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The development and implementation of health manpower planning in Canada with special reference to British… Manning, Wendy Gaye 1981

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THE DEVELOPMENT AND IMPLEMENTATION OF HEALTH MANPOWER PLANNING IN CANADA WITH SPECIAL REFERENCE TO BRITISH COLUMBIA by WENDY GAYE MANNING B.Ed., U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (The Department o f H e a l t h Care and E p i d e m i o l o g y ) We a c c e p t t h i s t h e s i s as conforming t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1981 © W e n d y Gaye Manning, 1981 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 t h e r e q u i r e m e n t s f o r an advanced degree a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e 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 p u r p o s e s may be g r a n t e d by t h e head o f my department 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 u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l 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 rj>j^a^tzJ^ ^ >q^^y ^ ^ ^ x ^ ^ ^ ^ ^ ^ The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e V ancouver, Canada V6T 1W5 Date (%n^J?£3 . / f f / ABSTRACT The Development and Implementation of H e a l t h Manpower P l a n n i n g i n Canada: W i t h S p e c i a l R e f e r e n c e t o B r i t i s h Columbia  The purpose of t h i s study i s t h r e e f o l d : a) t o r e v i e w c u r r e n t h e a l t h manpower p l a n n i n g m e t h o d o l o g i e s b) t o d e s c r i b e i n c o n t e x t , the growth and changes i n m e d i c a l manpower p l a n n i n g i n Canada w i t h s p e c i a l r e f e r e n c e t o B r i t i s h C o l u m b i a . The manpower i s s u e s i n f i v e o t h e r h e a l t h p r o f e s s i o n a l a r e a s w i l l a l s o be e x p l o r e d . c) t o c r i t i q u e the Canadian and B r i t i s h Columbian manpower p l a n n i n g p r o c e s s e s u s i n g c u r r e n t models and recommend on changes t o the system which would i n c r e a s e e f f e c t i v e n e s s . The Canadian h e a l t h c a r e system s e t s the st a g e f o r a study of the development of h e a l t h manpower s t r u c t u r e s and e f f o r t s i n Canada. The r o l e o f t h e t h i r d p a r t y payment system i s i n v e s t i g a t e d as the p r i m a r y r e a s o n f o r government's i n c r e a s e d i n t e r e s t i n t h e c o n t r o l of p h y s i c i a n manpower and h e a l t h c a r e l a b o u r c o s t s i n g e n e r a l . Problems i n d e f i n i n g h e a l t h and j u r i s d i c t i o n a l o v e r l a p s a r e o u t l i n e d . P l a n n i n g models and t h e i r r e l a t i o n t o h e a l t h manpower p l a n n i n g a r e d e s c r i b e d . Government's i n t e r e s t t o r e p l a c e the e n t r e p r e n e u r i a l p l a n n i n g methods w h i c h preceded h e a l t h i n s u r a n c e w i t h r a t i o n a l p l a n n i n g methods i s d i s c u s s e d . The major r a t i o n a l p l a n n i n g methods and t h e i r l i m i t a t i o n s a re r e v i e w e d . These i n c l u d e p h y s i c i a n ^ - p o p u l a t i o n r a t i o s , manpower needs, economic demand and s e r v i c e t a r g e t methods. Formal f e d e r a l and p r o v i n c i a l s t r u c t u r e s e s t a b l i s h e d t o a d d r e s s manpower i s s u e s a r e a n a l y z e d as are the b u f f e r and l o b b y groups e s t a b l i s h e d t o moderate t h e i r e f f o r t s . As p h y s i c i a n manpower p l a n n i n g i s t h e p a t t e r n s e t t e r f o r a l l o t h e r h e a l t h manpower p l a n n i n g , i s s u e s i n t h i s a r e a a r e examined i n c o n s i d e r a b l e d e t a i l . T h i s d i s c u s s i o n i s f o l l o w e d by a c o n s i d e r a t i o n o f p l a n n i n g i n f i v e o t h e r h e a l t h p r o f e s s i o n a l a r e a s : n u r s i n g , pharmacy, d e n t i s t r y , r e h a b i l i t a t i o n and d i e t e t i c s . T h i s d i s c u s s i o n shows how t h e s e groups have a l l c o n c erned t h e m s e l v e s w i t h t h e i r own i n d i v i d u a l s i t u a t i o n s and not w i t h i n t e r p r o f e s s i o n a l a r e a s . I n d i v i d u a l p r o f e s s i o n a l p r i o r i t i e s a r e a l s o d i s c u s s e d . i v I n s e n s i t i v i t y t o t h e h e a l t h c a r e system g e n e r a l l y and a l a c k o f u n d e r s t a n d i n g of r a t i o n a l p l a n n i n g i n r e l a t i o n t o o t h e r p l a n n i n g modes seem t o be the. r e a s o n f o r u n s u c c e s s f u l a t t e m p t s i n h e a l t h manpower p l a n n i n g . I t i s recommended these f a i l i n g s be add r e s s e d i f t h i s p l a n n i n g a c t i v i t y i s t o c o n t i n u e . V TABLE OF CONTENTS A b s t r a c t Acknowledgements 1. INTRODUCTION A. The D i s t r i b u t i o n of the Canadian P o p u l a t i o n B. D e f i n i t i o n a l and J u r i s d i c t i o n a l I ssues 1. S i c k n e s s Approach 2. Programs and S e r v i c e s Approach C. H e a l t h P o l i c y Development D. Development o f Concern About Manpower P l a n n i n g i n Canada E. H e a l t h Manpower P l a n n i n g Summary 2. PLANNING A. Frames o f I n f e r e n c e B. E n t r e p r e n e u r i a l P l a n n i n g 1. The M e d i c a l P r o f e s s i o n 2. I n s t i t u t i o n s : H o s p i t a l s 3. I n s t i t u t i o n s : C h a r i t a b l e O r g a n i z a t i o n s C. C o r p o r a t e P l a n n i n g - Government P l a n n i n g i n Canada D. R a t i o n a l P l a n n i n g E. B u r e a u c r a t i c P l a n n i n g F. H e a l t h Manpower P l a n n i n g G. When Do We Need P l a n n i n g ? Summary 3. RATIONAL MANPOWER PLANNING A. H e a l t h Manpower Research Developments 1. H e a l t h Manpower: P o p u l a t i o n R a t i o s 2. H e a l t h Needs Approach 3. Economic Demand Approaches 4. S e r v i c e T a r g e t Methods v i Page B. L i m i t a t i o n s 50 1. I s o l a t i o n from the H e a l t h Care System 51 2. Q u e s t i o n s r e : U s e f u l n e s s o f H e a l t h Manpower P r o j e c t i o n s 5 3 3. Lack of S o p h i s t i c a t e d Methodology 54 Summary 56 4. HEALTH MANPOWER PLANNING STRUCTURES IN CANADA 60 A. A c t i v i t i e s P r i o r t o 1979 60 B. F e d e r a l C o o r d i n a t i o n E f f o r t s (1969-80) 63 C. C o l l a b o r a t i o n Between H e a l t h and E d u c a t i o n 66 D. H e a l t h Manpower P l a n n i n g S t r u c t u r e s i n B r i t i s h Columbia 68 E. The H e a l t h Manpower Research U n i t 75 F. Other Government H e a l t h Manpower P l a n n i n g S t r u c t u r e s i n B r i t i s h Columbia 76 G. E d u c a t i o n / H e a l t h Committees i n B r i t i s h C olumbia 7 8 H. H e a l t h Manpower Committees i n the B.C. H e a l t h A s s o c i a t i o n , L i c e n s i n g Bodies and P r o f e s s i o n a l A s s o c i a t i o n 79 Summary 81 5. MEDICAL MANPOWER PLANNING IN CANADA 8 4 A. I m m i g r a t i o n v s . Home T r a i n e d 86 B. P h y s i c i a n S u b s t i t u t e s 87 C. M e d i c a l Manpower i n the S e v e n t i e s 90 D. P h y s i c i a n Manpower P l a n n i n g i n B r i t i s h C olumbia 91 E. Summary 100 6. MANPOWER PLANNING IN OTHER HEALTH PROFESSIONS AND OCCUPATIONS 102 A. N u r s i n g Manpower 103 B. Pharmacy Manpower 10 7 C. D e n t a l Manpower 109 v i i Page D. D i e t e t i c Manpower 111 E. P h y s i o t h e r a p y and O c c u p a t i o n a l Therapy Manpower 112 F. Summary 114 7. TOWARDS IMPROVEMENTS IN HEALTH MANPOWER PLANNING 117 B i b l i o g r a p h y 127 Appendices 13 9 VIIX ACKNOWLEDGEMENTS The a s s i s t a n c e , i n t e r e s t and s u p p o r t of many peopl e i n the c o m p l e t i o n o f t h i s t h e s i s i s r e c o g n i z e d and g r a t e f u l l y acknowledged. My f i r s t e x p r e s s i o n of a p p r e c i a t i o n must go t o my committee of . Dr. Ann C r i c h t o n , Dr. Morton Warner and Dr. L a r r y Moore f o r t h e i r a s s i s t a n c e and encouragement. P a r t i c u l a r a p p r e c i a t i o n goes t o Dr. Anne C r i c h t o n f o r h e r i n s i g h t and.hours o f h e l p d u r i n g t h i s s t u d y . Many f r i e n d s have p r o v i d e d encouragement and s u p p o r t . S p e c i a l thanks however must go t o L a u r i e Smyth, A l i s a G l a z e r and Dennis P a t t e r s o n f o r t h e i r encouragement, m o t i v a t i o n and l i m i t l e s s p a t i e n c e d u r i n g the f i n a l months. F i n a l l y , but most i m p o r t a n t l y , I would l i k e t o thank Dr. Donald Anderson f o r many y e a r s o f i n s p i r a t i o n , encouragement and wisdom. CHAPTER 1 INTRODUCTION I t i s the purpose o f t h i s s t u d y t o examine t h e development and i m p l e m e n t a t i o n o f h e a l t h manpower p o l i c y i n Canada. The p o t e n t i a l scope o f t h e t o p i c i s such t h a t b o u n d a r i e s must be e s t a b l i s h e d f o r d i s c u s s i o n p u r p o s e s . A c t i v i t i e s a t a n a t i o n a l l e v e l b o t h w i t h i n government and t h e p r o f e s s i o n a l a s s o c i a t i o n s w i l l be d i s c u s s e d . P r o v i n c i a l a c t i v i t i e s v a r y g r e a t l y a c r o s s the c o u n t r y , w i t h each p r o v i n c e p r o v i d i n g m a t e r i a l f o r a volume o f i t s own. B r i t i s h Columbia has t h e r e f o r e been s e l e c t e d f o r i n d e p t h d i s c u s s i o n . w i t h some comparisons t o o t h e r p r o v i n c i a l a c t i v i t i e s . W i t h i n t h e g e o g r a p h i c b o u n d a r i e s d e f i n e d above, p l a n n i n g achievements and a t t e m p t s w i l l be examined. F u t u r e d i r e c t i o n s i n h e a l t h manpower p l a n n i n g w i t h i n government, p r o f e s s i o n a l a s s o c i a t i o n s and the h e a l t h c a r e system as a whole w i l l be i d e n t i f i e d . The major q u e s t i o n t o be a d d r e s s e d i s how e f f e c t i v e t h e s e a c t i v i t i e s a r e o r i n f a c t whether t h e y a r e a t a l l e f f e c t i v e . T h i s s t u d y w i l l p r o v i d e a c r i t i c a l r e v i e w , c o n c l u d i n g w i t h an o v e r a l l assessment o f the a c t i v i t i e s and recommendations f o r improvements. 2 -H e a l t h manpower p l a n n i n g , on t h e s u r f a c e , appears t o be a c l e a r c u t segment o f "manpower p l a n n i n g i n g e n e r a l . Consequent-l y the e s t a b l i s h m e n t o f s p e c i a l h e a l t h manpower p l a n n i n g com-ponents w i t h i n t h e h e a l t h s e c t o r seems almost a w a s t e f u l e x e r c i s e . There a r e , however, p a r t i c u l a r c i r c u m s t a n c e s w h i c h n e c e s s i t a t e d i f f e r e n t i a t i o n . Government i n v o l v e m e n t i n Canadian h e a l t h c a r e and t h e r o l e o f t h e m e d i c a l p r o f e s s i o n as i t s g a t e k e e p e r has c r e a t e d a unique p l a n n i n g atmosphere and s t r u c t u r e . There are j u r i s d i c t i o n a l d i s p u t e s between government and t h e p r o f e s s i o n s o v e r i s s u e s o f p r o f e s s i o n a l b o u n d a r i e s , i m m i g r a t i o n , m i g r a t i o n , and the i n t e g r a t i o n o f h e a l t h , e d u c a t i o n and l a b o u r p o l i c i e s . P r i o r t o ex a m i n i n g t h e h e a l t h manpower p l a n n i n g p r o c e s s , i t i s i m p o r t a n t t o d e s c r i b e t h e h e a l t h c a r e system i n Canada, the s e t t i n g i n which t h i s p l a n n i n g i s done. I t i s a l s o n e c e s s a r y t o d e s c r i b e t h e changes which have o c c u r r e d i n the p o p u l a t i o n and t o d e f i n e h e a l t h as i t a p p l i e s t o h e a l t h man-power p l a n n i n g . A. The DlstributioriiAOfo.theJ;CaBadian.. Populat/sioh. ;. . P o p u l a t i o n d i s t r i b u t i o n i n r e l a t i o n t o h e a l t h c a r e has always been an i s s u e t o Canadians as i n d i v i d u a l s and as members o f s o c i e t y . As i n d i v i d u a l s they have been s u c c e s s f u l - 3 -e n t r e p r e n e u r s w i t h the a b i l i t y t o d e c i d e how t o a l l o c a t e t h e i r money, whether i t be on h e a l t h c a r e o f o t h e r t h i n g s . W i t h i n s o c i e t y t h e i r i n d i v i d u a l h e a l t h s t a t u s p o t e n t i a l l y a f f e c t s t h e h e a l t h s t a t u s o f o t h e r s . S i n c e C o n f e d e r a t i o n , the p o p u l a t i o n o f Canada has grown r a p i d l y from j u s t o v e r 3 m i l l i o n i n 1867, t o 11 m i l l i o n a t the end o f the d e p r e s s i o n and 23% m i l l i o n t o d a y . I n i t i a l l y t h i s p o p u l a t i o n was p r i m a r i l y r u r a l i n n a t u r e b u t the m a j o r i t y o f t h e p o p u l a t i o n has become s e t t l e d i n urban areas (Appendix A ) . There remains, however, a l a r g e number o f p e o p l e l i v i n g i n r u r a l p a r t s o f Canada, many o f t h e s e b e i n g n a t i v e p e o p l e . R o b e r t s o n (1973) i n h i s survey o f Canadian h e a l t h needs, o u t l i n e d t h r e e u n d e r s e r v i c e d t e r r i t o r i e s f o r p l a n n i n g t h e p r o v i s i o n o f h e a l t h manpower: the i s o l a t e d r e g i o n s (ir.e.. t h e f a r north) ; remote a r e a s (some c o n s i d e r a b l e d i s t a n c e from, b u t i n communication w i t h urban c e n t r e s ) ; and some p a r t s o f urban c e n t r e s . D i f f e r e n t problems o c c u r i n each o f t h e s e areas b o t h i n t h e 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 and manpower. These d i f f e r e n t i s s u e s which a r i s e , r e l a t e t o the q u e s t i o n o f r i g h t s t o h e a l t h c a r e as proposed i n t h e H e a l t h C h a r t e r f o r Canadians."*" B. Definitio.nal.Candy. J u r i s d i c t i o n a l ; I s s u e s H e a l t h i s a concept w h i c h i n f r i n g e s upon many o t h e r human - 4 -s e r v i c e , l e g a l and o c c u p a t i o n a l a r e a s and, t h e r e f o r e , i t i s n e c e s s a r y t o d etermine b o u n d a r i e s i n o r d e r t o conduct a m e a n i n g f u l e x a m i n a t i o n . The p l a c e t o b e g i n i s w i t h a d e f i n i t i o n o f h e a l t h and i t s o p p o s i t e i l l n e s s . To do so a p p e a r s , t o t h e layman, t o be s t a t i n g t h e o b v i o u s . However, a r e v i e w o f r e l e v a n t l i t e r a t u r e , major s t u d i e s o f the h e a l t h c a r e f i e l d i n Canada and t h e l e g i s l a t i o n , q u i c k l y r e v e a l e i t h e r a l a c k o f a t t e n t i o n t o such a d e f i n i t i o n o r the a ssumption o f d e f i n i t i o n s s u f f i c i e n t l y b r o a d t o p r o v i d e i n -adequate b o u n d a r i e s t o i n v e s t i g a t o r s . Many c o u l d be con-s i d e r e d as d e l i b e r a t e a t t e m p t s t o m a i n t a i n a m b i g u i t y , p r o v i d -i n g a r e a s o v e r which c o n t r o l J m a y o r may not be e x e r c i s e d by a g e n c i e s . So w i t h a m b i g u i t y ; i n a r e l a t e d way, whatever t h e s t a t u s o f t h e i r s p e c i a l s k i l l s o r compet-e n c i e s where t h e r e are areas o f s o c i a l l i f e w h i ch a r e i l l - d e f i n e d , a p o t e n t i a l c o n t r o l f u n c t i o n i s a v a i l a b l e t o i n d i v i d u a l s o r groups who a r e w i l l i n g t o d e f i n e such s i t u a t i o n s . " The a b i l i t y o f groups o r i n d i v i d u a l s t o d e f i n e ambiguous area s has m a n i f e s t i t s e l f w i t h i n s e r v i c e and program a r e a s . L e g i s -l a t i o n does not d e f i n e what h e a l t h i s , g i v i n g r i s e t o j u r i s -d i c t i o n a l o v e r l a p s between government m i n i s t r i e s and o t h e r a g e n c i e s c h a r g e d w i t h r e s p o n s i b i l i t i e s i n h e a l t h and r e l a t e d b o r d e r l i n e a r e a s . Approaches which have been t a k e n t o t h i s d e f i n i t i o n a l a m b i g u i t y may be d i v i d e d i n t o two d i s t i n c t c a t e g o r i e s , the - 5 -S i c k n e s s Approach and the Program and S e r v i c e Approach. Each has a unique f o c u s w h i c h d i s t i n g u i s h e s i t from the o t h e r , a l -though elements o f each may not be unique. A d d i t i o n a l l y , i t s h o u l d be s t a t e d t h a t t h e Programs and S e r v i c e s Approach i s , t o some e x t e n t , a p r o d u c t o f t h e S i c k n e s s Approach. S i c k n e s s Approach D e f i n i t i o n a l d i f f i c u l t i e s o f ' h e a l t h ' , f o r the most p a r t , have a r i s e n from an i n a b i l i t y t o q u a n t i f y t h e term. Those who a r e h e a l t h y do not become p a r t o f the d a t a c o l l e c t i o n system, as they do n o t v i s i t ' h e a l t h p r a c t i t i o n e r s ' t o have t h e i r h e a l t h d i a g n o s e d , nor a r e they i n s t i t u t i o n a l i z e d because o f t h e i r h e a l t h y .con d i t i o n . : T h e r e f o r e , forms a r e not completed on them. Measures o f h e a l t h do not e x i s t whereas measures o f s i c k n e s s do e x i s t . V i s i t s t o a d o c t o r f o r d i a g n o s i s o f s i c k -ness and i n s t i t u t i o n a l i z a t i o n f o r ' s i c k n e s s ' c o n d i t i o n s a r e c o u n t e d . Data bases have been d e v e l o p e d t o q u a n t i f y t h i s c o n c e p t . Because o f t h i s q u a n t i f i c a t i o n o r a t l e a s t q u a n t i f i c a t i o n o f a c c e s s t o t h e s i c k n e s s (medical) system, one's p e r c e p t i o n o f h e a l t h and t h e h e a l t h c a r e system tends t o s h i f t t o s i c k n e s s and t h e m e d i c a l system. W i l d a v s k y d e s c r i b e s t h i s p r o c e s s i n h i s P r i n c i p l e o f G o a l D i s p l a c e m e n t where he s t a t e s : - 6 -. . . t h a t any o b j e c t i v e which cannot be a t t a i n e d w i l l be r e p l a c e d by one which can be a p p r o x i m a t e d . Every program needs an o p p o r t u n i t y t o be s u c c e s s f u l ; i f i t cannot succeed i n terms o f o s t e n s i b l e g o a l s , i t may s h i f t t o g o a l s whose achievement t h e y can c o n t r o l . - The p r o c e s s s u b t l y becomes the purpose. He continues;, by s a y i n g t h a t because government cannot p r o v i d e h e a l t h , i t p r o v i d e s what i t can - m e d i c i n e . Because m e d i c i n e i s d i r e c t e d not o n l y a t p h y s i c a l a s p e c t s b u t a l s o m ental a s p e c t s , m e d i c i n e becomes a c o v e r f o r ' c a r i n g ' and a s h i f t from the o r i g i n a l g o a l o f h e a l t h t o c a r i n g i s made, making a c c e s s a b e t t e r measure o f g o a l a t t a i n m e n t . The subsequent s h i f t t o a c c e s s l e a d s W i l d a v s k y t o go f u r t h e r , c a l l i n g t h i s second s h i f t double d i s p l a c e m e n t . Measures o f access a r e d e s c r i b e d by c o n t a c t s and by m o r b i d i t y . Double d i s p l a c e m e n t has s h i f t e d t h e d e f i n i t i o n a l base from h e a l t h t o i t s o p p o s i t e s i c k n e s s . The major d i f f i c u l t y i n d e f i n i n g h e a l t h i n terms o f a c c e s s t o m e d i c a l c a r e i s t h a t m e d i c i n e has l i t t l e , i f a n y t h i n g , t o do w i t h h e a l t h . T h i s i s acknowledged by W i l d a v s k y (19 77), argued s t r o n g l y by McKeown (19 75) and s t a t e d a l m o s t f a n a t i c a l l y by I l l i c h (19 75). Work by McKeown i n e a r l i e r y e a r s p r o v i d e d the b a s i s o f t h e L a l o n d e White Paper i n 19 74, e s t a b l i s h i n g a: .new p h i l o s o p h i c a l f o c u s i n Canadian h e a l t h c a r e , s h i f t i n g from a m e d i c a l c a r e o r i e n t a t i o n t o a p r e v e n t i v e h e a l t h o r i e n t a t i o n . I n W i l d a v s k y ' s P r i n c i p l e , t h i s would r e p r e s e n t one s t e p i n - 7 -r e t u r n i n g t o t h e o r i g i n a l g o a l . A second major d i f f i c u l t y i n d e f i n i n g h e a l t h , i n s i c k n e s s terms i s t he a m b i g u i t y w h i c h c r e e p s i n t o the h e a l t h f i e l d e i t h e r by d e s i g n o r by d e f a u l t . M o t i v a t e d a m b i g u i t y , such as i s seen i n t h e B.C. P r o v i n c i a l H e a l t h A c t , where no d e f i n i t i o n e x i s t s , o r i n the World H e a l t h O r g a n i z a t i o n d e f i n i t i o n (a s t a t e o f p h y s i c a l , m e n t a l and s o c i a l w e l l - b e i n g and not mer e l y t h e absence o f d i s e a s e and 4 i n f i r m i t y ) w h i c h i s s u f f i c i e n t l y b r oad t o a l l o w g r e a t l a t i t u d e t o t h o s e who use i t , l e a d s t o many j u r i s d i c t i o n a l and boundary problems e s p e c i a l l y a t the programs and s e r v i c e l e v e l . No doubt t h e p o p u l a r i t y o f t h e s e d e f i n i t i o n s ( o r n o n - d e f i n i t i o n s ) 5 r e s u l t s from t h e broad parameters they a l l o w . A l t h o u g h many 'grey a r e a s ' e x i s t , t h r e e major c a t e g o r i e s w h i c h s u f f e r most from l a c k o f a f i r m w o r k a b l e d e f i n i t i o n a r e c r i m i n a l b e h a v i o u r (drug a d d i c t i o n , e t c . ) , mental r e t a r d a t i o n and c a r e f o r t h e d i s a b l e d . I n each o f t h e s e a r e a s , t h e r e i s a l a c k o f con-sensus r e g a r d i n g the a p p r o p r i a t e t y p e o f c a r e and t h e system i n w hich i t s h o u l d t a k e p l a c e . . U l t i m a t e l y , who does t h e l a b e l l i n g d e t e r m i n e s what t y p e o f t r e a t m e n t i s r e c e i v e d and w i t h i n w h i c h system. The q u e s t i o n , "What i s i t r e a l l y ? ' ' "What i s i t s r i g h t name?" i s a nonsense q u e s t i o n . . . one t h a t i s not c a p a b l e o f b e i n g answered. ...The i n d i v i d u a l o b j e c t o r event we a r e - 8 -. naming, o f c o u r s e , has no name and belongs t o no c l a s s u n t i l we p u t i t i n one ... What we c a l l t h i n g s and where we draw the l i n e between one c l a s s o f t h i n g s and a n o t h e r depend upon the i n t e r e s t we have and t h e purposes o f t h e c l a s s i f i c a t i o n . Most i n t e l l e c t u a l problems a r e , u l t i m a t e l y , ^ problems o f c l a s s i f i c a t i o n and nomenclature.•" The p r o c e s s o f l a b e l l i n g i s b a s i c t o b o t h t h e S i c k n e s s Approach and t o t h e Programs and S e r v i c e s Approach. I t i s the p r o c e s s by which a group o r i n d i v i d u a l s d i a g n o s e o r c a t e g o r i z e a p e r s o n based upon s o c i a l , b e h a v i o r a l , b i o l o g i c a l , e d u c a t i o n a l , l e g a l o r o t h e r c r i t e r i a . The l a b e l p l a c e d upon a p e r s o n w i l l d e t e r m i n e t h e type o f t r e a t m e n t r e c e i v e d and t h e system i n w h i c h t h a t t r e a t m e n t i s d e l i v e r e d . As w i l l be seen l a t e r , i t i s the t r a n s i t i o n from l a b e l l i n g t o t r e a t m e n t w h i c h t a k e s us t o t h e Programs and S e r v i c e s Approach. Gove goes so f a r as t o s t a t e t h a t t h e l a b e l p l a c e d on an i n d i v i d u a l w i l l q u i t e o f t e n d etermine the e f f e c t i v e n e s s o f t h e t r e a t m e n t r e c e i v e d w i t h mental i l l n e s s and p h y s i c a l d i s a b i l i t y , l a b e l l i n g o f t e n appears t o l e a d t o e f f e c t i v e t r e a t m e n t , w h i l e w i t h c rime and drug a d d i c t i o n , l a b e l l i n g appears t o have a 7 d e t e r r e n t e f f e c t . ' Warham s t a t e s t h a t l e g i s l a t i o n i s most o f t e n t h e mechanism by which d i s c r e t i o n a r y powers a r e p r o v i d e d t o groups and i n d i v i d -u a l s , a l l o w i n g l a b e l l i n g i n c e r t a i n f i e l d s more than i n o t h e r s . - 9 -She s t a t e s : J I n t h e f i e l d s o f m e d i c a l c a r e , m ental h e a l t h and p e r s o n a l s o c i a l s e r v i c e s , w hatever t h e g e n e r a l c a t e g o r i e s p o s t u l a t e d by l e g i s l a t i o n , i n t h e l a s t r e s o r t an i n d i v i d u a l ' s a d m i s s i o n t o a c a t e g o r y , whether o f persons i n need o f m e d i c a l c a r e , o r r e q u i r i n g a d m i s s i o n t o m e n t a l h o s p i t a l , o r t o r e s i d e n t i a l accommodation, o r whatever, i s t o a c o n s i d e r a b l e e x t e n t a t the d i s c r e t i o n o f i n d i v i d u a l d o c t o r s o r s o c i a l w o r k e r s , o r o f t h e a d m i n i s t r a t o r s o f p a r t i c u l a r a g e n c i e s . Seven c a t e g o r i e s o f l a b e l l i n g agents a r e o u t l i n e d by Warham:. p o l i t i c i a n s , a d m i n i s t r a t o r s , p r o f e s s i o n a l s , u s e r s o f s o c i a l s e r v i c e s , s i g n i f i c a n t groups i n p a r t i c u l a r p o p u l a t i o n s , v o l u n -t a r y s o c i a l s e r v i c e s and employers. I t i s t h i s t h i r d c a t e g o r y , t h e p r o f e s s i o n a l s , w h i c h i s o f t h e most i n t e r e s t i n h e a l t h f o r i t i s i n the b o r d e r l i n e areas o f d i s p u t e t h a t p r o f e s s i o n a l d i s c r e t i o n a r y power becomes most e v i d e n t . I t i s i n t h e s e areas where l a b e l l i n g becomes key to what i s d e f i n e d as h e a l t h and what i s n o t . I f one were t o i d e n t i f y the l e s s o b v i o u s r o l e s o f a p h y s i c i a n , s o c i a l c o n t r o l would c e r t a i n l y be one o f them. I t i s t h i s r o l e w h ich i s c e n t r a l t o an u n d e r s t a n d i n g o f the p r o f e s s i o n a l r o l e i n d e f i n i n g h e a l t h , f o r i t i s the p h y s i c i a n who has t h e r e -s p o n s i b i l i t y (power) o f d e f i n i n g ( l a b e l l i n g ) what i s normal and c o n v e r s e l y what i s d e v i a n t as i t r e l a t e s t o s i c k n e s s . Once a d o c t o r has d i a g n o s e d someone as s i c k , he has not o n l y p r o -v i d e d him w i t h a c c e s s t o t h e h e a l t h system, b u t has t a k e n him - 10 -away from a n o t h e r system ( F r i e d s o n , 19 70). Many examples would s e r v e t o i l l u s t r a t e . t h i s p o i n t , among them the l a b e l l i n g o f t h e drug a d d i c t who, when l a b e l l e d w i t h i n the m e d i c a l system, r e c e i v e s m e d i c a l t r e a t m e n t and i s i n essence d e n i e d access t o t h e j u s t i c e s ystem where most l i k e l y t r e a t m e n t would mean imprisonment. Dependent upon wh i c h p r o f e s s i o n does t h e l a b e l l i n g , t h e c r i t e r i a used w i l l be d i f f e r e n t . M e rcer i n examining the l a b e l l i n g o f t h e m e n t a l l y r e t a r d e d c i t e s t h e f o l l o w i n g example: ... p r o b a t i o n o f f i c e r s f o c u s on b e h a v i o u r which v i o l a t e s the l e g a l code and have o n l y a secondary i n t e r e s t i n i n t e l l e c t u a l achievement. On t h e o t h e r hand, t h e s c h o o l s f o c u s on t h e i n t e l l e c t u a l d i m e n s i o n and may have o n l y a p e r i p h e r a l i n t e r e s t i n t h e l e g a l norms. M e d i c a l persons f o c u s m a i n l y on b i o l o g i c a l m a n i f e s t a t i o n s , and we would e x p e c t t h e p e r s o n s i d e n t i f i e d as r e t a r d a t e s by t h e County H e a l t h Department o r p e d i a t r i c i a n s w i l l show a h i g h e r r a t e o f p h y s i c a l d i s a b i l i t y ^ t h a n t h o s e d i a g n o s e d by non-medical a g e n c i e s . The.use o f t h e s e v a r y i n g c r i t e r i a i s what l e a d s t o d i f f e r e n t l a b e l s b e i n g a p p l i e d t o s i m i l a r i f not i d e n t i c a l c o n d i t i o n s . A p e r s o n w i t h a drug a d d i c t i o n problem l a b e l l e d by l e g a l c r i t e r i a i s c o n s i d e r e d a c r i m i n a l , by m e d i c a l c r i t e r i a he i s s i c k . Use o f l a b e l l i n g c r i t e r i a i s not r e s e r v e d s o l e l y f o r b o r d e r -l i n e a r e a s which are c o n s i d e r e d d e v i a n t . The a r e a o f Home Care, i f judged upon s o c i a l c r i t e r i a and need, w i l l f a l l - 11 -w i t h i n t h e s o c i a l s e r v i c e s system, i f judged on m e d i c a l need f a l l s w i t h i n t h e h e a l t h system. P r o v i n c i a l d i f f e r e n c e s i n t h e d e l i v e r y o f home c a r e a t t e s t t o t h i s f a c t . As t h e knowledge and s k i l l s o f a p r o f e s s i o n p r o v i d e a g r e a t d e a l o f power t o c a t e g o r i z e o r l a b e l , i n many r e s p e c t s t h e p r o f e s s i o n becomes t h e g a t e k e e p e r t o t h e system. "The c l a s s i c example i s t h a t o f d o c t o r s i n h e a l t h c a r e s e r v i c e s , w i t h whom r e s t s v e r y c o n s i d e r a b l e power t o d e c i d e b o t h whether i n d i v i d - . u a l s a r e c a t e g o r i z e d as e l i g i b l e f o r m e d i c a l s e r v i c e s o r not-, and how t h e s e m e d i c a l s e r v i c e s w i l l be s t r u c t u r e d , thus i n -d i r e c t l y how u s e r s a r e grouped o r c a t e g o r i z e d . S o c i a l w o r kers l i k e w i s e , a l t h o u g h t h e i r p r o f e s s i o n a l s t a t u s and i d e n t i t y may be l e s s c l e a r l y e s t a b l i s h e d t o p e r f o r m a c t i v i t i e s which have . . . „ . 10 s i m i l a r e f f e c t s . I t i s t h i s c a t e g o r i z a t i o n p r o c e s s w h i c h t r a n s f o r m s p o l i c i e s i n t o s e r v i c e s and u l t i m a t e l y a l l o c a t e s r e s o u r c e s . The R o y a l Commission, on H e a l t h S e r v i c e s i n 1961 was charged w i t h t h e r e s p o n s i b i l i t y o f d e f i n i n g 'the b e s t p o s s i b l e h e a l t h c a r e ' . H a l l was aware o f t h e d i f f i c u l t i e s , i n d i c a t i n g t h a t t i m e was a major problem i n v o l v e d i n such an a t t e m p t . Our terms o f R e f e r e n c e r e q u i r e us t o d e f i n e "the b e s t p o s s i b l e h e a l t h c a r e " , y e t d e s p i t e t h e advances i n m e d i c a l knowledge i n r e c e n t decades t h e con c e p t o f h e a l t h evades p r e c i s e - 12 -d e f i n i t i o n . The more v/e d i s c o v e r o f man's p h y s i c a l and s o c i a l nature,, t h e more d i f f i c u l t i s t h e t a s k o f a r r i v i n g at. a c o n s e n s u s . I 1 H a l l contends t h a t 1 ... .. m e d i c a l knowledge h e l p s us t o i d e n t i f y and deepen the meaning o f i l l n e s s and t h e p o s s i b i l i t i e s o f r e g a i n i n g "good" h e a l t h . I t i s t h e r e l a t i o n s h i p o f the t h r e e f a c t o r s w i t h i n t h e t o t a l environment w h i c h l a r g e l y d e t e r m i n e s what a community w i l l c o n s i d e r a t any moment o f t i m e , as the 12 b e s t p o s s i b l e h e a l t h c a r e a v a i l a b l e . H a l l ' s c o n c e p t l e g i t i m i z e s , i n some ways, b o t h th e S i c k n e s s Approach and, as s h a l l be seen, th e Program and S e r v i c e Approach by d e s c r i b i n g a n o n - s t a t i c system upon w h i c h bounds cannot r e a d i l y be p l a c e d . 2. Programs and S e r v i c e s Approach T h i s approach i s a n a t u r a l outcome o f t h e c a t e g o r i z a t i o n p r o c e s s o u t l i n e d under the S i c k n e s s Approach. Those programs o r s e r v i c e s e s t a b l i s h e d w i t h i n a h e a l t h m i n i s t r y , o r a v o l u n t a r y agency w i t h a h e a l t h mandate, de t e r m i n e how s o c i e t y w i l l d e f i n e h e a l t h a t any p a r t i c u l a r p o i n t i n t i m e . Once c a t e g o r i z a t i o n has o c c u r r e d , p o l i c i e s a r e t r a n s f o r m e d i n t o s e r v i c e s . The s e r v i c e may be b o r d e r -l i n e o r i n an a r e a o f d i s p u t e d t e r r i t o r y but because i t has been c a t e g o r i z e d as a h e a l t h s e r v i c e i t i s t a k e n from - 13 -a n o t h e r system o r becomes a j u r i s d i c t i o n a l o v e r l a p t o t h a t o t h e r system. One a r e a w h i c h s u f f e r s from b e i n g b o r d e r l i n e and i n t h e p r o c e s s o f a l m o s t c o n s t a n t r e c a t e g o r i z a t i o n i s m e ntal r e t a r d a t i o n . Dependent upon the p o l i t i c s and economics o f t h e t i m e as w e l l as t h e b e nt o f t h e p r o f e s s i o n a l s , mental r e t a r d a t i o n f i n d s i t s e l f b e i n g s h u f f l e d between h e a l t h and s o c i a l s e r v i c e areas r e g u l a r l y . C. H e a l t h P o l i c y Development From t h e b e g i n n i n g governments w i t h i n Canada have t a k e n th e r e s p o n s i b i l i t y f o r d i r e c t p r o v i s i o n o f p u b l i c h e a l t h s e r v i c e s : i n f e c t i o n c o n t r o l , s e r v i c e s t o h i g h r i s k groups (mothers and i n f a n t s ) , and m ental h e a l t h s e r v i c e s f o r t h o s e u n a c c e p t a b l e t o t h e i r communities. R e s p o n s i b i l i t y f o r i n d i r e c t h e a l t h and s o c i a l s e r v i c e , such as h o s p i t a l s , h e a l t h and s o c i a l s e r v i c e a g e n c i e s , was a l s o t a k e n on by l o c a l communities i n the l a t e n i n e t e e n t h c e n t u r y . However, the p r i n c i p a l r e l a t i o n s h i p was one o f p e r s o n a l p h y s i c i a n t o p a y i n g p a t i e n t . F i n a n c i n g o f h e a l t h c a r e s e r v i c e s had become a major problem by t h e 1930's. L o c a l m u n i c i p a l i t i e s and v o l u n t a r y o r g a n i z -a t i o n s c o u l d n o t f i n d enough r e s o u r c e s and p r o v i n c i a l govern-ments d i d not have s u f f i c i e n t t a x i n g powers. C o n s t i t u t i o n a l r e v i s i o n was n e c e s s a r y and s u b s e q u e n t l y recommended by t h e R o w e l l - S i r o i s Committee (19 40) . The second w o r l d war p o s t -poned t h i s r e v i s i o n u n t i l 1946. I n t e r v e n i n g y e a r s saw t h e - 14 -i n i t i a t i o n by t h e f e d e r a l government o f new p r o p o s a l s r e l a t e d t o t h e f e d e r a l / p r o v i n c i a l f u n d i n g o f a n a t i o n a l h e a l t h i n s u r a n c e system (Heagarty, 1943). I n the same y e a r p r o p o s a l s f o r a s o c i a l s e c u r i t y program were a l s o put f o r w a r d (Marsh 19 4 3 ) . W h i l e t h e s e p r o p o s a l s were adopted i n 19 46, i t took a n o t h e r twenty y e a r s t o l e g i s l a t e t h e changes. The e x t e n t o f government i n v o l v e m e n t i n the f u n d i n g o f n a t i o n a l h e a l t h i n s u r a n c e was not i m m e d i a t e l y a p p r e c i a t e d . However, as t h e c o n t r i b u t i o n i n c r e a s e d , t h e government began t o become con-cerned as t o how d o l l a r s were s p e n t . By t h e end o f the s i x t i e s , t h e f e d e r a l government had e s t a b l i s h e d a Task F o r c e on t h e Co s t of H e a l t h S e r v i c e s (1969). T h e i r recommendations i n i t i a t e d a new wave o f c o n c e r n r e g a r d i n g c o n t r o l r a t h e r t h a n e x p a n s i o n . Recommendations by t h e Task F o r c e c a l l e d f o r changes i n f e d e r a l / p r o v i n c i a l agreements i n f u n d i n g t o i n c r e a s e manage-ment f l e x i b i l i t y o f s e r v i c e s i n o r d e r t o c u r t a i l waste and c l o s e gaps i n p r o v i s i o n ; e x p l o r e o u t p a t i e n t c a r e as an a l t e r -n a t i v e t o i n p a t i e n t c a r e as a l e s s e x p e n s i v e c a r e d e l i v e r y mode; and e x p l o r e a d d i t i o n a l new forms o f s e r v i c e d e l i v e r y . The s e v e n t i e s have s t r u g g l e d t o f o l l o w t h rough w i t h t h e s e r e c -ommendations w i t h t h e p r o v i s i o n o f ambulatory c a r e and t h e e x p l o r a t i o n o f new s e r v i c e d e l i v e r y forms. Emphasis on i n -d i v i d u 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 f o l l o w e d a New P e r s p e c t i v e on H e a l t h f o r Canadians (1974) w i t h h e a l t h p r o m o t i o n and - 15 -p r e v e n t i o n becoming p r i o r i t y areas i n f e d e r a l h e a l t h p o l i c y . The E s t a b l i s h e d Programs F i n a n c i n g A c t (19 77) p r o v i d e d a new f e d e r a l / p r o v i n c i a l f u n d i n g agreement. W i t h t h e new f o c u s on c o n t r o l i n t h e s e v e n t i e s came a new e x a m i n a t i o n o f t h e need f o r and d i s t r i b u t i o n o f h e a l t h manpower. D.. . Development o f Concern About Manpower P l a n n i n g in_Canada Canada was conquered and annexed as a B r i t i s h c o l o n y a t t h e t i m e o f t h e American War o f Independence. C o n t r o l had passed from the F r e n c h t o t h e B r i t i s h and w i t h i t , t h e i n t e r e s t i n e x t r a c t i n g r e s o u r c e s and t h e need f o r manpower t o f a c i l i t a t e t h i s p r o c e s s . O v e r a l l manpower p o l i c i e s f o r Canada are g e n e r a l ones. They r e l a t e t o a r e a s such as unemployment, i m m i g r a t i o n and e d u c a t i o n . I n 1867, w i t h C o n f e d e r a t i o n , came t h e p o s s i b i l i t y o f f o r m a l c o n t r o l o f t h e use o f manpower by t h e government. However, t h e p r o c e s s a t t h i s t i m e was i n f o r m a l and t h e market d i c t a t e d manpower and i m m i g r a t i o n p o l i c i e s . . I n a l a r g e r con-t e x t t h e y were dependent upon w o r l d markets and economic c y c l e s . I n t h e e a r l y days manpower p o l i c i e s were, t o a l a r g e e x t e n t , i m m i g r a t i o n p o l i c i e s , . -The u n d e r s t a n d i n g o f i d e o l o g i c a l s t a n c e s i s c r u c i a l t o d i s c u s s i n g manpower p l a n n i n g . Marchak - 16 -(1975) has s t a t e d t h a t Canada i s a N o r t h American l i b e r a l democracy where t h e dominant i d e o l o g y i s e n t r e p r e n e u r i a l i s m . Government i n t e r v e n t i o n i s e x p e c t e d t o be m i n i m a l e x c e p t i n s u p p o r t o f t h e e n t r e p r e n e u r s . T h i s b e i n g t h e c a s e , i n p a s t y e a r s t h e r e has been g e n e r a l s u p p o r t f o r open i m m i g r a t i o n . I n f a c t i m m i g