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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 S P E C I A L REFERENCE TO B R I T I S H 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 T H E S I S SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in 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 c o n f o r m i n g  to the required  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA A p r i l 1981 © W e n d y Gaye M a n n i n g , 1 9 8 1  In p r e s e n t i n g  this  thesis  in partial  f u l f i l m e n t of the  r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e of B r i t i s h Columbia, I agree that it  freely  the L i b r a r y s h a l l  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 .  agree t h a t p e r m i s s i o n f o r extensive for  University  s c h o l a r l y p u r p o s e s may  for  financial  shall  thesis  be g r a n t e d by t h e h e a d o f  copying or publication of this  gain  further  copying of t h i s  d e p a r t m e n t 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 . understood that  I  make  It is thesis  n o t be a l l o w e d w i t h o u t my  written  permission.  Department  of  j>j^a^tzJ^  r  The U n i v e r s i t y o f B r i t i s h 2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5 Date  (%n^J?£3  .  ^>q^^y Columbia  / f f /  my  ^ ^ ^ x ^ ^ ^ ^ ^ ^  ABSTRACT  The  D e v e l o p m e n t and I m p l e m e n t a t i o n o f H e a l t h  i n Canada:  purpose of t h i s  a)  t o review  b)  to describe  study  i s threefold:  c u r r e n t h e a l t h manpower p l a n n i n g  i n context,  manpower p l a n n i n g B r i t i s h Columbia.  to critique  methodologies  t h e g r o w t h and c h a n g e s i n m e d i c a l  i n Canada w i t h  s p e c i a l reference  The manpower i s s u e s  p r o f e s s i o n a l areas w i l l  planning  Planning  With S p e c i a l Reference t o B r i t i s h Columbia  The  c)  Manpower  a l s o be  to  i n f i v e other  health  explored.  t h e C a n a d i a n and B r i t i s h C o l u m b i a n manpower  processes using  c u r r e n t m o d e l s 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 care  system s e t s the stage f o r a study of  t h e d e v e l o p m e n t o f 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 s y s t e m i s  i n v e s t i g a t e d as t h e p r i m a r y reason f o r government's interest  increased  i n t h e c o n t r o l o f p h y s i c i a n manpower and h e a l t h  care  labour costs i n general.  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 overlaps are outlined.  P l a n n i n g m o d e l s a n d t h e i r r e l a t i o n t o h e a l t h manpower are described.  Government's i n t e r e s t t o r e p l a c e t h e  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 p r e c e d e d insurance  planning  health  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 m a j o r r a t i o n a l p l a n n i n g m e t h o d s a n d t h e i r l i m i t a t i o n s a r e reviewed.  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  n e e d s , e c o n o m i c demand a n d s e r v i c e t a r g e t m e t h o d s .  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 address manpower i s s u e s a r e a n a l y z e d  as a r e t h e b u f f e r and lobby groups  e s t a b l i s h e d t o moderate t h e i r  efforts.  A s p h y s i c i a n manpower p l a n n i n g other  h e a l t h manpower p l a n n i n g ,  examined i n c o n s i d e r a b l e  issues i n t h i s area are  detail.  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 areas:  i s the pattern setter f o r a l l  This discussion i s followed  i n f i v e other health p r o f e s s i o n a l  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  dietetics.  T h i s d i s c u s s i o n shows how t h e s e g r o u p s h a v e a l l  c o n c e r n e d 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 a n d not w i t h i n t e r p r o f e s s i o n a l areas. p r i o r i t i e s are also  discussed.  Individual professional  iv  Insensitivity  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  understanding  of r a t i o n a l planning  modes seem  t o be the. r e a s o n  h e a l t h manpower p l a n n i n g . addressed  in relation  t o other  planning  f o r unsuccessful attempts i n  I t i s recommended t h e s e f a i l i n g s be  i f this planning a c t i v i t y i s to continue.  V  TABLE OF CONTENTS  Abstract Acknowledgements 1.  INTRODUCTION A.  The D i s t r i b u t i o n  B.  Definitional  and J u r i s d i c t i o n a l  1.  Sickness  Approach  2.  P r o g r a m s and S e r v i c e s A p p r o a c h Policy  Issues  C.  Health  D.  D e v e l o p m e n t o f C o n c e r n A b o u t Manpower Planning  E. 2.  of the Canadian P o p u l a t i o n  Development  i n Canada  H e a l t h Manpower  Planning  Summary PLANNING A.  Frames o f  B.  Entrepreneurial Planning  C.  Inference  1.  The M e d i c a l  Profession  2.  Institutions:  Hospitals  3.  Institutions:  Charitable Organizations  C o r p o r a t e P l a n n i n g - Government in  Planning  Canada  D.  Rational  Planning  E.  Bureaucratic  F.  H e a l t h Manpower  Planning  G.  When Do We  Planning?  Planning  Need  Summary 3.  RATIONAL MANPOWER PLANNING A.  H e a l t h Manpower R e s e a r c h D e v e l o p m e n t s 1.  H e a l t h Manpower:  Population  2.  H e a l t h Needs A p p r o a c h  3.  E c o n o m i c Demand A p p r o a c h e s  4.  Service Target  Methods  Ratios  vi Page B.  Limitations  50  1.  Isolation  from t h e H e a l t h Care System  2.  Questions  re:  Usefulness  of Health  Manpower P r o j e c t i o n s 3.  53  Lack o f S o p h i s t i c a t e d Methodology  Summary 4.  Prior  I N CANADA  A.  Activities  B.  Federal Coordination Efforts  C.  C o l l a b o r a t i o n B e t w e e n H e a l t h and E d u c 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  t o 1979 (1969-80)  The H e a l t h Manpower R e s e a r c h  F.  O t h e r G o v e r n m e n t H e a l t h Manpower P l a n n i n g  Unit  i n B r i t i s h Columbia  Education/Health  63 66 68  E.  Structures  60 60  B r i t i s h Columbia  75 76  Committees i n B r i t i s h  Columbia H.  54 56  HEALTH MANPOWER PLANNING STRUCTURES  G.  51  78  H e a l t h Manpower C o m m i t t e e s 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 Bodies and Professional Association  79  Summary 5.  81  MEDICAL MANPOWER PLANNING I N CANADA  84  A.  Immigration  86  B.  Physician Substitutes  87  C.  M e d i c a l Manpower i n t h e 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  v s . Home T r a i n e d  Columbia E. 6.  91  Summary  MANPOWER PLANNING I N OTHER HEALTH AND OCCUPATIONS  100 PROFESSIONS 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  vii Page D.  D i e t e t i c Manpower  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  111 Therapy  Manpower F. 7.  Summary  112 114  TOWARDS IMPROVEMENTS I N HEALTH MANPOWER PLANNING  117  Bibliography  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 completion  of this  o f many p e o p l e i n t h e  thesis i s recognized  and g r a t e f u l l y  acknowledged.  My f i r s t Dr.  expression  o f a p p r e c i a t i o n must go t o my c o m m i t t e e o f .  Ann C r i c h t o n , D r . M o r t o n W a r n e r and D r . 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 e n c o u r a g e m e n t .  Particular  appreciation  g o e s t o D r . Anne C r i c h t o n f o r h e r i n s i g h t a n d . h o u r s o f h e l p during  this  study.  Many f r i e n d s h a v e p r o v i d e d  e n c o u r a g e m e n t and s u p p o r t .  Special  t h a n k s h o w e v e r must g o t o L a u r i e Smyth, A l i s a G l a z e r and D e n n i s Patterson patience  f o r t h e i r encouragement, m o t i v a t i o n during  the f i n a l  F i n a l l y , b u t most  wisdom.  months.  i m p o r t a n t l y , I would l i k e  A n d e r s o n f o r many y e a r s  and l i m i t l e s s  t o t h a n k Dr. D o n a l d  o f i n s p i r a t i o n , e n c o u r a g e m e n t and  CHAPTER 1  INTRODUCTION  It  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 C a n a d a . potential  s c o p e o f t h e t o p i c i s s u c h t h a t b o u n d a r i e s must be  established  f o r d i s c u s s i o n purposes.  Activities at a national  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 will the of  be d i s c u s s e d . country, with  i t s own.  indepth  The  associations  P r o v i n c i a l a c t i v i t i e s vary greatly each province  providing  material  B r i t i s h Columbia has t h e r e f o r e  discussion.with  across  f o r a volume  been s e l e c t e d f o r  some c o m p a r i s o n s t o o t h e r p r o v i n c i a l  activities.  Within  the geographic boundaries defined  a c h i e v e m e n t s and a t t e m p t s w i l l in  h e a l t h manpower p l a n n i n g  associations  and t h e h e a l t h  above,  be e x a m i n e d .  planning  Future d i r e c t i o n s  w i t h i n government,  professional  care system as a whole w i l l  be  identified.  The  major question  activities This  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 r e o r i n f a c t whether they a r e a t a l l e f f e c t i v e .  study w i l l  provide  a critical  review, concluding  an o v e r a l l a s s e s s m e n t o f t h e a c t i v i t i e s for  improvements.  with  and recommendations  2 -  Health  manpower p l a n n i n g ,  on t h e s u r f a c e ,  c l e a r c u t s e g m e n t o f "manpower p l a n n i n g ly  the establishment  a p p e a r s t o be a  i n general.  Consequent-  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-  p o n e n t s w i t h i n t h e h e a l t h s e c t o r seems a l m o s t a w a s t e f u l exercise.  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  necessitate differentiation. Canadian h e a l t h care as and  structure.  Government i n v o l v e m e n t i n  and t h e r o l e o f t h e m e d i c a l  i t s g a t e k e e p e r has c r e a t e d  which  a unique planning  There a r e j u r i s d i c t i o n a l  profession atmosphere  disputes  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 boundaries, immigration, health, education  migration,  and l a b o u r  and t h e i n t e g r a t i o n o f  policies.  P r i o r t o e x 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 is the  important  to describe  s e t t i n g i n which t h i s planning  necessary t o describe population power  A.  the h e a l t h care  process, i t  system i n Canada,  i s done.  I t i s also  t h e changes which have o c c u r r e d  i n the  a n d t o d e f i n e h e a l t h a s i t a p p l i e s t o h e a l t h man-  planning.  The D l s t r i b u t i o r i i A O f o . t h e J ; C a B a d i a n . . Populat/sioh. ;. .  Population  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 care has always  b e e n an i s s u e t o C a n a d i a n s a s i n d i v i d u a l s a n d a s members o f society.  