A c t i s v e r y u n s p e c i f i c about j u r i s d i c t i o n b u t t h r o u g h t r a d i t i o n and c o u r t d e c i s i o n s the p r o v i n c e s have been g i v e n the r e s p o n s i b i l i t y f o r h e a l t h c a r e . A t the b e g i n n i n g t h i s was a m a t t e r o f r e g u l a t i n g s t a n d a r d s . However, the Canadian N a t i o n a l H e a l t h I n s u r a n c e program was d e v e l o p e d between the mid 1940's and the l a t e 1960's. Through t h i s , the f e d e r a l government o f f e r e d a s e r i e s o f m a t ching g r a n t s t o the p r o v i n c e s t o d e v e l o p p u b l i c l y funded h e a l t h c a r e programs. Government i n t e r v e n t i o n i n t o the p r o v i s i o n o f s i c k n e s s c a r e ^ h a s b r o u g h t w i t h i t a p e c u l i a r s e t o f "*"The phrase ' s i c k n e s s c a r e ' i s used because i t i s more c o r r e c t l y d e s c r i p t i v e o f the s e r v i c e s s u p p o r t e d t h r o u g h e a r l y f e d e r a l f u n d i n g . 7 problems. P o l i c i e s i n s t i t u t e d have had some p o s i t i v e r e s u l t s b u t have a l s o proven t o have some u n f o r e s e e n n e g a t i v e consequences. By the m i d - s i x t i e s , c o n c e r n s had begun t o be e x p r e s s e d about the e x t e n t o f commit-ment t o p r o v i d e s e r v i c e s and the methods f o r d o i n g so. 2 In Canada, as i n the U n i t e d S t a t e s , a c u t e c a r e h o s p i t a l beds were o v e r b u i l t and t h i s generous a v a i l -a b i l i t y o f beds has l e d t o usage w h i c h would n ot have been n e c e s s a r y e x c e p t t h a t the beds were a v a i l a b l e . The H o s p i t a l I n s u r a n c e and D i a g n o s t i c S e r v i c e s A c t o f 1958 f o c u s s e d on i n c e n t i v e s w h i c h promoted the use o f h o s p i t a l beds. T h i s l e g i s l a t i o n p r o v i d e d f e d e r a l funds on a ma t c h i n g b a s i s w i t h the p r o v i n c e s t o c o v e r a l m o s t a l l o p e r a t i n g c o s t s o f ac u t e c a r e h o s p i t a l s w h i c h had been c o n s t r u c t e d a c r o s s the c o u n t r y w i t h f e d e r a l funds g r a n t e d t h r o u g h e a r l i e r l e g i s l a t i o n . The e x t e n s i v e use o f i n p a t i e n t c a r e i n ac u t e c a r e h o s p i t a l s began t o be q u e s t i o n e d and a l t e r n a t i v e methods o f f u n d i n g c a r e and d e l i v e r y o f s e r v i c e s were s u g g e s t e d . S e v e r a l r e p o r t s and commissions, f e d e r a l and p r o v i n c i a l , p roposed means by which the h e a l t h c a r e system c o u l d reduce e x p e n d i t u r e s w i t h o u t e n d a n g e r i n g the p u b l i c h e a l t h and w e l l - b e i n g . The 1964 R o y a l Commission on H e a l t h 2 Robin E. M c S t r a v i c , "A Case F o r A H o s p i t a l Census V a r i a t i o n and Bed Needs Formula," American J o u r n a l o f  H e a l t h P l a n n i n g , ( A p r i l , 1978), 51. 8 S e r v i c e s s t a t e d t h a t an u n n e c e s s a r i l y l a r g e volume o f c a r e was b e i n g p r o v i d e d t o i n p a t i e n t s w h i c h c o u l d e q u a l l y 3 w e l l be p r o v i d e d a t lo w e r c o s t t o o u t p a t i e n t s . The Commission recommended t h a t h o s p i t a l s become i n v o l v e d w i t h development o f home c a r e programs t o f r e e beds and reduce "costs, and t o encourage t h i s development the Commission recommended the A c t be amended t o r e q u i r e o u t -p a t i e n t s e r v i c e s as a c o n d i t i o n f o r f u r t h e r payment o f i n p a t i e n t s e r v i c e s . I n Volume I I the Commission e x p r e s s e s the e x p e c t a t i o n t h a t o u t p a t i e n t and home c a r e s e r v i c e s w i l l 4 be h o s p i t a l a s s o c i a t e d . 5 The f e d e r a l l y a p p o i n t e d Task F o r c e s o f 1969 were t o determine means by which h e a l t h c a r e would remain o f h i g h q u a l i t y and a c c e s s w i t h improved a v a i l a b i l i t y b u t w i t h reduced e x p e n d i t u r e s . The recommendations o f t h e Task F o r c e s can be summarized as; 1. change 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 i n g mechanisms 2. i n c r e a s e o u t p a t i e n t (ambulatory care) a c t i v i t i e s i n o r d e r t o reduce dependency on h o s p i t a l i n p a t i e n t s e r v i c e s 3. use l e s s e x p e n s i v e manpower wherever p o s s i b l e I t was n o t u n t i l 19 77 t h a t the c o s t s h a r i n g mechanisms were changed and r e p l a c e d w i t h the E s t a b l i s h e d Program F i n a n c i n g A c t . The Task F o r c e on O p e r a t i o n a l E f f i c i e n c y d e s c r i b e d 3 Canada. R o y a l Commission on H e a l t h S e r v i c e s , Ottawa, 2 v o l s . (1964), p.13. 4 R o y a l Commission ( 1 9 6 4 ) , 6 5 Canada. Task F o r c e s R e p o r t s on the C o s t o f H e a l t h S e r v i c e s i n Canada, 3 vol s . , ! Ottawa, 1969. the h o s p i t a l o f t h e f u t u r e as an a m b u l a t o r y c a r e c e n t r e w i t h i n p a t i e n t beds a t t a c h e d . The h o s p i t a l ' s major s e r v i c e s h o u l d be a m b u l a t o r y c a r e i n c l u d i n g m u l t i p h a s i c s c r e e n i n g p r e v e n t i v e s e r v i c e s , d i a g n o s t i c and t r e a t m e n t s e r v i c e s , and a network o f r e l a t i o n s h i p s w i t h o t h e r h e a l t h c a r e programs. I t was s u g g e s t e d t h a t the h o s p i t a l s would o p e r a t e s a t e l l i t e u n i t s o f v a r i o u s t y p e s . 7 The Task F o r c e on Beds and F a c i l i t i e s recommended the development o f a 'broad range' o f a m b u l a t o r y s e r v i c e s i n o r d e r t o reduce the a c t u a l t r e a t m e n t bed r a t i o s . T h i s t a s k f o r c e a l s o s u g g e s t e d the p o s s i b i l i t y o f s a t e l l i t e arrangements. I t i s the o n l y t a s k f o r c e t h a t r e f e r r e d t o the p o s s i b i l i t y o f a community h e a l t h c e n t r e when i t s u g g e sted t h a t needs o f an a r e a s h o u l d be r e v i e w e d and c o n s i d e r a t i o n g i v e n t o e r e c t i n g a Community H e a l t h C e n t r e g r a t h e r t h a n a h o s p i t a l . S e v e r a l competing p o s s i b i l i t i e s e v o l v e d from t h e s e recommendations. F e d e r a l l y f i n a n c e d i n v e s t i g a t i o n s o f a m b u l a t o r y c a r e (The Community H e a l t h C e n t r e P r o j e c t 1971-72) and manpower s u b s t i t u t i o n (Report on Nurse P r a c t i t i o n e r s 1971-72 a n d . P h y s i c i a n s 1 A s s i s t a n t s 1971) f o l l o w e d . ^Task F o r c e on O p e r a t i o n a l E f f i c i e n c y ( V o l . 11,1969), 136. ? Task F o r c e on Beds and F a c i l i t i e s , 275 Task F o r c e on Beds and F a c i l i t i e s , Recommendation 19. 10 F e d e r a l l y Funded E x p e r i m e n t s Community H e a l t h C e n t r e s The c o n c e p t o f one e s t a b l i s h m e n t c o m b i n i n g p r i m a r y m e d i c a l c a r e and o r g a n i z e d p r e v e n t i v e s e r v i c e s was f i r s t f o r m u l a t e d i n the r e p o r t o f the C o n s u l t a t i v e C o u n c i l on M e d i c a l and A l l i e d S e r v i c e s m e e t i n g h e l d i n E n g l a n d i n 1920. In Canada, some more r e c e n t major r e p o r t s have s p e c i f i c a l l y recommended the e s t a b l i s h m e n t o f Community H e a l t h C e n t r e s (CHC). A t the f e d e r a l l e v e l , the H a s t i n g s 9 Report a t the p r o v i n c i a l l e v e l , t h e Castonguay-Nepveu Report (Quebec) , 1 9 7 0 , 1 0 the M a n i t o b a White P a p e r , 1 9 7 2 , 1 1 12 the F o u l k e s R e p o r t (B.C.),1973, . The M u s t a r d R e p o r t i n the P r o v i n c e o f O n t a r i o , 1 9 74. agreed t h a t CHCs were a 13 g o a l b u t t h a t they were not the immediate s o l u t i o n . The r e p o r t s t r e s s e d more c o n t r o l and p l a n n i n g i n the proposed r e o r g a n i z a t i o n b u t n o t n e c e s s a r i l y the CHC concept o f b r i n g i n g a l l s e r v i c e s t o g e t h e r . D e s p i t e the recommendations and f e d e r a l i n c e n t i v e s t o 9 Canada. Department o f N a t i o n a l H e a l t h and W e l f a r e . The Community H e a l t h C e n t r e i n Canada, Ottawa, I n f o r m a t i o n Canada, 1972 and 1973. "^Quebec. Commission o f I n q u i r y on H e a l t h and S o c i a l  W e l f a r e . 1970-71. 1 : L M a n i t o b a . White Paper on H e a l t h P o l i c y . J u l y , 1972. 12 . . B r i t i s h C olumbia. H e a l t h S e c u r i t y f o r B r i t i s h  C olumbians, Report o f R i c h a r d G. F o u l k e s t o the M i n i s t e r o f H e a l t h , December 1973. 13 O n t a r i o . Report o f the H e a l t h P l a n n i n g Task F o r c e , J a n u a r y 19 74, p.15. 11 change p i l o t p r o j e c t s i n many p r o v i n c e s c o n t i n u e t o be 14 p i l o t p r o j e c t s . The e x p e r i e n c e w i t h CHCs i n Quebec and B.C. (which i s b e t t e r documented than t h a t o f the o t h e r p r o v i n c e s ) i s d e s c r i b e d f u r t h e r i n the n e x t c h a p t e r and i n Appendix I . Nurse P r a c t i t i o n e r s 15 In response t o the Boudreau Re p o r t f e d e r a l f u n d i n g f o r d e m o n s t r a t i o n p r o j e c t s o f nurse p r a c t i t i o n e r s ' work was made a v a i l a b l e t h r o u g h N a t i o n a l H e a l t h R e s e a r c h and Development Programs t o determine the v a l i d i t y o f sub-s t i t u t i n g p r e p a r e d n u r s e s f o r f a m i l y p h y s i c i a n s i n some p o r t i o n s o f the d e l i v e r y o f p r i m a r y c a r e . A number o f such s t u d i e s were conducted a c r o s s the c o u n t r y , i n O n t a r i o , i n B r i t i s h C o lumbia, and l a t e r , i n Newfoundland. 16 P r o j e c t s i n O n t a r i o were conducted by McMaster and 17 Queen's U n i v e r s i t i e s . The two u n i v e r s i t i e s p r e p a r e d the 14 S u g g e s t i o n s by the F e d e r a l Government t o p r o v i d e i n c e n t i v e s f o r development o f a l t e r n a t i v e modes o f h e a l t h c a r e d e l i v e r y ( T h r u s t Funds) were n o t a c c e p t e d . 15 Canada. Report o f the Committee on Nurse  P r a c t i t i o n e r s , Department o f N a t i o n a l H e a l t h and W e l f a r e , Ottawa, 1972. 16 W.O. S p i t z e r , e t a l . "The B u r l i n g t o n Randomized T r i a l o f the Nurse P r a c t i t i o n e r . " New England J o u r n a l of.  M e d i c i n e , (January 31, 1974), 251-56. 17 R.E.M. Le e s , " P h y s i c i a n Time S a v i n g by Employment o f Expanded-Role Nurses i n F a m i l y P r a c t i c e . " Canadian  M e d i c a l A s s o c i a t i o n J o u r n a l , ( A p r i l 1973), 871-75. 12 n u r s e s and t h e n conducted a number o f d i f f e r e n t s t u d i e s d u r i n g the p r o j e c t ' s l i f e t i m e . I n B r i t i s h C o l u m b i a , UBC d e v e l o p e d a c o n t i n u i n g e d u c a t i o n program f o r n u r s e s and f u n d i n g was p r o v i d e d t o the V i c t o r i a n Order o f Nurses t o c a r r y o u t a s t u d y . ' M e m o r i a l U n i v e r s i t y i n Newfound-20 l a n d c o nducted the most r e c e n t s t u d i e s . G e n e r a l f i n d i n g s were s i m i l a r , - more p r i m a r y c a r e s e r v i c e s were p r o v i d e d ; d o c t o r time was saved; n u r s e s were a b l e t o t a k e o v e r between 60-70% o f the d o c t o r ' s r e s p o n -s i b i l i t y ; a s h i f t o c c u r r e d from the h o s p i t a l t o the community f o r l o c a t i o n o f s e r v i c e s ; t h e r e was no measurable change i n q u a l i t y o f c a r e ; the c a r e was a c c e p t a b l e t o p a t i e n t s ; d o c t o r s and n u r s e s were s a t i s f i e d w i t h the arrangement. B u t , most i m p o r t a n t l y , the arrangement was n o t f i n a n c i a l l y p r o f i t a b l e f o r the d o c t o r s and t h e r e f o r e g a i n e d l i t t l e s u p p o r t from t h a t q u a r t e r . I n i s o l a t e d i n s t a n c e s the p r o j e c t d o c t o r s and n u r s e s c o n t i n u e d w o r k i n g t o g e t h e r b u t , g e n e r a l l y , the c o n c e p t o f a p r e p a r e d nurse s u b s t i t u t i n g f o r a f a m i l y p h y s i c i a n i s n o t f u n c t i o n i n g e x c e p t i n g , o f c o u r s e , i n t h o s e a r e a s where d o c t o r s choose not t o p r a c t i s e , namely, the o u t p o s t s o f the c o u n t r y . 18 Canada. ( G r a s s e t ) , Department o f N a t i o n a l H e a l t h and W e l f a r e , A t t a c h i n g a V i s i t i n g Nurse t o a Group M e d i c a l P r a c t i c e t o Change H o s p i t a l S t a y P a t t e r n s , NHG 610-20-6, June, 1975. 19 Programs f o r the p r e p a r a t i o n o f o u t p o s t n u r s e s have l o n g e x i s t e d a t the U n i v e r s i t y o f A l b e r t a (Advanced O b s t e t r i c s ) and D a l h o u s i e (Outpost N u r s i n g ) . See Appendix I I f o r U n i v e r s i t y o f B r i t i s h Columbia c o u r s e o u t l i n e . 20 L.W.Chambers and A.E.West, "The S t . J o h n ' s Randomized T r i a l o f t h e F a m i l y P r a c t i c e N u r s e : H e a l t h Outcomes o f P a t i e n t s , " I n t e r n a t i o n a l J o u r n a l o f E p i d e m i o l o g y (1978) 7:153-161. _ i 13 Outcomes o f the P i l o t P r o j e c t s The g o a l s o f manpower s u b s t i t u t i o n and i n c r e a s e d use o f a m b u l a t o r y (primary) .care t h r o u g h CHC t o c o n t r o l h e a l t h c a r e e x p e n d i t u r e s have e s s e n t i a l l y d i e d i n t h i s c o u n t r y . The prime cause f o r t h i s outcome has been the i n d i f f e r e n c e o r a c t i v e h o s t i l i t y o f the m e d i c a l p r o f e s s i o n . There was s i m p l y i n s u f f i c i e n t advantage t o the p r o f e s s i o n i n e i t h e r p o s s i b i l i t y and b o t h caused t o o much change i n e s t a b l i s h e d modes o f p r a c t i c e . H o s p i t a l Ambulatory Care Programs H o s p i t a l - b a s e d a mbulatory c a r e programs have had a g r e a t e r degree o f s u c c e s s p r o b a b l y because the h o s p i t a l i s an e s t a b l i s h e d and f a m i l i a r h e a l t h c a r e r e s o u r c e b o t h t o the p u b l i c and d o c t o r s . Power has l a i n w i t h h o s p i t a l s r a t h e r than w i t h o t h e r components o f the h e a l t h c a r e system and so h o s p i t a l needs ( t h i s . i n c l u d e s m e d i c a l p r a c t i c e needs) a r e a d d r e s s e d f i r s t w i t h i n the system. F e d e r a l - P r o v i n c i a l Funding Changes These e x p e r i m e n t s were conducted i n the p e r i o d 1969-1977 when n e g o t i a t i o n s were o n - g o i n g between f e d e r a l and p r o v i n c i a l governments r e g a r d i n g changes i n the c o s t s h a r i n g f o r m u l a f o r h e a l t h , e d u c a t i o n and w e l f a r e s e r v i c e s . When the new agreements were r e a c h e d , t h e p r o v i n c i a l governments were f r e e d from h a v i n g t o o b s e r v e the t i g h t l y 14 w r i t t e n r u l e s o f the H o s p i t a l I n s u r a n c e and D i a g n o s t i c S e r v i c e s Act,1957. The b l o c k g r a n t s made a v a i l a b l e by the E s t a b l i s h e d P r o g r a m s . F i n a n c i n g A c t , 1977, p e r m i t t e d the p r o v i n c i a l governments t o d e v e l o p programs o u t s i d e the system o f c a r e w h i c h had been d e v e l o p e d up t o t h e n . By t h i s time most p r o v i n c e s had become aware o f the gaps between the s e p a r a t e l y funded programs, p a r t i c u l a r l y r e l a t i n g t o the c a r e p r o v i d e d f o r the e l d e r l y , t he h a n d i -capped and t h e c h r o n i c s i c k . I n t r o d u c t i o n o f the new f u n d i n g f o r m u l a , i t was hoped, would r e d r e s s t h e b a l a n c e i n the e x i s t i n g system o f p r o v i s i o n a) towards ambu l a t o r y c a r e , b) towards gap f i l l i n g , b u t power had passe d from the f e d e r a l government t o the p r o v i n c i a l governments who were now r e s p o n s i b l e f o r t a k i n g i n i t i a t i v e s i n the d e v e l o p -ment o f programs. The r e d e s i g n e d f e d e r a l p r o v i n c i a l f u n d i n g arrangements o f 1977 have i n c l u d e d the Extended H e a l t h Care S e r v i c e s Program w h i c h p r o v i d e s b l o c k f u n d i n g c o n t r i b u t i o n s t o the p r o v i n c e s i n : o r d e r t o p r o v i d e them w i t h g r e a t e r f l e x i b i l i t y i n t he i d e n t i f i c a t i o n , i m p l e m e n t a t i o n and development o f h e a l t h s e r v i c e s such as n u r s i n g homes, i n t e r m e d i a t e c a r e , a d u l t r e s i d e n t i a l c a r e , c o n v e r t e d m e n t a l h o s p i t a l s , home ca r e ( h e a l t h a s p e c t s ) and ambulatory c a r e w h i c h a r e comp-le m e n t a r y t o e x i s t i n g funded s e r v i c e s . 15 CHAPTER I I I PROVINCIAL ACTIVITY IN AMBULATORY CARE B r i t i s h Columbians, u n t i l r e c e n t l y , were r e l u c t a n t s u p p o r t e r s o f government i n t e r v e n t i o n i n the p r o v i s i o n o f h e a l t h c a r e . The governments m a i n t a i n e d o n l y p u b l i c h e a l t h , m e ntal h e a l t h , and p u b l i c a s s i s t a n c e programs w i t h the p r o v i n c i a l f u n d s . U n t i l 1973, p u b l i c a s s i s t a n c e programs were funded by m u n i c i p a l governments. Between 1920 and 194 8 s u c c e s s i v e L i b e r a l governments had t r i e d t o i n t r o d u c e one v e r s i o n o r an o t h e r o f p r e p a i d h e a l t h i n s u r a n c e schemes w i t h o u t s u c c e s s . I n f a c t , the L i b e r a l government o f 1952 was d e f e a t e d o v e r a proposed compulsory h o s p i t a l i z a t i o n i n s u r a n c e scheme. The inadequacy o f t h i s p r o v i n c i a l , m u n i c i p a l , and p r i v a t e s e c t o r a c t i v i t y and the t i m e l y a r r i v a l o f the f e d e r a l government c o s t - s h a r i n g programs o f 1948 f i n a l l y i n v o l v e d the p r o v i n c i a l government i n f u n d i n g more s e r v i c e s b u t t h e r e was s t i l l a r e l u c t a n c e t o ta k e d i r e c t c o n t r o l . S u c c e e d i n g S o c i a l C r e d i t governments p r i m a r i l y d e l e g a t e d r e s p o n s i b i l i t i e s f o r h e a l t h and w e l f a r e t o muni-c i p a l i t i e s , v o l u n t a r y o r g a n i z a t i o n s and p r o f e s s i o n a l " a s s o c i a t i o n s . H o s p i t a l s and d o c t o r s were s t i l l e x p e c t e d t o manage t h e i r own a c t i v i t i e s . I n consequence new s e r v i c e s w hich were d e v e l o p e d were u s u a l l y i n i t i a t e d by i n s t i t u t i o n s o r d o c t o r s . Under the r e v i s e d H o s p i t a l A c t o f 196 0 h o s p i t a l s 16 c o n t i n u e d t o be v o l u n t a r y o r g a n i z a t i o n s s u b s i d i z e d by government r e s p o n d i n g t o l o c a l need.''' B r i t i s h Columbia a c c e p t e d the h o s p i t a l c o n s t r u c t i o n s u p p o r t (1948) o f the f e d e r a l government and t h e n , i n 195 8, a c c e p t e d a l s o the s u p p o r t o f f e r e d t h r o u g h t h e H o s p i t a l I n s u r a n c e and D i a g n o s t i c S e r v i c e s A c t . Emphasis was p l a c e d on h o s p i t a l i z a t i o n as the p r i m a r y means f o r c a r e d e l i v e r y . A l s o , the l a t e development o f t h e BC M e d i c a l S c h o o l i n 1951, on a ' s p e c i a l i s t ' t e a c h i n g model, s e r i o u s l y d e f e r r e d the a b s o r p t i o n o f a m b u l a t o r y c a r e i n t o p r o v i n c i a l models o f h e a l t h c a r e d e l i v e r y . P h y s i c i a n s found the s p e c i a l i s t h o s p i t a l model o f c a r e f a v o r a b l e t o themselves and the p u b l i c has come t o equate good c a r e w i t h m e d i c a l a d v i c e and h o s p i t a l i z a t i o n . In the s i x t i e s , even b e f o r e the i n t r o d u c t i o n o f the M e d i c a l Care Program o f 196 7, the l a s t o f the f e d e r a l -p r o v i n c i a l matched g r a n t programs, t h e r e was c o n c e r n about the r i s i n g c o s t s o f h e a l t h c a r e . A t the p r o v i n c i a l l e v e l , the S o c i a l C r e d i t government i n t r o d u c e d R e g i o n a l H o s p i t a l D i s t r i c t s i n 1967. The r e g i o n a l d i s t r i c t s were t o be r e s p o n s i b l e f o r h o s p i t a l f a c i l i t y c o n s t r u c t i o n •. (ac u t e and extended c a r e ) . They were g i v e n l i m i t e d b u d g e t s . •It i s o n l y i n 1980 t h a t a government f i n a n c i a l d i s -c u s s i o n paper has proposed t h a t h o s p i t a l s s h o u l d become ' p u b l i c b o d i e s ' under more d i r e c t c o n t r o l o f the p r o v i n c e . W h i l s t t h i s c o n c e p t has been s e t a s i d e , i t may w e l l r e -s u r f a c e i n the n e x t few y e a r s . 17 T h i s arrangement e n a b l e d the p r o v i n c i a l government t o l i m i t c a p i t a l developments - c o n s t r u c t i o n and equipment -t h r o u g h a b u f f e r group w h i c h managed 40% o f the l o c a l e x p e n d i t u r e s and w h i c h would presumably a p p l y p r i o r i t i e s . However, l i m i t i n g o p e r a t i o n a l e x p e n d i t u r e was much more d i f f i c u l t . The government c o n t i n u e d t o n e g o t i a t e d i r e c t l y w i t h each o f i t s 120 h o s p i t a l s t h r o u g h the Rate Review Board and o t h e r mechanisms. P l a n n i n g as p a r t o f a p o l i t i c a l i d e o l o g y has been 2 i d e n t i f i e d most s t r o n g l y w i t h s o c i a l i s m . D u r i n g the s i n g l e term o f the New Democratic P a r t y government i n BC (1972-76) c e n t r a l i z e d p l a n n i n g was i n t r o d u c e d i n the h e a l t h c a r e f i e l d and system-wide changes which demon-s t r a t e d t h i s p o l i c y were i n i t i a t e d . Dr. R. G. F o u l k e s , a s t a u n c h p a r t y member, was engaged as a c o n s u l t a n t t o work w i t h the M i n i s t e r o f H e a l t h t o d e v e l o p a master p l a n o f h e a l t h c a r e f o r the p r o v i n c e . B e f o r e t h i s was p u b l i s h e d , however, c e r t a i n s t e p s had a l r e a d y been t a k e n t o change d i r e c t i o n s . A c o n s o r t i u m o f t e a c h i n g h o s p i t a l s was s e t up as t h e B r i t i s h Columbia M e d i c a l C e n t r e and a Development Group was formed t o r e v i e w the p o t e n t i a l o f community h e a l t h c e n t r e s . M a u r i c e S p i e r s , Techniques and P u b l i c A d m i n i s t r a t i o n , (Fontana, 1975) p. 155. 18 B r i t i s h Columbia M e d i c a l C e n t r e The BCMC was e s t a b l i s h e d as a c o r p o r a t i o n i n 19 73 t o o p e r a t e a m e d i c a l and h e a l t h s c i e n c e s c e n t r e f o r the p r o v i n c e , i n Vancouver. F a c i l i t i e s a f f i l i a t e d w i t h t h e c e n t r e i n c l u d e d the Vancouver G e n e r a l H o s p i t a l , S t . P a u l ' s H o s p i t a l , Shaughnessy H o s p i t a l , C h i l d r e n ' s H o s p i t a l , the BC Cancer I n s t i t u t e , the G. F. S t r o n g R e h a b i l i t a t i o n C e n t r e , and the U n i v e r s i t y o f B r i t i s h Columbia H e a l t h S c i e n c e s C e n t r e H o s p i t a l . The c o r p o r a t i o n c o m p r i s e d a Board o f D i r e c t o r s o f t w e l v e p e r s o n s a p p o i n t e d by the L i e u t e n a n t - G o v e r n o r i n C o u n c i l and i n c l u d e d p r o f e s s i o n a l and b u s i n e s s p e o p l e from the community. The Board was r e s p o n s i b l e f o r the c o -o r d i n a t i o n o f p l a n n i n g f o r the h o s p i t a l s b u t had d i r e c t o p e r a t i n g r e s o n s i b i l i t y f o r t h e Shaughnessy H o s p i t a l w h i c h was t r a n s f e r r e d from the F e d e r a l t o the P r o v i n c i a l Government i n J u l y , 19 74. I n s t i t u t i o n s a f f i l i a t e d w i t h the C e n t r e were t o have i n t e g r a t e d s e r v i c e s w i t h a t o t a l o f 2,850 acute, a c t i v a t i o n , and r e h a b i l i t a t i o n beds. Each i n s t i t u t i o n had a s p e c i a l r o l e t o f i l l i n the i n t e g r a t i o n o f s e r v i c e s , e.g. S t . P a u l ' s H o s p i t a l was t o be a 600-bed f a c i l i t y and was t o become the major ambul a t o r y c a r e c e n t r e . The VGH was t o have been a 970-bed i n s t i t u t i o n p r o v i d i n g the major trauma, emergency, and s u r g i c a l s e r v i c e s , the s u r g i c a l r o l e b e i n g h e a v i l y emphasized. 19 A l l the h o s p i t a l s named would have t o submit changes i n program and f u t u r e p r o p o s a l s t o the Board. The Board a l s o had the a u t h o r i t y t o c o o r d i n a t e and i n t e g r a t e educa-t i o n a l programs i n the h e a l t h f i e l d and t o e s t a b l i s h p o l i c i e s and d i r e c t i o n s f o r e d u c a t i o n a l programs a f t e r c o n s u l t a t i o n w i t h the h o s p i t a l o r e d u c a t i o n a l i n s t i t u t i o n b u t o n l y w i t h p r i o r a p p r o v a l o f the L i e u t e n a n t - G o v e r n o r i n C o u n c i l . A number o f committees were s t r u c k t o f a c i l i t a t e the work. One o f t h e s e was t h e Ambulatory Care Committee formed i n March, 19 75. The committee's purpose was t o " l o o k i n t o the problems o f am b u l a t o r y c a r e and t o o f f e r some r e -3 commendations r e g a r d i n g f u t u r e changes." The committee's recommendations i n c l u d e d a p l e a f o r a " b a s i c framework o f 4 o v e r a l l d i r e c t i o n and p o l i c y . " By t h i s time t h e r e was a s t r o n g p r e s s u r e t o change the d i r e c t i o n o f the m e d i c a l s c h o o l towards the H e a l t h S c i e n c e s C e n t r e model"* (the emphasis b e i n g on teamwork) and community c e n t r e d m e d i c a l c a r e (not h o s p i t a l c e n t r e d c a r e ) . I t s h o u l d be n o t e d , however, t h a t i n BCMC Ambulatory Care S e r v i c e s i n t h e BCMC P r o g r e s s R e p o r t , June 10, 19 75. 4 I b i d . p. 10 ^The H e a l t h S c i e n c e s C e n t r e model has s i n c e been i n t r o d u c e d a t the U n i v e r s i t y o f B r i t i s h C o lumbia. 20 d i s c u s s i o n s o f amb u l a t o r y c a r e were based e n t i r e l y upon the m e d i c a l model o f c a r e d e l i v e r y , c o m p l e t e l y o m i t t i n g any recommendations about i n v o l v e m e n t o f o t h e r h e a l t h p r o f e s s i o n a l s i n new r o l e s . W i t h the change i n government i n 19 76 t h e BCMC was di s b a n d e d and the h e a l t h c a r e system r e t u r n e d t o t h e o p e r a t i o n a l d e s i g n which e x i s t e d d u r i n g the p r e v i o u s S o c i a l C r e d i t governments. Many h e a l t h systems managers s u p p o r t e d the con c e p t o f BCMC because o f i t s p o t e n t i a l f o r r e d u c i n g c o m p e t i t i o n between h o s p i t a l s and improved c o -o r d i n a t i o n o f s e r v i c e s t o the immediate community and the p r o v i n c e . The m e d i c a l p r o f e s s i o n was l e s s s u p p o r t i v e . H o s p i t a l Based Ambulatory C a r e : The Arguments F o r and A g a i n s t R e s u l t i n g from the d i s c u s s i o n s o f need and t h e p o s i t i v e c o n t r i b u t i o n t h a t a l t e r n a t i v e c a r e can b r i n g t o t h e h e a l t h c a r e d e l i v e r y system, h o s p i t a l s began t o see a r o l e f o r themselves i n t h i s form o f c a r e d e l i v e r y i n the e a r l y 1970's. American h o s p i t a l s w i t h low occupancy and t h r e a t e n e d r e s o u r c e s began t u r n i n g t o a v a r i e t y o f a l t e r n a t i v e c a r e 7 programs. C o n v e n t i o n R e p o r t s , H o s p i t a l s , Oct. 1, 1978, pp. 128-129. 7 Mark Tager and C h a r l e s J e n n i n g s , " H o s p i t a l s now are d i s c o v e r i n g w e l l n e s s " , S e a t t l e Times, F e b r u a r y 10, 19 80. 21 Some U.S. a u t h o r s promote the i d e a o f the h o s p i t a l becoming the community h e a l t h c e n t r e o r the c o n t r o l f o r s a t e l l i t e c e n t r e s . I t i s s u g g e s t e d t h a t the h o s p i t a l s h o u l d be the v e h i c l e f o r r e o r g a n i z i n g the h e a l t h system. They view the h o s p i t a l as the c e n t r e o f t o t a l h e a l t h c a r e f o r t h e community, c o o r d i n a t i n g a v a r i e t y o f c a r e programs f o r p a t i e n t s , e d u c a t i o n programs f o r h e a l t h p r o f e s s i o n s , s e r v i c e programs f o r the community, w i t h a f f i l i a t i o n s t o m e d i c a l s c h o o l s and c l i n i c a l r e s e a r c h . A number o f Canadian h o s p i t a l a d m i n i s t r a t o r s r e a c t e d t o the Community H e a l t h C e n t r e p r o j e c t r e p o r t a r g u i n g t h a t such s e r v i c e s h o u l d be p r o v i d e d t h r o u g h h o s p i t a l o u t r e a c h . 8 9 These a u t h o r s ' . p r e d i c t t h a t the h o s p i t a l s w i l l and s h o u l d expand s e r v i c e s and w i l l be viewed as r e s p o n s i b l e f o r t o t a l h e a l t h c a r e d e l i v e r y r a t h e r than as p r o v i d e r s o f a c u t e and emergency care-. F o u l k e s t h o u g h t the community h e a l t h c e n t r e c o u l d be p a r t o f an a c u t e c a r e h o s p i t a l a l l o w i n g c l o s e r e l a t i o n s h i p s and s h a r e d services."*"^ J . D. W a l l a c e , M.D. " H o s p i t a l s and New P e r s p e c t i v e s i n H e a l t h C a r e", H o s p i t a l A d m i n i s t r a t i o n i n Canada, March 19 76, p. 18. 9 P e t e r F. H a r t , M.D. " P r i m a r y C a r e : t h e H o s p i t a l P e r s p e c t i v e " , H o s p i t a l A d m i n s t r a t i o n i n Canada, F e b r u a r y 1976, p. 16. " ^ B r i t i s h C o lumbia. H e a l t h S e c u r i t y f o r B r i t i s h C olumbians, Report o f R. G. F o u l k e s t o t h e M i n i s t e r o f H e a l t h , December 19 73, 11:1-3. 22 I t seems the p u b l i c has a l r e a d y a c c e p t e d t h i s r o l e f o r the h o s p i t a l by the e x t e n s i v e use o f Emergency Departments f o r p r i m a r y c a r e i n s t e a d o f a d o c t o r ' s o f f i c e . Emergency i s one s e r v i c e the p u b l i c has a v a i l a b l e w i t h o u t the use o f a p r o f e s s i o n a l "gatekeeper:. 1' " C u g l i a n i adds t h a t the s c a r c i t y o f p h y s i c i a n s i n u n d e s i r a b l e l o c a t i o n s c o n t r i b u t e t o t h e use o f emergency departments f o r p r i m a r y c a r e . ^ 12 I n t e r v i e w s w i t h s e v e r a l C h i e f E x e c u t i v e O f f i c e r s o f h o s p i t a l s i n Canada i n d i c a t e d t h a t t h e use o f Emergency Departments f o r p r i m a r y c a r e was n o t seen as an abuse. Those h o s p i t a l s w i t h l e s s b u s i n e s s t h a n c a p a c i t y were a g r e e -a b l e t o t h i s use o f t h e i r f a c i l i t i e s ; t h o s e w i t h b u s i e r departments thought p u b l i c e x p e c t a t i o n s must be met, and the remainder were so busy few p a t i e n t s sought p r i m a r y c a r e i n the Emergency Department. The C.E.O.'s thought t h a t a v a i l a -b i l i t y and a c c e s s i b i l i t y o f p h y s i c i a n s a f f e c t e d usage and i n some c a s e s p a t i e n t p r e f e r e n c e e x p l a i n e d the usage. In 1975, M. L a l o n d e , F e d e r a l H e a l t h M i n i s t e r , encouraged the Canadian H o s p i t a l A s s o c i a t i o n membership t o unde r t a k e e d u c a t i o n i n f a m i l y p l a n n i n g , s a f e t y on the r o a d , a t home, Anne C u g l i a n i , " P a t t e r n s o f H o s p i t a l Based on Ambulatory Care", S o c i a l S c i e n c e and M e d i c i n e , ( V o l 1 2 ) , 55-8. 1 2 " I s Emergency Abuse a Problem?" H e a l t h C a r e , Ja n u a r y 19 81, p. 13. 