r a t i o n has been promoted as a means o f f i l l i n g v a c a n t job p o s i t i o n s and t o d e v e l o p new b u s i n e s s when markets a r e booming (Richmond 19 7 4 ) . Hawkins (19 74) has d e s c r i b e d o t h e r i n f l u e n c e s upon i m m i g r a t i o n p o l i c i e s such as r a c i a l a t t i t u d e s w hich l e d t o b a r r i e r s b e i n g s e t up t o h i n d e r O r i e n t a l s and E a s t I n d i a n s from e n t e r i n g t h e c o u n t r y and e n c o u r a g i n g e n t r y o f educated and t r a i n e d C a u c a s i a n i m m i g r a n t s . Manpower p o l i c i e s cannot be d i s c u s s e d i n i s o l a t i o n from e d u c a t i o n p o l i c i e s . Canada's e d u c a t i o n system has been e v o l v i n g r a p i d l y i n t h e p o s t war y e a r s , w i t h t h e f e d e r a l government s u b s i d i z i n g p o s t s e c o n d a r y e d u c a t i o n developments. However, b a r r i e r s t o e f f e c t i v e o v e r a l l manpower p l a n n i n g l i n k -ages have been c r e a t e d by v i r t u e o f l a b o u r b e i n g a f e d e r a l r e s p o n s i b i l i t y and e d u c a t i o n a p r o v i n c i a l one. E. H e a l t h Manpower P l a n n i n g I t i s o b v i o u s t h a t h e a l t h manpower p l a n n i n g was a t one ti m e a minor c o n c e r n t o governments, g i v e n t h e g e n e r a l approach t o - 17 -manpower p l a n n i n g they had m a i n t a i n e d . I n t e r e s t d i d not grow u n t i l governments became i n v o l v e d i n f u n d i n g h e a l t h c a r e d e l i v e r y and even t h e n i t was a l o n g time b e f o r e a c t i v e s t e p s were t a k e n t o c o n s i d e r p l a n n i n g . By t h e mid s i x t i e s t h e number o f u n i v e r s i t y g r a d u a t e s was i n -c r e a s i n g a t a g r e a t r a t e . Community c o l l e g e s and t e c h n i c a l i n s t i t u t i o n s e x p e r i e n c e d phenomenal growth and w i t h t h i s , a growth i n the numbers o f t e c h n i c a l l y t r a i n e d p e o p l e . The H a l l Commission i n 1964 encouraged t h i s e x p a n s i o n e s p e c i a l l y towards t h e p r o d u c t i o n o f more p h y s i c i a n s . The e f f o r t s o f t h e H a l l Commission i n t h e e a r l y 1960's l e d t o 1 13 t h e e s t a b l i s h m e n t o f t h e H e a l t h C h a r t e r f o r C a n a d i a n s , a document wh i c h p u t f o r t h ,the v i r t u e s o f a c c e s s i b i l i t y and u n i v e r s a l i t y . W i t h U n i v e r s a l H e a l t h I n s u r a n c e , t h i s a c c e s s -i b i l i t y was e x p e c t e d t o be e n s u r e d . I t was a t t h i s p o i n t i n t h e growth o f t h e Canadian h e a l t h c a r e system t h a t p l a n n i n g was r e q u i r e d t o r e a l l o c a t e r e s o u r c e s f o r t h e p r o v i s i o n o f c a r e t o t h o s e who had not p r e v i o u s l y had a c c e s s . Once the q u e s t i o n o f a c c e s s i b i l i t y had been a d d r e s s e d , a r e d i s t r i b u t i o n p o l i c y was n e c e s s a r y . I n a c c e s s i b i l i t y does not n e c e s s a r i l y mean a s h o r t a g e o f a s p e c i f i c r e s o u r c e , f o r i n some ca s e s a g e n e r a l o v e r s u p p l y o f a - 18 -r e s o u r c e can be i n e x i s t e n c e , b u t g e o g r a p h i c m a l d i s t r i b u t i o n can r e s u l t i n a s h o r t a g e - n o n - a c c e s s s i t u a t i o n i n a s p e c i f i c a r e a . I n many i n s t a n c e s , s u p p l y may e x i s t b u t c u l t u r a l o r s o c i a l r e s t r a i n t s may h i n d e r a c c e s s by c l i e n t e l e . O v e r s u p p l y o f a s p e c i f i c r e s o u r c e such as manpower may nec-e s s i t a t e a r e a l i g n m e n t o f p r i o r i t i e s t o produce l e s s o f one p a r t i c u l a r r e s o u r c e and more o f a n o t h e r . Ten y e a r s a f t e r H a l l and M e d i c a r e , i n t e r e s t i n r e d i s t r i b u t i o n o f a d i f f e r e n t k i n d can be o b s e r v e d . The i n c e p t i o n o f M e d i c a r e b r o u g h t a growth i n t h e c o s t o f h e a l t h s e r v i c e s , Canada became a care-dependent n a t i o n w i t h i n t h e bounds o f h e r e v e r expanding r e s o u r c e s . Demands were no l o n g e r l i m i t e d by income and t h e e l d e r l y were a b l e t o seek more c a r e . I m m i g r a t i o n emerged as a problem when i t was r e a l i z e d t h a t Canada was b e i n g used as a s t e p p i n g s t o n e i n a s e r i e s o f p r o f e s s i o n a l moves th r o u g h t h e E n g l i s h s p e a k i n g w o r l d . The b r a i n d r a i n o f p h y s i c i a n s from G r e a t B r i t a i n i n t h e mid s i x t i e s was p a r t o f a g e n e r a l m i g r a t i o n o f p r o f e s s i o n a l s t o N o r t h A m e r i c a . H a v i n g s p e n t time i n Canada, they t h e n would move t o more l u c r a t i v e f i n a n c i a l markets i n t h e U.S. The Vietnam War slowed t h i s p r o c e s s because young p h y s i c i a n s c o u l d be d r a f t e d . I n a d d i t i o n , t h e American dream was b e i n g q u e s t i o n e d . Canada began t o r e t a i n t h o s e p r o f e s s i o n a l s who had p r e v i o u s l y moved on, and a p h y s i c i a n s u r p l u s became a r e a l i t y . - 19 -By t h e l a t e s i x t i e s government had become concerned about un-p l a n n e d growth i n e d u c a t i o n and t r a i n i n g programs, t h e c h a n g i n g p a t t e r n s o f i m m i g r a t i o n and e m i g r a t i o n , and t h e c o s t o f h e a l t h c a r e . P l a n n i n g seemed t o have become a n e c e s s i t y and i n v o l v e -ment i n h e a l t h manpower p l a n n i n g began t o grow. The Task F o r c e on t h e C o s t s o f H e a l t h C a r e , f o c u s s e d on t h e need t o make b e t t e r use o f . r e s o u r c e s . Manpower> t h e most e x p e n s i v e r e s o u r c e , was key i n t h e i r d e l i b e r a t i o n s . Over-e x p l o i t a t i o n o f m e d i c a l t e c h n o l o g y and i t s a p p l i c a t i o n s a l s o became an i s s u e i n t h e l a t e s i x t i e s and f e d e r a l p o l i c i e s began t o emphasize s o c i a l c a r e needs r a t h e r t h a n f i n a n c i n g f u r t h e r t e c h n o l o g i c a l advances. T h i s i s e v i d e n c e d i n t h e r e v i s i o n o f the N a t i o n a l H e a l t h G r a n t s i n 19 69. H e a l t h p l a n n i n g i n g e n e r a l was emphasized and w i t h i t h e a l t h manpower p l a n n i n g . I f one were r e q u i r e d t o i d e n t i f y t h e major p o l i c i e s r e l a t i n g t o h e a l t h manpower i n Canada o v e r t h e p a s t f i f t y y e a r s , i t would p r o v e t o be a d i f f i c u l t t a s k . I n f a c t , i f h e a l t h man-power p o l i c y were d e s c r i b e d f o r Canada .as a whole, what would emerge would be a fragmented p i c t u r e c o n s i s t i n g o f t e n p r o v i n c i a l s c e n a r i o s each w i t h a d i f f e r e n t s e t o f problems, p r i o r i t i e s and p o l i c i e s . A t t e m p t i n g t o c o o r d i n a t e t h e s e t e n unique agendas would be a f e d e r a l manpower "component", w h i c h i n i t s e l f was d i s j o i n t e d and l a c k i n g i n mandate. - 20 -T h i s p i c t u r e i s not one r e s t r i c t e d t o h e a l t h manpower, most o t h e r p o l i c y a r e a s s u f f e r i n t h i s manner. The n a t u r e of our u n i t y as a c o u n t r y d e s t i n e s t h i s t o o c c u r . In h e a l t h manpower, however, the r e a l i z a t i o n of p r o v i n c i a l u niqueness and attem p t s t o address the s e p a r a t e agendas are r e l a t i v e l y new. In. the l a s t t e n y e a r s t h e r e has been r e c o g n i t i o n of need f o r a p o l i c y r e q u i r i n g the r e d i s t r i b u t i o n of h e a l t h manpower r e s o u r c e s not o n l y on a p r o v i n c i a l b a s i s , but on a r e g i o n a l and n a t i o n a l b a s i s as w e l l . Summary T h i s c h a p t e r has s e t the s t a g e f o r subsequent c h a p t e r s by d e v l o p i n g t h e Canadian c o n t e x t i n which h e a l t h manpower p l a n n i n g has o c c u r e d . I t began w i t h an e x a m i n a t i o n of the r u r a l / u r b a n s h i f t which has o c c u r e d i n the c o u n t r y ' s p o p u l a t i o n and the e f f e c t t h a t has had on h e a l t h c a r e d e l i v e r y . D e f i n i t i o n a l and j u r i s d i c a t i o n a l i s s u e s were then a d d r e s s e d . Attempts t o d e f i n e h e a l t h have most o f t e n c e n t e r e d on d e f i n i n g i t s o p p o s i t e s i c k n e s s or have found parameters by use of program o r s e r v i c e b o u n d a r i e s . J u r i s d i c t i o n a l . o v e r l a p s o c c u r i n grey areas such as the j u s t i c e system o r s o c i a l , s e r v i c e system. Dependent upon who - 21 -l a b e l s a p r o s p e c t i v e c l i e n t the p e r s o n may e n t e r one of a number o f ' t r e a t m e n t 1 systems. I f l a b e l l e d by a p h y s i c i a n , he may be l a b e l l e d s i c k , by a judge or lawyer the l a b e l w i l l l i k e l y be c r i m i n a l . S i n c e e a r l y ; o n , C a n a d i a n governments have been i n v o l v e d i n h e a l t h c a r e , o r i g i n a l l y t h r o u g h the p r o v i s i o n of p u b l i c h e a l t h s e r v i c e s . As time went b y , f i n a n c i n g became a r e s p o n s i b i l i t y and a problem t o government. Du r i n g the 1940's r e f o r m was r e q u i r e d t o p r o v i d e p r o v i n c e s w i t h the a b i l i t y t o t a x . The f o r t i e s a l s o saw the commencement of n e g o t i a t i o n s between the f e d e r a l government and the p r o v i n c e s over h e a l t h i n s u r a n c e (Heagerty, 1943) and s o c i a l s e c u r i t y systems (Marsh, 1943). F e d e r a l c o n t r i b u t i o n s began t o i n c r e a s e and by the l a t e s i x t i e s c o n c e r n o v e r c o s t s had r i s e n c o n s i d e r a b l y . The Task Force on the C o s t s of H e a l t h C are d e l i v e r e d i t s r e p o r t i n 1969 p l a c i n g heavy emphasis on ambulatory and o u t p a t i e n t programs. The s e v e n t i e s s t r u g g l e d w i t h these recommendations and those of the Lalonde r e p o r t which handed the r e s p o n s i b i l i t y of an i n d i v i d u a l s own h e a l t h back t o the i n d i v i d u a l . O v e r a l l manpower p o l i c i e s d u r i n g t h i s time have been g e n e r a l ones, r e l a t e d t o unemployment, i m m i g r a t i o n and e d u c a t i o n . L i t t l e i n t e r e s t was e x p r e s s e d i n h e a l t h manpower u n t i l t a x d o l l a r s - 22 -became an i s s u e and even then i n t e r e s t was slow t o come. Fear of t o o few p r a c t i t i o n e r s under h e a l t h i n s u r a n c e l e d H a l l (1964) t o encourage e x p a n s i o n o f t r a i n i n g programs. Q u e s t i o n s of a c c e s s q u i c k l y became i s s u e s o f r e d i s t r i b u t i o n . Problems of i m m i g r a t i o n , e m i g r a t i o n , the unplanned growth of e d u c a t i o n programs, the c o s t of h e a l t h c a r e and an o v e r e x p l o i t a t i o n o f m e d i c a l t e c h n o l o g y have a l l l e d t o an i n t e r e s t i n h e a l t h manpower p l a n n i n g . I t i s i m p o s s i b l e t o i d e n t i f y major h e a l t h manpower p o l i c i e s i n Canada. Attempts t o c o o r d i n a t e e f f o r t s a r e met w i t h t en d i f f e r e n t p r o v i n c i a l s c e n a r i o s , s e t s of p r o b l e m s , p r i o r i t i e s and p o l i c i e s . T h i s s t u d y a d d r e s s e s r e g i o n a l , p r o v i n c i a l and n a t i o n a l a t t e m p t s t o address p o l i c y f o r m u l a t i o n . - 23 -F o o t n o t e s 1. R o y a l Commission on H e a l t h S e r v i c e s / Government o f Canada, Ottawa, 19 64, V o l . 1. p. 11. 2. W a t k i n s , K., S o c i a 1 C o n t r o 1 , Longman, London, 1975, p. 118. 3. W i l d a v s k y , A., Doing B e t t e r and F e e l i n g Worse. The P o l i t i c a l P a t h o l o g y o f H e a l t h P o l i c y i n Knowles, J . Doing B e t t e r and F e e l i n g Worse, H e a l t h i n t h e U n i t e d S t a t e s , N o r t o n , New York, 1977, p. 106. 4. Wo r l d H e a l t h O r g a n i z a t i o n , C o n s t i t u t i o n , Geneva: The O r g a n i z a t i o n , 1960, p. 1. 5. Examples o f t h i s can be found i n the Task F o r c e R e p o r t s on th e C o s t o f H e a l t h S e r v i c e s i n Canada (19 69) and i n 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 ( F o u l k e s 1973). 6. Hayakawa, S . I . , i n M e r c e r , J . L a b e l l i n g t h e M e n t a l l y R e t a r d e d , U n i v e r s i t y o f C a l i f o r n i a P r e s s , B e r k l e y , 19 73, p. 1. 7. Gove, W.R., The L a b e l l i n g o f De v i a n c e , Sage, B e v e r l y H i l l s , 1975, p. 295. 8. Warham, J . 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 , U.B.C., Vancouver, 1974, p. 112. 9. M e r c e r , J . L a b e l l i n g t h e M e n t a l l y R e t a r d e d , U n i v e r s i t y o f C a l i f o r n i a P r e s s , B e r k l e y , 1973, p. 24. 10. Warham, J . 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 , U.B.C., Vancouver, 1974, p. 112. 11. R o y a l Commission on H e a l t h S e r v i c e s , Government o f Canada, Ottawa, 1964, V o l . 1, p. 97. 12. I b i d . 13. I b i d . - 24 -CHAPTER 2 PLANNING A. Frames o f I n f e r e n c e A l a r g e number o f p l a n n i n g models have been d e v e l o p e d , however no one i d e a l model has emerged. I t has been suggested by A l f o r d (19 7 5) t h a t t h o u g h t s about p l a n n i n g a r e c l o s e l y r e l a t e d t o i d e o l o g i e s . E n t r e p r e n e u r s t h e r e f o r e have one view o f how t h e w o r l d s h o u l d be, c o r p o r a t e p l a n n e r s a d i f f e r e n t v iew and consumer groups y e t a n o t h e r . I t has been argued by Marmor (1973) t h a t d i f f e r e n t p l a n n i n g a c t i v i t i e s may be a p p r o p r i a t e a t d i f f e r e n t s t a g e s i n t h e development o f a p o l i c y i s s u e . R a t i o n a l p l a n n i n g t h e r e f o r e i s a p p r o p r i a t e i n the e a r l y s t a g e s . T h i s w i l l most l i k e l y be f o l l o w e d by w o r k i n g through t h e o r g a n i z a t i o n a l p r o c e s s and by n e g o t i a t i o n . H i s t h r e e 'frames o f i n f e r e n c e ' a r e o u t l i n e d i n Appendix B. The views o f t h e s e two p o l i c y a n a l y s t s n e c e s s i t a t e a r e -e x a m i n a t i o n o f t h e r a t i o n a l p l a n n i n g p r o c e s s e s which have been attem p t e d i n r e c e n t y e a r s by p r o f e s s i o n a l p l a n n e r s . These at t e m p t s a r e most e v i d e n t i n government, where i t has been the i n t e n t t h a t r a t i o n a l p l a n n i n g r e p l a c e the e n t r e p r e n e u r i a l p l a n n i n g w h i c h was c a r r i e d o u t p r i o r t o government's i n v o l v e m e n t - 25 -i n the 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 . Donnison (197 2) not u n l i k e Marmor, s u g g e s t s t h a t t h e r e i s a t i m e and p l a c e f o r r a t i o n a l p l a n n i n g . Donnison has b u i l t on t h e work o f L i n d b l o m (19 59) who l o o k s upon the p r o c e s s o f day t o day d e c i s i o n making as ' p a r t i s a n m utual accommodation' and ' i n c r e m e n t a l i s m ' . T a k i n g t h i s f u r t h e r , Donnison s u g g e s t s t h a t d e c i s i o n makers a r e i n f l u e n c e d by t h e knowledge t h e y p o s s e s s , t h e i r i d e o l o g i e s and any e x i s t i n g p l a n s which r e l a t e t o t h e s e i d e o l o g i e s . C o n s e q u e n t l y , r a t i o n a l p l a n s w h i c h are c o n s i s t e n t w i t h the i d e o l o g y and which t h e d e c i s i o n maker i s c o m f o r t a b l e w i t h a r e more l i k e l y t o i n f l u e n c e day t o day d e c i s i o n s . E t z i o n i (19 67) has reached th e same c o n c l u s i o n as Donnison and Marmor b u t d e s c r i b e s i t as 'mixed-scanning'. T h i s mixed-s c a n n i n g i n v o l v e s a b l e n d i n g o f r a t i o n a l p l a n n i n g and n e g o t i a t -i o n t o r e a c h a s o l u t i o n . B. E n t r e p r e n e u r i a l P l a n n i n g 1. The M e d i c a l P r o f e s s i o n H e a l t h Manpower P l a n n i n g d i d not r e c e i v e a t t e n t i o n by g o v e r n -ment u n t i l many o t h e r p l a n n i n g e f f o r t s were w e l l under way. A l t h o u g h a number of these o t h e r v e n t u r e s were r e l e v a n t t o h e a l t h manpower development, none f o c u s s e d s p e c i f i c a l l y on i t . - 26 -M e d i c a l A c t s , p r o c l a i m e d about t h e time o f C o n f e d e r a t i o n d e l e g a t e d r e s p o n s i b i l i t y t o t h e m e d i c a l p r o f e s s i o n f o r t h e c o l l e g i a l c o n t r o l o f i t s members th r o u g h o u t t h e d i f f e r e n t C anadian p r o v i n c e s . These A c t s had been m o d e l l e d a f t e r t h e B r i t i s h A c t p r o c l a i m e d i n 1858. A u t h o r i t y was g i v e n t o t h e v a r i o u s C o l l e g e s o f P h y s i c i a n s and Surgeons t o c o n t r o l a d m i s s i o n to t h e p r o f e s s i o n , r e g u l a t e t h r o u g h e t h i c a l r u l e s the conduct o f members r e g a r d i n g p a t i e n t s and peers and i n i t i a t e d i s c i p l i n -a r y p r o c e d u r e s where and when n e c e s s a r y . Fee s c h e d u l e s were th e r e s p o n s i b i l i t y o f p r o f e s s i o n a l a s s o c i a t i o n s . A l t h o u g h s t a n d a r d s r e c e i v e d t h e p r i m a r y l i p s e r v i c e , economic i s s u e s were c l o s e l y l i n k e d t o them. • I t was not u n t i l t h e i n t r o d u c t i o n o f H o s p i t a l A c c r e d i t a t i o n i n t h e e a r l y 1900"s t h a t c o n t r o l o f s t a n d a r d s became a r e a l i t y . P h y s i c i a n s were more concerned about r e g u l a t i n g t h e market t o t h e i r advantage t h a n a n y t h i n g e l s e . Monopoly c o n t r o l by t h e p r o f e s s i o n q u i c k l y moved t h e system o f h e a l t h c a r e "beyond t h e m e d i c a l market p l a c e ' (Evans 1975). The a b i l i t y o f t h e p h y s i c i a n t o d i c t a t e what t h e volume o f work w i l l be through use o f d i s c r e t i o n a r y . t a c t i c s i s d i s c u s s e d by Fuchs (1974) . B a d l y a f f e c t e d by t h e d e p r e s s i o n and f i n d i n g t hemselves w i t h many bad deb t s t h e p r o f e s s i o n p r o v i d e d a f e r t i l e f i e l d f o r t h e e s t a b l i s h m e n t o f a n a t i o n a l h e a l t h i n s u r a n c e scheme. T r a n s -- 27 -Canada M e d i c a l p l a n s e s t a b l i s h e d l a t e r by t h e p r o f e s s i o n were non-p r o f i t prepayment schemes w h i c h p r o v i d e d more se c u r e income f o r t h e p h y s i c i a n s i n v o l v e d . A f t e r t h i s t i me a t t i t u d e s changed and i t was o n l y a f t e r d i f f i c u l t n e g o t i a t i o n s o v e r t h e Sask a t o o n Agreement i n 1962 and t h e 1964 H a l l Commission t h a t they agreed t o a c c e p t M e d i c a r e . - A m b i g u i t i e s n o t r e s o l v e d d u r i n g i n i t i a l n e g o t i a t i o n s such as whether p h y s i c i a n s a r e s u b s i d i z e d e n t r e -p r e n e u r s o r under c o n t r a c t have l e d t o c u r r e n t c o n f r o n t a t i o n s w i t h government. H a l l , i n 19 80, once a g a i n was r e q u e s t e d t o i n v e s t i g a t e g o v e r n m e n t / p r o f e s s i o n a l r e l a t i o n s h i p s . 2. I n s t i t u t i o n s ; H o s p i t a l s H e a l t h c a r e i n s t i t u t i o n s have not been a b l e t o m a i n t a i n t h e s t r o n g b a r g a i n i n g p o s i t i o n h e l d by p h y s i c i a n s . T h e i r g r e a t e r dependence on government has r e s u l t e d i n a g r a d u a l d e c r e a s e i n power. Consumer demand f o r h o s p i t a l s i n the e a r l y post-war y e a r s r e -s u l t e d i n r e m a r k a b l e development i n t h a t f i e l d . I n the 1940's n a t i o n a l p l a n n e r s had s t r e s s e d t h e n e c e s s i t y o f e s t a b l i s h i n g a p r i m a r y h e a l t h c a r e s e r v i c e and f o l l o w i n g i t w i t h h o s p i t a l s as a s u p p o r t mechanism. There.were o t h e r p o l i c i e s o f im p o r t a n c e i n the l a t e 4 0 1 s and h o s p i t a l s became a t o o l f o r the r e d i s t r i b u t i o n o f w e a l t h a c r o s s the c o u n t r y and as such p r o v i d e d p a r l i a m e n t w i t h two s i g n i f i c a n t p o l i c i e s f o r t h e p r i c e o f one. H e a l t h became an i s s u e o f e q u a l i m p o r t a n c e t o t h a t o f h e a l t h c a r e i n 19 4 8 t h rough t h e N a t i o n a l Health. G r ants and i n 19 57 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 when the h e a l t h c a r e f u n c t i o n o f h o s p i t a l s was i n t e g r a t e d w i t h t h e t o t a l w e l f a r e package. The Task F o r c e on the C o s t s o f H e a l t h S e r v i c e s i n i t i a t e d i n 196 7, however, was not i n t e r e s t e d i n the r e d i s t r i b u t i o n o f t h e Gross N a t i o n a l P r o d u c t , b u t r a t h e r i n how t o b r i n g under c o n t r o l t h e c o s t s o f d e l i v e r i n g h e a l t h c a r e t h r o u g h t h e s e i n s t i t u t i o n s . V o l u n t a r y h o s p i t a l a s s o c i a t i o n s c o o r d i n a t e d many h o s p i t a l a c t i v i t i e s b u t were weakened i n t h i s by t h e d e s i r e o f members to address t h e i r own h o s p i t a l s ' problems r a t h e r t h a n t h o s e o f the group. 3. I n s t i t u t i o n s : C h a r i t a b l e O r g a n i z a t i o n s P r i o r t o t h e 19 60's, f a m i l i e s , f r i e n d s and c h a r i t i e s had s h o u l d e r e d much o f t h e burden o f p r o v i d i n g s e r v i c e s t o t h e c h r o n i c a l l y i l l and d i s a b l e d i n Canada. M a n y , h o w e v e r , f e l l between t h e c r a c k s and r e c e i v e d no s e r v i c e a t a l l . The human r i g h t s movement a t t h e end o f t h e s i x t i e s s u c c e s s f u l l y en-couraged a change i n p e o p l e ' s a t t i t u d e from dependence on c h a r i t y t o the b e l i e f t h a t t a x e s should"pay f o r t h e s e s e r v i c e s . - 29 -The power t h a t t h e U n i t e d Fund had had f o r many y e a r s t h r o u g h i t s p l a n n i n g f o r v o l u n t a r y o r g a n i z a t i o n s began t o d i m i n i s h as government assumed t h e f u n d i n g r o l e f o r more and more s e r v i c e s . C u r r e n t l y many o f t h e s e a c t i v i t i e s a r e c o o r d i n a t e d by Long Term Care and Home Care o r g a n i z e r s . V o l u n t a r y o r g a n i z a t i o n s a r e sometimes used as p a i d agents o f government t o p r o v i d e s e r v i c e . C. C o r p o r a t e P l a n n i n g - Government P l a n n i n g i n Canada American c o r p o r a t e p l a n n e r s c o n c e r n t h e m s e l v e s m a i n l y w i t h t h e e f f e c t o f u n c o n t r o l l e d e n t r e p r e n e u r i a l i s m i n t h e d i s t r i b u t i o n o f h e a l t h s e r v i c e s . Donnison has i d e n t i f i e d two s t a n d p o i n t s from w h i c h p o l i t i c a l p l a n n i n g d e c i s i o n s a r e made. Roughly t r a n s l a t e d t hey a r e t h e s t a n d p o i n t o f economic growth and t h a t o f s o c i a l j u s t i c e . I n o t h e r words c o r p o r a t e p l a n n e r s c o n c e r n t h e m s e l v e s w i t h t h e e f f e c t o f e n t r e p r e n e u r i a l i s m on t h e s o c i a l o r d e r . The need t o b a l a n c e t h e two i d e o l o g i e s and t r a n s l a t e t h a t b a l a n c e i n t o h e a l t h c a r e p r o v i s i o n has o c c u r r e d i n Canada as a r e s u l t o f t h e d e c i s i o n t o d e v e l o p a w e l f a r e s t a t e . S i x key b a r g a i n i n g p o i n t s i n t h e c u r r e n t p o l i t i c a l frame have been i d e n t i f i e d and a r e o u t l i n e d i n F i g u r e 1. The f i r s t two o f - t h e s e o c c u r a t the f e d e r a l government l e v e l and w i l l be a d d r e s s e d o n l y b r i e f l y . P o i n t s f o u r t o s i x i d e n t i f y key - 30 -F i g u r e I Key B a r g a i n i n g P o i n t s (1) FEDERAL GOVERNMENT (2) Social u s t i c e Economic Growth P r o v i n c e I T P r o v i n c e 2 (3) P r o v i n c i a l Government (4) S o c i a l J u s t i c e (5) H e a l t h <Care Programs conomic Growth A t t o r n e y G e n e r a l Human Resources P r e v e n t i o n P l a n n i n g and Research (6) D e l i v e r y Method - 31 -b a r g a i n i n g o r t r a d e o f f p o i n t s a t a p r o v i n c i a l l e v e l . T h i s diagram i s n o t meant t o i l l u s t r a t e a l l p o s s i b l e b a r g a i n i n g p o i n t s b u t does i l l u s t r a t e t h e major ones. Three s t a g e s o f government development have been d e s c r i b e d by L o w i . They i n c l u d e d i s t r i b u t i v e (pork b a r r e l l i n g ) , r e g u l a t i v e and r e d i s t r i b u t i v e and may a l l be p r e s e n t a t t h e same t i m e . I n d i s c u s s i n g d i s t r i b u t i v e i s s u e s Judge (19 78) has i d e n t i f i e d t h a t government can c o n t r o l o n l y r e g u l a t i v e and f i n a n c i a l m a t t e r s . S e r v i c e d e c i s i o n s a r e c o n t r o l l e d by t h e p r o v i d e r s o f t h a t s e r v i c e . As i n d i v i d u a l s and as p r o f e s s i o n a l a s s o c i a t i o n s t hey c l o s e l y guard t h e i r autonomy. I n t h e n i n e t e e n t h c e n t u r y government i n t h e absence o f s t r o n g a d m i n i s t r a t o r s was f a c e d w i t h no o t h e r c h o i c e t h a n t o d e l e g a t e t h i s a u t h o r i t y t h r o u g h l e g i s l a t i o n and r e g u l a t i o n . Even w i t h a s t r o n g a d m i n i s t r a t i v e component, s t a n d a r d s would have remained o u t s i d e o f t h e i r a b i l i t y t o c o n t r o l . I n Quebec a t p r e s e n t t h e r e are q u e s t i o n s b e i n g asked about th e e x e r c i s e o f g r e a t e r c o n t r o l o v er the p r o f e s s i o n (Brunet./ V i n e t 19 7 8 ) . They view p r o f e s s i o n a l p e o p l e as agents o f government t o be b r o u g h t under b u r e a u c r a t i c c o n t r o l r a t h e r t h a n under the t r a d i t i o n a l p eer group c o n t r o l T h i s concept has not g a i n e d s u p p o r t i n o t h e r p r o v i n c e s o r i n Quebec. - 32 -D. R a t i o n a l P l a n n i n g R a t i o n a l approaches t o h e a l t h manpower p l a n n i n g a r e d i s c u s s e d i n d e t a i l i n the f o l l o w i n g c h a p t e r . They a r e p r i m a r i l y t h e r e s u l t o f work by c o r p o r a t e p l a n n e r s b u i l d i n g on American models. Anderson (19 76) has d e s c r i b e d t h e a p p l i c a t i o n o f t h i s model a l o n g w i t h t h e advantages o f u s i n g an academic base t o d e v e l o p t h i s r a t i o n a l i n p u t . E s t a b l i s h e d i n B.C. between 1972 and 19 76. t h i s model s u f f e r e d when l i n k s between t h e r a t i o n a l p l a n n i n g s t r u c t u r e and t h e system began t o d e t e r i o r a t e . More a p p r o p r i a t e models have s i n c e been i d e n t i f i e d , however t h e s e have not been a p p l i e d t o the r e s t r u c t u r e d M i n i s t r y o f H e a l t h . These approaches g a i n e d much s u p p o r t i n t h e e a r l y s e v e n t i e s . S i n c e t h a t time however, prime advocates have s t a r t e d t o q u e s t i o n them. E. B u r e a u c r a t i c P l a n n i n g W i t h t h e e x c e p t i o n o f Saskatchewan, i n Canada government p l a n n i n g i s a r e l a t i v e l y new a c t i v i t y and as such i s f a i r l y i n e f f i c i e n t . Saskatchewan's e a r l y s t a r t r e s u l t e d from t h e commitment by the C.C.F. government o f 1944 t o s o c i a l p l a n n i n g . The s i x t i e s and s e v e n t i e s saw t h e i n i t i a t i o n o f h e a l t h and s o c i a l p l a n n i n g a c t i v i t i e s as p r o v i n c i a l governments s t r u g g l e d t o d e v e l o p t h e i r p o l i c i e s . A c t i v i t i e s i n t h i s a r e a l e d t o 4 5 theCastonguay-Nepveu Report ,Manitoba White Paper, the F o u l k e s c R e p o r t and many o t h e r s i m i l a r p l a n n i n g a c t i v i t i e s . - 33 -P r i o r t o t h i s f l u r r y o f p l a n n i n g , however, governments had r e c o g n i z e d t h e n e c e s s i t y o f d e v e l o p i n g b u f f e r groups between the e n t r e p r e n e u r s and t h e m s e l v e s . These b u f f e r groups i n c l u d e d v o l u n t a r y o r g a n i z a t i o n s such as h o s p i t a l a s s o c i a t i o n s , 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 and u n i o n b o a r d s . Each s e r v e d as a b u f f e r i n a d i f f e r e n t a r e a such as c o l l e c t i v e b a r g a i n i n g , f u n d i n g o r s e r v i c e p r o v i s i o n . I n the l a r g e r p r o v i n c e s such as O n t a r i o and Quebec, e x t e n s i v e r e g i o n a l a c t i v i t y d e v e l o p e d f o r t h e purposes o f consumer p a r t i c i p a t i o n and c o s t s a v i n g . Consumer i n v o l v e m e n t i n an a d v i s o r y o r e x e c u t i v e c a p a c i t y was meant t o c r e a t e a b e t t e r u n d e r s t a n d i n g o f h e a l t h p o l i c i e s . F. H e a l t h Manpower P l a n n i n g The c o n t e x t i n w h i c h h e a l t h manpower p l a n n i n g o c c u r s i s a c o m p l i c a t e d one. S t r a u s s (19 79) would l a b e l i t an arena f o r t h e n e g o t i a t i o n o f o r d e r . The d i f f i c u l t y i s t h a t t h e o r d e r which a p p e a l s t o t h e n a t i o n a l p l a n n e r f i n d s i t s r o o t s i n a d i f f e r e n t i d e o l o g y than t h a t o f t h e m o n o p o l i s t i c e n t r e p r e n e u r -i a l p r o f e s s i o n a l a s s o c i a t i o n s . How can t h e s e d i f f e r e n t i d e o l o g i e s be b r o u g h t i n t o r e l a t i o n s h i p , i f i n f a c t they can be? I f r e s o l v e d , can they i n t u r n be i n c o r p o r a t e d i n t o C a nadian n a t i o n a l i d e o l o g i e s r e l a t e d t o r e s o u r c e development and s o c i a l j u s t i c e ? T h i s would be e s p e c i a l l y d i f f i c u l t , con-s i d e r i n g t h e c o n f l i c t s which, e x i s t between p r o v i n c i a l and n a t i o n a l v i e w p o i n t s . - 3'4 -The f o l l o w i n g c h a p t e r s e x p l o r e t h e n a t i o n a l p l a n n e r s ' approach. The l i t e r a t u r e w i l l be r e v i e w e d , and t h e Canadian c l i m a t e f o r r a t i o n a l p l a n n i n g c o n s i d e r e d . Q u e s t i o n s o f how p l a n n i n g i s o r g a n i z e d , what i t s impact on t h e e x i s t i n g h e a l t h c a r e d e l i v e r y system and how e f f e c t i v e i t i s w i l l be a d d r e s s e d . G. When Do we Need P l a n n i n g ? P o l i c i e s , whether f o r m a l o r i n f o r m a l , a r e e v i d e n t i n a l l a r e a s o f l i f e . The development o f t h e s e p o l i c i e s can be t h e r e s u l t o f a v a r i e t y o f p r o c e s s e s and i t i s presumptuous t o assume t h a t p l a n n i n g i s always used i n t h e i r development. Tropman (19 76) s u g g e s t s t h i s b u t i n c l u d e s p l a n n i n g as a major t o o l a l o n g w i t h n e g o t i a t i o n and a c c i d e n t a l i n c r e m e n t a t i o n . P o l i c y i s d e v e l o p e d t h r o u g h t h e employment o f s e v e r a l means. We suggest t h e s e i n c l u d e : ^ . p l a n n i n g , n e g o t i a t i o n , and a c c i d e n t a l i n c r e m e n t . '' A l t h o u g h a l l t h r e e a r e d e s e r v i n g o f e q u a l a t t e n t i o n , t h i s s t u d y w i l l c o n c e n t r a t e upon p l a n n i n g and i t s r o l e i n p o l i c y d e v e l o p -ment. B e f o r e a d d r e s s i n g how p l a n n i n g becomes p a r t o f the ' p o l i c y system', t h e need f o r p l a n n i n g must be examined. There a r e t h o s e i d e a l i s t s among us who l i k e t o b e l i e v e t h a t p l a n n i n g i s t h e t o o l by w h i c h a l l o f l i f e ' s s y stems, s e r v i c e s , programs and o t h e r s t r u c t u r e s a r e r a t i o n a l l y d e v e l o p e d . We r e a l i z e t h a t t h i s i s not always t h e c a s e , b u t c o n t i n u e t o h o l d t h i s i d e a l as our g o a l . - 35 -Friedman (1967), however, has d e f i n e d p l a n n i n g as 'the guidance of change w i t h i n a s o c i a l system'^ and f o r the purpose o f t h i s s t u d y , t h i s d e f i n i t i o n w i l l be a c c e p t e d . W i t h i n t h i s d e f i n i t i o n p l a n n i n g then becomes a t o o l f o r r e d i s t r i b u t i o n , f o r the system i s c r e a t e d as a r e the programs, s e r v i c e s and o t h e r s t r u c t u r e s . Change ' w i t h i n the s o c i a l system' i n d i c a t e s the r e a l l o c a t i o n o f some component of t h a t system be i t goods, s e r v i c e s , manpower or o t h e r r e s o u r c e s . Summary C h a p t e r 2 has addressed the q u e s t i o n of p l a n n i n g models. Marmor's argument t h a t d i f f e r e n t models may be a p p r o p r i a t e a t d i f f e r e n t times was d i s c u s s e d . He has s t a t e d t h a t r a t i o n a l p l a n n i n g may be a p p r o p r i a t e e a r l y on but t h a t o r g a n i z a t i o n a l p r o c e s s and n e g o t i a t i o n may then f o l l o w . has s t a t e d t h a t t h e r e i s a time and p l a c e f o r p l a n n i n g and t h a t the more c o n s i s t e n t r a t i o n a l i s w i t h the d e c i s i o n makers' i d e o l o g y the more l i k e l y i n f l u e n c e day t o day d e c i s i o n s . Donnison r a t i o n a l p l a n n i n g i t i s t o The e n t r e p e n e u r i a l p l a n n i n g o f p h y s i c i a n s was r e c o g n i z e d as h a v i n g grown out o f the P r o v i n c i a l M e d i c a l A c t s e s t a b l i s h e d around t h e time o f C o n f e d e r a t i o n . These gave c o n t r o l of a d m i s s i o n , r e g u l a t i o n , d i s c i p l i n e and f e e s c h e d u l e s t o the p h y s i c i a n s . The q u e s t i o n o f s t a n d a r d s was p a i d o n l y l i p - 36 -s e r v i c e u n t i l the e a r l y 1900's when h o s p i t a l a c c r e d i t a t i o n was i n t r o d u c e d . The e f f e c t s of the d e p r e s s i o n and bad debts made the p h y s i c i a n s a f e r t i l e f i e l d f o r the e s t a b l i s h m e n t o f h e a l t h i n s u r a n c e . D i f f i c u l t n e g o t i a t i o n s l e d t o i t s e s t a b l i s h m e n t and many a m b i g u i t i e s i n the agreement a t t h a t time have l e d t o the c u r r e n t d i s p u t e s and t h e 1980 H a l l Commission. Donnison has s t a t e d t h a t t h e r e a r e two s t a n d - p o i n t s from which p o l i t i c a l p l a n n i n g d e c i s i o n s a re made: economic growth and s o c i a l j u s t i c e . In Canada the b a l a n c e of these two i d e o l o g i e s i s seen i n the development of the w e l f a r e . s t a t e . Lowi d e s c r i b e s t h r e e s t a g e s of government development: d i s t r i b u t i v e , r e g u l a t i v e and r e d i s t r i b u t i v e . Judge i n d i s c u s s i n g the d i s t r i b u t i v e s t a g e says t h a t government can o n l y c o n t r o l r e g u l a t i v e and f i n a n c i a l m a t t e r s . S e r v i c e d e c i s i o n s a r e c o n t r o l l e d by s e r v i c e p r o v i d e r s . R a t i o n a l p l a n n i n g has been attempted by governments t o b r i n g some o r d e r t o t h e system. Because i t i s o n l y one s t a g e o f p l a n n i n g i t b e g i n s t o f a i l when l i n k s between r a t i o n a l p l a n n i n g s t r u c t u r e and the system b e g i n t o d e t e r i o r a t e . The c o n t e x t i n which h e a l t h manpower p l a n n i n g i s conducted i s a complex one. S t r a u s s would c a l l .it an arena f o r the n e g o t i a t i o n o f o r d e r . The problem a r i s e s when the o r d e r which a p p e a l s t o the n a t i o n a l p l a n n e r d i f f e r s from t h a t of the p r o f e s s i o n a l a s s o c i a t i o n . I f t h a t were t o o c c u r i t i s not known i f t h e outcome o f t h a t n e g o t i a t i o n c o u l d t h e n be i n c o r p o r a t e d i n t o Canada's n a t i o n a l i d e o l o g y o f r e s o u r c e development and s o c i a l j u s t i c e . F o o t n o t e s A c c i d e n t a l i n c r e m e n t i s d e f i n e d by Tropman as - 'the a c c u m u l a t i o n of d e c i s i o n s based upon the s i t u a t i o n s w i t h which, an o r g a n i z a t i o n i s c o n f r o n t e d . ' Tropman, John E. e t a l . S t r a t e g i c P e r s p e c t i v e s on S o c i a l  P o l i c y . New Y o r k , Pergamon P r e s s , 1976, p. 2. Friedman, J . A C o n c e p t u a l Model f o r t h e A n a l y s i s o f P l a n n i B e h a v i o r , A d m i n i s t r a t i v e S c i e n c e Q u a r t e r l y , V o l . 12 (2) , September, 19 67, p. 346. 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 . R e p o r t s o f t h e 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 . Government o f Quebec;' 1970-1971. (C. Castonguay and J . Nepveu, Chairmen.) M a n i t o b a . White Paper on H e a l t h S e r v i c e s . Queen's P r i n t e r , Winnipeg, 1972. F o u l k e s , R.G. 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. M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h C o lumbia, V o l . I - I I , December 1973. - 39- -CHAPTER 3 RATIONAL MANPOWER PLANNING • R a t i o n a l p l a n n i n g f o r h e a l t h manpower has been a r e l a t i v e l y r e c e n t phenomenon. I n t e r e s t i n i t r e s u l t s from concerns r e -g a r d i n g t h e r e - d i s t r i b u t i o n o f r e s o u r c e s o u t l i n e d i n Ch a p t e r 1, as i t has r e q u i r e d t h e development o f r e s e a r c h t o o l s t o f a c i l i t a t e t h e p r o c e s s . A. H e a l t h Manpower Research Developments Four major m e t h o d o l o g i c a l c a t e g o r i e s have been i d e n t i f i e d i n th e l i t e r a t u r e : h e a l t h manpower/population r a t i o s ; h e a l t h needs, economic demand; and t h e s e r v i c e t a r g e t approach ( H a l l 19 73). A l t h o u g h , i n some i n s t a n c e s , o t h e r t i t l e s a r e used f o r methods t h e e s s e n t i a l elements w i l l p l a c e a p l a n n i n g a c t i v i t y w i t h i n one o f t h e s e f o u r c a t e g o r i e s . 