As i n d i v i d u a l s t h e y h a v e b e e n s u c c e s s f u l  - 3 -  entrepreneurs  with the a b i l i t y  t o decide  how t o a l l o c a t e  t h e i r money, w h e t h e r i t be o n h e a l t h c a r e o f o t h e r Within society their individual health status  things.  potentially  affects the health status of others.  Since  Confederation,  t h e p o p u l a t i o n o f C a n a d a h a s grown  r a p i d l y f r o m j u s t o v e r 3 m i l l i o n i n 1 8 6 7 , t o 11 m i l l i o n a t the end o f t h e d e p r e s s i o n  and 23% m i l l i o n today.  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 nature  Initially  but the  m a j o r i t y o f t h e p o p u l a t i o n h a s become s e t t l e d i n u r b a n areas  (Appendix A ) .  of people l i v i n g  T h e r e r e m a i n s , h o w e v e r , a l a r g e number  i n r u r a l p a r t s o f C a n a d a , many o f t h e s e  being n a t i v e people.  Robertson  (1973) i n h i s s u r v e y  Canadian h e a l t h needs, o u t l i n e d t h r e e territories the  f o r planning  i s o l a t e d regions  (some c o n s i d e r a b l e  underserviced  t h e p r o v i s i o n o f h e a l t h manpower:  (ir.e.. t h e f a r n o r t h ) ; r e m o t e a r e a s  d i s t a n c e from, b u t i n communication w i t h  u r b a n c e n t r e s ) ; a n d some p a r t s o f u r b a n c e n t r e s . problems occur  i n each o f these  o f h e a l t h s e r v i c e s a n d manpower. which a r i s e , care  B.  of  Different  areas both i n the p r o v i s i o n These d i f f e r e n t  issues  r e l a t e to the question of r i g h t s t o health  as p r o p o s e d i n t h e H e a l t h C h a r t e r  f o r Canadians."*"  Definitio.nal.Candy.J u r i s d i c t i o n a l ; I s s u e s  Health  i s a c o n c e p t w h i c h i n f r i n g e s upon many o t h e r  human  - 4 -  service,  l e g a l and  occupational  a r e a s and,  necessary to determine boundaries i n order meaningful examination.  The  d e f i n i t i o n o f h e a l t h and  i t s opposite  appears, to the  l a y m a n , t o be  a review of relevant care  field  place  therefore,  i t is  to conduct a  to begin i s with illness.  To  a do  s t a t i n g the obvious.  so  However,  l i t e r a t u r e , major s t u d i e s of the  i n Canada and  the  legislation, quickly  health  reveal  e i t h e r a l a c k of a t t e n t i o n to such a d e f i n i t i o n or  the  assumption of d e f i n i t i o n s s u f f i c i e n t l y broad to provide adequate boundaries to i n v e s t i g a t o r s .  Many c o u l d be  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 i n g a r e a s o v e r w h i c h c o n t r o l J m a y o r may  con-  ambiguity,  n o t be  in-  provid-  exercised  by  agencies. 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 compete 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 which are 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 s u c h s i t u a t i o n s . "  The  a b i l i t y of groups or i n d i v i d u a l s to d e f i n e  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  l a t i o n does not  d e f i n e what h e a l t h  d i c t i o n a l overlaps  program areas.  Legis-  i s , g i v i n g r i s e to  juris-  b e t w e e n g o v e r n m e n t m i n i s t r i e s and  agencies charged w i t h borderline  ambiguous a r e a s  responsibilities  i n h e a l t h and  other related  areas.  Approaches w h i c h have been t a k e n t o t h i s a m b i g u i t y may  be  d i v i d e d i n t o two  definitional  distinct categories,  the  - 5 -  Sickness Approach  and t h e P r o g r a m  and S e r v i c e A p p r o a c h .  Each  has a u n i q u e 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 f r o m t h e o t h e r , a l t h o u g h e l e m e n t s o f e a c h may  n o t be u n i q u e .  s h o u l d be s t a t e d t h a t t h e P r o g r a m s  Additionally, i t  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 A p p r o a c h . Sickness  Approach  Definitional difficulties a r i s e n f r o m an i n a b i l i t y  of 'health',  f o r t h e most p a r t ,  t o q u a n t i f y the term.  T h o s e who  have are  h e a l t h y do n o t become p a r t o f t h e d a t a c o l l e c t i o n s y s t e m , as t h e y do n o t v i s i t  'health p r a c t i t i o n e r s '  t o have t h e i r  diagnosed, nor are they i n s t i t u t i o n a l i z e d because o f h e a l t h y .condition.:  Measures s i c k n e s s do e x i s t .  their  T h e r e f o r e , f o r m s a r e n o t c o m p l e t e d on t h e m .  o f h e a l t h do n o t e x i s t w h e r e a s Visits  measures o f  to a doctor f o r diagnosis of  n e s s and i n s t i t u t i o n a l i z a t i o n counted.  health  sick-  f o r 'sickness' conditions are  Data bases have been d e v e l o p e d t o q u a n t i f y  this  concept.  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 access to the sickness  ( m e d i c a l ) s y s t e m , one's  of  perception of  h e a l t h and t h e h e a l t h c a r e s y s t e m t e n d s 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 s y s t e m .  Wildavsky describes t h i s process i n h i s P r i n c i p l e of Goal D i s p l a c e m e n t w h e r e he  states:  - 6 -  . . . t h a t any o b j e c t i v e w h i c h c a n n o t be a t t a i n e d w i l l be r e p l a c e d b y one w h i c h c a n be a p p r o x i m a t e d . E v e r y p r o g r a m n e e d s 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 c a n n o t 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 a c h i e v e m e n t t h e y c a n 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 b e c a u s e  health, is  government cannot p r o v i d e  i t p r o v i d e s what i t can - m e d i c i n e .  Because  d i r e c t e d not only at p h y s i c a l aspects but a l s o  medicine  mental  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 f r o m t h e 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, 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  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 , second s h i f t double displacement.  Measures  d e s c r i b e d by c o n t a c t s and b y m o r b i d i t y . has s h i f t e d  the d e f i n i t i o n a l base  making  subsequent  calling  this  of access are  Double d i s p l a c e m e n t  from h e a l t h to i t s o p p o s i t e  sickness.  The m a j o r 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 t e r m s 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 with health.  T h i s i s acknowledged  s t r o n g l y by McKeown (19 75) Illich  (19 7 5 ) .  little,  i f a n y t h i n g , t o do  b y W i l d a v s k y (19 7 7 ) ,  and s t a t e d a l m o s t f a n a t i c a l l y  argued by  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 t h e  b a s i s o f t h e L a l o n d e W h i t e P a p e r i n 19 74, e s t a b l i s h i n g a: .new philosophical  focus i n Canadian h e a l t h care, s h i f t i n g from a  medical care o r i e n t a t i o n to a preventive health In Wildavsky's P r i n c i p l e ,  orientation.  t h i s w o u l d r e p r e s e n t one s t e p i n  - 7 -  returning to the o r i g i n a l  goal.  A second major d i f f i c u l t y  i n d e f i n i n g health, i n sickness  is  the ambiguity which creeps i n t o the h e a l t h  terms  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 , s u c h a s i s s e e n i n t h e B.C.  Provincial  H e a l t h A c t , w h e r e no d e f i n i t i o n e x i s t s , o r i n t h e W o r l d H e a l t h Organization definition  (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 n o t m e r e l y t h e absence o f d i s e a s e and 4 infirmity)  which i s s u f f i c i e n t l y broad t o allow great l a t i t u d e  t o t h o s e who u s e i t , problems  l e a d s t o many j u r i s d i c t i o n a l  e s p e c i a l l y a t t h e programs and s e r v i c e l e v e l .  doubt t h e p o p u l a r i t y o f these d e f i n i t i o n s results  and b o u n d a r y  from t h e broad parameters  'grey a r e a s ' e x i s t ,  No  (or non-definitions) 5  they a l l o w .  A l t h o u g h many  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 workable d e f i n i t i o n a r e c r i m i n a l behaviour (drug a d d i c t i o n , disabled.  e t c . ) , m e n t a l r e t a r d a t i o n and c a r e f o r t h e  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-  s e n s u s r e g a r d i n g t h e 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 s y s t e m i n w h i c h 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 d o e s 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 which 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 n o n s e n s e q u e s t i o n . . . one t h a t i s n o t c a p a b l e o f b e i n g a n s w e r e d . ...The i n d i v i d u a l o b j e c t o r e v e n t we a r e  - 8 -  . n a m i n g , o f c o u r s e , h a s no name and b e l o n g s 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 a n d w h e r e we draw t h e l i n e b e t w e e n one c l a s s o f t h i n g s and a n o t h e r d e p e n d upon t h e i n t e r e s t we h a v e and t h e p u r p o s e s o f t h e classification. 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 , ^ p r o b l e m s o f c l a s s i f i c a t i o n and n o m e n c l a t u r e . • "  The  process of l a b e l l i n g  Approach the  a n d t o t h e P r o g r a m s and S e r v i c e s  Approach.  a p e r s o n b a s e d upon s o c i a l , b e h a v i o r a l ,  educational,  l e g a l or other c r i t e r i a .  a person w i l l  The  biological,  l a b e l placed  determine the type of treatment received  system i n which that treatment i s d e l i v e r e d .  seen l a t e r ,  upon and  As w i l l  be  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 P r o g r a m s and S e r v i c e s  Approach.  g o e s s o 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 will  It is  p r o c e s s by w h i c h 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  categorize  the  i s b a s i c to both the Sickness  Gove  o n an i n d i v i d u a l  q u i t e o f t e n determine the e f f e c t i v e n e s s of the treatment  received  with  mental i l l n e s s  l a b e l l i n g o f t e n appears  and p h y s i c a l  disability,  to lead to e f f e c t i v e treatment, while  with  c r i m e and d r u g a d d i c t i o n , l a b e l l i n g a p p e a r s t o h a v e a 7 deterrent 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 m e c h a n i s m by w h i c h 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 uals, allowing labelling  t o groups  and  individ-  i n c e r t a i n f i e l d s more t h a n i n o t h e r s .  - 9 -  She s t a t e s : J  I n the f i e l d s of medical care, mental 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 h a t e v e r 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 medical care, o r r e q u i r i n g admission t o mental 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 to a considerable extent at the d i s c r e t i o n of i n d i v i d u a l doctors or s o c i a l workers, o r of the administrators o f p a r t i c u l a r agencies.  