23 a t work, and on n u t r i t i o n . """^  I n o t h e r words, t o become a CHC and t o emphasize p r e v e n t i v e measures. The Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n has a l s o r e c e n t l y l e g i t i m i z e d t h e development o f h o s p i t a l based a l t e r n a t i v e c a r e w i t h t h e s u r v e y g u i d e l i n e s f o r a m b u l a t o r y 14 c a r e c e n t r e s . One o f the s i x c r i t e r i a w h i c h must be met i s t h a t the c e n t r e must have a f u n c t i o n a l a s s o c i a t i o n w i t h a h o s p i t a l o r o t h e r s t r u c t u r e d h e a l t h c a r e agency such as a government s e r v i c e o r a h e a l t h c a r e o r g a n i z a t i o n . As o f O c t o b e r 1980, t e n c e n t r e s i n Canada have been a c c r e d i t e d by the c o u n c i l . There can be some advantages t o such developments. Expanding a l r e a d y r e c o g n i z e d c a r e c e n t r e s w i l l improve th e p o s s i b i l i t y t h a t b o t h th e p u b l i c and the m e d i c a l p r o f e s s i o n w i l l make the n e c e s s a r y a d j u s t m e n t s and use t h e s e r v i c e s . There would be no need f o r a complete change o f l o n g s t a n d i n g h a b i t s . I n f a c t , new c o n c e p t s may be more e a s i l y a c c e p t e d i n f a m i l i a r s u r r o u n d i n g s , e.g. h e a l t h p r o m o t i o n programs. "Ottawa t o promote improved l i f e s t y l e - L a l o n d e t e l l s CHA." H o s p i t a l A d m i n i s t r a t i o n i n Canada, J u l y 19 75, p. 6. 14 Dr. A. L. Swanson, "Report from the Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n . " Dimensions i n H e a l t h  S e r v i c e , November 19 80, p. 36. 24 I n i t i a l c a p i t a l c o s t s may be l e s s i f new f a c i l i t i e s a r e un n e c e s s a r y and e x i s t i n g f a c i l i t i e s may c o n t r i b u t e t o the ^ s p e c i f i c c h a r a c t e r i s t i c s o f the s e r v i c e s o f f e r e d , f o r example, Emergency Department s e r v i c e s might emphasize p r i m a r y c a r e , becoming Ambulatory Care Departments. The h o s p i t a l ' s t e c h n i c a l and o r g a n i z a t i o n a l s k i l l s a r e a v a i l a b l e t o the d e v e l o p i n g a m b u l a t o r y c a r e programs r e s u l t i n g i n lower s t a r t -up costs.--Not everyone f e e l s h o s p i t a l based development i s advantageous. The U n i v e r s i t y o f Ottawa, S c h o o l o f H o s p i t a l A d m i n i s t r a t i o n , p u t s f o r w a r d t h e s e major d i s a d v a n t a g e s : 1. p e r p e t u a t i o n o f i n p a t i e n t p rimacy 2. d i f f i c u l t y d i v i d i n g c i t i e s i n t o h o s p i t a l s e r v i c e a r e a s 3. f a i l u r e t o r e c o g n i z e t h a t a mbulatory c a r e r e l a t i o n -s h i p s ought t o be p r i m a r i l y w i t h the community and w i t h o t h e r s o c i a l s e r v i c e s . ^ The developments i n Quebec demonstrate i n t e r e s t i n g d i f f e r e n c e s o f o p i n i o n between the community workers and the government about the purposes o f the CLSC and the r e s u l t a n t d i f f i c u l t i e s o f the c e n t r e s a t t a c h e d t o h o s p i t a l s . S c h o o l o f H e a l t h A d m i n i s t r a t i o n , "Community H e a l t h C e n t r e s " , U n i v e r s i t y o f Ottawa, January 19 72. ) (mimeographed) 25 The h o s p i t a l c e n t r e (HC) - l o c a l community s e r v i c e c e n t r e (CLSC) has been d e v e l o p e d i n t h o s e r e g i o n s where low p o p u l a t i o n d e n s i t y and d i s t a n c e from major c e n t r e s r e q u i r e s such a development. S i n c e i m p l e m e n t a t i o n o f t h i s o r g a n i z a t i o n , t h e r e has been c o n f l i c t between t h e c e n t r e s and the h o s p i t a l s and. the community about purpose so t h a t the CLSC a r e c a l l i n g f o r complete s e p a r a t i o n . I n t h e f a l l o f 1976 the M i n i s t r y o f S o c i a l A f f a i r s commissioned * 16 Clermont B e g i n t o stu d y the s i t u a t i o n . F i n d i n g s l e d t o the c o n c l u s i o n t h a t t h e r e were many b a s i c d i f f e r e n c e s between t h e v a l u e s , t e c h n o l o g i e s and the s t r u c t u r e o f s o c i a l o r g a n i z a t i o n o f the two components and t h a t t h e c a p a c i t y f o r i n t e g r a t i o n was n o t p r e s e n t i f the CLSC was d e t e r m i n e d t o m a i n t a i n i t s community a c t i o n r o l e as for e m o s t . Home Care: A P u b l i c H e a l t h I n i t i a t i v e From the b e g i n n i n g o f the t w e n t i e t h c e n t u r y , t h e V i c t o r i a n Order o f Nurses has p r o v i d e d a d i s t r i c t n u r s i n g s e r v i c e i n most o f the l a r g e r c i t i e s o f Canada. When t h i s t y p e o f c a r e began t o be #emaM<edo'ou>£sd<de. it-he-se c i t i e s , t h e p u b l i c h e a l t h s e r v i c e assumed more r e s p o n s i -b i l i t y i n the a r e a o f home n u r s i n g . C lermont Be-gin", "Can the HC's and t h e LCSC's C o - e x i s t ? " Canada's M e n t a l H e a l t h , V o l . 25, December 1977, p. 11. 26 The f e d e r a l government has been i n t e r e s t e d i n home c a r e s i n c e 1949 when d e m o n s t r a t i o n g r a n t s were made a v a i l -a b l e t o the p r o v i n c e s f o r program development. B r i t i s h Columbia home c a r e s e r v i c e s were d e v e l o p e d by the p r o v i n c i a l P u b l i c H e a l t h S e r v i c e from 1940 onward. I n B.C. f i f t y p e r c e n t o f the c l i e n t e l e o f the Home Care P r o -gram come d i r e c t l y from the community w i t h the g o a l o f p r e v e n t i n g a d m i s s i o n t o h o s p i t a l . I n 1971 t h i s t y pe o f s e r v i c e was extended i n t o a h o s p i t a l s u b s t i t u t i o n program i n o r d e r t o f a c i l i t a t e e a r l i e r d i s c h a r g e o f i n p a t i e n t s and t o promote the use o f day c a r e s u r g e r y . The f i r s t c a t e g o r y o f c a r e , N o n - h o s p i t a l Replacement, p r o v i d e s p r o f e s s i o n a l n u r s i n g c a r e and some p h y s i o t h e r a p y s e r v i c e a t no d i r e c t c h a r g e . Other s u p p o r t s e r v i c e s , e.g. p h y s i o t h e r a p y , a re c o o r d i n a t e d by program s t a f f b u t pay-ment i s the r e s p o n s i b i l i t y o f the p a t i e n t . The second c a t e g o r y , H o s p i t a l Replacement, c o m p r i s e s s e r v i c e s p r o v i d e d a t no d i r e c t charge t o the p a t i e n t a n d . i n c l u d e s v i s i t i n g n u r s e s e r v i c e , p h y s i o t h e r a p y , v i s i t i n g homemaker, M e a l s -on-Wheels, t r a n s p o r t a t i o n , m e d i c a t i o n s , m e d i c a l s u p p l i e s , equipment and o t h e r s e r v i c e s as i n d i c a t e d . The p a t i e n t ' s e l i g i b i l i t y f o r t h i s range o f s e r v i c e s i s l i m i t e d t o the number o f h o s p i t a l days r e p l a c e d as d e t e r m i n e d by the l i a i s o n n u r s e . The s e r v i c e s p r o v i d e d i n e i t h e r c a t e g o r y a r e n o t i n t e n d e d t o r e l i e v e p e r s o n s and f a m i l i e s o f any f u n c t i o n s which t h e y can o r s h o u l d p r o v i d e . 27 Requests f o r s e r v i c e may o r i g i n a t e w i t h the p a t i e n t , the p a t i e n t ' s f a m i l y o r p h y s i c i a n , Long Term Care Program, l o c a l h o s p i t a l s , o r o t h e r community a g e n c i e s . The a t t e n d i n g p h y s i c i a n must be aware and must c o n t i n u e h i s / h e r r e s p o n s i -b i l i t y f o r the d i r e c t i o n o f the m e d i c a l c a r e o f the p a t i e n t w h i l e on the Home Care Program. P a t i e n t s a r e s e l e c t e d f o r a d m i s s i o n t o the Home Care Program on the b a s i s o f i n d i v i d -u a l assessment. I f the p a t i e n t does n o t meet a d m i s s i o n c r i t e r i a f o r e i t h e r c a t e g o r y they may be r e f e r r e d t o the Long Term Care Program f o r placement. A c c o r d i n g t o the M i n i s t r y , the program i s a v a i l a b l e t o 80-90% o f the p o p u l a -t i o n , i . e . t h o s e who l i v e w i t h i n r e a s o n a b l e d i s t a n c e o f a p u b l i c h e a l t h o f f i c e a l t h o u g h each l o c a t i o n may n o t have a comprehensive range o f s e r v i c e s a v a i l a b l e . Governments have viewed home c a r e programs as c o s t e f f e c t i v e i n the use o f p u b l i c f u n d s , d i s r e g a r d i n g the added c o s t s t o i n d i v i d u a l s and f a m i l i e s , and as a means t o reduce a c u t e c a r e bed usage. E v a l u a t i o n s o f c o s t e f f e c t i v e -ness a r e u s u a l l y made on a c o s t - ^ s u b s t i t u t i o n b a s i s . D i r e c t comparison o f home c a r e and h o s p i t a l c o s t s i s d i f f i c u l t . Home c a r e c o s t s can be d e t e r m i n e d r e l a t i v e l y e a s i l y s i n c e the c a r e r e c e i v e d i s made up o f d i s t i n c t s e r v i c e s which have been c o s t e d p r e v i o u s l y . H o s p i t a l c o s t s a r e presumably r e f l e c t e d i n the per diem a l l o c a t i o n and the average c o s t per day m u l t i p l i e d by the number o f days e q u a l s h o s p i t a l c o s t s b u t home c a r e does n o t r e p l a c e the i n t e n s i v e and 28 e x p e n s i v e days o f h o s p i t a l c a r e . I t would a p p l y o n l y t o the c o n v a l e s c e n t , much l e s s e x p e n s i v e days near t h e end o f the h o s p i t a l s t a y . The G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t R e p o r t on Home Care, 1973, p r o p o s e s , f i r s t l y , t h a t Home Care o f f e r s s u b s t a n t i a l s a v i n g s i n o p e r a t i n g c o s t s o v e r h o s p i t a l c o s t s f o r the end p e r i o d o f h o s p i t a l i z a t i o n , i . e . the 'housekeeping' a s p e c t s o f the h o s p i t a l c o s t s w h i c h a r e borne by the f a m i l y a t home. S e c o n d l y , the r e p o r t a l s o s t a t e s t h a t the s h o r t e n e d h o s p i t a l s t a y r e s u l t i n g from the Home Care Program w i l l reduce t h e need f o r a c u t e beds and t h e r e f o r e w i l l r e s u l t i n reduced c a p i t a l c o s t s . T h i r d l y , the s h o r t e r s t a y and h i g h e r t u r n o v e r o f p a t i e n t s w i l l r e -s u l t i n g r e a t e r p e r diem c o s t s o f o p e r a t i o n o f a c u t e c a r e beds because o f the g r e a t e r c o s t i n v o l v e d i n the e a r l y days o f h o s p i t a l i z a t i o n . The Home Care Program has had some major l i m i t a t i o n s from t h e v i e w o f the h o s p i t a l s t a f f ; f o r example, t h e n o t i f i c a t i o n o f d i s c h a r g e i s e x p e c t e d t o be r e c e i v e d by the l i a i s o n nurse 48 hours p r i o r and no r e f e r r a l s a r e ac c e p t e d on the weekends. These r e s t r i c t i o n s f o r c e e i t h e r a l e n g t h e n e d h o s p i t a l s t a y o r a s i t u a t i o n where no a s s i s -t a n c e i s a v a i l a b l e t o the d i s c h a r g e d p a t i e n t . The 19 81 f u n d i n g a l l o c a t i o n s t o the Home. Care Program w i l l r e s u l t i n a s i g n i f i c a n t c u t b a c k i n the number o f hours o f c a r e a v a i l a b l e t o p a t i e n t s a l r e a d y on the p r o -gram and w a i t i n g l i s t s w i l l expand f o r t h o s e n o t y e t on the program. One would s u s p e c t t h a t the r e s u l t o f t h i s s i t u a t i o n w i l l be an i n c r e a s e d use o f a c u t e c a r e h o s p i t a l beds f o r p a t i e n t s p r e v i o u s l y m a i n t a i n e d i n t h e i r homes, when f a m i l i e s become u n w i l l i n g t o absorb the r e d u c t i o n i n 17 s e r v i c e . The e x p a n d i n g c a p a b i l i t y o f m e d i c a l .technology i s a s s u r i n g t h a t the need f o r acu t e c a r e beds w i l l r emain h i g h . The h o s p i t a l w i t h h i g h occupancy problems i s a l s o the s o p h i s t i c a t e d h o s p i t a l which o f f e r s h i g h t e c h n o l o g y and the accompanying e x p e r t i s e . T h i s h o s p i t a l i s v e r y u n l i k e l y t o e x p e r i e n c e a l e s s e n i n g i n bed usage t h r o u g h the e x i s t e n c e o f a home c a r e program a l t h o u g h a h i g h u s e r o f the s e r v i c e . Long Term Care Program V a r i e t i e s o f l o n g term c a r e have been p r o v i d e d o v e r the y e a r s t h r o u g h many programs and s e r v i c e s r a n g i n g from the Workers' Compensation Boards aimed a t r e h a b i l i t a t i n g w o r k e rs f o l l o w i n g i l l n e s s o r i n j u r y , t he a c u t e s e r v i c e s o f Renal D i a l y s i s t o the Home Maker s e r v i c e s a v a i l a b l e t o the e l d e r l y o r o t h e r w i s e d i s a b l e d and c o u l d i n c l u d e t he numerous v o l u n t a r y o r g a n i z a t i o n s p r o v i d i n g s e r v i c e s t o groups o f pe o p l e w i t h s p e c i f i c h e a l t h problems. S i x t y p e r c e n t o f the Home Care Program p a t i e n t s are o v e r s i x t y y e a r s o f age. 30 F o l l o w i n g the changes i n f e d e r a l - p r o v i n c i a l f u n d i n g arrangements i n 1977, Mr. J . B a i n b r i d g e , Deputy M i n i s t e r , was commissioned t o i n i t i a t e a major new government p o l i c y , Long Term C a r e . E f f e c t i v e J a n u a r y 1, 19 78, r e s i d e n t s o f B r i t i s h Columbia became e l i g i b l e f o r a government sponsored Long-Term Care Program. The d e f i n i t i o n o f the program as p r e s e n t e d by the M i n i s t r y Of H e a l t h i s : 1. Long-Term Care i s a continuum o f c a r e s e r v i c e s f o r t h o s e p e o p l e who a r e unable t o l i v e i ndepend-e n t l y w i t h o u t h e l p , because o f h e a l t h r e l a t e d p r oblems, which do n o t w a r r a n t a d m i s s i o n t o an a c u t e h o s p i t a l . 2. Long-Term Care Program w i l l range from home s u p p o r t s e r v i c e s and p e r s o n a l c a r e t o the more i n t e n s i v e c a r e s e r v i c e s p r o v i d e d a t the i n t e r -18 mediate and extended c a r e l e v e l s . A d m i n i s t r a t i o n o f a number o f s e p a r a t e A c t s have been p u l l e d t o g e t h e r under the P r o v i n c i a l A d u l t Care F a c i l i t i e s L i c e n s i n g Board. The A d m i n i s t r a t i v e S e r v i c e s D i v i s i o n o f H o s p i t a l Programs was c h a r g e d w i t h the r e v i e w o f the e x i s t i n g l e g i s l a t i o n w i t h a'view t o d e v e l o p i n g new l e g i s -l a t i o n s p e c i f i c t o l o n g - t e r m c a r e . B r i t i s h Columbia M i n i s t r y o f H e a l t h , I n t r o d u c t i o n t o the Program f o r Long-Term C a r e , January 1, 1978. 31 The p o i n t o f e n t r y i n t o the Long-Term Care Program (LTC) i s thr o u g h the Long-Term Care A d m i n s t r a t o r i n the P u b l i c H e a l t h U n i t s e r v i c i n g t he community i n whi c h the a p p l i c a n t r e s i d e s . A p p l i c a t i o n s f o r placement may be i n i t i a t e d by p h y s i c i a n s , p u b l i c h e a l t h n u r s e s , s o c i a l w o r k e r s , and o t h e r s who may have knowledge o f a need. The p r i m a r y aim o f the Long-Term Care Program i s t o p e r -m i t t h a t segment o f the p o p u l a t i o n who q u a l i f y f o r b e n e f i t s t o remain i n t h e i r own homes amongst t h e i r own f a m i l i e s when d e s i r a b l e and p r a c t i c a l . When the former i s n o t p o s s i b l e , the i n d i v i d u a l w i l l be p l a c e d i n an approved community c a r e f a c i l i t y , o r a d m i t t e d t o an extended c a r e h o s p i t a l , w h i c h -e v e r i s a p p r o p r i a t e . Where p o s s i b l e t h i s accommodation w i l l be i n the i n d i v i d u a l ' s own community. The t y p e s o f s e r v i c e s and f a c i l i t i e s a v a i l a b l e t h r o u g h the program a r e : 1. c a r e i n mental h e a l t h b o a r d i n g home 2. home s u p p o r t s e r v i c e 3. c a r e i n a p e r s o n a l c a r e f a c i l i t y 4. c a r e i n an i n t e r m e d i a t e c a r e f a c i l i t y 5. c a r e i n an extended c a r e h o s p i t a l ^ There i s a charge o f $10.50 p e r day f o r any i n s t i t u t i o n a l c a r e and home s u p p o r t s e r v i c e s a re p a i d f o r on a gr a d u a t e d s c a l e i n accordance w i t h the r e c i p i e n t s ' means. These c a t e g o r i e s o f c a r e were d e f i n e d i n a c l a s s i f i -c a t i o n document p u b l i s h e d by the B r i t i s h Columbia g o v e r n -ment i n September, 1973. 32 I n i t i a t i v e s f o r d e v e l o p i n g f a c i l i t i e s and an a p p r o p r i a t e range o f s e r v i c e s i s e x p e c t e d t o stem from the community, b u t the Community Care F a c i l i t i e s L i c e n s i n g ( A d u l t ) Board i s r e s p o n s i b l e f o r . t o t a l c o o r d i n a t i o n o f the program. The GVRHD i s r e s p o n s i b l e f o r c o n s t r u c t i o n o f a c u t e and extended c a r e i n s t i t u t i o n s i n Vancouver M e t r o p o l i t a n a r e a . The autonomous p r o v i n c i a l Long Term Care Program i s r e s p o n s i b l e f o r d e v e l o p i n g p e r s o n a l and i n t e r m e d i a t e c a r e f a c i l i t i e s . T h i s s e p a r a t i o n o f c o n t r o l i s o f c o n c e r n t o t h e GVRHD because o f the r e s u l t i n g c o o r d i n a t i o n d i f f i c u l t i e s . Recommendations to c o n s o l i d a t e a l l f a c i l i t y p l a n n i n g under one body w i l l be forw a r d e d t o the M i n i s t r y o f H e a l t h from the GVRHD H o s p i t a l s Committee i n the near f u t u r e . Response t o i n t r o d u c t i o n o f the LTC program was o v e r -whelming. Home s u p p o r t s e r v i c e s and i n s t i t u t i o n a l c a r e were t a x e d beyond p o s s i b i l i t y a l m o s t i m m e d i a t e l y , and hundreds o f names were p l a c e d on w a i t i n g l i s t s . Media announcements o f the new program were q u i c k l y withdrawn. I t seems l i k e l y t h a t p l a n n e r s had n o t a d e q u a t e l y a s s e s s e d the need o r r e s o u r c e s r e q u i r e d . The most s e v e r e r e p e r c u s s i o n s o f th e s e developments was the i m pact on acu t e c a r e f a c i l i t i e s because i n a d e q u a t e f a c i l i -t i e s f o r p e r s o n a l , i n t e r m e d i a t e and extended c a r e e x i s t e d t o meet t h e sudden and overwhelming demand which s u r f a c e d . D i s t i n c t i o n s between l o n g term c a r e f a c i l i t i e s and ac u t e c a r e f a c i l i t i e s f aded o r perhaps were never e s t a b l i s h e d i n the 33 minds of those who heeded.the promise of the p o l i t i c i a n s that care would be available to a l l . E l d e r l y people admit-ted to acute care f a c i l i t i e s are simply never discharged. Many of these patients require care that some families are unable to provide but many others come from families which are unwilling to keep e l d e r l y family members i n th e i r homes despite home support services. 20 The proportion of 'placement patients' i n the patient population of the two t e r t i a r y care, r e f e r r a l hospitals i n Vancouver has grown to a constant 20%. Both hospitals have had severe problems meeting t h e i r acute care mandate under these conditions as well as having grave concerns about the a b i l i t y of nursing s t a f f to cope with these very time-consuming but not acutely i l l patients. Expensive registered nurse time i s not usually required for these 'placement patients' so acute care hospitals have, i n some cases, re-organized nursing units to consolidate these patients in.a single area where appropriate s t a f f i n g can be introduced and attempts made to provide more appropriate environments. The hospitals are concerned about the costs of these unit changes and about t h e i r permanency since most acute care hospitals wish to r e s t r i c t t h e i r a c t i v i t y to acute care. Patients requiring placement i n a long term care f a c i l i t y . 34 Some p r i n c i p l e s under w h i c h the LTC Program o p e r a t e s have e x a c e r b a t e d the s i t u a t i o n i n ac u t e c a r e h o s p i t a l s . P e o p l e i n the community, i . e . o u t s i d e a c u t e c a r e i n s t i t u -t i o n s , a r e g i v e n p r i o r i t y f o r placement o v e r p a t i e n t s i n the h o s p i t a l s w h i c h l e a d s t o s i t u a t i o n s i n w h i c h p a t i e n t s r e -main i n a c u t e c a r e h o s p i t a l s from 3-9 months b e f o r e p l a c e -ment o r de a t h i n t e r v e n e s . A l s o , the program promis e s p l a c e -ment o f c h o i c e . T h e r e f o r e , when a bed becomes a v a i l a b l e i t can be r e f u s e d as u n d e s i r a b l e . Abuses o f the system abound and a r e p a r t i c u l a r l y e v i d e n t i n the use o f the a c u t e h o s p i t a l s t o g e t "granny" i n t o t h e i n s t i t u t i o n a l system and 21 o u t o f t h e home. In June 1981, the M i n i s t r y o f H e a l t h ' s a l l o c a t i o n s t o the home s u p p o r t s e r v i c e s i n t h e p r o v i n c e were i n a d e q u a t e t o m a i n t a i n c u r r e n t s e r v i c e s . R e d u c t i o n s i n the hours a v a i l a b l e t o i n d i v i d u a l s w i l l , w i t h o u t doubt, p l a c e even more p e o p l e i n t o the a c u t e c a r e h o s p i t a l system. Long Term Care f a c i l i t i e s a r e under c o n s t r u c t i o n t h r o u g h o u t the p r o v i n c e b u t i n the f a c e o f a w a i t i n g l i s t o f a p p r o x i m a t e l y 1200 names i n the Lower M a i n l a n d , the 400 a d d i t i o n a l beds t o be a v a i l a b l e by f a l l , 1981, w i l l n o t make any s i g n i f i c a n t r e d u c t i o n i n t h e a c u t e c a r e S t o r i e s o f abuses are not uncommon among p h y s i c i a n s , assessment, l i a i s o n and h o s p i t a l n u r s e s . 35 h o s p i t a l s ' i n v o l v e m e n t w i t h l o n g term c a r e . The government's c o s t s f o r m a i n t a i n i n g t h e LTC Program a r e p r o b a b l y c o n s i d e r -a b l y more than p r o j e c t i o n s and would h e l p t o e x p l a i n t he r e c e n t a c t i v i t y o f the T r e a s u r y Board w i t h i n t h e M i n i s t r y o f H e a l t h . There a r e some presumably s e r e n d i p i t o u s r e s u l t s w h i c h have d e v e l o p e d s i n c e i n t r o d u c t i o n o f the LTC Program (19 78) . Acute c a r e h o s p i t a l s a r e r e q u i r e d t o n o t i f y the M i n i s t r y o f each p a t i e n t who no l o n g e r r e q u i r e s a c u t e c a r e b u t remains a p a t i e n t i n an a c u t e c a r e f a c i l i t y . R e d u c t i o n o f bed usage by a c u t e l y i l l p a t i e n t s and i n c r e a s e d use by l o n g term c a r e p a t i e n t s , a l o n g w i t h t he r e q u i r e d n o t i f i c a t i o n o f 22 BCHP o f the l o n g term c a r e p a t i e n t s l e a d s t o s i g n i f i c a n t downward p e r diem f u n d i n g r e a d j u s t m e n t s . The an n u a l o p e r a t i n g a l l o c a t i o n s r e c e i v e d by acute c a r e h o s p i t a l s have r e c e n t l y i n c l u d e d a s p e c i f i c number o f l o n g term c a r e p a t i e n t 23 days w h i c h a r e remunerated a t a lower p e r diem r a t e . The compromised a d m i s s i o n p o s s i b i l i t i e s f o r a c u t e and e l e c t i v e p a t i e n t s and the c o n c e r n about d i m i n i s h i n g ' t e a c h i n g B r i t i s h Columbia M i n i s t r y o f H e a l t h , C i r c u l a r l e t t e r 79/10, March 2, 1979. The a c u t e c a r e p e r diem a t St.: P a u l ' s H o s p i t a l ; . i n 19 80 was $2 32.40,- the l o n g term c a r e p e r diem was $37 .80 . 36 m a t e r i a l ' f o r t h e m e d i c a l s t u d e n t ' s c l i n i c a l l e a r n i n g i s c o n t r i b u t i n g t o p h y s i c i a n s l e a v i n g t h e s t a f f s o f the s e v e r e l y a f f e c t e d h o s p i t a l s . W i t h t h e l a r g e number o f a d d i t i o n a l a c u t e c a r e beds opened r e c e n t l y , o r o p e n i n g soon, such r e -a l i g n m e n t i s i n t h e M i n i s t r y o f H e a l t h ' s and the new h o s p i - : t a l ' s f a v o r . The new h o s p i t a l can become f u l l y f u n c t i o n a l more q u i c k l y . U n f o r t u n a t e l y , i t may a l s o undermine t h e q u a l i t y o f c a r e i n the o l d e r h o s p i t a l s . E x p e r i m e n t s i n H o s p i t a l A m b u l a t o r y Care i n B.C. Amb u l a t o r y c a r e s e r v i c e s as p r o v i d e d by h o s p i t a l s i n B r i t i s h Columbia u s u a l l y mean a s e r v i c e p r o v i d e d w i t h o u t a d m i s s i o n t o a h o s p i t a l bed, w i t h i n one.day and c o n t r o l l e d by the a t t e n d i n g p h y s i c i a n . These s e r v i c e s a r e s i m p l y an e x t e n s i o n o f t h e t r a d i t i o n a l c o r e model, not i n c o r p o r a t i n g any o f the i n n o v a t i v e f e a t u r e s s u g g ested i n t h e s t u d i e s and r e p o r t s d e s c r i b e d p r e v i o u s l y . Work done i n Ambulatory Care i n the Vancouver a r e a has f o c u s s e d on h o s p i t a l - b a s e d programs, t o o . S t . P a u l ' s and Vancouver G e n e r a l H o s p i t a l have d e v e l o p e d s i m i l a r programs; L i o n ' s Gate H o s p i t a l has i n t r o d u c e d a s l i g h t l y d i f f e r e n t approach, b u t a l l remain m e d i c a l l y c o n t r o l l e d . The G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t has, t h r o u g h s e v e r a l a t t e m p t s , c o n t i n u a l l y promoted h o s p i t a l - b a s e d a m b u l a t o r y c a r e programs. More r e c e n t l y , the U n i v e r s i t y C o u n c i l o f Te a c h i n g H o s p i t a l s has shown i n t e r e s t i n c o n t r o l l i n g de-velopment o f ambulat o r y c a r e . 37 The G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t : A c t i v i t y i n the E a r l y '70's The G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t (GVRHD) has sponsored s e v e r a l a t t e m p t s t o e x p l o r e and encourage the p r o v i s i o n o f c a r e on an ambulatory c a r e b a s i s . I n March, 1973, a Day Care F a c i l i t i e s Study Group was formed t o s t u d y and examine a l l e x i s t i n g and p o t e n t i a l Day Care S e r v i c e s i n terms o f s e r v i c e components, space r e q u i r e m e n t s , and t o d e v e l o p s t a n d a r d s and s p e c i f i c a t i o n s . The Group's recommendations can be summarized a s : 1. Day Care s h o u l d be renamed Ambulatory Care and Treatment S e r v i c e s (ACTS) 2. F a c i l i t i e s f o r ACTS s h o u l d r e c e i v e u r g e n t p r i o r i t y a t a l l l e v e l s o f h e a l t h c a r e a d m i n i s t r a t i o n i n the p r o v i n c e . 3. A l l new c o n s t r u c t i o n and r e c o n s t r u c t i o n s h o u l d i n c l u d e f a c i l i t i e s t o p r o v i d e a m b u l a t o r y s e r v i c e s i n k e e p i n g w i t h the d e f i n e d r o l e o f the h o s p i t a l . L i o n s ' Gate and S t . P a u l ' s H o s p i t a l s ' a m b u l a t o r y c a r e developments were, presumably i m p a c t e d by t h e p o s i t i v e •nature o f the 19 73 s t u d y group's recommendations. L i o n s ' Gate H o s p i t a l The L i o n s ' Gate H o s p i t a l i n N o r t h Vancouver, B.C. has been a c t i v e i n a t t e m p t i n g t o d e v e l o p a s p e c i f i c 24 Ambulatory Care C e n t r e . From 1969 t o 1973 members o f the 24 V a l e r i e Young and L o r n a R o m i l l y , New Models i n  Ambulatory Care, Dimensions i n H e a l t h S e r v i c e , June 1981, p. 17-19. 38 m e d i c a l s t a f f p r e s s e d the M i n i s t r y o f H e a l t h t o s u p p o r t the e s t a b l i s h m e n t o f a m b u l a t o r y programs on the b a s i s o f a low-e r e d l e n g t h o f s t a y f o r i n p a t i e n t s and o f i n p a t i e n t r e p l a c e -ment days, i . e . d i r e c t s u b s t i t u t i o n . W i t h i n the e x p a n s i o n and redevelopment o f the h o s p i t a l an Ambulatory Care C e n t r e was completed i n December, 1979. The programs a r e t y p i c a l o f h o s p i t a l - b a s e d a m b u l a t o r y c a r e , i . e . m e d i c a l l y c o n t r o l l e d . A l l p a t i e n t s are r e f e r r e d by t h e i r a t t e n d i n g p h y s i c i a n and the programs a r e r e s t r i c t e d t o a s p e c i f i c d i a g n o s i s , problem o r p r o c e d u r e . To overcome some s e n s i t i v i t y and h e s i t a n c y towards the use o f the s e r -v i c e s , s i n c e some p h y s i c i a n s , e s p e c i a l l y g e n e r a l p r a c t i t i o n e r s v i ew them as c o m p e t i t i o n , the v o l u n t a r y / e l e c t e d d i r e c t o r s o f each program a r e sometimes g e n e r a l p r a c t i t i o n e r s . F u n d i n g t o the h o s p i t a l i s r e s t r i c t e d t o the -e s t a b l i s h e d l i s t , $2.00 f o r the u n l i s t e d s e r v i c e s such as Chemotherapy, i s p a i d by the p a t i e n t . There i s b l o c k f u n d i n g f o r the R e h a b i l i t a t i o n , C h r o n i c O b s t r u c t i v e Lung D i s e a s e , Asthma, Back Problems, S t r o k e and P a r k i n s o n ' s D i s e a s e Programs. L i o n s ' Gate H o s p i t a l does n o t m a i n t a i n l a r g e i n d i g e n t p r i m a r y c a r e c l i n i c s as do Vancouver G e n e r a l and S t . P a u l ' s H o s p i t a l s . L i o n s ' Gate H o s p i t a l has i n i t i a t e d program e v a l -u a t i o n s u s i n g the c r i t e r i a o f p a t i e n t b e n e f i t and c o s t e f f e c t i v e n e s s . I r o n i c a l l y , f u n d i n g f o r the e v a l u a t i o n i s b e i n g sought from s o u r c e s o t h e r than the M i n i s t r y o f H e a l t h . 39 S t . P a u l ' s H o s p i t a l i n v o l v e m e n t w i t h a m b u l a t o r y c a r e s e r v i c e s w i l l be d i s c u s s e d i n the n e x t c h a p t e r . G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t : A c t i v i t y i n the L a t e '70's In F e b r u a r y 19 76 the GVRHD s t r u c k the Ambulatory S e r v i c e s Study Committee. The committee went o v e r ground s i m i l a r t o the 1973 s t u d y group, w i t h some new d i r e c t i o n s added. The terms o f r e f e r e n c e were t o 1. de t e r m i n e and c a t a l o g u e w h i c h a m b u l a t o r y s e r v i c e s a r e p r o v i d e d i n each h o s p i t a l a t p r e s e n t , 2. d e t e r m i n e w h i c h h o s p i t a l s a r e p l a n n i n g new or expanded programs and t o document t h e s e programs 3. e x p l o r e w h i c h o t h e r d i s e a s e s o r c o n d i t i o n s may b e n e f i t from s p e c i f i c new programs 4. i d e n t i f y a l l s e r v i c e s w h i c h c o u l d be p r o v i d e d i n an ambulato r y s e t t i n g and de v e l o p models ( a p p r o p r i a t e t o each, i . e . community, r e g i o n a l , r e f e r r a l and t e r t i a r y r e f e r r a l h o s p i t a l s ) o f how b e s t t o p r o v i d e a m b u l a t o r y c a r e t h e r e b y e n c o u r a g i n g new programs t o d e v e l o p , 5. d e v e l o p g u i d e l i n e s f o r p h y s i c a l f a c i l i t i e s ( space, r e l a t i o n s h i p s , u t i l i z a t i o n ) r e q u i r e d t o c a r r y o u t i d e n t i f i e d ambula-t o r y c a r e programs, 6. r e p o r t r e g u l a r l y t o the P r o f e s s i o n a l P r a c t t i c e s Sub-Committee. The t a s k p r o v e d t o o l a r g e f o r the committee and no r e p o r t was e v e r f i n a l i z e d a l t h o u g h an enormous amount o f i n f o r m a t i o n was accumulated and some p r e l i m i n a r y models were d e v e l o p e d . I n 19 79 the GVRHD t r i e d t o e s t a b l i s h 40 f u t u r e d i r e c t i o n s again. Based on the experience o f the 1976 committee, they approached the problem i n a more s p e c i f i c manner than committee work. In September, 19 80, i n a j o i n t venture with the M i n i s t r y o f Hea l t h , a p o s i t i o n was developed i n GVRHD to study and encourage the development of ambulatory care s e r v i c e s . I t i s e n t i t l e d "Medical P l a n n i n g and L i a i s o n O f f i c e r , Ambulatory Care Programs." A S t e e r i n g Committee composed of r e p r e s e n t a t i v e s from the. M i n i s t r y and GVRHD w i l l prepare and a s s i g n t a s k s ; e v a l u a t e progress and r e -po r t s o f the o f f i c e r ; make recommendations to BCHP P l a n -ning Group and GVRHD H o s p i t a l A d v i s o r y Committee r e g a r d i n g development; an expansion o f ambulatory care s e r v i c e s ; i d e n t i f y p o t e n t i a l areas f o r new ambulatory care s e r v i c e s , and develop g u i d e l i n e s f o r t h e i r study. The job d e s c r i p t i o n o f the Med i c a l P l a n n i n g and L i a i s o n O f f i c e r i s summarized as f o l l o w s : 1. w i l l h e lp e s t a b l i s h the c r i t e r i a and i n the development o f program p o l i c y of Ambulatory Care i n l i a i s o n w i t h BCHP and GVRHD making use o f the conceptual models as prepared by the GVRHD Ambulatory S e r v i c e s Study Committee (of 1976). 