1. H e a l t h Manpower : P o p u l a t i o n R a t i o s T h i s method, the most p o p u l a r o f t h e manpower r e s e a r c h methods ( S o r k i n 19 77) has been d e f i n e d by H a l l as f o l l o w s : T h i s method i n v o l v e s t h e i d e n t i f i c a t i o n o f a s u i t a b l e h e a l t h manpower : p o p u l a t i o n r a t i o f o r a f u t u r e p o i n t i n time and th e n t h e a p p l i c a t i o n o f t h i s r a t i o t o t h e p r o j e c t e d p o p u l a t i o n t o d e r i v e manpower r e q u i r e m e n t s . Many d i f f e r e n t methods have been used t o d e r i v e t h e d e s i r e d r a t i o s . These i n c l u d e : a) I n t e r n a t i o n a l comparisons b) M a i n t a i n i n g t h e c u r r e n t s i t u a t i o n - 40 -c) Use o f r e c o g n i z e d s t a n d a r d s d) A d o p t i o n o f t h e r a t i o c u r r e n t l y o b s e r v e d i n a f a v o u r e d p o r t i o n o f t h e c o u n t r y e) C o n s t r u c t i o n o f a model u s i n g one o f t h e o t h e r methods, c o n v e r s i o n o f t h e r e q u i r e -ments i n t o a r a t i o , and a d o p t i o n o f t h i s as a s t a n d a r d ^ d) E x t r a p o l a t i o n o f p a s t r a t i o t r e n d l i n e s R e s e a r c h e r s a r e s low t o jump t o t h e d e f e n s e o f t h i s method. H a l l (1978) s u p p o r t e d by K r i e s b e r g (1976) however, has l i s t e d t h r e e advantages t o i t s use: easy t o use and t o i n t e r p r e t ; d a t a r e q u i r e m e n t s u s u a l l y modest and not v e r y s e n s i t i v e t o e r r o r s w i t h i n t h e v a l i d i t y o f t h e u n d e r l y i n g assumptions and; i f c u r r e n t s i t u a t i o n i s judged adequate, maintenance o f s t a t u s quo i s a d e f e n s i b l e p o l i c y . Two a u t h o r s ( S e g a l 1972, Baker 1972) d i s a g r e e w i t h H a l l ' s s i x methods o f d e r i v i n g r a t i o s , s t a t i n g t h a t use o f a manpower : p o p u l a t i o n r a t i o l o c k s one i n t o p r o j e c t i n g the s t a t u s quo. These authors: do n o t a l l o w t h e i n c o r p o r a t i o n o f t h e o t h e r f i v e methods i n t o t h e development of. t h e r a t i o . O t h e r c r i t i c s o f t h e method a r e much more v o c a l . D i s a d v a n t a g e s t o t h e method w h i c h have been i d e n t i f i e d a r e : a) t h a t i t does not i n c l u d e the t o t a l h e a l t h s e c t o r i n development o f r a t i o ( H a l l 19 78, Hansen 19 70, K r i e s b e r g 1976) b) t h e r e i s v e r y l i t t l e supply/demand i n t e r a c t i o n ( H a l l 1978) c) i t tends t o be used w i t h s i n g l e o c c u p a t i o n a l c a t e g o r i e s w i t h t h e r i s k o f i g n o r i n g p o t e n t i a l improvements i n u t i l i z a t i o n t h r o u g h changed i n t e r p e r s o n a l r a t i o s ( H a l l 1973, S e g a l 1972, S o r k i n 1977, Hansen 1970) d) i t does not account f o r demographic changes (Baker 19 72, S e g a l 1972, Hansen 1970, K r i e s b e r g 1976, H a l l 1978, S o r k i n 19 77, Judek 19 64) e) i t i g n o r e s i n c r e a s e d p r o d u c t i v i t y ( S e g a l 19 72, Hansen 1970, S o r k i n 1977, K r i e s b e r g 1976). The c l a s s i c s t u d y u t i l i z i n g p o p u l a t i o n r a t i o n s was conducted by F e i n (1967). A l t h o u g h t h i s s t u d y was more s o p h i s t i c a t e d t h a n i t s p r e d e c e s s o r s , o r t h o s e s t u d i e s which f o l l o w e d , i t s t i l l s u f f e r e d from two major weaknesses ( S e g a l 1972). M i s - s p e c i f i c -a t i o n o f r e l a t i o n s h i p s i n c l u d e d i n t h e a n a l y s i s d i d n o t a l l o w f o r complete c o r r e c t i o n o f f a c t o r s such as income and e d u c a t i o n . S e c o n d l y , some r e l a t i o n s h i p s were o m i t t e d from t h e a n a l y s i s . These i n c l u d e d t h e c o s t o f m e d i c a l c a r e u t i l i z a t i o n , w a i t i n g t i me and changes i n m e d i c a l t e c h n o l o g y . However, many examples o f t h i s approach can be found i n Canadian works. Three w h i c h d e s e r v e mention a r e : Judek's (19 64) work f o r the R o y a l Commission on H e a l t h S e r v i c e s , t h e work o f t h e N a t i o n a l Committee on P h y s i c i a n Manpower (1975) and t h e V i s i o n Care Task F o r c e Report f o r B r i t i s h Columbia (19 77). - 42 -2 . H e a l t h Needs Approach. H a l l (1973) d e f i n e s t h e h e a l t h needs approach as ' s e e k i n g t o d e t e r m i n e , based on e x p e r t o p i n i o n and t a k i n g i n t o a c c o u n t a v a i l a b l e t e c h n o l o g y , what k i n d s , amounts, and q u a l i t y o f l e v e l s o f s e r v i c e s a r e r e q u i r e d t o a t t a i n and m a i n t a i n a h e a l t h y p o p u l a t i o n . S e r v i c e t a r g e t s a r e t h e n c o n v e r t e d i n t o manpower r e q u i r e m e n t s by means o f s t a f f i n g and p r o d u c t i v i t y s t a n d a r d s . C o n s i d e r a t i o n o f s e r v i c e c o s t s and d i s t r i b u t i o n 2 a r e o f secondary i m p o r t a n c e . ' T h i s method i s b a s i c a l l y an e x t e n s i o n o f the S e r v i c e T a r g e t s Approach ( K r i e s b e r g 1976). (See S e c t i o n 4 ) . Advantages t o t h i s approach which have been i d e n t i f i e d a r e more numerous t h a n f o r t h e manpower : p o p u l a t i o n r a t i o method. They a r e t h a t : a) i t i s l o g i c a l , i n t h a t 'what ought t o be' i s used as the r e f e r e n c e p o i n t r a t h e r t h a n s o c i a l and economic c o n d i t i o n s ( K r i e s b e r g 1976, H a l l 1973, S e g a l 1972) b) i t p r o v i d e s u l t i m a t e o r maximum g o a l s f o r the p r o -v i s i o n o f s e r v i c e s ( H a l l 1973) c) i t s importance w i l l i n c r e a s e w i t h t h e h e a l t h s e c t o r ' s a b i l i t y t o measure needs and respond t o them ( H a l l 19 7 8 ) . C r i t i c s l i s t t h e f o l l o w i n g drawbacks t o t h e method: - 43 -a) i t does not n e c e s s a r i l y produce th e most e c o n o m i c a l l y e f f i c i e n t mixes nor a r e the s t a n d a r d s which a r e s e t always the o n l y way o f e f f e c t i v e l y p r o v i d i n g r e q u i r e d t r e a t m e n t ( S e g a l 1972, H a l l 1978, Baker 1972) b) i t f a i l s t o c o n s i d e r t h a t p e r s o n s who cannot a f f o r d t r e a t m e n t a r e not l i k e l y t o g e t i t ( S e g a l 19 72). c) i t i s d i f f i c u l t t o measure f u t u r e i n c i d e n c e i f t e c h -n o l o g y wipes out one d i s e a s e and a n o t h e r becomes more p r e v a l e n t ( S e g a l 1972). d) i t i m p l i c i t l y assumes t h a t such a g o a l i s e c o n o m i c a l l y p o s s i b l e and r e a l i s t i c f o r everyone t o o b t a i n whatever s t a n d a r d i s s e t ( S e g a l 1972., H a l l 1978) . e) d a t a r e q u i r e m e n t s a r e beyond th e c a p a b i l i t i e s o f t h e h e a l t h s t a t i s t i c s systems ( H a l l 1978, B a k e r 1972, K r i e s b e r g 1976) = f) t h e r e i s i n s u f f i c i e n t s e c t o r a l c o n t r o l t o ensure t h a t , when the r e s o u r c e s a r e adequate,' p r o v i d e r s w i l l i n d e e d produce t h e needed s e r v i c e s and consumers use them ( H a l l 1978) . g) t h e r e i s the i n h e r e n t d i f f i c u l t y o f d e v e l o p i n g optimum s t a n d a r d s f o r the management o f many d i s e a s e c o n d i t i o n s and o f e v a l u a t i n g them i n terms o f t h e i r h e a l t h outcome ( H a l l 1978) ,. h) need i s n o t a measure o f p u b l i c demand f o r p r o f e s s i o n a l s e r v i c e s (Baker 1 972) v K r i e s b e r g . (1976) t a k e s t h i s f u r t h e r , s t a t i n g l a c k o f p u b l i c demand can l e a d t o f u t u r e unemployment - 44. -The c l a s s i c s t u d y conducted u s i n g t h i s methodology (and p r o b a b l y t h e major h e a l t h manpower st u d y t o date) was conducted i n 19 33 by Lee and J o n e s . Four t y p e s o f m e d i c a l s e r v i c e s n e c e s s a r y f o r 'good m e d i c a l c a r e ' were d e f i n e d based upon e x p e r t o p i n i o n . I t was then e s t a b l i s h e d how f r e q u e n t l y p e r y e a r d i f f e r e n t age groups would need t h e s e s e r v i c e s and t h e amount o f ti m e nec-e s s a r y t o complete an e x a m i n a t i o n o r s e r v i c e . The p o p u l a t i o n was then d e f i n e d and t h e number o f p h y s i c i a n s r e q u i r e d t o s e r v e them c a l c u l a t e d . Three major c r i t i c i s m s have been made o f t h i s s t u d y . Conducted c l o s e t o f i f t y y e a r s ago, i t does n o t p r o v i d e f o r c h a n g i n g r o l e s o f p r o f e s s i o n a l s , m e d i c a l t e c h n o l o g y o r cha n g i n g i n c i d e n c e p a t t e r n s ( F e i n 1967, S e g a l 1972). S e c o n d l y , i t does not t a k e i n t o a c c o u n t t h e a b i l i t y o f t h e p u b l i c t o purchase t h e s e s e r v i c e s ( S e g a l 1972). T h i r d l y , u t i l i z a t i o n o f s e r v i c e s i s not accou n t e d f o r ( S e g a l 1972) . The Lee-Jones s t u d y was updated i n 1972 by S c h o n f e l d e t a l . , b u t i n c l u d e d o n l y two groups o f p r i m a r y c a r e p h y s i c i a n s ( i n t e r n i s t s and p a e d i a t r i c i a n s ) and e x c l u d e d f a m i l y p h y s i c i a n s . A d d i t i o n a l a t t e m p t s w h i c h have been made t o overcome t h e problems o f t h e h e a l t h , needs method a r e found i n the CENDES/PAHO p l a n n i n g method (19 65) d e v e l o p e d f o r t h e Pan American H e a l t h - 45. -O r g a n i z a t i o n . H a l l (19 78) c i t e s the major d i f f i c u l t y with, t h i s method as b e i n g i t s use o f t h e h e a l t h , needs approach, o n l y i n r e l a t i o n t o d i s e a s e o r s e r v i c e c a t e g o r i e s c o n s i d e r e d t o have a f a v o u r a b l e c o s t - b e n e f i t r a t i o , w h i l e o t h e r c a t e g o r i e s (e.g. c a n c e r , p r i v a t e s e c t o r s e r v i c e s ) l e s s amenable t o p r e v e n t i o n , c u r e , o r p u b l i c s e c t o r i n t e r v e n t i o n a r e accommodated under d i f f e r e n t p l a n n i n g c r i t e r i a . I n Canada, the o n l y s t u d y o f any s i g n i f i c a n c e w h i c h has a t t e m p t -ed t o use any component o f need has been t h a t o f t h e N a t i o n a l Committee on P h y s i c i a n Manpower (1975). T h i s was used o n l y i n some s e c t i o n s o f t h e s t u d y to e s t a b l i s h a manpower : p o p u l a t i o n r a t i o . 3. Economic Demand Approaches Economic demand approaches as d e f i n e d by H a l l (19 73) c o n c e r n the measurements and p r o j e c t i o n o f what h e a l t h s e r v i c e s p e o p l e are w i l l i n g and a b l e t o pay f o r , i r r e s p e c t i v e o f the q u a l i t y o f t h e s p e c i f i c s e r v i c e s o b t a i n e d o r o f t h e i r need f o r them. The s e r v i c e s demanded ten d t o be c u r a t i v e i n n a t u r e and t o be p r o v i d e d p r e d o m i n a n t l y through the p r i v a t e s e c t o r , w i t h o r w i t h o u t the i n t e r v e n t i o n o f t h i r d p a r t y reimbursement, mechanisms. The method c o n s i s t s o f c o r r e l a t i n g j t h e r e c e i p t o f s e r v i c e s with, s e l e c t e d economic and o t h e r v a r i a b l e s , and t h e n p r o j e c t i n g t h e changes l i k e l y t o o c c u r r e g a r d i n g t h e s e v a r i a b l e s , i n o r d e r t o d e r i v e t h e i m p a ct of t h e s e changes on the - 4.6 -demand f o r s e r v i c e s , and u l t i m a t e l y on h e a l t h manpower r e q u i r e -ments. V a r i a b l e s i n c l u d e : a), c o n s t a n t u t i l i z a t i o n r a t e s f o r a c h a n g i n g p o p u l a t i o n , b) p o p u l a t i o n and income c) t r e n d i n e x p e n d i t u r e s , d) . job v a c a n c i e s e) . r e l a t i v e e a r n i n g s . f) r a t e o f r e t u r n . S o p h i s t i c a t i o n o f methods i n t h i s c a t e g o r y range from v e r y s i m p l e a n a l y s i s o f c e r t a i n v a r i a b l e s , such as job v a c a n c i e s , t o complex economic models o f the h e a l t h c a r e system as a whole. Advantages w h i c h have been a t t r i b u t e d t h i s method i n c l u d e : ( H a l l 19 7 3) a) i t h e l p s d e s c r i b e dynamics and d e t e r m i n a n t s o f h e a l t h s e r v i c e s u t i l i z a t i o n b) i t tends t o produce e c o n o m i c a l l y r e a l i s t i c p r o -j e c t i o n s c.) i t a l l o w s f o r d i s a g g r e g a t i o n o f v a r i o u s components o f demand d) i t p r o b a b l y p r o v i d e s a good e s t i m a t e o f t h e minimum growth i n demand and ensures t h a t the l e v e l o f f u t u r e s a t i s f a c t i o n a t l e a s t e q u a l s s a t i s f a c t i o n e) some v a r i a n t s o f t h i s approach a r e q u i t e s i m p l e f) i t may p r o v i d e u s e f u l i n f o r m a t i o n f o r comparing r e t u r n s from t r a i n i n g f o r h e a l t h o c c u p a t i o n s w i t h t h o s e o f o t h e r s e c t o r s . - 4.7 -A d d i t i o n a l advantages c i t e d by Y e t t (19 75) i n c l u d e : a) i t i s b e t t e r f o r s t u d y i n g d i s t r i b u t i o n i m p a c t s b) i t can r e a d i l y e x p l o i t economic t h e o r y t h a t c o n c e n t r a t e s , on i n d i v i d u a l b e h a v i o u r u n i t s . K r i e s b e r g ( 1 9 7 6 ) s t a t e s the advantage t o t h i s method l i e s i n i t s a b i l i t y t o e s t i m a t e r e q u i r e m e n t s which r e l a t e t o j o b o p p o r t u n i t i e s . C r i t i c s o f economic demand methods, as w i t h o t h e r methods, have many p o i n t s t o p u t f o r t h c o n c e r n i n g t h i s method: a) i t may be c o m p l i c a t e d , c o s t l y and r e q u i r e s o p h i s t i c a t e d d a t a ( H a l l 1973, Y e t t 1975) b) i t i g n o r e s many p o l i t i c a l and s o c i e t a l r e a s o n s f o r i m p r o v i n g t h e d i s t r i b u t i o n o f h e a l t h s e r v i c e s ( H a l l 1973) c) i t does not n e c e s s a r i l y t a k e i n t o a c c o u n t t h e q u a l i t y o f s e r v i c e s o r t h e i r r e l e v a n c e t o t h e h e a l t h problems o f t h e c o u n t r y ( H a l l 1973) d) i t may n e g l e c t c o n s i d e r a t i o n o f ways t o improve man-power p r o d u c t i v i t y ( H a l l 19 73) e) i t i s h a r d t o i n t e r p r e t t o h e a l t h s e c t o r a u t h o r i t i e s and t o t h e p u b l i c ( H a l l 1973) f) d a t a e x i s t s a t macro l e v e l b u t i s f a r from p e r f e c t ( Y e t t 19 7 5) - 48 -g) t h e c o n v e n t i o n a l economic model i s d a n g e r o u s l y o v e r -s i m p l i f i e d , i g n o r i n g t h e power o f t h e p h y s i c i a n o v e r t h e l e v e l o f s e r v i c e and c h o i c e o f t e c h n o l o g y and b e i n g n a i v e about t h e p r i c e s e t t i n g p r o c e s s . A p o p u l a r economic demand method i n Canada, c u r r e n t l y , i s t h e jo b vacancy o r c o u n t i n g - u p - j o b - s l o t s approach ( S e g a l 19 72). B r i t i s h Columbia i n i t s D i f f i c u l t - t o - F i l l - V a c a n c y M o n i t o r i n g System (1979) has f o l l o w e d Saskatchewan and A l b e r t a ' s e a r l i e r l e a d i n t h i s endeavour. A t a n a t i o n a l l e v e l some at t e m p t s o f t h i s k i n d have been made i n t h e p a s t w i t h t h e j o b vacancy s u r v e y . Some a t t e m p t s have been made t o a b s t r a c t h e a l t h o c c u p a t i o n d a t a (Imai 19 74) . A major s t u d y r e c e n t l y completed f o r t h e Canadian D i e t e t i c A s s o c i a t i o n (HMRU 19 80) used t h i s method t o i n v e s t i g a t e t h e r e q u i r e m e n t s f o r d i e t e t i c manpower i n B r i t i s h Columbia. I t was b e l i e v e d however, t h a t r e s u l t s d i d not t r u l y r e p r e s e n t t h e e x i s t i n g market. S e g a l (19 7 2) l i s t s t h e advantages o f t h i s method as: a) i n f o r m a t i o n can be c o l l e c t e d s t r a i g h t f o r w a r d l y and i n e x p e n s i v e l y , v b) t a r g e t d a t a i s not t o o f a r o f f , and i f t h e i n f o r m a n t s b o t h know t h e i r community w e l l enough t o p r e d i c t t h e growth o f demand and o t h e r f a c t s , such a.scheme might be f a i r l y r e l i a b l e . Weaknesses as s t a t e d by S e g a l i n c l u d e : a) vacancy e s t i m a t e s a r e an u n r e l i a b l e g u i d e t o f u t u r e manpower needs u n l e s s they t a k e i n t o a c c o u n t the e f f e c t o f one a r e a ' s growth on the demand f o r s e r v i c e s i n a n o t h e r a r e a b) i t w i l l n o t have good r e s u l t s u n l e s s demands f o r and s u p p l y o f p e r s o n n e l a r e f a i r l y s t a b l e . 4. S e r v i c e T a r g e t Methods These methods emphasize t h e development o f d e t a i l e d s t a n d a r d s f o r t he p r o v i s i o n o f d i f f e r e n t k i n d s o f s e r v i c e s , s t a n d a r d s which a r e then used t o d e r i v e t a r g e t s f o r t h e p r o d u c t i o n o f t h e s e s e r v i c e s . Manpower s t a f f i n g and p r o d u c t i v i t y s t a n d a r d s a r e t h e n used t o c o n v e r t s e r v i c e t a r g e t s i n t o t h e manpower r e q u i r e d t o a t t a i n them. V a r i o u s methods can be used t o d e v e l o p t h e s e r v i c e s t a n d a r d s , i n c l u d i n g t h o s e used i n t h e h e a l t h needs and t o a l a r g e r e x t e n t , t h e manpower : p o p u l a t i o n r a t i o methods. Other t e c h n i q u e s f o r d e v e l o p i n g s t a n d a r d s i n c l u d e : a) Task and f u n c t i o n a l a n a l y s i s b) E m p i r i c a l e x p e r i e n c e c) P r o f e s s i o n a l judgement d) I n t e r n a t i o n a l l y recommended s t a n d a r d s e) I n t e r n a t i o n a l comparisons. - 50 -The advantages o f t h i s method a r e t h a t ( H a l l 1973): a), i t a l l o w s easy d i s a g g r e g a t i o n o f h e a l t h s e r v i c e s w h i c h i n t u r n f a c i l i t a t e t h e m a tching o f each component p a r t o f t h e h e a l t h c a r e system. b) c o s t e s t i m a t i o n i s r e l a t i v e l y easy c) i t i s r e l a t i v e l y easy t o i n t e r p r e t the r a t i o n a l e t o o t h e r s . D i s a d v a n t a g e s , a c c o r d i n g t o H a l l , i n c l u d e l a c k o f a l l o w a n c e f o r : a) budgeted v a c a n c i e s t h a t o f f e r n o n - c o m p e t i t i v e s a l a r i e s b) budgeted p o s t s which a r e d e l i b e r a t e l y k e p t v a c a n t c) i n a b i l i t y o f a d m i n i s t r a t i o n t o p r e d i c t needs d) t h e . f a c t t h a t the method i s prone t o h a v i n g s t a n d a r d s based more on d e s i r e s t h a n on r e a l i t y , l e a d i n g t o major p o l i c y e r r o r s , e) t h e f a c t t h a t t h e l o g i c o f the methods i n v i t e s e x c e s -s i v e l y d e t a i l e d p l a n n i n g f o r segments o f t h e s e c t o r not s u b j e c t t o t i g h t c o n t r o l . The N u r s i n g E d u c a t i o n Study Report (1979) f o r t h e P r o v i n c e o f B r i t i s h Columbia i s one example o f t h i s approach. B. L i m i t a t i o n s A number o f l i m i t a t i o n s p l a g u e h e a l t h manpower as an a r e a f o r r a t i o n a l p l a n n i n g . They i n c l u d e b e i n g conducted i n i s o l a t i o n from o t h e r developments i n t h e h e a l t h c a r e f i e l d , dubious - 51 -u s e f u l n e s s o f p r o j e c t i o n s and l a c k o f adequate methodology. 1. I s o l a t i o n from t h e H e a l t h Care System H e a l t h manpower s t u d i e s a r e o f t e n conducted i n i s o l a t i o n from the remainder o f the h e a l t h c a r e system and as such do n o t d e a l w i t h a l l the key i s s u e s i n v o l v e d (Badgley 1971, M e j i a 1979). Badgley l a b e l s h e a l t h , manpower s t u d i e s which have been under-t a k e n as l i t t l e more than m e t h o d o l o g i c a l e x e r c i s e s , p l a y i n g the 'numbers game', y i e l d i n g l i m i t e d i n s i g h t s i n t o t h e c o m p l e x i t i e s o f t h e s o c i a l i s s u e s w i t h w h i c h they d e a l . H a l l (1973) c i t e s t h i s as a major f l a w i n many o f t h e p o p u l a r r e s e a r c h methods used. Three r e a s o n s have been g i v e n f o r i t s o c c u r r e n c e : ; a l a c k o f h e a l t h c a r e p o l i c y and f r a g m e n t a t i o n w i t h i n t h e h e a l t h system ( H a l l 19 78); f a i l u r e t o acknowledge t h a t h e a l t h manpower p r i o r i t i e s have changed r e t a i n i n g the b e l i e f t h a t more i s b e t t e r . ( G i n z b e r g 19 78); and p r i m i t i v e methods t o model t h e h e a l t h c a r e market (Hansen 1970, H a l l 1973). H a l l (.19 78) contends t h a t components o f t h e h e a l t h , system f u n c t i o n l a r g e l y i n i s o l a t i o n from each o t h e r . The r e s u l t i s a fragmented approach t h a t l e a d s t o p o l i c i e s , p l a n s , and a c t i v i t i e s which o v e r l a p w a s t e f u l l y o r c o n f l i c t w i t h each o t h e r and, i n many i n s t a n c e s , t a c k l e the wrong problems. T h i s - 52 -i s r e f l e c t e d i n manpower research, and p l a n n i n g a t t e m p t s . G i n z b e r g (19 78) speaks o f t h e s a c r e d cows w h i c h pervade t h e f i e l d o f h e a l t h manpower. The f i r s t o f the s e i s t h e deep-s e a t e d b e l i e f t h a t a d d i t i o n a l h e a l t h manpower w i l l r e s u l t i n improved c a r e and, c o n s e q u e n t l y , i n improved h e a l t h . T h i s b e l i e f i s not c o m p a t i b l e w i t h r e d i s t r i b u t i o n t h e o r y , nor i s i t c o m p a t i b l e w i t h c u r r e n t e v a l u a t i o n s t u d i e s . Economics d i c t a t e t h a t more i s n o t n e c e s s a r i l y f e a s i b l e and a l t e r n a t i v e s such as s u b s t i t u t i o n ( B u t t e r 1967) and r e d i s t r i b u t i o n must be c o n s i d e r e d . B u t t e r (1967) i l l u s t r a t e s t h i s i n h e r c r i t i q u e o f F e i n ' s (1967) a t t e m p t t o e s t i m a t e the f u t u r e r e q u i r e m e n t s f o r p h y s i c i a n s . She argues t h a t a l t h o u g h h i s s t u d y i s s u p e r i o r t o p r e v i o u s ones making use o f an a n a l y t i c a l framework f o r t h e s t u d y o f h e a l t h manpower and o f more s o p h i s t i c a t e d e s t i m a t i o n methods, i t f a i l s t o d e v e l o p e s t i m a t e s o f f u t u r e r e q u i r e m e n t s . H a l l (19 73) c i t e s a n o t h e r r e a s o n f o r i s o l a t i o n when he speaks o f t h e l a c k o f s o p h i s t i c a t i o n i n h e a l t h manpower r e s e a r c h . T h i s i s combined w i t h t h e i n a b i l i t y o f r e s e a r c h e r s t o d e v i s e a model t o d e a l w i t h the e n t i r e h e a l t h system and t h e h e a l t h manpower market i n p a r t i c u l a r . Hansen (19 70) s t a t e s t h i s does not a l l o w f o r i n c o r p o r a t i o n o f many b a s i c i s s u e s . Some a t t e m p t s have been made i n the U n i t e d S t a t e s t o d e v e l o p such a model ( Y e t t 19 75, N avarro 19 6 9 ) . These models have been e c o n o m e t r i c i n n a t u r e , e x amining t h e problem a t a macro l e v e l . Lipscome - 53 -e t a l . . (1976) have a t t e m p t e d a q u a s i - e p i d e m i o l o g i c a l approach, t o the problem a t a m i c r o l e v e l w i t h t h e Papago I n d i a n R e s e r v a t i o n o f A r i z o n a . Canadian a t t e m p t s i n t h i s a r e a a r e al m o s t n o n - e x i s t e n t with, the p o s s i b l e e x c e p t i o n o f t h e V i s i o n Care Task F o r c e i n B.C. (.1977) . B u t t e r (1967) d e s c r i b e s the d i f f i c u l t y f u r t h e r when she p o i n t s o u t t h a t the demands f o r ) h e a l t h manpower a r e e x t r e m e l y d i f f i c u l t t o e s t i m a t e and measure. T h i s i s because i t i s d e r i v e d from t h e demand f o r h e a l t h c a r e , which e n t a i l s a v a r i e t y o f heterogeneous s e r v i c e s produced j o i n t l y by a v a r i e t y o f h e a l t h p e r s o n n e l i n c o n j u n c t i o n w i t h n o n - l a b o u r i n p u t s . 2. Q u e s t i o n s r e : U s e f u l n e s s o f H e a l t h Manpower P r o j e c t i o n s Hansen (1970), i n an a p p r a i s a l o f p h y s i c i a n manpower p r o j e c t i o n s , r a i s e s q u e s t i o n s c o n c e r n i n g t h e methodology o f making p r o j e c t i o n s , t h e i r p u r p o s e s , and t h e u s e f u l n e s s o f p o l i c y recommendations which f l o w from them. H i s e x a m i n a t i o n o f p h y s i c i a n p r o j e c t i o n s t o t h a t d a t e showed e s t i m a t e s which p r e d i c t e d e i t h e r an o v e r -abundance or a s h o r t f a l l t o o c c u r i n 19 75. He c o n c l u d e s t h a t w i t h t h e p o s s i b l e e x c e p t i o n o f p h y s i c i a n s , who r e q u i r e many y e a r s l e a d t i m e f o r t r a i n i n g , a t t e m p t s a t p r o j e c t i o n s a re a somewhat u s e l e s s e f f o r t . H i e s t a n d (1976) i n d i c a t e s f u r t h e r problems i n h e r e n t i n t h e p r o c e s s t h r o u g h t h e r e l a t i v e l y s h o r t p e r i o d o f t i m e . i n w h i c h - 54 -demand f o r manpower may s h i f t . T h i s problem became e v i d e n t i n B r i t i s h Columbia i n 19 78 when Long Term Care Program was i n i t i a t e d and r e q u i r e m e n t s f o r c e r t a i n c a t e g o r i e s o f workers grew phenomenally o v e r n i g h t . I n t h i s i n s t a n c e p r o j e c t i o n s c o u l d not have p r e d i c t e d even b a l l p a r k f i g u r e s as t o f u t u r e demand. S o r k i n (19 77) p o i n t s o u t t h a t i n a d e q u a t e f i n a n c i a l r e s o u r c e s l i m i t t h e number o f manpower groups which can be s t u d i e d and t h e r e f o r e t h e degree t o which a p p r o p r i a t e p r o j e c t i o n s can be made. The m a j o r i t y o f n a t i o n a l and p r o v i n c i a l s t u d y e f f o r t s have been dev o t e d t o examining r e q u i r e m e n t s f o r p h y s i c i a n s and n u r s e s . 3• Lack o f S o p h i s t i c a t e d Methodology The r e l a t i v e y o uth o f manpower r e s e a r c h has r e s u l t e d i n a g e n e r a l l a c k o f s o p h i s t i c a t i o n i n t h e methodology. Three main areas o f weakness have been i d e n t i f i e d i n t h e l i t e r a t u r e : The absence o f a s o l i d a n a l y t i c a l base ( B u t t e r 1967, H a l l 1973, H i e s t a n d 1976, M e i j a 19 79); t h e s u p p l y o r i e n t a t i o n o f most m e t h o d o l o g i c a l a t t e m p t s ( H a l l 19 7 3 ) ; and t h e f a i l u r e t o i n -c o r p o r a t e a l l n e c e s s a r y elements i n t o d e s i g n ( d i s c u s s e d e a r l i e r by B a d g l e y 1971). B u t t e r (196 7) has i d e n t i f i e d t h e absence o f a s o l i d a n a l y t i c a l - 55. -base as a major weakness i n at t e m p t s t o p r o j e c t r e q u i r e m e n t s . H a l l (.1973) has p o i n t e d t o t h i s as a f l a w i n d e v e l o p i n g more s o p h i s t i c a t e d models. Refinement o f p r o j e c t i o n s i s d i r e c t l y r e l a t e d t o t h e q u a n t i t y and q u a l i t y o f d a t a a v a i l a b l e . The l e a s t s o p h i s t i c a t e d and r e l i a b l e method - t h e p o p u l a t i o n r a t i o method-is most o f t e n based upon i n a d e q u a t e d a t a . H a l l (19 73) i n h i s r e v i e w o f c a t e g o r i e s o f h e a l t h manpower r e s e a r c h methods, has i n d i c a t e d most r e s e a r c h e f f o r t s a r e un-b a l a n c e d , p l a c i n g too much emphasis on t h e s u p p l y s i d e o f t h e e q u a t i o n . He a t t r i b u t e s t h i s t o t h e e x i s t e n c e o f t h e a v a i l -a b i l i t y o f more e x t e n s i v e d a t a on s u p p l y . Anderson (1976) i l l u s t r a t e s t h i s when he d e s c r i b e s t h e c o m p o s i t i o n o f t h e h e a l t h manpower d a t a base i n B r i t i s h Columbia. T h i s document, r e v i s e d by Manning (1979), shows t h a t t h e s i t u a t i o n has become more e x a g g e r a t e d s i n c e 19 76 w i t h t h e i n c o r p o r a t i o n o f a d d i t i o n a l s u p p l y d a t a w i t h o u t an i n c r e a s e i n demand o r need i n f o r m a t i o n . R e p o r t s produced, n a t i o n a l l y ( A z i z 19 74) show a predominance o f s u p p l y i n f o r m a t i o n w i t h l i t t l e a t t e n t i o n t o demand a s p e c t s . Few e x c e p t i o n s t o t h i s emphasis a t a n a t i o n a l i n-house l e v e l e x i s t . However, t h o s e which do t a k e r e q u i r e m e n t s i n t o a c c o u n t s h o u l d be acknowledged ( A z i z 1973, Imai 1974, Ahamad 1969). A t the p r o v i n c i a l l e v e l , ongoing manpower e f f o r t s f o c u s upon d e s c r i p t i o n s and a c c o u n t s o f manpower s u p p l y . These a r e u s u a l l y e n c a p s u l a t e d i n a n n u a l o r b i a n n u a l p u b l i c a t i o n s . - 56 -i n c l u d i n g a l l h e a l t h manpower c a t e g o r i e s (e.g. R o l l c a l l 79) . S t u d i e s which address r e q u i r e m e n t s u s u a l l y i n v o l v e the e s t a b l i s h m e n t o f a s p e c i a l committee charged w i t h the mandate of c o l l e c t i n g v a s t amounts o f demand d a t a t o address the q u e s t i o n . At a n a t i o n a l l e v e l two c l a s s i c examples are the R o y a l Commission on H e a l t h S e r v i c e s (1964) and the N a t i o n a l Committee on P h y s i c i a n Manpower (1975). P r o v i n c i a l l y , the V i s i o n Care Task Force (1977) and the A d v i s o r y Committee on M e d i c a l Manpower (1979) had t h i s mandate. The degree t o which each f u l f i l l e d i t v a r i e s . Summary C h a p t e r t h r e e reviewed the f o u r major r a t i o n a l p l a n n i n g m e t h o d o l o g i e s f o r h e a l t h manpower r e s e a r c h and t h e i r l i m i t a t i o n s . The ease w i t h which the p o p u l a t i o n : h e a l t h manpower r a t i o method can be used was examined a l o n g w i t h the l a c k of s o p h i s t i c a t i o n o f the method. The h e a l t h needs method was p r a i s e d f o r i t s l o g i c and i t s a b i l i t y t o p r o v i d e maximum g o a l s ; however, the f a c t t h a t i t i g n o r e d economic c o n s i d e r a t i o n s and r e q u i r e d e x t e n s i v e d a t a d i d not add t o i t s p o p u l a r i t y . Economic demand approaches v a r i e d i n t h e i r degree of s o p h i s t i c a t i o n and were c o n s i d e r e d t o be u s e f u l , however, they t o o r e q u i r e d e x t e n s i v e d a t a . S e r v i c e t a r g e t a p p r o a c h e s , a l t h o u g h l o g i c a l and r e l a t i v e l y s i m p l e t o u s e , r e l y h e a v i l y upon d e s i r e s r a t h e r than f a c t . Three major problems were a s s o c i a t e d w i t h a l l r a t i o n a l p l a n n i n g i n h e a l t h manpower. Most s t u d i e s were conducted on h e a l t h manpower al o n e and g e n e r a l l y i n i s o l a t i o n from the dynamics o f the h e a l t h c a r e system i n g e n e r a l . The u s e f u l n e s s o f p r o j e c t i o n s i n g e n e r a l was q u e s t i o n e d i n view o f l a g time i n e d u c a t i o n and system changes. The g e n e r a l l a c k of s o p h i s t i c a t e d methodology does not s e r v e t o enhance the a p p e a l o f any of the methods used. Two t h i n g s become i m m e d i a t e l y apparent when r e v i e w i n g e x i s t i n g h e a l t h manpower methodology. F i r s t l y , no method i s i n i t s e l f unique., Each i n c o r p o r a t e s some v a r i a b l e s and t e c h n i q u e s found i n o t h e r methods. S e c o n d l y , no one method i s p e r f e c t . A l l methods are r e l a t i v e l y new and r e q u i r e development. - 58 -I t i s however, many of the d i f f i c u l t i e s noted above which l e a d t o problems i n a c c u r a t e l y p r o j e c t i n g f u t u r e r e q u i r e m e n t s . Others such as p o l i t i c a l i n f l u e n c e s w i l l be d i s c u s s e d l a t e r . - 5 9 -F o o t n o t e s 1. H a l l , T. E s t i m a t i n g Requirements and S u p p l y : Where do we s t a n d ? PAHO Confer e n c e on H e a l t h Manpower P l a n n i n g , September 19 73, Ottawa. 2. i b i d . - 60 -CHAPTER 4 HEALTH MANPOWER PLANNING STRUCTURES IN CANADA The p r i o r i t y f o r h e a l t h manpower p l a n n i n g has changed c o n s i d e r -a b l y o v e r t h e p a s t f i f t y y e a r s . The r a p i d e v o l u t i o n o f manpower p l a n n i n g a c t i v i t i e s i n t h e e a r l y s e v e n t i e s b r o u g h t about a p r o l i f e r a t i o n o f committees and s t r u c t u r e s as w e l l as c o n s i d e r -a b l e f r a g m e n t a t i o n . These s t r u c t u r e s e x i s t b o t h w i t h i n and o u t -s i d e o f government. Some a r e f o r m a l l y e s t a b l i s h e d on-going committees w h i l e o t h e r s can be c o n s i d e r e d n o t h i n g more t h a n ad hoc v e n t u r e s . T h i s s e c t i o n w i l l f o c u s on t h e f o r m a l committee s t r u c t u r e s e s t a b l i s h e d i n government o v e r the p a s t t e n y e a r s . I t w i l l b e g i n w i t h a b r i e f o v e r v i e w o f s i g n i f i c a n t p l a n n i n g v e n t u r e s p r i o r t o 1970. I t w i l l t h e n r e v i e w f o r m a l n a t i o n a l s t r u c t u r e s and p r o v i n c i a l s t r u c t u r e s w i t h p a r t i c u l a r a t t e n t i o n t o B r i t i s h C olumbia. A l t h o u g h t h e major c o n c e r n o f t h i s c h a p t e r w i l l be b u r e a u c r a t i c s t r u c t u r e s , t h e r o l e o f s p e c i a l committees, f r i n g e and b u f f e r groups, w i l l a l s o be a d d r e s s e d . A. A c t i v i t i e s P r i o r t o 1970 P l a n n i n g i n the h e a l t h manpower f i e l d p r i o r t o t h e 1960's and 1970's r e s t e d p r i m a r i l y w i t h t h e p r o f e s s i o n s . Government l a c k e d - 61 -i n t e r e s t i n t h i s a c t i v i t y , p r i m a r i l y because i t had l i t t l e r e s p o n s i b i l i t y f o r f u n d i n g . P l a n n i n g a c t i v i t i e s were, and t o a g r e a t e x t e n t s t i l l a r e , . s c a t t e r e d , r e s t i n g w i t h p r o f e s s i o n a l a s s o c i a t i o n s , governments a t v a r i o u s l e v e l s , e d u c a t i o n a l i n s t i t u t i o n s , l i c e n s i n g b o d i e s and a v a r i e t y o f o t h e r a g e n c i e s . Attempts t o p l a n were s p o r a d i c , p r i m a r i l y a d d r e s s i n g q u e s t i o n s o f p h y s i c i a n s h o r t a g e s . The f i r s t s i g n i f i c a n t attempt a t p l a n n i n g i n t h i s a r e a i s t o be found i n Saskatchewan w i t h the i n i t i a t i o n o f t h e m u n i c i p a l d o c t o r s 1 system i n 1914. Faced w i t h a d i r e s h o r t a g e o f p h y s i c i a n s , a c t i o n was t a k e n t o a l l o w m u n i c i p a l i t i e s t o l e v y f o r t h e p u r -pose o f p a y i n g the s a l a r y o f a d o c t o r , thus i n t e r f e r i n g w i t h the f r e e market. A l t h o u g h t h e p l a n had a number o f sh o r t c o m i n g s , as a p l a n n i n g / r e c r u i t m e n t method, i t was r e p o r t e d t o be r e l a t i v e l y s u c c e s s f u l . " ^ I t was not u n t i l t h e R o y a l Commission on H e a l t h S e r v i c e s i n 19 64 t h a t government began t o address t h e i s s u e o f t h e immigrant p h y s i c i a n and o f the need f o r Canadian m e d i c a l s c h o o l s t o b e g i n t o meet t h e demands o f t h e c o u n t r y : The Commission's c h i e f c o n c e r n w i t h m e d i c a l e d u c a t i o n i s t h e c a p a c i t y o f t h e m e d i c a l s c h o o l s i n Canada t o g r a d u a t e s u f f i c i e n t s u p p l y o f w e l l q u a l i f i e d p h y s i c i a n s t o meet t h e expanding demands r e s u l t i n g from an i n c r e a s i n g p o p u l a t i o n and a d o u b l i n g o f t h e number o f pe r s o n s who w i l l have t h e i r h e a l t h s e r v i c e s p r e p a i d t h r o u g h e x t e n s i o n o f prepayment t o t h e e n t i r e p o p u l a t i o n , as w e l l as t o meet Canada's i n c r e a s i n g i n t e r n a t i o n a l - 62 -o b l i g a t i o n s t o t r a i n p r o f e s s i o n a l h e a l t h p e r s o n n e l f o r t h e d e v e l o p i n g n a t i o n s . Based upon J u d e k 1 s p r o j e c t i o n o f f u t u r e r e q u i r e m e n t s and recommendations c o n c e r n i n g the e s t a b l i s h m e n t o f a h e a l t h i n s u r a n c e scheme, the Commission recommended l a r g e amounts o f money be d e v o t e d t o t h e t r a i n i n g o f p h y s i c i a n s . T h i s was t o be a c c o m p l i s h e d by t h e p r o v i s i o n o f d i r e c t g r a n t s t o expand e x i s t i n g s c h o o l s and e s t a b l i s h new f a c i l i t i e s . Time has shown the s h o r t c o m i n g s o f t h i s c o u r s e o f a c t i o n , s i n c e i t has n o t c o r r e c t e d t h e c u r r e n t p h y s i c i a n s u r p l u s / d i s t r i b u t i o n problems and has i n c r e a s e d the c o s t o f m e d i c a l c a r e . The Task F o r c e on t h e C o s t s o f H e a l t h i n 19 69 attempted t o address s h o r t a g e s w h i l e recommending ways o f a c h i e v i n g more c o s t e f f e c t i v e d e l i v e r y methods. W h i l e recommending e x p a n s i o n o f e d u c a t i o n a l f a c i l i t i e s t o d e c r e a s e dependency upon immigrant p h y s i c i a n s , t h e Task F o r c e a l s o recommended the development o f a u x i l i a r y p e r s o n n e l t o u n d e r t a k e t a s k s then b e i n g c a r r i e d o u t by p h y s i c i a n s . A l t h o u g h a s i g n i f i c a n t advance i n r a t i o n a l p l a n n i n g , i t has y e t t o see f r u i t i o n i n p r a c t i c e . The most s i g n i f i c a n t outcome o f t h i s r e p o r t was the e s t a b l i s h -ment o f t h e 1 s t N a t i o n a l Conference on H e a l t h Manpower, h e l d i n Ottawa i n October; 1969.. T h i s c o n f e r e n c e l a i d t h e _ f o u n d a t i o n f o r t h e c u r r e n t h e a l t h manpower p l a n n i n g s t r u c t u r e s . - 63 -B. F e d e r a l C o o r d i n a t i o n E f f o r t s (1969-80) The f i r s t n a t i o n a l h e a l t h manpower c o n f e r e n c e was' sponsored by t h e 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 and by t h e A s s o c i a t i o n o f U n i v e r s i t i e s and C o l l e g e s o f Canada. O b j e c t i v e s o f t h e 3 C o n f e r e n c e were to s e c u r e agreement on g u i d e l i n e s f o r : 1. P l a n n i n g t h e d e l i v e r y o f t o t a l h e a l t h s e r v i c e s d u r i n g t h e n e x t decade. 