S e v e n c a t e g o r i e s o f l a b e l l i n g a g e n t s a r e o u t l i n e d by Warham:. politicians,  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 , users  of social  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 , tary s o c i a l  s e r v i c e s and e m p l o y e r s .  the professionals,which it  I t i s this  third  voluncategory,  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 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 m o s t e v i d e n t .  I t i s i n these  a r e a s w h e r e l a b e l l i n g becomes k e y t o w h a t i s d e f i n e d as h e a l t h and w h a t i s n o t .  I f one w e r e t o i d e n t i f y  the l e s s obvious r o l e s of a p h y s i c i a n ,  s o c i a l c o n t r o l w o u l d c e r t a i n l y be o n e o f them. w h i c h 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  I t i s this  role  of 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 t h e p h y s i c i a n who h a s t h e r e sponsibility and  (power) o f d e f i n i n g ( l a b e l l i n g ) w h a t i s n o r m a l  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 .  a d o c t o r h a s d i a g n o s e d someone as s i c k , he h a s n o t o n l y v i d e d him w i t h access  t o t h e h e a l t h system, b u t has t a k e n  Once  prohim  - 10 -  away f r o m a n o t h e r s y s t e m  ( F r i e d s o n , 19 7 0 ) .  Many  examples  w o u l d 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 t h e l a b e l l i n g of  t h e d r u g a d d i c t who,  when l a b e l l e d w i t h i n t h e m e d i c a l s y s t e m ,  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 e s s e n c e d e n i e d a c c e s s t o the  j u s t i c e s y s t e m w h e r e m o s t l i k e l y t r e a t m e n t w o u l d mean  imprisonment.  D e p e n d e n t u p o n w h 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 u s e d w i l l be d i f f e r e n t . the  criteria  Mercer i n examining the l a b e l l i n g of  mentally retarded cites  the 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 w h i c h v i o l a t e s t h e l e g a l c o d e and h a v e o n l y a s e c o n d a r y 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 h a v e 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 p e r s o n s 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 w o u l d 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 C o u n t y H e a l t h D e p a r t m e n t o r p e d i a t r i c i a n s w i l l show a higher rate of p h y s i c a l d i s a b i l i t y ^ t h a n those d i a g n o s e d by n o n - m e d i c a l 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 labels  being applied to similar  i s what l e a d s t o  i f not i d e n t i c a l  A person w i t h a drug a d d i c t i o n problem l a b e l l e d criteria  i s considered a criminal,  different  conditions. by  legal  b y m e d i c a l c r i t e r i a he i s  sick.  Use o f l a b e l l i n g c r i t e r i a l i n e areas which  i s not r e s e r v e d s o l e l y  are c o n s i d e r e d d e v i a n t .  The  for border-  a r e a o f Home  C a r e , i f j u d g e d upon s o c i a l c r i t e r i a and n e e d , w i l l  fall  -  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 within the health d e l i v e r y o f home c a r e  As  system.  Provincial differences i n the  attest to this  fact.  t h e knowledge and s k i l l s o f a p r o f e s s i o n  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 ,  provide  r e s t s very  considerable  uals are categorized and  i n health  care  s e r v i c e s , w i t h whom individ-.  f o r m e d i c a l s e r v i c e s o r not-,  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 b e s t r u c t u r e d , t h u s i n -  d i r e c t l y how u s e r s a r e g r o u p e d o r c a t e g o r i z e d . likewise, although t h e i r professional status be  "The c l a s s i c  power t o d e c i d e b o t h w h e t h e r  as e l i g i b l e  great  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 s y s t e m . example i s t h a t o f d o c t o r s  a  less clearly  S o c i a l workers  and i d e n t i t y  may  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 similar effects.  It  i s t h i s c a t e g o r i z a t i o n process which transforms  policies  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  resources.  The  i n 1 9 6 1 was c h a r g e d  with  R o y a l Commission, on H e a l t h  Services  the responsibility of defining  care'.  'theb e s t p o s s i b l e  H a l l was a w a r e o f t h e d i f f i c u l t i e s ,  t i m e was a m a j o r p r o b l e m i n v o l v e d  health  i n d i c a t i n g that  i n s u c h an a t t e m p t .  Our t e r m s o f R e f e r e n c e r e q u i r e us t o "the b e s t p o s s i b l e h e a l t h care", y e t the advances i n m e d i c a l knowledge i n decades t h e c o n c e p t o f h e a l t h evades  define despite recent precise  - 12  -  definition. 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 n a t u r e , , 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 and  1  ... .. m e d i c a l k n o w l e d g e h e l p s  deepen the meaning o f i l l n e s s  regaining  "good" h e a l t h .  f a c t o r s w i t h i n the  and  I t i s the  us  to  identify  the p o s s i b i l i t i e s  r e l a t i o n s h i p of the  of three  t o t a l environment which l a r g e l y determines  what a community w i l l  consider  a t any  moment o f t i m e ,  as  the  12 best p o s s i b l e h e a l t h care 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 w a y s , b o t h t h e A p p r o a c h and, A p p r o a c h by  as  s h a l l be  describing a non-static  c a n n o t r e a d i l y be  2.  P r o g r a m s and  This  seen, the  P r o g r a m and  Service  s y s t e m upon w h i c h b o u n d s  placed.  Services  Approach  a p p r o a c h i s a n a t u r a l outcome o f t h e  p r o c e s s o u t l i n e d under the  Sickness  categorization  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 m i n i s t r y , or a voluntary d e t e r m i n e how p o i n t i n time. are  has  agency w i t h a h e a l t h  society w i l l  define  area of disputed  been c a t e g o r i z e d  The  mandate,  occurred,  s e r v i c e may  t e r r i t o r y but  as a h e a l t h  health  h e a l t h a t any p a r t i c u l a r  Once c a t e g o r i z a t i o n has  transformed i n t o services.  l i n e o r i n an  Sickness  be  policies border-  because i t  service i t i s taken  from  -  13  -  a n o t h e r s y s t e m 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 other system. and  i n the  One  area which s u f f e r s from b e i n g  D e p e n d e n t upon t h e p o l i t i c s  t i m e as w e l l as  retardation  finds  social service  C.  that  borderline  process of almost constant r e c a t e g o r i z a t i o n  mental r e t a r d a t i o n . of the  to  the bent of the  and  is  economics  professionals,  mental  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  areas  and  regularly.  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 g o v e r n m e n t s w i t h i n C a n a d a h a v e t a k e n responsibility  f o r d i r e c t p r o v i s i o n of p u b l i c health  infection control, services  t o h i g h r i s k groups  i n f a n t s ) , and  services  mental h e a l t h  t h e i r communities.  a l s o t a k e n on by  by  the  ations  1930's. could  ments d i d n o t r e v i s i o n was Rowell-Sirois  to paying  and  had  voluntary  poned t h i s r e v i s i o n u n t i l  organiz-  p r o v i n c i a l govern-  have s u f f i c i e n t t a x i n g powers.  Constitutional  s u b s e q u e n t l y recommended by  (19 40) . 1946.  late  become a m a j o r p r o b l e m  f i n d enough r e s o u r c e s and  Committee  service  patient.  care services  n e c e s s a r y and  social  to  p r i n c i p a l r e l a t i o n s h i p was  L o c a l m u n i c i p a l i t i e s and  not  and  and  l o c a l communities i n the  However, t h e  of p e r s o n a l p h y s i c i a n of health  (mothers  Responsibility for indirect health  nineteenth century.  Financing  services:  f o r those unacceptable  s o c i a l s e r v i c e , s u c h as h o s p i t a l s , h e a l t h a g e n c i e s , was  the  The  s e c o n d w o r l d war  Intervening  y e a r s saw  the postthe  one  - 14 -  i n i t i a t i o n b y t h e f e d e r a l g o v e r n m e n t o f new p r o p o s a l s r e l a t e d to  the federal/provincial funding of a national health  system  (Heagarty, 1943).  insurance  I n t h e 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 p u t forward W h i l e t h e s e p r o p o s a l s were adopted  (Marsh  i n 19 46, i t t o o k  19 4 3 ) . another  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 t h e 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 n o t 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 g o v e r n m e n t b e g a n t o become c e r n e d a s t o how d o l l a r s w e r e s p e n t .  con-  By t h e end o f t h e 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 Cost 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  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  a  expansion.  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 a g r e e m e n t s i n f u n d i n g t o i n c r e a s e management 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 w a s t e 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  delivery  mode; a n d e x p l o r e a d d i t i o n a l new f o r m s o f s e r v i c e  delivery.  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 through w i t h these  ommendations w i t h t h e p r o v i s i o n o f a m b u l a t o r y 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.  rec-  care and t h e  E m p h a s i s on i n -  dividual responsibility  f o rhealth  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 federal health  The E s t a b l i s h e d P r o g r a m s F i n a n c i n g A c t (19 77) 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.  With  policy.  p r o v i d e d a new  t h e new f o c u s o n  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 a n d d i s t r i b u t i o n o f h e a l t h manpower.  D.. . D e v e l o p m e n t o f C o n c e r n A b o u t Manpower P l a n n i n g i n _ C a n a d a C a n a d a was c o n q u e r e d a n d a n n e x e d as a B r i t i s h t i m e o f t h e A m e r i c a n War o f I n d e p e n d e n c e . from t h e French  to the B r i t i s h  colony a t the  C o n t r o l had  and w i t h i t ,  passed  the interest i n  e x t r a c t i n g r e s o u r c e s a n d t h e n e e d f o r manpower t o f a c i l i t a t e this  process.  O v e r a l l manpower p o l i c i e s r e l a t e t o areas education.  such  f o r Canada a r e g e n e r a l o n e s .  a s unemployment,  They  i m m i g r a t i o n and  I n 1 8 6 7 , 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 u s e o f manpower b y t h e g o v e r n m e n t . 