2. w i l l promote the expansion o f Ambulatory Care S e r v i c e s and Programs which have p r i o r a p p r o v a l of the M i n i s t r y o f Hea l t h i n the h o s p i t a l s o f the GVRHD through e d u c a t i o n a l e f f o r t s d i r e c t e d towards p a t i e n t s , a d m i n i s t r a t i o n , and medical s t a f f . 3. w i l l e v a l u a t e the v a r i o u s kinds o f s e r v i c e which can be i n c l u d e d i n the Ambulatory Care 41 Programs. As p a r t o f t h i s e v a l u a t i o n the eco-nomics, changes i n m e d i c a l p r a c t i c e , a b i l i t y o f h o s p i t a l s t o p a r t i c i p a t e , and s p e c i f i c needs w i l l be c o v e r e d . 4. w i l l r e p o r t r e g u l a r l y t o the P r o f e s s i o n a l P r a c t i c e s Sub-committee o f GVRHD and t h r o u g h the P l a n n i n g Group o f the BCHP t o the M i n i s t e r o f H e a l t h . The f i r s t completed t a s k o f the M e d i c a l P l a n n i n g and L i a i s o n O f f i c e r i s b e f o r e t h e GVRHD H o s p i t a l A d v i s o r y Committee a t the time o f w r i t i n g . The r e p o r t d e a l s w i t h S u r g i c a l Day Care and p r o v i d e s a h i s t o r i c a l p e r s p e c t i v e as w e l l as recommendations aimed a t p r o m o t i n g t h i s 25 s e r v i c e . C o u n c i l o f U n i v e r s i t y T e a c h i n g H o s p i t a l s Y e t a n o t h e r group showing i n t e r e s t i n the d e v e l o p -ment o f Ambulatory Care S e r v i c e s appears t o be the C o u n c i l o f U n i v e r s i t y T e a c h i n g H o s p i t a l s . A p o s i t i o n paper d a t e d September, 1980, i s p r e s e n t l y i n c i r c u l a t i o n f o r d i s -c u s s i o n among the f o u r u n i v e r s i t y a f f i l i a t e d ( m e d i c a l ) t e a c h i n g h o s p i t a l s . The paper promotes h o s p i t a l - b a s e d a m b u l a t o r y c a r e programs as the b e s t t y p e o f o u t p a t i e n t c a r e and recommends the e s t a b l i s h m e n t o f an i n t e r - h o s p i t a l p l a n n i n g committee t o d e v e l o p a comprehensive h e a l t h c a r e The w r i t e r o f t h i s t h e s i s was a member o f the 19 76 Ambulatory Care Study Committee and i s p r e s e n t l y a member o f the GVRHD H o s p i t a l A d v i s o r y Committee. 42 p l a n n i n g base f o r ambulatory care programs. At t h i s w r i t i n g no p u b l i c a c t i o n has been taken. T h i s i n t e r e s t i n the promotion and c o n t r o l o f ambulatory care programs and f a c i l i t i e s i s probably r e l a t e d t o the d i f f i c u l t i e s which the medical s c h o o l i s having i n seeking student placements f o r c l i n i c a l l e a r n i n g o p p o r t u n i t i e s ; a s i t u a -t i o n which w i l l become i n c r e a s i n g l y p r o b l e m a t i c as the student numbers are i n c r e a s e d . 2 ^ Funding of H o s p i t a l - B a s e d Ambulatory Care: P r o v i n c i a l Involvement: H o s p i t a l Programs Methods of h o s p i t a l funding i n B.C. have been under a t t a c k by h o s p i t a l a d m i n i s t r a t o r s f o r many, ye a r s . Fund-i n g f o r i n p a t i e n t care i s through a per diem a l l o c a t i o n a p p l i e d a n n u a l l y to a pre-determined number of p a t i e n t days. Seldom, i f ever, does the a l l o c a t i o n approach p r o j e c t e d need i n the t e r t i a r y care r e f e r r a l and t e a c h i n g h o s p i t a l s o f the p r o v i n c e . T h i s arrangement l e a d s to cash flow problems and to a d e f i c i t a t year's end. O c c a s i o n a l l y a program w i l l be funded s e p a r a t e l y , f o r example, the Open Heart Surgery Programs. Ambulatory s e r v i c e s are funded q u i t e d i f f e r e n t l y . The government has developed a very s h o r t l i s t o f Government p e r m i s s i o n has been r e c e i v e d to double the enrolment o f the UBC M e d i c a l S c h o o l . 43 r e c o g n i z e d s e r v i c e s f o r w h i c h the h o s p i t a l i s p a i d a s p e c i f i c amount o f money.for each s e r v i c e . The l i s t has n o t changed o v e r s e v e r a l y e a r s d e s p i t e new p o s s i b i l i t i e s f o r c a r e t o be d e l i v e r e d i n t h i s manner. I t i n c l u d e s S u r g i c a l Day C a r e , P s y c h i a t r i c Day/Night Care, P h y s i o t h e r a p y , . D e i t e t i c Coun-s e l l i n g and R enal D i a l y s i s . Any o t h e r p r o c e d u r e , no m a t t e r how complex, i s p a i d f o r by t h e r e c i p i e n t o f the s e r v i c e a t $2.00 per v i s i t . R e v i s e d Approaches t o H o s p i t a l F u n d i n g A h o s p i t a l f u n d i n g s t u d y , j o i n t l y s ponsored by the M i n i s t r y o f H e a l t h and t h e B.C. H e a l t h A s s o c i a t i o n , was i n s t i t u t e d i n May, 1978, i n o r d e r t o d e v e l o p a more r a t i o n a l and e q u i t a b l e approach t o f u n d i n g h o s p i t a l s i n the p r o v i n c e and w hich would aim f o r optimum use o f a v a i l a b l e funds i n a manner which i s c l e a r l y u n d e r s t o o d by a l l - p a r t i e s . I n 1979, as an e s s e n t i a l p a r t o f t h e i n i t i a l s t u d y , a j o i n t l y sponsored (B.C. H o s p i t a l Programs, d i v i s i o n o f the M i n i s t r y o f H e a l t h and BCHA) h o s p i t a l r o l e s t u d y began. H o s p i t a l s would be d e f i n e d and c a t e g o r i z e d on t h e b a s i s o f the c h a r a c t e r i s t i c s o f the i n d i v i d u a l h o s p i t a l and f u n d i n g would r e f l e c t each h o s p i t a l ' s mandate. D r a f t I was c i r c u -l a t e d t o a l l h o s p i t a l s f o r c r i t i q u e and comment. S e v e r a l r e s p o n d e n t s r e q u e s t e d more e x p l i c i t r e f e r e n c e t o the a m b u l a t o r y c a r e r o l e o f the h o s p i t a l s . 44 As a r e s u l t of these r e q u e s t s , a study group was formed i n the M i n i s t r y ' s Department of Pl a n n i n g and Develop-ment. The group found the area o f h o s p i t a l - b a s e d ambula-t o r y care f r a u g h t w i t h l a c k o f data, d e f i n i t i o n s and standards. I t i s a n t i c i p a t e d some ge n e r a l development p r i n c i p l e s ; and p l a n n i n g g u i d e l i n e s f o r f u t u r e h o s p i t a l -based programs w i l l be a v a i l a b l e i n 1981 as a c o n c l u s i o n t o 27 t h i s study. Community Human:. Resources and Health Centres Another a c t i o n which had begun b e f o r e the Foulkes Report was p u b l i s h e d was the formation o f the Development Group which was charged w i t h the task o f implementing and e v a l u a t i n g the v a l i d i t y o f i n t r o d u c i n g a new e n t r y p o i n t i n t o the h e a l t h care system through the Community H e a l t h Centres. The CHC would p l a c e emphasis on care d e l i v e r e d o u t s i d e h o s p i t a l s p r o v i d i n g b e t t e r f i r s t c o n t a c t (primary) medical care, h e a l t h promotion a c t i v i t i e s and p r e v e n t i v e s e r v i c e s a l l through an i n t e g r a t e d s e r v i c e c o n t r i b u t e d to by a l l h e a l t h and s o c i a l workers. Simultaneously, the M i n i s t r y of Human Resources was deve l o p i n g the i d e a o f Community Resource Boards. Pe r s o n a l Communication from Diane Layton, P l a n n i n g and Development. 4 5 The two M i n i s t r i e s , H e a l t h , and Human Resources, j o i n e d f o r c e s to prese n t l e g i s l a t i o n f o r the i n s t i t u t i o n o f Community Human Resource and Hea l t h Centres (CHRHC). The proposed l e g i s l a t i o n came from the M i n i s t r y of Human Resources w i t h the p o s s i b i l i t y o f i n c l u d i n g h e a l t h s e r v i c e s because p r o v i s i o n o f h e a l t h s e r v i c e s through the c e n t r e s h e l d much more heated c o n t r o v e r s y than the s o c i a l s e r v i c e s . The NDP government's s h o r t term denied the completion of the o r g a n i z a t i o n a l changes i t began. The succeeding S o c i a l C r e d i t government c a n c e l l e d a l l new a c t i v i t y and withdrew the e n a b l i n g l e g i s l a t i o n . Those CHRHC which continue to e x i s t have proven t h e i r a c c e p t a b i l i t y and e f f e c t i v e n e s s i n c o s t r e d u c t i o n s . ^ As can be deduced from t h i s b r i e f summary, B r i t i s h Columbia has not advanced f a r i n the d i r e c t i o n of new a l t e r n a t i v e care d e l i v e r y systems. The CHRHC were aborted, the Long Term Care Program i s de v e l o p i n g a need f o r other types o f i n s t i t u t i o n s and Home Care's p o t e n t i a l .has been cu t back. There has been some advancement i n h o s p i t a l -based programs but these are r e s t r i c t e d to the t r a d i t i o n a l mode of care d e l i v e r y on an ambulatory b a s i s . See Appendix I f o r a more complete d e s c r i p t i o n of the CHRHC developed d u r i n g t h i s p e r i o d . 4 6 CHAPTER IV MEDICAL DAY CARE PROGRAM AT ST. PAUL'S HOSPITAL H i s t o r y o f Ambulatory Care S e r v i c e s a t S t . Paul's H o s p i t a l St. Paul's H o s p i t a l has long maintained an o u t p a t i e n t s e r v i c e f o r i n d i g e n t s and s k i d road i n h a b i t a n t s . Such s e r -v i c e was f r e q u e n t l y found i n the t e a c h i n g h o s p i t a l s and i n the h o s p i t a l s operated by r e l i g i o u s o r d e r s . Even today, d e s p i t e comprehensive medical coverage s i n c e 1968, a p p r o x i -mately 19 00 i n d i v i d u a l s s t i l l use the department f o r e p i s o d i c and c o n t i n u i n g c a r e . These o u t p a t i e n t s e r v i c e s are p r o v i d e d through c l i n i c s of v a r i o u s medical s p e c i a l t i e s conducted by medical c l i n i c a l s u p e r v i s o r s w i t h medical l e a r n e r s p r o v i d i n g the c a r e . A gene r a l c l i n i c conducted by the Department of Family P r a c t i c e p r o v i d e s primary care and a t r i a g e f u n c t i o n to r e d i r e c t p a t i e n t s to the s p e c i a l t y c l i n i c s . 1 G e n e r a l l y , the medical s t a f f ' s a t t i t u d e toward the s e r v i c e has been n e g a t i v e . The c l i n i c s conducted f o r medical t e a c h i n g purposes are i n c o n -s i s t e n t l y attended by medical s t a f f and are conducted by d i f f e r e n t d o c t o r s on r o t a which a f f e c t s the a v a i l a b i l i t y and q u a l i t y of c a r e . An aura o f poverty and d i s i l l u s i o n m e n t permeates the s e r v i c e . There have been p e r i o d s where the The Vancouver General H o s p i t a l i s the o n l y other h o s p i t a l i n the p r o v i n c e m a i n t a i n i n g a s i m i l a r s e r v i c e . Seen as the m u n i c i p a l h o s p i t a l , the VGH, u n t i l r e c e n t l y , r e c e i v e d a funding a l l o c a t i o n from the C i t y of Vancouver to m a i n t a i n the s e r v i c e . 4 7 g e n e r a l c l i n i c was seen t o be i n c o m p e t i t i o n w i t h the g e n e r a l p r a c t i t i o n e r s on s t a f f , e s p e c i a l l y a f t e r a f u l l time p h y s i c i a n 2 was employed i n 1976. D u r i n g t h e l a t e 1960's and e a r l y 1970's s e v e r a l o t h e r a m b u l a t o r y s e r v i c e s were i n i t i a t e d t h r o u g h o u t the h o s p i t a l where s e r v i c e s were r e n d e r e d p r i m a r i l y t o p r i v a t e p a t i e n t s , w i t h few i n d i g e n t p a t i e n t s e x c e p t as they were r e f e r r e d . Some o f t h e s e c l i n i c s were t h e D i a b e t i c C l i n i c , t he Eye C l i n i c , the G a s t r o i n t e s t i n a l C l i n i c , t he E n t e r o s t o m a l C l i n i c . These s e r v i c e s were, and a r e t o d a y , a v a i l a b l e t o i n p a t i e n t s as w e l l as o u t p a t i e n t s . . These c l i n i c s p r o v i d e d i a g n o s t i c , t r e a t -ment, and p a t i e n t e d u c a t i o n s e r v i c e s . I n 1974, when the BCMC was f u n c t i o n i n g as the c o o r d i n a -t o r o f h e a l t h c a r e d e l i v e r y o r g a n i z a t i o n i n the Lower Main-l a n d , S t . P a u l ' s H o s p i t a l was a l l o c a t e d the t a s k o f d e v e l o p i n g 3 a major ambul a t o r y c a r e s e r v i c e f o r Vancouver. The h o s p i t a l a c c e p t e d the c h a l l e n g e and h e n c e f o r t h p l a n n e d a c t i v e l y t o -ward t h i s g o a l . A m b u l a t o r y s e r v i c e s were seen t o be a means t o p r o v i d e h e a l t h c a r e t o more p a t i e n t s . I t was viewed as an a c t i v e l y f u n c t i o n i n g and growing s e r v i c e w h i c h would a l l e v i a t e the i n p a t i e n t occupancy p r e s s u r e . I n some.-instances, 2 I n 19 81 the g e n e r a l p r a c t i c e c l i n i c r e v e r t e d t o a r o t a t i o n o f p r a c t i c i n g f a m i l y p h y s i c i a n s . 3 B r i t i s h Columbia M e d i c a l C e n t r e document d a t e d F e b r u a r y 25, 1975, o u t l i n e d the Ambulatory S e r v i c e s w hich were t o be a v a i l a b l e a t S t . P a u l ' s H o s p i t a l . 48 t h i s commitment on the p a r t o f the h o s p i t a l a d m i n i s t r a t i o n l e d to the es t a b l i s h m e n t o f some o u t p a t i e n t programs without formal funding. A r e n o v a t i o n o f the former i n d i g e n t o u t p a t i e n t department has i n c l u d e d c o n s i d e r a b l y more space and i n c o r p o r a t e d s e v e r a l s e r v i c e s f o r p r i v a t e p a t i e n t s as w e l l (e.g. minor surgery, which had p r e v i o u s l y been scheduled i n the Emergency Department, was now s e t up i n the newly named Ambulatory Care Department). Space'was prepared i n the same area to r e c e i v e a Med i c a l Day Care s e r v i c e but remained unused u n t i l September 6, 1978. E s t a b l i s h e d c l i n i c s s i t u a t e d around the h o s p i t a l c o u l d not be c o n s o l i d a t e d . i n one l o c a t i o n because of i n s u f f i c i e n t space but plans f o r the f u t u r e r e c o n s t r u c t e d h o s p i t a l i n c l u d e such a c o n s o l i d a t i o n i n Phase I I I . Replacement of the e x i s t i n g h o s p i t a l has been planned i n three phases. Completion dates are dependent upon government fun d i n g . Development Plan f o r a Medical Day Care Program Development of a Medical Day Care Program was based on a r a t i o n a l d e c i s i o n made by i n t e r e s t e d p a r t i e s w i t h i n the h o s p i t a l s t r u c t u r e to answer some r e c o g n i z e d i n t e r n a l needs as w e l l as to respond to BCMC commitments. The c o n s i s t e n t l y h i g h occupancy, the number of e l e c t i v e p a t i e n t s c a n c e l l e d each day, and the medical s t a f f ' s concerns about p h y s i c i a n ' s i n a b i l i t y to admit p a t i e n t s d e s p i t e one of the lowest l e n g t h o f stay (LOS) i n the country, were the immediate m o t i v a t i o n s i n d e v e l o p i n g the Me d i c a l Day Care 49 Program. A commitment to ambulatory care g e n e r a l l y , and to improvements i n p a t i e n t use of beds, were u n d e r l y i n g c o n s i d e r a t i o n s . Program Pl a n n i n g The M e d i c a l Day Care Program was conceived as a complement to Medicine as the S u r g i c a l Day Care Program f u n c t i o n s f o r Surgery. The concept was f i r s t f o r m a l l y 4 recommended xn the Ambulatory Care Committee 1974-75 Annual Report. The f i r s t p r o p o s a l to government went forward i n the f a l l o f 1976. On A p r i l 18,1977 and again on December 6, 1977 (See Appendix I I I and IV) a f t e r no response and some v e r b a l exchanges, a p r o p o s a l f o r a p i l o t p r o j e c t was submitted. In May 1978 approval to proceed w i t h a one-year p i l o t p r o j e c t was r e c e i v e d . The proposed program was to f u n c t i o n seven hours d a i l y , w i t h i n which time c e r t a i n more complicated d i a g n o s t i c and treatment procedures, which then r e q u i r e d h o s p i t a l i z a t i o n , would be c a r r i e d out, w i t h the p a t i e n t r e t u r n i n g home f o l l o w i n g each s e s s i o n . Use o f program s e r v i c e s was r e s t r i c t e d , i n i t i a l l y , to members of the Department of Medicine, thereby r e d u c i n g the number of p h y s i c i a n s i n v o l v e d . A l s o , the number of p a t i e n t s was r e s t r i c t e d , i n i t i a l l y . Both these measures allowed the The committee, wi t h medical and n u r s i n g membership, a c t s as a p r o b l e m - s o l v i n g and a d v i s o r y group. 50 Department of Nursing time to become competent i n s p e c i f i c procedures and to work out o r g a n i z a t i o n a l 'bugs'. L a t e r , the s e r v i c e was opened to a l l members of the medical s t a f f . P a t i e n t numbers are r e s t r i c t e d by time requirements and the number of beds a v a i l a b l e . Each procedure has to meet s a f e t y , knowledge, and l e g a l c r i t e r i a , b e f o r e being accepted. For example, the D i r e c t o r of Ambulatory Care must be s a t i s f i e d the p a t i e n t can ex-p e r i e n c e the t e s t or treatment and r e c o v e r s u f f i c i e n t l y to be d i s c h a r g e d i n seven hours. The Nursing Department has to accept the r e s p o n s i b i l i t y and l i a b i l i t y o f safe n u r s i n g , s i n c e most procedures are c a r r i e d out by n u r s i n g s t a f f . (See Appendix V) The Pharmacy and T h e r a p e u t i c s Committee sanctioned the use of c e r t a i n drugs, and agreed to t h e i r use by nurses independent of medical s u p e r v i s i o n . A p r o t o c o l was e s t a b l i s h e d to c o n s i d e r a p r o p o s a l f o r any added procedure so t h a t the c r i t e r i a f o r acceptance can be reviewed b e f o r e i t s i n c l u s i o n . As time passes, new procedures are added. E x t e n s i v e i n s e r v i c e e d u c a t i o n and o r i e n t a t i o n programs to prepare the n u r s i n g s t a f f were designed, implemented, and are on-going any time a new procedure i s accepted or when new n u r s i n g s t a f f are employed. In March 1980, as p r e s s u r e on i n p a t i e n t beds i n c r e a s e d , even more than p r e v i o u s l y , the hours of s e r v i c e were ex-tended to a l l o w f o r the implementation of e i t h e r medical or 51 s u r g i c a l p r o c e d u r e s r e q u i r i n g an o v e r n i g h t s t a y . P a t i e n t s l e a v e a t 0700 and t h a t day's p a t i e n t s a r r i v e a t 0730. T h i s arrangement a l s o a l l o w s a s i n g l e s t r e t c h e r bed t o be used by 5 two, and sometimes t h r e e , p a t i e n t s i n one 12-hour p e r i o d . Program usage grew s l o w l y b u t t o d a y , as t h e d o c t o r s become more adapted, th e t e n s t r e t c h e r beds accommodate a range o f 7-14 p a t i e n t s i n 24 h o u r s . S i n c e h o u s e - s t a f f a r e not a v a i l a b l e t o t h e program, c o n s i d e r a b l y more p l a n n i n g i n p u t i s r e q u i r e d o f the a t t e n d i n g p h y s i c i a n f o r the MDC p a t i e n t t h a n f o r an i n p a t i e n t . The p a t i e n t ' s h i s t o r y and o r d e r s precede th e p a t i e n t by 24 h o u r s . A l s o , the o r d e r s f o r t h e day have t o t a k e i n t o a c c o u n t s e q u e n c i n g and i n c o m p a t i b i l i t i e s o f t e s t s , a l t h o u g h t h e Ambulatory Care Department does u n d e r t a k e t o make t h e n e c e s s a r y appointments i n v a r i o u s h o s p i t a l d epartments. D e s p i t e t h e s e a d d i t i o n a l demands on t h e p h y s i c i a n s and the i n e v i t a b l e problems e x p e r i e n c e d i n i n s t i t u t i o n o f the new p r o c e d u r e , t h e r e was no r e s i s t a n c e t o the e s t a b l i s h m e n t o f the program. I t s i n i t i a t i o n had s u p p o r t t h r o u g h t h e Ambula-t o r y Care Committee membership b u t most i m p o r t a n t l y , t h e program was seen by some m e d i c a l s t a f f members as a means t o 5The e x t e n s i o n o f time i s n o t funded i n any a s p e c t , 52 t r e a t more p a t i e n t s a t a time when e l e c t i v e p a t i e n t s must w a i t extended p e r i o d s o f time b e f o r e a d m i s s i o n . Problems t h a t d i d o c c u r were p r i m a r i l y r e l a t e d t o t h e changes i n e s t a b -l i s h e d modes o f p r a c t i c e r e q u i r e d o f the d o c t o r s and h a v i n g t o meet program r e q u i r e m e n t s b e f o r e the p a t i e n t c o u l d be t r e a t e d . R e c o r d i n g the a c t i v i t y o f t h e program and r e c o r d i n g the p a t i e n t ' s e x p e r i e n c e were e s t a b l i s h e d i n a manner which f i t t e d i n t o the s t a n d a r d i z e d m e d i c a l r e c o r d s and a d m i t t i n g p r o -cedures o f t h e h o s p i t a l . Management E n g i n e e r i n g U n i t 13.1 was r e q u e s t e d t o d e s i g n a d a i l y s t a t i s t i c s s h e e t w h i c h would s e r v e as a d a i l y w orksheet as w e l l as a s t a t i s t i c a l r e c o r d . T h i s a c c u m u l a t i o n o f d a t a became v e r y s i g n i f i c a n t when the program was a c c e p t e d . a s a p i l o t p r o j e c t . A t no time d i d the BCHP i n d i c a t e what e v a l u a t i o n c r i t e r i a would be r e q u i r e d . The w r i t e r made the d e c i s i o n about what it e m s o f d a t a would be m a i n t a i n e d . Resource P l a n n i n g A f t e r F e b r u a r y , 19 75, a t t e n t i o n w i t h i n the h o s p i t a l was f o c u s s e d on e x i s t i n g programs and f a c i l i t i e s f o r a m b u l a t o r y s e r v i c e s . A r e n o v a t i o n and u p d a t i n g o f t h e O u t p a t i e n t D e p a r t -ment and i t s program was u n d e r t a k e n and space was added t o t h e department f o r the i n t r o d u c t i o n o f a M e d i c a l Day Care Program. The c o s t o f t h e r e n o v a t i o n was $69, 4 9 0 . 0 0 , and was completed i n 1976; a d d i t i o n a l equipment c o a s t s were $7, 3 9 5 . 0 0 . 53 The MDC program was t o be p a r t o f t h e a d m i n i s t r a t i v e o r g a n i z a t i o n o f the Ambulatory Care ( O u t p a t i e n t ) Department and t h e r e f o r e would share i n the e s t a b l i s h e d r e s o u r c e s a v a i l a b l e i n the department, b u t by i t s n a t u r e , i t r e q u i r e d s p e c i a l r e s o u r c e p l a n n i n g . S i n c e t h e O u t p a t i e n t D e p a r t -ment had been o n l y a b a s i c p r i m a r y c a r e f a c i l i t y , a d d i t i o n a l s u p p l i e s , manpower, and equipment were r e q u i r e d t o p r o v i d e an MDC s e r v i c e a t secondary and t e r t i a r y l e v e l s . By O c t o b e r , 1977, in - h o u s e p l a n n i n g f o r an MDC s e r v i c e had p r o g r e s s e d t o the p o i n t where a memo, da t e d October 28, 1977, gave i n s t r u c t i o n s t o p r e p a r e s u b m i s s i o n s f o r e q u i p -ment t o BCHP and t o p r o c e s s n e c e s s a r y t e n d e r i n g and purchase documents. T h i s equipment was pu r c h a s e d a t a c o s t o f $9,225.28. I n June, 1978, an a d d i t i o n a l sum o f $1,225.00 was spe n t f o r more equipment, w h i c h was r e l a t e d t o the f i n a l i z e d n a t u r e o f the s p e c i f i c p r o c e d u r e s t o be o f f e r e d . More r e c e n t l y , the r e c l i n i n g c h a i r s o r i g i n a l l y p u r -chased have prove d t o be l e s s a c c e p t a b l e t o p a t i e n t s t h a n e x p e c t e d and were r e p l a c e d w i t h s t r e t c h e r beds t h r o u g h t h e an n u a l C a p i t a l Budget P r o c e s s . E x p e n d i t u r e s n e c e s s a r y i n t h e C e n t r a l S u p p l y D e p a r t -ment f o r a d d i t i o n a l p r o c e d u r e t r a y s and equipment was e s t i m a t e d i n i t i a l l y a t $452.50 b u t when the p r o c e d u r e l i s t was completed, c o s t s r o s e t o $905.00. I t was w e l l under-s t o o d t h a t the MDC s e r v i c e would be an add-on s e r v i c e i n t h i s department. 54 Some manpower r e s o u r c e s were t o be sh a r e d w i t h the l a r g e r department. P o r t e r , a i d e , a n d ^ c l e r k s e r v i c e s were s h a r e d . Requested a d d i t i o n a l s t a f f i n g was: 1.6 R.N. p o s i t i o n s 1.0 U n i t C l e r k .5 P h a r m a c i s t .2 M e d i c a l Records C l e r k .4 A d m i t t i n g Department C l e r k W i t h a c c e p t a n c e o f the p i l o t p r o j e c t , a p o r t i o n o f the manpower r e q u e s t was g r a n t e d by BCHP: 1.1 R.N. p o s i t i o n s .6 U n i t C l e r k .5 A d m i t t i n g C l e r k The inadequacy o f the manpower r e s o u r c e s g r a n t e d became app a r e n t w i t h i n a s h o r t time and a d d i t i o n a l R e g i s t e r e d Nurse s e r v i c e s were added. The o p e r a t i o n a l c o s t s o f equipment, s u p p l i e s , and manpower, were absorbed i n t o the e x i s t i n g and on - g o i n g c o s t s o f o p e r a t i n g e x i s t i n g s e r v i c e s which c o n t r i b u t e d t o the c a s h f l o w d i f f i c u l t i e s , the need f o r c a s h advances, and f i n a l l y , t h e year-end d e f i c i t p o s i t i o n o f the h o s p i t a l . No monies ear-marked f o r MDC were r e c e i v e d . F i n a n c i a l P l a n n i n g Much o f the w r i t t e n and v e r b a l d i s c u s s i o n w i t h government was about s u b s t i t u t i o n , i . e . , what would the h o s p i t a l exchange i n e x i s t i n g e x p e n d i t u r e s i f a M e d i c a l Day Care Program was i n t r o d u c e d ? 55 S p e c i f i c r e q u e s t s " were made f o r the "...percentage days w h i c h the h o s p i t a l hopes t o save ... o u t o f e x i s t i n g p a t i e n t s t a t i s t i c s ... 'and' ... d e t a i l e d p r o j e c t i o n s o f work volume ..." Attempts were made t o p r o v i d e t h i s i n -f o r m a t i o n b u t i t was based on'the b e s t judgment o f h o s p i t a l p e r s o n n e l s i n c e t h e r e were no p r e v i o u s MDC programs i n the p r o v i n c e . U s i n g an e s t i m a t e o f d i r e c t r e p l a c e m e n t days, i . e . , how many days would the p a t i e n t occupy a h o s p i t a l bed f o r the same s e r v i c e , w i t h no a c c o u n t i n g f o r . t h e l e s s e r e f f i c i e n c y o f h o s p i t a l i z a t i o n ; the response was a r e d u c t i o n o f t e n a c u t e c a r e beds and a commensurate r e d u c t i o n i n s u p p l i e s and drug s . E s t i m a t e d o p e r a t i n g c o s t s o f the new s e r v i c e would r e s u l t i n a n e t s a v i n g o f a p p r o x i m a t e l y $20,000.00 per y e a r a t 1977 r a t e s . 7 The response t o the i n f o r m a t i o n s u b m i t t e d was the s u g g e s t i o n o f M i n i s t r y o f f i c i a l s t h a t t h e CEO o f t h e h o s p i -t a l approach the Mr. and Mrs. P. A. Woodward F o u n d a t i o n f o r f u n d i n g t o promote o r g a n i z a t i o n and development o f May 16, 1977. L e t t e r from the A s s o c i a t e Deputy M i n i s t e r H o s p i t a l Programs. See Appendix V I . 7 December 6, 1977. L e t t e r from C h i e f E x e c u t i v e O f f i c e r t o BCHP. V e r b a l exchange preceded t h i s f o r m a l l e t t e r . 56 Ambulatory Care a t S t . Paul's H o s p i t a l . The request was r e j e c t e d "... u n t i l some concept of government p o l i c y on 9 s u p p o r t i n g such a programme i s a v a i l a b l e . " Eventually,monies were made a v a i l a b l e to purchase equipment and some personnel p o s i t i o n s r e q u i r e d were granted by BCHP. The program was to have been a p i l o t p r o j e c t of one year d u r a t i o n when, presumably, i t would be e v a l u a t e d and funded,or perhaps r e j e c t e d . At t h i s w r i t i n g , the program i s approaching three years of f u n c t i o n i n g without any government e v a l u a t i o n having taken p l a c e . In the p a s t , the h o s p i t a l , u s i n g d i s c r e t i o n a r y funds, had i n t r o d u c e d new programs without formal acceptance of BCHP, i f the programs complemented p a t i e n t c a r e . In 19 77 the p r e s s u r e s on a l l acute care h o s p i t a l s r e g a r d i n g ' d e f i c i t s ' and bed r e d u c t i o n s , w h i l e m a i n t a i n i n g a l l s e r -v i c e s , l e d to an a d m i n s t r a t i v e d e c i s i o n not to implement the MDC u n t i l a s p e c i f i c payment s c a l e was r e c e i v e d i n w r i t i n g from BCHP. T h i s d e c i s i o n , of course, was changed when the suggestion of a p i l o t p r o j e c t was put b e f o r e BCHP. No a c t u a l r e d u c t i o n of beds or p e r s o n n e l , s u p p l i e s , L e t t e r to Foundation dated November 7, 1977. (See Appendix VII) L e t t e r from Foundation dated December 8, 1977. (See Appendix VIII) 57 or drugs, r e s u l t e d from the i n t r o d u c t i o n o f the MDC p r o -gram. The o r i g i n a l need f o r the r e l e a s e v a l v e due to occupancy pressure and p a t i e n t c a n c e l l a t i o n s was exacer-bated by the i n t r o d u c t i o n of the Long Term Care Program and none of the a n t i c i p a t e d savings were r e a l i z e d although the MDC p a t i e n t i s being p r o v i d e d s e r v i c e i n a l e s s c o s t l y way. Remuneration from BCHP f o r the s e r v i c e has never been e s t a b l i s h e d . At present, the h o s p i t a l c o l l e c t s a $ 2 . 0 0 o u t p a t i e n t fee d i r e c t l y from the p a t i e n t f o r each v i s i t to the Med i c a l Day Care s e r v i c e , no matter how complex or c o s t l y the care p r o v i d e d . P a t i e n t B e n e f i t The M e d i c a l Day Care Program cont i n u e s i n the mode of s i c k n e s s c a r e . The p o p u l a t i o n served are p a t i e n t s with c h r o n i c i l l n e s s (hemophilia, cancer) who r e q u i r e r e g u l a r treatment i n t e r v e n t i o n s such as chemotherapy, and people w i t h symptomology who have c o n s u l t e d d o c t o r s . The p h y s i c i a n s c o n t r o l the a v a i l a b i l i t y of the s e r v i c e . The d i a g n o s t i c workups are e x t e n s i v e and o f t e n i n c l u d e t e s t s which cannot be done w e l l , or done a t a l l , o u t s i d e the h o s p i t a l . A s i m i l a r p o p u l a t i o n , without doubt, became i n -p a t i e n t admissions p r i o r to the es t a b l i s h m e n t of the MDC. Ambulatory care p a t i e n t s may s t i l l have i n p a t i e n t admissions, p e r i o d i c a l l y or t e r m i n a l l y , i n the c h r o n i c i l l n e s s e s , or a f t e r d i a g n o s i s i s e s t a b l i s h e d . The MDC 58 s e r v i c e s , however, reduces the number of i n p a t i e n t admis-s i o n s these people would r e q u i r e . T e s t i m o n i a l evidence, r e c e i v e d from p a t i e n t s , f a m i l y , and p h y s i c i a n s , i n d i c a t e s h i g h p a t i e n t acceptance, w i t h many p a t i e n t s ( e s p e c i a l l y the c h r o n i c a l l y i l l ) p r e f e r r i n g day care admission over i n p a t i e n t admission. The s p e c i a l a b i l i t i e s o f the n u r s i n g s t a f f have c o n t r i b u t e d g r e a t l y to t h i s h i g h l e v e l o f p a t i e n t acceptance. Methodology o f Data C o l l e c t i o n Once the d e c i s i o n to examine the process i n v o l v e d with the i n t r o d u c t i o n o f the Medi c a l Day Care p i l o t pro-j e c t was taken, a l l r e l a t e d documentation a v a i l a b l e through h o s p i t a l sources was c o l l e c t e d . T h i s documenta-t i o n i n c l u d e d minutes o f the meetings o f the Ambulatory Care Management, the Ad Hoc Ambulatory Care P l a n n i n g and the E x e c u t i v e Committees, in-house memos, correspondence between the C h i e f E x e c u t i v e O f f i c e r and s e n i o r o f f i c i a l s o f B r i t i s h Columbia H o s p i t a l Programs, M i n i s t r y of Heal t h , the w r i t t e n p r o p o s a l , the r e p o r t a f t e r one year o f o p e r a t i o n , S t . Paul's Development Plan F u n c t i o n a l Program, annual r e p o r t s o f the Ambulatory Care Committee, BCMC document, Study o f S t . Paul's Ambulatory Care S e r v i c e s , correspondence with the Woodward Foundation, Management En g i n e e r i n g U n i t 13.1, and p e r s o n a l communications. A l s o , a d i a r y o f events o f the f i r s t year o f o p e r a t i o n was 59 kept by the w r i t e r who a t t h a t time h e l d the p o s i t i o n of C o o r d i n a t o r of S p e c i a l t y S e r v i c e s a t S t . Paul's H o s p i t a l and was r e s p o n s i b l e f o r p l a n n i n g and implementation of the M e d i c a l Day Care Program as p a r t of Ambulatory Care S e r v i c e s . 