2. D e t e r m i n i n g t h e numbers and q u a l i t y o f h e a l t h manpower r e q u i r e d f o r t h e s e s e r v i c e s . 3. P l a n n i n g t h e e d u c a t i o n o f t h e r e q u i r e d manpower. Among t h e outcomes o f the Co n f e r e n c e was a recommendation t h a t p l a n n i n g groups be e s t a b l i s h e d i n a l l h e a l t h departments, t h a t n a t i o n a l and p r o v i n c i a l h e a l t h c o u n c i l s be e s t a b l i s h e d , and t h a t l a r g e r p r o v i n c e s be d i v i d e d i n t o r e g i o n s f o r purposes o f 4 h e a l t h s e r v i c e s . A second n a t i o n a l c o n f e r e n c e h e l d i n October 19 71, had as i t s purpose: To r e v i e w h e a l t h manpower e d u c a t i o n a l programs f o r t he purpose o f pr o m o t i n g f l e x i b i l i t y , adapt-a b i l i t y and c o o r d i n a t i o n . The r e s u l t s o f t h i s c o n f e r e n c e were more s i g n i f i c a n t t h a n t h o s e o f i t s p r e d e c e s s o r . By May o f 1972 the F e d e r a l / P r o v i n c i a l H e a l t h Manpower Committee had been c r e a t e d w i t h a t e c h n i c a l sub-committee t o examine H e a l t h Manpower I n v e n t o r y Data. The - 64 -Terms o f R e f e r e n c e adopted by t h e Committee i n November of 1972 were: 1. To s e r v e as a F e d e r a l / P r o v i n c i a l c l e a r i n g house o f manpower i n f o r m a t i o n . 2. To d e v e l o p : a) a l i s t o f e s s e n t i a l h e a l t h o c c u p a t i o n s t o g e t h e r w i t h scopes o f p r a c t i c e and a n a t i o n a l s t a n d a r d o f nomenclature o f t i t l e s , b) a n a t i o n a l i n v e n t o r y o f h e a l t h s e r v i c e s p e r s o n n e l by q u a l i f i c a t i o n , p l a c e o f work, and f i e l d o f employment, c) a n a t i o n a l i n v e n t o r y o f approved t r a i n i n g i n s t i t u t i o n s f o r the e s s e n t i a l h e a l t h o c c u p a t i o n s , d) n a t i o n a l s t a n d a r d s f o r the a c c r e d i t a t i o n o f t r a i n i n g programmes f o r the r e c o g n i t i o n o f q u a l i f i c a t i o n s . 3. To make n a t i o n a l h e a l t h manpower e s t i m a t e s t h a t r e f l e c t h e a l t h s e r v i c e s r e q u i r e m e n t s , p r o d u c t i o n , m i g r a t i o n and o t h e r d e t e r m i n i n g f a c t o r s . 4. To i d e n t i f y n a t i o n a l manpower imbalances as t o numbers, g e o g r a p h i c d i s t r i b u t i o n and types o f p r a c t i t i o n e r s , and t o d e v e l o p g e n e r a l g u i d e l i n e s t h a t would be u s e f u l on a n a t i o n a l b a s i s f o r the development, d i s t r i b u t i o n and u t i l i z a t i o n o f h e a l t h manpower. 5. To m o n i t o r n a t i o n a l and r e g i o n a l t r e n d s i n h e a l t h m a t t e r s as may be e v i d e n c e d by v a r i o u s h e a l t h s e r v i c e s arrangements, th e e x p a n s i o n and a l t e r a t i o n s o f t h e r o l e s o f h e a l t h w o r k e r s , t h e emergence o f new c a t e g o r i e s f o r w o r k e r s , th e c h a n g i n g h e a l t h needs o f g e n e r a l o r - 65 -p a r t i c u l a r p o p u l a t i o n g r o u p i n g s and the o p e r a t i o n a l p o l i c i e s o f p r o v i n c i a l governments as they might a f f e c t h e a l t h manpower, i 6. To i d e n t i f y r e q u i r e m e n t s and o p p o r t u n i t i e s f o r i n t e r -p r o v i n c i a l c o o p e r a t i o n and t o p a r t i c i p a t e i n such o t h e r a c t i v i t i e s c o n s i d e r e d t o be m u t u a l l y advantageous as r e g a r d s h e a l t h manpower p r o d u c t i o n and u t i l i z a t i o n . The terms o f r e f e r e n c e were n ot a m b i t i o u s , d e s c r i b i n g t h e Committee b a s i c a l l y as an i n f o r m a t i o n exchange mechanism r a t h e r t h a n one wh i c h c o u l d p l a y much o f a c o o r d i n a t i o n r o l e . I n May o f 19 73, t h e Committee d e v e l o p e d and r e l e a s e d a 'He a l t h Manpower Development Program f o r Canada' d e s c r i b i n g t h e Committee's o b j e c t i v e s , g o a l s and methods f o r the f i s c a l y e a r 1973/1974 (Appendix G) .. S i m i l a r work p l a n s were p r e p a r e d f o r 1974/1975, and 1975/1976. I n s p i t e o f i t s - terms o f r e f e r e n c e , t h e Committee attempted an a m b i t i o u s work p l a n f o r i t s f i r s t y e a r o f o p e r a t i o n . Many o f the t a s k s l i s t e d f o r t h a t y e a r a r e s t i l l on t h e 19 80/19 81 work s c h e d u l e and have y e t t o be done. The Committee has undergone v e r y few changes d u r i n g i t s e i g h t y e a r , n i n e t e e n m e e t i n g s ' l i f e t i m e . However some n o t e -a b l e changes', d i d o c c u r . I n 19 76 d i s c u s s i o n s began w i t h i n the Committee r e g a r d i n g i t s i n a b i l i t y t o e f f e c t p o l i c y . Two o r t h r e e y e a r s were t h e n s p e n t r e v i e w i n g the terms o f r e f e r e n c e f o r the Committee. New terms f i n a l l y r e c e i v e d a p p r o v a l by b o t h t h e - 6,6 -Committee i t s e l f and i t s p a r e n t body, t h e C o u n c i l o f Deputy M i n i s t e r s i n 1979. The outcome o f t h i s was t h e e s t a b l i s h m e n t o f f o r m a l r e p o r t i n g r e l a t i o n s h i p s and g u i d e l i n e s f o r i n v e s t -i g a t i o n . A second change b r o u g h t about i n June 19 79 was t o t r a n s f e r t h e c h a i r m a n s h i p o f the Committee from t h e f e d e r a l government t o a r e p r e s e n t a t i v e o f one o f the p r o v i n c e s . T h i s C h a i r m a n s h i p was t o be on a one y e a r r o t a t i n g b a s i s . I t r e s u l t e d from a b e l i e f by t h e Committee t h a t t h e r e was a l a c k o f commitment by t h e f e d e r a l government t o h e a l t h manpower p l a n n i n g and t h a t t h e needs o f the p r o v i n c e s and t h e Committee as a whole, m i g h t be b e t t e r s e r v e d by a p r o v i n c i a l chairman. To d a t e t h e r e has been b u t one p r o v i n c i a l chairman. I n 19 80 t h e time came f o r t r a n s f e r o f t h e p o s i t i o n t o a n o t h e r p r o v i n c e , b u t t h e r e i s a r e l u c t a n c e t o a c c e p t t h e r e s p o n s i b i l i t y . C. C o l l a b o r a t i o n between H e a l t h and E d u c a t i o n I n t h e e a r l y y e a r s o f t h e Committee's l i f e , t h e j u r i s d i c t i o n a l o v e r l a p s between h e a l t h manpower and e d u c a t i o n became ap p a r e n t . I t was b e l i e v e d a p p r o p r i a t e t o i n v i t e p o s t - s e c o n d a r y e d u c a t i o n r e p r e s e n t a t i v e s from t h e p r o v i n c e s t o j o i n t h e Committee; i n a d d i t i o n , a r e p r e s e n t a t i v e from the C o u n c i l o f M i n i s t e r s o f E d u c a t i o n a t t e n d e d t h e meetings as an o b s e r v e r . The f o u r w e s t e r n p r o v i n c e s were the f i r s t t o send d u a l r e p r e s e n t a t i o n , f o l l o w e d soon a f t e r by O n t a r i o . To d a t e , although, encouraged - 67. -t o do s o , none o f t h e o t h e r p r o v i n c e s o r t e r r i t o r i e s have p r o -v i d e d d u a l r e p r e s e n t a t i o n w i t h t h e e x c e p t i o n o f Quebec wh i c h r e c e n t l y d i d so (June 19 8 0 ) . I n A p r i l 1974 t h e Western P o s t - S e c o n d a r y C o o r d i n a t i n g Committee r e q u e s t e d t h e f o r m a t i o n o f a H e a l t h Manpower Requirements Sub-committee. The Western P o s t - S e c o n d a r y C o o r d i n a t i n g Committee i s c o m p r i s e d o f s e n i o r o f f i c i a l s from p o s t - s e c o n d a r y e d u c a t i o n m i n i s t r i e s i n t h e f o u r w e s t e r n p r o v i n c e s . I t has been charged w i t h t h e r e s p o n s i b i l i t y o f i d e n t i f y i n g and c o o r d i n a t i n g p o s t secondary t r a i n i n g r e q u i r e m e n t s i n the w e s t e r n p r o v i n c e s . F o r m a t i o n o f t h e H e a l t h Manpower Sub-committee a r o s e from the d e s i r e t o examine, and c o o r d i n a t e h e a l t h p e r s o n n e l t r a i n i n g programs i n t h e west. The sub-committee i s c o m p rised o f two s e n i o r o f f i c i a l s , one r e p r e s e n t i n g the department r e s p o n s i b l e f o r h e a l t h and t h e o t h e r r e p r e s e n t i n g t h e department r e s p o n s i b l e f o r p o s t - s e c o n d a r y e d u c a t i o n i n each p r o v i n c e . The f o c u s o f t h i s sub-committee's a c t i v i t i e s so c l o s e l y a p p r o x i m a t e d t h e a c t i v i t i e s o f the f e d e r a l / p r o v i n c i a l committee, t h a t r e p r e s e n t -a t i v e s on one u s u a l l y s a t on t h e o t h e r . The g e n e r a l mandate f o r t h e sub-committee i s t o promote c l o s e l i a i s o n and communication i n t h e h e a l t h manpower f i e l d on a W estern Canada b a s i s . S p e c i f i c a l l y , the sub-committee's f u n c t i o n s are:. - 6.8 -a) t o d e t e r m i n e t h e t r a i n i n g needs f o r h e a l t h c a r e p e r s o n n e l ; . b) t o d e v e l o p i n t e g r a t e d p l a n n i n g f o r t h e d e l i v e r y o f e d u c a t i o n a l programs f o r h e a l t h p e r s o n n e l ; and c) t o make recommendations t o the Western Canada P o s t -Secondary C o o r d i n a t i n g Committee. T h i s Committee p o s s e s s e s a f a r s t r o n g e r mandate than d i d t h e f e d e r a l committee as w e l l as some consensus between the p r o -v i n c e s c o n c e r n i n g t h e problems a t hand and t h e o b j e c t i v e s o f t h e p r o c e s s . I n Western Canada t h i s sub-committee has emerged as t h e c e n t r a l f o c u s f o r manpower p l a n n i n g and c o o r d i n a t i o n . D. H e a l t h Manpower P l a n n i n g S t r u c t u r e s i n B r i t i s h Columbia I n F e b r u a r y o f 19 72 the M i n i s t e r o f H e a l t h , t h e H o n orable Mr. Ralph L o f f m a r k , i n a ccordance w i t h t h e r e g u l a t i o n s o f t h e H o s p i t a l A c t , e s t a b l i s h e d a M e d i c a l Manpower Committee. It-'s o v e r a l l mandate was t o address r e q u i r e m e n t s f o r p h y s i c i a n s , g i v i n g p a r t i c u l a r a t t e n t i o n t o s h o r t a g e s , s u r p l u s e s , d i s t r i b u t -i o n a l problems, and i n c e n t i v e programs. The urgency o f t h e s h o r t a g e p r oblem d i c t a t e d t h a t t h e Committee dev o t e i t s e n e r g i e s t o s h o r t a g e q u e s t i o n s and c r i s i s s i t u a t i o n s r a t h e r t h a n attempt t o f u l f i l l i t s e n t i r e mandate. - 6.9 -The c r e a t i o n o f t h e F e d e r a l / P r o v i n c i a l Committee l a t e r t h a t y e a r b r o u g h t w i t h i t t h e n e c e s s i t y o f d e v e l o p i n g a p r o v i n c i a l h e a l t h manpower committee t o l i n k w i t h i t s f e d e r a l c o u n t e r p a r t . The f o l l o w i n g r e p r e s e n t a t i o n had been suggested by t h e H e a l t h Manpower Development Program: a) each p r o v i n c i a l department o f h e a l t h w i l l d e s i g n a t e a p e r s o n t o be o r to p e r f o r m a f u n c t i o n as D i r e c t o r o f H e a l t h Manpower ( P r o v i n c i a l D i r e c t o r ) ; b) P r o v i n c i a l D i r e c t o r s s h o u l d by the end o f 19 74 a c q u i r e t h e n e c e s s a r y a u t h o r i t y and s u p p o r t s t a f f t o manage o r c o o r d i n a t e p r o v i n c i a l h e a l t h manpower development programs ( P r o v i n c i a l Program). P r i o r i t y f o r t h e e s t a b l i s h m e n t o f p r o v i n c i a l manpower committees v a r i e d from p r o v i n c e t o p r o v i n c e . Where r e s o u r c e s were a v a i l -a b l e and p r i o r i t y f o r h e a l t h manpower p l a n n i n g h i g h , committees were q u i c k l y e s t a b l i s h e d . I n o t h e r p r o v i n c e s , t h e low p r i o r i t y a c c o r d e d h e a l t h manpower p l a n n i n g and u n a v a i l a b i l i t y o f r e s o u r c e s meant t h a t f o r m a l s t r u c t u r e s were slow i n emerging. Some p r o v i n c e s s t i l l do not have manpower p l a n n i n g committees and v e r y few p o s s e s s p l a n n i n g o r r e s e a r c h components. Appendix D d e s c r i b e s t h e n a t i o n a l and p r o v i n c i a l committee s t r u c t u r e s as they were i n 19 78. B r i t i s h Columbia was t h e f i r s t p r o v i n c e t o commit i t s e l f t o a p r o v i n c i a l ' h e a l t h manpower p l a n n i n g committee, e s t a b l i s h i n g t h e H e a l t h Manpower Working Group i n 19 72. - 70 " The c r e a t i o n o f t h i s Committee began t h e demise o f t h e p r o -v i n c i a l M e d i c a l Manpower Committee e s t a b l i s h e d i n 1972 by t h e M i n i s t e r o f H e a l t h . By l a t e 1973 . t h a t c o m m i t t e e had been di s b a n d e d and i t s f u n c t i o n s assumed by the H e a l t h Manpower Working Group. I n i t s e a r l y days th e Working Group was comprised o f the t h r e e Deputy M i n i s t e r s o f H e a l t h -- H o s p i t a l I n s u r a n c e , P u b l i c H e a l t h and M e n t a l H e a l t h - t h e Chairman o f the M e d i c a l S e r v i c e s Commission and a r e p r e s e n t a t i v e from t h e M i n i s t r y o f E d u c a t i o n . T h i s membership has been a l t e r e d numerous ti m e s o v e r t h e e i g h t y e a r h i s t o r y o f t h e Committee. R e p r e s e n t a t i o n from t h e M i n i s t r y o f H e a l t h has v a r i e d due t o o r g a n i z a t i o n a l . s h i f t s w i t h i n t h e M i n i s t r y , and t h e p r i o r i t y i t has p l a c e d upon h e a l t h manpower p l a n n i n g a t v a r i o u s t i m e s . I n 19 74 t h e M i n i s t r y o f Labour was r e q u e s t e d t o p r o v i d e r e p -r e s e n t a t i o n t o t h e Working Group. T h i s was t o f a c i l i t a t e communication w i t h the Manpower Needs Committee o f t h a t M i n i s t r y and p r o v i d e i n p u t r e g a r d i n g i m m i g r a t i o n and l a b o u r m a t t e r s . A t t h e r e q u e s t o f t h e C o l l e g e o f P h y s i c i a n s and Surgeons, an o b s e r v e r was s e n t from t h e C o l l e g e t o Working Group m e e t i n g s . T h i s p r a c t i c e , i n i t i a t e d i n 1975, was d i s c o n t i n u -ed i n 1978. . Terms o f r e f e r e n c e f o r t h e H e a l t h Manpower Working Group a c c e p t e d i n 19 73, were as f o l l o w s : 1. To a d v i s e Departments*-and M i n i s t e r s on m a t t e r s r e l a t i n g t o h e a l t h manpower p r o d u c t i o n , a t t r i t i o n , m i g r a t i o n , p a t t e r n s o f p r a c t i c e , t r a n s f e r o f f u n c t i o n s and geo-g r a p h i c l o c a t i o n ; 2. To recommend on t h e conduct o f r e s e a r c h and t o a r r a n g e c o n t r a c t s f o r n e c e s s a r y development s t u d i e s done o u t -s i d e t h e government s e r v i c e ; 3. To r e c e i v e r e p o r t s and comment on m a t t e r s p e r t a i n i n g t o t h e F e d e r a l / P r o v i n c i a l H e a l t h Manpower Committee; 4. To r e c e i v e r e p o r t s and a d v i s e on a p p r o p r i a t e a c t i o n a r i s i n g from e x p e r t committees and p r o f e s s i o n a l committees e s t a b l i s h e d i n d e p e n d e n t l y t o d e a l w i t h more s p e c i f i c m a t t e r s o f h e a l t h manpower. The r o l e o f t h e Working Group as o u t l i n e d i n i t s terms o f r e f e r e n c e was weak. Any a b i l i t y i t would have t o f u n c t i o n as an e f f e c t i v e p o l i c y / p l a n n i n g committee was t o be found not i n i t s mandate b u t r a t h e r i n i t s membership. Changes i n the o r g a n i z a t i o n a l s t r u c t u r e o f government M i n i s t r i e s d u r i n g the l a t e 1970's l e f t o n l y one deputy m i n i s t e r i n each m i n i s t r y , w i t h a number o f a s s i s t a n t d e p u t i e s . T h i s change was t h e f i r s t i n a s e r i e s o f e v e n t s which r a d i c a l l y a l t e r e d t h e membership o f t h e Committee. By 1978 the Committee l a c k e d teeth b o t h i n terms o f i t s membership and i t s mandate. A t t h a t - 72 -s t a g e , a d e c i s i o n was made t o r e v i e w and r e v i s e t h e terms o f r e f e r e n c e , b r i n g i n g them more i n t o l i n e w i t h t h e newly d e v e l o p -ed o b j e c t i v e s o f t h e M i n i s t r y o f H e a l t h and i t s o r g a n i z a t i o n a l s t r u c t u r e . The r e v i s e d terms o f r e f e r e n c e o f the H e a l t h Man-power Working Group a r e as f o l l o w s : Terms o f R e f e r e n c e 1. To recommend and a d v i s e on a p p r o p r i a t e p o l i c y r e g a r d -i n g t h e growth, development and c o n t r o l o f h e a l t h man-power i n the P r o v i n c e . 2. To e s t a b l i s h p r i o r i t y a r e a s f o r h e a l t h manpower r e s e a r c h i n t h e P r o v i n c e and t o a r r a n g e f o r t h i s r e s e a r c h t o be conducted. 3. To a d v i s e t h e Deputy M i n i s t e r o f H e a l t h on a p p r o p r i a t e a c t i o n r e g a r d i n g the r e s u l t s o f r e s e a r c h conducted i n t h e a r e a o f h e a l t h manpower. 4. To address o r respond t o s p e c i f i c manpower c o n c e r n s , c o n s u l t i n g w i t h e x p e r t committees, p r o f e s s i o n a l a s s o c i a t i o n s , t h e M i n i s t r i e s o f L a bour, E d u c a t i o n and U n i v e r s i t i e s , S c i e n c e & Communication and o t h e r a g e n c i e s o r M i n i s t r i e s as n e c e s s a r y . 5. To r e c e i v e r e p o r t s a d d r e s s i n g s p e c i f i c c o n cerns and t a k e a c t i o n where n e c e s s a r y o r a d v i s e t h e Deputy M i n i s t e r on a p p r o p r i a t e a c t i o n w i t h r e g a r d t o t h e s e c o n c e r n s . 6. To a c t as l i a i s o n w i t h o t h e r M i n i s t r i e s and t o d i s c u s s w i t h , and recommend a c t i o n through t h e Deputy M i n i s t e r - 73 -on m a t t e r s o f i n t e r - m i n i s t e r i a l c o n c e r n r e g a r d i n g h e a l t h manpower. 7. Through the chairman and/or h i s a p p o i n t e e s , t o p r o -v i d e r e p r e s e n t a t i o n on b e h a l f o f the P r o v i n c i a l M i n i s t r y o f H e a l t h t o f e d e r a l / p r o v i n c i a l , i n t e r -p r o v i n c i a l and i n t r a - p r o v i n c i a l committees concerned w i t h h e a l t h manpower, a d v i s i n g t h e M i n i s t r y o f H e a l t h on m a t t e r s o f c o n c e r n and a p p r o p r i a t e a c t i o n . 8. To r e v i e w proposed h e a l t h manpower l e g i s l a t i o n f o r i t s i m p l i c a t i o n s r e g a r d i n g t h e d i s t r i b u t i o n , c o n t r o l and s u p p l y o f h e a l t h manpower s t o c k and t o a d v i s e t h e Deputy M i n i s t e r o f any c o n c e r n s . 9. To a d v i s e o t h e r M i n i s t r i e s , o u t s i d e a g e n c i e s , l i c e n s -i n g b o d i e s , and a s s o c i a t i o n s o f e x i s t i n g p o l i c i e s r e -g a r d i n g h e a l t h manpower. 10. To be aware o f , and where n e c e s s a r y , a s s e s s proposed h e a l t h c a r e programs f o r i m p l i c a t i o n s f o r h e a l t h man-power and, where n e c e s s a r y , a d v i s e t h e M i n i s t r y o f H e a l t h o f t h e s e i m p l i c a t i o n s . 11. To r e v i e w p r o p o s a l s r e g a r d i n g t h e e s t a b l i s h m e n t o f new " t y p e s " o f h e a l t h c a r e w o r k e r s and a d v i s e on p o l i c y w i t h r e g a r d t o t h e employment o f t h e s e new t y p e s o f p e r s o n n e l . I n o r d e r t o c l a r i f y membership on the Committee, g u i d e l i n e s were p r o v i d e d w i t h i n t h e terms o f r e f e r e n c e . - 34 -Membership 1. The H e a l t h Manpower Working Group s h a l l r e p o r t t o the Deputy M i n i s t e r o f H e a l t h and s h a l l be r e s p o n s i b l e t o him f o r meetin g i t s terms o f r e f e r e n c e . 2. Membership on t h e Working Group s h a l l c o n s i s t s o f ; a) S i x r e p r e s e n t a t i v e s from t h e M i n i s t r y o f H e a l t h a p p o i n t e d by t h e Deputy M i n i s t e r . These r e p r e s e n t -a t i v e s s h a l l be o f s u f f i c i e n t s e n i o r i t y w i t h i n t h e i r j u r i s d i c t i o n s as t o have an o v e r v i e w o f t h e i r h e a l t h manpower needs. They s h o u l d a l s o be a b l e t o f o r m u l a t e a p p r o p r i a t e p o l i c y and a d v i s e the Deputy M i n i s t e r w i t h r e g a r d t o i m p l i c a t i o n s f o r manpower i n t h e i r r e s p e c t i v e j u r i s d i c t i o n s . These s i x r e p r e s e n t a t i v e s s h a l l be drawn from t h e D i v i s i o n s o f P l a n n i n g and Development, Support S e r -v i c e s , H o s p i t a l Programs, M e d i c a l S e r v i c e s Commission, D i r e c t Care S e r v i c e s , P r e v e n t i v e and S p e c i a l Community Service's.-.'-,;The chairman w i l l be a p p o i n t e d by t h e  Deputy M i n i s t e r from among t h e members, u s u a l l y t h e  E x e c u t i v e D i r e c t o r o f P l a n n i n g ' and'Development. b) One r e p r e s e n t a t i v e each from t h e M i n i s t r y o f E d u c a t i o n , and the M i n i s t r y o f U n i v e r s i t i e s , S c i e n c e and Communic-a t i o n , a p p o i n t e d by t h e M i n i s t e r s o r t h e D e p u t i e s o f t h o s e M i n i s t r i e s . c) As many as two r e p r e s e n t a t i v e s from t h e M i n i s t r y o f Labour, a p p o i n t e d by t h e M i n i s t e r o f Labour o r h i s Deputy. These r e p r e s e n t a t i v e s s h o u l d be know-l e d g e a b l e o f p o l i c y w i t h i n the M i n i s t r y o f Labour r e g a r d i n g i m m i g r a t i o n , unemployment, and any o t h e r p o l i c i e s a f f e c t i n g h e a l t h manpower. d) Such r e p r e s e n t a t i v e s of, o t h e r h e a l t h o r g a n i z a t i o n s (e.g. BCHA) as a r e n e c e s s a r y from t i m e t o t i m e . 3. R e p r e s e n t a t i o n from the S e c r e t a r i a t s h a l l be a p p o i n t e d by t h e D i r e c t o r o f t h e S e c r e t a r i a t . A member o f t h e Sec-r e t a r i a t s h a l l a c t as S e c r e t a r y o f t h e Working Group. These p e o p l e w i l l n o t be v o t i n g members o f t h e Committee. - 75 -E. The H e a l t h Manpower Research U n i t I n a d d i t i o n t o t h e e s t a b l i s h m e n t o f a h e a l t h manpower committee, a need e x i s t e d t o p r o v i d e s e c r e t a r i a t / p l a n n i n g / r e s e a r c h s u p p o r t t o the Committee. I n a l l p r o v i n c e s b u t B r i t i s h Columbia t h i s s u p p o r t i s p r o v i d e d by government p l a n n i n g o r r e s e a r c h d i v i s i o n s . I t i s e i t h e r a f u n c t i o n o f an o v e r a l l , p l a n n i n g d i v i s i o n o r i s m a i n t a i n e d as- a s e p a r a t e p l a n n i n g s e c t i o n o f t h e H e a l t h M i n i s t r y . I n B r i t i s h C o lumbia, t h e H e a l t h Manpower Research U n i t was e s t a b l i s h e d a t t h e U n i v e r s i t y o f B r i t i s h Columbia t o p r o v i d e t h e r e q u i r e d s u p p o r t . T h i s u n i t was unique i n t h a t a l t h o u g h r e c e i v -i n g f u n d i n g i n t h e form o f a b l o c k g r a n t from government, i t m a i n t a i n e d a n e u t r a l p o s i t i o n between government, e d u c a t i o n a l i n s t i t u t i o n s and t h e p r o f e s s i o n a l a s s o c i a t i o n s . The Research U n i t was housed w i t h i n t h e D i v i s i o n o f H e a l t h S e r v i c e s Research & Development, a d i v i s i o n c r e a t e d i n 19 71 w i t h t h e o v e r a l l m i s s i o n o f : s t i m u l a t i n g s c i e n t i f i c e n q u i r y i n t o i s s u e s o f h e a l t h i n p o p u l a t i o n groups, ways i n wh i c h h e a l t h s e r v i c e s can b e s t be o r g a n i z e d and d e l i v e r e d g a n d ways i n which i n s t i t u t i o n s s h o u l d r e s p o n d . The U n i t became t h e foc u s o f f e d e r a l / p r o v i n c i a l and i n t e r -p r o v i n c i a l h e a l t h manpower p l a n n i n g a c t i v i t y i n t h e p r o v i n c e . A database f o r h e a l t h manpower p l a n n i n g was e s t a b l i s h e d i n c o o p e r a t i o n w i t h government, l i c e n s i n g b o d i e s , p r o f e s s i o n a l - 76 -a s s o c i a t i o n s , S t a t i s t i c s Canada and e d u c a t i o n a l i n s t i t u t i o n s . The major purpose o f the U n i t was t o i n t r o d u c e t o t h e manpower p l a n n i n g p r o c e s s , a r a t i o n a l approach t o p o l i c y f o r m u l a t i o n . A c t i n g as S e c r e t a r i a t t o the H e a l t h Manpower Working Group, t h e major t h r u s t o f t h e U n i t ' s work has been t o p r o v i d e s t a t i s t i c a l i n f o r m a t i o n t o t h a t body, w i t h t h e p e r m i s s i o n o f d a t a owners. A g r e a t amount o f work however has a l s o been p r o v i d e d f o r v a r i o u s d i v i s i o n s i n t h e U n i v e r s i t y , t h e F e d e r a l / P r o v i n c i a l Committee and o t h e r manpower committees, as w e l l as f o r l i c e n s i n g b o d i e s and a s s o c i a t i o n s . F. Other Government H e a l t h Manpower P l a n n i n g S t r u c t u r e s i n B r i t i s h Columbia I n t h e p a s t t e n y e a r s t h e p r o v i n c e has seen t h e e s t a b l i s h m e n t o f a v a r i e t y o f s t r u c t u r e s t o address h e a l t h c a r e d e l i v e r y , w h i c h have i n c o r p o r a t e d h e a l t h manpower p l a n n i n g components. The f i r s t o f t h e s e a r o s e w i t h t h e c r e a t i o n o f t h e B.C. M e d i c a l C e n t r e (B.C.M.C.) f o r t h e purposes o f p l a n n i n g a t e a c h i n g h o s p i t a l and f o r c o o r d i n a t i n g h e a l t h manpower e d u c a t i o n i n Vancouver, and i t s P r o v i n c i a l C o u n c i l i n 1973. I t was a t t h i s p o i n t t h a t t h e j u r i s d i c t i o n a l o v e r l a p s between h e a l t h and e d u c a t i o n i n t h e ar e a o f h e a l t h manpower i n t h e p r o v i n c e were b r o u g h t t o t h e f o r e f r o n t . An E d u c a t i o n Committee was e s t a b l i s h e d - .7.7 -w i t h i n B.C.M.C. t o as s e s s needs f o r h e a l t h manpower as w e l l as t a k e on t h e r e s p o n s i b i l i t y f o r e d u c a t i o n a l p l a n n i n g and man-power p r o d u c t i o n i n Vancouver. The E d u c a t i o n Committee was s u p p o r t e d by t h e D i v i s i o n o f E d u c a t i o n a l P l a n n i n g - a t B.C.M.C, funded t h r o u g h .the C e n t r e and r e p o r t e d t o the P r o v i n c i a l C o u n c i l s e t up under t h e B.C.M.C. A c t . C o n f u s i o n o v e r t h e j u r i s d i c t i o n o f t h e two Committees q u i c k l y a r o s e . Both t h e P r o v i n c i a l C o u n c i l and the H e a l t h Manpower Working Group were a d v i s o r y t o t h e M i n i s t e r o f H e a l t h ; t h e C o u n c i l was a d v i s o r y t o t h e M i n i s t e r o f E d u c a t i o n w h i l e t h e Working Group had c o o r d i n a t i n g l i n k s t o s e n i o r o f f i c i a l s i n t h a t m i n i s t r y . I n p r a c t i c e , t h e P r o v i n c i a l C o u n c i l r e l a t e d more c l o s e l y t o E d u c a t i o n w h i l e t h e Working Group r e l a t e d more c l o s e l y t o H e a l t h . B oth t h e P r o v i n c i a l C o u n c i l and the H e a l t h Manpower Working Group were c h a r g e d , among o t h e r r e s p o n s i b i l i t i e s , w i t h d e t e r -m i n i n g t h e 'need' f o r h e a l t h manpower. A c o n f l i c t and d u p l i c a t i o n o f a c t i v i t i e s o f t h e two r e s e a r c h and development u n i t s s u p p o r t i n g t h e s e n i o r b o d i e s o c c u r r e d . L i n k a g e s between the s t r u c t u r e s were tenuous, dependent upon s i x i n d i v i d u a l s who com p r i s e d an u n o f f i c i a l i n t e r l o c k i n g d i r e c t o r a t e t h r o u g h c r o s s membership on committees. L i t t l e c o o r d i n a t i o n o f s t u d i e s between t h e groups o c c u r r e d . - 78 -The demise o f B.C.M.C. i n 1975 br o u g h t w i t h i t t h e demise o f i t s E d u c a t i o n Committee. G. E d u c a t i o n / H e a l t h Committees i n B.C. O v e r l a p p i n g j u r i s d i c t i o n s between h e a l t h and e d u c a t i o n c o n -t i n u e d t o r e s u l t i n t h e c r e a t i o n o f committees w i t h o v e r l a p p i n g mandates. I n 19 76 the M i n i s t e r o f E d u c a t i o n c r e a t e d t h e H e a l t h E d u c a t i o n A d v i s o r y C o u n c i l w i t h t h e mandate o f a s s e s s i n g and a p p r o v i n g e d u c a t i o n programs i n t h e h e a l t h f i e l d . T h i s Committee a c t e d as a replacement f o r the B.C.M.C. E d u c a t i o n Committee a f t e r t h e change i n government. A g a i n o v e r l a p p i n g r e p r e s e n t a t i o n between t h i s Committee and t h e H e a l t h Manpower Working Group o c c u r r e d . The Committee c o n t i n u e d t o ' e x i s t ' u n t i l 19 78. The f u z z i n e s s o f i t s mandate and the power o f ve t o o f t h e M i n i s t e r o f Educat-i o n o v e r any o f i t s a c t i o n s l e d t o i t s d e a t h . I t s most s i g n i f -i c a n t c o n t r i b u t i o n d u r i n g i t s e x i s t e n c e was t o o v e r s e e a nursl-i n g e d u c a t i o n s t u d y i n t h e p r o v i n c e . S i m u l t a n e o u s l y w i t h t h e demise o f t h e H e a l t h E d u c a t i o n A d v i s o r y C o u n c i l was t h e M i n i s t e r - o f E d u c a t i o n ' s d e c i s i o n t o e s t a b l i s h the C o u n c i l s , c r e a t e d by the C o l l e g e s and P r o v i n c i a l I n s t i t u t i o n s A c t (1977). These C o u n c i l s , the Academic C o u n c i l , t h e Occupat-i o n a l T r a i n i n g C o u n c i l and t h e Management A d v i s o r y C o u n c i l were 79 -meant to. complement t h e U n i v e r s i t i e s C o u n c i l c r e a t e d y e a r s e a r l i e r (1963) under s e p a r a t e l e g i s l a t i o n . The U n i v e r s i t i e s C o u n c i l was e s t a b l i s h e d t o approve and c o o r d i n a t e f u n d i n g between p r o v i n c i a l u n i v e r s i t i e s . The r o l e o f t h e Academic C o u n c i l i s t o r e v i e w program p r o p o s a l s f o r academic programs i n c o l l e g e s and t h e B r i t i s h Columbia I n -s t i t u t e o f Technology, a p p r o v i n g o r d e n y i n g f u n d i n g f o r same. T h i s c o u n c i l i s s u p p o r t e d i n the h e a l t h o c c u p a t i o n s by an E d u c a t i o n / H e a l t h Sub-committee which r e v i e w s h e a l t h manpower e d u c a t i o n p r o p o s a l s and a d v i s e s t h e c o u n c i l as t o t h e i r s u i t a b i l i t y . T h i s Academic C o u n c i l c a n , i n e f f e c t , b y p a s s t h e f o r m a l h e a l t h manpower p l a n n i n g s t r u c t u r e s i n t h e M i n i s t r y o f H e a l t h . L i n k a g e s between the H e a l t h Manpower Working Group, the M i n i s t r y o f E d u c a t i o n and t h e E d u c a t i o n / H e a l t h Sub-committee a r e m a i n t a i n e d t h r o u g h membership o f the Working Group Chairman and C o o r d i n a t o r o f h e a l t h programs ( M i n i s t r y o f E d u c a t i o n ) on t h e E d u c a t i o n / H e a l t h Sub-committee i n an attempt t o keep t h i s from o c c u r r i n g . H. H e a l t h Manpower Committees i n t h e B.C. H e a l t h A s s o c i a t i o n , L i c e n s i n g B o d i e 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 I n November o f 1979, t h e B.C. H e a l t h A s s o c i a t i o n , an a s s o c i a t -i o n r e p r e s e n t i n g t h e h e a l t h manpower employers i n t h e p r o v i n c e , e s t a b l i s h e d a h e a l t h manpower committee (Terms o f R e f e r e n c e '. Appendix E ) . The reasons f o r i t s c r e a t i o n were based on i t s d e s i r e t o have employer i n p u t i n t o t h e h e a l t h manpower p l a n n i n g p r o c e s s and an attempt t o p u t on a s t a n d i n g b a s i s what had p r e v i o u s l y been ad hoc v e n t u r e s i n t o t h e f i e l d . Membership on t h e committee c o n s i s t s o f h o s p i t a l t r u s t e e s , a d m i n i s t r a t o r s and p e r s o n n e l d i r e c t o r s , t o g e t h e r w i t h t h e Chairman o f t h e H e a l t h Manpower Working Group, who p r o v i d e s t h e l i n k a g e w i t h t h e Working. Group. I n t e r e s t by l i c e n s i n g b o d i e 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 i n p l a n n i n g f o r t h e i r own p r o f e s s i o n i s not new. The B.C. C o l l e g e o f P h y s i c i a n s and Surgeons and t h e B.C. M e d i c a l A s s o c i a t i o n have m a i n t a i n e d a j o i n t manpower committee f o r many y e a r s . M a j o r n a t i o n a l and p r o v i n c i a l committees have been e s t a b l i s h e d i n t h e p a s t t o address t h e manpower q u e s t i o n o f a s p e c i f i c p r o f e s s i o n o r s e r v i c e a r e a . These have been committees w i t h a l i m i t e d mandate and t i m e frame w i t h few o r no t i e s t o e x i s t i n g manpower p l a n n i n g s t r u c t u r e s . I n r e c e n t y e a r s however, i n t e r e s t has i n c r e a s e d among o t h e r o c c u p a t i o n a l groups w i t h s t a n d i n g manpower o r e d u c a t i o n committees b e i n g e s t a b l i s h e d w i t h i n many o f t h e s e b o d i e s . N u r s i n g has been a l e a d e r i n t h i s r e s p e c t b u t has been c l o s e l y f o l l o w e d by such groups as d e n t i s t s , d i e t i t i a n s and o c c u p a t i o n a l t h e r a p i s t s . The main f u n c t i o n o f t h e s e committees has been t o - 81 -lo b b y government. However because i t i s l o b b y i n g , commun-i c a t i o n most o f t e n o c c u r s d i r e c t l y w i t h the H e a l t h M i n i s t e r r a t h e r than w i t h the f o r m a l manpower p l a n n i n g committees.of government. Because t i e s t o the. e x i s t i n g s t r u c t u r e s a r e q u e s t i o n a b l e , t h e y w i l l be d i s c u s s e d • w i t h i n the f o l l o w i n g c h a p t e r s concerned w i t h p l a n n i n g . i n s p e c i f i c d i s c i p l i n e s . Summary R e s p o n s i b i l i t y f o r h e a l t h manpower p l a n n i n g has always been a r e s p o n s i b i l i t y spread. . between government, p r o f e s s i o n a l a s s o c i a t i o n s and the e d u c a t i o n s e c t o r . The f i r s t p l a n n i n g of s i g n i f i c a n c e o c c u r r e d i n 1914 w i t h t h e i n i t i a t i o n of the m u n i c i p a l d o c t o r system. Judek's c o n t r i b u t i o n t o the H a l l Commission (1964) was the n e x t i m p o r t a n t move i n the ar e a of m e d i c a l manpower p l a n n i n g . The Task Force on t h e Cost of H e a l t h S e r v i c e s (1969) recommended an i n c r e a s e i n the use of a u x i l i a r y p e r s o n n e l as a more c o s t e f f e c t i v e method of h e a l t h c a r e d e l i v e r y . The f e d e r a l manpower p l a n n i n g s t r u c t u r e as we now see i t was e s t a b l i s h e d i n 1972 as a r e s u l t of t h a t committee's Report. The committee has a weak mandate and has" s u f f e r e d froni'a" l a c k o f f o r m a l r e p o r t i n g r e l a t i o n s h i p s . I n 1979 a r e v i s i o n o f the terms of r e f e r e n c e p r o v i d e d a s t r o n g e r mandate but t e n d i f f e r i n g agendas and s e t s o f p r i o r i t i e s w i t h i n p r o v i n c e s . - 82 -R e g i o n a l p l a n n i n g e f f o r t s i n the west have r e s t e d w i t h the Western Post-Secondary H e a l t h Manpower Committee which was e s t a b l i s h e d t o address the needs of the e d u c a t i o n s e c t o r . I t has a s t r o n g e r mandate than i t s n a t i o n a l c o u n t e r p a r t and add r e s s e s r e g i o n a l i s s u e s r a t h e r than n a t i o n a l ones. I n B r i t i s h C olumbia t h e f i r s t p l a n n i n g s t r u c t u r e was t h e M e d i c a l Manpower Committee e s t a b l i s h e d i n 1972. I t was soon r e p l a c e d by the H e a l t h Manpower Working Group a committee comprised o f Deputy M i n i s t e r s and S e n i o r Government O f f i c i a l s . S e v e r a l e d u c a t i o n h e a l t h committees have been e s t a b l i s h e d o v e r the p a s t s i x y e a r s t o address i s s u e s of mutual c o n c e r n . These were i n t e n d e d as E d u c a t i o n ' s f o r a y i n t o h e a l t h manpower p l a n n i n g . J u r i s d i c t i o n a l problems have caused the demise of the m a j o r i t y of t h e s e committees. Those which have s u r v i v e d s t i l l s u f f e r from o v e r l a p problems". - 83 -F o o t n o t e s 1. T a y l o r , M., H e a l t h I n s u r a n c e and Canadian P u b l i c P o l i c y , The I n s t i t u t e o f P u b l i c A d m i n i s t r a t i o n , M c G i l l , Queens U n i v e r s i t y P r e s s , M o n t r e a l , 19 78. 2. R o y a l Commission on H e a l t h S e r v i c e s , Government o f Canada, Ottawa, 1964, V o l . 