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 a n d t h e m a r k e t  d i c t a t e d manpower a n d i m m i g r a t i o n p o l i c i e s . .  In a larger  con-  t e x t t h e y were dependent upon w o r l d m a r k e t s and economic cycles.  I n t h e e a r l y d a y s manpower p o l i c i e s w e r e , t o a l a r g e e x t e n t , immigration policies,. stances  -The u n d e r s t a n d i n g  of ideological  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) h a s s t a t e d t h a t C a n a d a i s a N o r t h A m e r i c a n  liberal  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 support o f the entrepreneurs. years  t o be m i n i m a l  except i n  This being the case,  t h e r e has been g e n e r a l support  i n past  f o r open i m m i g r a t i o n .  f a c t i m m i g r a t i o n h a s b e e n p r o m o t e d as a means o f f i l l i n g job p o s i t i o n s and t o d e v e l o p booming  vacant  new b u s i n e s s when m a r k e t s a r e  ( R i c h m o n d 19 7 4 ) .  H a w k i n s (19 74) policies  In  such  h a s 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 as r a c i a l  immigration  a t t i t u d e s which l e d t o b a r r i e r s  being  s e t up t o h i n d e r O r i e n t a l s a n d E a s t I n d i a n s f r o m e n t e r i n g t h e c o u n t r y and encouraging  entry o f educated  and t r a i n e d  Caucasian  immigrants.  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  education p o l i c i e s .  from  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 secondary However, b a r r i e r s  education  developments.  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  link-  ages h a v e b e e n 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 responsibility  E. It  and e d u c a t i o n a p r o v i n c i a l one.  H e a l t h Manpower P l a n n i n g i s obvious  t h a t h e a l t h manpower p l a n n i n g was a t one t i m e  minor concern  t o governments, g i v e n t h e g e n e r a l approach t o  a  - 17  -  manpower p l a n n i n g t h e y h a d m a i n t a i n e d .  I n t e r e s t d i d n o t grow  u n t i l g o v e r n m e n t s 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  e v e n t h e n i t was  a long time b e f o r e a c t i v e  steps  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  sixties  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  creasing at a great rate. institutions  Community c o l l e g e s and  was i n -  technical  e x p e r i e n c e d p h e n o m e n a l g r o w t h and w i t h t h i s ,  g r o w t h i n t h e 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 . H a l l C o m m i s s i o n i n 1964  encouraged t h i s expansion  a  The  especially  t o w a r d s 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 the H a l l Commission i n the e a r l y  1960's l e d t o  1  the establishment of the Health Charter f o r Canadians, document w h i c h  put 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  universality.  With  i b i l i t y was  expected  U n i v e r s a l Health Insurance, t o be e n s u r e d .  I t was  and access-  that planning  r e q u i r e d to r e a l l o c a t e resources f o r the p r o v i s i o n of  t o t h o s e who  had  not p r e v i o u s l y had  o f a c c e s s i b i l i t y had was  a  at this point i n  the growth of the Canadian h e a l t h care system was  this  13  been addressed,  access.  care  Once t h e q u e s t i o n  a redistribution  policy  necessary.  Inaccessibility  does n o t 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 c a 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 c a n 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 can r e s u l t i n a shortage-non-access area.  maldistribution  situation i n a specific  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  clientele.  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 s u c h a s manpower may e s s i t a t e a realignment of p r i o r i t i e s  t o produce  nec-  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 a n d 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 a n d 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 c a n be o b s e r v e d . brought  a growth  a care-dependent resources.  The i n c e p t i o n o f M e d i c a r e  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 , C a n a d a became 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  Demands w e r e no l o n g e r l i m i t e d by i n c o m e a n d t h e  e l d e r l y w e r e a b l e t o s e e k more c a r e . I m m i g r a t i o n emerged as a p r o b l e m when i t was r e a l i z e d  that  C a n a d a was b e i n g u s e d 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 t h 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 . b r a i n d r a i n o f p h y s i c i a n s from Great B r i t a i n  The  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 North America.  H a v i n g s p e n t time i n Canada, they t h e n  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.  would The  V i e t n a m War s l o w e d t h i s p r o c e s s b e c a u s e y o u n g p h y s i c i a n s c o u l d be d r a f t e d .  In addition,  the American  dream was b e i n g  questioned.  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  h a d p r e v i o u s l y moved o n , a n d a p h y s i c i a n s u r p l u s became a reality.  - 19 -  By  the late s i x t i e s  g o v e r n m e n t h a d become c o n c e r n e d a b o u t u n -  planned growth i n education patterns of immigration care.  Planning  and t r a i n i n g programs, t h e c h a n g i n g  and e m i g r a t i o n ,  seemed t o h a v e become a n e c e s s i t y a n d 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  The  T a s k F o r c e on t h e C o s t s  b e g a n t o grow.  of Health  n e e d t o make b e t t e r u s e o f . r e s o u r c e s . expensive  resource,  Care, focussed  technology  Over-  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  e m p h a s i z e 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. the N a t i o n a l H e a l t h  This  i s evidenced  G r a n t s i n 19 69.  Health  i n the revision of planning i n  g e n e r a l was e m p h a s i z e d a n d w i t h i t h e a l t h manpower  I f one were r e q u i r e d t o i d e n t i f y to  on t h e  Manpower> t h e m o s t  was k e y i n t h e i r d e l i b e r a t i o n s .  e x p l o i t a t i o n of medical  to  and t h e c o s t o f h e a l t h  the major p o l i c i e s  h e a l t h manpower i n C a n a d a o v e r t h e p a s t  w o u l d p r o v e t o be a d i f f i c u l t power p o l i c y w e r e d e s c r i b e d  task.  planning.  relating  f i f t y years, i t  In fact,  i f h e a l t h man-  f o r C a n a d a .as a w h o l e , w h a t w o u l d  emerge w o u l d b e a f r a g m e n t e d p i c t u r e c o n s i s t i n g o f t e n provincial scenarios priorities  each w i t h a d i f f e r e n t s e t o f problems,  and p o l i c i e s .  Attempting  to coordinate  these t e n  u n i q u e a g e n d a s w o u l d b e a f e d e r a l manpower " c o m p o n e n t " , w h i c h in  i t s e l f was d i s j o i n t e d a n d l a c k i n g i n m a n d a t e .  - 20 This picture  i s n o t one r e s t r i c t e d  other p o l i c y areas s u f f e r  t o h e a l t h manpower, most  i n t h i s manner.  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  The n a t u r e o f o u r  to occur.  I n h e a l t h manpower, h o w e v e r , t h e r e a l i z a t i o n o f p r o v i n c i a l uniqueness  and a t t e m p t s  relatively  new.  t o address  t h e s e p a r a t e agendas a r e  In. t h e 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 o f need f o r a p o l i c y  requiring  the r e d i s t r i b u t i o n  o f h e a l t h manpower r e s o u r c e s n o t o n l y on a p r o v i n c i a l  basis,  b u t 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 t h e s t a g e f o r s u b s e q u e n t c h a p t e r s by d e v l o p i n g the Canadian c o n t e x t i n which p l a n n i n g has o c c u r e d . r u r a l / u r b a n s h i f t which  h e a l t h manpower  I t b e g a n w i t h an e x a m i n a t i o n has o c c u r e d  of the  i n the country's  p o p u l a t i o n and t h e e f f e c t t h a t has had on h e a l t h c a r e delivery.  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 Attempts its  i s s u e s were t h e n  addressed.  t o d e f i n e h e a l t h h a v e most o f t e n c e n t e r e d on  o p p o s i t e s i c k n e s s or have found  program o r s e r v i c e  parameters  by use o f  boundaries.  J u r i s d i c t i o n a l . o v e r l a p s occur i n grey areas such j u s t i c e system  defining  o r s o c i a l , s e r v i c e system.  as t h e  Dependent upon  who  - 21 labels  a p r o s p e c t i v e c l i e n t t h e p e r s o n may e n t e r  number o f ' t r e a t m e n t may be l a b e l l e d likely  be  systems.  1  sick,  If labelled  by a j u d g e o r l a w y e r  one o f a  by a p h y s i c i a n , he the l a b e l  will  criminal.  Since early on,Canadian ;  governments have been i n v o l v e d i n h e a l t h  care, o r i g i n a l l y through the p r o v i s i o n of p u b l i c health services. and  a problem t o government.  required  The  As t i m e went b y , f i n a n c i n g became a  to provide  provinces  During  responsibility  t h e 1940's r e f o r m  with the a b i l i t y  was  to tax.  f o r t i e s a l s o saw t h e commencement o f n e g o t i a t i o n s  t h e f e d e r a l g o v e r n m e n t and t h e p r o v i n c e s (Heagerty,  1943) and s o c i a l s e c u r i t y  over h e a l t h  between insurance  systems (Marsh, 1943).  Federal  c o n t r i b u t i o n s b e g a n t o i n c r e a s e and by t h e l a t e  sixties  c o n c e r n o v e r c o s t s had r i s e n  considerably.  The T a s k  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 d e l i v e r e d i t s r e p o r t p l a c i n g h e a v y e m p h a s i s on a m b u l a t o r y and o u t p a t i e n t The  seventies  struggled with  these  programs.  r e c o m m e n d a t i o n s and  of t h e L a l o n d e r e p o r t w h i c h handed t h e r e s p o n s i b i l i t y individuals  those o f an  own h e a l t h b a c k t o t h e 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 ones, r e l a t e d Little  i n 1969  t h i s t i m e have been  t o unemployment, i m m i g r a t i o n  interest  was e x p r e s s e d  and  general  education.  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 a n i s s u e and e v e n t h e n i n t e r e s t was s l o w t o come.  Fear o f t o o few p r a c t i t i o n e r s  under h e a l t h  insurance  (1964) t o e n c o u r a g e e x p a n s i o n o f t r a i n i n g p r o g r a m s . of access q u i c k l y  of medical  i n h e a l t h manpower  It  i s impossible  Canada. different and  emigration,  the unplanned growth of  programs, the cost of h e a l t h care  exploitation  technology  and a n o v e r  h a v e a l l l e d t o an  interest  planning.  