60 Summary of the Development of Ambulatory Care a t S t . Paul's H o s p i t a l (SPH) 1875 - 1960 1958 196 0 onward - Free food and h e a l t h care to those who presented themselves a t the h o s p i t a l . (One o f the d u t i e s o f the student nurses as l a t e as 1960 was to d i s t r i b u t e f r e e food to those who l i n e d up a t the k i t c h e n door each mealtime.) - E s t a b l i s h m e n t of an O u t p a t i e n t Department - E s t a b l i s h m e n t of ambulatory s e r v i c e s f o r p r i v a t e p a t i e n t s as w e l l as the i n d i g e n t , e.g. D i a b e t i c Enterostomal Therapy, G a s t r o i n t e s t i n a l J u l y 1974 BCMC c h a l l e n g e to develop St. Paul's H o s p i t a l as the major ambulatory care c e n t r e i n the Lower Mainland 1974 Ambulatory Care Committee p r o p o s a l f o r a Medical Day Care program (MDC) February 19 75 - Document prepared by BCMC o u t l i n i n g s e r v i c e s to be accommodated i n the l a r g e ambulatory care complex to be i n c o r p o r -ated i n t o new c o n s t r u c t i o n June 19 75 January 19 76 Me d i c a l A d v i s o r y Committee St. Paul's H o s p i t a l s t r u c k and Ad Hoc Ambulatory Committee to review requirements. An expanded v e r s i o n became the p l a n n i n g committee f o r redevelopment. Submissions r e c e i v e d from a l l h o s p i t a l departments, medical departments, r e -gardi n g s e r v i c e s and programs which should be developed March 19 76 A p r i l 1976 Chairman, Ambulatory Care Committee submitted o u t l i n e o f proposed s e r v i c e s to SPH D i r e c t o r o f P l a n n i n g Proposed Ambulatory Care Centre i n -c o r p o r a t e d i n t o F u n c t i o n a l Program f o r redevelopment 61 i August 1976 - Proposed MDC Program s u b m i t t e d f o r a p p r o v a l t o BCHP F u l l - t i m e s a l a r i e d g e n e r a l p r a c t i t i o n e r employed t o p r o v i d e p r i m a r y c a r e September 19 76 March 19 77 A p r i l May Study o f S t . P a u l ' s H o s p i t a l O u t p a t i e n t s e r v i c e s and r e m u n e r a t i o n commissioned S e n i o r a d m i n i s t r a t i v e o f f i c e r s s e e k i n g a way t o g a i n BCHP a p p r o v a l f o r an MDC d e c i d e d t o r e - s u b m i t the p r o p o s a l as a p i l o t p r o j e c t s i n c e a l l i n d i c a t i o n s were the f i r s t p r o p o s a l would n ot be a c c e p t a b l e 19 77 - L e t t e r t o BCHP r e q u e s t i n g a c o o p e r a t i v e endeavour. I d e n t i c a l p r o p o s a l as p r e v i o u s l y s u b m i t t e d b u t c a l l e d a p i l o t p r o j e c t 1977 - BCHP r e q u i r i n g d e t a i l e d p r o j e c t i o n s o f work volume, s p e c i a l i z e d equipment and p e r s o n n e l , and i n p a t i e n t day s a v i n g s August 19 77 - Response t o May 19 77 l e t t e r , w i t h e s t i m a t e s , r e q u i r e d C i r c u l a t i o n o f in-house p l a n n i n g document i R e n o v a t i o n and e x p a n s i o n o f O u t p a t i e n t Department completed - renamed Ambulatory Care Department October 19 7 7 - Second d r a f t o f p l a n n i n g document c i r c u l a t e d CEO a u t h o r i z e d s u b m i s s i o n f o r equipment t o BCHP November 1977 - Requests t o Woodward F o u n d a t i o n s e e k i n g f u n d i n g t o s u p p o r t a d i r e c t o r o f ambulatory c a r e s e r v i c e s December 1977 - Second attempt t o s a t i s f y a v e r b a l r e q u e s t f o r more d e t a i l about i n p a t i e n t days t o be saved, number o f beds t o be red u c e d , s t a f f r e d u c t i o n s December 1977 -January 1978 May 1978 Request to Woodward Foundation r e j e c t e d " ... u n t i l some concept of government p o l i c y on s u p p o r t i n g such a programme i s a v a i l a b l e . " - Implementation o f LTC Program - BCHP approval to proceed w i t h implemen-t a t i o n o f a p i l o t MDC Program June 1978 - S p e c i f i c p l a n n i n g began w i t h Ambulatory Care Committee J u l y 19 78 September 19 78 March - F i n a l i z e d implementation document - A d d i t i o n a l e xpenditures f o r equipment w i t h f i n a l i z i n g s e r v i c e s to be. p r o v i d e d Opening o f the MDC Program 19 80 - Expansion o f the program to al l o w an o v e r - n i g h t stay from MDC and SDC program 1981 - General p r a c t i c e c l i n i c r e v e r t e d to a r o t a t i o n o f p r a c t i s i n g f a m i l y p h y s i c i a n s 6 3 CHAPTER V INCONSISTENCIES IN BEHAVIOR ON THE PART OF GOVERNMENT When a h o s p i t a l i n i t i a t i v e does a r i s e , d e l a y s , requests f o r more i n f o r m a t i o n , and r e r o u t i n g through a v a r i e t y of o f f i c i a l s and s e c t i o n s o f the M i n i s t r y d e f e r the need to make a d e c i s i o n . T h i s vagueness and l a c k of l e a d e r s h i p l e a d s to c o n f u s i o n and d i s i l l u s i o n a t the i n s t i t u t i o n a l l e v e l . H o s p i t a l a d m i n i s t r a t o r s con-t i n u a l l y wonder what i s a c c e p t a b l e , what .is the g o a l , who makes the d e c i s i o n ? In the case of the M e d i c a l Day Care Program i n i t i a t i v e from S t . Paul's H o s p i t a l , the i n s t i t u t i o n was t r y i n g to f i n d a way the p r o p o s a l would become accep-t a b l e , because i t had become c l e a r a f t e r two years o f deferment t h a t i n t r o d u c t i o n of such a program was not going to happen, although there had been no r e j e c t i o n . Why, i f the government i s i n t e r e s t e d i n determining the e f f e c t i v e n e s s of ambulatory care programs and con-cerned about f i n a n c i a l commitment bef o r e proven, d i d the suggestion of a p i l o t p r o j e c t have to be i n i t i a t e d by h o s p i t a l personnel r a t h e r than by the government? The p i l o t p r o j e c t was a c c e p t a b l e f o r reasons known onl y to government o f f i c i a l s , s i n c e n o t h i n g but the. i n c l u s i o n 64 of those two words had changed i n the proposal," 1" but S t . Paul's H o s p i t a l ' s experience would i n d i c a t e t h a t 2 ambulatory care i s not a p r i o r i t y among a l t e r n a t i v e s . Despite what seems s u f f i c i e n t reason to pursue the develop-ment of a l t e r n a t i v e care d e l i v e r y modes, l i t t l e has a c t u a l l y happened on a s c a l e which c o u l d be adequately e v a l u a t e d . Having e s t a b l i s h e d the encouragement of ambu-l a t o r y care development as an o b j e c t i v e of the M i n i s t r y , a c t u a l commitment to a c t i o n seems i n d e c i s i v e and c o n f u s i n g . There i s no s i g n i f i c a n t promotion or p l a n n i n g e f f o r t on the p a r t of government d i r e c t l y i n r e g a r d to ambulatory ca r e . A c t i v i t y which does e x i s t , demonstrates a d e s i r e to m a i n t a i n an 'arm's l e n g t h 1 r e l a t i o n s h i p to any a c t u a l commitment. S e v e r a l examples of t h i s stance can be g i v e n . P l a n n i n g and Development Group of the M i n i s t r y documented e x i s t i n g ambulatory care s e r v i c e s i n B.C., once the need f o r such documentation was i n i t i a t e d by h o s p i t a l a d m i n i s t r a t o r s as a r e s u l t of the f i r s t c i r c u l a t e d d r a f t of the H o s p i t a l Role Study (1979). xSee Chapter IV f o r s p e c i f i c dates of submissions, requests f o r more i n f o r m a t i o n , deferments, e t c . 2 Ambulatory care approaches were favored by the M i n i s t e r as s t a t e d by the S e n i o r D i r e c t o r , H o s p i t a l Programs, i n a l e t t e r t o S t . Paul's H o s p i t a l and dated May 16, 19 77, but the M i n i s t r y ' s b ehavior does not support the statement. 65 C o n s t r u c t i o n p l a n s f o r redevelopment o r new development o f h o s p i t a l s may i n c l u d e a m b u l a t o r y c a r e f a c i l i t i e s and programs i n f u n c t i o n a l programs i f r e q u e s t e d by the h o s p i -t a l , b u t n o t as a s u g g e s t i o n o r r e q u i r e m e n t o f t h e M i n i s t r y . Funded ambula t o r y s e r v i c e s have not changed o v e r s e v e r a l y e a r s d e s p i t e many new p o s s i b i l i t i e s w h i c h have been demonstrated e f f e c t i v e . The M i n i s t r y has a c c e p t e d j o i n t s p o n s o r s h i p w i t h GVRHD o f a t t e m p t s t o expand the use o f ambulato r y c a r e s e r v i c e s and the i n t r o d u c t i o n o f new s e r v i c e s , b u t a l s o has a p p l i e d a p o t e n t i a l l y s e v e r e con-s t r a i n t w i t h e f f o r t s h a v i n g t o be l i m i t e d t o " ... p r o -3 grams wh i c h have p r i o r a p p r o v a l o f the M i n i s t r y o f H e a l t h . I n i t i a t i v e s appear t o r e s t w i t h b o d i e s o t h e r t h a n the M i n i s t r y . The M i n i s t r y ' s r o l e appears t o be one o f acce p t a n c e o r r e j e c t i o n b u t most o f t e n i t appears t o be one o f d e l a y and deferment. As Warham w r i t e s , no d e c i s i o n 4 " ... may c o n s t i t u t e p o l i c y ..." , a p o l i c y t o a v o i d p r o a c t i o n , t o r e a c t b u t n o t t o c r e a t e . C u r r e n t Government O b j e c t i v e s F i n a l l y , i n 1977, the 1969 Task F o r c e ' s recommenda-t i o n s t o r e d e s i g n f e d e r a l f u n d i n g o f h e a l t h c a r e was J T a k e n from the j o b d e s c r i p t i o n o f the M e d i c a l P l a n -n i n g and L i a i s o n O f f i c e r employed t o promote ambula t o r y c a r e programs. See page 41. 4 J o y c e Warham,"Notes on P l a n n i n g i n the C o n t e x t o f S o c i a l P o l i c y . " U n i v e r s i t y o f B r i t i s h C o lumbia, 1974, p . l . 66 e f f e c t e d i n the F e d e r a l - P r o v i n c i a l F i s c a l Arrangements and E s t a b l i s h e d Programs F i n a n c i n g A c t . T h i s l e g i s l a t i o n i s now the b a s i s o f f e d e r a l a s s i s t a n c e t o p r o v i n c i a l h e a l t h c a r e programs. I t i s d e s i g n e d t o change the i n c e n t i v e s away from i n p a t i e n t c a r e , t o cause c a r e f u l m o n i t o r i n g o f r e s o u r c e s by removing open-ended c o s t s h a r i n g and i n t r o -d u c i n g p e r c a p i t a a l l o c a t i o n s . The p r o v i n c e ' s c o s t s i n -c r e a s e w i t h usage o f s e r v i c e s , t h e f e d e r a l government's do n o t . The p r o v i n c e s a r e no l o n g e r m o n i t o r e d by the f e d e r a l government and t h e r e i s no l e g a l o b l i g a t i o n t o i n c r e a s e s p e n d i n g f o r a l t e r n a t i v e c a r e modes b u t i t i s e x p e c t e d t h a t i n e v i t a b l e c o s t c o n t a i n m e n t a t t e m p t s would s t e e r a c o u r s e i n t h a t d i r e c t i o n . Concern has been ex-p r e s s e d t h a t the p r o v i n c i a l government w i l l s i m p l y n o t p r o v i d e the r e q u i r e d f u n d i n g t o m a i n t a i n the system as i t i s known, now t h a t i t s share o f e x p e n d i t u r e s has 5 s i g n i f i c a n t l y i n c r e a s e d . The f i r s t w r i t t e n o b j e c t i v e s f o r the M i n i s t r y o f H e a l t h i n B.C. a r e d a t e d December, 1978, and were p r e -p a r e d by the t h e n Deputy M i n i s t e r , Dr. C h a pin Key. F r a n c e s R u s s e l l , C o n s i d e r B.C. W i t h o u t M e d i c a r e , Vancouver Sun, J u l y , 1976. 67 They read as f o l l o w s : I To promote programs o f a p r e v e n t i v e nature as w e l l as other a l t e r n a t i v e s i n order to c o n t a i n r i s i n g c o s t s of h e a l t h care and p r o v i d e an optimum s t a t e o f h e a l t h . II To f o s t e r a r e s p o n s i v e o r g a n i z a t i o n o f the M i n i s t r y o f Hea l t h which f a c i l i t a t e s e f f e c t i v e communication, co-operation and c o - o r d i n a t i o n and achieves a.planning and e v a l u a t i o n c a p a b i l -i t y supported by an i n t e g r a t e d h e a l t h i n f o r m a t i o n system. I l l To pr o v i d e an e f f e c t i v e d e l i v e r y system through-out the pr o v i n c e which p r o v i d e s e q u i t a b l e access to p r e v e n t i v e and treatment programs. IV To implement a province-wide P u b l i c Education program d i r e c t e d a t the P u b l i c d e a l i n g w i t h t h e i r : (a) f i n a n c i a l r e s p o n s i b i l i t y and u t i l i -l i z a t i o n o f s e r v i c e s (b) l i f e s t y l e and a t t i t u d e s (c) p e r s o n a l , f a m i l y , and community involvement V To i d e n t i f y and reduce environmental hazards to h e a l t h i n c o - o p e r a t i o n w i t h other m i n s t r i e s and agencies. Dr. Key has s i n c e been r e p l a c e d by a new Deputy who has emphasized c o s t c o n t r o l r a t h e r than standards. However, the g e n e r a l statement of o b j e c t i v e s has been accepted, w i t h some m o d i f i c a t i o n s . I f o b j e c t i v e s mean i n t e n t , i t seems the government of B.C. has a t l a s t ( r e l u c t a n t l y ? ) accepted i t s r o l e i n the p r o v i s i o n o f h e a l t h care to the c i t i z e n s of the p r o v i n c e . T h i s commitment was f u r t h e r demonstrated d u r i n g the r e c e n t fee schedule n e g o t i a t i o n s with the p r o v i n c i a l medical 68 a s s o c i a t i o n . ( O b j e c t i v e I I I ) . When t h e a s s o c i a t i o n t h r e a t e n e d added b i l l i n g , l e g i s l a t i o n t o p r o h i b i t i t was f o r m u l a t e d and remains p e n d i n g . The government's commitment t o i n c r e a s i n g p e r s o n a l r e s p o n s i b i l i t y f o r h e a l t h c a r e c o s t s has a l s o been demon-s t r a t e d as a r e s u l t o f t h e s e n e g o t i a t i o n s ( O b j e c t i v e I V ) . B e g i n n i n g J u l y , 1981, h e a l t h i n s u r a n c e premiums w i l l r i s e and the d i r e c t c o s t t o u s e r s o f h o s p i t a l c a r e was a l s o • 'A 6 r a i s e d . There i s i n c o n s i s t e n c y between O b j e c t i v e I I I and O b j e c t i v e IV. " E q u i t a b l e a c c e s s " i s i n c o n s i s t e n t w i t h r i s i n g p e r s o n a l c o s t s o f c a r e , s i n c e t h o s e who do not have a c c e s s a re a l s o those who cannot a f f o r d added c o s t s . The new regime i n V i c t o r i a has s a i d t h a t t h i s o b j e c t i v e i s b e i n g r e c o n s i d e r e d i n l i n e w i t h S o c r e d i d e o l o g y . These i n c o n s i s t e n c i e s i n government b e h a v i o r may r e f l e c t i n t e r n a l s t r u g g l e s between r i v a l f a c t i o n s w i t h i n the M i n i s t r y , o r perhaps the c o n t i n u i n g r e l u c t a n c e o f t h e government t o a c c e p t the leadership/management r o l e i n h e a l t h c a r e , o r , perhaps r e f l e c t the r i v a l p r o p o s a l s i n i t i a t e d from many s o u r c e s (GVRHD, BCHP, P u b l i c H e a l t h , F e d e r a l d e m o n s t r a t i o n g r a n t s ) and which a l l d e a l w i t h A c u t e c a r e c o - i n s u r a n c e r o s e from $5.50 t o $6.50 per day. Extended c a r e r o s e from $6.50 t o $10.50 p e r day, and S u r g i c a l Day Care r o s e from $5.00 t o $6.00 per v i s i t . 69 d i f f e r e n t s e c t i o n s of the M i n i s t r y l e a d i n g to a l a c k of c o o r d i n a t i o n w i t h i n the M i n i s t r y . The M i n i s t e r o f H e a l t h , commenting on the i n t r o d u c t i o n of the 1978 r e o r g a n i z a t i o n of the M i n i s t r y , i n d i c a t e d the e x i s t e n c e of such a d i f f i c u l t y when he t o l d r e p o r t e r s : "We have to remember t h a t i n r e c e n t years the M i n i s t r y of H e a l t h has been f u n c t i o n i n g as an amalgam o f o p e r a t i o n s which were once more or l e s s independent, and t h i s r e q u i r e d c o n s i d e r -able e f f o r t i n c o o r d i n a t i o n . " 7 T h i s ad hoc manner o f a d m i n i s t r a t i o n by the government e l i m i n a t e s the p o s s i b i l i t y o f a h e a l t h care system and u s u a l l y reduces any i n c e n t i v e s s e n i o r e x e c u t i v e s may have to c o n t r i b u t e toward i n t e g r a t i o n o f s e r v i c e s i n an area. In t h i s k i n d of environment each i n s t i t u t i o n i s i s o l a t e d , open, and probably r e c e p t i v e to the needs and l e a d e r s h i p of members o f the medical p r o f e s s i o n a t t a c h e d to the i n s t i t u t i o n and i n c o m p e t i t i o n w i t h other i n s t i t u t i o n s . An i n c o n s i s t e n t approach must r e s u l t i n unnecessary expenditures through uncoordinated a c t i o n . A f t e r acceptance of the p i l o t p r o j e c t , there was no i n p u t from the M i n i s t r y r e g a r d i n g i n f o r m a t i o n r e q u i r e d and no e v a l u a t i o n c r i t e r i a p r o v i d e d . I f a p i l o t p r o j e c t B r i t i s h Columbia. M i n i s t r y of H e a l t h Newsletter No. 1, November 30, 19 78. 70 was a p p r o p r i a t e , one would e x p e c t some i n t e r e s t i n g a i n i n g d a t a t o prove o r d i s p r o v e the v a l i d i t y o f the p r o j e c t f o r f u t u r e a p p l i c a t i o n s . The h o s p i t a l s t a f f f e l t v e r y p o s i t i v e about the p r o j e c t e d program outcomes, b u t w i t h o u t any M i n i s t r y i n v o l v e m e n t t h e y d i d n o t know what the g o v e r n -ment e x p e c t a t i o n s were. I f e x p e c t a t i o n s a r e unknown, how c o u l d they be met? Even i f the program were a g r e a t s u c -c e s s , t h e r e was no a s s u r a n c e t h a t the program would be m a i n t a i n e d and funded. The M i n i s t r y m a i n t a i n e d an 'arm's l e n g t h ' s t a n c e as though o f f i c i a l s c o u l d d i s s o c i a t e t h emselves from the e x p e r i m e n t i f t h a t p r o v e d t o be u s e f u l . 71 CHAPTER VI Pl a n n i n g : A P o l i t i c a l Process With the use of p u b l i c monies f o r the p r o v i s i o n of h e a l t h s e r v i c e s to the populace there f o l l o w s an expec-t a t i o n t h a t these funds w i l l be w e l l spent and t h a t s e r v i c e s p r o v i d e d w i l l be assessed f o r e f f e c t i v e n e s s and q u a l i t y . In attempting to f u l f i l these e x p e c t a t i o n s , governments have e s t a b l i s h e d v a s t b u r e a u c r a c i e s which are mo n i t o r i n g agencies, e s p e c i a l l y o f ex p e n d i t u r e s . One might a l s o expect t h a t p o l i c y f ormation/decision-making/planning would be aimed at f u l f i l l i n g the i d e o l o g y o f high q u a l i t y c a r e , a c c e s s i b l e to a l l f o r the l e a s t p o s s i b l e expenditure, as d e s c r i b e d i n the Hea l t h Charter f o r Canadians. In the mundane day-to-day we f i n d the system i n s u f f i c i e n t l y funded, c o n t r o l l e d i n a piecemeal f a s h i o n , d i v i d e d by d i v e r s e i n t e r e s t s but, h i g h l y regarded by most consumers of the e x i s t i n g s e r v i c e s who have l i t t l e awareness of t r u e c o s t and who are gener-a l l y unaware of the gaps i n s e r v i c e . S ince the c o s t s o f h e a l t h care are s u b s t a n t i a l , e s t a b l i s h i n g means to monitor expenditures i s a reasonable undertaking, as are attempts to d i s c o v e r l e s s expensive means to pr o v i d e s e r v i c e s ; t o p l a n and to ev a l u a t e these attempts. N a t i o n a l l y , cheaper a l t e r n a t i v e s have been sought and resea r c h e d . A consensus had developed i n the country t h a t ambulatory care c o u l d c o n t r i b u t e to a 72 r e d u c t i o n i n e x p e n d i t u r e s . I f ambulatory care i s a 'good t h i n g ' , one would expect t h a t p r o v i n c i a l resources would be made a v a i l a b l e f o r the development of a p p l i c a t i o n s . Despite t h i s r a t i o n a l con-sensus re s o u r c e s d i d not flow o r , more c o r r e c t l y , some money was spent i n a seemingly unplanned manner i n B.C. In order to understand t h i s c o n t r a d i c t i o n i t was necessary to e x p l o r e the area o f p l a n n i n g seeking e x p l a n a t i o n s f o r t h i s govern-ment b e h a v i o r . In the search f o r an understanding o f the r o l e o f p l a n -n i n g i n the government's r e s p o n s i b i l i t y f o r the d e l i v e r y of h e a l t h c a r e , t h i s w r i t e r has been c o n f r o n t e d w i t h wide-spread d i f f e r e n c e s o f o p i n i o n about the purpose of p l a n n i n g . Is p l a n n i n g p o l i c y f o r m u l a t i o n , p o l i c y a n a l y s i s , g o a l -s e t t i n g , decision-making, implementation, a means of c o n t r o l -l i n g or merely c r y s t a l - b a l l gazing? R a t i o n a l P l a n n i n g M i c h a e l d e f i n e s p l a n n i n g as a l l of these a c t i v i t i e s and more. He i s c a r e f u l to c a l l i t the p l a n n i n g p r o c e s s , presumably meaning t h a t a number of d i f f e r e n t sources o f i n p u t might be i n v o l v e d . " ... the p l a n n i n g process i n c l u d e s : s y s t e m a t i c c o n j e c t u r e about f u t u r e s e t t i n g s f o r which d e v e l -oping o f plans over time i s r e l e v a n t and d e s i r a b l e ; goal s t a t i n g ( ... r e g u l a t i v e as w e l l as t a r g e t s e t t i n g ) ; e s t i m a t i n g c o s t s and b e n e f i t s ( i n c l u d i n g non-moneitory ones) att a c h e d to - a l t e r n a t i v e means f o r moving toward s t a t e d g o a l s ; a t t e n d i n g to circumstances o u t s i d e the d i r e c t l y r e l e v a n t e n v i r o n -ment to understand t h e i r i m p l i c a t i o n s f o r the 73 o p e r a t i o n o f the p l a n ; o f the s p e c i f y i n g sequenced a c t i o n s n e c e s s a r y f o r r e a l i z a t i o n o f the p l a n ; c o n t i n u i n g t o e v a l u a t e e s t i m a t e d f u t u r e s , s t a t e d g o a l s , and programs i n s t i t u t e d i n r e s ponse t o them; a l l a c c o m p l i s h e d i n ways t h a t r e s u l t i n a p p r o p r i -a t e r e v i s i o n s . " ! M i c h a e l ' s d e s c r i p t i o n o f t h e p l a n n i n g p r o c e s s i s e s s e n -t i a l l y a d e f i n i t i o n o f r a t i o n a l p l a n n i n g . A d e f i n i t i o n by H a r r i s h o l d s t h e same sequenced s e r i e s o f s t e p s , the s e t t i n g o f g o a l s , the f o r m u l a t i o n o f a l t e r n a t i v e s , t h e p r e d i c t i o n o f outcomes and the e v a l u a t i o n o f the a l t e r n a -t i v e s i n ; r e l a t i o n t o the g o a l s and the outcomes.2 M i c h a e l i n s i s t s t h a t we must l e a r n t o p l a n i n t h i s s y s t e m a t i c manner because p l a n n n i n g schemes r e j e c t i n g t h i s approach have, f o r the most p a r t , been f a i l u r e s . He v iews f u t u r e c o n d i t i o n s such as s c a r c i t y o f r e s o u r c e s , the i n c r e a s i n g demand f o r e q u i t a b l e s h a r e s , a p p r e c i a t i o n o f secondary and t e r t i a r y consequences o f t e c h n o l o g i c a l i n p u t s , and t e c h n o l o g y used t o cope w i t h s h o r t a g e s w h i c h w i l l c o n s t r a i n r e l a t e d s o c i a l and economic systems as r e q u i r i n g s y s t e m a t i c r a t i o n a l p l a n n i n g . M i c h a e l b e l i e v e s t h a t p r e s e n t day p l a n n i n g c o u l d be b e t t e r i f we would Donald N. Michael., 1 S p e c u l a t i o n s , on F u t u r e P l a n n i n g P r o c e s s Theory," i n P l a n n i n g i n A m e r i c a ; L e a r n i n g  From T u r b u l e n c e , ed. by D a v i d R. Godchalk (Washington, D.C. American I n s t i t u t e o f P l a n n e r s P u b l i c a t i o n , 1974) p.40. 2 B r i t t o n H a r r i s i n , t h e Foreward o f D e c i s i o n - M a k i n g i n Urban P l a n n i n g ed. by I r a M. R o b i n s o n , B e v e r l y H i l l s , C a l i f o r n i a : Sage P u b l i c a t i o n s , 1972. 74 maximize our a v a i l a b l e a b i l i t i e s r a t h e r than 1 s a t i s f i c i n g ' . E c k s t e i n supports, t h i s when he says t h a t planners s u b s t i -t u t e r o u t i n e responses f o r r a t i o n a l c a l c u l a t i o n i n 4 d i f f i c u l t decision-making s i t u a t i o n s . Michael brands the p r e s e n t p l a n n i n g process as un-a c c e p t a b l e because when i n f o r m a t i o n i s inadequate, o r not c r e d i b l e , r e s o l u t i o n and r i s k - t a k i n g are turned over to the p o l i t i c a l p r o c e s s , " ... to the workings of mutual p a r t i s a n adjustment and p l u r a l i s t i c c o n t e s t and accom-5 modation." H a r r i s presents a c o n f l i c t i n g view when he w r i t e s t h a t value systems t h a t must be s a t i s f i e d are becoming 6 7 more complex and c o n f l i c t i n g and s u b j e c t to change. ' Herbert Simon's term to express man's tendency to s e i z e upon the f i r s t a c c e p t a b l e a l t e r n a t i v e r a t h e r than seeking the b e s t . Harry E c k s t e i n , "Planning: The N a t i o n a l H e a l t h S e r v i c e " , i n P o l i c y - M a k i n g i n B r i t a i n , ed. by R i c h a r d Rose, (London, MacMillan & Co., 1969), p. 230. M i c h a e l , p. 43. B r i t t o n H a r r i s , "Planning Method: The State o f the A r t " i n P l a n n i n g In America: L e a r n i n g From Turbu-lence , ed. by David R. Godschalk. (Washington, D.C, A.I.P. 1974) , p. 65. Rein goes as f a r as to say t h a t i n a democratic s o c i e t y there are no commonly shared goals which can g i v e d i r e c t i o n to the p l a n n i n g p r o c e s s . 75 I f t h i s i s so, and b e a r s some importance i n the p l a n -n i n g p r o c e s s , how can t h e r e e v e r be a ' c o r r e c t ' o r r a t i o n a l answer. Even a 'best' answer would have time l i m i t a t i o n s u n l e s s c o n t r o l i s i n h e r e n t i n the p r o c e s s . B o u l d i n g t h i n k s d e c i s i o n s a r e c o n s t a n t l y b e i n g made on the b a s i s o f m i s i n f o r m a t i o n , f a l s e images o f the w o r l d , g absence o f c r u c i a l i n f o r m a t i o n w h i c h may o r may n o t e x i s t . M o t t i s r e a l i s t i c when he says t h a t the s e l e c t i o n o f p l a n n i n g g o a l s i s p r i m a r i l y a p o l i t i c a l a c t and a l t h o u g h a n a l y s i s p l a y s a r o l e i n w e i g h i n g a l t e r n a t i v e c o u r s e s o f a c t i o n , t h e r e i s an i m p o r t a n t and c r u c i a l p o l i t i c a l a s p e c t here as w e l l . To u n d e r l i n e t h i s v i e w , Mott r e f e r s t o 9 p l a n n i n g as a ' p o l i t i c a l p r o c e s s ' and Mechanic w r i t e s t h a t " p o l i c i e s d e s i g n e d s i m p l y on r a t i o n a l a ssumptions a r e l i k e l y t o m iss t h e i r mark i n s u c c e s s f u l l y a l t e r i n g b e h a v i o r . " 1 ^ I n a p a r t i c u l a r s i t u a t i o n , i f power r e s t s w i t h the p l a n n e r s , t h e n the t e c h n i c a l a n a l y t i c p r o c e s s may be a p p l i e d , Kenneth E. B o u l d i n g , "The B o u n d a r i e s o f S o c i a l P o l i c y , " S o c i a l Work, (January 1967), p. 10. B a s i l J . F. M o t t , " P o l i t i c s and I n t e r n a t i o n a l P l a n -n i n g , "Soci^]^_Sc±ei)£e_a^ V o l . 8, (1974), p. 271. Da v i d Mechanic, F u t u r e I s s u e s i n H e a l t h Care, S o c i a l  P o l i c y and the R a t i o n i n g o f M e d i c a l S e r v i c e s , New York: The Fr e e P r e s s , 19 79, p. 3. 76 but no p l a n works of i t s e l f . The i n c e n t i v e s to behavior change must be r e c o g n i z e d and a s s i m i l a t e d by the implemen-t o r s o f the p l a n . T h i s concept would e x p l a i n developments i n the area of Community H e a l t h Centres and manpower sub-s t i t u t e s . The r a t i o n a l i t y o f these means to reduce h e a l t h care c o s t s has been shown, nonetheless, they have not been a p p l i e d . For the change to succeed, the medical p r o f e s s i o n would have to cooperate, but there are no i n c e n t i v e s to do so. To give up c o n t r o l and the l e a d e r s h i p r o l e of the doctor, which would r e f l e c t on s o c i a l s t a n d i n g , without even f i n a n c i a l b e n e f i t , does not promote w i l l i n g n e s s to absorb such a change. A c c o r d i n g to Tannen, c o n t r o l has been the major impetus i n the development of the f e d e r a l N a t i o n a l H e a l t h P l a n n i n g and Resource Development A c t of 1973 i n the U n i t e d S t a t e s . "Portrayed as an o b j e c t i v e and r a t i o n a l mechanism of determining the f u t u r e , p l a n n i n g i s a s o c i a l l y a c c e p t a b l e means of e x e r t i n g t h i r d - p a r t y c o n t r o l over a s e c t o r of the economy l o n g a b l e t o escape ^, meaningful c o n t r o l s on i t s growth and development." Klarman sees the American p l a n n i n g i n c e n t i v e as an attempt t o d i l u t e the med i c a l p r o f e s s i o n ' s c o n t r o l of the 12 h e a l t h i n d u s t r y . J"" LLouis Tannen, "Health P l a n n i n g as a Regulatory S t r a t e g y : A D i s c u s s i o n of I t s H i s t o r y and C u r r e n t Uses,". I n t e r n a t i o n a l J o u r n a l o f H e a l t h S e r v i c e s , V o l . 10, No. 1, (1980) p. 115. 12 Herbert E. Klarman, " N a t i o n a l P o l i c i e s and L o c a l Planning f o r Health S e r v i c e s . " MMFQ/Health and S o c i e t y (Winter 1976), p. 1-28. 77 From t h i s b r i e f e x p l o r a t i o n i t would appear t o t h i s w r i t e r t h a t the a p p l i c a t i o n o f r a t i o n a l i s t p l a n n i n g r e q u i r e s a h i g h degree o f c o n t r o l ; c l e a r l y s t a t e d o b j e c t i v e s a c c e p t e d by i n t e r e s t e d p a r t i e s and l i m i t e d numbers o f v a r i a b l e s t o a l l o w the development o f c l e a r a l t e r n a t i v e s o f c h o i c e , the r a m i f i c a t i o n s , o f w h i c h , a r e u n d e r s t o o d . I n B r i t i s h C o lumbia, t o d a t e , t h e r e has been v e r y l i t t l e c e n t r a l i z e d c o n t r o l o f h e a l t h c a r e and even l e s s p r o v i n c e - w i d e p l a n n i n g o f h e a l t h c a r e . I n f a c t t h e r e appeared t o have been a r e s i s t a n c e t o c e n t r a l i z a t i o n . S i n c e t h e r e has been no p r o v i n c i a l p l a n f o r h e a l t h c a r e and o b j e c t i v e s o f the M i n i s t r y o f H e a l t h h o l d i n c o n s i s t e n -c i e s , i t i s p r o b a b l y f a i r t o say r a t i o n a l i s t p l a n n i n g does not f u n c t i o n i n B.C. Perhaps r a t i o n a l i s t p l a n n i n g as d e s c r i b e d by i t s p roponents c o u l d n o t f u n c t i o n anywhere. I n c r e m e n t a l i s m : P o l i t i c a l o r B u r e a u c r a t i c P l a n n i n g I f r a t i o n a l i s t p l a n n i n g i s u n l i k e l y t o f u n c t i o n e f f e c t i v e l y where o b j e c t i v e s h o l d i n c o n s i s t e n c i e s and c o n t r o l i s s l i g h t o r f o c u s s e d e l s e w h e r e than program p l a n n i n g what i s a c t u a l l y happening i n most systems? L i n d b l o m r e p r e s e n t s the s c h o o l o f 'Muddling Through", the mutual p a r t i s a n a d j u s t m e n t approach t o p o l i c y - m a k i n g r e j e c t e d by r a t i o n a l i s t p l a n n e r s such as M i c h a e l and H a r r i s . Most p o l i t i c a l i n t e r v e n t i o n s i n v o l v e add-ons o r t i n k e r i n g a t the margins o f e x i s t i n g programs t o a v o i d 12 H e r b e r t E. Klarman, " N a t i o n a l P o l i c i e s and L o c a l P l a n n i n g f o r H e a l t h S e r v i c e s , " MMFQ/Health and S o c i e t y , (Winter 1976), p.1-28. 