1, p. 69. 3. F i r s t N a t i o n a l C o n f e r e n c e on H e a l t h Manpower, Government o f Canada, Ottawa, 1969. 4. Hacon, W. Canadian P u b l i c H e a l t h A s s o c i a t i o n J o u r n a l , V o l . 64, 19 7 3 , p . 6 . 5. Second N a t i o n a l C o n f e r e n c e on H e a l t h Manpower, Government o f Canada, Ottawa, 1971.. 6. M i n u t e s o f t h e T h i r d M e e t i n g o f the F e d e r a l / P r o v i n c i a l H e a l t h Manpower Committee, Ottawa, November 23, 19 72. 7. H e a l t h Manpower Development Program, Government o f Canada, Ottawa, May 1973, p.. 2. 8. P r o p o s a l f o r t h e Development o f t h e D i v i s i o n o f H e a l t h S e r v i c e s Research and Development, U n i v e r s i t y o f B r i t i s h C olumbia, Vancouver, 19 71. - 84 -CHAPTER 5  MEDICAL MANPOWER PLANNING IN CANADA I t i s a p p r o p r i a t e t h a t an e x a m i n a t i o n o f s p e c i f i c h e a l t h man-power groups i n Canada b e g i n by a d d r e s s i n g p h y s i c i a n manpower, th e s e r v i c e c o n t r o l l e r s o f the h e a l t h c a r e d e l i v e r y systemard the p a t t e r n l e a d e r s f o r o t h e r h e a l t h manpower o c c u p a t i o n s . T r a d i t i o n a l l y i n the n i n e t e e n t h c e n t u r y , p h y s i c i a n s were r e -s p o n s i b l e f o r t h e i r own p l a n n i n g . Through r e g i s t r a t i o n , p h y s i c i a n s m a i n t a i n e d c o n t r o l o f a d m i s s i o n t o t h e p r o f e s s i o n , s t a n d a r d s , q u a l i t y and f e e s e t t i n g . Johnson (1972) c a l l s t h i s t y p e o f c o n t r o l , c o l l e g i a t e c o n t r o l . Governments have t r a d i t i o n a l l y been i n t e r e s t e d i n h e a l t h c a r e t o o . I n the e a r l y y e a r s they took r e s p o n s i b i l i t y f o r me n t a l h e a l t h , i n f e c t i o n c o n t r o l and p u b l i c h e a l t h . L a t e r t h e y became i n -v o l v e d i n t h e e s t a b l i s h m e n t o f h o s p i t a l s . Recommendations c o n t a i n e d i n t h e H a l l Commission Re p o r t (19 64) c o n c e r n i n g h e a l t h i n s u r a n c e and p h y s i c i a n s h o r t a g e i n i t i a t e d a more s e r i o u s e x a m i n a t i o n o f p h y s i c i a n manpower p l a n n i n g . However, s i n c e r e i n t e r e s t by government began much e a r l i e r , i n Saskatchewan. The m u n i c i p a l d o c t o r s ' scheme o f 1914 o u t l i n e d i n C h a p t e r 3, i s p r o b a b l y t h e most s i g n i f i c a n t e a r l y attempt a t p h y s i c i a n manpower p l a n n i n g . A t t e m p t s t o i n c r e a s e t h e p h y s i c i a n manpower s u p p l y l e d t o t h e e s t a b l i s h m e n t o f h o s p i t a l s t o a t t r a c t p h y s i c i a n s t o u n d e r s e r v i c e d a r e a s . I n t h e y e a r s t h a t f o l l o w e d and most e s p e c i a l l y t h e 1940's, p h y s i c i a n manpower and th e p o s s i b i l i t y o f s h o r t a g e s became a p r i o r i t y and i n 1948 when N a t i o n a l H e a l t h Grants came i n t o b e i n g , p r o v i n c i a l governments were asked t o examine and r e p o r t on b o t h manpower and h o s p i t a l s . C o n c e n t r a t e d i n t e r e s t i n p l a n n i n g by government came o n l y when the r e s p o n s i b 1 1 1 t y .for payment became t h e i r s under h e a l t h . i n s u r a n c e . Under t h i s new scheme government f e l t i t had a moral commitment t o p r o v i d e e q u i t a b l e s e r v i c e and t h e r e f o r e i s s u e s o f e q u a l a c c e s s became i m p o r t a n t . Manpower had t o be p r o v i d e d . U n t i l h e a l t h i n s u r a n c e , p h y s i c i a n s had h e l d c o n t r o l o f b o t h t h e demand f o r s e r v i c e , and i t s c o s t under a somewhat m o d i f i e d market system. Faced w i t h t h e dilemma o f b a l a n c i n g s o c i a l ' j u s t i c e w i t h economic growth, t h e s e new c o r p o r a t e p l a n n e r s were f o r c e d t° examine t h e s e r v i c e p r o v i d e d . The ga t e k e e p e r s t o t h e system, p h y s i c i a n s , were t h e n a t u r a l s t a r t i n g p o i n t . I n i t i a l l y / f a c e d w i t h a s h o r t a g e o f p h y s i c i a n manpower due t o th e advent o f the new M e d i c a r e scheme i n t h e s i x t i e s , p l a n n i n g f o c u s s e d on s u p p l y i n g s u f f i c i e n t manpower t o meet growing demand. Q u e s t i o n s o f i m m i g r a t i o n and i t s a l t e r n a t i v e s u p p l y m e c h a n i s m s , i n c r e a s e d t r a i n i n g , and o f s u b s t i t u t i o n came t o the - 86 -f o r e f r o n t . A. I m m i g r a t i o n vs Home T r a i n e d Canada's dependency on f o r e i g n m e d i c a l g r a d u a t e s had re a c h e d a l a r m i n g p r o p o r t i o n s by the mid s i x t i e s . By 19 67 immigrant p h y s i c i a n s exceeded Canadian g r a d u a t e s by 14% i n new r e g i s t r a n t s and c o m p r i s e d a p p r o x i m a t e l y 25% o f a l l a c t i v e p h y s i c i a n s i n the c o u n t r y (Task F o r c e on C o s t o f H e a l t h S e r v i c e s ) . T h i s s i t u a t i o n was n o t unique t o p h y s i c i a n s , and i n f a c t i t i s i m m i g r a t i o n w hich t i e s h e a l t h manpower p l a n n i n g i n Canada t o manpower p l a n -n i n g i n g e n e r a l , w i t h common p o l i c i e s l i n k i n g b o t h . The ' b r a i n - d r a i n ' o f t r a i n e d p h y s i c i a n s from B r i t a i n and o t h e r c o u n t r i e s was a b l e s s i n g a t a t i m e when Canada c o u l d not meet h e r own needs. L a t e r , however, e x c e s s i v e i m m i g r a t i o n was t o become a s e r i o u s problem. B r i t a i n ' s c o n t r i b u t i o n t o p h y s i c i a n i m m i g r a t i o n were o f t e n ' r e f u g e e s ' from t h e N a t i o n a l H e a l t h S e r v i c e i n t h a t c o u n t r y . They were unhappy w i t h t h e way t h a t system had worked and had come t o Canada t o d e v e l o p t h e i r c a r e e r s under an e n t r e p r e n e u r i a l system. T h i s has r e s u l t e d i n c o n f l i c t s b o t h w i t h i n t h e p r o f e s s i o n and o u t s i d e o f i t . From t i m e t o t i m e c o n f l i c t s have s p l i t t he ranks o f t h e p r o f e s s i o n . Dependency on immigrant p h y s i c i a n s c r e a t e d a d d i t i o n a l problems. As d e s c r i b e d i n Ch a p t e r One, p r o f e s s i o n a l s i m m i g r a t i n g t o t h i s - 87 -c o u n t r y q u i t e o f t e n d i d so as one s t e p p i n g s t o n e i n t h e i r p r o f e s s i o n a l c a r e e r . Once e s t a b l i s h e d i n the w e s t e r n w o r l d , they e m i g r a t e d t o . g r e e n e r p a s t u r e s i n the U n i t e d S t a t e s . Many o t h e r s who used t h e 'have n o t ' p r o v i n c e s such as t h e M a r i t i m e s as a p o i n t o f e n t r y q u i c k l y m i g r a t e d west t o O n t a r i o o r B r i t i s h C o lumbia. As t h e s u p p l y o f p h y s i c i a n s r e a c h e d adequate and s u r p l u s p r o -p o r t i o n s , numbers o f immigrants began t o become a burden because o f t h e c o s t s t h e y g e n e r a t e d . I n an attempt t o reduce dependency upon i m m i g r a t i o n and p r o v i d e s u f f i c i e n t p h y s i c i a n s f o r t h e newly e s t a b l i s h e d h e a l t h i n s u r a n c e scheme, t r a i n i n g programs f o r p h y s i c i a n s were i n c r e a s e d c o n s i d e r a b l y . I t was f e l t t h a t home grown p e o p l e may t e n d t o s t a y i n an a r e a l o n g e r and might be more ready t o l i v e i n r u r a l a r e a s . Numbers o f graduates from Canadian m e d i c a l s c h o o l s grew s l o w l y p r i o r t o M e d i c a r e , w i t h o n l y 769 gra d u a t e s i n 1945 i n c r e a s i n g t o 838 i n 19 62 ( R o y a l Commission on H e a l t h S e r v i c e s , 19 6 4 ) . By 19 70 t h i s number had i n c r e a s e d s u b s t a n t i a l l y t o 1,071, t o 1,565 i n 1975, and an e s t i m a t e d 1,754 i n 1980. ( H e a l t h Manpower I n v e n t o r y , 1978), B. P h y s i c i a n S u b s t i t u t e s The m a l d i s t r i b u t i o n and t h e apparent s h o r t a g e o f p h y s i c i a n man-power s t a r t e d up d i s c u s s i o n s as t o the use o f p h y s i c i a n sub-s t i t u t e s . The concept had been p o p u l a r i n o t h e r c o u n t r i e s f o r - 88 -c e n t u r i e s i n t h e form o f f e l d s h e r s , d o c t o r s ' a s s i s t a n t s o r o t h e r such t y p e s o f p e r s o n n e l . The economic e f f e c t i v e n e s s o f t h e s e a s s i s t a n t s has been w e l l documented (McCormack 19 72, G o l l a d a y 19 7 3 ) , however a c c e p t a n c e i n the west has n o t become a r e a l i t y (Badgley 1971) . B a d g l e y (19 71) s u g g e s t s t h a t s u b s t i t u t i o n by p h y s i c i a n a s s i s t -a n t s and n u r s e p r a c t i t i o n e r s i s p o p u l a r o n l y when i t i s seen as a s o l u t i o n t o p h y s i c i a n s h o r t a g e , a t h e o r y a l s o p u t f o r t h by J e f f e r s (1974) . I t was about t h e r o l e o f s u b s t i t u t e s i n r u r a l a r e a s t h a t d i s c u s s i o n s began. The f i r s t t r a i n i n g program f o r th e U n i t e d S t a t e s began a t Duke U n i v e r s i t y i n 19 65 f o l l o w e d by a number o f o t h e r s i n t h e y e a r s which f o l l o w e d . As a r e s u l t o f t h e Task F o r c e on t h e C o s t o f H e a l t h S e r v i c e s , a c o n f e r e n c e was h e l d t o d i s c u s s t h e r o l e o f p h y s i c i a n a s s i s t a n t s i n Canada ( N a t i o n a l C o n f e r e n c e on A s s i s t a n c e t o t h e P h y s i c i a n , 1971), where s u p p o r t was g i v e n by p h y s i c i a n s , n urses and consumers a l i k e t o t h e concept o f t h e expanded r o l e o f the n u r s e . D e m o n s t r a t i o n g r a n t s were awarded t o s t u d y t h e con c e p t . Hart. ;Scarrow, . i n a s u r v e y conducted i n B r i t i s h C olumbia, r e c e i v e d a p o s i t i v e i n d i c a t i o n from t h e m e d i c a l p r o f e s s i o n t h a t a u x i l i a r i e s would be u s e f u l . S a c k e t t and Chambers (19 77) have a t t e s t e d t o t h e s u c c e s s o f t h e s e p r a c t i t i o n e r s ! . However, the i s s u e s r e g a r d i n g s u b s t i t u t i o n began t o change as the number o f p h y s i c i a n s grew. P h y s i c i a n a s s i s t a n t s were : - 89 -p e r c e i v e d as weakening t h e r o l e o f the g e n e r a l p r a c t i t i o n e r (Roemer 19 79) and o f l o w e r i n g t h e income o f t h e p h y s i c i a n s ( B e r k i 19 7 2 ) . I n a d d i t i o n , u p g r a d i n g the r o l e o f t h e s e w o rkers r e q u i r e d not o n l y a t r a n s f e r o f f u n c t i o n , b u t a l s o a t r a n s f e r o f p r i v i l e g e t o t h a t w o r k e r (Badgley 19 71). P h y s i c i a n s f a c e d w i t h i n t r o d u c t i o n o f an unwanted o c c u p a t i o n a l group have Coun t e r e d and e f f e c t i v e l y quashed i t s growth. The N u r s e . P r a c t i t i o n e r has met w i t h s i m i l a r f r u s t r a t i o n s i n a t t e m p t i n g t o d e v e l o p h e r r o l e , m e e t i n g w i t h s t r o n g o p p o s i t i o n from the m e d i c a l p r o f e s s i o n . T h i s t h r e a t i s most o f t e n based upon t h e number o f g e n e r a l p r a c t i t i o n e r s a v a i l a b l e t o p r o v i d e s e r v i c e . When the p r o f e s s i o n f e e l s t h e r e i s a s h o r t a g e i t i s more l i k e l y t o advocate the t r a i n i n g o f n u rse p r a c t i t i o n e r s as a s t o p gap measure than when an adequate s u p p l y o r s u r p l u s o f p h y s i c i a n s e x i s t (Imai 19 74). R o l e i s n o t the q u e s t i o n , i t m a t t e r s not what q u a l i t y c a r e the n u r s e p r a c t i t i o n e r i s a b l e t o d e l i v e r o r i f p h y s i c i a n s a r e u n w i l l i n g t o p r a c t i c e i n c e r t a i n g e o g r a p h i c a r e a s . The q u e s t i o n i s two edged. P r i m a r i l y t h e p h y s i c i a n r e s e n t s th e i n t r u s i o n o nto h i s p r o f e s s i o n a l t u r f by the n u r s e . The a u ra c r e a t e d by h i s t e c h n i c a l e x p e r t i s e q u i c k l y b e g i n s t o d i m i n i s h when t h i s o c c u r s . S e c o n d l y , t h e n u rse p r a c t i t i o n e r has t h e p o t e n t i a l o f c r e a t i n g a l o s s i n revenue f o r t h e p h y s i c i a n — a d e f i n i t e r e a s o n f o r c o n c e r n . - 90 -R e c e n t l y , a t t e m p t s have been made t o i n t r o d u c e nurse-midwives i n t o Canada as a form o f p h y s i c i a n s u b s t i t u t e s . I n t h e same manner t h a t p r e v i o u s moves i n t h i s d i r e c t i o n have been t h w a r t e d by t h e m e d i c a l p r o f e s s i o n , t h i s one seems t o be f o l l o w i n g a s i m i l a r r o u t e . C. M e d i c a l Manpower P l a n n i n g i n t h e S e v e n t i e s I s s u e s o f s u r p l u s , m a l d i s t r i b u t i o n and h i g h c o s t q u i c k l y r e -s u l t e d from t h e i n c r e a s e d t r a i n i n g c a p a c i t y combined w i t h a r e v e r s e t i d e o f e m i g r a t i o n , an i n a b i l i t y t o curb i m m i g r a t i o n , t h e growth i n t e c h n o l o g y and the i n c r e a s e d use o f p a r a m e d i c a l p e r s o n n e l . M e d i c a l manpower p l a n n i n g i n t h e s e v e n t i e s q u i c k l y moved from q u e s t i o n s o f p r o v i s i o n t o q u e s t i o n s o f c o n t r o l . Government p l a n n e r s s t r u g g l e d t o a p p l y r a t i o n a l p l a n n i n g t o the problem, b u t were f r u s t r a t e d i n t h e i r a t t e m p t s . R a t i o n a l methods such as t h o s e d e v i s e d by Lee and Jones (19 3 3) were com-p l e x and open t o much c r i t i c i s m by t h e m e d i c a l p r o f e s s i o n . P r o f e s s i o n a l judgement as t o consumer need and t h e manner o f c a r i n g f o r t h o s e needs, p r o v i d e d t h e m e d i c a l p r o f e s s i o n w i t h a knowledge base w h i c h r a t i o n a l p l a n n e r s found d i f f i c u l t t o d i s -p u t e . P h y s i c i a n s have never wavered i n t h e i r s t a n d t h a t p l a n n -i n g f o r t h e s u p p l y o f p h y s i c i a n s i s t h e r o l e o f t h e m e d i c a l community. Arguments c o n c e r n i n g ownership and c o n t r o l o f p h y s i c i a n d a t a b a s e s , c o n t i n u e a t b o t h n a t i o n a l and p r o v i n c i a l l e v e l s . The f i r s t f o r m a l p l a n n i n g e f f o r t f o r m e d i c a l manpower i n Canada, and t h e o n l y n a t i o n a l study f o r t h e s e v e n t i e s , a r o s e from the Task F o r c e on the Cost o f H e a l t h S e r v i c e s . The N a t i o n a l Committee on P h y s i c i a n Manpower was i n i t i a t e d i n 1971 by t h e F e d e r a l government and r e l u c t a n t l y a c c e p t e d by p r o v i n c i a l governments, who b e l i e v e d t h e y would not be a b l e t o implement recommendations made by t h i s Committee. E s t a b l i s h e d s h o r t l y a f t e r t h e c o m p l e t i o n o f t h e Task F o r c e on t h e C o s t o f H e a l t h Care, t h e Committee found i t s e l f o p e r a t i n g i n a t u r b u l e n t ; and u n c e r t a i n environment. The f e d e r a l government found i t s e l f w i t h o u t funds and w i t h the r e s t r u c t u r i n g o f t h e f u n d i n g system n e i t h e r t h e f e d e r a l nor p r o v i n c i a l governments knew where t h e y s t o o d . To c a r r y o u t t h e work o f t h e Committee an e l a b o r a t e system o f e x p e r t p h y s i c i a n committees was e s t a b l i s h e d and a complex methodology d e v i s e d t o a r r i v e a t a s e r i e s o f p h y s i c i a n : pop-u l a t i o n r a t i o s f o r g e n e r a l i s t s and s p e c i a l i s t s a l i k e . By t h e ti m e t h e p a r e n t body s u b m i t t e d i t s r e p o r t i n 19 75, many o f t h e s u g g e s t e d t a r g e t s f o r 1981 had a l r e a d y been r e a c h e d , and s u r -p a s s e d i n some p r o v i n c e s . Other p r o v i n c e s would n ot a c c e p t the t a r g e t s as r e a s o n a b l e . Problems i n e s t a b l i s h i n g an o v e r a l l t a r g e t r a t i o were f u r t h e r c o m p l i c a t e d by l a c k o f concensus o v e r t h e mix o f g e n e r a l i s t s and s p e c i a l i s t s w h i c h would be a c c e p t a b l e F e d e r a l r : p r . o v i n c i a l d i s c u s s i o n s o f the r e p o r t have y i e l d e d l i t t l e f r u i t and Canada has y e t t o e s t a b l i s h a p h y s i c i a n : p o p u l a t i o n r a t i o w hich meets w i t h consensus. Q u e s t i o n o v e r t h e v a l i d i t y o f t h e Committee's recommendations has not r e s t e d s o l e l y w i t h government. The p r o f e s s i o n i t s e l f has d i s a g r e e d o v e r many recommendations, and most p a r t i c u l a r l y t h o s e which s u g g e s t e d reduced work l o a d s f o r g e n e r a l p r a c t i t i o n -e r s (Geekie 19 76). Recommendations c o n c e r n i n g t h e e s t a b l i s h -ment o f a n a t i o n a l d a t a b a se, b r o u g h t o u t t h e w o r s t f e a r s o f p h y s i c i a n s c o n c e r n i n g the c o n t r o l o f government. The Canadian M e d i c a l A s s o c i a t i o n e x p r e s s e d t h e d o c t o r s ' views t h a t c o n t i n u -i n g work i n p h y s i c i a n manpower p l a n n i n g s h o u l d be done by d o c t o r s and not by o u t s i d e groups, e s p e c i a l l y t h e government. Garner (19 76) quotes t h e p r e s i d e n t o f t h e O n t a r i o M e d i c a l A s s o c i a t i o n as s a y i n g : 'We have t o p l a y t h e manpower game - i t ' s t h e o n l y game i n town'. A s t a t e m e n t such as t h i s b r i n g s t o the f o r e f r o n t t h e j u r i s -d i c t i o n a l i s s u e s i n p l a n n i n g p h y s i c i a n manpower. I s i t the r o l e o f government t o p l a n f o r t h e number o f d o c t o r s who w i l l be a l l o w e d t o p r a c t i c e ? The number t o be funded? Or i s i t t h e r o l e o f t h e p r o f e s s i o n , based upon t h e i r r c l i n i c a l e x p e r t i s e , , t o a d v i s e government o f how many p h y s i c i a n s w i l l be r e q u i r e d t o d e l i v e r adequate s e r v i c e . E x a m i n i n g i t r e a l i s t i c a l l y , g o v e r n -ments never Can o b t a i n f i n a n c i a l c o n t r o l because p h y s i c i a n s r e t a i n power o v e r demand g e n e r a t i o n . To d a t e t h e o n l y outcome o f t h e r e p o r t has been much d i s c u s s i o n c o n c e r n i n g t h e e s t a b l i s h m e n t o f a n a t i o n a l d a t a base f o r p h y s i c i a n s and t h i s l i n e o f d i s c u s s i o n has r e c e i v e d more a t t e n t i o n by t h e m e d i c a l community t h a n i t has by government. I t i s c u r r e n t l y the i n t e n t o f CM.A. t o e s t a b l i s h and c o n t r o l i t s own d a t a f i l e , p r o v i d i n g , s u b j e c t t o n e g o t i a t i o n , a n a l y s e s t o government. Many p r o v i n c e s c u r r e n t l y m a i n t a i n o r a r e a t t e m p t i n g t o d e v e l o p t h e i r own p h y s i c i a n d a t a f i l e s . These a r e d e v e l o p e d e i t h e r i n c o n j u n c t i o n w i t h p r o v i n c i a l m e d i c a l c o l l e g e s o r m e d i c a l p l a n s . A u t h o r i t y t o do so i s p r o v i d e d under p r o v i n c i a l m e d i c a l a c t s and i n s u r a n c e agreements. I m m i g r a t i o n has p r o v i d e d a n o t h e r f o c u s f o r n a t i o n a l p h y s i c i a n p l a n n i n g . G e n e r a l c o n c e r n as t o t h e l a r g e p e r c e n t a g e o f f o r -e i g n m e d i c a l g r a d u a t e s l e d t o a d e s i r e t o c u r t a i l i m m i g r a t i o n . The s i g n i f i c a n c e o f t h e problem v a r i e d a c r o s s t h e c o u n t r y . I n 1973, Quebec's m e d i c a l p o p u l a t i o n i n c l u d e d o n l y 16% f o r e i g n m e d i c a l g r a d u a t e s whereas Saskatchewan and Newfoundland e x p e r -i e n c e d f a r g r e a t e r p r o p o r t i o n s o f 53% and 63% r e s p e c t i v e l y (Roemer & Roemer 19 77). The s h o r t a g e system w h i c h s t i l l e x i s t -ed i n many p r o v i n c e s a t t h a t time l e d t o d i f f i c u l t i e s i n a t t e m p t i n g t o a r r i v e a t a n a t i o n a l p o l i c y on p h y s i c i a n i m m i g r a t i o n . I n 19 75 t h e ( B r i t i s h Columbia) C o l l e g e o f P h y s i c i a n s and Surgeons changed i t s r e g u l a t i o n s i n r e g a r d t o t h e r e g i s t r a t i o n o f f o r e i g n t r a i n e d p h y s i c i a n s . Based p a r t i a l l y upon the s u r -p l u s o f p h y s i c i a n s i n t h e m e t r o p o l i t a n areas and p r i m a r i l y upon u n s u c c e s s f u l f e e n e g o t i a t i o n s i n 19 74, t h e C o l l e g e s e t about r e s t r i c t i n g r e g i s t r a t i o n of\ f o r e i g n m e d i c a l g r a d u a t e s . Only Canadian c i t i z e n s were t o be .allowed f u l l r e g i s t r a t i o n w i t h f o r e i g n r e g i s t r a n t s r e s t r i c t e d t o temporary r e g i s t r a t i o n and a r e q u i r e m e n t t o p r a c t i c e i n a d e s i g n a t e d u n d e r s e r v i c e d a r e a . I n May 19 76, t h e Human R i g h t s Commission of B r i t i s h Columbia r u l e d t h e a c t i o n i n c o n t r a v e n t i o n o f t h e Human R i g h t s CodeL; I t was not . u n t i l r e v i s i o n s t o the g e n e r a l i m m i g r a t i o n law and c r i t e r i a i n 19 77, t h a t e f f e c t i v e c u r t a i l m e n t was made. Then f i g u r e s f o r immigrant p h y s i c i a n s dropped from o v e r 1,00 0 t o j u s t o v e r 200 p e r y e a r w i t h i n t h r e e y e a r s . Many o f t h o s e c u r r e n t l y e n t e r i n g , do so because o f f a m i l i a l t i e s r a t h e r t h a n as p a r t o f t h e work a l l o c a t i o n s e l e c t i o n p r o c e d u r e . D. P h y s i c i a n Manpower P l a n n i n g I n B r i t i s h Columbia P r i o r t o t h e New Democratic P a r t y coming t o power i n 1973, l i t t l a t t e n t i o n had been p a i d t o p h y s i c i a n manpower p l a n n i n g by govern ment. Under t h e S o c i a l C r e d i t ' s twenty y e a r r e i g n s h o r t a g e s had been t h e o r d e r o f t h e day. I n a d d i t i o n , i t was t h e s t y l e o f t h a t p a r t y not t o p l a n . I t was o n l y under p r e s s u r e from th e m e d i c a l community t h a t i n 1972 the Honourable Ralph L o f f m a r k , t h e M i n i s t e r o f H e a l t h , e s t a b l i s h e d a M e d i c a l Manpower Committee f o r t h e p r o v i n c e . Terms o f r e f e r e n c e f o r t h e work of t h e committee l a c k e d t e e t h not a l l o w i n g i t t o do o t h e r t h a n e x t i n g u i s h bush f i r e s h o r t a g e s i t u a t i o n s . M e d i c a l Manpower Committee Terms o f R e f e r e n c e 1. The Committee w i l l s t u d y t h e p r e s e n t and f u t u r e s u p p l y o f d o c t o r s , i n r e l a t i o n t o g r a d u a t e s from B r i t i s h C o lumbia, o t h e r p r o v i n c e s o f Canada and from o t h e r c o u n t r i e s . 2. The Committee w i l l r e v i e w the p r e s e n t and f u t u r e d i s t r i b u t -i o n o f d o c t o r s . S o u r c e s o f i n f o r m a t i o n w i l l i n c l u d e s t a t i s -t i c a l m a t e r i a l from th e Dominion Bureau o f S t a t i s t i c s , the C o l l e g e M e d i c a l D i r e c t o r y , and messages t o and from d o c t o r s and communities. Records w i l l be d e v e l o p e d f o r f o u r areas where m e d i c a l manpower problems may e x i s t ("designated- a r e a s " (a) Areas w i t h no d o c t o r a t a l l ; (b) A reas w i t h o n l y one d o c t o r , u n a b l e t o g e t r e l i e f ; (c) A reas w i t h one o r two d o c t o r s , n e e d i n g one more i n o r d e r t o p r o v i d e improved s e r v i c e ; (d) Areas w i t h a need f o r a s p e c i f i c s p e c i a l i s t . 3. The Committee w i l l c o n s i d e r f a c t o r s c a u s i n g p r e s e n t and f u t u r e a t t r i t i o n , o f p r o f e s s i o n a l s e r v i c e s , such as l a c k o f f a c i l i t i e s , l a c k o f adequate r e m u n e r a t i o n , e t c . 4. The Committee w i l l s t udy t h e needs o f v a r i o u s branches of t h e p r o f e s s i o n , and a c q u a i n t i t s e l f w i t h s h o r t a g e s and s u r p l u s e s i n d i f f e r e n t d i s c i p l i n e s . I t w i l l r e c o r d t h e needs o f c e r t a i n a r e a s f o r d o c t o r s w i t h v a r y i n g degrees o f e x p e r i e n c e , t r a i n i n g and a b i l i t y . The numbers o f g e n e r a l p r a c t i t i o n e r s and g e n e r a l surgeons w i l l be r e v i e w e d , t o g e t h e r w i t h t h o s e o f o t h e r s p e c i a l i s t s . 5. Armed w i t h i n f o r m a t i o n d e v e l o p e d from what has been d e s c r i b ed i n t h e f o u r p r e c e d i n g p a r a g r a p h s , the Committee w i l l c o n s i d e r methods t o o b t a i n d o c t o r s w i t h s u i t a b l e q u a l i f i c -a t i o n and e x p e r i e n c e t o s e r v e d i f f e r e n t a r e a s i n the P r o v i n c e , b e a r i n g i n mind the f o l l o w i n g f e a t u r e s : (a) d o c t o r s who have had b a s i c t r a i n i n g ; (b) d o c t o r s who have had s p e c i a l i s t t r a i n i n g ; (c) d o c t o r s who a r r i v e i n B r i t i s h Columbia from o t h e r p r o v i n c e s o r o t h e r c o u n t r i e s ; (d) d o c t o r s who a r e w o r k i n g under s p e c i a l l i c e n c e s ; (e) t h e e x t e n t o f the f a c i l i t i e s a v a i l a b l e f o r m e d i c a l p r a c t i c e ; (f) m o d i f i c a t i o n s r e l a t e d t o m e d i c a l manpower s t u d i e s and r e q u i r e m e n t s i n o t h e r p r o v i n c e s ; (g) t h e need f o r p e r i o d i c r e l i e f f o r d o c t o r s w o r k i n g i n d e s i g n a t e d a r e a s . 6. The Committee w i l l c o n s i d e r t h e q u e s t i o n o f d i r e c t and i n -d i r e c t i n c e n t i v e s i n the d e l i v e r y o f h e a l t h c a r e , i n c l u d i n g f i n a n c i a l and l e g i s l a t i v e measures, w h i c h c o u l d be con-s i d e r e d a c c e p t a b l e , and what degree o f Government, communit o r p r i v a t e p r o v i s i o n o f f a c i l i t i e s (such as h o s p i t a l s , )• .. h e a l t h c e n t r e s , o f f i c e s , p a r a m e d i c a l p e r s o n n e l , e t c . ) would be f e a s i b l e . 7. I n i t s work the Committee w i l l m a i n t a i n l i a i s o n w i t h t h e M e d i c a l A p p e a l s B o a r d , th e S p e c i a l M e d i c a l Review B o a r d , t h e C o l l e g e o f P h y s i c i a n s and Surgeons, t h e B.C. M e d i c a l A s s o c i a t i o n , and i t s a f f i l i a t e d s o c i e t i e s , l o c a l u n i v e r s -i t i e s and t h e M e n t a l H e a l t h Branch o f t h e Department o f H e a l t h S e r v i c e s and H o s p i t a l I n s u r a n c e , and by any o t h e r a p p r o p r i a t e body. I n a d d i t i o n t o a weak mandate, the Committee d i d n o t c o n s i s t o f s t r o n g 1 p r o f e s s i o n a ' l — o r o t h e r members. I t i s n o t a s u r p r i s e t h a t i n 19 73 t h e newly formed p r o v i n c i a l H e a l t h Manpower Working Group, c o m p r i s e d p r i m a r i l y o f s e n i o r c i v i l s e r v a n t s took o v e r t h e r o l e o f p h y s i c i a n manpower p l a n n i n g . Of l a t e , p h y s i c i a n manpower p l a n n i n g i n B r i t i s h Columbia has c o n t a i n e d s e v e r a l s i g n i f i c a n t p o l i c y / p l a n n i n g v e n t u r e s , t h r e e o f which s h o u l d be a d d r e s s e d . The f i r s t was t h e d e c i s i o n t o double t h e s i z e o f t h e m e d i c a l s c h o o l , made i n 19 77 by t h e M i n i s t e r o f E d u c a t i o n , t h e Honourable D r . . ' P a t r i c k McGeer - a p h y s i c i a n on l e a v e from t h e U n i v e r s i t y o f B r i t i s h C o lumbia. The second was the e s t a b l i s h m e n t i n 1976 o f a t a s k f o r c e t o st u d y t h e p r o v i s i o n o f v i s i o n c a r e s e r v i c e s i n t h e p r o v i n c e . The t h i r d , t h e e s t a b l i s h m e n t i n 1978, a g a i n by t h e M i n i s t e r o f H e a l t h , o f a committee t o s t u d y t h e r e q u i r e m e n t s f o r p h y s i c i a n manpower i n t h e p r o v i n c e . The d e c i s i o n t o i n c r e a s e t h e s i z e o f the m e d i c a l s c h o o l was made by t h e M i n i s t e r o f E d u c a t i o n . I t was made w i t h o u t t h e b e n e f i t o f r a t i o n a l h e a l t h manpower p l a n n i n g , e i t h e r w i t h i n t h e M i n i s t r y o f E d u c a t i o n o r H e a l t h . I n f a c t , r a t i o n a l h e a l t h p l a n n e r s b o t h p r o v i n c i a l l y and f e d e r a l l y , have d i f f i c u l t y d e f e n d i n g t h e move. J u s t i f i c a t i o n was e q u a l o p p o r t u n i t y f o r B r i t i s h Columbia youth t o pursue a m e d i c a l c a r e e r , an e d u c a t i o n r a t i o n a l e r a t h e r t h a n a h e a l t h one. T h i s c o n c e p t was c o n s i s t e n t w i t h views e x p r e s s e d i n the Task F o r c e on t h e Cost o f H e a l t h S e r v i c e s and found s u p p o r t when B.C. enrolment f i g u r e s were compared w i t h t h o s e a c r o s s t h e c o u n t r y . The move, t o t a l l y p o l i t i c a l i n n a t u r e , r e c e i v e d m i n i m a l s u p p o r t from t h e c i v i l s e r v i c e and from t h e p r o f e s s i o n . Condemnation came from o t h e r p r o v i n c e s i n l i g h t o f e f f o r t s b e i n g made t o c o n t r o l t h e s u p p l y o f - 9:8 -p h y s i c i a n s . I n a d d i t i o n , the move s e t b a t t l e l i n e s between the M i n i s t r i e s o f H e a l t h and E d u c a t i o n , once a g a i n b r i n g i n g t o the f o r e f r o n t t h e j u r i s d i c t i o n a l o v e r l a p s between the two. I t has o n l y been w i t h i n t h e p a s t y e a r t h a t g u i d e l i n e s have been e s t a b l i s h e d t o s o r t o u t many o f t h e s e b o r d e r l i n e i s s u e s . T h i s has n o t been a c c o m p l i s h e d a t a p o l i t i c a l l e v e l , b u t r a t h e r w i t h i n the b u r e a u c r a c y . The V i s i o n Care Task F o r c e e s t a b l i s h e d w i t h t h e o v e r a l l mandate o f e x a m i n i n g 'the p r e s e n t v i s i o n c a r e system i n B r i t i s h C o lumbia, t o a p p r o ximate i t s c o s t , and t o recommend any changes i n t h e system w h i c h , i n t h e o p i n i o n o f t h e Task F o r c e , would p r o v i d e 2 b e t t e r , more e f f i c i e n t c a r e a t t h e l o w e s t c o s t . 1 The s i g n i f i c a n c e o f t h i s committee as a p h y s i c i a n p l a n n i n g committee r e s t s i n the f a c t t h a t f o r the f i r s t time a l l com-ponents o f a s e r v i c e a r e a met t o d i s c u s s t h e i r f u t u r e r o l e s . Membership on t h e Committee i n c l u d e d r e p r e s e n t a t i v e s from a l l a s p e c t s o f t h e V i s i o n Care f i e l d - o p h t h a l m o l o g i s t s , o p t o m e t r i s t s and o p t i c i a n s - as w e l l as government r e p r e s e n t a t i o n from H e a l t h and E d u c a t i o n . N e g o t i a t i o n s u l t i m a t e l y c e n t e r e d around i s s u e s o f economics and t u r f , w i t h t h e o p h t h a l m o l o g i s t s a t t e m p t i n g t o h o l d onto t h e l u c r a t i v e market o f r e f r a c t i o n s on grounds o f e x p e r t i s e . A l t h o u g h a q u a l i t y and more c o s t e f f i c i e n t system was proposed, - 9 9 -the m i n o r i t y r e p o r t s u b m i t t e d by t h e p h y s i c i a n s and subsequent b a r g a i n i n g , have l e d t o s h e l v i n g o f t h e r e p o r t , and l i t t l e f u r t h e r a c t i o n a r i s i n g from i t . The A d v i s o r y Committee on M e d i c a l Manpower p r e s e n t s y e t a t h i r d example o f p h y s i c i a n p l a n n i n g i n B.C. E s t a b l i s h e d i n 19 78 by t h e p r e s e n t M i n i s t e r o f H e a l t h , and c h a i r e d by a former M i n i s t e r o f H e a l t h , t h e Honourable Mr. Wesley B l a c k , t h e A d v i s o r y Committee on M e d i c a l Manpower found i t s r o o t s i n t h e f a i l u r e o f r a t i o n a l p l a n n i n g . R a t i o n a l i z a t i o n o f p h y s i c i a n manpower p l a n n i n g i n t h e p r o v i n c e , had become i m p o s s i b l e , e s p e c i a l l y i n t h e wake o f t h e d e c i s i o n t o double the s i z e o f t h e m e d i c a l s c h o o l . The t i m e was l o n g overdue t o f a c e t h e b a s i c i s s u e s o f c o s t , r e q u i r e m e n t s and d i s t r i b u t i o n , b o t h by government and by t h e p r o f e s s i o n . The Committee was co m p r i s e d o f b o t h t h e s e components, t h r o u g h r e p r e s e n t a t i o n from t h e C o l -l e g e o f P h y s i c i a n s - and Surgeons, the M e d i c a l A s s o c i a t i o n , ; t h e H e a l t h A s s o c i a t i o n , the H e a l t h E d u c a t i o n A d v i s o r y Committee and t h e M e d i c a l S e r v i c e s Commission. I t - spent two y e a r s i n i t s a n a l y s i s and d e l i b e r a t i o n s . The r e s u l t was s i x t y - s e v e n recommendations c o v e r i n g n o t o n l y i s s u e s o f m e d i c a l manpower, b u t o f a l l a s p e c t s o f t h e m e d i c a l c a r e d e l i v e r y system. The scope o f i t s recommendations and t h e p o l i t i c a l i m p o r t o f most o f them have l e d t o c o n f u s i o n and r e l u c t a n c e f o r f u t u r e a c t i o n . To d a t e , t h e r e p o r t has been r e l e a s e d o n l y f o r d i s c u s s i o n w i t h m i n i m a l a c t i o n r e s u l t i n g . I t i s u n l i k e l y t h a t a c t i o n w i l l be - .1.00 -f o r t h c o m i n g . E. Summary Each o f the p l a n n i n g e f f o r t s d e s c r i b e d above s e r v e t o i l l u s t -r a t e two p o i n t s . F i r s t l y , t h e nature, o f m e d i c a l manpower p l a n -n i n g i s such, t h a t a l t h o u g h i t i s t h e prime arena i n which r a t -i o n a l p l a n n i n g s h o u l d o c c u r , i t i s the a r e a l e a s t r e c e p t i v e t o i t . M e d i c a l manpower i s s u e s need t o be r e s o l v e d b e f o r e any hope can be h e l d f o r r a t i o n a l l y a d d r e s s i n g o t h e r manpower c a t e g o r i e s . The n a t u r e o f t h e p r o f e s s i o n i s such t h a t t h e knowledge and power c o n t r o l h e l d by t h e p h y s i c i a n , p r o v i d e him w i t h g r e a t b a r g a i n i n g power b o t h w i t h government and w i t h o t h e r h e a l t h p r o f e s s i o n a l and o c c u p a t i o n a l groups. Attempts by government t o c o n t r o l c o s t s w i l l always be t h w a r t e d by the p h y s i c i a n ' s a b i l i t y t o g e n e r a t e h i s own demand. S e c o n d l y ; p l a n n i n g / d e c i s i o n making i n a l l i n s t a n c e s , o c c u r r e d o u t s i d e the e s t a b l i s h e d b u r e a u c r a t i c h e a l t h manpower s t r u c t u r e s . Impetus f o r b o t h s t u d i e s o r i g i n a t e d w i t h t h e s e s t r u c t u r e s , b u t p r i m a r i l y from an i n a b i l i t y o f .the system t o a p p l y r a t i o n a l t e c h n i q u e s t o m e d i c i n e . Recommendations e v o l v i n g from the r e p o r t s were met w i t h e q u a l d i f f i c u l t y and an i n a b i l i t y t o s o u n d l y a d v i s e on f u t u r e a c t i o n . B a r g a i n i n g by p h y s i c i a n s c o n c e r n i n g recommend-a t i o n s has o c c u r r e d d i r e c t l y w i t h t h e M i n i s t e r , a g a i n b y p a s s i n g f o r m a l c h a n n e l s . - 1 0 1 -F o o t n o t e s 1. Garner, J . , "Conference i n CMA House Concludes P h y s i c i a n s Have t o P l a y the Manpower Game". 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 V o l . 115 ( 7 ) , October 1976, p. 664. 2. V i s i o n Care Task F o r c e R e p o r t , M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h Columbia, O c t o b e r , 1977. - 102--CHAPTER 6 MANPOWER PLANNING IN OTHER HEALTH PROFESSIONS AND OCCUPATIONS P h y s i c i a n s , because they have been t h e prime c o s t c o n c e r n i n the f i e l d , have s t i m u l a t e d the most p l a n n i n g a t t e n t i o n b o t h w i t h i n government and w i t h i n t h e p r o f e s s i o n . Other p r o f e s s i o n s and o c c u p a t i o n s have been slow t o address t h e i r own manpower problems and government has been t o o busy w i t h p h y s i c i a n s t o devote much energy t o t h e s e o t h e r a r e a s . P l a n n i n g f o r t h e most p a r t has not f o c u s s e d on numbers. I n s t e a d i s s u e s have c e n t r e d on l i c e n s u r e , t r a i n i n g , and a c c r e d i t a t i o n . Q u e s t i o n s o f numbers have o n l y r e c e n t l y a c h i e v e d s i g n i f i c a n c e because i m m i g r a t i o n o f f o r e i g n t r a i n e d w o r kers has become o f prime c o n c e r n . F o r e i g n t r a i n e d p e r s o n n e l a c c o u n t f o r h i g h p e r c e n t a g e s o f p h y s i o t h e r a p i s t s , o c c u p a t i o n a l t h e r a p i s t s and p s y c h i a t r i c n u r s e s i n B.C., t o name j u s t a few. Concern as t o the mushrooming e f f e c t o f t e c h n o l o g y and the p r o l i f e r a t i o n o f new t y p e s o f h e a l t h w o r k e r s , have q u i t e n a t u r a l l y grown. New o c c u p a t i o n s and s p e c i a l i z a t i o n w i t h i n e x i s t i n g o c c u p a t i o n s a r e h a v i n g i n c r e a s i n g e f f e c t on b o t h t r a i n i n g and l a b o u r c o s t s . J u r i s d i c t i o n a l d i s p u t e s a r e growing between e s t a b l i s h e d p r o f e s s i o n s and a i d e and a s s i s t a n t l e v e l w o r k ers who a r e f i l l i n g - .