t o i d e n t i f y m a j o r h e a l t h manpower p o l i c i e s i n  Attempts t o coordinate provincial  policies.  Questions  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 immigration, education  led Hall  This  e f f o r t s a r e met w i t h t e n  scenarios, sets of problems, study  addresses r e g i o n a l ,  n a t i o n a l attempts t o address p o l i c y  priorities  p r o v i n c i a l and  formulation.  -  23 -  Footnotes  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, O t t a w a , 19 64, V o l . 1. p . 1 1 .  2.  W a t k i n s , K., S o c i a 1  3.  W i l d a v s k y , A., D o i n g B e t t e r a n d F e e l i n g W o r s e . 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 W o r s e , 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 Y o r k , 1 9 7 7 , p. 1 0 6 .  4.  W o 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: O r g a n i z a t i o n , 1 9 6 0 , p . 1.  5.  Examples o f t h i s c a n be f o u n d i n t h e Task F o r c e R e p o r t s on t h e C o s t o f H e a l t h S e r v i c e s i n C a n a d a (19 69) a n d 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 (Foulkes 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 D e v i a n c e , S a g e , B e v e r l y 1975, p. 2 9 5 .  8.  Warham, J . The C o n c e p t o f E q u a l i t y i n S o c i a l P o l i c y , V a n c o u v e r , 1974, p. 112.  9.  Mercer, J . L a b e l l i n g the Mentally Retarded, 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 , 1 9 7 3 , p . 24.  Contro1,  Longman, L o n d o n , 1 9 7 5 , p . 1 1 8 .  The  10.  Warham, J . The C o n c e p t o f E q u a l i t y i n S o c i a l P o l i c y , V a n c o u v e r , 1974, p. 112.  11.  Royal  Commission on H e a l t h  Ibid.  13.  Ibid.  U.B.C.,  U.B.C.,  S e r v i c e s , Government o f Canada,  O t t a w a , 1 9 6 4 , V o l . 1, p. 9 7 . 12.  Hills,  - 24 -  CHAPTER 2  PLANNING  A.  Frames o f  Inference  A l a r g e number o f p l a n n i n g m o d e l s h a v e b e e n d e v e l o p e d ,  however  no one i d e a l m o d e l h a s emerged.  by  Alford  (19 7 5) t h a t t h o u g h t s  to ideologies.  I t has been suggested  about planning are c l o s e l y  Entrepreneurs  t h e r e f o r e h a v e one v i e w o f how  the 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 consumer g r o u p s y e t  a d i f f e r e n t v i e w and  another.  I t h a s b e e n a r g u e d by Marmor (1973) t h a t d i f f e r e n t 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  development o f a p o l i c y  issue.  Rational planning  i s appropriate i n the e a r l y stages. be f o l l o w e d by w o r k i n g by n e g o t i a t i o n . i n Appendix  related  through  His three  planning i n the therefore  T h i s w i l l most  likely  the o r g a n i z a t i o n a l process  and  'frames o f i n f e r e n c e ' a r e o u t l i n e d  B.  The v i e w s 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 examination  of the r a t i o n a l planning processes  which have been  a t t e m 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 . attempts  These  a r e most e v i d e n t i n government, where i t has been t h e  i n t e n t t h a t r a t i o n a l planning replace 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  involvement  -  25  -  i n the p r o v i s i o n of h e a l t h s e r v i c e s .  Donnison  (197 2)  t i m e and  place  n o t u n l i k e Marmor, s u g g e s t s t h a t t h e r e for rational planning.  the work o f L i n d b l o m t o day  (19 59)  d e c i s i o n m a k i n g as  'incrementalism'.  with  ideology  (19 67)  Marmor b u t scanning  and  has  and  f u r t h e r , Donnison suggests the knowledge they  which the  d e c i s i o n maker i s  t o i n f l u e n c e day  i t as  t o day  these  consistent comfortable  decisions.  same c o n c l u s i o n as D o n n i s o n  'mixed-scanning'.  involves a blending  that  possess,  e x i s t i n g plans which r e l a t e to  reached the  describes  i o n to reach  This  of r a t i o n a l planning  and  mixedand  negotiat-  a solution.  B.  Entrepreneurial  1.  The  Health  ' p a r t i s a n mutual accommodation'  Consequently, r a t i o n a l plans which are  a r e more l i k e l y  Etzioni  any  on day  i n f l u e n c e d by  t h e i r i d e o l o g i e s and  w i t h the  looks  built  upon t h e p r o c e s s o f  Taking this  d e c i s i o n makers a r e  ideologies.  who  D o n n i s o n has  is a  Medical  Planning  Profession  Manpower P l a n n i n g  d i d not  ment u n t i l many o t h e r p l a n n i n g  r e c e i v e a t t e n t i o n by  govern-  e f f o r t s were w e l l under  way.  A l t h o u g h a number o f t h e s e o t h e r v e n t u r e s w e r e r e l e v a n t t o manpower d e v e l o p m e n t , none f o c u s s e d  s p e c i f i c a l l y on i t .  health  - 26 -  Medical Acts,  proclaimed about the time o f C o n f e d e r a t i o n  delegated r e s p o n s i b i l i t y to the medical profession collegial  c o n t r o l o f i t s members t h r o u g h o u t t h e d i f f e r e n t  C a n a d i a n p r o v i n c e s . These  Acts had been modelled 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. various to t h e  f o r the  Colleges  profession,  of Physicians regulate  o f members r e g a r d i n g  Authority  and Surgeons t o c o n t r o l  through e t h i c a l r u l e s  patients  p r o c e d u r e s w h e r e a n d when n e c e s s a r y .  the  responsibility of professional  admission  the conduct  and p e e r s a n d i n i t i a t e  ary  Although standards received  was g i v e n t o t h e  disciplin-  Fee s c h e d u l e s were  associations.  the primary l i p service,  economic  i s s u e s w e r e c l o s e l y l i n k e d t o them. • I t was n o t u n t i l t h e introduction of Hospital Accreditation that  c o n t r o l o f s t a n d a r d s became a  Physicians  physician use  (Evans 1975).  the market to  M o n o p o l y c o n t r o l by t h e  q u i c k l y moved t h e s y s t e m o f h e a l t h  m e d i c a l market p l a c e '  1900"s  reality.  w e r e more c o n c e r n e d a b o u t r e g u l a t i n g  t h e i r advantage than anything e l s e . profession  i n the early  care  "beyond t h e  The a b i l i t y o f t h e  t o d i c t a t e what t h e volume o f work w i l l be t h r o u g h  of discretionary .tactics i s discussed  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 themselves many b a d d e b t s t h e p r o f e s s i o n  with  provided a f e r t i l e f i e l d f o r the  establishment of a national health  i n s u r a n c e scheme.  Trans-  - 27 -  Canada M e d i c a l  plans  e s t a b l i s h e d l a t e r b y t h e p r o f e s s i o n were n o n -  p r o f i t p r e p a y m e n t schemes w h i c h p r o v i d e d more s e c u r e  income  for  the physicians involved.  A f t e r t h i s time 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 S a s k a t o o n  A g r e e m e n t i n 1962 a n d t h e 1964 H a l l C o m m i s s i o n t h a t t h e y to  accept  Medicare. -Ambiguities  not resolved during  agreed  initial  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 preneurs o r under c o n t r a c t have l e d t o c u r r e n t w i t h government.  Hall,  i n 19 80,  o n c e a g a i n was r e q u e s t e d  i n v e s t i g a t e government/professional  2.  Institutions  Health  care  confrontations to  relationships.  ; Hospitals  i n s t i t u t i o n s have n o t 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 .  Their  dependence on government has r e s u l t e d i n a g r a d u a l  greater  decrease i n  power.  Consumer demand f o r h o s p i t a l s i n t h e e a r l y p o s t - w a r y e a r s r e s u l t e d i n remarkable development i n t h a t f i e l d . n a t i o n a l planners primary  I n t h e 1940's  had s t r e s s e d the n e c e s s i t y o f e s t a b l i s h i n g a  h e a l t h c a r e s e r v i c e a n d 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 support  mechanism.  There.were o t h e r  p o l i c i e s o f i m p o r t a n c e i n t h e l a t e 4 0 s and 1  h o s p i t a l s became a t o o l f o r t h e r e d i s t r i b u t i o n o f w e a l t h the country  a n d as s u c h p r o v i d e d  parliament  across  w i t h two s i g n i f i c a n t  policies  f o r t h e p r i c e o f one.  Health  importance t o that o f h e a l t h care  became an i s s u e o f e q u a l  i n 19 4 8 t h r o u g h t h e N a t i o n a l  H e a l t h . G r a n t s a n d 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 a n d Diagnostic  S e r v i c e s A c t when t h e h e a l t h c a r e  h o s p i t a l s was i n t e g r a t e d w i t h  The  function of  the t o t a l welfare  Task F o r c e on t h e C o s t s o f H e a l t h  Services  package.  initiated i n  196 7, h o w e v e r , was n o t i n t e r e s t e d i n t h e r e d i s t r i b u t i o n o f t h e G r o s s 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 u n d e r c o n t r o l the  costs of d e l i v e r i n g health  Voluntary  care  through these  h o s p i t a l associations coordinated  institutions.  many h o s p i t a l  a c t i v i t i e s b u t w e r e w e a k e n e d i n t h i s b y t h e d e s i r e o f members t o a d d r e s s t h e i r own h o s p i t a l s ' p r o b l e m s r a t h e r t h a n t h o s e o f the  group.  3.  Institutions : Charitable  P r i o r t o t h e 19 6 0 ' s ,  Organizations  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 h a d  s h o u l d e r e d much o f t h e b u r d e n o f p r o v i d i n g s e r v i c e s t o t h e chronically i l l  and d i s a b l e d i n Canada.  between t h e cracks  and r e c e i v e d  Many,however,fell  no s e r v i c e a t a l l .  r i g h t s movement a t t h e e n d o f t h e s i x t i e s  The human  s u c c e s s f u l l y en-  c o u r a g e d a change i n p e o p l e ' s a t t i t u d e f r o m dependence on c h a r i t y to  the b e l i e f that taxes should"pay f o r these s e r v i c e s .  -  The  power t h a t t h e U n i t e d  i t s planning  29 -  F u n d h a d h a d f o r many y e a r s  f o r voluntary  through  o r g a n i z a t i o n s b e g a n t o d i m i n i s h as  g o v e r n m e n t assumed t h e f u n d i n g  r o l e f o r more a n d 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 C a r e a n d Home C a r e o r g a n i z e r s .  are coordinated  Voluntary  by L o n g Term  organizations are  sometimes u s e d as p a i d agents o f government t o p r o v i d e  C.  Corporate Planning  American corporate  - Government P l a n n i n g i n  planners  Donnison has i d e n t i f i e d  from which p o l i t i c a l  planning  justice.  themselves w i t h  two  d e c i s i o n s a r e made.  t r a n s l a t e d they a r e t h e standpoint  with the  i n the distribution  of h e a l t h s e r v i c e s .  of s o c i a l  Canada  concern themselves mainly  effect of uncontrolled entrepreneurialism  service.  