78 13 l a r g e s c a l e c o n f l i c t . So, d e s p i t e the d i s s e n t e r s and the attempts to develop r a t i o n a l approaches, the i n c r e -mental approach to p o l i c y f o r m u l a t i o n and p l a n n i n g appears 14 to be the most common approach used. K l e i n supports the use of t h i s method f o r t h e . B r i t i s h N a t i o n a l H e a l t h S e r v i c e p r i m a r i l y because of the absence of o b j e c t i v e s f o r the s e r v i c e . " ^ E c k s t e i n echoes t h i s view when he w r i t e s t h a t people who p l a n and c o n t r o l i n b u r e a u c r a c i e s cannot use r a t i o n a l i s t approaches to decision-making because of the i n c o n s i s t e n c i e s w i t h i n o b j e c t i v e s . He says i t i s the i m p o s s i b l e task of planners to t r a n s l a t e v a l u e s w i t h a l l t h e i r a m b i g u i t i e s a n d . i n c o n s i s t e n c i e s i n t o c o n s i s t e n t , r a t i o n a l , p o l i t i c a l l y d e f e n s i b l e programs i n an e n v i r o n -ment of g r e a t p s y c h o l o g i c a l p r e s s u r e and with l a c k of c o n t r o l over a m u l t i t u d e of f a c t o r s c r u c i a l to adequate , , .. 16 c a l c u l a t i o n . E c k s t e i n ' s and K l e i n ' s views on the d i f f i c u l t i e s w ith the implementation of a r a t i o n a l i s t approach to p l a n n i n g w i t h i n b u r e a u c r a c i e s apply i n B.C. as w e l l . 13 C h a r l e s E. Lindblom, "The Science of 'Muddling Through'", Reprinted from P u b l i c A d m i n i s t r a t i o n Review (Spring 1959) p.86. 14 One c o u l d argue, as K l e i n has done, t h a t a p o l i c y may be p o l i t i c a l l y r a t i o n a l or a d m i n i s t r a t i v e l y r a t i o n a l and not both. 15 Rudolf K l e i n , " P o l i c y Problems and P o l i c y Percep-t i o n s i n the N a t i o n a l H e a l t h S e r v i c e " , P o l i c y and P o l i t i c s , Vol.2, No.3, p.224. 16 E c k s t e i n p.226 79 The i n c o n s i s t e n c i e s i n o b j e c t i v e s and the the l a c k o f c e n t r a l c o n t r o l make inc r e m e n t a l change the most l i k e l y to occur. H e a l t h P l a n n i n g i n Canada There are some who view the Canadian h e a l t h care system p o s i t i v e l y s p e c i f i c a l l y because of the use of incremental ( p o l i t i c a l ) p l a n n i n g . Hatcher s t a t e s Canadian h e a l t h care p o l i c i e s have been pragmatic and in c r e m e n t a l r a t h e r than based on a broad i d e o l o g i c a l or systems approach. P o l i c i e s were adopted because they worked to the s a t i s f a c -t i o n o f the p o p u l a t i o n and without too much grumbling from 17 s p e c i a l i n t e r e s t s . Development of a h e a l t h care system i n Canada was c o n t r o l l e d to some degree because p r a c t i c a l men responded to f i n a n c i a l i n c e n t i v e s but t h i s i s not to say t h a t the system developed i n a comprehensive way. There i s no l e g i s l a t e d h e a l t h care p l a n n i n g r e q u i r e -ment but i n r e c e n t years the need f o r the c o n t r o l i m p l i c i t i n p l a n n i n g has come forward. Government i n t e r v e n t i o n has always been suspect and government c o n t r o l l e d p l a n n i n g more suspect s t i l l but the p r e s s u r e s of c o s t s are f o r c i n g governments to take steps toward i n c r e a s e d c o n t r o l . T h i s c o n t r o l may be expressed as f i s c a l c o n t r o l or as program and systems c o n t r o l . 17 * Gordon H. Hatcher, "Canadian Approaches To H e a l t h P o l i c y D e c i s i o n s - N a t i o n a l H e a l t h Insurance", American J o u r n a l of P u b l i c H e a l t h , (September, 1978) p.888. 80 Two j o u r n a l i s t s , Bennett and Krasny, responding to f e d e r a l government concerns about the r i s i n g expenditure f o r h e a l t h care, c a r r i e d out an assessment of the Canadian system and have d e v i s e d i n g e n e r a l terms a grand p l a n to meet the o v e r a l l o b j e c t i v e of c o n t a i n i n g expenditure growth while m a i n t a i n i n g or upgrading the q u a l i t y of c a r e . These men p o i n t out t h a t i t i s the ten p r o v i n c i a l govern-ments which are most able to determine the d i r e c t i o n of the Canadian h e a l t h system. They c o n t r o l funding and most of the p l a n n i n g and decision-making mechanisms t h a t a f f e c t the b a s i c c o n f i g u r a t i o n of care d e l i v e r y and t h e r e -f o r e each should develop a long term p l a n ; a h e a l t h care s t r a t e g y . In f a c t , s e v e r a l p r o v i n c e s have developed grand p l a n s which f o r the most p a r t are g a t h e r i n g dust on l i b r a r y 19 s h e l v e s . In B r i t i s h Columbia, the Foulkes Report would have been the master p l a n had the v a g a r i e s o f p o l i t i c s not i n t e r v e n e d . I t would remain to be seen what a govern-ment c o u l d accomplish i n the face of s t r o n g o p p o s i t i o n from powerful groups. As d e s c r i b e d p r e v i o u s l y , the governments are now b e g i n n i n g to a s s e r t the n e c e s s i t y to p l a c e c o n t r o l s on the growth and c o s t s of the h e a l t h care 18 James E. Bennett, Jacques Krasny, "Time to Face Up To The Health Care Crunch", F i n a n c i a l Post, (May 7,1977) p.39. 19 John Browne, Summary of Recent Major S t u d i e s of  Health Care i n Canada, Department of Health A d m i n i s t r a t i o n , U n i v e r s i t y of Toronto f o r the Canadian C o l l e g e o f H e a l t h S e r v i c e E x e c u t i v e s . 81 system. Planning must, of n e c e s s i t y , f o l l o w . H e a l t h Planning i n B r i t i s h Columbia McQueen suggests a master p l a n f o r the Canadian system i s i m p o s s i b l e , but supports a combined e f f o r t of i n t e r e s t e d p a r t i e s to work together e s p e c i a l l y f o r systems and program p l a n n i n g through a p r o v i n c i a l government 20 p l a n n i n g o f f i c e . In B r i t i s h Columbia the P l a n n i n g and Development Group of the M i n i s t r y of H e a l t h was developed f o r the s p e c i f i c task of p l a n n i n g , implementing and e v a l u a t i n g the community h e a l t h care c e n t r e s which came i n t o e x i s t e n c e d u r i n g the tenure of the s o c i a l i s t NDP government. In the r e o r g a n i z a t i o n of 1978, the group became r e s p o n s i b l e f o r the g e n e r a l p l a n n i n g , development, e v a l u a t i o n and r e s e a r c h f u n c t i o n of the M i n i s t r y though: the major s u b s e c t i o n s of the M i n i s t r y continued to main-t a i n t h e i r own p l a n n i n g s e c t i o n s . Perhaps t h i s r e o r g a n i -z a t i o n , i n c l u d i n g a g e n e r a l p l a n n i n g s e c t i o n , s i g n a l s a r e c o g n i t i o n of the n e c e s s i t y t h a t the government analyse p r o p o s a l s f o r t h e i r e f f e c t i v e n e s s and the range of a p p l i c a t i o n i n the system. The much more d i s r u p t i v e 1981 r e o r g a n i z a t i o n r e t a i n e d the s o - c a l l e d p l a n n i n g department. L i t t l e has been heard from or about them as yet. but change may be on the h o r i z o n . Each s u b s e c t i o n of the M i n i s t r y , such as i n s t i t u t i o n a l Ronald J.C. McQueen, "Governments and Long-Range Planning", H o s p i t a l A d m i n i s t r a t i o n i n Canada, (September 1976), p.34. 82 s e r v i c e s , community h e a l t h , and the s p e c i a l Long Term Care Program, develop plans i n i s o l a t i o n . H o s p i t a l -based ambulatory care was, t h e r e f o r e , i s o l a t e d from the p l a n n i n g o f other forms of ambulatory care or from any assessment by other s e c t i o n s f o r wider e f f e c t s . The g e n e r a l p l a n n i n g s e c t i o n may take over and c o o r d i n a t e p l a n n i n g a c t i v i t i e s of the M i n i s t r y i n the f u t u r e but a t the time S t . Paul's H o s p i t a l M e d i c a l Day Care Program p r o p o s a l broached the M i n i s t r y i t assessment would have been c o n f i n e d to BCHP. There i s no evidence t h a t the MDC p r o p o s a l was submitted to any a n a l y s i s of a r a t i o n a l p l a n n i n g n a t u r e . Nor i s there any evidence to show more than c u r s o r y i n t e r e s t i n other a p p l i c a t i o n s of the program as p a r t of some p r o v i n c i a l p l a n . The i m p l i c a t i o n i n Michael's d e s c r i p t i o n of r a t i o n a l p l a n n i n g i s t h a t there w i l l always be one b e s t answer. U n f o r t u n a t e l y the 'best' answer may vary dependent upon whose r a t i o n a l i t y i s a p p l i e d . What i s r a t i o n a l to the consumer whose e x p e c t a t i o n s are those of h i g h q u a l i t y c a r e , e a s i l y a c c e s s i b l e f o r as l i t t l e p e r s o n a l c o s t as p o s s i b l e may not be r a t i o n a l to the government bureaucrat who must f u n c t i o n w i t h i n budgetary r e s t r i c t i o n s , or the p o l i t i c i a n who must be seen as f i s c a l l y r e s p o n s i b l e as w e l l as improving s e r v i c e s , or the h o s p i t a l a d m i n i s t r a t o r whose mandate i s to meet consumer e x p e c t a t i o n s and pro-f e s s i o n a l demands w i t h i n r e s t r i c t i v e funding a l l o c a t i o n s . O b v iously t h i s v a r i e t y o f viewpoints causes problems 83 which a f f e c t outcomes. The medical p r o f e s s i o n has c o n t r o l l e d h e a l t h care d e l i v e r y through the c o n t r o l of the i n d i v i d u a l p a t i e n t ' s access to h e a l t h care and i n the i n t r o d u c t i o n and u t i l -i z a t i o n of very expensive, h i g h l y s p e c i a l i z e d technology used f o r d i a g n o s i s and treatment. While c o s t s of h e a l t h care appeared reasonable and while the h e a l t h s t a t u s of the p o p u l a t i o n was improving l i t t l e concern was heard. Now t h a t c o s t s continue to i n c r e a s e and the h e a l t h s t a t u s of the p o p u l a t i o n has reached a p l a t e a u p o l i t i c i a n s and bureaucrats are becoming more v o c a l about the need to c o n t r o l c o s t . U l t i m a t e l y t h i s i n t e n t i o n to c o n t r o l c o s t s means a t r a n s f e r o f power from the medical entrepreneurs to the government. How e a s i l y t h i s can be accomplished remains to be seen. The c o n t r o l i m p l i e d i n t h i s t r a n s f e r of power r e q u i r e s c o n t i n u i t y which p l a c e s the b u r e a u c r a t i n a s t r o n g e r p o s i t i o n than the s h o r t term p o l i t i c i a n . Power f i n a l l y r e s i d e s with the b u r e a u c r a t s . The means of c o n t r o l i s p l a n n i n g . Whatever the p l a n n i n g model " . . . f a r from being the n e u t r a l s c i e n c e which i t i s h e r a l d e d to be, the p l a n n i n g process serves the i n t e r e s t s 21 t h a t are able to c o n t r o l x t s use." So f a r , the B.C. government has played a t p l a n n i n g . Planning methods have been used w i t h i n d i v i d u a l p r o j e c t s but there were no system-wide c r i t e r i a a g a i n s t which p r o p o s a l s were analysed. 21 Tannen. p.115 84 O b j e c t i v e s f o r the M i n i s t r y o f H e a l t h were w r i t t e n i n 1978 but ad hoc p l a n n i n g continued, probably because there was no a d m i n i s t r a t i v e set-up to i n c l u d e p l a n n i n g and c o o r d i n a t i o n of M i n i s t r y a c t i v i t i e s . The machinery must be pre s e n t and supported b e f o r e p l a n n i n g and c o o r d i n a t i o n can e x i s t . The i n t r o d u c t i o n of s t r o n g p u b l i c a d m i n i s t r a -t o r s i n s t e a d of medical p r o f e s s i o n a l s i n t o deputy and a s s i s t a n t deputy m i n i s t e r i a l p o s i t i o n s probably i n d i c a t e s the government i n t e n t i o n to take a 'hard l i n e ' , to e s t a b -l i s h c o n t r o l s . P r a c t i c a l i t y must p r e v a i l and the system p l a n n i n g f u n c t i o n w i l l g a i n importance i n the M i n i s t r y when i t i s r e c o g n i z e d as the major t o o l of c o n t r o l and as c o s t containment measures and f i s c a l management a p p l i e d to h o s p i t a l s f a l l s h o r t o f o b j e c t i v e s i n the face of demand. The p l a n n i n g model most a p p l i c a b l e to the B.C. s i t u a -t i o n i s the i n c r e m e n t a l . No p l a n n i n g theory has been a p p l i e d w i t h i n t e n t . Developments i n the B.C. h e a l t h care system have depended upon ad hoc i n i t i a t i v e s from a v a r i e t y of sources w i t h p e r s o n a l and/or l o c a l m o t i v a t i o n s . No doubt pas t d e c i s i o n s taken would be defended as r a t i o n a l although i s o l a t e d from other components of the system and without any c o o r d i n a t e d p l a n f o r h e a l t h care i n t h i s p r o v i n c e . Planning as an a c t i v i t y i s f r a u g h t w i t h c o n t r a d i c -t i o n s and human i n a b i l i t y . There i s no s t r a i g h t l i n e to a c o n c l u s i o n but the p l a n n i n g e x e c c i s e does o f f e r a 85 b e t t e r chance of success i f there i s an attempt to c o n s i d e r v a r i a b l e s i n f l u e n c i n g the outcome. The p l a n n i n g process i s a p o l i t i c a l process i n which v a r i o u s a c t o r s e x e r c i s e i n f l u e n c e to v a r y i n g degrees dependent upon t h e i r power re s o u r c e s , a c c o r d i n g to t h e i r i n t e r e s t s and p r e f e r e n c e s and those with the g r e a t e s t i n f l u e n c e c o n t r o l the outcome. 86 CHAPTER VII PROPOSALS AND THE POLITICAL SYSTEM The e x p l o r a t i o n of p l a n n i n g models o f f e r e d some e x p l a n a t i o n s f o r government b u r e a u c r a t i c behavior i n r e l a t i o n to ambulatory care but a l s o opened the avenue of p o l i t i c a l c o n s i d e r a t i o n s . I t was decided to review some d i f f e r e n t models which might p r o v i d e other ways of l o o k i n g a t the d i f f i c u l t i e s encountered i n the development of the Medical Day Care Program. One model which t r a c e s the move-ment of an i s s u e through the p o l i t i c a l system i s a p p l i e d below. The model developed by H a l l e t a l may e x p l a i n the l a c k of a c t i o n . The model d e a l s w i t h the reasons why a p r o p o s a l gains the a t t e n t i o n of p o l i c y makers and what c r i t e r i a a f f e c t the p o s s i b i l i t y of the p r o p o s a l ' s a c c e p t -ance and implementations. The c r i t e r i a h e l p to s i m p l i f y , o r g a n i z e and understand the evidence. These c r i t e r i a are Legitimacy, F e a s i b i l i t y and Support. I n t e r p r e t a t i o n of these c r i t e r i a i s a f f e c t e d by a government's i d e o l o g y . 1  L e g i t i m a c y / U n d e r l y i n g I d e o l o g i e s I d e o l o g i e s are d e f i n e d as p a t t e r n s of a t t i t u d e s and a s p i r a t i o n s l e a d i n g to programs of a c t i o n and s u s t a i n e d by reasonably coherent s e t s of assumptions and prognoses about the workings of s o c i e t y . I d e o l o g i e s are the b a s i s "'"P.Hall e t a l . Change, Choice and C o n f l i c t i n S o c i a l P o l i c y (London : Heinemann) 1975, Chapter 15. 87 upon which p o l i t i c a l p a r t i e s l o o s e l y r e s t . The concept of l e g i t i m a c y r e v o l v e s around.assumptions h e l d about the proper r o l e and sphere of government a c t i o n . The l e g i -timacy of a contemplated i n t e r v e n t i o n by government depends upon the i d e o l o g y of the p a r t y i n power and with i t s s u p p o s i t i o n s about p r i v a t e and p u b l i c support f o r i n t e r v e n t i o n . Donnison w r i t e s t h a t c l a r i f i c a t i o n of g o als can be 3 c o u n t e r p r o d u c t i v e to the maintenance of i d e o l o g i e s . Sometimes p o l i t i c a l i d e o l o g i e s are r e l a t e d to p o l i t i c a l b ehavior but u s u a l l y a g r e a t d e a l happens between the i d e o l o g i c a l pronouncements and the a p p l i c a t i o n s as they 4 f i n a l l y take form, i f they take form. N e v e r t h e l e s s Donnison argues t h a t governments need s o c i a l i d e o l o g i e s to guide and c o o r d i n a t e t h e i r work, to secure the support of the v o t e r s and to make the behavior of c i t i z e n s o r d e r l y and p r e d i c t a b l e . Canadian I d e o l o g i e s Which i d e o l o g i e s are i n f a v o r i s dependent upon the s o c i a l v a l u e s of the day. One of the accepted i d e o l o g i e s i n Canada i s the i d e a of c o l l e c t i v e a c t i o n to s o l v e i n d i v i d u a l ' s problems. T r a n s l a t e d i n t o a c t i o n t h i s 2 David Donnison, " I d e o l o g i e s and P o l i c i e s " , J o u r n a l  o f S o c i a l P o l i c y ( V o l . 1, No.2) p. 100 3 Donnison p. 10 0 4 D a n i e l S. Greenberg, "Washington Report, The F r u s t r a t e d Reformers", The New England J o u r n a l of Medicine (January 25, 1979) p. 211 88 i d e o l o g y p r o v i d e s a b a s i s f o r the w e l f a r e programs of many d i f f e r e n t governments and p o l i t i c a l p a r t i e s . An example of t h i s commitment i n Canada i s the 40% of Gross N a t i o n a l Product spent on w e l f a r e programs i n 1977.^ But Canada i s not m o n o l i t h i c . I d e o l o g i e s h e l d by d i f f e r e n t s e c t i o n s o f the s o c i e t y may c o n f l i c t . One i d e o l o g i c a l commitment which i s ambiguous i s toward r e d i s t r i b u t i o n and the r o l e of government i n t h i s p r o c e s s . Man has developed a boundless sense o f h i s c a p a c i t y to c o n t r o l h i s world. T h i s view i n c r e a s i n g l y focuses on government as the f o r c e f o r s o l v i n g s o c i a l problems and e n g i n e e r i n g s o c i e t y . T h i s view i s not without c o n f l i c t s i n c e the concept of e q u a l i t y has i m p l i c a t i o n s f o r the l i m i t a t i o n o f some i n d i v i d u a l s ' p r i v i l e g e s i n favour o f the i n c r e a s e d good of oth e r g i n d i v i d u a l s . There i s a growing p u b l i c r e c o g n i t i o n o f the government's powers to r e g u l a t e and d i s t r i b u t e wealth and o p p o r t u n i t i e s through s o c i a l p o l i c y f o r m u l a t i o n . Walter Stewart, " The God That F a i l e d ", Macleans, January 24, 1977, pp. 30-34. cz M a r t i n A. L e v i n , " P o l i t i c a l Dilemmas of S o c i a l P o l icy-Making", JHHRA, (May 1979) p. 464. 7 Donald N. M i c h a e l , " S p e c u l a t i o n s on Future P l a n n i n g Process Theory", i n Pla n n i n g i n America: L e a r n i n g From  Turbulence, ed. by David R. Godschalk (Washington, D.C: American I n s t i t u t e o f Planners P u b l i c a t i o n , 1974) p. 54-6. Joyce Warham, The Concept of E q u a l i t y i n S o c i a l ; P o l i c y , Department of Health Care and Epidemiology, U n i v e r s i t y o f B r i t i s h Columbia (mimeograph) 89 There i s a d i s t i n c t i o n between the amount of commit-ment of d i f f e r e n t Canadian governments to t h i s p o l i c y of r e d i s t r i b u t i o n . The f e d e r a l government i s more deeply i n v o l v e d i n r e d i s t r i b u t i o n p o l i c i e s because of the i n -e q u a l i t i e s of r e s o u r c e s e x i s t i n g i n d i f f e r e n t p a r t s of Canada and the n e c e s s i t y f o r a c e n t r a l government to be concerned about the country's s t r e n g t h s and weaknesses. In B.C. the dominant i d e o l o g y i s much more t h a t of i n -d i v i d u a l i s m , s e l f h elp and l e t the b e s t man win. Government i n t e r v e n t i o n i n a s s i s t i n g c i t i z e n s procure h e a l t h care has had a long i n c r e m e n t a l h i s t o r y i n Canada. The l o n g e v i t y of the f e d e r a l L i b e r a l government has allowed a c o n t i n u i n g development of h e a l t h and w e l f a r e s e r v i c e s \ through the use of f e d e r a l f i n a n c i a l r e s o u r c e s to s t i m u l a t e p r o v i n c i a l governments to e x e r c i s e t h e i r c o n s t i t u t i o n a l r e s p o n s i b i l i t i e s . There i s an element of t i m e l i n e s s i n l e g i t i m i z i n g government i n t e r v e n t i o n . Wars, p a r t i c u l a r l y , a l t e r assump-t i o n s about l e g i t i m a t e spheres of government f u n c t i o n . T h i s was t r u e i n Canada as development of a n a t i o n a l h e a l t h s e r v i c e was viewed by the f e d e r a l government as an important r e c o n s t r u c t i o n measure f o l l o w i n g the Second World War. To d e f i n e the scope of f e d e r a l i n t e r v e n t i o n two r e p o r t s were commissioned, the Heagarty, d e a l i n g w i t h 9 h e a l t h i s s u e s and the Marsh, d e a l i n g w i t h s o c i a l Canada. (Heagarty) H e a l t h Insurance Report of the A d v i s o r y Committee on H e a l t h Insurance. Ottawa : King's P r i n t e r , 1943. 90 s e r v i c e s . These r e p o r t s p r o v i d e d the background f o r an o v e r a l l h e a l t h and w e l f a r e p o l i c y statement presented a t the D o m i n i o n - P r o v i n c i a l Conference of 1946. That the o v e r a l l p o l i c y was never implemented comes as no s u r p r i s e but i t s p r e s e n t a t i o n d i d a l l o w the f e d e r a l government to assess the g e n e r a l a c c e p t a b i l i t y of the i d e a of government i n t e r v e n t i o n i n h e a l t h care and s o c i a l s e r v i c e s . T h i s g e n e r a l i z e d acceptance r e a s s u r e s government t h a t p r o p o s a l s should proceed toward implementation and l e g i t i m i z e s i t s a c t i o n s . The f e d e r a l government was not always the f i r s t t o move i n i n t r o d u c i n g new programs. The s o c i a l i s t i d e o l o g y of the C.C.F. Pa r t y i n Saskatchewan pr o v i d e d l e a d e r s h i p i n the area of government involvement i n p r o v i d i n g h e a l t h care to a l l c i t i z e n s . The absence of p h i l a n t h r o p y and the sparse settlement made government the most e f f i c a c i o u s v e h i c l e f o r s o l v i n g s i c k n e s s care problems on the Canadian P r a i r i e s . Other programs were begun by a v a r i e t y of i n s t i t u t i o n s a c r o s s the country, f o r example, medical care insurance was e s t a b l i s h e d by insurance companies and by the doctors themselves who sought a means to e s t a b l i s h r e g u l a r payment f o r t h e i r s e r v i c e s . P r o v i n c i a l commitment to the h e a l t h care system i s not as w e l l documented as f e d e r a l commitment except i n Canada. (Marsh) S o c i a l S e c u r i t y f o r Canada, Report of the A d v i s o r y Committee on R e c o n s t r u c t i o n . Ottawa : King's P r i n t e r , 1943. 91 Saskatchewan. Before f e d e r a l involvement the S o c i a l C r e d i t P a r t y and i t s supporters i n B.C. r e s i s t e d any e f f o r t s to i n t r o d u c e government sponsored p u b l i c w e l f a r e programs. A f t e r 1945 a c o n t i n u i n g adjustment between the two l e v e l s of government began. Ottawa's c o n t r o l of f i n a n c i a l r e sources allowed i t s involvement i n matters which were t r a d i t i o n a l l y p r o v i n c i a l r e s p o n s i b i l i t i e s . By 1957, o p e r a t i n g funds were ba d l y needed f o r the h o s p i t a l s which had been c o n s t r u c t e d through the stimulus of the N a t i o n a l H e a l t h Grants Program of 1948. A c o s t - s h a r i n g arrangement was then developed and implemented through the H e a l t h 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. In 1966 the H e a l t h Resources Fund p r o v i d e d monies f o r the develop-ment of f a c i l i t i e s f o r t e a c h i n g h e a l t h p r o f e s s i o n a l s and i n 196 7 the M e d i c a l Care A c t was passed to match payments of d o c t o r s ' f e e s . In 1962 a Royal Commission was s e t up by O r d e r - i n -C o u n c i l of the L i b e r a l Government to make recommendations which would ensure the b e s t p o s s i b l e h e a l t h care was a v a i l a b l e to a l l C a n a d i a n s . 1 1 The Commission l e g i t i m i z e d past government a c t i o n i n the p r o v i s i o n of h e a l t h care and recommended even more i n t e r v e n t i o n ( i n the form o f Canada. Royal Commission on H e a l t h S e r v i c e s , Ottawa, 1964. 92 medical care payments). The Commission developed the H e a l t h Charter f o r Canadians which embodies the i d e o l o g y of o p t i m a l h e a l t h care f o r every c i t i z e n . The C h a r t e r has become the normative e x p e c t a t i o n . Sometimes an i d e o l o g y transcends p o l i t i c a l p a r t y boundaries, such an example i s the Canadian H e a l t h Care System. During i t s s h o r t l i f e the C o n s e r v a t i v e Government commissioned a review of the h e a l t h care system (19 79) 12 to assure i t s e l f t h a t the i n i t i a l charge was being met. The q u e s t i o n of government i n t e r v e n t i o n i n h e a l t h care i s beyond p o l i t i c a l p l a t f o r m s on the f e d e r a l l e v e l . Regula-t i o n and a d m i n i s t r a t i v e arguments continue between the p a r t i e s but the i d e o l o g y remains i n t a c t . However, there are d i s s e n t i n g v o i c e s . The F r a s e r I n s t i t u t e of Vancouver views h e a l t h care as a p e r s o n a l r e s p o n s i b i l i t y i . e . an i n d i v i d u a l can have as much h e a l t h 13 care as he can a f f o r d to purchase. I r o n i c a l l y , the e a r l i e s t m o t i v a t i o n f o r government i n t e r v e n t i o n i n the p u b l i c h e a l t h was as a support to the market economy i d e o l o g y . Healthy workers meant h i g h e r and more c o n s i s t e n t p r o d u c t i v i t y . Another i d e o l o g y , about which there i s c o n f l i c t , i s the e x t e n t of t e c h n o l o g i c a l development. I l l i c h t h i n k s Canada. Canada's N a t i o n a l - P r o v i n c i a l H e a l t h Program f o r the 19 80's, Ottawa. 1980. 13 Ake Blomqvist, The H e a l t h Care B u s i n e s s , The F r a s e r I n s t i t u t e , 1979. 93 the commitment to medical t e c h n o l o g i c a l development has 14 gone too f a r . He r e p r e s e n t s the i d e o l o g y of more r e a l -i s t i c e x p e c t a t i o n s about l i f e and death. He d e s i r e s a r e t u r n to an acceptance o f p e r s o n a l r e s p o n s i b i l i t y f o r h e a l t h and an acceptance t h a t l i f e holds p a i n and death. I l l i c h and Laframboise"*"^ both make the p o i n t t h a t the North American tends to p l a c e h i s f a i t h i n the r e s t o r a t i v e powers of d o c t o r s , h o s p i t a l s and medical technology r a t h e r than assume r e s p o n s i b i l i t y f o r m a i n t a i n i n g h e a l t h through p e r s o n a l b e h a v i o r . In 19 77 the f e d e r a l government removed i t s e l f from the open-ended f i n a n c i a l arrangements w i t h the p r o v i n c e s . T h i s readjustment of f i n a n c i a l r e s p o n s i b i l i t y i s t e s t i n g the Canadians' commitment t o one i d e o l o g y over another because the p r o v i n c e s w i l l now be the s i n g l e d e c i s i o n -making a u t h o r i t i e s f o r f i n a n c i a l resource a l l o c a t i o n . B r i t i s h Columbia, wi t h i t s h i s t o r y o f r e s i s t a n c e to government i n t e r v e n t i o n and the c u r r e n t S o c i a l C r e d i t Government's espousal o f i n c r e a s e d p e r s o n a l r e s p o n s i b i l i t y f o r h e a l t h care c o s t s , i s one of the most l i k e l y t e s t i n g 16 grounds f o r l e g i t i m a c y . The f i n a n c i a l l a r g e s s e o f the f e d e r a l government i n su p p o r t i n g h e a l t h care c o u l d be 14 • . Ivan I l l i c h , M e d i c a l Nemesis : The E x p r o p r i a t i o n of H ealth, New York : Pantheon, 19 76. 15 H.L. Laframboise, "Health P o l i c y : B r e a k i n g the Problem Down Into More Manageable Segments", CM.A J o u r n a l (February 3, 1973) p. 393. 1 6 S e e Appendix IX f o r a statement of S o c i a l C r e d i t i d e o l o g y . 94 i g n o r e d o n l y w i t h severe r e p e r c u s s i o n s , d e s p i t e some pr o v i n c e ' s dominant i d e o l o g y of p e r s o n a l r e s p o n s i b i l i t y . Since i t would be p o l i t i c a l l y unwise to d i s c o n t i n u e a p r o v i n c i a l h e a l t h care system, the a l t e r n a t i v e i s to l i m i t and reduce involvement as much as the e l e c t o r a t e w i l l t o l e r a t e . I f a government's i d e o l o g y i s one of pe r s o n a l r e s p o n s i b i l i t y the e v o l v i n g f i n a n c i a l p r e s s u r e s and the i d e o l o g y combine to support such a c t i o n s . The q u e s t i o n o f l e g i t i m a c y has seemed s e t t l e d but remains tenuous i n the face o f these two p r e s s u r e s i n B.C. Being one's b r o t h e r ' s keeper depends on h i s b e l i e f s as w e l l as' how deep he has to d i g i n t o h i s own pocket. T h i s g e n e r a l a t t i t u d e of l i m i t a t i o n would permeate the H e a l t h M i n i s t r y ' s s t a f f and be demonstrated i n the nature of the response to any new p r o p o s a l s i f there were no obvious savings or government involvement i s seen to be i n c r e a s e d . Any added s e r v i c e p r o p o s a l , i n c l u d i n g ambulatory care p r o p o s a l s , submitted i n t o t h i s atmosphere would probably not f a r e w e l l . F e a s i b i l i t y F e a s i b i l i t y i s the second c r i t e r i a o f the H a l l e t a l model which attempts to e x p l a i n the acceptance or r e j e c t i o n of p r o p o s a l s by b u r e a u c r a t i c p o l i c y makers. I t i s the de t e r m i n a t i o n o f the ease of a s s i m i l a t i o n i n t o the e x i s t i n g system, the amount of ne g a t i v e impact on the government i f implementation occured and the reso u r c e s r e q u i r e d . 95 Broadly speaking, f e a s i b i l i t y i s l i m i t e d by the p r e v a i l i n g s t r u c t u r e and d i s t r i b u t i o n of t h e o r e t i c a l and t e c h n i c a l knowledge. The concept of a l t e r n a t i v e care d e l i v e r y systems p l a c e s no unusual demands upon e x i s t i n g 17 theory or technology but the matter p a r t i c u l a r i d e o -l o g i e s , i n t e r e s t s , p r e j u d i c e s and i n f o r m a t i o n does a f f e c t c o n c l u s i o n s drawn about f e a s i b i l i t y . H a l l e t a l e x p l a i n t h a t a c t o r s i n the p o l i c y - m a k i n g process are l i k e l y to assess f e a s i b i l i t y d i f f e r e n t l y because they are aware of 18 and are i n f l u e n c e d by d i f f e r e n t s e t s of c o n s t r a i n t s . These c o n s t r a i n t s have become known as i n p u t s and w i t h i n p u t s . Pross w r i t e s t h a t governments not o n l y process 'i n p u t s ' i . e . demands e x t e r n a l to the system ( M i n i s t r y ) but a l s o 'withinputs' which are demands generated w i t h i n the system. Withinputs may be products of b u r e a u c r a t s percep-t i o n s o f short-comings i n e x i s t i n g p o l i c y ; r e p r e s e n t a t i o n s f o r outside, i n t e r e s t s ; l o g i c a l consequences of e x i s t i n g s t r u c t u r e s and p o l i c i e s ; or may grow out of innumerable 19 r i v a l r i e s which e x i s t w i t h i n complex o r g a n i z a t i o n s . Improved technology has allowed c e r t a i n treatment and d i a g n o s t i c i n t e r v e n t i o n s to be p r o v i d e d on an ambula-t o r y b a s i s . 18 Royal Commission 1964, p. 479. 19 A.Paul Pross, Input Versus Withmput : Pressure Group Demands and A d m i n i s t r a t i v e S u r v i v a l , i n Pressure Group Behavior i n Canadian P o l i t i c s , ed. by A.Paul Pross, McGraw-Hill Ryerson S e r i e s i n Canadian P o l i t i c s , p. 161. 96 Of a l l the o p t i o n s developed from i n p u t s and w i t h i n p u t s o n l y a few are examined s i n c e i t i s im p o s s i b l e to c l o s e l y analyse a l l p o s s i b l e c h o i c e s as recommended by the r a t i o n a l -i s t p l a n n e r s . To s i m p l i f y a complex concept H a l l e t a l have o r g a n i z e d t h e i r d i s c u s s i o n of f e a s i b i l i t y under three headings, namely, r e s o u r c e s , c o l l a b o r a t i o n and a d m i n i s t r a -t i v e c a p a c i t y . These elements w i l l be employed to demon-s t r a t e some o f the c o n s i d e r a t i o n s a f f e c t i n g the f e a s i b i l i t y o f a l t e r n a t i v e care d e l i v e r y systems. Resources Resource f e a s i b i l i t y i n c l u d e s f i n a n c i a l and manpower resou r c e s and i s concerned w i t h r e s o u r c e s a v a i l a b l e now, i n the f u t u r e and those r e l e a s e d by the proposed change. 