-1.03 -gaps i n s e r v i c e o r p r o v i d i n g a l t e r n a t e d e l i v e r y methods. T h i s i s becoming most e v i d e n t i n t h e r e h a b i l i t a t i o n f i e l d where c r a f t w o r k e r s , r e c r e a t i o n a i d e s , a c t i v i t y a i d e s , o c c u p a t i o n a l t h e r a p y a i d e s , p h y s i o t h e r a p y a i d e s , massage t h e r a p i s t s and a new b r e e d o f r e m e d i a l gymnasts a r e a t t e m p t i n g t o f i l l gaps i n s e r v i c e l e f t by s h o r t a g e s o f t r a d i t i o n a l w o r k e r s . A l a c k o f d e f i n i t i o n o f p r a c t i c e f i e l d s t h r o u g h l i c e n s u r e o r r e g i s t r a t i o n o f t e n makes a t t e m p t s t o c u r t a i l t h e s e i n t r u s i o n s by e x i s t i n g w o r k e r s a f u t i l e e f f o r t . I n some i n s t a n c e s , such as d i e t e t i c s , t h e demand.is d e c r e a s i n g because o f an i n a b i l i t y on the p a r t o f t h e p r o f e s s i o n t o d e f i n e i t s f i e l d o f p r a c t i c e and defend i t s t u r f . Few p r o f e s s i o n s / o c c u p a t i o n s have seen p l a n n i n g as a p r i o r i t y and t h e r e f o r e few have d e v e l o p e d t h e h a r d l i n e t a k e n by phy-s i c i a n s t h a t t h i s f u n c t i o n s h o u l d remain w i t h i n t h e p r o f e s s i o n . W i t h few e x c e p t i o n s , n u r s i n g b e i n g a n o t a b l e one, e f f o r t s i n p l a n n i n g have r e s t e d w i t h government and w i t h academics. T h i s c h a p t e r w i l l examine f i v e h e a l t h o c c u p a t i o n a l a r e a s , each i l l u s t r a t i n g a d i f f e r e n t p l a n n i n g c l i m a t e . They i n c l u d e n u r s i n g , pharmacy, d e n t i s t r y , d i e t e t i c s , p h y s i o t h e r a p y and o c c u p a t i o n a l t h e r a p y . A. N u r s i n g Manpower The r o l e o f nurses i n t h e h e a l t h c a r e f i e l d has undergone - 104 -d r a m a t i c changes i n t h e y e a r s s i n c e F l o r e n c e N i g h t i n g a l e . The sense o f m i s s i o n so o f t e n a t t r i b u t e d t o them has f a d e d , w i t h a sense o f m i l i t a n c y r e p l a c i n g i t . More t h a n any o t h e r h e a l t h o c c u p a t i o n , t h e r o l e o f the nurse has always e v o l v e d i n r e l a t i o n t o t h a t o f t h e p h y s i c i a n . Any r o l e change has been c l o s e l y s c r u t i n i z e d t o a s c e r t a i n how i t i n f r i n g e s upon p h y s i c i a n t e r r i t o r y . Some a n a l y s t s c a r r y t h e i n f r i n g e m e n t a n a l o g y t o extremes and see t h e r o l e o f t h e nurse as no l o n g e r n e c e s s a r y . L e v i (19 80) has s t a t e d t h a t no t a s k c u r r e n t l y p e r -formed by t h e nurse i s not c a r r i e d o u t by some o t h e r h e a l t h w o r k e r . She r e f e r s t o the nurse as b e i n g ' f u n c t i o n a l l y redundant'. Movement towards more r e s p o n s i b l e r o l e s , such as e x e m p l i f i e d by t h e nurse p r a c t i t i o n e r , has been met w i t h f o r c e f u l and s u c c e s s f u l o p p o s i t i o n from t h e m e d i c a l f i e l d . E f f o r t s by nurses t o assume t h e s e more r e s p o n s i b l e r o l e s have t a k e n v a r i o u s r o u t e s - r e g i s t r a t i o n / l i c e n s u r e t a c t i c s , e d u c a t i o n r e q u i r e m e n t s , s t a n d a r d s o f p a t i e n t c a r e and s a l a r y demands. P l a n n i n g o f n u r s i n g manpower by government has been m i n i m a l . P o s s i b l y t h i s i s due t o a f e a r o f t h e numbers i n v o l v e d o r a l a c k o f c l a r i t y as t o the r o l e o f t h e nurse i n t h e h e a l t h c a r e team. A t t h e n a t i o n a l l e v e l , a N u r s i n g Requirements Committee was e s t a b l i s h e d i n 19 70 p r i o r t o e i t h e r t h e F e d e r a l - P r o v i n c i a l H e a l t h Manpower Committee o r the N a t i o n a l Committee on - 105--P h y s i c i a n Manpower. I n s t i g a t e d a t the r e q u e s t o f t h e n u r s i n g p r o f e s s i o n and w o r k i n g under s i m i l a r terms o f r e f e r e n c e t o t h e p h y s i c i a n committee, i t met w i t h an e a r l y demise. Lack o f agreement on o b j e c t i v e s and upon methodology, w i t h i n t h e p r o f e s s i o n , b r o u g h t t h e s t u d y t o an end b e f o r e i t s work was completed. A t t e m p t s have not been made s i n c e t o i n i t i a t e a n a t i o n a l n u r s i n g s t u d y . A t t h e p r o v i n c i a l l e v e l , few attemp t s have been made t o t a c k l e n u r s i n g manpower p l a n n i n g r e q u i r e m e n t s . The Kermacks Rep o r t (19 79) on n u r s i n g e d u c a t i o n i n B.C. a d d r e s s e d t h i s i s s u e i n o n l y a p e r i p h e r a l f a s h i o n , as i t at t e m p t e d t o r a t i o n a l i z e t he n u r s i n g e d u c a t i o n system. Conducted under t h e a u s p i c e s o f the M i n i s t r y o f E d u c a t i o n , t h e r e p o r t g a i n e d l i t t l e s u p p o r t i n t h e M i n i s t r y o f H e a l t h as i t a d v o c a t e d a l a d d e r i n g c o n c e p t i n n u r s i n g from a i d e l e v e l t o b a c c a l a u r e a u t e l e v e l based upon d i f f e r e n t r e q u i r e d competencies. The H e a l t h M i n i s t r y was un-w i l l i n g t o a c c e p t t h i s c oncept u n t i l i t f e l t i t had been t h o r o u g h l y i n v e s t i g a t e d - a p r o c e s s which c o u l d t a k e y e a r s . I n a d d i t i o n , Kermacks recommended r e p e a l i n g t h e P s y c h i a t r i c N u r s i n g A c t , e f f e c t i v e l y e l i m i n a t i n g one s p e c i a l t y group o f n u r s e s a l t o g e t h e r . T h i s l a t t e r recommendation was most u n a c c e p t a b l e t o t h e M i n i s t r y o f H e a l t h as i t f e a r e d a s e v e r e s h o r t a g e o f nurs e s t o s t a f f p r o v i n c i a l p s y c h i a t r i c i n s t i t u t i o n s . The u n a c c e p t a b i l i t y o f t h e Kermacks Report t o Health, was - 106 -p r o b a b l y more r e l a t e d t o t h e f a c t i t was done by t h e M i n i s t r y o f E d u c a t i o n than any o t h e r r e a s o n . The M i n i s t r y o f H e a l t h has always seen h e a l t h manpower as i t s t e r r i t o r y , e s p e c i a l l y as i t r e l a t e s t o n u r s i n g - a f i e l d f o r which i t has always m a i n t a i n e d a t r a i n i n g r e s p o n s i b i l i t y . W i t h i n n u r s i n g i t s e l f , i t appears t h a t u n t i l r e c e n t l y t h e p r o f e s s i o n has n o t f u l l y r e a l i z e d t h e power i t h e l d , p u r e l y i n numbers. I n f a c t , numbers more o f t e n than n ot have been n u r s e s ' undoing r a t h e r than h e l p i n g them t o a c h i e v e s u c c e s s , as they appear t o l a c k u n i t y w i t h i n t h e r a n k s . On the s u r f a c e t h e r e i s a. l a c k o f c l e a r o b j e c t i v e s , but i s t h i s n e c e s s a r i l y the case? A l t h o u g h h i d d e n w i t h i n o t h e r g u i s e s , an upward m o b i l i t y o f n u r s i n g as an o c c u p a t i o n has always o c c u r r e d . I n most o c c u p a t i o n a l a r e a s , a pyramid e f f e c t o c c u r s w i t h l e s s s k i l l e d members f o r m i n g t h e base by v i r t u e o f numbers. T h i s has not o c c u r r e d i n n u r s i n g where t h e more h i g h l y t r a i n e d n u r s e s form a much l a r g e r p r o p o r t i o n o f the n u r s i n g p o o l t h a n do L i c e n s e d P r a c t i c a l Nurses (LPN) and R e g i s t e r e d P s y c h i a t r i c Nurses (RPN). L i c e n s e d p r a c t i c a l n u r s e s are found a t the base o f t h e pyramid w i t h a p p r o x i m a t e l y one t h i r d t h e number o f r e g i s t e r e d n u r s e s . The i n t e r e s t i n g phenomenon i s found i n the g r a d u a l p h a s i n g out o f p s y c h i a t r i c nurses and l i c e n s e d p r a c t i c a l n u r s e s . N e i t h e r - 10,7 -f i e l d has grown o v e r the p a s t few y e a r s and i n f a c t , each has e f f e c t i v e l y been k e p t s m a l l i n r e l a t i o n t o t h e number o f r e g i s t e r e d n u r s e s . The a u t h o r o f t h e Kermacks R e p o r t , h e r s e l f an R.N.-, has p u t f o r t h t h e recommendation c o n c e r n i n g the demise o f t h e p s y c h i a t r i c n u r s e . The recommendation has a r a t i o n a l base, i n t h a t p s y c h i a t r i c n u r s i n g i s the o n l y n u r s i n g s p e c i a l t y t r a i n e d , i n a s e p a r a t e stream, and changing i t t o s p e c i a l t y t r a i n i n g f o r r e g i s t e r e d n u r s e s , i s e x t r e m e l y l o g i c a l . However, one cannot h e l p b u t wonder what s t r u c t u r e R e g i s t e r e d Nurses are a i m i n g t o a c h i e v e . As R.P.N.'s and L.P.N.'s g r a d u a l l y d e c r e a s e and b a c c a l a u r e a t e , masters and d o c t o r a l l e v e l n urses i n c r e a s e , the pyramid b e g i n s t o r i g h t i t s e l f w i t h R.N.'s f o r m i n g t h e base. T h i s j e l l y - l i k e movement through the system p r o v i d e s an i n t e r e s t i n g p e r s p e c t i v e t o h e a l t h manpower p l a n n i n g . A l b e r t a ' s Task F o r c e on N u r s i n g Manpower (19 77) recommended t h a t by 19 81, t h e b a c c a l a u r e a t e degree be c o n s i d e r e d as m i n i m a l r e q u i r e m e n t f o r n u r s e s . A f u r t h e r s h u f f l e upwards? A l t h o u g h not c l e a r l y ..enunciated, n u r s e s do seem u n i t e d i n one a r e a - a d e s i r e f o r r e s p o n s i b i l i t y and a d e s i r e f o r upward m o b i l i t y towards t h e p h y s i c i a n . .'. B. : Pharmacy. Manpower Pharmacy i l l u s t r a t e s a d i f f e r e n t f o c u s f o r manpower p l a n n i n g from t h a t o b s e r v e d i n n u r s i n g . I n n u r s i n g i t was shown t h a t - 108 -power r o s e from w i t h i n the p r o f e s s i o n i n cha n g i n g b o t h the l e v e l o f worker and t h e numbers r e q u i r e d . I n pharmacy,' i n B.C.- p l a n n i n g came from w i t h i n t h e e d u c a t i o n a l i n s t i t u t i o n . Government has not i n t e r v e n e d i n the p r o c e s s e i t h e r a t a n a t i o n a l o r a p r o v i n c i a l l e v e l , l e a v i n g t h e s c h o o l , i n c o n j u n c t i o n w i t h d i s c u s s i o n s w i t h t h e p r o f e s s i o n a l a s s o c i a t i o n , t o expand as i t saw f i t . P o l g l a s e (19 79) has d e s c r i b e d how co n c e r n had grown i n t h e mid-s i x t i e s o v e r t h e d e c l i n i n g e n r o l m e n t i n t h e F a c u l t y o f P h a r m a c e u t i c a l S c i e n c e s a t U.B.C. The g r a d u a l d e c l i n e i n the pe r c e n t a g e o f U.B.C. graduates r e g i s t e r i n g as p h a r m a c i s t s w i t h the C o l l e g e o f P h a r m a c i s t s from 81.6% i n the e a r l y 1950's t o 64.3% i n 1966 was a l s o o f c o n c e r n . By 1971, due t o the h a r d work o f t h e Dean o f Pharmacy, t h e s c h o o l had s t a r t e d on a p e r i o d o f growth. Between 19 70 and 19 77, t h e s c h o o l ' s enrolment grew from 221 t o 361. The advent o f t h e Pharmacare program p r o v i d i n g a t h i r d p a r t y payment system f o r drugs t o c e r t a i n groups under t h e N.D.P. government, i n c r e a s e d t h e demand f o r p h a r m a c i s t s . T h i s demand, however, has l e v e l e d o f f and c o n c e r n now c e n t e r s around a s a t u r a t i o n o f t h e market. Government has not d i r e c t e d p l a n n i n g e f f o r t s t o pharmacy manpower. However, s e v e r e budget c u t b a c k s g e n e r a l l y i n 19 75 - 109 -f i l t e r e d t h r o u g h th e system t o t h e F a c u l t y o f Pharmacy, p l a c i n g some r e s t r a i n t s on e x p a n s i o n ( P o l g l a s e 19 7 9 ) . P r o t e c t i o n o f t h e i r t e r r i t o r y by p h a r m a c i s t s i s e v i d e n t i n t h e slow growth o f pharmacy a i d e s . I t i s b e l i e v e d t h a t many t a s k s c u r r e n t l y c a r r i e d o u t by p h a r m a c i s t s , c o u l d q u i t e r i g h t l y be a s s i g n e d toithese l e s s e r t r a i n e d w o r k e r s . S a t u r a t i o n o f t h e market by p h a r m a c i s t s has l e d t o a r e l u c t a n c e t o e s t a b l i s h a i d e t r a i n i n g programs i n t h i s f i e l d . To d a t e o n l y one program e x i s t s , t r a i n i n g a p p r o x i m a t e l y 60 p e o p l e p e r y e a r i n a t h r e e month c o u r s e . C. D e n t a l Manpower The p r a c t i c e o f d e n t i s t r y and m o n i t o r i n g o f d e n t a l manpower has, u n t i l r e c e n t l y , been l e f t t o the market p l a c e . Government has had l i t t l e i n t e r e s t i n c o n t r o l l i n g d e n t a l manpower, because a t h i r d p a r t y payment system d i d not e x i s t . The d e n t a l p r o -f e s s i o n , s i m i l a r l y t o the m e d i c a l p r o f e s s i o n , i s t h e g a t e k e e p e r t o s e r v i c e , d e n t i s t s b a s i c a l l y o r d e r i n g s e r v i c e as they deem i t n e c e s s a r y . The o n l y r e s t r i c t i o n on t h i s s e r v i c e , i s the number o f s u r f a c e s i n w h i c h t o p l a c e f i l l i n g s . C o n t r o l o f numbers o f p r a c t i t i o n e r s has been l e f t t o the p r o f e s s i o n and because s e r v i c e d e l i v e r e d was d i r e c t l y r e l a t e d t o p r o f i t , i t was t o t h e d e n t i s t s ' advantage t o encourage th e development o f a u x i l i a r y p e r s o n n e l . D e n t a l A s s i s t a n t s and H y g i e n i s t s have grown b o t h i n - no. -number and i n demand o v e r t h e p a s t few y e a r s . A p a r t from Saskatchewan's s o c i a l i s t v e n t u r e i n t o d e n t a l c a r e f o r c h i l d r e n and B.C.'s st u d y o f p o s s i b l e p r o v i s i o n a l o n g s i m i l a r l i n e s (Evans 19 75), government c o n c e r n has r e a l l y begun t o grow, b o t h a t t h e n a t i o n a l and p r o v i n c i a l l e v e l , w i t h t h e a r r i v a l o f D e n t i c a r e p l a n s . A l t h o u g h t h e impact o f t h i s t h i r d p a r t y system has n o t y e t been d e t e r m i n e d , the c o s t o f such a program r a i s e s many q u e s t i o n s (Evans & W i l l i a m s o n 1976) . The d e n t a l p r o f e s s i o n has, u n t i l now, been s u c c e s s f u l i n con-t r o l l i n g i t s numbers, p r i m a r i l y f o r f i n a n c i a l r e a s o n s . However, c o n c e r n i s growing b o t h w i t h i n t h e p r o f e s s i o n and a t some p r o -v i n c i a l government l e v e l s , as t o t h e open door i m m i g r a t i o n p o l i c y towards d e n t i s t s . As i t c u r r e n t l y e x i s t s , p o i n t s f o r i m m i g r a t i o n a c c o r d e d an o c c u p a t i o n are. a composite o f p r o v i n c i a l p i c t u r e s . Those p r o v i n c e s w i t h "needs" f o r an o c c u p a t i o n can sway th e p o i n t s a l l o c a t e d . M i g r a t i o n p a t t e r n s i n Canada a r e such t h a t B.C. q u i c k l y becomes the r e c i p i e n t o f immigrants who g a i n e n t r y t o a 'needy' p r o v i n c e , and w i s h t o move t o t h e g r e e n e r , more p r o s p e r o u s p a s t u r e s o f the west. The n a t u r e o f the f e d e r a t i o n and human r i g h t s l e g i s l a t i o n make t h i s f a c t o r d i f f i c u l t t o c o n t r o l . R e g i s t r a t i o n mechanisms and c o n t r o l o f the s i z e o f t h e d e n t a l s c h o o l ( o n l y 40 s t u d e n t s a d m i t t e d t o U.B.C. each. year), have been - I l l -more o r l e s s t h e o n l y f o r m a l mechanisms o f c o n t r o l w i t h i n b o t h the p r o f e s s i o n and government i n B.C. u n t i l r e c e n t l y . E a r l y i n 19 80 w i t h growing c o n c e r n about numbers and the promise o f D e n t i c a r e , t h e C o l l e g e o f D e n t a l Surgeons e s t a b l i s h e d a s t a n d i n g committee on d e n t a l manpower t o address numbers i s s u e s . How t h i s committee i s f u n c t i o n i n g i s unknown. D. D i e t e t i c Manpower Never o f p r i m a r y i m p o r t a n c e t o manpower p l a n n e r s , d i e t e t i c s p r o v i d e s a d i f f e r e n t approach t o p r o f e s s i o n a l i n v o l v e m e n t i n i t s own p r o f e s s i o n ' s manpower p l a n n i n g . Faced w i t h a p e r c e i v e d s h o r t a g e o f i n t e r n s h i p p o s i t i o n s and a d e s i r e t o be i n v o l v e d i n i t s own p l a n n i n g , t h e Canadian D i e t e t i c A s s o c i a t i o n i n i t i a t e d a s t u d y o f t h e r e q u i r e m e n t s f o r D i e t i t i a n s i n Canada. The e n o r m i t y o f the t a s k , and i t s q u e s t i o n a b l e u s e f u l n e s s , l e d t o t h e i n i t i a t i o n o f a p i l o t p r o j e c t t o examine t h e f e a s i b i l i t y o f a n a t i o n a l s t u d y . ( H e a l t h S e r v i c e s R esearch and Development, 1980) F i n d i n g s i n d i c a t e d t h a t d i e t i t i a n s , u n l i k e t h o s e h e a l t h p r o -f e s s i o n a l s mentioned p r e v i o u s l y , had f a i l e d t o s t r u g g l e w i t h t h e i r i d e n t i t y and t e r r i t o r i a l c l a i m s . Beyond t h e i r t r a d i t i o n a l r o l e as h o s p i t a l d i e t i t i a n s , they had f a i l e d t o d e f i n e t h e i r f i e l d o f p r a c t i c e and defend a d e q u a t e l y the need f o r d i e t i t i a n s i n new and emerging a r e a s . T h e i r i n a b i l i t y t o c a r v e out space f o r themselves has l e d t o a g r e a t d e a l o f i n f r i n g e m e n t upon - 112 -t h e i r t e r r i t o r y by l e s s e r t r a i n e d p e o p l e such as f o o d s e r v i c e s u p e r v i s o r s , , d i e t a r y a i d e s and d i e t a r y t e c h n i c i a n s . I t was recommended t o t h e Canadian D i e t e t i c A s s o c i a t i o n t h a t p r i o r t o e ngaging i n manpower p l a n n i n g a c t i v i t i e s , i t s h o u l d d e f i n e t h e p r o f e s s i o n and i t s f i e l d o f p r a c t i c e i n such a way t h a t i t i s a b l e a d e q u a t e l y t o d e f e n d th e c o n t i n u e d need and growth o f t h e p r o f e s s i o n . I f t h i s i s not a d d r e s s e d i n t h e near f u t u r e , i t i s b e l i e v e d t h a t such a p r o f e s s i o n w i l l g r a d u a l l y be phased o u t . E. P h y s i o t h e r a p y and O c c u p a t i o n a l Therapy Manpower T h i s f i n a l example p o i n t s t o a p r o f e s s i o n a l a r e a w h i c h has been t r e a t e d as a f r i n g e a r e a i n the p a s t , b u t f o r v a r i o u s p o l i t i c a l r e a s o n s i s now g a i n i n g i n c r e a s i n g s i g n i f i c a n c e . P h y s i o t h e r a p y and O c c u p a t i o n a l Therapy i n t h i s p r o v i n c e have b o t h been dominated by f o r e i g n t r a i n e d p e o p l e f o r many y e a r s . The m a j o r i t y o f t h e s e have been B r i t i s h t r a i n e d , l u r e d by s h o r t a g e s i n Canada and promises o f h i g h e r wages. S e p a r a t e i s s u e s have a r i s e n i n each d i s c i p l i n e r e l a t e d t o t r a i n i n g and l i c e n s u r e . These w i l l be examined f i r s t , f o l l o w e d by a d i s c u s s i o n o f t h e common mandate f o r p l a n n i n g bestowed upon them. P h y s i o t h e r a p y t r a i n i n g has t r a d i t i o n a l l y been a t a d i p l o m a - 113 -l e v e l b o t h i n B r i t a i n and Canada. Membership i n the Canadian P h y s i o t h e r a p y A s s o c i a t i o n has u n t i l 19 77, r e q u i r e d o n l y a d i p l o m a . I n 19 79, i n an e f f o r t t o c u r t a i l f o r e i g n i m m i g r a t i o n and t o r a i s e t h e p r o f i l e o f the p r o f e s s i o n , t h e Canadian P h y s i o t h e r a p y A s s o c i a t i o n changed membership r e q u i r e m e n t s , i n s i s t i n g on a minimum o f a b a c c a l a u r e a t e degree t o m a i n t a i n membership. Because membership i n t h i s a s s o c i a t i o n i s con-s i d e r e d as a p r e r e q u i s i t e t o l i c e n s u r e , t h e r u l i n g p l a c e d many p r o v i n c i a l governments i n a pre d i c a m e n t f o r they were s a t i s f i e d w i t h t h e d i p l o m a p r o d u c t and u n w i l l i n g t o pay f o r b a c c a l a u r e a t e g r a d u a t e s . I n many r e s p e c t s , t h e move was u n s u c c e s s f u l f o r few dip l o m a p e o p l e took advantage o f u p g r a d i n g c o u r s e s which were o f f e r e d and e v e n t u a l l y t h e s e c o u r s e s were d i s c o n t i n u e d . S h o r t a g e s remain a major problem and e x p a n s i o n o f e x i s t i n g e d u c a t i o n a l .programs has y e t t o be r e a l i z e d . I n B.C. i n O c c u p a t i o n a l Therapy, t h e i s s u e i s , and has been f o r many y e a r s , one o f l i c e n s u r e . S t r i v i n g t o a c h i e v e e q u a l s t a t u s w i t h p h y s i o t h e r a p y , o c c u p a t i o n a l t h e r a p i s t s have p r e s s e d government h a r d f o r l i c e n s u r e . To dat e t h e i r q u e s t has been u n s u c c e s s f u l . B oth p r o f e s s i o n s have s u f f e r e d from a c h r o n i c s h o r t a g e o f t r a i n e d p e o p l e t o meet e x i s t i n g p o s i t i o n s . The advent o f Long Term Care added t o t h i s p r o b l e m b o t h from t h e a s p e c t o f v a c a n t p o s i t i o n s and i d e n t i f i e d "need". Few moves have been made i n - 114 -the p a s t t o i n c r e a s e enrolment o f e x i s t i n g s c h o o l s o r t o improve t r a i n i n g f a c i l i t i e s . An i n t e r e s t i n g s i t u a t i o n has begun t o o c c u r w i t h t h e e s t a b l i s h m e n t o f t h e I n t e r n a t i o n a l Year o f D i s a b l e d P e r s o n s by the U n i t e d N a t i o n s . S i n c e 1978 and t h e r e a l i z a t i o n o f i t s o c c u r r e n c e i n 1981, f u n d i n g has begun t o be c h a n n e l l e d i n t o handicapped and r e h a b i l i t a t i o n s t u d i e s as w e l l as i n t o s t u d i e s o f manpower t o s e r v i c e the needs o f t h e s e p e o p l e . A s t u d y o f r e h a b i l i t a t i o n manpower, i n g e n e r a l , has been l a u n c h e d a t the n a t i o n a l l e v e l as has a p r o v i n c i a l s t u d y s p e c i f i c t o p h y s i o t h e r a p y and o c c u p a t i o n a l t h e r a p y manpower. S t u d i e s o f t h i s t y pe a r e p o l i t i c a l l y i n vogue and p r a c t i t i o n e r s - l i k e t he handicapped - a r e s a y i n g " I t ' s my t u r n " . F. Summary T h i s c h a p t e r has examined f i v e ' h o n r a t i o n a l " approaches t o h e a l t h manpower p l a n n i n g t h r o u g h the example o f f i v e p r o f e s s i o n a l groups. I t began w i t h an e x a m i n a t i o n o f the p l a n n i n g o f n u r s -i n g manpower and the a b i l i t y o f the p r o f e s s i o n ' t o g a i n s t a t u s and r e c o g n i t i o n t h r o u g h t h w a r t i n g the growth o f lo w e r l e v e l n u r s i n g p e r s o n n e l . S e c o n d l y , pharmacy manpower was d i s c u s s e d i n l i g h t o f t h e power o f t h e Dean o f Pharmacy t o i n c r e a s e e n r o l m e n t , p r e v e n t f o r e i g n i m m i g r a n t s from s p o i l i n g t h e 'pharmacy e c o l o g y ' o f the p r o v i n c e and e v e n t u a l l y f l o o d t h e market. - 115 -D e n t i s t r y p r o v i d e d an example o f an e n t r e p r e n e u r i a l group w h i c h has used t h e s u b s t i t u t i o n o f lo w e r l e v e l a u x i l i a r i e s t o i t s members' f i n a n c i a l b e n e f i t as w e l l as t o c o n t r o l i t s own man-power market. D i e t e t i c manpower i s t h e s t u d y o f a manpower group i n danger o f e x t i n c t i o n due t o t h e l a c k o f a d e f i n e d f i e l d o f p r a c t i c e and of a c l e a r r o l e . A l t h o u g h i n t e r e s t e d i n p u r s u i n g a r a t i o n a l p l a n n i n g framework t h e ground work has n o t been l a i d t o a l l o w them t o do t h i s . F i n a l l y , d i s c u s s i o n o f p h y s i o t h e r a p y and o c c u p a t i o n a l t h e r a p y manpower has r e v e a l e d two f r i n g e groups who, u n t i l r e c e n t l y , and i n s p i t e o f s h o r t a g e s , have r e c e i v e d l i t t l e p l a n n i n g a t t e n t i o n . The p o l i t i c a l c l i m a t e has now become r i p e f o r the st u d y o f t h e s e groups . as t h e I n t e r n a t i o n a l y e a r o f t h e D i s -a b l e d i s upon us. Wit h t h e e x c e p t i o n o f n u r s i n g , a l l f o u r a r e a s share the common c h a r a c t e r i s t i c o f b e i n g o v e r l o o k e d by government i n p l a n n i n g and even n u r s i n g has r e c e i v e d o n l y p o l i t i c a l a t t e m p t s r a t h e r t h a n p l a n n i n g a t t e n t i o n o f a r e s e a r c h v a r i e t y . I n none o f t h e s e f i e l d s has r a t i o n a l p l a n n i n g been c o n s i d e r e d and a l l have atte m p t e d t o i n c r e a s e t h e i r power and numbers t h r o u g h n e g o t i a t i o n . Some have been more s u c c e s s f u l than o t h e r s . - 116 -N u r s i n g has r e c e i v e d l i t t l e a t t e n t i o n i n comparison t o t h a t a c c o r d e d p h y s i c i a n s . The r e a l i t y appears t o be t h a t p h y s i c i a n s , as the g a t e k e e p e r s , have been o v e r p l a n n e d t o the e x c l u s i o n o f t h o s e p r o f e s s i o n s and o c c u p a t i o n s w h i c h form the base o f t h e h e a l t h p y r a m i d . T h i s f a c t o r a l o n e may account f o r t h e s k y -r o c k e t i n g c o s t o f h e a l t h c a r e . - 117 -CHAPTER_7 TOWARDS IMPROVEMENTS IN HEALTH MANPOWER PLANNING The purpose o f t h i s study was t h r e e f o l d : a) t o r e v i e w c u r r e n t h e a l t h manpower p l a n n i n g methodogies. b) t o d e s c r i b e i n c o n t e x t , the growth and changes i n m e d i c a l manpower p l a n n i n g i n Canada w i t h s p e c i a l r e f e r e n c e t o B r i t i s h C o l u m b i a . The manpower i s s u e s o f f i v e o t h e r h e a l t h p r o f e s s i o n a l a r e a s were a l s o e x p l o r e d . c) t o c r i t i q u e t he Canadian and B r i t i s h Columbian manpower p l a n n i n g p r o c e s s e s u s i n g c u r r e n t models and recommend changes t o the system which would i n c r e a s e e f f e c t i v e n e s s . In f u l f i l l i n g t h i s purpose a r e v i e w was made of s i x h e a l t h p r o f e s s i o n a l groups and how r a t i o n a l p l a n n i n g has not taken p l a c e i n s p i t e o f government's d e s i r e t o ..plan. These groups were examined i n l i g h t of p a s t and p r e s e n t b u r e a u c r a t i c p l a n n i n g s t r u c t u r e s . I t was r e a l i z e d t h a t h e a l t h p r o f e s s i o n s and o c c u p a t i o n s o t h e r t h a n p h y s i c i a n s r e c e i v e l i t t l e p l a n n i n g a t t e n t i o n from government because they a re n e i t h e r the gate keepers t o the - 118 -h e a l t h c a r e s e r v i c e system nor do the same c o s t f a c t o r s a p p l y t o them t h a t a p p l y t o p h y s i c i a n s . These p r o f e s s i o n s have been slow t o address t h e i r own manpower problems and when they have done so i n most i n s t a n c e s the approach has been one o f n e g o t i a t i o n r a t h e r than r a t i o n a l p l a n n i n g . I s s u e s f o r th e s e groups have o f t e n c e n t e r e d on l i c e n s u r e , t r a i n i n g and a c c r e d i t a t i o n r a t h e r than on numbers. Q u e s t i o n s of i m m i g r a t i o n , t e c h n o l o g y , p r o l i f e r a t i o n and s p e c i a l i z a t i o n now n e c e s s i t a t e t h a t numbers be examined. J u r i s d i c t i o n a l d i s p u t e s a r e growing between v a r i o u s l e v e l s of worker and t h i s i s e x a g g e r a t e d i n o c c u p a t i o n a l areas where d e f i n i t i o n of the p r a c t i c e f i e l d t h r o u g h l i c e n s u r e o r r e g i s t r a t i o n does not e x i s t . N u r s i n g has p r o v i d e d an i n t e r e s t i n g example of a p r o f e s s i o n which has atte m p t e d t o r e - d e f i n e i t s r o l e and i n d o i n g so has begun a r e s t r u c t u r i n g o f the normal p r o f e s s i o n a l p y ramid. A l t h o u g h s u c c e s s f u l w i t h i n the p r o f e s s i o n i n r e q u i r i n g i n c r e a s e d t r a i n i n g l e v e l s t o p e r f o r m t r a d i t i o n a l n u r s i n g f u n c t i o n s , n u r s e s have been l e s s s u c c e s s f u l i n a c q u i r i n g from the m e d i c a l p r o f e s s i o n s a n c t i o n f o r new and expanded r o l e s . Movement towards more r e s p o n s i b l e r o l e s such as e x e m p l i f i e d by the nurse p r a c t i t i o n e r have been met w i t h f o r c e f u l and s u c c e s s f u l o p p o s i t i o n . - 119 -Attempts a t r a t i o n a l p l a n n i n g i n n u r s i n g have been f r u i t l e s s e i t h e r because the p r o f e s s i o n i t s e l f c o u l d not come t o g r i p s w i t h the q u e s t i o n or because b u r e a u c r a t i c j u r i s d i c t i o n a l o v e r l a p s have negated recommendations. On the s u r f a c e t h e r e i s a l a c k of c l e a r o b j e c t i v e s i n n u r s i n g manpower p l a n n i n g . However, the upward m o b i l i t y of the o c c u p a t i o n i n the p a s t number of y e a r s l e a d s one t o q u e s t i o n how R.N. s have been a b l e t o form a f a r l a r g e r p o r t i o n of the n u r s i n g p o o l than L.P.N.'s and i n f a c t have almost caused the demise of the L.P.N, as the base l e v e l worker. Through t h i s government has s a t back and done n o t h i n g . Pharmacy p r o v i d e s a second model of n e g o t i a t i o n , but one u n l i k e t h a t o f n u r s i n g . In pharmacy p r e s s u r e and power from w i t h i n the e d u c a t i o n s e c t o r l e d t o a p e r i o d o f growth d u r i n g the s i x t i e s . T h i s r e s u l t e d i n a g r a d u a l f l o o d i n g o f the market and had i t not been f o r budget c u t b a c k s a s e v e r e problem would have r e s u l t e d . W i t h i n the p r o f e s s i o n , the s u r p l u s s i t u a t i o n has r e s u l t e d i n a r e l u c t a n c e t o e s t a b l i s h o r promote a i d e programs. U n t i l r e c e n t l y f p l a n n i n g f o r d e n t a l manpower has been l e f t t o the m a r k e t p l a c e . The i n t r o d u c t i o n of a t h i r d p a r t y payment system however has l e d t o governmental i n t e r e s t i n c o n t r o l . - 120 -The d e n t a l p r o f e s s i o n t o date has been s u c c e s s f u l i n c o n t r o l l i n g i t s own a d m i s s i o n p r i m a r i l y f o r p r o f i t r e a s o n s . The advent of d e n t a l plans,however/may l e a d t o an e a s i n g up of t h i s s i t u a t i o n . D i e t e t i c s i s the s t o r y of a p r o f e s s i o n concerned w i t h i t s own d w i n d l i n g numbers. U n l i k e n u r s i n g , pharmacy or d e n t i s t r y , t h e y have f a i l e d t o s t r u g g l e w i t h t h e i r i d e n t i t y and w i t h t e r r i t o r i a l c l a i m s . D i e t i t i a n s have been unable t o d e f i n e t h e i r f i e l d o f p r a c t i c e and t h e r e f o r e a d e q u a t e l y defend the need f o r c o n t i n u e d e x i s t a n c e . Less q u a l i f i e d a i d e and t e c h n i c i a n l e v e l workers have been s u c c e s s f u l i n t a k i n g over many t r a d i t i o n a l d i e t e t i c j o b s because o f the l a c k of def.in.it i o n . P h y s i o t h e r a p y and O c c u p a t i o n a l Therapy i l l u s t r a t e how a p r o f e s s i o n can g a i n s i g n i f i c a n c e based upon p o l i t i c a l atmosphere r a t h e r than r a t i o n a l e . The s h o r t a g e o f these two o c c u p a t i o n s has been a well-known f a c t f o r many y e a r s . D e s p i t e many p l e a s i t took 'The I n t e r n a t i o n a l Year of the D i s a b l e d ' t o p l a c e emphasis on the s h o r t a g e . P l a n n i n g e f f o r t s a re now commencing i n t h i s a r e a . C h a p t e r 5 s p e c i f i c a l l y a d d r e s s e s the p h y s i c i a n as gatek e e p e r t o the h e a l t h c a r e system. Each of the p l a n n i n g e f f o r t s d e s c r i b e d s e r v e s t o i l l u s t r a t e two p o i n t s . F i r s t , the na t u r e of m e d i c a l manpower p l a n n i n g i s s u c h , t h a t a l t h o u g h i t i s the prime arena - 121 -i n w hich r a t i o n a l p l a n n i n g s h o u l d o c c u r i t i s ' t h e g r o u p l e a s t r e c e p t i v e t o i t . I s s u e s o f s e r v i c e c o n t r o l must be r e s o l v e d b e f o r e any hope can be h e l d f o r r a t i o n a l l y a d d r e s s i n g p l a n n i n g e i t h e r f o r p h y s i c i a n or any o t h e r h e a l t h o c c u p a t i o n s . The n a t u r e of the p r o f e s s i o n i s such t h a t the knowledge and c o n t r o l h e l d by the p h y s i c i a n p r o v i d e him w i t h g r e a t b a r g a i n i n g power, b o t h w i t h government and w i t h o t h e r h e a l t h p r o f e s s i o n a l and o c c u p a t i o n a l groups. Attempts by government t o c u r t a i l c o s t s w i l l always be thwarted by the p h y s i c i a n ' s a b i l i t y t o g e nerate h i s own demand. S e c o n d l y , p l a n n i n g and d e c i s i o n making i n a l l i n s t a n c e s i l l u s t r a t e d , o c c u r r e d o u t s i d e the e s t a b l i s h e d b u r e a u c r a t i c h e a l t h manpower s t r u c t u r e s . Impetus f o r many s t u d i e s , o r i g i n a t e d w i t h i n t h e s e s t r u c t u r e s , but were p r i m a r i l y i n i t i a t e d because of an i n a b i l i t y o f the system t o a p p l y r a t i o n a l t e c h n i q u e s t o m e d i c i n e . B a r g a i n i n g by p h y s i c i a n s c o n c e r n i n g recommendations has o c c u r r e d d i r e c t l y w i t h the M i n i s t e r , a g a i n b y p a s s i n g f o r m a l c h a n n e l s . What i s t h e r o l e o f t h e m e d i c a l p r o f e s s i o n i n i t s own manpower. ,, p l a n n i n g ? I t has o b v i o u s l y been q u i t e i n v o l v e d i n t h e .past. P r i o r t o t h e e s t a b l i s h m e n t o f t h e t h i r d p a r t y system t h i s was p r o b a b l y l e g i t i m a t e . However, i t i s q u e s t i o n a b l e t h a t s o l e r e s p o n s i b i l i t y s h o u l d be w i t h p h y s i c i a n s when c o s t i s . b o r n by t h e .government. - 122 -F e d e r a l and p r o v i n c i a l p l a n n i n g s t r u c t u r e s as d e s c r i b e d i n the f o u r t h c h a p t e r have f a i l e d a d e q u a t e l y t o address the manpower i s s u e s p l a c e d b e f o r e them. F e d e r a l i n v o l v e m e n t i n h e a l t h manpower p l a n n i n g has always been q u e s t i o n a b l e , w i t h the p r o v i n c e s r e l u c t a n t t o a c c e p t i n t e r f e r e n c e . The f e d e r a l government has tended t o p o r t r a y i t s r o l e on the f e d e r a l / p r o v i n c i a l committee as one of c o o r d i n a t i o n and as such they have p r o v i d e d a t o o t h l e s s v e h i c l e on i s s u e s of n a t i o n a l c o n c e r n . Ten d i f f e r e n t s c e n e r i o s , s e t s of problems and p r i o r i t i e s a s s i s t i n t h i s . The t i g h t e n i n g o f i m m i g r a t i o n laws and the a p p l i c a t i o n of z e r o p o i n t s t o p h y s i c i a n s as an o c c u p a t i o n a l c a t e g o r y f o r purposes of i m m i g r a t i o n have been the o n l y accomplishments of the f e d e r a l government t o d a t e . These moves came not as the r e s u l t o f r a t i o n a l p l a n n i n g , but r a t h e r as the r e s u l t of b a r g a i n i n g and n e g o t i a t i o n both w i t h p r o v i n c i a l government and the p r o f e s s i o n . I n i t i a l changes i n g e n e r a l i m m i g r a t i o n laws were made t o t a l l y i n i s o l a t i o n from the h e a l t h f i e l d and a p p l i e d g e n e r a l l y t o a l l i m m i g r a n t s , not j u s t p h y s i c i a n s . P r o v i n c i a l l y , p o l i c y development and i m p l e m e n t a t i o n i n the a r e a of h e a l t h manpower has tended t o oc c u r o u t s i d e of the bounds of the r a t i o n a l s t r u c t u r e . T h i s o c c u r s because of the s t r u c t u r e ' s i n a b i l i t y t o d e v e l o p l i n k s w i t h s e r v i c e a r e a s or t o n e g o t i a t e w i t h the p r o f e s s i o n s . - 123 -Government s t r u c t u r e s f o r h e a l t h manpower p l a n n i n g as they e x i s t , o p e r a t e a l m o s t t o t a l l y o u t s i d e of o t h e r h e a l t h s e r v i c e p l a n n i n g s t r u c t u r e s . Membership on the P r o v i n c i a l H e a l t h Manpower Working Group, f o r many y e a r s , has not been a t a p o l i c y - m a k i n g l e v e l . T h i s has n o t a l l o w e d -members t o b e - s e n s i t i \ t o changes i n the p r o v i s i o n of s e r v i c e , nor has i t f a c i l i t a t e d communication w i t h s e r v i c e p l a n n e r s . Recent changes i n membership may change t h i s p i c t u r e , as more s e n i o r r e p r e s e n t a t i v e s are c u r r e n t l y b e i n g a p p o i n t e d from each s e r v i c e a r e a . However, u n l e s s b r i d g e s can be b u i l t t o f a c i l i t a t e n e g o t i a t i o n , t h i s t o o w i l l be a wasted e f f o r t . I m p l e m e n t a t i o n , o r f o r t h a t m a t t e r i n i t i a t i o n of s t u d i e s , q u i t e o f t e n has a r i s e n from s e r v i c e a r e a s r a t h e r than from the r a t i o n a l p l a n n i n g s t r u c t u r e . In the cases of the V i s i o n Care Task Force R e p o r t , and the i n i t i a t i o n of the Long Term Care Program and i t s need f o r Homemakers and Long Term Care A i d e s and the C h i l d r e n s ' D e n t a l H e a l t h Study, a l l manpower a r e a s ' needs were d e c i d e d o u t s i d e of f o r m a l government h e a l t h manpower s t r u c t u r e s . Government has f a i l e d t o overcome many j u r i s d i c t i o n a l o v e r l a p s . These o c c u r p r i m a r i l y between the M i n i s t r i e s o f H e a l t h and E d u c a t i o n who a r e r e s p e c t i v e l y r e s p o n s i b l e f o r d e c i d i n g on numbers r e q u i r e d , and the c a l i b r e of manpower t r a i n e d . The E d u c a t i o n s e c t o r has ta k e n the p e r o g a t i v e of i n i t i a t i n g a - 124 -t r a i n i n g program or a l t e r i n g the numbers of s t u d e n t s i n e x i s t i n g t r a i n i n g programs, w i t h o u t c o n s u l t a t i o n w i t h those who w i l l e v e n t u a l l y h i r e t h e s e p o e p l e . The most b l a t a n t o r c r o s s i n g o f j u r i s d i c t i o n a l b o u n d a r i e s was the d o u b l i n g of the s i z e of a m e d i c a l s c h o o l by the M i n i s t e r of E d u c a t i o n a t a time when a s u r p l u s o f p h y s i c i a n s was acknowledged. I t i s not the o n l y example,however, pharmacy programs, d e n t a l a s s i s t a n t programs and n u r s i n g programs have a l l grown w i t h o u t c o n s u l t a t i o n w i t h f o r m a l s t r u c t u r e s . Problems a r i s e not o n l y w i t h numbers of p e o p l e t r a i n e d , but a l s o w i t h the placement of s t u d e n t s f o r c l i n i c a l e x p e r i e n c e . The M i n i s t r y o f H e a l t h has' y e t t o d e c i d e whether i t w i l l acknowledge a r e s p o n s i b i l i t y f o r p r o v i s i o n o f s t u d e n t e x p e r i e n c e . J u r i s d i c t i o n d i f f i c u l t i e s o c c u r w i t h the M i n i s t r y of Labour both i n terms of H e a l t h ' s c o n t r o l of the p l a n n i n g p r o c e s s and Human R i g h t s ' L e g i s l a t i o n . I s s u e s of u n i o n s , wages, working c o n d i t i o n s and a p p r e n t i c e s h i p programs a l l f a l l w i t h i n the j u r i s d i c t i o n of Labour. C o n f l i c t over payment of wages t o s t u d e n t s w o r k i n g i n h o s p i t a l s ( e s p e c i a l l y L.P.N.'s), has c o n t i n u e d between H e a l t h , E d u c a t i o n and Labour f o r many y e a r s . The purpose o f C h a p t e r 3 was t o r e v i e w the f o u r major r e s e a r c h c a t e g o r i e s used i n n a t i o n a l p l a n n i n g . The f a c t t h a t these h e a l t h manpower r e s e a r c h a c t i v i t i e s a r e conducted m o s t l y i n i s o l a t i o n from o t h e r a r e a s of the h e a l t h c a r e system have,to a c e r t a i n e x t e n t , been the cause of the f a i l u r e of many p l a n n i n g - 125 -e f f o r t s . Much of t h i s has r e s u l t e d from a l a c k o f an o v e r a l l h e a l t h p o l i c y . Q u e s t i o n s r e g a r d i n g the o v e r a l l u s e f u l n e s s of h e a l t h manpower p r o j e c t i o n s have been r a i s e d i n l i g h t of the l a r g e number of changes which c o u l d o c c u r i n a s h o r t p e r i o d o f t i m e . There i s a l a c k of s o p h i s t i c a t e d methodology which l e a d s t o an i n a b i l i t y a p p r o p r i a t e l y t o r e s o l v e even the l e a s t complex problems. Two t h i n g s become im m e d i a t e l y apparent when r e v i e w i n g e x i s t i n g h e a l t h manpower methodology. F i r s t , no method i s i n i t s e l f u n i q u e , each i n c o r p o r a t e s some v a r i a b l e s and t e c h n i q u e s found i n o t h e r methods. S e c o n d l y , no one method i s p e r f e c t . A l l methods a r e r e l a t i v e l y new and r e q u i r e development. Has r a t i o n a l p l a n n i n g f a i l e d . Marmor, as was s t a t e d i n C h a p t e r 2 argues t h a t r a t i o n a l p l a n n i n g i s v a l u a b l e but e a r l y on i n the p r o c e s s . O r g a n i z a t i o n a l p r o c e s s and n e g o t i a t i o n must f o l l o w . I t i s p o s s i b l y l a c k o f r e c o g n i t i o n o f t h i s w h i c h has r e s u l t e d i n f a i l u r e . E x c e s s i v e a t t e n t i o n has been p a i d t o r a t i o n a l p l a n n i n g w i t h o u t due c a r e t o t h e s e ' o t h e r p r o c e s s e s and the i n t e g r a t i o n o f manpower p l a n n i n g i n t o o v e r a l l p l a n n i n g . Donnison has s a i d t h a t the more c l o s e l y l i n k e d the concepts of the r a t i o n a l p l a n n e r are t o the i d e o l o g i e s of the d e c i s i o n - 126 -maker the more l i k e l y the p l a n has o f a c c e p t a n c e . T h i s i s t r u e a l s o f o r h e a l t h manpower p l a n n i n g . Good p l a n n i n g cannot be a c c o m p l i s h e d w i t h o u t o v e r a l l i n t e g r a t i o n i n t o the h e a l t h c a r e system. Changes w h i c h a r e made must p r o v i d e a p l a n n i n g s t r u c t u r e w h i c h r e f l e c t s the o v e r a l l i d e o l o g y o f t h e Canadian w e l f a r e s t a t e , b a l a n c i n g s o c i a l j u s t i c e w i t h economic development. The power o f the m e d i c a l p r o f e s s i o n must be r e a l i z e d and i s s u e s c e n t r a l t o p r o f e s s i o n a l autonomy s o l v e d b e f o r e any u s e f u l p l a n n i n g o c c u r s . R a t i o n a l p l a n n i n g i s r e q u i r e d f o r b e t t e r deployment o f h e a l t h manpower.. However t h i s must be c a r e f u l l y tempered and n e g o t i a t e d i f we a r e t o see any p l a n s r e a c h f r u i t i o n . - 127 -BIBLIOGRAPHY - 128 -B i b l i o g r a p h y Ahamad, B. A P r o j e c t i o n o f Manpower Requirements by O c c u p a t i o n  i n 19 75. Canada and i t s R e g i o n s , Dept. o f Manpower & I m m i g r a t i o n , Ottawa, 1969. A l b e r t a Government. 