standpoints Roughly  o f economic growth and t h a t  I n o t h e r words c o r p o r a t e  planners  concern  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  order.  The  n e e d t o b a l a n c e t h e two i d e o l o g i e s a n d 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 care p r o v i s i o n has o c c u r r e d a r e s u l t of the decision t o develop a welfare  Six  key b a r g a i n i n g  state.  points i n the current p o l i t i c a l  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 of-these  i n Canada as  1.  frame have  The f i r s t two  o c c u r a t t h e f e d e r a l government l e v e l and w i l l be  addressed only b r i e f l y .  P o i n t s four t o s i x i d e n t i f y key  - 30 -  Figure I  Key B a r g a i n i n g  (1)  FEDERAL GOVERNMENT  (2)  Province  (3)  (4)  (5)  Economic Growth  Social ustice I  T  Province  2  Provincial Government  Social Justice  Health  Points  conomic Growth Attorney General  Human Resources <Care Programs  (6)  Prevention  D e l i v e r y Method  Planning and Research  - 31  bargaining  -  or tradeoff points  at a p r o v i n c i a l l e v e l .  d i a g r a m i s n o t meant t o i l l u s t r a t e p o i n t s but  a l l possible  This  bargaining  does i l l u s t r a t e t h e m a j o r o n e s .  Three s t a g e s o f government development have been d e s c r i b e d Lowi. and  They i n c l u d e d i s t r i b u t i v e  r e d i s t r i b u t i v e and  may  discussing distributive government can Service service.  As  a l l be  c o n t r o l l e d by  no  other  l e g i s l a t i o n and  identified  financial  the p r o v i d e r s  a strong  e x e r c i s e of greater  t o be  they  was  faced through  of  their  to c o n t r o l .  I n Quebec a t p r e s e n t t h e r e  19 7 8 ) .  that  administrative  component, s t a n d a r d s w o u l d have r e m a i n e d o u t s i d e ability  that  century  this authority  Even w i t h  In  matters.  of  administrators  than to delegate  regulation.  has  In the nineteenth  absence of s t r o n g  choice  regulative  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  c l o s e l y g u a r d t h e i r autonomy.  with  (19 78)  r e g u l a t i v e and  i n d i v i d u a l s and  government i n the  barrelling),  p r e s e n t a t t h e same t i m e .  i s s u e s Judge  control only  decisions are  (pork  by  are questions  being  asked about  c o n t r o l over the p r o f e s s i o n  (Brunet./  They v i e w p r o f e s s i o n a l p e o p l e as a g e n t s o f brought under b u r e a u c r a t i c  t r a d i t i o n a l peer group c o n t r o l support i n other  provinces  Vinet  government  c o n t r o l r a t h e r than under This  c o n c e p t has  o r i n Quebec.  the  not  gained  the  - 32 -  D.  Rational Planning  R a t i o n a l a p p r o a c h e s 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 in detail  i n the f o l l o w i n g chapter.  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 models.  Anderson  (19 76)  They a r e p r i m a r i l y t h e b u i l d i n g on A m e r i c a n  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  m o d e l a l o n g w i t h t h e a d v a n t a g e s o f u s i n g an a c a d e m i c b a s e t o develop and  this rational  input.  E s t a b l i s h e d i n B.C. b e t w e e n 1972  19 76. t h i s m o d e l s u f f e r e d when l i n k s b e t w e e n t h e r a t i o n a l  planning  s t r u c t u r e and t h e s y s t e m b e g a n t o d e t e r i o r a t e .  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  More these  have n o t been a p p l i e d t o t h e 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 . T h e s e a p p r o a c h e s g a i n e d much s u p p o r t  i n the early seventies.  S i n c e t h a t time however, prime advocates have s t a r t e d t o question  E.  them.  Bureaucratic  Planning  W i t h t h e e x c e p t i o n o f Saskatchewan, i n Canada government planning i s a r e l a t i v e l y inefficient.  new a c t i v i t y  and a s s u c h i s f a i r l y  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 b y t h e C.C.F. g o v e r n m e n t o f 1944 t o s o c i a l The  sixties  a n d 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 a n d  social planning a c t i v i t i e s to  develop  planning.  their policies.  as p r o v i n c i a l governments s t r u g g l e d Activities  i n t h i s area  led to  4 5 theCastonguay-Nepveu Report ,Manitoba White Paper, t h e Foulkes c  R e p o r t a n d many o t h e r s i m i l a r p l a n n i n g  activities.  - 33  P r i o r to t h i s recognized  -  f l u r r y o f p l a n n i n g , however, governments  the n e c e s s i t y of developing  the entrepreneurs  and  themselves.  had  b u f f e r groups between  These b u f f e r groups  included  v o l u n t a r y o r g a n i z a t i o n s s u c h 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 hospital districts  and  union  boards.  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 s u c h 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 service provision. Quebec, e x t e n s i v e  In the  larger provinces  regional activity  o f c o n s u m e r p a r t i c i p a t i o n and  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 understanding  F.  Health  The  context  of health  Manpower  complicated  one.  (19 79) The  would l a b e l  difficulty  to the n a t i o n a l planner  occurs  i t an a r e n a f o r  i s t h a t the  than t h a t of the m o n o p o l i s t i c  professional associations.  How  I f r e s o l v e d , can  they  can  i n t u r n be  these  justice?  entrepreneur-  i f i n f a c t they  incorporated  viewpoints.  can  into  development  T h i s w o u l d be e s p e c i a l l y d i f f i c u l t ,  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 national  order  different  Canadian 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 to resource social  is a  finds i t s roots i n a  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 ,  and  involvement  Planning  Strauss  d i f f e r e n t ideology  purposes  meant t o c r e a t e a b e t t e r  i n w h i c h h e a l t h manpower p l a n n i n g  which appeals  be?  Consumer  and  policies.  the n e g o t i a t i o n of order.  ial  s u c h as O n t a r i o  developed f o r the  cost saving.  or  and  con-  - 3'4 -  The f o l l o w i n g c h a p t e r s The l i t e r a t u r e w i l l  explore the national planners'  be r e v i e w e d ,  r a t i o n a l planning considered.  approach.  and t h e Canadian c l i m a t e f o r  Questions  o f how p l a n n i n g i s  o r g a n i z e d , w h a t i t s i m p a c t 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 s y s t e m a n d how e f f e c t i v e i t i s w i l l  G.  When Do we N e e d  be  addressed.  Planning?  P o l i c i e s , whether formal o r i n f o r m a l , are evident i n a l l areas of l i f e .  The d e v e l o p m e n t o f t h e s e  of a v a r i e t y of processes  policies  c a n be t h e r e s u l t  a n d i t i s p r e s u m p t u o u s 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. (19 76)  suggests  Tropman  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 m a j o r  tool  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 s u g g e s t 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 increment Although will ment.  a l l three are deserving o f equal  concentrate Before  attention, this  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  .  ^ . ''  study  develop-  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 t h e  ' p o l i c y s y s t e m ' , t h e n e e d f o r p l a n n i n g must be e x a m i n e d .  There a r e those  idealists  among us who  like to believe that  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  systems, 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 . realize that this this  i s not always the case, but continue  i d e a l as o u r g o a l .  We to hold  - 35 Friedman  ( 1 9 6 7 ) , h o w e v e r , has d e f i n e d p l a n n i n g as ' t h e  g u i d a n c e o f change w i t h i n a s o c i a l purpose of t h i s study, Within this  this definition will  d e f i n i t i o n planning  redistribution,  s y s t e m ' ^ and f o r t h e  then  be  accepted.  becomes a t o o l f o r  f o r t h e s y s t e m i s c r e a t e d as a r e t h e p r o g r a m s ,  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  s y s t e m ' i n d i c a t e s t h e r e a l l o c a t i o n o f some component o f t h a t s y s t e m be i t g o o d s , s e r v i c e s , manpower o r o t h e r  resources.  Summary C h a p t e r 2 has addressed Marmor's  times  p l a n n i n g may  was d i s c u s s e d .  He h a s s t a t e d t h a t  rational  then f o l l o w .  Donnison has s t a t e d t h a t t h e r e rational planning  it  be a p p r o p r i a t e a t  be a p p r o p r i a t e e a r l y on b u t t h a t o r g a n i z a t i o n a l  and n e g o t i a t i o n may  planning  of p l a n n i n g models.  a r g u m e n t t h a t d i f f e r e n t m o d e l s may  different  process  the question  i s a time  and p l a c e f o r  and t h a t t h e more c o n s i s t e n t  rational  i s w i t h t h e d e c i s i o n m a k e r s ' i d e o l o g y t h e more  likely  i s t o i n f l u e n c e d a y t o day d e c i s i o n s .  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 having  recognized  as  grown o u t o f t h e 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 admission, physicians.  of Confederation.  regulation, discipline  These gave c o n t r o l o f and f e e s c h e d u l e s  The q u e s t i o n o f s t a n d a r d s  t o the  was p a i d o n l y l i p  - 36 service until  t h e 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  introduced.  The  e f f e c t s of the depression  physicians  a fertile  insurance.  Difficult  field  and bad d e b t s made t h e  f o r the establishment  negotiations  led to i t s  of health  establishment  and  many a m b i g u i t i e s  i n t h e a g r e e m e n t a t t h a t t i m e have l e d t o  the  current disputes  and t h e 1980 H a l l  Donnison has s t a t e d t h a t t h e r e political social  planning  justice.  Commission.  a r e two s t a n d - p o i n t s  from which  d e c i s i o n s a r e made: e c o n o m i c g r o w t h and  I n C a n a d a t h e b a l a n c e o f t h e s e two i d e o l o g i e s  i s seen i n t h e development o f the w e l f a r e . s t a t e .  Lowi d e s c r i b e s  three  stages  o f 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 . discussing only  the d i s t r i b u t i v e  stage says t h a t government c a n  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 .  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  Rational planning some o r d e r  h a s b e e n a t t e m p t e d by g o v e r n m e n t s t o b r i n g  t o t h e system.  Because i t i s only  one s t a g e o f  when l i n k s b e t w e e n  rational  i t begins t o f a i l  planning  s t r u c t u r e and t h e s y s t e m b e g i n  context  Service  providers.  