20 S u b s t i t u t i o n i s a concept w i d e l y used i n the d i s c i p l i n e o f economics to d e s c r i b e a s i t u a t i o n i n which one commodity t h a t s a t i s f i e s s i m i l a r needs or d e s i r e s r e p l a c e s the o r i g i n a l commodity, u s u a l l y a t a lower p r i c e . 21 F r e i b e r g l i s t s f our sources o f s u b s t i t u t i o n i n h e a l t h care 1. t e c h n o l o g i c a l i n v e n t i o n and i n n o v a t i o n 2. changed o r g a n i z a t i o n a l arrangements 3. i n c r e a s e d c a p i t a l accumulation 4. i n c r e a s e d medical knowledge Ric h a r d G. L i p s e y , Gordon R. Sparks, and Peter 0. S t e i n e r , Economics (San F r a n c i s c o : Harper and Row, P u b l i s h e r s , 1979) p. 898. 21 Lewis F r e i b e r g , J r . , " S u b s t i t u t i o n o f O u t p a t i e n t Care f o r I n p a t i e n t Care:Problems and Experience", J o u r n a l o f  Health P o l i t i c s , P o l i c y and Law. (Winter 1979), p. 479 97 The source of s u b s t i t u t i o n a p p l i c a b l e i n the c o n t e x t of a l t e r n a t i v e care d e l i v e r y systems i s changed o r g a n i z a t i o n a l arrangements, i . e . the way i n which the use of manpower and technology are o r g a n i z e d to d e l i v e r c a r e . In the c o n t e x t of s i c k n e s s c a r e , i t i s s a i d t h a t many episodes of care c o u l d be p r o v i d e d as e f f e c t i v e l y f o r l e s s c o s t i n s e t t i n g s o t h e r than i n p a t i e n t s e t t i n g s , and i n some cases a p p r o p r i a t e care c o u l d be p r o v i d e d by h e a l t h workers l e s s c o s t l y than p h y s i c i a n s . Both expected outcomes of ambulatory care would r e l e a s e r e s o u r c e s ; some i n p a t i e n t bed usage and some p h y s i c i a n time, thereby r e d u c i n g the number of necessary acute care beds and a l l o w i n g p h y s i c i a n s to work more e f f e c t i v e l y i n the areas of care f o r which they have been prepared or perhaps even r e d u c i n g the number of p h y s i c i a n s r e q u i r e d i n the h e a l t h care system. As more e m p i r i c a l r e s e a r c h i s c a r r i e d out, the d i r e c t s u b s t i t u t i o n of ambulatory care f o r i n p a t i e n t care becomes 22 23 24 l e s s c l e a r . ' ' The concept  rof complementarity i s now a p a r t of the d i s c u s s i o n . A complement i s d e f i n e d as "a commodity t h a t tends to be used j o i n t l y w i t h the o r i g i n a l 25 commodity. Over time, a s i n g l e p a t i e n t may use both 22 F r e i b e r g p.480 23 A. E l n i c k i , " S u b s t i t u t i o n of O u t p a t i e n t f o r I n p a t i e n t H o s p i t a l Care : A Cost A n a l y s i s " , I n q u i r y . (September 1976) p. 248 24 Wm. G. W e i s s e r t , "Costs of A d u l t Day Care:A Compari-son to Nursing Homes", I n q u i r y . (March 1978) p. 12 25 L i p s e y / S p a r k s / S t e i n e r p.884 98 ambulatory and i n p a t i e n t care m o d a l i t i e s f o r one or more episodes o f i l l n e s s . I t i s l i k e l y t h a t i f no a l t e r n a t e s e r v i c e s were a v a i l a b l e even more i n p a t i e n t bed usage would occur. D i r e c t s u b s t i t u t i o n e x i s t s i n some a p p l i c a t i o n s o f ambulatory care but with c o n s t a n t l y changing needs, e s p e c i a l l y toward maintenance programs, the r e a l s i t u a -t i o n i s not s t a t i c . Government appears to be c l i n g i n g to the d i r e c t s u b s t i t u t i o n requirement when approving ambulatory program p r o p o s a l s . C e r t a i n l y t h i s was tr u e i n the communications between S t . Paul's H o s p i t a l admin-i s t r a t i o n and BCHP r e g a r d i n g the implementation of the Medi c a l Day Care Program. (See Appendix VI) The concern about 'add on' s e r v i c e s i s understand-able and r e a l i s t i c but the r e s i s t a n c e to ambulatory s e r v i c e s i s i n c o n f l i c t w i t h the i d e o l o g y o f op t i m a l h e a l t h care a t l e a s t c o s t f o r a l l Canadians. H o s p i t a l - b a s e d programs r e q u i r e manpower which i s al r e a d y a v a i l a b l e and f u n c t i o n i n g i n the h e a l t h care system but programs such as community h e a l t h c e n t r e s which r e q u i r e h e a l t h p r o f e s s i o n a l s t o p r a c t i c e i n an expanded r o l e would cause manpower d i f f i c u l t i e s and im-pact f e a s i b i l i t y . There would be need to prepare these workers i n s u f f i c i e n t numbers, to have them accepted by the medical p r o f e s s i o n and to change e x i s t i n g l e g i s l a -t i o n to a l l o w expanded p r a c t i c e . (See Chapter II) 99 C o l l a b o r a t i o n P a t t e r n s o f c o l l a b o r a t i o n on the p a r t o f those i n -d i v i d u a l s and o r g a n i z a t i o n s upon whom s u c c e s s f u l imple-mentation depends are another element of f e a s i b i l i t y . Unless the p r o v i d e r s o f the care s e r v i c e s agree upon the goals and methods of goal achievement the e n t e r p r i s e w i l l f a i l . T e i t z w r i t e s t h a t p r o f e s s i o n a l i d e n t i f i c a t i o n depends upon p o s s e s s i o n of c e r t a i n methods which become the i n s i g n i a o f acceptance by c l i e n t s and c o l l e a g u e s . A p r o f e s s i o n i s made up of three elements, b e s i d e s mainten-ance of the t r a d i t i o n a l problem area, knowledge and o r -g a n i z a t i o n a l i n t e g r i t y , the second element, content i n n o v a t i o n , extends the area o f c o n t r o l and enhances both self-image and s t a t u s . The t h i r d element, r o l e i n n o v a t i o n , i s d i f f i c u l t to c o n f r o n t . New methods a p p r o p r i a t e to a new context are o f t e n too d i f f i c u l t to a s s i m i l a t e and may , . . . . . . - - • ,. 26,27,28,29,30 be r e j e c t e d i n the name of p r o f e s s i o n a l i s m . ^26 Michael B. Teitz,"Toward a Responsive P l a n n i n g Methodology", i n Pla n n i n g i n America:Learning From  Turbulence, ed. by David R. Godschalk, (Washington D.C, American I n s t i t u t e o f Planners P u b l i c a t i o n 1974) p. 89. 27 James 0. Hepner, Donna M. Hepner, The H e a l t h S t r a t e g y Game. S t . L o u i s : C V . Mosby Company, 1973. 2 8 Michele Vigeoz-Souchon, "Thoughts on C e r t a i n Aspects of the 'Mission' on the LCSC's", Canada's Mental H e a l t h , (December 1977) p. 8. 29 "Ideology and Change", Doctors and D o c t r i n e s - The  Ideology o f Med i c a l Care In Canada, (Toronto : U n i v e r s i t y of Toronto Press 1969) 30 Canada. Task Force Reports on the Cost of H e a l t h S e r v i c e s i n Canada, V o l . 3, 1969, p. 276. 100 Despite demonstrations of nurse p r a c t i t i o n e r s p r o v i d i n g a c c e p t a b l e and adequate s u b s t i t u t i o n f o r p h y s i c i a n s the r o l e i n n o v a t i o n r e q u i r e d o f the powerful medical p r o f e s s i o n has k i l l e d t h i s e f f e c t i v e and l e s s expensive mode of care d e l i v e r y . Success of t h i s manpower change'requires medical c o o p e r a t i o n to f u n c t i o n u n l e s s the medical and n u r s i n g a c t s are r e w r i t t e n . At t h i s p o i n t i n time no government i s w i l l i n g to take on the c o n f l i c t i n h e r e n t i n such a move. K l e i n has w r i t t e n t h a t the decision-makers w i l l assess the l i k e l i h o o d of r e s i s t a n c e on the p a r t of some important i n t e r e s t group and may decide t h a t a p r o p o s a l i s not f e a s i b l e . They would c o n s i d e r t h a t p u r s u i n g the pro-p o s a l has l e s s m e r i t than m a i n t a i n i n g good r e l a t i o n s w i t h 3 the i n t e r e s t group as a form of investment f o r the f u t u r e . T h i s would seem to have been p a r t l y the case i n the d i s -c o n t i n u a t i o n o f f u r t h e r Community Human Resource and Heal t h Centres i n B.C. s i n c e o f f i v e p i l o t p r o j e c t s the on l y one t h a t f a i l e d d i d so due to medical r e s i s t a n c e . The medical p r o f e s s i o n perpetuates the myth t h a t appro-p r i a t e h e a l t h s e r v i c e s are a l r e a d y p r o v i d e d w i t h i n the e x i s t i n g system and l o b b i e s a g a i n s t s e r v i c e s which would Rudolf K l e i n , " P o l i c y Problems and P o l i c y P e r c e p t i o n s i n the N a t i o n a l H e a l t h S e r v i c e " , P o l i c y and  P o l i t i c s . Vol.2, No. 3, p. 22 7. 101 be p r o v i d e d o u t s i d e the t r a d i t i o n a l m edical model. In Vancouver a p r o p o s a l i s p r e s e n t l y c i r c u l a t i n g which recommends development of ambulatory care programs 33 i n the f o u r u n i v e r s i t y a f f i l i a t e d t e a c h i n g h o s p i t a l s . T h i s document g i v e s credence to M i t c h e l l ' s i d e a t h a t groups r e - e v a l u a t e t h e i r a c t i v i t i e s and change t h e i r 34 behavior but not n e c e s s a r i l y t h e i r g o a l s . The p o i n t of the p r o p o s a l i s t h a t the ambulatory programs i n these h o s p i t a l s would be c o n t r o l l e d by m e d i c i n e / u n i v e r s i t y , demand no r o l e i n n o v a t i o n and thereby m a i n t a i n the gate-keeper f u n c t i o n of the p h y s i c i a n . At S t . Paul's H o s p i t a l , r e s i s t a n c e by medical s t a f f has been absent or muted. Concern has been expressed about ambulatory care s e r v i c e s competing wi t h the f a m i l y p h y s i c i a n s i n the community and the new program d i d have d i f f i c u l t y w i t h some p h y s i c i a n s ' r e s i s t a n c e to a c c e p t i n g more r e s p o n s i b i l i t y f o r p l a n n i n g the p a t i e n t s ' care (which was necessary because time was l i m i t e d to a 7-hr. p e r i o d ) . There has been no s e r i o u s t e s t , however, f o r example, no attempt has been made to i n t r o d u c e the nurse p r a c t i t i o n e r , which would have, been a r o l e i n n o v a t i o n . J iAnne C r i c h t o n , Community Hea l t h Centres : H e a l t h Care O r g a n i z a t i o n s of the Future? Information Canada, 1973 33 H o s p i t a l Based Ambulatory Care, A P o s i t i o n Paper, September, 1980. 34 F r e d H. M i t c h e l l J r . , " A n t i c i p a t i o n Versus R e s u l t s : An Approach to Improved F o r e c a s t i n g " , American J o u r n a l of  H e a l t h P l a n n i n g ( A p r i l 1978) pp. 7-14. 102 T r a d i t i o n a l medical p r a c t i c e has not been c h a l l e n g e d . A d m i n i s t r a t i v e C a p a c i t y Tests of a d m i n i s t r a t i v e f e a s i b i l i t y i n v o l v e q u e s t i o n s such as - Can the scheme be implemented? Are r e l a t e d p o l i c i e s e n f o r c e a b l e ? Does an a d m i n i s t r a t i v e s t r u c t u r e e x i s t ? Can one be adapted? The term ambulatory care has a v a r i e t y of d e s c r i p t i v e meanings, dependent upon i t s a p p l i c a t i o n . S e r v i c e s as v a r i e d as a v i s i t to a p h y s i c i a n ' s o f f i c e , v i s i t s to i n d i g e n t c l i n i c s , to assessment c l i n i c s , home care v i s i t s by a nurse and care p r o v i d e d i n f r e e s t a n d i n g c e n t r e s i n the U n i t e d S t a t e s have been termed ambulatory c a r e . Ambulatory care may be pr o v i d e d as a s i n g l e episode o r numerous episodes f o r h e a l t h maintenance of c h r o n i c i l l n e s s treatment. I t i s d e s c r i b e d as not r e q u i r i n g an i n p a t i e n t h o s p i t a l s t a y . Yet some s e r v i c e s termed ambulatory p r o v i d e o v e r n i g h t care or a l i m i t e d stay i n a h o s p i t a l bed. An a d d i t i o n a l d i f f i c u l t y with d e f i n i t i o n i s r e l a t e d to the f a c t t h a t much o f what i s or c o u l d be o f f e r e d i n a l t e r n a t i v e care d e l i v e r y f a l l s o u t s i d e the medical model. The r o l e s of the p r o v i d e r s are l e s s d i f f e r e n t i a t e d and the r o l e of the p a t i e n t i s much more a c t i v e than w i t h i n the h o s p i t a l s t r u c t u r e . I t i s d i f f i c u l t to c a t e g o r i z e a c t i v -35 i t i e s which do not f i t e x i s t i n g a d m i n i s t r a t i v e norms. H.L. Laframboise p. 393, 103 Governments h e s i t a t e to fund, users h e s i t a t e to use and t r a d i t i o n a l p r o v i d e r s h e s i t a t e to p r o v i d e s e r v i c e s . Not o n l y do the s e r v i c e s rendered vary but the term ambulatory care i t s e l f has a v a r i e t y o f d i s g u i s e s . Some of these d i s g u i s e s are p u b l i c 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 3 6 care, o u t p a t i e n t c a r e , ambulatory medicine, p a r t i a l 37 38 h o s p i t a l i z a t i o n day care and day h o s p i t a l . Each of these terms has a c o l o r a t i o n s p e c i f i c to the user and/or the s p e c i f i c nature of the s e r v i c e . The l a c k of a d m i n i s t r a t i v e o r g a n i z a t i o n has t r o u b l e d p l a n n e r s , both p r o f e s s i o n a l and governmental, and i s r e f l e c t e d i n the p a u c i t y o f r e s u l t s from s e v e r a l attempts to develop models or o u t l i n e boundaries f o r ambulatory care w i t h i n the h e a l t h care system. The l a c k of e x p l i c i t standards of c a r e , o f standard-39 l z e d r e c o r d keeping, a u d i t methods and coding systems compounds the a d m i n i s t r a t i v e d i f f i c u l t i e s . 3 6 Task Force Reports p. 359 and p.118 37 Raymond F. Luber. The Scope and Growth of P a r t i a l H o s p i t a l i z a t i o n ed. by Raymond F. Luber, New York, Plenum Press, 1978. 3 8 M. Farquhar, V.E.R. E a r l e , "Day H o s p i t a l s : a Program Development P e r s p e c t i v e " , Dimensions i n H e a l t h  S e r v i c e (January 1981) p. 16 - 18. 39 E l l e n A. O'Neal, "A Framework f o r Ambulatory Care E v a l u a t i o n " , J o u r n a l of Nursing A d m i n i s t r a t i o n ( J u l y 1978) p. 15 - 20. 104 I t i s p o s s i b l e t h a t p a r t of the h e s i t a t i o n to accept the MDC p r o p o s a l was r e l a t e d to the d i f f i c u l t y o f funding. Other ambulatory, day.care type s e r v i c e s have been r e -cognized but expanding i n t o medical as opposed to s u r g i c a l procedures may have appeared a 'bottomless p i t ' f o r funding. I t may be, too, t h a t the a d m i n i s t r a t i v e energy necessary to d e f i n e a c c e p t a b l e procedures was thought e x c e s s i v e . Laframboise e x p l a i n s t h a t g e n e r a l c l a s s i f i c a t i o n s a l l o w e a s i e r communication and d e f i n e s the a l l o c a t i o n o f re s o u r c e s . "...organized t h i n k i n g permits a more r a p i d i d e n t i f i c a t i o n of i n t e r - r e l a t i o n s h i p s and s i m p l i f i e s the assessment o f t h e i r importance." He was w r i t i n g o f the e n t i r e h e a l t h care system but the p r i n c i p l e a p p l i e s e q u a l l y w e l l w i t h i n one s e c t o r o f the system. The es t a b l i s h m e n t of a common understanding through language and o r g a n i z a t i o n such as attempted by the 1976 GVRHD /Ambulatory S e r v i c e s Study Committee would to a long way toward the r e c o g n i t i o n , p l a n n i n g and funding of a l t e r n a t i v e care d e l i v e r y modes w i t h i n the h e a l t h care system p r o v i n c i a l l y and nationally. 4"*" A u t h o r i t i e s assess f e a s i b i l i t y w i t h i n a r e s t r i c t e d time span, say between now and the next e l e c t i o n , or w i t h i n accustomed p l a n n i n g p e r i o d s . T h i s element i s w e l l 40 H.L. Laframboise, 394 41 See Chapters I I and I I I 105 demonstrated by the c u r r e n t 5-year c a p i t a l c o n s t r u c t i o n p r o j e c t i o n and the r e c e n t requirement o f h o s p i t a l s to p r o j e c t work volumes, revenues and c o s t s f o r the p e r i o d 1981 - 1986. There was no e s t a b l i s h e d a d m i n i s t r a t i v e c a p a b i l i t y i n the M i n i s t r y to a l l o w easy a s s i m i l a t i o n o f the Me d i c a l Day Care Program. There were no pr e v i o u s programs f o r precedent, there was no e s t a b l i s h e d f i n a n c i a l r e c o g n i t i o n of the procedures and s e r v i c e s i n c l u d e d i n MDC and there probably was concern about the exte n t o f t h i s 'add-on' s e r v i c e i f i t were i n t r o d u c e d i n many oth e r h o s p i t a l s . I t i s probably f o r these reasons t h a t a p i l o t p r o j e c t was more ac c e p t a b l e than a permanent commitment. Support H a l l and a s s o c i a t e s speak of the 'stock' or ' c r e d i t ' of a government to make new commitments without l o s i n g e l e c t o r a l support. Since p o l i c y change a l t e r s some f e a -t u r e s o f an e x i s t i n g d i s t r i b u t i o n o f power, i n f l u e n c e , b e n e f i t s , s t a t u s or va l u e s i t w i l l , i n e v i t a b l y , c r e a t e s a t i s f a c t i o n i n some s e c t o r s , d i s c o n t e n t i n o t h e r s . Whose s a t i s f a c t i o n s , whose d i s c o n t e n t s and the gen e r a l s t a t e o f the government's p u b l i c support w i l l be c o n s i d e r e d 42 . i n e s t i m a t i n g the value o f s u p p o r t i n g a p r o p o s a l x. e. how n e g a t i v e l y or p o s i t i v e l y w i l l i t a f f e c t the p a r t y a t 4 2 H a l l e t a l p. 483 106 the next e l e c t i o n . In g e n e r a l the d i s c o n t e n t of groups which c o n t r o l key r e s o u r c e s , f o r example, medical c a r e , w i l l be avoided as much as p o s s i b l e . Supporters of a p r o p o s a l seek f u r t h e r support from 43 what Marmor terms the ' s u b s t a n t i a l m a j o r i t y ' . Through p o l l s , p u b l i c d i s c u s s i o n , White Papers, Royal Commission Reports and l o c a t i n g o f s u p p o r t i v e groups the government determines w i t h what degree of s u r e t y i t can proceed to p l a c e the p r o p o s a l i n the p o l i t i c a l arena. The h i s t o r y of Canadian h e a l t h care l e g i s l a t i o n amply demonstrates t h i s type of a c t i v i t y . K l e i n i n t r o d u c e s a very i n t e r e s t i n g a p p l i c a t i o n of the p s y c h o l o g i c a l theory o f c o g n i t i v e dissonance. He says t h i s theory suggests t h a t " . . . . i n f o r m a t i o n i n c o n s i s t e n t w i t h e x i s t i n g a t t i t u d e s w i l l tend to be ignored; there may be an attempt to d i s c r e d i t i t s sources, there w i l l c e r t a i n l y be a r e a d i n e s s to e x p l o i t any a m b i g u i t i e s which j u s t i f y h o l d i n g on to one's pr e s e n t views." 44 A c c o r d i n g to K l e i n policy-making w i l l remain i n c r e m e n t a l , based on agreed consensus, but o c c a s i o n a l l y the i n c o n g r u i t y between the model and the experience w i l l prove too g r e a t and l e a d to a change i n p e r c e p t i o n and to a search f o r new 45 models. "*~JT.R. Marmor, The P o l i t i c s of Medicare, A l d i n e P u b l i s h i n g Co., 1973, p. 95 - 132. 4 4 R u d o l f K l e i n , p.229 4 5 R u d o l f K l e i n , p.229 107 H o s p i t a l - b a s e d ambulatory care s e r v i c e s have grown i n c r e m e n t a l l y , program by program and b r i n g no s i g n i f i c a n t r e d u c t i o n i n e x p e n d i t u r e s . There i s no c h a l l e n g e to the medical model of h e a l t h c a r e . The programs a s s i s t p a t i e n t s i n an undramatic manner; they support the p h y s i c i a n because more work can be processed; they a l l o w c e r t a i n p h y s i c i a n s an o u t l e t f o r i n d i v i d u a l e x p e r t i s e and may a s s i s t h o s p i t a l s with high occupancy problems. To ignore a h o s p i t a l - b a s e d program p r o p o s a l would cause no s i g n i f i c a n t r e p e r c u s s i o n s . On the o t h e r hand government c o u l d c r e a t e enough d i s s o n -ance to a l l o w wider implementation of a l t e r n a t i v e care d e l i v e r y systems i f i t chose to do so. U n t i l r e c e n t l y , government emphasis has been upon c o s t containment through a cutback program i n 1976-77 and, subsequently, by the inadequacy o f a l l o c a t i o n s ( e s p e c i a l l y i n the face of i n f l a t i o n and union c o n t r a c t i n c r e a s e s ) . Now i n 1981, perhaps, i n d i c a t i n g a change i n p o l i c y , the government has c o n f r o n t e d the m e d i c a l p r o f e s s i o n over medical s e r v i c e s payment schedules. The government's e s t i m a t i o n of i t s ' c r e d i t ' must be h i g h to c o n f r o n t a group which i s u s u a l l y avoided, i f not c o u r t e d - a group which embodies the government's own e n t r e p r e n e u r i a l i d e o l o g y . A c r i s i s o f c o s t has been manufactured over these n e g o t i a t i o n r e s u l t s . Government and m i n i s t e r i a l statements made c l e a r t h a t the i n c r e a s e demanded by the d o c t o r s would j e o p a r d i z e the system and c o u l d not be met out of g e n e r a l revenues but had to be met through h i g h e r 108 premiums and c o - i n s u r a n c e . The c o r r e c t i v e a c t i o n under-taken by the government was not d i r e c t e d toward develop-ment of l e s s c o s t l y ambulatory care but toward a s h i f t i n g of i n c r e a s i n g f i n a n c i a l r e s p o n s i b i l i t y from government to j the i n d i v i d u a l (government's v e r s i o n of balance b i l l i n g ) f o r payment o f s e r v i c e s . I t i s i n t e r e s t i n g to c o n j e c t u r e about the government's ch o i c e of a c t i o n . Was the fee n e g o t i a t i o n i s s u e one i n which government f e l t s u f f i c i e n t p u b l i c support t h a t a c o n f r o n t a t i o n w i t h the medical p r o f e s s i o n was l i k e l y to make p o l i t i c a l g a ins i n the p u b l i c eye through a demon-s t r a t i o n of f i s c a l r e s p o n s i b i l i t y . In c o n t r a s t , was the r o l e i n n o v a t i o n necessary to develop and operate a l t e r n a -t i v e care systems (such as the community h e a l t h centres) viewed as a s i t u a t i o n i n which the p u b l i c would support the medical p r o f e s s i o n and thus has been avoided d e s p i t e proven c o s t e f f e c t i v e n e s s ? As K l e i n and o t h e r s have w r i t t e n , government u s u a l l y avoids c o n v r o n t a t i o n w i t h powerful groups. Lukes d e s c r i b e s the most p e r s u a s i v e e x e r c i s e o f power as t h a t which i s maintained through the w i l l i n g c o o p e r a t i o n of those to be c o n t r o l l e d , p r e v e n t i n g people from having grievances by shaping t h e i r p e r c e p t i o n s , c o g n i t i o n s and p e r f e r e n c e s i n such a way t h a t they accept t h e i r r o l e i n 46 e x i s t i n g order of t h i n g s . In t h i s s o c i e t y the medical 4 6 . Stephen Lukes, Power : A R a d i c a l View, Toronto Macmillan 1974, p. 21-5. 109 p r o f e s s i o n has gained t h i s type of power. The g e n e r a l p u b l i c b e l i e v e s t h a t i t i s r e c e i v i n g the b e s t p o s s i b l e h e a l t h care through a m e d i c a l l y c o n t r o l l e d system. I t would take a s i t u a t i o n of c r i s i s p r o p o r t i o n (extreme dissonance) be f o r e government would c o n f r o n t such power i f i t i s assessed t h a t the p u b l i c would support the medical p r o f e s s i o n . As a consequence of these r e a l i t i e s , the government w i l l continue to attempt c o n t r o l of the medical f u n c t i o n through f i s c a l c o n t r o l of fees and h o s p i t a l s . Laframboi w r i t e s t h a t o n l y p o l i t i c i a n s and c i v i l s e r v a n t s are 4 7 concerned about h e a l t h care c o s t s . T h i s concern i s g a i n i n g a g r e a t d e a l of h i g h powered a t t e n t i o n c u r r e n t l y Van Loon p r e d i c t e d t h a t , as h e a l t h care expenditures became more s i g n i f i c a n t , h e a l t h care d e c i s i o n s would be taken over by p u b l i c f i n a n c e s p e c i a l i s t s , p r o v i n c i a l t r e a s u r e r s , premiers and prime m i n i s t e r s . 4 ^ A shake-up i n the B.C. M i n i s t r y of H e a l t h has r e p l a c e d incumbent c l i n i c a l l y t r a i n e d o f f i c i a l s w i t h i n d i v i d u a l s of adminis t r a t i v e and r e g u l a t o r y backgrounds and there are example of d i r e c t i n t e r v e n t i o n by the Treasury Board i n M i n i s t r y "*'H.L. Laframboise p.390 . 48 R.J. Van Loon, "From Shared Cost t o Block Funding and Beyond, The P o l i t i c s of H e a l t h Insurance i n Canada", J o u r n a l of Health P o l i t i c s , P o l i c y and Law, V o l . 2, P a r t 1978, p. 454-478. 110 o p e r a t i o n s . ' ' I t i s even rumored t h a t one M i n i s t e r of H e a l t h r e s i g n e d over Treasury Board i n t r u s i o n i n t o H e a l t h M i n i s t r y matters. 52 Laframboise has suggested t h a t a p r o p o s a l which s o l v e s more than one problem has a much g r e a t e r chance f o r acceptance and implementation. The M e d i c a l Day Care Program was a p a r t i a l s o l u t i o n to S t . Paul's H o s p i t a l occupancy problems but h e l d l i t t l e or no r e c o g n i z e d p o s s i b i l i t i e s f o r c o n t r i b u t i n g toward the c o s t containment goals of the M i n i s t r y . As a p i l o t p r o j e c t , the program was simply too small to cause immediate a c t i o n and was probably f i n a l l y accepted because of i t s i n s i g n i f i c a n t e f f e c t on expendi-t u r e s and the p o s s i b i l i t y t h a t h o s p i t a l revenues would r i s e s l i g h t l y r e d u c i n g the next annual a l l o c a t i o n . 49 Si x Lower Mainland h o s p i t a l s ' f i n a n c i a l methods are being assessed by a c o n s u l t i n g f i r m r e t a i n e d by the Treasury Board. 50 . • I n t e r e s t has been expressed m u s i n g a n u r s i n g care management t o o l a s a means to fund h o s p i t a l s . A committee c o n s i d e r i n g t h i s p o s s i b i l i t y submitted a r e p o r t i n June 1981 51 The F i n a n c i a l A d m i n i s t r a t i o n Act i s proposed to improve f i n a n c i a l c o n t r o l by naming h o s p i t a l s p u b l i c bodies and thus s u b j e c t to d i r e c t Finance M i n i s t r y i n t e r -v e n t i o n . 52 H.L. Laframboise, Moving a P r o p o s a l to a P o s i t i v e D e c i s i o n : A Case H i s t o r y of the I n v i s i b l e P rocess, Reprinted from Optimum, Vol.4, No.3, 1973. I l l In c o n t r a s t , the p r e f e r r e d Long Term Care Program d i d not o f f e n d the medical p r o f e s s i o n ( i t took some weight o f f the doctors) and i t seemed t o have p o t e n t i a l f o r s o l v i n g some of the c o s t problems. At the time of i t s implementation i t was c l e a r l y c o n s i d e r e d to be a vote g e t t e r . 112 CHAPTER V I I I CONCLUSIONS The q u e s t i o n posed a t the begin n i n g o f t h i s study-was why an a p p a r e n t l y s u c c e s s f u l program f a i l e d to r e c e i v e c o n t i n u i n g government support when ambulatory care was the h e a l t h p o l i c y of the 1970's i n Canada? Th i s i n v e s t i g a t i o n has attempted to s e t out answers to the q u e s t i o n . The r i s i n g c o s t s of h e a l t h care and the l a c k of i n t e g r a t i o n between p a r t s o f the d e l i v e r y system has l e d to d i s c u s s i o n of new forms of care d e l i v e r y . S e v e r a l demonstration p r o j e c t s have shown the e f f e c t i v e -ness of a v a r i e t y o f approaches under the umbrella o f ambulatory c a r e . H e a l t h care c o u l d be p r o v i d e d by ot h e r s as w e l l as by doc t o r s and much more care c o u l d be p r o v i d e d on an o u t p a t i e n t b a s i s without any decrease i n the q u a l i t y of the care r e c e i v e d and f o r l e s s c o s t . Across Canada a consensus developed t h a t ambulatory care was a 'good t h i n g ' . Governments i n c l u d e d the development of ambula-t o r y care i n statements o f o b j e c t i v e s and g o a l s . The est a b l i s h m e n t of a l t e r n a t i v e care d e l i v e r y systems became the p o l i c y o f the 1970's. Ambulatory Care a t St. Paul's H o s p i t a l The process of t r y i n g to g a i n government acceptance of the Med i c a l Day Care ambulatory care program was p u z z l i n g to the h o s p i t a l managers. The M i n i s t r y of H e a l t h 113 seemed u n e n t h u s i a s t i c and d i d not respond to the submission f o r ten months and f i n a l l y responded o n l y a f t e r a second submission proposed a p i l o t p r o j e c t . By the time the h o s p i t a l ' s MDC component of the Ambulatory Care S e r v i c e s was proposed (1976) the adminis-t r a t i o n was aware of the l i m i t a t i o n s of d i r e c t s u b s t i t u t i o n . The major, m o t i v a t i o n f o r the p r o p o s a l was as a s o l u t i o n to occupancy problems although the v a l i d i t y of ambulatory care as a l e s s expensive o p t i o n had a l r e a d y been proven by the h o s p i t a l . There f o l l o w e d requests from the M i n i s t r y f o r more i n f o r m a t i o n a l l of which was f i n a n c i a l l y o r i e n t e d . The major c o n s i d e r a t i o n of these requests remained s u b s t i t u -t i o n , even though i t s l i m i t a t i o n s were presumably common knowledge, and d e s p i t e the h o s p i t a l ' s s t a t e d m o t i v a t i o n f o r implementation. Acceptance of a " p i l o t " p r o j e c t seemed to a l l o w M i n i s t r y O f f i c i a l s .an o p p o r t u n i t y to d i s s o c i a t e themselves and the M i n i s t r y from the program should t h a t prove u s e f u l . The MDC Program has been very s u c c e s s f u l c o n t r i b u -t i n g some s u b s t i t u t i o n of i n p a t i e n t c a r e , and p r o v i d i n g some l e s s expensive care and i s extremely w e l l r e c e i v e d by p a t i e n t s . There was no attempt to change the p h y s i -c i a n s 'gatekeeper' r o l e , t h e r e f o r e there has been no u n w i l l i n g n e s s to use the s e r v i c e . 