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Government o f Canada, Ottawa, V o l . 1-2, 19 64. ~ S c h e f f l e r , R.M., Yoder, S.G., W e i s f e l d , N., and Ruby, G. " P h y s i c i a n s and New H e a l t h P r a c t i t i o n e r s : I s s u e s f o r t h e 19 80's." I n q u i r y , V o l . XVI ( 3 ) , F a l l 1979, pg. 195-229. Schmidt, P a u l i n e . "Expanded D u t i e s o f A u x i l i a r i e s : A H y g i e n i s t V i e w p o i n t " . American J o u r n a l o f P u b l i c H e a l t h . J a n u a r y , 1972, V o l . 62 ( 1 ) , pp. 54-56. S c h o n f e l d , H., H eston, J.F. and F a l k , I . "Number o f P h y s i c i a n s R e q u i r e d f o r P r i m a r y M e d i c a l C a r e " . S p e c i a l A r t i c l e , .New  E n g l a n d J o u r n a l o f M e d i c i n e , V o l . 28 6 ( 1 1 ) , March 19 72, pp. 571-76. Second N a t i o n a l C o n f e r e n c e on H e a l t h Manpower. Health, and W e l f a r e Canada, Ottawa, 19 71. S h i l l i n g t o n , C.H. The Road t o M e d i c a r e i n Canada. D e l G r a p h i c s T o r o n t o , 19 72. - 137 -Shuman, L . J . , Young, J.P., and Naddor, E. "Manpower Mix f o r H e a l t h S e r v i c e s : A P r e s c r i p t i v e R e g i o n a l P l a n n i n g Model'!. H e a l t h S e r v i c e s R e s e a r c h , Summer 1971, pp. 103-119. S o r k i n , A l a n L. H e a l t h Manpower, An Economic P e r s p e c t i v e . L e x i n g t o n Books, D.C. Heath and Company, T o r o n t o , 1977. S p a u l d i n g , W. B. and S p i t z e r , W.O. " I m p l i c a t i o n s o f M e d i c a l Manpower Trends i n O n t a r i o 19 61-71". . O n t a r i o M e d i c a l  Review, V o l . 39 ( 9 ) , September 1972,' pp. 527-533. Spooner, S.A. and M e i l i c k i , C. H e a l t h Manpower P l a n n i n g and  U t i l i z a t i o n : I n f o r m a t i o n Bases~and P l a n n i n g Models. Edmonton, March 22, 19 76, Mimeo. S t a n l e y , R.A. E v a l u a t i o n o f t h e E f f e c t i v e n e s s o f Programs Designed t o D i s t r i b u t e H e a l t h Care Manpower i n t o Under-S e r v i c e d A r e a s . C o l l e g e o f F a m i l y P h y s i c i a n s o f Canada, March, 1973. S t e v e n s , C M . and Brown,,G.D. "Market S t r u c t u r e Approach t o H e a l t h Manpower P l a n n i n g " . American J o u r n a l o f P u b l i c  H e a l t h . V o l . 6 1 , ( 1 0 ) , O c t o b e r , 1971, pp. 1988-1995. S t r a u s s , Anselm. N e g o t i a t i o n s - V a r i e t i e s , C o n t e x t s , P r o c e s s e s  and S o c i a l O rder. San F r a n c i s c o : J o s s e y - B a s s , 1978. Task F o r c e R e p o r t s on the Cost o f H e a l t h S e r v i c e s i n Canada. H e a l t h and W e l f a r e Canada, Ottawa, V o l . 1-3, 1969. T a y l o r , M a l c o l m G. H e a l t h I n s u r a n c e and Canadian P u b l i c P o l i c y . The I n s t i t u t e o f P u b l i c A d m i n i s t r a t i o n o f Canada. M c G i l l , Queen's U n i v e r s i t y P r e s s , M o n t r e a l , 19 78. T i t m u s , R.M. The G i f t R e l a t i o n s h i p : From Human B l o o d t o S o c i a l  P o l i c y , New Y o r k , Pantheon Books, 19 70. Tompkins, R.K. M e a s u r i n g t h e Q u a l i t y o f M e d i c a l Care Rendered by  M i d - l e v e l H e a l t h Workers: A Key F a c t o r i n D e t e r m i n i n g Task  D e l e g a t i o n , S u p e r v i s i o n Requirements and Mechanisms o f  C e r t i f i c a t i o n . H e a l t h Manppwer*Policy D i s c u s s i o n Paper: S e r i e s , R o b e r t Wood Johnson F o u n d a t i o n , M i c h i g a n , May 19 74, No. M9. Tropman, J o h n E. S t r a t e g i c P e r s p e c t i v e s on S o c i a l P o l i c y . New Yo r k , Pergamon P r e s s , 1976. U.S. Department o f H e a l t h , E d u c a t i o n and W e l f a r e . H e a l t h Manpower P l a n n i n g P r o c e s s , V o l . 1, Washington, 19 76. - 138 -U.S. Department o f Health., E d u c a t i o n and W e l f a r e . The Su p p l y o f  Hea11h Ma np ow e r . DHEW (HRA) 75-38, Washington, 1974. U.S. Department o f H e a l t h , E d u c a t i o n and W e l f a r e . Ah A n a l y s i s  o f H e a l t h Manpower' Models - Volume 1. Monographs and Data f o r H e a l t h Resources P l a n n i n g S e r i e s , DHEW P u b l i c a t i o n No. (HRA) 75-19, May 1974. U.S. Department o f H e a l t h , E d u c a t i o n and W e l f a r e . An I n v e n t o r y o f H e a l t h Manpower Models - Volume I I . Monographs and Data f o r H e a l t h Resources P l a n n i n g S e r i e s , DHEW P u b l i c a t i o n No. (HRA) 75-19, May 1974. V i s i o n Care Task F o r c e R e p o r t . M i n i s t r y o f H e a l t h , P r o v i n c e o f B r i t i s h Columbia, O c t o b e r 1977. Warham, J . 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 . U n i v e r s i t y o f B r i t i s h C o lumbia, 1974, pp. 1-127. W a t k i n s , K. S o c i a l C o n t r o l , Longman, London, 19 75. Werner, J . L . , L a n g w e l l , K.M. Budde, N.W. " D e s i g n a t i o n o f P h y s i c i a n S h o r t a g e A r e a s : The Problem o f S p e c i a l t y V a r i a t i o n s " . I n q u i r y , V o l . XVI ( 1 ) , 1979, pp. 31-3.7. W i l d a v s k y , A. "Doing B e t t e r and F e e l i n g Worse: The P o l i t i c a l P a t h o l o g y o f H e a l t h P o l i c y " , i n Knowles, J.H. Doing B e t t e r  and F e e l i n g Worse: H e a l t h i n the U n i t e d S t a t e s . W.W. No r t o n & Co., 1977, pp. 105-123. World H e a l t h O r g a n i z a t i o n , C o n s t i t u t i o n , Geneva: The O r g a n i z a t i o n , . 1960. Y e t t , D.E., Drabek, L., I n t r i l i g a t o r , M.D., and K i m b e l l " H e a l t h Manpower P l a n n i n g : An Ec o n o m e t r i c Approach". H e a l t h S e r v i c e s R e s e a r c h , V o l . 7 ( 2 ) , Summer 1972, pp. 134-147. Y e t t , D., Drabek, L., I n t r i l i g a t o r , M.D., K i m b e l l , L . J . "A M i c r o e c o n o m e t r i c Model o f t h e h e a l t h c a r e system i n t h e U n i t e d S t a t e s " . A n n a l s o f Economic & S o c i a l Measurement. 1975, pp. 413. ~ 139 -22,000 "20, 000 18,000* 16,000 14,:000 12,000 10,000' 8,000 6, 00 0 4, 000 2,000 U T o t a l P o p u l a t i o n and Ru r a l - U r b a n P o p u l a t i o n D i s t r i b u t i o n ( i n thousands) 1871 1881 1891 1901 1911 1921 1931 1941 1951 1961 Source: P e r s p e c t i v e s Canada - 1974, Government o f Canada, Ottawa, T a b l e 1:1 - ,141 -APPENDIX - 142 -Marmor's Frames of I n f e r e n c e The R a t i o n a l A c t o r Model: W i t h i n t h i s model, government i s thought of as a s i n g l e r a t i o n a l a c t o r . The o c c u r e n c e s of n a t i o n a l p o l i t i c s a r e "the c h o i c e s o f d o m e s t i c a c t o r s " and p o l i c y i s u n d e r s t o o d as the a c t i o n o f the r a t i o n a l d e c i s i o n maker. C h o i c e s and a c t i o n s o f the n a t i o n a r e 'viewed as means c a l c u l a t e d t o a c h i e v e n a t i o n a l g o a l s and p u r p o s e s ' . R a t i o n a l a c t i o n i s i n t e r p r e t e d as showing what g o a l a n a t i o n i s p u r s u i n g i n f o l l o w i n g a c o u r s e of a c t i o n and t h a t i n l i g h t of t h a t g o a l the a c t i o n was the most r e a s o n a b l e one. 'The b a s i c u n i t of a n a l y s i s i n such work i s the government's c h o i c e of s t r a t e g y . 1 The O r g a n i z a t i o n a l P r o c e s s Model Under t h i s model what r a t i o n a l p o l i c y a n a l y s t s c a l l c h o i c e s and a c t s are o u t p u t s of o r g a n i z a t i o n s f u n c t i o n i n g a c c o r d i n g t o s t a n d a r d s of b e h a v i o r under the o r g a n i z a t i o n a l p r o c e s s model. Marmor, T.R. The P o l i t i c s of M e d i c a r e , A l d e l i n e , C h i c a g o , 1973 pp 95 - 125. - 143 -'The b a s i c u n i t o f a n a l y s i s i s the o r g a n i z a t i o n , and the f o c a l c oncepts i n c l u d e r o u t i n e b e h a v i o u r s t a n d a r d o p e r a t i n g p r o c e d u r e s , b i a s e d i n f o r m a t i o n , i n c r e m e n t a l change, and o r g a n i z a t i o n a l p e r s p e c t i v e ? 1 The B u r e a u c r a t i c P o l i t i c s Model 'The b u r e a u c r a t i c p o l i t i c s framework c o n s i d e r s "domestic p o l i c y t o c o n s i s t of outcomes o f a s e r i e s o f o v e r l a p p i n g b a r g a i n i n g games" a r r a n g e d h i e r a r c h i c a l l y w i t h i n the n a t i o n a l government. 1 P l a y e r s w i t h d i f f e r i n g p o i n t s o f view and s e t s o f p r i o r i t i e s s t r u g g l e f o r t h e i r c h o i c e of outcomes u s i n g the power a t t h e i r d i s p o s a l . 'The b a s i c u n i t of a n a l y s i s i s the d e c e n t r a l i z e d b a r g a i n i n g game p l a y e d by r e l a t i v e l y autonomous a c t o r s . The f o c a l c o n c e p t s i n c l u d e b a r g a i n i n g s t r a t e g i e s , r o l e s , moves, s t a k e s , t r a d e - o f f s , t a c t i c s and c o n v e n t i o n s ( o r r u l e s of the game). - 144 -APPENDIX C - 145 -HEALTH MANPOWER DEVELOPMENT PROGRAM, CANADA A Statement Approved by the F e d e r a l / P r o v i n c i a l H e a l t h Manpower Committee 1 May 1973  Obj e c t i v e : To improve and m a i n t a i n , through the c o l l a b o r a t i o n o f f e d e r a l and p r o v i n c i a l governments and o t h e r concerned a g e n c i e s , the s u p p l y , q u a l i t y , d i s t r i b u t i o n and p r o d u c t i v i t y of a l l h e a l t h manpower i n Canada a t a l e v e l t h a t makes p o s s i b l e the d e l i v e r y o f e f f e c t i v e and e f f i c i e n t t o t a l h e a l t h s e r v i c e s . Goals and Methods - F i s c a l Year 19 75/74 1. O r g a n i z a t i o n (a) Goal To e s t a b l i s h a n a t i o n - w i d e o r g a n i z a t i o n based on the F e d e r a l / P r o v i n c i a l H e a l t h Manpower Committee (The Committee) w i t h the n e c e s s a r y a u t h o r i t y and a b i l i t y t o undertake h e a l t h manpower development programs. (b) Method (See Annex A) ( i ) ( i i ) ( i i i ) ( i v ) (v) The working c a p a c i t y o f the H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. w i l l be improved to a l e v e l t h a t i t can und e r t a k e the t a s k s a s s i g n e d by The Committee. The working r e l a t i o n s h i p s between the H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. and the n a t i o n a l a g e n c i e s concerned w i t h the d e v e l o p -ment of h e a l t h manpower w i l l be improved t o a l e v e l t h a t the D i r e c t o r G e n e r a l may p r o p e r l y a d v i s e The Committee. Each p r o v i n c i a l department o f h e a l t h w i l l d e s i g n a t e a person t o be or to p e r f o r m the f u n c t i o n s of D i r e c t o r of H e a l t h Manpower ( P r o v i n c i a l D i r e c t o r ) . P r o v i n c i a l D i r e c t o r s w i l l attempt t o a c q u i r e the ne c e s s a r y a u t h o r i t y and su p p o r t s t a f f t o manage or to c o o r d i n a t e P r o v i n c i a l H e a l t h Manpower Development Programs ( P r o v i n c i a l Program). The working r e l a t i o n s h i p s between P r o v i n c i a l D i r e c t o r s and the p r o v i n c i a l a g e n c i e s concerned w i t h the development o f h e a l t h manpower w i l l be improved t o a l e v e l t h a t p e r m i t s the im-p l e m e n t a t i o n o f P r o v i n c i a l Programs. - 146 -( v i ) The Committee w i l l meet at l e a s t t w i c e i n the year t o ensure maximum p o s s i b l e f e d e r a l / p r o v i n c i a l and i n t e r - p r o v i n c i a l c o l l a b o r a t i o n . ( v i i ) The Committee w i l l c o n t r i b u t e to and p a r t i c i p a t e i n the Pan American Conference on H e a l t h Manpower Development to be h e l d i n Ottawa, September 10 - 14, 1973. ( v i i i ) The Committee w i l l r e a c h agreement on go a l s t o be a t t a i n e d d u r i n g the f i s c a l y e a r 1974/75. 2. I n f o r m a t i o n System (a) Goal To c o n t i n u e the development of a system f o r c o l l e c t i n g , a n a l y z i n g and d i s t r i b u t i n g i n -f o r m a t i o n on h e a l t h manpower and t o dev e l o p a H e a l t h Manpower Data Bank. (b) Method ( i ) The H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. w i l l i n c o o p e r a t i o n w i t h P r o v i n c i a l D i r e c t o r s , p r e p a r e and p u b l i s h the "Canada H e a l t h Manpower I n v e n t o r y 1973" by March 31, 1974. ( i i ) The M e d i c o — S o c i a l S t a t i s t i c s O f f i c e , D.N.H. & W. w i l l p u b l i s h B u l l e t i n s showing d e t a i l s o f p h y s i c i a n manpower on p r i n t o u t s from the M e d i c a l M a r k e t i n g Systems tapes and w i l l attempt to o b t a i n tapes from t h i s s o u r c e on d e n t a l , p h y s i o t h e r a p y and o c c u p a t i o n a l t h e r a p y l i s t i n g s . ( i i . i ) S t a t i s t i c s Canada w i l l p u b l i s h a t h i r d e d i t i o n o f " H e a l t h Manpower - R e g i s t e r e d N u r s e s " by March 31, 1974. ( i v ) S t a t i s t i c s Canada w i l l c o n t i n u e t o dev e l o p the H e a l t h Manpower Data Bank i n c l o s e c o o p e r a t i o n w i t h members o f The Committee. P r i o r i t i e s f o r p l a n n i n g purposes a r e : 1. P h y s i c i a n s 2 . Nurses 3. D e n t a l Manpower 4. A u d i o l o g i s t s and Speech T h e r a p i s t s 5. P h y s i o t h e r a p i s t s and O c c u p a t i o n a l T h e r a p i s t s 6. P h a r m a c i s t s 7. H e a l t h S e r v i c e s A d m i n i s t r a t o r s 8 . L a b o r a t o r y & R a d i o l o g i c a l T e c h n i c i a n s 9. O p t o m e t r i s t s and O p t i c i a n s . . .3 - 147 -(v) The H e a l t h Manpower D i r e c t o r a t e w i l l p r e p a r e p r o p o s a l s f o r a common h e a l t h manpower t e r m i n o l o g y . Requirements (a) Goal To c o o r d i n a t e and make recommendations c o n c e r n i n g the p r o v i n c i a l and o v e r a l l r e quirements f o r p h y s i c i a n s of a l l k i n d s , n u r s e s , p h a r m a c i s t s , a d m i n i s t r a t o r s and f o r the d e n t a l p r o f e s s i o n s . (b) Method ( i ) P h y s i c i a n s - A Task Force s e t up by the D.N.H. & W. H e a l t h Manpower C o o r d i n a t i n g Committee w i l l work i n c o n j u n c t i o n w i t h a Requirements Committee o f the N a t i o n a l P h y s i c i a n Manpower Committee and the n a t i o n a l s p e c i a l i s t s a s s o c i a t i o n s to develop r e -commendations f o r the o v e r a l l r e q u i r e m e n t s f o r p h y s i c i a n s o f a l l k i n d s . The Committee w i l l r e v i e w recommendations a r i s i n g from t h i s a c t i v i t y and o t h e r s o u r c e s and from p r o v i n c i a l s t u d i e s i n o r d e r t o r e a c h an agreement on recommendations f o r o v e r a l l r e q u i r e m e n t s . ( i i ) Nurses - The Committee w i l l r e v i e w the recommendations a r i s i n g from a stu d y c a r r i e d out by the Canadian Nurses' A s s o c i a t i o n under c o n t r a c t to D.N.H. & W. to e s t i m a t e the r e q u i r e m e n t s f o r nurses and n u r s i n g a s s i s t a n t s i n Canada over the next 5 y e a r s i n c o n j u n c t i o n w i t h the r e p o r t s o f p r o v i n c i a l s t u d i e s to r e a c h agreement on recommendations f o r o v e r a l l r e q u i r e m e n t s . ( i i i ) H e a l t h S e r v i c e s A d m i n i s t r a t o r s - The Committee w i l l r e v i e w the recommendations a r i s i n g from a study c a r r i e d out by the Canadian C o l l e g e o f H e a l t h S e r v i c e s E x e c u t i v e s under c o n t r a c t t o D.N.H. & W. to prepare a p r e l i m i n a r y f o r e c a s t of req u i r e m e n t s f o r h e a l t h s e r v i c e s a d m i n i s t r a t o r s i n Canada f o r the next 7 ye a r s and t o o u t l i n e a methodology f o r f u r t h e r and more complete f o r e c a s t s as needed. - 148 -( i v ) D e n t a l Manpower - The Committee w i l l r e v i e w the recommendations a r i s i n g from a study c a r r i e d out by Dr. D. IV. Lewis and Mrs. B . I . Brown o f the U n i v e r s i t y o f Toronto under c o n t r a c t to D.N.H. & W. to e s t i m a t e the requi r e m e n t s f o r d e n t i s t s and t h e r a p i s t s i n Canada i n the l i g h t o f f o u r p o s s i b l e s i t u a t i o n s : w i t h and w i t h o u t the i n t r o d u c t i o n o f prepayment p l a n s and w i t h and w i t h o u t the g e n e r a l employment o f t h e r a p i s t s . (v:) Other H e a l t h Manpower - The Committee w i l l examine methods and p r i o r i t i e s f o r d e t e r m i n i n g r e q u i r e m e n t s f o r o t h e r h e a l t h manpower. 4. Suppl y (a) Goal To r e v i e w the p r o j e c t i o n s o f h e a l t h manpower s u p p l y i n r e l a t i o n t o the agreed r e q u i r e m e n t s and to d e c i d e what must be done t o c o r r e c t any p e r c e i v e d imbalances w i t h p a r t i c u l a r a t t e n t i o n to p h y s i c i a n s and n u r s e s . (b) Method ( i ) The H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. w i l l u n dertake f u r t h e r s t u d i e s t o determine methods o f i m p r o v i n g m i g r a t i o n f o r e c a s t s . ( i i ) The Committee w i l l r e v i e w the r e p o r t s on the stu d y undertaken by A.U.C.C. w i t h Dr. Rocke R o b e r t s o n as the c h i e f i n v e s t i g a t o r , and funded through the N a t i o n a l H e a l t h Grant Program t o determine the t o t a l p l a n n e d o u t p u t s o f a l l Canadian H e a l t h S c i e n c e s E d u c a t i o n a l I n s t i t u t i o n s by d i s c i p l i n e and to e s t i m a t e t h e i r maximum output c a p a c i t i e s . ( i i i ) The H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. w i l l p r e p a r e recommendations on a method o f u p d a t i n g a n n u a l l y the i n f o r m a t i o n on the ou t p u t c a p a c i t i e s . ( i v ) The Committee w i l l make recommendations on the e x t e n t t o which the f l o w o f immigrant p h y s i c i a n s and nurses and the o u t p u t s o f our m e d i c a l and n u r s i n g s c h o o l s must be changed and how t h i s s h o u l d be a c c o m p l i s h e d . (v) The Committee w i l l make recommendations on methods o f r e d u c i n g the a t t r i t i o n o f h e a l t h manpower. ( v i ) The Committee w i l l o f f e r a d v i c e t o the H e a l t h Resources A d v i s o r y Committee on f u t u r e commitments from the H e a l t h Resources Fund towards the con-s t r u c t i o n , r e n o v a t i o n and a c q u i s i t i o n o f h e a l t h t r a i n i n g and r e s e a r c h f a c i l i t i e s . .5 - 149 -Q u a l i t y (a) Goal (b) Method To r e a c h agreement on methods f o r e n s u r i n g t h a t the h e a l t h manpower g r a d u a t i n g from our e d u c a t i o n a l i n s t i t u t i o n s are o f a s u f f i c i e n t l y h i g h q u a l i t y t o meet the needs o f Canadian communities. ( i ) The Committee w i l l make recommendations on r e s e a r c h p r i o r i t i e s . ( i i ) The Committee w i l l a s s i s t the A.U.C.C.. i n c a r r y i n g out t h e i r p r o j e c t funded t h r o u g h the N a t i o n a l H e a l t h Grant Program t o a p p r a i s e a l l t e a c h i n g i n the h e a l t h s c i e n c e s i n . Canada. The p r o j e c t w i l l r e s u l t i n r e -commendations i d e n t i f y i n g : (a) A c t i o n s which e d u c a t i o n a l i n s t i t u t i o n s and governments c o u l d take t o improve the e f f e c t i v e n e s s o f h e a l t h manpower. (b) The need f o r f u r t h e r r e s e a r c h on v a r i o u s a s p e c t s o f the e d u c a t i o n a l p r o c e s s and on the types of competence r e q u i r e d by h e a l t h p e r s o n n e l i n v a r i o u s s e t t i n g s . ( i i i ) The Committee w i l l a s s i s t D.N.H. & W. i n the t a s k o f c o - s p o n s o r i n g w i t h the Canadian Nurses' A s s o c i a t i o n a N a t i o n a l Conference on Nurses f o r Community S e r v i c e i n Ottawa, November 13 - 16, 1973. The purpose o f the c o n f e r e n c e w i l l be t o a c h i e v e a consensus on: (a) The a p p r o p r i a t e r o l e s and f u n c t i o n s o f nurses i n community h e a l t h s e r v i c e s . (b) Methods f o r d e v e l o p i n g a l o g i c a l and o r d e r l y system f o r t h e i r p r e p a r a t i o n . ( i v ) The Committee w i l l a s s i s t P r o v i n c i a l D i r e c t o r s i n s p o n s o r i n g any p r o v i n c i a l , r e g i o n a l or l o c a l h e a l t h manpower c o n f e r e n c e s . D i s t r i b u t i o n (a) Goal To i d e n t i f y e f f e c t i v e methods of i m p r o v i n g the d i s t r i b u t i o n o f h e a l t h manpower, p a r t i c u l a r l y i n u n d e r s e r v i c e d areas and to i n a u g u r a t e new programs. .6 - 150 -(b) Method ( i ) The Committee w i l l r e v i e w the recommendations a r i s i n g from a s t u d y c a r r i e d out by t h e C o l l e g e o f F a m i l y P h y s i c i a n s o f Canada under c o n t r a c t to D.N.H. & W. t o e v a l u a t e the e f f e c t i v e n e s s of programs d e s i g n e d t o d i s t r i b u t e h e a l t h manpower i n t o u n d e r s e r y i c e d areas w i t h p a r t i c u l a r r e f e r e n c e t o community p r i m a r y c a r e s e r v i c e s and f a m i l y p h y s i c i a n s . The Committee w i l l make recommendations on the i n a u g u r a t i o n o f new programs t o improve the d i s t r i b u t i o n o f h e a l t h manpower. The Committee w i i l r e v i e w the advantages and d i s a d v a n t a g e s o f l i m i t i n g the l i c e n s e s o f p h y s i c i a n s f o r purposes o f e n s u r i n g b e t t e r g e o g r a p h i c a l d i s t r i b u t i o n , b e t t e r f u n c t i o n a l d i s t r i b u t i o n and h i g h l e v e l s o f competence. In o r d e r t o improve the m o b i l i t y o f h e a l t h manpower i n a l l r e s p e c t s w i t h i n the p r o v i n c e s and w i t h i n Canada, The Committee w i l l make recommendations on what must be done i n the f i e l d s o f : (a) S t a n d a r d i z a t i o n o f l i c e n s i n g and e d u c a t i o n a l programs. (b) R e c o g n i t i o n of e d u c a t i o n a l c r e d i t s . P r o d u c t i v i t y and U t i l i z a t i o n (a) Goal To i d e n t i f y e f f e c t i v e methods o f i m p r o v i n g the p r o d u c t i v i t y and u t i l i z a t i o n of h e a l t h manpower p a r t i c u l a r l y i n community h e a l t h s e r v i c e s . (b) Method ( i ) The Committee w i l l r e v i e w the v a l u e and the p o t e n t i a l v a l u e o f e f f o r t s made t o expand the r o l e o f the nurse i n p r i m a r y h e a l t h c a r e s e r v i c e s and the e f f o r t s made to expand the r o l e s o f the nurse i n h o s p i t a l and s p e c i a l i s t s e r v i c e s . ( i i ) The Committee w i l l make recommendations on what s h o u l d be done to t r a n s f e r f u n c t i o n s o f o t h e r h i g h l y t r a i n e d p r o f e s s i o n a l p e r s o n n e l to p e r s o n n e l l e s s h i g h l y t r a i n e d . ( i i ) ( i i i ) ( i v ) - 151 -Research (a) Goal (b) Method To r e a c h agreement on p r i o r i t i e s f o r h e a l t h manpower r e s e a r c h and s t u d i e s and t o i n a u g u r a t e h i g h p r i o r i t y p r o j e c t s . ( i ) The H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W, w i l l update t h e i r p u b l i c a t i o n " H e a l t h Manpower B i b l i o g r a p h y " by December 31, 1973. ( i i ) The Committee r e c o g n i z e s the r e s e a r c h p r o j e c t s l i s t e d i n Annex B as h i g h p r i o r i t y p r o j e c t s . ( i i i ) The H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. w i l l u n d e r t a k e work on those p r o j e c t s l i s t e d • i n Annex B which are marked w i t h a s t a r . ( i v ) L i s t s o f p r o j e c t s s u p p o r t e d by the N a t i o n a l H e a l t h Grant Program W i l l be p r e p a r e d by D.N.H. & W. and d i s t r i b u t e d t o members o f The Committee. P r o j e c t r e p o r t s w i l l a l s o be d i s t r i b u t e d when a v a i l a b l e . (v) The Committee w i l l make recommendations on f u t u r e r e s e a r c h p r o j e c t s f o r s u p p o r t by the N a t i o n a l H e a l t h Grant Program. - 152 — H e a l t h Manpower Development Program - Canada ANN F- X A O r g a n i s a t i o n a l Rase - 153 -ANNEX B RESEARCH PROJECTS  HEALTH MANPOWER Requirements *1. Requirements for physicians of a l l kinds. *2. Requirements for nurses. *3. Requirements for health services administrators. *4. Requirements for dentists/therapists. 5. Examination of new health d i s c i p l i n e s l i k e l y to be required for new health programs. | S u p p l y and A t t r i t i o n r ! *6. Analysis of discrepancies between projections ] of health manpower supply and estimated I requirements. *7. Analysis of data on the supply, d i s t r i b u t i o n I and educational requirements of nursing personnel . ... *8. Analysis of a t t r i t i o n of nurses, composition | . . . • of new infusion into the nursing ranks and the career patterns of nurses. 9. Analysis of supply and requirements f o r pharmacists, i 10. Analysis of a t t r i t i o n in a l l d i s c i p l i n e s except j : nursing. • j D i s t r i b u t i o n *11. Evaluation of programs for the d i s t r i b u t i o n of health manpower into underserviced areas. *12. Analysis of medical graduates by location and | f i e l d of practice. *13. Analysis of job vacancy surveys to determine functional and geographic demand patterns for health manpower. *14. Analysis of the pattern of emigration of Canadian medical graduates to the U.S.A. 1965/70. ' *15. Analysis of foreign medical graduates by sp e c i a l t y ! and by province. ! Applicants *16. ' Analysis of medical school applicants and enrollments. *17. Analysis of nursing school applicants and enrollments. 18. Analysis of applicants and enrollments in a l l d i s c i p l i n e s except medicine and nursing. .2 -.154 -Education *19. Capacities of health sciences educational i n s t i t u t i o n s . . *20. Appraisal of teaching i n the health sciences. *21. Revision of the survey of university programs to prepare nurses for expanded r o l e s . 22. Evaluation of the quality of graduates i n the l i g h t of community requirements. Employment *23. Analysis of occupational employment surveys produced by S t a t i s t i c s Canada. *24. Comparative analysis of f i n a n c i a l rewards for health manpower. 25. Analysis of the employment of nurses. 26. Analysis of the present u t i l i z a t i o n of nurses. 27. Analysis of the functions of a l l health manpower. 28. Analysis of the barriers which prevent the better u t i l i z a t i o n of nurses. * Already included i n work plans, contracts or National Health Grant projects of the Department of National Health and Welfare. • •'' - 155 -A P P E N D I X D - 156 -ORGANIZATIONAL PATTERNS FOR HEALTH MANPOWER DEVELOPMENT AND PLANNING 1978 Health Manpower Division Health Resources Directorate Health Services and Promotion Branch Published by Authority of the Minister of National Health and Welfare - 157 -FOREWORD This report is an update of the Health Manpower Report No. 2/75 entitled "Provincial Organizational Patterns for Health Manpower Development", describing the provincial administrative structures for health manpower. In order to maintain the infor-mation value of that report, members of the Federal/Provincial Advisory Committee on Health Manpower expressed the wish to update it. The information contained in this new report reflects the major changes which took place in the last four years, in health manpower administration at the respective governmental levels. The material is based on reports received during the year 1978 from representa-tives of the Advisory Committee. They are reproduced as submitted. This explains the fact that there is less uniformity of style than in the report of 1975. - 158 -CANADA The centre of the national structure for health manpower information, develop-ment and planning is the Federal-Provincial Advisory Committee on Health Manpower. This Committee is one of five advisory committees reporting to the conference of Deputy Ministers of Health. The four other committees deal with: Institutional Care Services, Community Care Services, Health Promotion and Environmental/Occupational Health. The committee on Health Manpower has an important role in the coordination of health manpower programs in Canada. It is. an ongoing committee whose continued exis-tence has been recently reaffirmed by the Deputy Ministers of Health, and its structure, role, function, terms of reference and workplans are at present subject to revision by its members. It' meets regularly twice yearly, one meeting being in Ottawa and the other in a host province. The Committee addresses itself to such aspects of health manpower problems as information systems, stock, supply, requirements, quality, distribution, productivity, utilization, education and training, employment, mobility, attrition, emigration and immigration, legislative control and research. The Committee is composed of representatives of the federal government and of each of the 10 provincial governments, the Northwest Territories and the Yukon. Feder-al representation- is from the Health Services and Promotion Branch of the Department of National Health and Welfare. The senior representative, Acting/Director General of Health Resources,, at present acts as Chairman, and the Manpower Division of his Directorate provides secretariat services. At the federal level, health manpower development, information and planning activities are centralized in the Health Resources Directorate of the Health Services and Promotion Branch. The Health Manpower Division, under a Director of Health Man-power, coordinates related programs and policies within the Department of National Health and Welfare and exchanges information with other federal departments, provincial governments and professional organizations. Restructuring is at present taking place in order to better integrate health man-power development and planning with other major health care system policies of the Department. Officers from the Branch may be called upon to serve on the Advisory Committee as federal representatives, observers or resource personnel. The Research and Evaluation Directorate, which is responsible for the support and assistance of health research, frequently consults the Committee on matters related to health manpower research before granting support to such projects. Statistics Canada and the Department of Employment and Immigration regularly send observers and resource personnel to the Committee's meetings. In the Committee's provincial representation, delegates from provincial departments of education are regu-larly included in order to give further dimension to discussions concerning health man-power education and training. The Health Manpower Division has diverse functions and assignments. Interde-partmental and intradepartmental liaison is assured, not by tightly structured standing committees, but through the interaction and cross participation of different departments, branches and directorates in federal policies, programs and projects. The work of the Division consists largely of: carrying out assignments of the Advisory Committee in order to achieve the Committee's objectives and goals; analyzing information material and documentation received from the provinces and territories, and presenting statistical data as a foundation to rational health manpower planning; participating in the establishment of guidelines for the clinical prac-tice and professional activities of health professionals in various health manpower categories; administering the Health Resources Fund, which contributes towards the costs of construction, renovation, acquisition and equipping of health training and/or research facilities according to established provincial plans, and administering the Professional Training Pro-gram,* which provides bursaries, and short-term support according to provincial priorities, for trainees in health sciences' educational programs; analyzing health manpower implications of federal health care programs and policies; presenting, whenever possible, the national picture based on amalgamation of provincial health manpower pro-grams and policies, pointing out favourable and unfavourable influ-ences that the planning of one may have on others, and on the country as a whole. * Terminated on March 31, 1979. - 160 -Of the three national health manpower committees - Physician, Nursing and Dental Manpower - only the National Committee on Physician Manpower is at present active. These committees were originally created to provide an opportunity for partici-pation in health manpower development and planning by national associations and agen-cies concerned with each of these disciplines. Due partly to financial constraints and monetary obligations, the demands that such committees put on their member organiza-tions, and the fact that some of these national professional organizations find other forums and channels more effective to make their voices and opinions heard in the dialogue