planning  The  Judge i n  to deteriorate.  i n w h i c h h e a l t h manpower p l a n n i n g  i s conducted i s  a c o m p l e x one.  Strauss  n e g o t i a t i o n of order. a p p e a l s t o the  would c a l l The  . i t an a r e n a f o r  p r o b l e m a r i s e s when t h e o r d e r  national planner d i f f e r s  professional association.  from t h a t of  outcome o f t h a t n e g o t i a t i o n c o u l d  incorporated  i n t o Canada's n a t i o n a l i d e o l o g y social  justice.  of  then  which  the  I f t h a t were t o o c c u r i t i s  known i f t h e  d e v e l o p m e n t and  the  not  be  resource  Footnotes  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 o f d e c i s i o n s b a s e d upon t h e s i t u a t i o n s w i t h w h i c h , 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, J o h n 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 Policy. New Y o r k , Pergamon P r e s s , 1976, p. 2.  Social  Friedman, J . A Conceptual Model f o r the A n a l y s i s of 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) , S e p t e m b e r , 19 67, p. 346. Quebec: C o m m i s s i o n 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 C o m m i s s i o n o f I n q u i r y on H e a l t h and S o c i a l Welfare. G o v e r n m e n t o f Quebec;' 1 9 7 0 - 1 9 7 1 . (C. C a s t o n g u a y and J . N e p v e u , C h a i r m e n . ) M a n i t o b a . W h i t e P a p e r on W i n n i p e g , 1972.  Health  Services.  Queen's P r i n t e r ,  F o u l k e s , R.G. Health 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 of Health, Province of B r i t i s h Columbia, V o l . I - I I , December 1973.  - 39- -  CHAPTER 3  RATIONAL MANPOWER PLANNING •  Rational planning recent garding as  f o r h e a l t h manpower h a s b e e n a r e l a t i v e l y  phenomenon.  I n t e r e s t i n i t r e s u l t s from concerns r e -  the r e - d i s t r i b u t i o n of resources  i t has r e q u i r e d t h e development o f research  facilitate  the process.  A.  Manpower R e s e a r c h D e v e l o p m e n t s  Health  Four major methodological the  o u t l i n e d i n C h a p t e r 1,  literature:  tools to  c a t e g o r i e s have been i d e n t i f i e d i n  h e a l t h manpower/population r a t i o s ;  health  n e e d s , e c o n o m i c demand; a n d t h e s e r v i c e t a r g e t a p p r o a c h 19 7 3 ) .  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  methods t h e e s s e n t i a l e l e m e n t s w i l l w i t h i n one o f t h e s e f o u r 1.  Health  a r e used f o r  a planning  activity  categories.  Manpower : P o p u l a t i o n  T h i s method, t h e most p o p u l a r ( S o r k i n 19 77)  place  titles  (Hall  Ratios  o f t h e manpower r e s e a r c h  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 t i m e and t h e n t h e application of this r a t i o to the projected 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 h a v e b e e n u s e d t o derive the desired ratios. These i n c l u d e : a) I n t e r n a t i o n a l c o m p a r i s o n s 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  methods  -  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 favoured p o r t i o n of the country e) C o n s t r u c t i o n o f a m o d e l 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 the r e q u i r e m e n t s 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 l o w t o jump t o t h e d e f e n s e o f t h i s Hall  (1978) s u p p o r t e d by  three  Kriesberg  advantages to i t s use:  (1976) h o w e v e r , h a s  e a s y t o use  d a t a r e q u i r e m e n t s u s u a l l y m o d e s t and  not  and  current  i s a defensible policy.  Two  authors  (Segal  1972,  B a k e r 1972)  assumptions  disagree  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 r a t i o l o c k s one not  methods i n t o t h e  d e v e l o p m e n t of. t h e  Other c r i t i c s  allow the  status  quo.  i n c o r p o r a t i o n of the other  i n c l u d e the  five  ratio.  t o t h e method w h i c h h a v e b e e n i d e n t i f i e d  development of r a t i o  status  o f a manpower :  o f t h e m e t h o d a r e much more v o c a l .  t h a t i t does not  and;  with Hall's s i x  i n t o p r o j e c t i n g the  T h e s e a u t h o r s : do  a)  s e n s i t i v e to  s i t u a t i o n i s judged adequate, maintenance of  quo  population  listed  to i n t e r p r e t ;  very  e r r o r s w i t h i n the v a l i d i t y of the u n d e r l y i n g if  method.  Disadvantages  are:  total health sector  ( H a l l 19 78, H a n s e n 19 70,  in  Kriesberg  1976) b)  there 1978)  i s very  little  supply/demand i n t e r a c t i o n ( H a l l  c) i t t e n d s t o be u s e d w i t h s i n g l e o c c u p a t i o n a l with the r i s k of ignoring potential utilization  t h r o u g h changed  categories  improvements  interpersonal ratios  in (Hall  1973, S e g a l 1 9 7 2 , S o r k i n 1 9 7 7 , H a n s e n 1970) d) i t does n o t a c c o u n t f o r d e m o g r a p h i c  changes  ( B a k e r 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, J u d e k  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 1970, S o r k i n 1 9 7 7 , K r i e s b e r g  The  classic  by F e i n its  ( S e g a l 19 72, H a n s e n  1976).  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  (1967).  conducted  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  than  predecessors, o r those studies which followed, i t s t i l l  s u f f e r e d f r o m two m a j o r w e a k n e s s e s  (Segal 1972).  Mis-specific-  ation of relationships included i n the analysis d i d not allow for  c o m p l e t e 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 w e r e o m i t t e d f r o m 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 , t i m e and changes  i n medical technology.  H o w e v e r , many e x a m p l e s works. for  waiting  of this  approach can be found i n C a n a d i a n  Three which deserve mention a r e : Judek's  t h e R o y a l Commission  (19 64)  work  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 C o m m i t t e e o n P h y s i c i a n Manpower  (1975)  C a r e Task F o r c e R e p o r t f o r B r i t i s h C o l u m b i a  and t h e V i s i o n  (19 7 7 ) .  - 42 -  2.  Hall  Health  Needs  Approach.  (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  d e t e r m i n e , b a s e d on e x p e r t available levels  technology,  o p i n i o n and t a k i n g i n t o  account  what k i n d s , amounts, and q u a l i t y  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  healthy  population.  Service targets are then converted  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 standards.  Consideration  o f s e r v i c e c o s t s and  to  of a into  productivity distribution  2 are o f secondary  importance.'  T h i s method i s b a s i c a l l y Approach  an e x t e n s i o n  of the Service  Targets  ( K r i e s b e r g 1 9 7 6 ) . (See S e c t i o n 4 ) .  Advantages t o t h i s approach w h i c h 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  ratio  method.  They a r e t h a t : a) i t i s l o g i c a l , the reference conditions b) i t p r o v i d e s  i n that  p o i n t r a t h e r t h a n s o c i a l and e c o n o m i c  ( K r i e s b e r g 1976, H a l l  i t s importance w i l l ability  Critics  list  1973, S e g a l  u l t i m a t e o r maximum g o a l s  vision of services c)  'what o u g h t t o b e ' i s u s e d as  (Hall  f o r the pro-  1973)  increase with  the health  t o m e a s u r e needs and r e s p o n d t o them  the following  1972)  drawbacks t o t h e method:  sector's ( H a l l 19 7 8 ) .  - 43  a)  i t does not  a l w a y s t h e o n l y way  of e f f e c t i v e l y providing required  i t fails  ( S e g a l 1972,  are not  i t is difficult  prevalent  likely  p o s s i b l e and  e)  data  which are  Baker  1972)  cannot a f f o r d  t o g e t i t ( S e g a l 19 7 2 ) .  disease  and  a n o t h e r becomes more  1972).  assumes t h a t s u c h a g o a l i s realistic  i s set  set  t o measure f u t u r e i n c i d e n c e i f t e c h -  (Segal  i t implicitly  standard  1978,  t o c o n s i d e r t h a t p e r s o n s who  n o l o g y w i p e s o u t one  d)  Hall  standards  economically  are the  treatment c)  n e c e s s a r i l y p r o d u c e t h e most  e f f i c i e n t mixes nor  treatment b)  -  economically  f o r everyone to o b t a i n whatever  ( S e g a l 1972., H a l l  1978) .  r e q u i r e m e n t s are beyond the c a p a b i l i t i e s o f  health statistics  systems  ( H a l l 1978,  Baker  the  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 to ensure t h a t ,  when t h e 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  p r o d u c e t h e n e e d e d s e r v i c e s and  consumers use  indeed  them  ( H a l l 1978) . g)  there  i s the  standards and  inherent d i f f i c u l t y  of developing  f o r t h e management o f many d i s e a s e  optimum  conditions  o f e v a l u a t i n g them i n t e r m s 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 services  a m e a s u r e o f p u b l i c demand f o r p r o f e s s i o n a l  (Baker  1972)  v  K r i e s b e r g . (1976) t a k e 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 c a n f u t u r e unemployment  this  lead  to  - 44. -  The  c l a s s i c study conducted  u s i n g t h i s methodology  (and p r o b a b l y  t h e m a j o r h e a l t h manpower s t u d y t o d a t e ) was c o n d u c t e d by L e e a n d J o n e s .  Four types o f medical s e r v i c e s necessary f o r  'good m e d i c a l c a r e ' w e r e d e f i n e d b a s e d was  i n 19 33  upon e x p e r t o p i n i o n . I t  t h e n 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  g r o u p s w o u l d n e e d t h e s e s e r v i c e s a n d t h e amount o f t i m e e s s a r y t o complete was  an e x a m i n a t i o n o r s e r v i c e .  nec-  The p o p u l a t i o n  t h e n d e f i n e d a n d 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  calculated.  T h r e e m a j o r c r i t i c i s m s h a v e b e e n made o f t h i s  study.  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 of  roles  p r o f e s s i o n a l s , medical technology o r changing i n c i d e n c e  patterns  ( F e i n 1967, S e g a l 1972).  Secondly,  i t does n o t t a k e  i n t o account t h e a b i l i t y o f t h e p u b l i c t o purchase services accounted  ( S e g a l 1972).  Thirdly, utilization  these  of services i s not  f o r ( S e g a l 1972) .  The  L e e - J o n e s s t u d y was u p d a t e d  but  i n c l u d e d o n l y two g r o u p s 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 )  i n 1972 b y S c h o n f e l d e t a l . ,  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 h a v e b e e n made t o o v e r c o m e t h e p r o b l e m s o f t h e h e a l t h , n e e d s m e t h o d a r e f o u n d i n t h e CENDES/PAHO p l a n n i n g method  (19 65)  developed  f o r t h e Pan American  Health  - 45. -  Organization.  