114 R i v a l Programs The program d i d not even p a r t i a l l y r e s o l v e the problem of high occupancy due to o t h e r events which were happening c o n c u r r e n t l y and which a c t u a l l y worsened the h o s p i t a l ' s s i t u a t i o n . Government r e s o u r c e s had allowed Home Care to expand to i n c l u d e a h o s p i t a l day replacement program (19 71) which presumably would reduce acute care c o s t s s i n c e the l e n g t h of stay would be shortened. The a c t u a l r e s u l t was t h a t acute care beds were t u r n i n g over more r a p i d l y and t h e r e f o r e h o s p i t a l s were d e a l i n g w i t h even more p a t i e n t s i n the i n i t i a l v e ry expensive p o r t i o n of a h o s p i t a l s t a y . The a n t i c i p a t e d empty beds never o c c u r r e d . When i t became known t h a t the M i n i s t r y was d e v e l o p i n g a Long Term Care (LTC) Program (1977) i t was obvious t h a t other program p r o p o s a l s submitted, i n c l u d i n g the MDC program would be i n c o m p e t i t i o n f o r r e s o u r c e s w i t h a pro-gram to which a very l a r g e commitment had a l r e a d y been made. ,Once the LTC program began, January 1978, the numbers o f p a t i e n t s occupying acute care beds but not r e q u i r i n g acute care s t e a d i l y grew from approximately 20 to 100 i n S t . Paul's H o s p i t a l a l o n e . A program which was supposed to a s s i s t the e l d e r l y to remain w i t h t h e i r f a m i l i e s a c t u a l l y p r o v i d e d i n c e n t i v e s to i n s t i t u t i o n a l i z e the e l d e r l y . The problem o f i n s u f f i c i e n t beds was m a g n i f i e d 5 - f o l d . As time passed the types of ambulatory care which 115 a c t u a l l y developed and, more important, those which d i d not develop, demonstrated where power l a y i n the h e a l t h care system a t d i f f e r e n t times. H o s p i t a l - b a s e d programs developed more q u i c k l y and i n a manner which supported the t r a d i t i o n a l , m e d i c a l l y c o n t r o l l e d h e a l t h system but they d i d not go f a r because the power of h o s p i t a l s de-c l i n e d d u r i n g the '70's. Other a l t e r n a t i v e s to i n p a t i e n t care s u f f e r e d from i n d i f f e r e n c e , o u t r i g h t h o s t i l i t y and from the f a c t these a l t e r n a t i v e s , f o r example, community h e a l t h c e n t r e s and nurse p r a c t i t i o n e r s r e q u i r e d enormous governmental resource i n p u t and commitment to e f f e c t these changes. Governments, Quebec excluded, a f t e r t r y i n g out p i l o t p r o j e c t s , d e c i d e d a g a i n s t the i n e v i t a b l e c o n f r o n t a t i o n s such commitments e n t a i l e d . Home Care and LTC have had s e t backs a f t e r i n i t i a l enthusiasm but they seem l i k e l y to be more l a s t i n g programs. The i n i t i a l e x p e c t a t i o n s f o r the s u b s t i t u t i o n of these o u t p a t i e n t (ambulatory care) s e r v i c e s f o r i n p a t i e n t s e r v i c e s proved o v e r e n t h u s i a s t i c . As the h e a l t h care s y s -tem was more and more r e q u i r e d to respond to c h r o n i c i l l -nesses as w e l l as to acute e p i s o d i c i l l n e s s e s the use of o u t p a t i e n t s e r v i c e s became p r i m a r i l y an o p t i o n r a t h e r than a d i r e c t s u b s t i t u t e f o r i n p a t i e n t c a r e . These clou d s on the h o r i z o n were not v i s i b l e to a D i r e c t o r of Nursing i n a h o s p i t a l which had accepted the 116 c h a l l e n g e to develop ambulatory s e r v i c e s and was p l a n n i n g i n t h a t d i r e c t i o n . S e v e r a l p o s s i b l e e x p l a n a t i o n s or combinations of e x p l a n a t i o n s f o r the i n c o n s i s t e n c i e s between s t a t e d government o b j e c t i v e s and behavior i n the development o f ambulatory care i n B.C. have been s e t out i n t h i s paper. The M i n i s t r y of H e a l t h o b j e c t i v e s would l e a d one to b e l i e v e t h a t ambulatory care would be a p l a n n i n g p r i o r i t y but there i s no evidence to i n d i c a t e so. The GVRHD and the h o s p i t a l s are d a b b l i n g i n h o s p i t a l - b a s e d programs but government i s not e x p l o r i n g the other more s i g n i f i -cant and c o n f l i c t f i l l e d a l t e r n a t i v e d e l i v e r y systems. Pl a n n i n g l i t e r a t u r e reviewed i n d i c a t e d t h a t the p l a n n i n g process should be a r a t i o n a l process but i n f a c t i s not. P l a n n i n g appears to be p r i m a r i l y p l a n n i n g imple-mentation of a l t e r n a t i v e s chosen through a p o l i t i c a l process i n r e a c t i o n to a number of c o n s t a n t l y s h i f t i n g c o n s i d e r a t i o n s . V a r i o u s a c t o r s e x e r c i s e i n f l u e n c e on c h o i c e s to v a r y i n g degrees dependent upon t h e i r power re s o u r c e s , a c c o r d i n g to t h e i r i n t e r e s t s and p r e f e r e n c e s . There appears to be no o v e r a l l h e a l t h care p l a n f o r s e r v i c e s and programs. The c u r r e n t major e f f o r t i s focussed on f i s c a l c o n t r o l of e x i s t i n g s e r v i c e s . The p o l i t i c a l model of H a l l e t a l e l u c i d a t e d government's behavior as being p r i m a r i l y r e l a t e d to 117 c o n t i n u i t y i n the bureaucracy and r e - e l e c t i o n o f the p o l i t i c i a n s . Government's mandate i s so s h o r t t h a t i t i s extremely d i f f i c u l t to make long term commitments or to implement what are seen to be necessary or unpopular measures. D e c i s i o n s taken are based upon a l t e r n a t i v e s chosen f o r c o n s i d e r a t i o n because they r e f l e c t i d e o l o g y , are f e a s i b l e and w i l l i n c r e a s e the ' c r e d i t ' o f the government with the e l e c t o r a t e . These a l t e r n a t i v e s w i l l u s u a l l y not i n c l u d e any which i n v o l v e c o n f r o n t a t i o n w i t h power groups i n the s o c i e t y e.g. the medical p r o f e s s i o n . With government a p p a r e n t l y l o s i n g enthusiasm f o r o u t p a t i e n t as w e l l as i n p a t i e n t care the a l t e r n a t i v e r e -maining i s a move toward p e r s o n a l r e s p o n s i b i l i t y both i n f i n a n c i n g h e a l t h care used and i n p r e v e n t i v e h e a l t h b e h a v i o r . F i r s t steps i n p e r s o n a l f i n a n c i a l r e s p o n s i b i l i t y have a l r e a d y been taken. P r e v e n t i v e programs are one of the o b j e c t i v e s of the M i n i s t r y which have not y e t been 53 implemented but the f u t u r e promises v i g o r o u s a c t i o n . From P o l i c y Formulation to Management P r a c t i c e The process of government acceptance o f the MDC program was c l e a r l y a f l u c t u a t i n g p o l i t i c a l process r a t h e r than a r a t i o n a l i s t p l a n n i n g one. The process a p r o p o s a l The Senior Deputy M i n i s t e r , i n a speech to the Canadian C o l l e g e of Hea l t h S e r v i c e E x e c u t i v e s September 17, 1981, s t a t e d p r e v e n t i v e programs w i l l become a p r i o r i t y of the M i n i s t r y d i r e c t l y a f t e r f i s c a l c o n t r o l . 118 undergoes i s dependent upon the s p e c i f i c s of the p r o p o s a l , the t i m e l i n e s s of p r e s e n t a t i o n , the c h a r a c t e r i s t i c s of the government and the p r e s s u r e s being experienced by the government and the c i v i l s e r v i c e a t a p a r t i c u l a r time. I t i s a p p r o p r i a t e t h a t the h e a l t h care manager assess the f o r c e s which w i l l i n f l u e n c e any p r o p o s a l he might formulate and submit f o r approval i n order to design a p p r o p r i a t e s t r a t e g i e s f o r p r e s e n t a t i o n and to decide i f i t i s worthwhile undertaking the p r o j e c t s i n c e f u t u r e n e g o t i a t i o n might be a f f e c t e d . Laframboise has o f f e r e d l i g h t h e a r t e d and c o n c i s e means to analyse a p r o p o s a l f o r i t s l i k e l i h o o d of acceptance and suggests means to make 54 a p r o p o s a l more a c c e p t a b l e . I m p l i c a t i o n s of C o n f l i c t i n g I d e o l o g i e s The f e d e r a l government commitment to m a i n t a i n i n g a h e a l t h care system i s now without q u e s t i o n , no matter which of the f e d e r a l p o l i t i c a l p a r t i e s i s i n power. T h i s commitment i s not so c l e a r i n the case of some p r o v i n c i a l governments. Recent changes i n the f i n a n c i a l arrangements between the f e d e r a l and p r o v i n c i a l governments has made the p r o v i n c i a l j u r i s d i c t i o n i n h e a l t h care e x p l i c i t . Those p r o v i n c i a l governments wi t h c o n s e r v a t i v e i d e o l o g i e s , such as i n B.C., are c o n f r o n t e d as never b e f o r e w i t h the dilemma of p u b l i c e x p e c t a t i o n of government f o r the pro-H.L. Laframboise, Moving a Pr o p o s a l to a P o s i t i v e D e c i s i o n : A Case H i s t o r y of the I n v i s i b l e Process, Reprinted from Optimum, Vol.4, No.3, 1973. 119 v i s i o n of h e a l t h care versus t h e i r p e r s o n a l r e s p o n s i b i l i t y i d e o l o g y . Despite Socred i d e o l o g y i t i s very d i f f i c u l t to m a i n t ain an 'arms l e n g t h ' stance when a growing p o r t i o n of the government budget i s being spent by h e a l t h care e n t r e p r e n e u r s . Pressures are g a t h e r i n g , demanding a more p e r v a s i v e government presence i n the management of the h e a l t h care system. The p u b l i c e x p e c t a t i o n t h a t govern-ment w i l l assure o p t i m a l h e a l t h care be a v a i l a b l e and 55 e a s i l y a c c e s s i b l e , the u n r e m i t t i n g demand f o r more and broader s e r v i c e s , the e n t r e p r e n e u r i a l aspects of h e a l t h care which assume l i t t l e r e s p o n s i b i l i t y f o r expenditures and, f i n a l l y , the i n c r e a s i n g p r o p o r t i o n of p u b l i c monies expended on h e a l t h care are major developments which w i l l f o r c e a l a r g e r government presence. At the same time the p u b l i c ' s g e n e r a l l a c k of d i s s a t i s f a c t i o n w i t h the present m e d i c a l l y c o n t r o l l e d model of h e a l t h care d e l i v e r y makes p o l i t i c i a n s v ery c a r e f u l about making changes which might d i s a f f e c t the v o t e r . Every government response to these p r e s s u r e s impacts the h e a l t h care manager. The s c e n a r i o surrounding the h o s p i t a l i s c o n s t a n t l y s h i f t i n g . The h o s p i t a l has l i t t l e i f any c o n t r o l s to apply. I t has no r e s o u r c e s other than those a l l o c a t e d by government. I t s range of decision-making i s s e v e r e l y The government does noth i n g to dissuade people of t h i s e x p e c t a t i o n hoping to c o n t r o l c o s t s through p r e s s u r e s on a d m i n i s t r a t o r s of h o s p i t a l s . 120 l i m i t e d and, i n a fundamental way, c o n t r o l o f h e a l t h care has been given to the medical p r o f e s s i o n . The h o s p i t a l i s b u f f e t e d by the p o l i t i c a l requirements of the government which change without warning and the f i n a l ignominy i s t h a t managements are p u b l i c l y s c o l d e d f o r poor management p r a c t i c e s . The S o c i a l C r e d i t i d e o l o g y i s c o n t r a r y to government c o n t r o l , and pro b l e m - s o l v i n g techniques a p p l i e d are those developed i n the p r i v a t e s e c t o r but l a c k i n g the market-pl a c e i n c e n t i v e s . Concerns about h e a l t h care expenditures are the prime mo t i v a t o r of government a c t i o n s s i n c e i n t r o -d u c t i o n of the new f i n a n c i a l arrangements. For s e v e r a l years c o s t containment programs were expected i n each i n s t i t u t i o n but these programs have had no s i g n i f i c a n t r e s u l t s . Now st r o n g e r measures have been i n t r o d u c e d . REcent a l l o c a t i o n s are much below even the i n f l a t i o n r a t e and are presumably i n c e n t i v e s to more p r o d u c t i v e . The Problems of Delegated A u t h o r i t y Managers of i n s t i t u t i o n s have a l r e a d y been g i v e n warning t h a t performance c o n s i d e r e d inadequate w i l l s u f f e r the i n t r o d u c t i o n of p u b l i c a d m i n i s t r a t o r s . A l s o a t h r e a t to d e f i n e h o s p i t a l s as p u b l i c bodies e x i s t s . Despite Recently p l a c e d advertisements seeking three deputy m i n i s t e r s c o n t a i n f u t u r e p o l i c y '...to p l a n , develop and monitor the p o l i c i e s o f the m i n i s t r y to t u r n i t i n t o the most c o s t e f f i c i e n t government h e a l t h care o r g a n i z a t i o n i n the c o u n t r y . 1 Taken from the Vancouver Sun, J u l y 17, 1981 121 these i n c e n t i v e s i t i s d i f f i c u l t to see how t h i s p r e s s u r e on h e a l t h care managers can p o s s i b l y succeed i f a t the same time the government upholds the e n t r e p r e n e u r i a l r i g h t s of the primary c o s t g e n e r a t o r s . Continued p r e s s u r e i n t h i s v e i n w i l l i n e v i t a b l y b r i n g government and the medical p r o f e s s i o n i n t o c o n f r o n t a t i o n . The government does not wish to c o n t r o l d i r e c t l y or to manage h o s p i t a l s (although there are those who b e l i e v e t h i s should occur) and i t does not wish c o n f r o n t a t i o n or to e x e r c i s e c o n t r o l over the medical p r o f e s s i o n but these two r e s u l t s seem i n e v i t a b l e g i v e n the circumstances d e s c r i b e d . I t can be expected t h a t i n the near f u t u r e govern-ment w i l l continue to promise o p t i m a l h e a l t h c a r e , w i l l m a i n t a i n the h e a l t h system with "as l i t t l e government as p o s s i b l e " , w i l l use every o p p o r t u n i t y to p l a c e more f i n a n c i a l r e s p o n s i b i l i t y on i n d i v i d u a l s w i t h i n the p o l i -t i c a l r e a l i t y , w i l l c u t back on s e r v i c e s p e r c e i v e d to be l e s s p o l i t i c a l l y p r o b l e m a t i c , w i l l support p r i v a t e medical p r a c t i c e and care d e l i v e r y , w i l l a v o i d add-on s e r v i c e s u n l e s s p o l i t i c a l l y advantageous and w i l l continue to pressure h o s p i t a l managers to reduce spending which i s e s s e n t i a l l y an attempt to c o n t r o l medical p r a c t i c e . True stewardship of the h e a l t h care system r e s t s with no one. The a d m i n i s t r a t i v e and r e g u l a t o r y nature of the h e a l t h care system i s a f f e c t e d by these v a r i a b l e s . R e action to s p e c i f i c s i t u a t i o n s i n s t e a d of long term 122 p l a n n i n g , leads to fragmented attempts to c o n t r o l which f i n a l l y become a c o n t r a d i c t o r y and c o n f u s i n g maze f o r the g o a l o r i e n t e d h e a l t h care manager to n e g o t i a t e . Because of the a m b i g u i t i e s , the c o n t r a d i c t i o n s and the double messages i n o b j e c t i v e s and b e h a v i o r s managers can never be sure of the 'mission' of the e x e r c i s e . Suggestions f o r Improvements T h e o r e t i c a l models of the h e a l t h care system would enhance understandings and p r o v i d e means which would a l l o w q u i c k e r responses to i n n o v a t i v e p r o p o s a l s . A model does imply p r e v i o u s l y e s t a b l i s h e d o b j e c t i v e s as w e l l as a s t a b l e environment which all o w s c o n t i n u i n g development and implementation. In r e v e r s e a model would g i v e d i r e c -t i o n to the h e a l t h care manager de v e l o p i n g an i n i t i a t i v e . A model i s not the complete answer because models i n e v i t a b l y d e p i c t i d e o l o g i e s and t h e r e f o r e would probably be redesigned or a t l e a s t r e a d j u s t e d with changes i n government. A l f o r d has suggested t h a t l i t t l e has been w r i t t e n of the p o l i t i c a l processes which are p a r t of h e a l t h care 57 systems. Much more must be w r i t t e n i f t h e o r e t i c i a n s as w e l l as p r a c t i t i o n e r s are to b u i l d a u s e f u l body of knowledge f o r management. Managers of h e a l t h care Robert R. A l f o r d , H e a l t h Care P o l i t i c s , The U n i v e r s i t y of Chicago Press : Chicago, 1975, p. 15. 123 i n s t i t u t i o n s have a wealth of case study experience which should be committed to paper and used i n the development of theory and models. For the pres e n t i t i s not l i k e l y t h a t anything but i n c r e m e n t a l r e a c t i o n w i l l o ccur. 124 APPENDIX I COMMUNITY HEALTH CENTRES Over the p a s t s e v e r a l years c o n s i d e r a b l e a t t e n t i o n has been g i v e n to the community h e a l t h c e n t r e as a new e n t r y p o i n t to the d e l i v e r y system which would reduce the need f o r s i c k n e s s care through p r o v i d i n g b e t t e r f i r s t c o n t a c t (primary) medical c a r e , by p r o v i d i n g h e a l t h pro-motion a c t i v i t i e s and by p r o v i d i n g p r e v e n t i v e s e r v i c e s , a l l through an i n t e g r a t e d s e r v i c e c o n t r i b u t e d to by a l l h e a l t h and s o c i a l workers. There are problems to overcome be f o r e CHC can c o n t r i b u t e o p t i m a l l y to the h e a l t h care of Canadians. L e g i s l a t i v e steps would be necessary to a l l o w f u l l y i n t e g r a t e d p r a c t i c e among the d i s c i p l i n e s , payment systems must be developed, the CHC must be i n t e g r a t e d i n t o the o v e r a l l h e a l t h system and f i n a l l y , the p u b l i c would be r e q u i r e d to a d j u s t c u r r e n t p e r c e p t i o n s about the d o c t o r being the s i n g l e purveyor of h e a l t h c a r e . C r i c h t o n d e s c r i b e s the CHC as the c e n t r e of a system of communications which s o r t s out problems and channels, them. She sees the CHC as an attempt .to f i n d a d i f f e r e n t balance i n h e a l t h care away from the excesses of b i o -medical technology.''" Anne C r i c h t o n , Community H e a l t h Centres : H e a l t h Care O r g a n i z a t i o n s of the Future? (1973) p. 19. 125 A s p i n - o f f of a r e d u c t i o n i n the use of 'bio-medical technology' would be reduced use of acute care h o s p i t a l s and an e v e n t u a l readjustment of the number of acute care beds a v a i l a b l e . The concept of one e s t a b l i s h m e n t combining primary medical care and o r g a n i z e d p r e v e n t i v e s e r v i c e s was f i r s t formulated i n the r e p o r t of the C o n s u l t a t i v e C o u n c i l on M e d i c a l and A l l i e d S e r v i c e s meeting h e l d i n 1920 i n England. ' In Canada, some more r e c e n t major r e p o r t s have s p e c i -f i c a l l y recommended the e s t a b l i s h m e n t CHC. The Castonguay-2 3 Nepveu Report 1970, the Manitoba White Paper 1972, the 4 5 Foulkes Report 1973, and the Hastings Report. The Mustard Report i n the P r o v i n c e of O n t a r i o 1974 agreed t h a t CHC were a g o a l but t h a t they were not the immediate s o l u t i o n . The r e p o r t s t r e s s e d more c o n t r o l and p l a n n i n g i n the proposed r e o r g a n i z a t i o n but not n e c e s s a r i l y the CHC Quebec. Commission of I n q u i r y on H e a l t h and S o c i a l  Welfare. 1970 - 71. 3 Manitoba. White Paper on H e a l t h P o l i c y . J u l y , 19 72. 4 B r i t i s h Columbia. H e a l t h S e c u r i t y f o r B r i t i s h  Columbians, Report of Richard G. Foulkes to the M i n i s t e r of H ealth, December 1973. ^Canada. Department of N a t i o n a l H e a l t h and Welfare. The Community H e a l t h Centre i n Canada, 1972. 6 O n t a r i o . Report of the Health Planning Task Force, January 19 74, p.15. 126 Foulkes thought the CHC c o u l d be p a r t of an acute h o s p i t a l o p e r a t i o n which would al l o w c l o s e r e l a t i o n s h i p s 7 and s h a r i n g s e r v i c e s . Only two p r o v i n c e s have a c t u a l l y developed v e r s i o n s of the CHC separate from the h o s p i t a l . The Quebec government, a c t i n g upon the recommendations of the Castonguay-Nepveu Report, i s the o n l y government which has undertaken to r e s t r u c t u r e the p r o v i n c e ' s h e a l t h care d e l i v e r y system. There are three o p e r a t i o n a l l e v e l s i n t h i s r e s t r u c t u r i n g , the l o c a l h e a l t h c e n t r e , the community h e a l t h c e n t r e ( the g e n e r a l h o s p i t a l ) and the u n i v e r s i t y h e a l t h c e n t r e , a l l to be found o p e r a t i n g w i t h i n a s i n g l e h e a l t h r e g i o n . The new component of t h i s stepped d e l i v e r y system i s the l o c a l h e a l t h c e n t r e which o f f e r s primary care and ambulatory medical s e r v i c e s and b a s i c s o c i a l s e r v i c e s . The c e n t r e s are r e s p o n s i b l e f o r the h e a l t h of the e n t i r e p o p u l a t i o n i n the community (10 - 15,000) and f o r c o n t i n -u i t y of c a r e . M. Vigeoz-Suchon, a Montreal CLSC A d m i n i s t r a t o r , b e l i e v e s the ' r a i s o n d ' e t r e ' of the CLSC ( Centre L o c a l de S e r v i c e Communautaire ) i s p r e v e n t i v e a c t i o n ; t h a t p the major mandate i s not to assume g e n e r a l c u r a t i v e c a r e . Foulkes I I , 1-3 g Michele Vigeoz-Suchon, "Thoughts on C e r t a i n Aspects of the 'Mission' of the LCSC's", Canada's Mental H e a l t h , V o l . 25 (December 1977) p.8. 127 Begin w r i t e s t h a t CLSC r e f u s e to be l o c a l h e a l t h c e n t r e s d e f i n i n g f o r themselves a p o l i t i c a l r o l e t h a t i s aimed a t ' c o n s c i o u s n e s s - r a i s i n g ' r e g a r d i n g e c o l o g i c a l , s o c i a l and 9 economic c o n d i t i o n s as the f i r s t step to h e a l t h promotion. The r e s p o n s i b l e M i n i s t r y seems to d i f f e r w i t h t h i s i n t e r -p r e t a t i o n of the CLSC's m i s s i o n . Diagnosis and primary medical and s o c i a l treatment, s c r e e n i n g and e d u c a t i o n programs are the intended major m i s s i o n . Community a c t i o n i s seen as a support a c t i v i t y o n l y . At present, i n B r i t i s h Columbia, there are four f u n c t i o n i n g Community Human Resource and H e a l t h Centres (CHRHC) which began as p i l o t p r o j e c t s d u r i n g the NDP government of 1972-76. 1 (^ Two m i n i s t r i e s , H e a l t h and Human Resources, agreed to develop the concept of a community centre t o g e t h e r . The e n a b l i n g l e g i s l a t i o n was brought forward by the M i n i s t r y of Human Resources r a t h e r than the M i n i s t r y o f H e a l t h because h e a l t h s e r v i c e s o f f e r e d i n a community h e a l t h c e n t r e were much more c o n t r o v e r s i a l than s o c i a l s e r v i c e s . A Development Group was e s t a b l i s h e d i n c l u d i n g people from the Foulkes s t a f f and from the M i n i s t r y o f H e a l t h . 1 1 9 Clermont Begin, "Can the HC's and the LCSC's C o - e x i s t ? " , Canada's Mental"Health, V o l . 25 (December 1977) p. 11. " ^ H i s t o r y of the Development Group was by p e r s o n a l communication from Paul P a l l a n . "^Implementation of recommendations found i n the Foulkes Report began before the r e p o r t ' s p u b l i c a t i o n . 128 I t was to develop the p r i n c i p l e s o f o p e r a t i o n f o r a number of c e n t r e s around the pr o v i n c e which would be e s t a b l i s h e d as p i l o t p r o j e c t s . The M i n i s t r y o f H e a l t h r e c e i v e d r e q u ests from many communities wi s h i n g to be the s i t e f o r a p i l o t p r o j e c t . Only f i v e were chosen due to c o s t i m p l i c a t i o n s They were chosen because o f p a r t i c u l a r c h a r a c t e r i s t i c s which would le n d themselves to e v a l u a t i n g the concept o f CHRHC i n a v a r i e t y of s e t t i n g s . Queen C h a r l o t t e s had a d e f i n e d p o p u l a t i o n , James Bay was the urban s e t t i n g , Houston and Gran I s l e were newly d e v e l o p i n g i n d u s t r i a l towns and Grand Forks where the do c t o r s had shown i n t e r e s t i n e s t a b l i s h i n g a new d e l i v e r y system. Informal a d v i s o r y groups were formed i n each community and acted to determine community needs and to develop a submission to the M i n i s t r y u n t i l e n a b l i n g l e g i s l a t i o n was passed i n 1975. Thereupon formal Boards were e l e c t e d by the community i n m u n i c i p a l e l e c t i o n s . Once the community's submission had come forward the Development Group developed the r a m i f i c a t i o n s . o f the implementation. When accepted, the Group worked with the. community. A major problem was the h i r i n g o f s t a f f . The h e a l t h d i s c i p l i n e s a l r e a d y f u n c t i o n i n g i n the community were to be i n t e g r a t e d i n t o the CHRHC through seconding arrangements. Other necessary s t a f f would be employed d i r e c t l y by the Centre. The seconding arrangement p l a c e d i n t o q u e s t i o n 129 the l i n e s of r e s p o n s i b i l i t y to be f o l l o w e d . There was o u t r i g h t disagreement with the ph i l o s o p h y o f the concept and there was f e a r of l o s i n g c o n t r o l on the p a r t of the e x i s t i n g agencies. Due to the h o s t i l i t y which f i n a l l y developed among the d o c t o r s and the s h o r t tenure of the NDP government the c e n t r e i n Grand Forks never began. Once the S o c i a l C r e d i t p a r t y r e t u r n e d to government the Development Group was r e q u i r e d to g i v e reason why the CHRHC p r o j e c t should proceed. The government argued i t was d u p l i c a t i o n of s e r v i c e s . The group argued t h a t the investment had a l r e a d y been s i z e a b l e , t h a t s e r v i c e s i n the community had improved s i g n i f i c a n t l y and t h a t the government c o u l d expect a p u b l i c o u t c r y i f the c e n t r e s were d i s c o n t i n u e d . The Development Group was giv e n 12-18 months to conduct an e v a l u a t i o n o f the c e n t r e s . An independent a u d i t committee composed of r e p r e s e n t a t i v e s of the RNABC, BCMA, BCASW, M i n i s t r y o f Hea l t h , M i n i s t r y o f Human Resources, the Chairman was a member of the F a c u l t y o f Commerce a t the U n i v e r s i t y of B r i t i s h Columbia, was s t r u c k and the r e p o r t submitted to the Deputy M i n i s t e r s of Hea l t h and Human Resources, February 28, 1977. The a u d i t committee was to eval u a t e the degree to which the goals of CHRHC had been met. These goals were 130 \ 1. f o s t e r c o o r d i n a t e d and i n t e g r a t e d s e r v i c e s 2. be p r e v e n t i v e i n focus 3. have community involvement i n o p e r a t i o n and p l a n n i n g 4. be c o s t e f f e c t i v e The a u d i t committee's task was d i f f i c u l t because of the very s h o r t h i s t o r y of the c e n t r e s . The committee's r e p o r t c o u l d not be d e f i n i t i v e but d i d s t a t e t h a t a l l c e n t r e s were making good progress, t h a t the e x i s t i n g f o u r should be made a permanent p a r t o f the d e l i v e r y system, t h a t others should be s t a r t e d and t h a t medical, s o c i a l s e r v i c e s and p u b l i c h e a l t h f a c i l i t i e s i n urban areas should be s i m i l a r l y c o o r d i n a t e d . In i n v e s t i g a t i n g the c o s t e f f e c t i v e n e s s g o a l the committee found t h a t the communities wi t h c e n t r e s were spending more f o r primary care than other s i m i l a r communities. The i n c r e a s e was approximately 8-10% per c a p i t a . On the other hand the committee found a 20-30% decrease i n h o s p i t a l u t i l i z a t i o n . The committee recommended 12 continued e s t a b l i s h m e n t of community h e a l t h c e n t r e s . I t would appear these r e s u l t s were unexpected and unwelcomed by the government. As a consequence the e v a l u a t i o n p e r i o d continues w i t h no t e r m i n a t i o n date and no a c t i v i t y . No more c e n t r e s have been developed and B r i t i s h Columbia. Report of the A u d i t on Community Human Resources and Hea l t h Centres i n B r i t i s h Columbia, February 28, 1977. 131 the e s t a b l i s h e d c e n t r e s are w e l l a b l e to manage t h e i r own a f f a i r s through the e l e c t e d Boards. The Development Group was g i v e n d i f f e r e n t a c t i v i t i e s and the c e n t r e s were t r a n s f e r r e d to the S p e c i a l Care S e r v i c e s D i v i s i o n i n 1979. The remaining f o u r c e n t r e s are funded through g r a n t s , one from Human Resources and one from H e a l t h . These grants pay f o r d o c t o r s s a l a r i e s as w e l l r a t h e r than the us u a l arrangement of payment t o doc t o r s from M e d i c a l S e r v i c e s d i r e c t l y . Other communities, e.g. Pender Harbor, Lumby, Courtnay have evolved Community He a l t h and Human Resource Centres under the Community Resources Board l e g i s l a t i o n . These c e n t r e s are c o n t r o l l e d and or g a n i z e d as s o c i e t i e s , „ s t a f f o f the c e n t r e s cooperate w i t h e x i s t i n g community h e a l t h and s o c i a l workers. The committee s t a t e d t h a t these attempts to i n t e g r a t e s e r v i c e s were la u d a b l e but they d i d not achieve the same q u a l i t y as the p i l o t CHRHC and t h a t government support o f the nature o f the Develop-ment Group was e s s e n t i a l to s t a r t up. 132 X! H Q IS W CU PM < o o -t o o i z z m H H C c c < i i 3 O O cn z m zz\ c o 3 33 C n z >ro M l z 1 c 2 2 —i > i cn O m z o University, of British Coiumb'a ISchoot'Of-'Nursing i R *• * I -* ' •*" * iv.x *. i ***** 1 W J 3 ^ * ««i t * t t ' * f V ' i I PROGRAMME O B J E C T I V E S The first objective ot this programme Is to prepare nurses to function in expanded roles In primary health care in British Columbia. Through the programme, efforts will be made to evaluate the effects of nurses functioning in expanded roles in the delivery of primary health care and to evaluate patient attitudes toward care received from nurses In this role. A second objective is to teach physician and nurse associates to work together effectively in the delivery of primary health care. PROGRAMME SPONSORSHIP The Provincial Government of British Columbia has funded The University of British Columbia School of Nursing for two years to implement and evaluate this programme. The Millbank Foundation has also provided support for interprofessional workshops. Programme implementation will be through the Division of Continuing Education in the Health Sciences, University of British Columbia. The programme is endorsed by the Registered Nurses Association of British Columbia and by the College of Physicians and Surgeons of British Columbia. PROGRAMME S T R U C T U R E Three types of educational offerings are planned: (1) supplementary programmes of 2 to 5 days duration for nurses already in expanded roles or those-having had equivalent experience and needing toHfjTI- gaps in their background; (2) a preparatory programme of approximately 12 weeks for nurses wishing to work in the field of primary health care and needing a general introduction to community practice; and (3) interprofessional programmes of approximately 3 to 5 days duration for physicians and nurse associates already working together or for those wishing to-en-ter- this type of practice and focussing on team work ,§1. Paul 's h o s p i t a l Appendix ' I ' V A N C O U V E R 1. B . C . APPENDIX I I I A p r i l 18, 1977 Mr. J.G. Clenwright, Associate Deputy M i n i s t e r , H o s p i t a l Programs, Department of Health, Parliament Buildings,-V i c t o r i a , B.C., V8V 1X4 Dear Mr. Clenwright, r e t Ambulatory Care Services We have witnessed in the past ten years an enormous upswing of s u r g i c a l , day • c-'ire i n B r i t i s h Coluribia 122k ing I t possible to t r e a t an ever increasing nu;-ber of patients on a day cr.re basis. Through t h i s systera i t i s now possible to keep numerous p a t i e n t s out of i n - p a t i e n t beds which r e s u l t s i n s i g n i f i c a n t ; savings and b e n e f i t s . At St. Paul's H o s p i t a l the number of s u r g i c a l day care cases during 1976 increased to 2,247. '' . . . . . . BCHP has promoted g r e a t l y the development of ambulatory care prog rasas s not only i n s u r g i c a l day' care but also In p s y c h i a t r i c and d i a b e t i c clay care, and i n the treatment of p a t i e n t s requiring r e n a l d i a l y s i s e t c. In our opinion a number of r a d i c a l p a t i e n t s who are presently admitted to In-p a t i e n t beds could be cared for on a cay care b a s i s . Ambulatory care a l l o c s an intermediate l e v e l of care between o f f i c e p r a c t i c e s and hospital'admissions.- • Already during the'BCMC era St. Paul's Hospital.was assigned a very s i g n i f i -cant r o l e In o f f e r i n g ambulatory care In the Greater Vancouver area. - V.'ith t h i s i n mind the Cut Patient Department was renovated allowing a. separate area for r s d i c l cay cr.re p a t i e n t s which would ~ake i t possible to introduce a programme for i n v e s t i g a t i o n and treatment of these kinds of p a t i e n t s , which are e i t h e r -ncv admitted as an In-patient or treated i n other areas scattered a l l over the h o s p i t a l . The area Is now c a l l e d the "Ambulatory Care Department" and the reno-vations have j u s t been completed but the area reserved f o r medical cay care i s s t i l l empty. Medical day care p a t i e n t s would d i f f e r from s u r ^ i c n l day care i n that they would not be r e q u i r i n g a general anaesthesia f o r the c e r t a i n procedures c a r r i e d out. St. Paul's H o s p i t a l Is r o s t anxious to explore and develop ambulatory care r.itVicds of t r e a t i n g p a t i e n t s , not with the prima goal of a t t r a c t i n g r>ore patients but to provide a more e f f i c i e n t type of care at a lover cost and, at the sa~2 tim develop a system of coping e f f e c t i v e l y with the c o n t i n u a l l y Increasing workload demand over which we have l i t t l e or no c o n t r o l . 