between governments and professionals they represent, the national Nursing and Dental committees have not met on a regular basis nor have they undertaken studies or developed work plans over the last three to four years. The National Committee on Physician Manpower was created (by the concerned agencies) in August 1971. Its composition includes representation from 10 national professional agencies, the Federal Department and, (since 1977) Statistics Canada. Chairmanship and Secretariat are provided by the Health Services and Promotion Branch. A Requirements Sub-committee, established in 1973, undertook the task of forecasting requirements for general/family practitioners and specialist physicians in Canada. Its report has been widely read, and, though considered "soft" for practical manpower planning, is still looked upon as pioneer work in manpower studies. Assistance of provincial representatives in providing information on respective organizations and functions, is acknowledged. - 161 -Health" Manpower Development and Pl a n n i n g - Canada -O r g a n i z a t i o n a l Base - 162 -NEWFOUNDLAND In Newfoundland the health manpower planning functions are the responsibility of the Division of Planning and Research of the Department of Health. The position of Director of Health Manpower Planning has recently been filled, after being vacant for a number of years. The new director is at present in the process of redefining the terms of reference and responsibilities of the position. It is anticipated that in the near future the Provincial Health Manpower Commit-tee will be reactivated, and that procedures will be devised to examine the various aspects of health manpower planning in the province. NEWFOUNDLAND Provincial Manpower Planning Committee .User Organizations Professional Associations Federal/Provincial Health Manpower Committee Director Health Manpower Planning Memorial University of Newfoundland Department of Education Department of Recreation & Rehabilitation Divisional Representative Department of Health - 164 -PRINCE EDWARD ISLAND In Prince Edward Island there is no formal structure for health manpower planning. The province handles planning on an ad hoc basis because of the following: a. its size; b. a minimum of training facilities, (nursing, nursing assistants, nursing attendents and assistants to. health professionals); c. generally, there is a good supply of health professionals (trained elsewhere); d. no major manpower problems exist. Since manpower issues are primarily of a staffing nature, there would appear to be little need to expand provincial efforts in this field. The province recognizes the value and need for regional and national planning efforts and will continue to support them whenever feasible. It continues to be part of the national reporting systems and will exchange information in the manpower field. The province is interested in broadening its efforts in an attempt to develop auxiliary health workers and volunteers to reduce the demand of high cost health special-ities. There is a need for the development of community training packages and of resource material to supplement this effort. - 165 -NOVA SCOTIA The Department of Health's primary concern in the manpower field is to ensure that the province has a satisfactory supply and distribution of adequately trained person-nel in all required health professions and occupations. The Department's activities in the manpower area are carried out by a Co-ordinator of Health Manpower (position established in April, 1979) in cooperation with a Provincial Health Manpower Co-ordinating Committee, with several subcommittees and working parties dealing with specific health manpower areas. Under the direction of the Administrator of Program Development and Evaluation Division, the Co-ordinator is required to plan and to monitor human health resources, (primarily in the areas of manpower utilization, productivity, supply, distribution and education), to recommend comprehensive provincial health manpower policies, and to keep the Deputy Minister advised of all significant matters related to health manpower. More specifically, the responsibilities and planning activities of the Health Manpower Section include: a) Keeping pace with all health field developments and changes at the Federal, Provincial and Regional- levels as they relate to health manpower issues; b) Overseeing the establishment of a cooperative, linked information system which would generate valid, reliable accessible and timely health manpower information. This data is to be collected, assimi-lated and interpreted as a basis for policy decisions, planning and to permit monitoring of the health manpower resources and issues in order that policy could be examined and evaluated; c) Identifying present manpower supply, assessing its appropriateness in relation to requirements, and recommending policy action and system modification; d) Developing a system to produce regular projections and forecasts of future supply and demand for all major categories of health per-sonnel in the province with the aim of gearing the enrolments and subsequent outputs of provincial health manpower training programs to meet Nova Scotia's future annual requirements for health personnel; e) Assisting in the monitoring and administration of a provincial physician placement program, which includes the review of resident, intern and immigrant/non-immigrant employment appli-cations, as well as the maintenance of monthly rosters of physician vacancies; f) Assisting as required in the development and implementation of health manpower policy studies designed to optimize cost effective health manpower utilization. g) Assisting in the conceptual design and development and a compre-hensive legislative base for program activity that considers occupational definitions, overlapping fields and specialties, man-power requirements of current shifts in health care delivery, registration and accreditation practices, as well as continuing education and career mobility planning requirements. Established in 1973, the Nova Scotia Health Manpower Co-ordinating Committee is the principal manpower coordinating body in the province. It communicates directly with the Federal/Provincial Manpower. Committee, and as chief advisory committee to the Department on health manpower matters, it forwards appropriate resolutions to the Minister. The Committee acts as the coordinating agency for intragovernmental and intergovernmental relations on health manpower and education, and as such, monitors the manpower requirements of Nova Scotia's health care system and the output of the province's health manpower training programs. Through active manpower subcommittees in the areas of physician, nursing, dental, pharmaceutical and technician services, as well as ad hoc working parties in special fields, the Manpower Co-ordinating Committee keeps pace with the developments in all major spheres of health care delivery. The Co-ordinating Committee has representation from the following organizations: Department of Health; Nova Scotia Dental Association; ... Department of Education; Medical Society of Nova Scotia; Provincial Medical Board; Registered Nurses Association of Nova Scotia; Health Services and Insurance Commission; \: Nova Scotia Pharmaceutical Society; Nova Scotia Association of Health Organizations. 167 -The Physician Manpower Sub-Committee has recently undergone a review and modification of its terms of reference. The primary purpose of the Committee, as the principal advisory body to the Department on physician manpower matters, is to study, plan, monitor and report on physician resources with the overall aim of making appropriate recommendations to . government to augment the effectiveness of current provincial physician manpower poli-cies. The Commitee will be directly involved with the Department on an ongoing basis in data collection and assessment, policy study design and implementation, annual report production, monitoring and adminstration of the provincial physician placement program, and cooperative regional physician manpower; planning. One of the Committee's top priorities is to recommend various programs and procedures which will help to achieve and maintain a balance in the supply of physicians and a more equitable distribution of physician services. The membership of the new Physician Manpower Committee includes representa-tives from: Department of Health; Council of Teaching Hospitals; Medical Services Insurance Commission; Dalhousie University Faculty of Medicine; Resident Training Program at Dalhousie; Nova Scotia Medical Society; Nova Scotia Provincial Medical Board. NOVA SCOTIA Ministry of Health -Administrator Program Development and Evaluation Department of Health Federal/Provincial Health Manpower Committee Co-ordinator Health Manpower Technician Subcommittee Nursing Subcommittee Health Manpower Co-ordinating Committee Professional Associations Department of Education Dalhousie University Health Services Commission Nova Scotia Health Council Nova Scotia Hospital Commission Board - of Registration of Nursing Assistants Physician Services Subcommittee Pharmacy Subcommittee Dental Services Subcommittee - 169 -NEW BRUNSWICK Health manpower planning in New Brunswick was conducted on an ad hoc basis for several years. However, in 1977 the general responsibility for coordinating health manpower planning activities was assigned to the newly-created Planning and Evaluation Division in the Department of Health. It consists of a Director (who serves as Secre-tary to the provincial Physician Manpower Committee), a Medical Consultant and Infor-mation Systems Coordinator, and Health Services Planners, one of whom is responsible for manpower planning activities. One of the major goals of the division is the develop-ment and implementation of a manpower planning structure and process that will help to promote better distribution and utilization of the province's health care personnel. The first step in this process is, of course, the establishment of adequate health manpower data bases in order to describe the current situation, determine trends and project future needs. Subsequently, the implications for training, recruitment and health service development plans can be ascertained. Action is currently under way to design and implement suitable data bases in consultation with health care provider groups, attention being given to physicians, nurses and rehabilitation personnel. The Provincial Physician Manpower Committee, in existence for four years, has generally confined Its activities to the review of requests for immigration to the prov-ince. However, in line with the recommendations of the recent Report of the Task Force on New Brunswick Health Care, the Committee has revised its terms of reference and is expected to play a more active role in identification and assessment of issues, problems and solutions related to the supply, distribution and mix of physicians in the province (including an adequate data base). The present Physician Manpower Committee has representation from the following organizations: Department of Health (two representatives); New Brunswick Medical Society (one representative from each health region); New Brunswick Medical Council (one representative); New Brunswick Hospital Association (one representative); New Brunswick Association of Registered Nurses (one representative). - 170 -The Task Force also recommended the establishment of Nursing and Paramedical Manpower Committees to serve as consultative and advisory bodies in the implementation of a coordinated planning process for these groups. The committees would be linked to the Planning and Evaluation Division through the Manpower Planner, who would serve as Secretary to both. It is currently anticipated that these committees will be set up within the next six months and will include representatives from the Department, relevant health care provider groups and the N.B. Hospital Association. Coordination of the activities of the three committees would be through the common departmental representation, regular exchanges of information and minutes, and periodic joint meetings. The, Planning and Evaluation Division has held preliminary discussions with the N.B. Community College regarding joint studies of health manpower needs and options for meeting them. •3 171 -. PROVINCE OF NEW BRUNSWICK ORGANIZATIONAL CHART FOR HEALTH MANPOWER Deputy Minister of Health Federal-Provincial Advisory Committee on Health Manpower Director Planning & Evaluation Division Physician Manpower \ \ / Committee \ : \ / / / / / i i i \ \ Health Manpower Nursing Manpower Planner Committee Paramedical Manpower Committee - 172 -QUEBEC A Service Planification et Developpement de la main-d'oeuve (Manpower Planning and Development Unit) has just been set up within the Direction Generate des Relations  de travail (Labour Relations Branch) of the Quebec Department of Social Affairs. The objective of its creation was to place more emphasis on the Department's programs and priorities in directing negotiations and to ensure that long-term studies on manpower and policies affecting it correspond with all department activities related to planning and labour relations. The Direction de la Main-d'oeuvre et de la Remuneration (Manpower and Remu-neration) includes three other units in addition to Manpower Planning and Development: Recherches en relations de travail (Labour relations research), Soutien technique des  relations de travail (labour relations technical support) and Formation (Training). Its mandate is: a. To design and carry our research in the area of remuneration, working conditions, training and manpower; b. To propose orientations and policies in these areas for staff of the Social Affairs network and for professionals providing services covered under the Health Insurance and Hospital Insurance Acts; c. To evaluate policies established with respect td remuneration, working conditions, training and other manpower-related areas. In fact, the growing importance of collective agreements, agreements negotiated with professionals and policies relating to executive-level staff, has placed this Branch in the forefront among the instruments for network orientation, due to its impact on delivery of services, administration of facilities and on the general level of resources allocated to Social Affairs as a whole. With this aim in mind, Manpower Planning and Development must: carry out forecasts on needs and availability of manpower in the social affairs area and propose measures to ensure better use and distribution of manpower; draw up departmental training and upgrading policies and carry out research in this area; participate in projects relating to evaluation of policies for remu-neration , working conditions, training of manpower in order to ensure cohesion between the orientations of Social Affairs, man-power policies and labour relations policies. In addition, the Training Unit also carries out activities related to manpower planning, due to its involvements in the design and implementation of training programs and administers the departmental scholarship and fellowship policy. The two components work together in projects with other departments and organizations (Education, Labour and Manpower, Office des Professions, etc.) who are responsible for manpower, training and upgrading matters. DEPARTMENT OF SOCIAL AFFAIRS Labour Relations Branch QUEBEC Unionized Staff Directorate Negotiations Negotiating body Professional Staff Directorate Negotiations Negotiating body Executive Staff Directorate Relations with associations and institutions Relations with executive staff Manpower and Remuneration Directorate Labour relations research Labour relations technical support Manpower planning and development Training - 175 -ONTARIO As of January, 1979, the Health Manpower Section of the Ontario Ministry of Health was located within the Policy Development and Research Branch, reporting directly to the Deprty Minister. The Manpower Section is responsible for monitoring trends in supply and require-ments, and advises on policies required to compensate for manpower imbalances or deficiencies. To assist in this, it maintains close relationships with professional organi-zations and advisory bodies, including the Ontario Council of Health (which has the Human Resources Committee), the Clinical Education Committee, and the Provincial (Educational) Review Subcommittee (which advises on community college programs). The Section provides resource suport for these bodies, and for the medical manpower policies. Manpower data is obtained from a variety of sources and the Minis-try, together with the College of Physicians and Surgeons and the Council of Ontario Faculties of Medicine, supports a Medical Manpower Data Centre which maintains comprehensive data on 2600 postgraduate trainees and provides to specialty manpower study groups information to assist in determining specialty manpower requirements. The Section is also responsible for developing policy studies and recommendations in response to requests from senior officials, and for certain management tasks: viz. (1) reviewing requests for physician immigration support, received from the Department of Employment and Immigration via Canada Manpower, and (2). establishing and admin-istering the Ministry of Health budget for clinical education. Responsibility for health disciplines legislation is assigned to the Health Disci-plines Coordinator, who reports to the Assistant Deputy Minister for Community Health Services. A major link between the Ministry of Health and the Ministry of Education (which now includes colleges and universities) is the Health Sciences Education Commitr tee, .chaired jointly by the two Deputy Ministers. This body makes final decisions with respect to government commitments that involve new capital or major operating costs. PROVINCE OF ONTARIO Administrative Structures Concerned with Health Manpower Health Education (Colleges & Universities) Ontario Council of Health Minister Deputy Minister Human Resources Committee Provincial Review (Education) Committee Policy Development and Research Branch Clinical Education Committee Health Manpower Section Minister Deputy Minister Health Sciences Education Committee ADM Community Health Services Medical Manpower Advisory Committee Health Disciplines Coordinator \ \ \ \ \ ^ I \ \ Coordinator Health Sciences Education University Affairs College Affairs Ontario Council on University Affairs - 177 -MANITOBA The province of Manitoba does not have a formal organizational structure that deals with manpower planning and development matters. It has, however,; an active informal organization that coordinates and liaises in manpower issues. The ongoing Manpower Committee is comprised of Dr. R.H. Tavener, Chief Medi-cal Consultant in the Department of Health and Community Services; Ms. B. Havens, Director of Research in the Department, and Mrs. L. Bell, Manager of Manpower and Education at the Manitoba Health Services Commission. This Committee addresses con-tinuing and new manpower issues such as stock, supply, mobility, attrition, immigration and emigration, legislation and research. It liaises with the Department of Education and specific health-related associations and organizations as appropriate. A representative of the Manitoba Committee also sits with a representative from the Education Sector on the Western Canada Post-Secondary Health Manpower Require-ments Sub-Committee. This Sub-Committee, which reports to the Western Ministers of Post-Secondary Education, monitors training needs for all Western Canada health person-nel and plans cooperatively for training health personnel on a western regional basis. - 178 -SASKATCHEWAN Within the Government of Saskatchewan, responsibility for policy and planning related to health manpower in the province lies with the Department of Health and the Department of Continuing Education. These two departments also participate in health manpower discussions at the provincial, inter-provincial, and federal levels through membership on the following committees: a. Interdepartmental Committee on Health Manpower and Education; b. Western Canada Post-Secondary Health Manpower Requirements Sub-committee; c. Federal/Provincial Advisory Committee- on Health Manpower. The roles of the two departments and their joint activities are described below. Department of Continuing Education The Department of Continuing Education is responsible for all forms of publicly supported postrsecondary and adult education in the Province of Saskatchewan. The post-secondary system, encompasses three major components: universities, technical in-stitutes, and community colleges. The Saskatchewan concept of community colleges is different from elsewhere in Canada as these institutions do not offer any ongoing occu-pational training programs except on a contract basis with universities or institutes. All health manpower training, therefore, occurs in either the universities or technical. institutes. The relationship between the Department of Continuing Education and the univer-sities is largely financial in nature. The Saskatchewan Universities Commission has been established to act as an intermediary body between the universities and government. Programing decisions are largely dealt with by the universities themselves in concert with the Commission. While the Department of Continuing Education does not directly become involved in university program decisions, there are several formal avenues for dialogue (e.g., representation on the Senates, Boards of Governors, and University Commissions Committees). Also, there is much informal dialogue on health manpower matters between the Department and the university sector. It is becoming increasingly evident to both the Department and the university sector that joint planning in terms of health manpower programs is desirable and several consultative mechanisms are being developed towards that end. - 179 -The health manpower programs in technical institutes are under the direct control of the Department of Continuing Education. All proposals for new progams, program expansions, or program modifications are examined by the Department's Policy Planning Branch. To ensure that health manpower programs in the institutes are responsive to changing needs and standards, each program has an advisory board. These boards pro-vide an avenue for input to employers, professional associations, and consumers. The Department's Policy Planning Branch conducts a number of ongoing research activities which provide valuable data for health manpower planning. These studies monitor student application levels, enrolments, and the demographic characteristics of students for each institute program. In addition, the Branch has developed an ongoing follow-up study system for institute graduates to ascertain employment rates, type of employment, and the students' perception as to the adequacy of training. The system includes a standard questionnaire for all programs and the provision for supplementary questionnaires for individual programs. Over the last few years, several health, science programs, have utilized special questionnaires. The graduate follow-up study system includes surveys at two points in time - the first conducted about six months after graduation and the second about 18 months after graduation. Reports from these surveys are available on a regular basis. In addition to the ongoing research activities, the Policy Planning Branch be-comes involved in assessing new program proposals, program revisions and program modi-fications. Close liaison is maintained with the Department of Health and with other provincial governments, both through formal mechanisms and informal dialogue. Department of Health The. Department of Health's primary concern in the manpower field is to ensure that the province has a satisfactory supply and distribution of adequately trained person-nel in all required health professions and occupations. The Department's activities in the health manpower field are carried out by. the Health Manpower Studies Division of the Policy Research and Management Services Branch. The Health Manpower Studies Divi-sion performs the. following functions, either regularly or as needed: a. To provide the offices of the Minister and Deputy Minister with day-to-day consultation, on request, about current health man-power policy problems; - 180 -b. To maintain a system for monitoring the supply and demand for health personnel in the province; c. To study various manpower problems with regard to health disci-plines, including the following areas: the recruitment of personnel; the attrition of personnel; geographical distribution of personnel; regulation and licensing of health disciplines; required outputs from existing health manpower training programs and the need for new training programs under the jurisdiction of the Department of Continuing Educa-tion , and financial assistance programs for students undergoing training. The Health Manpower Studies Division established a Health Manpower Monitoring System in 1976. This system consists of semi-annual surveys among employers of health personnel in the province. The surveys provide data on the current number of establish-ed positions and vacant positions (categorized by type of employer) and on the distribu-tion of positions and personnel (by Health Region), for 27 health manpower groups. A Saskatchewan Health Manpower Annual Report is also produced. This report provides information on the number of health personnel currently in the province, on the number of established positions for personnel, on attrition rates among health profes-sional and occupational groups, and on the geographical distribution of personnel. The report also summarizes information on provincial health manpower training programs, continuing education programs for health personnel, and licensing and registration re-quirements for all major categories of health personnel. Apart from the activities of the Department of Health in the manpower area, individual health professional associations are engaged in extensive independent activities to develop their respective health disciplines. The Health Manpower Studies Division cooperates closely with these associations to obtain their views and recommendations on health manpower matters. The Division also relies upon the associations for various types of statistical information about health personnel in the province. r- 181 ~ Interdepartmental Committee on Health Manpower and Education Close coordination between the Department of Continuing Education and the Department of Health in the area of health manpower development is maintained through the Interdepartmental Committee on Health Manpower and Education. The Interdepart-mental Committee is made up of four representatives from the Department of Health (Deputy Minister; Executive Director, Saskatchewan Hospital Services Plan; Assistant Deputy Minister; Senior Research Officer, Policy Research and Management Services Branch) and four representatives from the Department of Continuing Education (Deputy Minister; Assistant Deputy Minister; Director of Policy Planning Branch; Senior Research Officer responsible for health and social service prorams). This Committee was established to serve as a formal mechanism for the defini-tion and resolution of policy matters regarding health manpower training programs and health manpower issues of concern to both departments. More specifically, the terms of reference of the Interdepartmental Committee on Health Manpower and Education are as follows: a. The Committee will establish policy, or make recommendations to the Ministers on policy, with regard to health sciences education and manpower in the province. Implementation of established policy will be the responsibility of the : appropriate department. b. The Committee will establish priorities and procedures for activities requiring interdepartmental cooperation. c. The Committee will act as the primary official point for exchange between the two departments of information concerning health manpower, such as: manpower requirements of health service programs; new or modified education programs; continuing education; facilities and program financing. d. The Committee will act as the coordinating agency for intragovern-mental and intergovernmental relations on health manpower and education. e. The Committee will monitor, through the respective departments, the manpower requirements of Saskatchewan's health care system and the output of the province's health manpower training programs. - 182 -f. The Committee may initiate and/or review and/or recommend ac-tion upon research studies relevant to the Committee's terms of reference. g. The Committee may discuss and recommend on any other items which fall within the broad general area of health manpower and education. Western Canada Post-Secondary Health Manpower Requirements Sub-committee On the Western inter-provincial level, health manpower is examined by the Western Canada Post-Secondary Health Manpower Requirements Sub-committee. This is a sub-committee of the Western Canada Post-Secondary Co-ordinating Committee, which consists of ministers and deputy ministers responsible for post-secondary education in the four western provinces. The Sub-committee is composed of one representative of the Department of Health and one representative from the Department charged with post-secondary education in each province. Saskatchewan's representatives on the Sub-committee are from the Policy Research and Management Services Branch of the Department of Health and. the Policy Planning Branch of the Department of Continuing Education. The function of the Sub-committee is to monitor the training needs for health personnel in Western Canada and to discuss cooperative planning for training health personnel on a western regional basis. Such planning helps to eliminate the unnecessary duplication of training programs and facilities, in the four western provinces. Federal/Provincial Advisory Committee on Health Manpower Coordination of federal and provincial efforts in the health manpower field is handled by the Federal/Provincial Advisory Committee on Health Manpower, which meets twice a year. Saskatchewan's representatives on this Committee are from the Policy Research and Management Services Branch of the Department of Health and the Policy Planning Branch of the Department of Continuing Education. The Federal/Provincial Advisory Committee on Health Manpower serves as a clearinghouse for health manpower information and assists in the identification of health manpower problems and require-ments of national significance. SASKATCHEWAN: Health Manpower Development Organization Pattern 2. Inter-provincial Committees Federal Provincial Advisory Committee on Health Manpower Western Canada Post-Secondary Health Manpower Requirements Subcommittee Department of Health Interdepartmental Committee on Health Manpower & Education Provincial Health Professional Associations and Agencies Department of Continuing Education Saskatchewan Universities Commission University of Saskatchewan Technical Institute University of Regina indicates liaison and discussion - 184 -ALBERTA In August 1973, The Alberta Health Manpower Committee was established. Its membership was composed of senior officials from Health and Social Development, Advanced Education, Labour and Manpower, and the Alberta Hospital Services Commis-sion. The Deputy Minister of Health Services acted as Chairman. With the government reorganization following their last election in 1975, and the appointment of Dr. Cochrane, who was Chairman of the Committee, to the Presidency of the University of Calgary, the Committee thought this presented an opportune time to review the func-tions, terms of reference, and composition of the Committee. New Coordinating Arrangements Subsequent changes in government organization and an increasing awareness of the importance of coordination in the area of health and social services manpower, necessitated a review of the Alberta Health Manpower Committee. This revision result-ed in the creation of the Alberta Health and Social Services Disciplines Committee (1976), with a chairman drawn from outside the government service. The coordinating arrangements reflected by the establishment of the Committee do not differ materially from the previous arrangements, other than to enlarge the Committee slightly to ensure more adequate representation. Government departments represented on the Committee are as follows: the Department of Social Services and Community Health; the Department of Advanced Education and Manpower, and the Department of Hospitals and Medical Care. The Committee is essentially internal to government to effect appropriate coordination. Provision has been made for input from other agencies, associations, educational institutions and individuals in accordance with the particular planning issue under consideration. Moreover, linkages between the Alberta Health and Social Services Discipline Committee and other planning committees at the federal and Western Canada regional levels were provided. The following are the terms of reference for this Committee: a. In conjunction with appropriate agencies, develop on an ongoing basis inventories on: Health and Social Services Disciplines Training Programs; Health and Social Services Disciplines Supply and Distribution. 185 -b. Review pertinent studies, data and executive decisions from other jurisdications on the training and supply of health and social ser-vices manpower. c. Review short and long-range plans from appropriate agencies for: Health and Social Services Disciplines Training Programs; Health and Social Services Disciplines Supply and Distribution. d. Review alternative requirements to meet the needs for the develop-ment of health and social services in the future. , e. Define areas of particular concern in the training and/or supply and/or distribution of health and social services personnel and recommend ways of resolving these concerns. f. Advise from time to time,, ab initio or on request, the need for in-depth studies in particular cases of .manpower training and supply. g. Undertake such other related activities as may be required. h. Submit an annual report on the activities of the Committee. Relationship with the Alberta Manpower Committee's Structure The Alberta Health and Social Services Disciplines Committee will be the Health Manpower Coordinating Group which advises the Alberta Manpower Committee on such matters required to enable that Committee to achieve its role of provincial, coordination and federal liaison in the manpower field. Articulation with National and Regional Health Manpower Committees Appropriate members of the Alberta Health and Social Services Disciplines Committee from the health and education sectors shall represent Alberta on the Federal/ Provincial Advisory Committee on Health Manpower and on the Western Canada Post-Secondary Health Manpower Requirements Sub-committee. - 186 -ALBERTA Department of Hospitals and Medical Care Department of Social Services & Community Health Department of Advanced Education and Manpower Alberta Manpower Committee Federal/Provincial Health Manpower Committee Alberta Health & Social Services Disciplines Committee ' 1 " V Social Services & Community • Health Advanced Education and Manpower Hospitals and Medical Care \ \ Professional Associations Western Canada Post-Secondary Health Man Power Requirements Subcommittee Educational Institutions - 187 -BRITISH COLUMBIA Health manpower requirements in British Columbia remain the responsibility of the Health Manpower Working Group. The Committee is composed of senior officials in the Ministries of Health, Education and. Labour and is supported by a research and development unit, the Health Manpower Research Unit, that is located in the Division of Health Services, Research and Development, Health Sciences Centre, University of British Columbia. BRITISH COLUMBIA Ministry of Health Ministry of Labour Ministry of Education 4/ Health Manpower Working Group 4^  Manpower Needs Committee Universities Council Academic Council Occupational Training Council Management Advisory Council Health . Manpower Research Unit - 189 -YUKON TERRITORY The present health care delivery system in the Yukon is a joint effort develop-ment on the part of the federal government (Medical Services Branch, Department of National Health and Welfare) and the Yukon Territorial Government. Transfer of the federally-operated services to the Yukon Territorial Government is proposed. - 190 -NORTHWEST TERRITORIES The responsibility for overall health manpower planning for the Northwest Territories has been assigned to the Health Programs and Standards Branch of the Department of Health. The following functions fall within Health Manpower Development: health career promotion; health bursary program; development of health training programs; manpower reviews. The attached organization chart indicates the position of Health Manpower Development within the Government of the Northwest Territories. - 191 -NORTHWEST TERRITORIES Organizational Chart For Health Manpower Development Minister of Health Director Chief Finance and Administration 1 1 .1 : 1 1 1 Health Manpower Development oi Health Chief Health Programs and Standards Chief Health Insurance . Programs - 192 -l APPENDIX E - 193 -B.C. HEALTH ASSOCIATION MANPOWER COMMITTEE TERMS OF REFERENCE 1. To advise and recommend to the Board of Directors on Health Manpower p o l i c y issues by a) Ensuring that the employers are involved i n the d e f i n i t i o n of manpower needs i n the health care industry now and i n the f u t u r e . b) Maintaining an inventory of B.C. Health A s s o c i a t i o n ' s and other agency's research e f f o r t s i n the he a l t h manpower f i e l d . c) I d e n t i f y i n g areas of health manpower research not now being addressed. 2. To recommend to the Board of the B.C. Health A s s o c i a t i o n , the establishment of ad hoc committees to study s p e c i f i c h e a l t h manpower i s s u e s . 3. To monitor the progress of such Committees or p r o j e c t s r e l a t e d to manpower iss u e s . 4. To encourage l i a i s o n v i a representation of one of the Manpower Committee members with the Health Manpower Working Group. 5. To l i a i s e with the B.C. Health A s s o c i a t i o n Education Committee on issues of mutual concern. January 14, 1980 

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