1 T/T Ihr. J.G. Cler.vrlght, A s s o c i a t i o n Deputy M i n i s t e r A p r i l 18, 1977 - 2 -A-i Lh.'.rc i s , a t p r e s e n t , no budgotry p r o v i s i o n f o r funding o f a d d i t i o n a l ar.'>-ii.:>tory c-i^ct s e r v i c e s which va b e l i e v e arc f e a s i b l e , and as have a f a c i l i t y capcble o f ncconnodatlng r.uch programs, with c l n i m a l a d d i t i o n a l o p e r a t i n g c o ^ t s t o our e x i s t i n g s e r v i c e s , ue wish to propose the f o l l o w i n g to yo-j: 1) That S t . P a : : l r s , j o i n t l y with bCHP and GVRDH develop a p i l o t anbulatury care p r o j e c t at St. Paul's H o s p i t a l Co: (a) determine the f e a s i b i l i t y of the v.irlous type:3 of serv'iccs *-'?. v i s u a l i s e f o r «?ay care x ind • fchp i-'.p.'ic t of s-uccv a. s e r v i c e ^ \;.'; ---. . on current ir.—pitl-'int mo'i-cei • knc\ ' r e l a t e d pro^ra^r-jus; (b) i d e n t i f y c o s t s p.nd b e n e f i t s ; . (c) i d e n t i f y nn a p p r o p r i a t e method f o r funding of approved and. _• f.•:."«nible c e r v i c e s ; (c) c.-tr.blish c r i t e r i a 'or the- pl-nnln;; of th.i a-bv.l.-itory Oi i r e f a c i l i t y cs propcred In the Phase I redevelopment p r o j e c t . • 2) That o f f i c i a l s f r c T ::CH? nnd ^YRrH ven; 'vith ths s t a f f at St. ?AU1*S H o s p i t n l co d-vtcrr.inc;: ( i ) o b j e c t i v e s o f the p i l o t p r o j e c t ; (b) s p e c i f i c s e r v i c e s , or procedures, to be provided w i t h i n the f a c i l i t i e s a v a i l a b l e ; Cc) th2 o p e r a t i n g costs and the nethod of funding; (d) p o l i c i e s f o r operating the prcgrar-.es; Co) ir.pler.entation and e v a l u a t i o n . A j;rc.-:t deal of thought has been given to £j-bul=:tory core prcgra;..:ees by the re-;heirs of c u r n s d i c a l «nd h o s p i t a l s t a f f . A synopsis of e x i s t i n g arrbulatory c're c e r v i c e s end an I n d i c a t i o n of wh.^ t hinds of c e r v i c e s c o u l d be provided i a attached <~3 Appendix "A**., 135 3 / I t i s r a t h e r u n l i k e l y that even wi t h the r e d u c t i o n of beds the p a t i e n t demands w i l l change, though through t h i s approach to medical care we w i l l be able to take care o f those p a t i e n t s who do not need acute i n - p a t i e n t care. V7e do not v i s u a l i z e a s o - c a l l e d "added on s e r v i c e " . Ke j u s t want to maximize the o p p o r t u n i t y f o r d i a g n o s t i c and treatment s e r v i c e s on an Ambulatory Care b a s i s as an a l t e r n a t e to an i n - p a t i e n t mode of d e l i v e r y and w i l l o f f e r a high l e v e l o f c l i n i c a l s k i l l s , o f t e n o f an i n t e r - d i s c i p l i n a r y nature, to a multitude o f p a t i e n t s who must be i n v e s t i g a t e d and/or t r e a t e d . - The S t a f f at St. Paul's H o s p i t a l has spent a g r e a t d e a l o f t i n e i n planning a v i a b l e programme f o r t h i s type of s e r v i c e . In your l e t t e r you ask f o r more in f o r m a t i o n about the number o f admissions, the p r o j e c t e d number of p a t i e n t days and the a n t i c i p a t e d savings t h a t could be the r e s u l t of such a Medical Day Care Programme. The impact on i n - p a t i e n t load i s estimated as f o l l o w Ke a n t i c i p a t e that we w i l l be able t o r e p l a c e 10 acute beds a f t e r we have introduced the s e r v i c e based on (1) 93% occupancy which has. been our experience f o r the year 1976 and (2) our length-of-stay.-for medical, patients, of .11, days. . We .feel t h a t t h i s , s e r v i c e can o b v i a t e t J ^ - a d m i s s i o n of 300 or more p a t i e n t s "with the savings o f approximately 3400 p a t i e n t days. With the l o s s of 10 acute beds we can v i s u a l i z e a s t a f f r e d u c t i o n of: R.N. 3.5 $52,780. P.N. 1.5 19,296. U n i t C l e r k 1.0 11,160. Aide . 1.0 10,740. 20% for f r i n g e b e n e f i t s should be added to t h i s amount which bri n g s i t t o a t o t a l of $112,771. The e s t i m a t i o n o f cost r e d u c t i o n i n medical s u p p l i e s and drugs amounts t o $26,220. These cost f i g u r e s are based on the 1977 s a l a r y r a t e . The t o t a l c o s t reduction f o r s a l a r i e s , medical s u p p l i e s and drugs i s $138,991. These are our estimates of c o s t r e d u c t i o n i n the d i r e c t component o f care at the bedside of the p a t i e n t . I t i s im-p o s s i b l e to c a l c u l a t e the i n d i r e c t cost reduction with the decreased number o f beds. We estimate, f o r instance, the cost o f p o r t e r i n g a p a t i e n t from the Ambulatory Care Unit to Radiology, and Labora-t o r i e s and other departments, w i l l be o f f - s e t i n p o r t e r i n g the p a t i e n t 3 138 who otherwise would have been admitted i n one o f the i n - p a t i e n t beds p r i o r to t h e reduction i n bed numbers. S t a t i s t i c a l Workload P r o j e c t i o n T h i s programme i s a n t i c i p a t e d to commence on January 2, 1978. Ke expect to s t a r t with 3 to 4 p a t i e n t s per day which w i l l g r a d u a l l y i n c r e a s e to 10 p a t i e n t s or more a day. An estimated 1500 p a t i e n t s w i l l be admitted to the Medical Day Care Unit i n 1978. Proj e c t e d Operating Cost of New Service _ This can be d i v i d e d thus - (a) Operating Cost and (b) C a p i t a l Cost. Operating Cost: Nursing 1.6 RN Un i t Clerk 1.0 Pharmacist 0.5 C l e r i c a l S t a f f 0.4 (Admitting Dept.) C l e r i c a l S t a f f 0.2 (Med. Records Dept.) • : T o t a l s a l a r i e s - -$61,238. •• •. •-- . -- * " • . Added to t h i s w i l l be the cost of p e r q u i s i t e s amounting t o 20% which amounts t o $73,485. Trays and supplies at $10.00 each = ,$15,000. Drugs at $5.00 per p a t i e n t = 7,500. Die t a r y s e r v i c e s 10 meals/day at $2.50 = 6,250. Forms and Sta t i o n a r y = 1,000. This amounts t o $29,750. T o t a l operating costs are estimated at $103,235. based on 1977 s a l a r y r a t e s . C a p i t a l Cost The c o s t of equipment necessary f o r the opening of the Medical Day Care U n i t t o t a l s $12,030.(see Appendix I I I ) . Please f i n d enclosed the f u n c t i o n a l program developed f o r the department and the p o l i c y f o r the operation of the C l i n i c (see Appendix IV). A system to assess the q u a l i t y of care and to evaluate the e f f e c t i v e n e s s of the programme w i l l be introduced when the program 4 139 - 4 -i s i n i t i a t e d . We w i l l provide you with a report of t h i s e v a l u a t i o n as w e l l as the s t a t i s t i c s at the end of the year and we s i n c e r e l y hope that i t w i l l be a s u c c e s s f u l p r o j e c t . We would request your comments and e a r l y approval f o r the 2-iedical Day Care Services so t h a t we may proceed with the h i r i n g of the S t a f f p r i o r to i n t r o d u c t i o n of t h i s programme on January 2, 1978 Yours s i n c e r e l y , H.D. McDonald, M.D. Executive D i r e c t o r . e n c l s . cc.: Dr. C. Ballam Medical D i r e c t o r Finance D i r e c t o r D i r e c t o r of Uursing. /CJM 140 -2-aged person can f u n c t i o n independently f o l l o w i n g d i s c h a r g e . This r e q u i r e s h e a l t h Eaintenance i n s t r u c t i o n i n h o s p i t a l , as w e l l as h e a l t h maintenance amublatory c a r e f a c i l i t i e s to prevent or minimize acute e p i s o d i c i l l n e s s so that they can f u n c t i o n i n the community and enjoy l i f e to the maximum degree p o s s i b l e . Such programs are d i a b e t i c c l i n i c s , pacemaker c l i n i c s , h i g h b l o o d pressure c l i n i c s , a r t h r i t i c c l i n i c s and g e r i a t r i c c l i n i c s . 3. The socio-economic p op ulatj-on _ t n e area served by St. P a u l ' s H o s p i t a l has a l a r g e number of unemployed, drug a d d i c t s , a l c o h o l i c s and a high i n c i d e n c e of p s y c h i a t r i c i l l n e s s . Programs and f a c i l i t i e s must be provided w i t h i n the h o s p i t a l not only t o manage the i l l n e s s e s of these i n d i v i d u a l s but t o attempt to r e t u r n them to a more p r o d u c t i v e l i f e . The primary method of p r o v i d i n g f o r these types of community needs w i l l be through the ambulatory cere program, p a r t i c u l a r l y i n the g e n e r a l p r a c t i c e c l i n i c and the m u l t i - d i s c i p l i n a r y c l i n i c s where much of the care can best be provided by nurses and other h e a l t h workers s u p e r v i s e d by a p h y s i c i a n . I f the o b j e c t i v e s of ambulatory care s e r v i c e s are to be achieved - i . e . , emphasis on h e a l t h maintenance and p r e v e n t i o n of i l l n e s s ; p r o v i s i o n of a l t e r n a t e d i a g n o s t i c end treatment s e r v i c e s f o r p a t i e n t s not r e q u i r i n g i n - h o s p i t a l admission - then such s e r v i c e s must be c a r e f u l l y o r g a n i z e d and d i r e c t e d . Of equal importance, r e s u l t s must be evaluated i n an on-going manner to ensure t h a t o b j e c t i v e s are being reached and t h a t we are not simply adding "another t a i l to the h e a l t h d e l i v e r y system dog." St. P a u l ' s was t h e r e f o r e d e l i g h t e d to read i n the Mr. end Mrs. P. A. Woodward's Foundation Annual Report that the Foundation Funds would be " d i r e c t e d to very s p e c i a l a c t i v i t i e s which cannot end should not be f i n a n c e d from government or other p u b l i c funds." I t i s our b e l i e f t h a t the new cost sharing formulas between f e d e r a l and p r o v i n c i a l governments w i l l remove the c o n s t r a i n t s which have p r e v i o u s l y prevented e i t h e r the establishment or e v a l u a t i o n of t h i s type of program. However, as i n the past, the e a r l y r e a l i s a t i o n i s only achieved through the s t i m u l u s of p r i v a t e funding, e.g., i n t e n s i v e care and coronary care u n i t s , and the G.I. l a b . St. P aul's hopes that the development of a major Ambulatory Care Centre l i e s w i t h i n the Terms of Reference f o r grant support o u t l i n e d by the rouneation. We t h e r e f o r e request t h a t the Mr. and Mrs. ?. A. Woodward's Foundation give approval i n p r i n c i p l e to a grant of $30,000 per annum f o r a p e r i o d of three years to support a q u a l i f i e d d i r e c t o r of ambulatory care s e r v i c e s vhcse f u n c t i o n s s h a l l be to ^ a n i z e , d i r e c t and evaluate the development of exemplary ambulatory cave s e r v i c e s at St. Paul's H o s p i t a l . " - such approval i n p r i n c i p l e being contingent upon -144 -3-1. the h o s p i t a l ' s a b i l i t y to a t t r a c t the r i g h t person to c a r r y out these d u t i e s , 2. w r i t t e n assurance to the Foundation from B. C. H o s p i t a l Programs that i t concurs i n the development of a major Ambulatory Care Centre at S t . Faui's H o s p i t a l . The program thus developed w i l l serve as a model ambulatory care s e r v i c e and t e a c h i n g u n i t f o r development i n other centres i n the p r o v i n c e . Your c o n s i d e r a t i o n of t h i s request i s most a p p r e c i a t e d . Yours s i n c e r e l y , H. D. McDonald, M.B. E x e c u t i v e D i r e c t o r HJLiMcD/bws 145 : Soc i a l Credit is based on four bas ic pr inc ip les . These pr inc ip les ; are our pol i t ica l gu ide l ines . These pr inc ip les show how and where i we stand as a po l i t i ca l party, and how we believe as members of the party. -For your informat ion, they are as f o l l ows : 1 . The indiv idual is the most important factor in organ ized ! soc iety and as a div inely-created ' being with both sp i r i tua l and ; phys ica l potent ia ls and needs, has certain ina l ienable rights wh ich ! must be respected and preserved. 2. The major funct ion of democrat ic government in organ ized soc iety is to secure for the people the results they want from the management of their pub l ic affairs as far as s uch results are physical ly" and moral ly right. 3. Secur ity with f reedom. Mater ia l security a lone is not enough. 4. Whatever is phys i ca l l y pos s ib le and des i rable and moral ly right can and shou ld be made f inanc ia l ly pos s ib le . Soc ia l Credit is unalterably opposed to c o m m u n i s m , f a s c i sm, and a!! other forms of s o c i a l i sm wh ich make the ind iv idua l c i t i zen subservient to the State. S oc i a l Credit recognizes the fami ly as the bas ic unit of soc iety and regards the sanct i ty of the home as fundamenta l . Soc ia l Credit means the credit of our soc iety to have and to use the g o o d s and services that we as a nation are able to produce under a compet i t ive free enterpr ise supply and demand economy. S j c i a ! Credit believes in the pr inc ip le of helping people to help ! themselves. I- We believe that a free e conomy, based on good moral p r inc ip les can provide a better way of l ife for those in need. We believe that one cannot have f reedom without respons ib i l i ty . • , 5 SOURCES CONSULTED CHAPTER I I B r i t i s h Columbia. H e a l t h S e c u r i t y f o r B r i t i s h Columbians, Report of Ri c h a r d G. Foulkes to the M i n i s t e r o f H e a l t h December, 19 73. Canada. Royal Commission on Health S e r v i c e s , 2 V o l s . Ottawa, 1964 . . Task Force Reports on the Cost o f H e a l t h S e r v i c e s i n Canada, 3 V o l s . , Ottawa, 196 9. . Task Force on O p e r a t i o n a l E f f i c i e n c y , V o l . I I , 1969. . Task Force on Beds and F a c i l i t i e s , V o l . I I , 1969. _. Department of N a t i o n a l Health and Welfare, The  Community Health Centre i n Canada, Ottawa, Information Canada, 1972 _. (Boudreau) Department of N a t i o n a l H e a l t h and Welfare, Report o f the Committee on Nurse P r a c t i t i o n -e r s , Ottawa, 1972. . (Grasset) Department of N a t i o n a l H e a l t h and Welfare, A t t a c h i n g a V i s i t i n g Nurse t o a Group M e d i c a l P r a c t i c e  to Change H o s p i t a l Stay P a t t e r n s , NHG 610-20-6, June 19 75. Chambers, L.W. and West, A.E. "The S t . John's Randomized T r i a l of the Family P r a c t i c e Nurse : H e a l t h Outcomes of P a t i e n t s . " I n t e r n a t i o n a l J o u r n a l o f Epidemiology, (7, 1978) . Lees, R.E.M. " P h y s i c i a n Time Saving by Employment of Expanded-Role Nurses i n Family P r a c t i c e " , Canadian  Me d i c a l A s s o c i a t i o n J o u r n a l , ( A p r i l 1973). MacStravic, Robin E. "A Case For a H o s p i t a l Census V a r i a t i o n and Bed Needs Formula". American J o u r n a l of H e a l t h P l a n n i n g , ( A p r i l 1978). Manitoba. White Paper on Health P o l i c y , J u l y , 1972. O n t a r i o . Report o f the Hea l t h P l a n n i n g Task Force, January,1974. 148 Quebec. Commission of I n q u i r y on Health and S o c i a l Welfare, 1970-71. S p i t z e r , W.O. e t a l , "The B u r l i n g t o n Randomized T r i a l o f the Nurse P r a c t i t i o n e r " . The New England J o u r n a l of Medicine, (January 31, 1974) . CHAPTER I I I Bain, S t a n l e y and Johnson, Susan. "Use and Abuse of H o s p i t a l Emergency Departments", Canadian Family  P h y s i c i a n , (May, 1971) . Begin, Clermont. "Can the HC's and the LCSC 1s C o - e x i s t ? " , Canada's Mental H e a l t h , V o l . 25 (December 1977). B r i t i s h Columbia..Health A s s o c i a t i o n , E x e c u t i v e Committee of A d m i n i s t r a t o r s ' S e c t i o n , "A Report on Day Care  S e r v i c e s i n B r i t i s h Columbia", p u b l i s h e d by BCHA : Vancouver, 19 71. B r i t i s h Columbia. Department of Hea l t h , The B r i t i s h Columbia C l a s s i f i c a t i o n o f Types of He a l t h Care, September, 1973. _. He a l t h S e c u r i t y f o r B r i t i s h Columbians, Report o f Richard G. Foulkes to the M i n i s t e r o f Health, December, 1973. . M i n i s t r y o f Hea l t h , Annual Report, 1974 . Department o f He a l t h , Ambulatory Care S e r v i c e s i n the BCMC Progress Report, June 10, 1975. . M i n i s t r y of Hea l t h , Report o f the A u d i t Committee on Community Human Resources and Hea l t h  Centres i n B r i t i s h Columbia, February 28, 1977. . M i n i s t r y of Hea l t h , I n t r o d u c t i o n to the Program f o r Long Term Care, January 1, 1978. . M i n i s t r y of He a l t h , Home Care Program Manual, 19 79 Care Program, 1979 M i n i s t r y of He a l t h , Annual Report, Home 79/10, March 2, 19 79. M i n i s t r y o f Hea l t h , C i r c u l a r L e t t e r , 149 B r i t i s h Columbia. M i n i s t r y of Finance, A New F i n a n c i a l A d m i n i s t r a t i o n A c t , D i s c u s s i o n Paper, August, 1980. Canada. M i n i s t r y o f H e a l t h and Welfare, The Community  Hea l t h Centre i n Canada, Report o f the Community Hea l t h Centre P r o j e c t to the Conference o f Health M i n i s t e r s , 1972. Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n Survey Program For Ambulatory Care Centres, General G u i d e l i n e s , September 16, 1980. "Convention Reports". H o s p i t a l s , October 1, 1978, 128. C r i c h t o n , Anne. Developing a More E f f e c t i v e P o l i c y For The Care o f Long Term P a t i e n t s , Read a t the 19 75 Confer-.ence o f the Canadian P u b l i c H e a l t h A s s o c i a t i o n (mimeograph). C u g l i a n i , Anne, "Patterns o f H o s p i t a l Based Ambulatory Care", S o c i a l Science and Medicine, V o l . 12, 55-8. Davenport, H a r o l d T.; Shah, Chandrakant, P.; and Robinson, G e o f f r e y C. "Day Surgery f o r C h i l d r e n " . Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , (September 4, 1971), 498-99. Greater Vancouver Regional H o s p i t a l D i s t r i c t , Report o f  the Day Care F a c i l i t i e s Study Group, p u b l i s h e d by GVRHD : Vancouver, February, 1973 . Report o f the Ambulatory Care Study Committee, Vancouver, 19 76. Hart, Peter F. MD. "Primary Care : The H o s p i t a l Perspec-t i v e " , H o s p i t a l A d m i n i s t r a t i o n i n Canada, (February, 1976), 16. Hepner, James 0., Hepner, Donna M., The H e a l t h - S t r a t e g y  Game. S t . Lo u i s : C.V. Mosby Company, 19 73. "Is Emergency Abuse a Problem?" Health Care, January 19 81. "Ottawa to Promote Improved L i f e s t y l e - Lalonde T e l l s CHA". H o s p i t a l A d m i n i s t r a t i o n i n Canada,(July 1975), 6. School o f Hea l t h A d m i n i s t r a t i o n , "Community He a l t h Centres", U n i v e r s i t y o f Ottawa, January 1972. (mimeographed) Somers, Anne R., H e a l t h Care i n T r a n s i t i o n : D i r e c t i o n s  f o r the Fu t u r e . Chicago : H o s p i t a l Research and E d u c a t i o n a l T r u s t , 1971. 150 S p i e r s , Maurice. Techniques and P u b l i c A d m i n i s t r a t i o n , Fontana, 1975. Swanson, Dr. A.L., "Report From the Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n " , Dimensions i n H e a l t h S e r v i c e , (November 1980), 36. Tager, Mark and Jennings, C h a r l e s , " H o s p i t a l s Now Are D i s c o v e r i n g Wellness", S e a t t l e Times, February 10,1980. Wallace, J.D. MD. " H o s p i t a l s and New P e r s p e c t i v e s i n Heal t h Care", H o s p i t a l A d m i n i s t r a t i o n i n Canada, (March 1976), 18. Young, V a l e r i e and Ro m i l l y , Lorna, "New Models i n Ambula-t o r y Care", Dimensions i n Health S e r v i c e , (June 1981). CHAPTER V A l f o r d , Robert R. He a l t h Care P o l i t i c s , Chicago : The U n i v e r s i t y o f Chicago Press, 1975. B r i t i s h Columbia. M i n i s t r y o f H e a l t h Newsletter, No. 1, November 30, 1978. Marmor, T.R. The P o l i t i c s o f Medicare. Chicago : A l d i n e P u b l i s h i n g Co., 1973. R u s s e l l , Frances, Consider B.C. Without Medicare, Vancouver Sun, J u l y 1976. Warham, Joyce. "Notes on Pl a n n i n g i n the Context of S o c i a l P o l i c y " , U n i v e r s i t y o f B r i t i s h Columbia, Department of H e a l t h Care and Epidemiology, January 1974. (mimeographed) CHAPTER VI Aucoin, Peter, "Pressure Groups and Recent Changes i n the Policy-making Process" i n Pressure Group Behavior i n  Canadian P o l i t i c s , E d i t e d by A. Paul Pross, McGraw-H i l l Ryerson S e r i e s i n Canadian P o l i t i c s , 1975. 151 Bennett, James E. and Krasny, Jacques, "Health Care i n Canada, A S e r i e s on the Nation's H e a l t h " . R e p r i n t from the F i n a n c i a l Post, March 26 - May 7, 1977. Boulding, Kenneth E., "The Boundaries of S o c i a l P o l i c y " . S o c i a l Work, January 1967. Browne, John, Summary of Recent Major Stud i e s o f H e a l t h Care i n Canada, Department of H e a l t h A d m i n i s t r a t i o n , U n i v e r s i t y of Toronto f o r the Canadian C o l l e g e of H e a l t h S e r v i c e E x e c u t i v e s . Dror, Yehezkel, "The P l a n n i n g Process : A F a c e t Design". i n A Reader i n P l a n n i n g Theory, E d i t e d by A. F a l u d i , Oxford : Pergamon Press, 19 73. E c k s t e i n , Harry, "Planning : The N a t i o n a l H e a l t h S e r v i c e " i n P o l i c y - M a k i n g i n B r i t a i n . E d i t e d by R i c h a r d Rose, Macmillan and Co., 1969. Friedman, John and Hudson, B a r c l a y , "Knowledge and A c t i o n : A Guide to P l a n n i n g Theory", American I n s t i t u t e of  Planners J o u r n a l , (January 1974), 2-16. Haeuser, P a t r i c i a , "Decision-Making S t r a t e g y U t i l i z i n g P r i o r i t y S e t t i n g and Program Data", J o u r n a l of  Health P o l i t i c s , P o l i c y and Law, (Spring 1980), 152-165. H a r r i s , B r i t t o n , "Planning Method : The S t a t e of the A r t " i n P l a n n i n g i n America : L e a r n i n g From Turbu- lence , E d i t e d by David R. Godschalk, American I n s t i t u t e of P l a n n e r s , Washington, D.C. 1974. , Foreword i n Decision-Making i n Urban Plan n i n g , E d i t e d by I r a M. Robinson, B e v e r l y H i l l s , C a l i f o r n i a : Sage P u b l i c a t i o n s , 1972. Hatcher, Gordon H., "Canadian Approaches to H e a l t h P o l i c y D e c i s i o n s - N a t i o n a l H e a l t h Insurance", American  J o u r n a l of P u b l i c H e a l t h , (September 1978), 881-8. Kahn, A l f r e d J . , "Formulation of P o l i c y , The Standing P l a n " from Theory and P r a c t i c e of S o c i a l P l a n n i n g , New York : R u s s e l l Sage Foundation, 1969, 130-4. K l e i n , Rudolf, " P o l i c y Problems and P o l i c y P e r c e p t i o n s i n the N a t i o n a l H e a l t h S e r v i c e " , P o l i c y and P o l i t i c s , V o l . 2, No. 3, 219-36. 152 Klarman, Herbert E., " N a t i o n a l P o l i c i e s and L o c a l Planning For Hea l t h S e r v i c e s " , MMRQ/Hea11h and  S o c i e t y , (Winter 1976), 1-28. Lindblom, C h a r l e s E., "The Science o f 'Muddling Through'", P u b l i c A d m i n i s t r a t i o n Review, (Spring 1959), 79-88. - . . f " R a t i o n a l P o l i c y Through Mutual Adjustment" i n S o c i a l Change - Sources, P a t t e r n s and  Consequences, E d i t e d by A m i t a i E t z i o n i and Eva E t z i o n i - H a l e v y , New York : B a s i c Books, 1973. McQueen, Ronald J.C., "Governments and Long-Range Planning", H o s p i t a l A d m i n i s t r a t i o n i n Canada, (September 1976), 34. Mankin, D.C. and Glueck, W.F., " S t r a t e g i c P l a n n i n g " , H o s p i t a l and Hea l t h S e r v i c e s A d m i n i s t r a t i o n , (Spring 1977) . M a r t i n , Joseph R., Comprehensive He a l t h P l a n n i n g : A n a l y t i c Concepts, Blue Cross A s s o c i a t i o n , 2nd e d i t i o n , 1975. Mechanic, David, Future Issues i n Hea l t h Care, S o c i a l  P o l i c y and the R a t i o n i n g o f Med i c a l S e r v i c e s , New York : The Free P r e s s , 1979. Mic h a e l , Donald N., " S p e c u l a t i o n s on Future P l a n n i n g Process Theory" i n Pl a n n i n g i n America ; Le a r n i n g  From Turbulence, E d i t e d by David R. Godschalk, X American I n s t i t u t e o f Planners, Washington, D.C, 1974. Mott, B a s i l J.F., " P o l i t i c s and I n t e r n a t i o n a l P l a n n i n g " , S o c i a l Science and Medicine, V o l . 8, 271-3. Rein, M., " C o n f l i c t i n g Goals i n S o c i a l P o l i c y " , S o c i a l  P o l i c y , Random House, 1970, Chapter 13. R i t c h i e , Ronald S., An I n s t i t u t e For Research on P u b l i c  P o l i c y , A Study and Recommendations, Toronto : Information Canada, 1969. Roseman, C y r i l , "The Planner as P u b l i c H e a l t h Resource A l l o c a t o r " , J o u r n a l o f He a l t h , P o l i t i c s , P o l i c y  and Law, (Spring 1980), 33-80 153 S p e i r s , Maurice, Techniques Fontana, 1975, Chapter and P u b l i c V. A d m i n i s t r a t i o n , Tannen, L o u i s , "Health Planning as a Regulatory S t r a t e g y : A D i s c u s s i o n o f I t s H i s t o r y and Current Uses", I n t e r n a t i o n a l J o u r n a l of Hea l t h S e r v i c e s , V o l . 10, No. 1, (1980) , 115-132. CHAPTER VII Blomqvist, Ake. The Hea l t h Care B u s i n e s s , Vancouver : The F r a s e r I n s t i t u t e , 1979. Canada. Royal Commission on Hea l t h S e r v i c e s , 1964. . Canada's N a t i o n a l - P r o v i n c i a l H e a l t h Program f o r the 1980's, 1980 . Task Force Reports on the Cost of H e a l t h S e r v i c e s i n Canada, 3 V o l s . , 1969. . (Heagarty) H e a l t h Insurance, Report of the Ad-v i s o r y Committee on Hea l t h Insurance, Ottawa : King's P r i n t e r , 1943. . (Marsh) S o c i a l S e c u r i t y f o r Canada, Report o f the A d v i s o r y Committee on R e c o n s t r u c t i o n , Ottawa : King's P r i n t e r , 1943. Crichton,Anne, Community He a l t h Centres : He a l t h Care O r g a n i z a t i o n s o f the Future?, Ottawa : Information Canada, 1973. De t w i l e r , L l o y d F., " S o c i a l and F i n a n c i a l E f f e c t s of Heal t h Care Programs", H o s p i t a l A d m i n i s t r a t i o n i n  Canada, (December 1976), 13-16. Donnison, David, " I d e o l o g i e s and P o l i c i e s " , J o u r n a l of  S o c i a l P o l i c y , V o l . 1, No.2, 97-117. E l n i c k i , A., " S u b s t i t u t i o n o f O u t p a t i e n t f o r I n p a t i e n t -H o s p i t a l Care : A Cost A n a l y s i s " , I n q u i r y , (September 1976), 245-59. Farquhar, M., and E a r l e , V.E.R., "Day H o s p i t a l s : A Program Development P e r s p e c t i v e " , Dimensions i n  Health S e r v i c e , (January 1981), 16-18. 154 F e s t i n g e r , Leon, A Theory of C o g n i t i v e Dissonance, Evanston, I l l i n o i s : Row Peterson and Co., 1957. F r e i b e r g , Lewis, J r . , " S u b s t i t u t i o n o f O u t p a t i e n t Care f o r I n p a t i e n t Care : Problems and E x p e r i e n c e 1 , J o u r n a l of H e a l t h P o l i t i c s , P o l i c y and Law, (Winter 1979), 479-95. Greenberg, D a n i e l S., "Washington Report, The F r u s t r a t e d Reformers", The New England J o u r n a l of Medicine, (January 25, 1979), 211-12. H a l l , P. e t a l , Change, Choice and C o n f l i c t i n S o c i a l  P o l i c y , London : Heinemann, 19 75. Hepner, James 0. and Hepner, Donna M., The H e a l t h S t r a t e g y Game, S t . L o u i s : C V . Mosby Company, 1973. H o s p i t a l Based Ambulatory Care, A P o s i t i o n Paper, C o u n c i l of U n i v e r s i t y Teaching H o s p i t a l s , September 1980. I l l i c h , Ivan, M e d i c a l Nemesis : The E x p r o p r i a t i o n of  H e a l t h , New York : Pantheon, 1976. K l e i n , Rudolf, " P o l i c y Problems and P o l i c y P e r c e p t i o n s i n the N a t i o n a l H e a l t h S e r v i c e " , P o l i c y and P o l i t i c s , Vol.2, No.3, 219-36. Laframboise, H.L., "Health P o l i c y : Breaking the Problem Down Into More Manageable Segments", CMA J o u r n a l , (February 3, 1973) . , " Moving a Proposal to a P o s i t i v e D e c i s i o n : A Case H i s t o r y of the I n v i s i b l e Process", Reprinted from Optimum, Vol.4, No. 3, 1973. L e v i n , M a r t i n A., " P o l i t i c a l Dilemmas of S o c i a l P o l i c y -Making", JHHRA, (May 1979), 463-71. L i p s e y , R i c h a r d G., Sparks, Gordon, R. and S t e i n e r , P e t e r 0., Economics, San F r a n c i s c o : Harper and Row, P u b l i s h e r s , 1979. Luber, Raymond, F., "The Scope and Growth of P a r t i a l H o s p i t a l i z a t i o n " i n P a r t i a l H o s p i t a l i z a t i o n , E d i t e d by Raymond R. Luber, New York : Plenum Press, 1978. Lukes, Stephen, Power : A R a d i c a l View, Toronto : Macmillan, 1974. 155 Marmor, T.R., The P o l i t i c s o f Medicare, A l d i n e P u b l i s h i n g Co., 1973 Mic h a e l , Donald N., " S p e c u l a t i o n s on Future P l a n n i n g Process Theory" i n Pla n n i n g i n America : L e a r n i n g  From Turbulence, E d i t e d by David R. Godschalk, Washington : American I n s t i t u t e o f Planners P u b l i c a t i o n , 1974. M i t c h e l l , Fred H. J r . , " A n t i c i p a t i o n Versus R e s u l t s : An Approach to Improved Program F o r e c a s t i n g " , American J o u r n a l o f He a l t h P l a n n i n g , ( A p r i l 1978) O'Neal, E l l e n A., "A Framework f o r Ambulatory Care E v a l u a t i o n ' , J o u r n a l . o f Nursing A d m i n i s t r a t i o n , ( J u l y 1978) , 15-20 . Pross, A. Pa u l , "Input Versus Withinput : Pressure Group Demands and A d m i n i s t r a t i v e S u r v i v a l " i n Pressure  Group Behavior i n Canadian P o l i t i c s , E d i t e d by A. Paul Pross, McGraw-Hill Ryerson S e r i e s i n Canadian P o l i t i c s , 1975. Stewart, Walter, "The God That F a i l e d " , Macleans, January 24, 1977. T e i t z , M i c h ael B., "Toward a Responsive P l a n n i n g Methodology" i n P l a n n i n g In America : L e a r n i n g  From Turbulence, E d i t e d by David R. Godschalk, Washington, D.C. : American I n s t i t u t e of Planners P u b l i c a t i o n , 1974. Van Loon, R.J., "From Shared Cost to Block Funding and Beyond : The P o l i t i c s o f H e a l t h Insurance i n Canada", J o u r n a l o f H e a l t h P o l i t i c s , P o l i c y and Law,(Vol. 2, P a r t 4, 1978), 454-78. Vigeoz-Souchon, M i c h e l e , "Thoughts on C e r t a i n Aspects of the 'Mission' o f the LCSC's", Canada's Mental H e a l t h , (December 1977), 8-10. Warham, Joyce, The Concept o f E q u a l i t y i n S o c i a l P o l i c y , Department of Hea l t h Care and Epidemiology, U n i v e r s i t y of B r i t i s h Columbia, (mimeograph) Weis s e r t , Wm. G., "Costs o f A d u l t Day Care : A Comparison to Nursing Homes", I n q u i r y , (March 1978), 10-18. 156 CHAPTER V I I I A l f o r d , Robert R., H e a l t h Care P o l i t i c s , The U n i v e r s i t y of Chicago Press : Chicago, 1975. B r i t i s h Columbia. M i n i s t r y of H e a l t h Newsletter, Deputy M i n i s t e r Announces Major R e o r g a n i z a t i o n , November 20, 1978. C a h i l l , Kevin M., "The H e a l t h Care Industry : A Case Study and Future P o l i c y I ssues", J o u r n a l of H e a l t h  P o l i t i c s , P o l i c y and Law, (Winter 1979) E l l i n g , R.H., "Case S t u d i e s of C o n t r a s t i n g Approaches to O r g a n i z i n g f o r H e a l t h : An I n t r o d u c t i o n to a Frame-work", S o c i a l Science and Medicine, ( V o l . 8, 1974). G l e n n e r s t e r , Howard, S o c i a l S e r v i c e Budgets and S o c i a l  P o l i c y , George A l l e n and Unwin : London, 19 75. APPENDIX I Begin, Clermont, "Can the HC's and the LCSC's C o - e x i s t ? " , Canada's Mental H e a l t h , V o l . 25,(December 1977) 11-15. B r i t i s h Columbia. H e a l t h S e c u r i t y f o r B r i t i s h Columbians, Report of R i c h a r d G. Foulkes to the M i n i s t e r of H e a l t h , December 1973. • Report of the A u d i t Committee on Comm-u n i t y Human Resources and H e a l t h Centres i n B r i t i s h Columbia, February 28, 1977. Canada. Department of N a t i o n a l H e a l t h and Welfare, The  Community He a l t h Centre i n Canada, Ottawa : Information Canada, 1972 and 1973. C r i c h t o n , Anne, Community He a l t h Centres : H e a l t h Care  O r g a n i z a t i o n s of the Future?, Ottawa : Information Canada, 1973. Manitoba. White Paper on H e a l t h P o l i c y , J u l y 1972. 157 O n t a r i o . Report of the H e a l t h P l a n n i n g Task Force, January 1974. Quebec. Commission of I n q u i r y on H e a l t h and S o c i a l  Welfare, 1970-71. Vigeoz-Suchon, Mich e l e , "Thoughts on C e r t a i n Aspects of the ' M i s s i o n 1 df the LCSC's", Canada's Mental H e a l t h , V o l . 25 (December 1977), 8. 158 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095070/manifest

Comment

Related Items