H a l l (19 78)  t h i s method as b e i n g  i t s use  i n r e l a t i o n to disease a  favourable  cites  or service categories  considered  cost-benefit r a t i o , while other  categories  or p u b l i c sector  d i f f e r e n t planning  any  l e s s amenable t o  t o have (e.g.  prevention,  i n t e r v e n t i o n a r e accommodated u n d e r  criteria.  I n Canada, the o n l y ed t o u s e  with,  o f t h e h e a l t h , needs approach, o n l y  cancer, p r i v a t e sector services) cure,  the major d i f f i c u l t 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  component o f n e e d h a s  been t h a t of the  C o m m i t t e e on P h y s i c i a n Manpower ( 1 9 7 5 ) . some s e c t i o n s o f t h e  T h i s was  attempt-  National  used o n l y  s t u d y t o e s t a b l i s h a manpower :  in  population  ratio.  3.  E c o n o m i c Demand A p p r o a c h e s  E c o n o m i c demand a p p r o a c h e s as d e f i n e d  by  H a l l (19 73)  concern  t h e m e a s u r e m e n t s 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  a r e w i l l i n g and  t o pay  of the The  able  f o r , i r r e s p e c t i v e of the q u a l i t y  s p e c i f i c services obtained  s e r v i c e s demanded t e n d t o be  provided  o r o f t h e i r n e e d f o r them. c u r a t i v e i n n a t u r e and  to  predominantly through the p r i v a t e s e c t o r , w i t h  or  w i t h o u t the mechanisms.  i n t e r v e n t i o n of t h i r d party The  p r o j e c t i n g the changes l i k e l y to derive  be  reimbursement,  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  s e r v i c e s w i t h , s e l e c t e d e c o n o m i c and  i n order  people  other  v a r i a b l e s , and  to occur regarding  t h e i m p a c t o f t h e s e c h a n g e s on  of  then  these v a r i a b l e s , the  - 4.6 -  demand f o r s e r v i c e s , a n d 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.  Variables  include:  a),  constant  utilization  rates f o r a changing  b)  population  c)  trend i n expenditures,  d) .  job vacancies  e).  relative  f)  rate of return.  and income  earnings.  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 simple  population,  range from  very  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 , s u c h as j o b v a c a n c i e s ,  to complex economic models o f t h e h e a l t h c a r e  s y s t e m as a w h o l e .  A d v a n t a g e s w h i c h h a v e b e e n 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 thelps  describe  dynamics and d e t e r m i n a n t s  of health services  utilization  b) i t t e n d s t o p r o d u c e e c o n o m i c a l l y  realistic  pro-  jections c.) i t a l l o w s of  f o r disaggregation  of various  components  demand  d) i t p r o b a b l y  provides  a good e s t i m a t e  o f t h e minimum  g r o w t h i n demand a n d e n s u r e s t h a t t h e 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 equals  satisfaction  e)  some v a r i a n t s o f t h i s a p p r o a c h a r e q u i t e  f)  i t may p r o v i d e returns  useful information  simple  f o r comparing  from t r a i n i n g f o r h e a l t h occupations  those o f other  sectors.  with  -  Additional  4.7 -  advantages c i t e d by Y e t t  include:  a)  i t i s better f o rstudying d i s t r i b u t i o n  impacts  b)  i t can r e a d i l y  that  exploit  economic t h e o r y  concentrates, on i n d i v i d u a l Kriesberg its  (19 75)  behaviour  units.  ( 1 9 7 6 ) s t a t e s t h e advantage t o t h i s method l i e s i n  ability  t o estimate requirements which r e l a t e  to job  opportunities.  C r i t i c s o f e c o n o m i c demand m e t h o d s , a s w i t h o t h e r m e t h o d s , h a v e many p o i n t s t o p u t f o r t h a)  i t may b e c o m p l i c a t e d , c o s t l y data  b)  c o n c e r n i n g t h i s method: and r e q u i r e  sophisticated  ( H a l l 1 9 7 3 , Y e t t 1975)  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 reasons f o r  improving the d i s t r i b u t i o n o f health services  (Hall  1973) c)  d)  i t does n o t n e c e s s a r i l y  account the q u a l i t y  of  services or their relevance to the health  of  the country  problems  ( H a l l 1973)  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 i m p r o v e manpower p r o d u c t i v i t y  e)  take into  ( H a l l 19 73)  i t i s hard t o i n t e r p r e t and  to the public  f) d a t a e x i s t s (Yett  19 7 5)  to health sector  authorities  ( H a l l 1973)  a t macro l e v e l b u t i s f a r f r o m p e r f e c t  - 48 -  g) t h e c o n v e n t i o n a l e c o n o m i c m o d e l i s d a n g e r o u s l y simplified,  over-  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  process.  A p o p u l a r e c o n o m i c demand m e t h o d i n C a n a d a , c u r r e n t l y , i s t h e job 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 7 2 ) .  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 S y s t e m (1979) h a s f o l l o w e d S a s k a t c h e w a n a n d A l b e r t a ' s e a r l i e r lead i n this  endeavour.  A t a n a t i o n a l l e v e l some a t t e m p t s i n t h e p a s t w i t h t h e j o b vacancy  o f t h i s k i n d h a v e b e e n made survey.  Some a t t e m p t s  b e e n 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 major study r e c e n t l y completed Association requirements  (HMRU 19 80)  have  ( I m a i 19 74) .  f o r the Canadian  A  Dietetic  u s e d t h i s method t o i n v e s t i g a t e t h e  f o r d i e t e t i c manpower i n B r i t i s h  Columbia.  It  was b e l i e v e d h o w e v e r , t h a t r e s u l t s d i d n o t t r u l y r e p r e s e n t t h e existing  Segal  market.  (19 7 2) l i s t s a)  t h e a d v a n t a g e s o f t h i s method a s :  i n f o r m a t i o n c a n 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 a n d 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 n o t t o o f a r o f f , a n d 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 c o m m u n i t y w e l l e n o u g h t o p r e d i c t t h e g r o w t h o f demand a n d o t h e r f a c t s , s u c h  a.scheme m i g h t  be  fairly  reliable.  W e a k n e s s e s a s s t a t e d by S e g a l a) v a c a n c y  include:  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 n e e d s u n l e s s t h e y t a k e i n t o a c c o u n t o f one a r e a ' s g r o w t h another  the e f f e c t  o n t h e demand f o r s e r v i c e s i n  area  b) i t w i l l n o t h a v e g o o d r e s u l t s u n l e s s demands f o r a n d supply o f personnel are f a i r l y  4.  Service  stable.  T a r g e t Methods  These methods emphasize t h e development o f d e t a i l e d for  the provision of d i f f e r e n t kinds of services,  which  a r e then used  these services. are then used required  to derive  targets  f o r the production of  to convert service targets  standards  i n t o t h e manpower  V a r i o u s methods c a n be u s e d  the 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 those used and  standards  Manpower s t a f f i n g a n d p r o d u c t i v i t y  t o a t t a i n them.  standards  to develop  i n the health  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  Other  techniques f o r developing standards a) T a s k a n d f u n c t i o n a l b) E m p i r i c a l  include:  analysis  experience  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)  International  comparisons.  needs  methods.  - 50  The  -  a d v a n t a g e s o f t h i s method are  a),  i t allows  that  easy d i s a g g r e g a t i o n  (Hall  1973):  of health services  in turn f a c i l i t a t e  t h e m a t c h i n g o f e a c h component  of the h e a l t h care  system.  b)  cost estimation  is relatively  c)  i t is relatively  which part  easy  easy to i n t e r p r e t the  r a t i o n a l e to  others. Disadvantages, according  to H a l l ,  include lack of  allowance  for: a) b u d g e t e d v a c a n c i e s  that o f f e r non-competitive s a l a r i e s  b)  budgeted posts  c)  i n a b i l i t y of a d m i n i s t r a t i o n to p r e d i c t needs  d)  t h e . f a c t t h a t t h e method i s p r o n e t o h a v i n g b a s e d more on  which are d e l i b e r a t e l y kept  d e s i r e s t h a n on  reality,  vacant  standards  leading  to  major p o l i c y e r r o r s , e)  the  f a c t that the  l o g i c o f t h e methods i n v i t e s  sively detailed planning subject  The  Nursing  sector  not  to t i g h t control.  E d u c a t i o n Study Report  B r i t i s h C o l u m b i a i s one  B.  f o r segments o f t h e  exces-  (1979) f o r t h e P r o v i n c e  example o f t h i s  of  approach.  Limitations  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 rational planning. from other  They i n c l u d e b e i n g  conducted i n  developments i n the h e a l t h care  field,  area  for  isolation  dubious  - 51 -  usefulness  1.  I s o l a t i o n from the Health  Health the  o f p r o j e c t i o n s and l a c k o f adequate  Care  System  manpower s t u d i e s a r e o f t e n c o n d u c t e d i n i s o l a t i o n  remainder o f the health care  with  methodology.  a l l the key i s s u e s  involved  from  s y s t e m a n d a s s u c h do n o t d e a l (Badgley 1971, M e j i a  1979).  B a d g l e y l a b e l s h e a l t h , manpower s t u d i e s w h i c h h a v e b e e n u n d e r t a k e n as l i t t l e more t h a n m e t h o d o l o g i c a l  exercises, playing 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 of t h e s o c i a l issues with which they d e a l .  H a l l (1973)  t h i s a s a m a j o r 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  cites  methods  used.  Three r e a s o n s have been g i v e n health care (Hall  19 7 8 ) ;  p o l i c y and f r a g m e n t a t i o n f a i l u r e t o acknowledge  p r i o r i t i e s have changed (Ginzberg market  Hall  f o r i t s occurrence:; a lack of  19 7 8 ) ;  (Hansen  that health  system  manpower  r e t a i n i n g t h e b e l i e f t h a t more i s b e t t e r .  a n d p r i m i t i v e methods t o m o d e l t h e h e a l t h  care  1970, H a l l 1973).  (.19 78) c o n t e n d s t h a t c o m p o n e n t s o f t h e h e a l t h , s y s t e m  function largely i n isolation  from each o t h e r .  a fragmented approach t h a t leads a c t i v i t i e s which overlap other  within the health  to policies,  The r e s u l t i s p l a n s , and  wastefully or conflict with  a n d , i n many i n s t a n c e s ,  each  t a c k l e t h e wrong problems.  This  - 52 -  is  r e f l e c t e d i n manpower r e s e a r c h , a n d p l a n n i n g  Ginzberg  (19 78)  speaks o f t h e sacred  f i e l d o f h e a l t h manpower. seated  cows w h i c h p e r v a d e t h e  The f i r s t o f t h e s e i s t h e d e e p -  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  improved care belief  attempts.  result i n  and, c o n s e q u e n t l y , i n improved h e a l t h .  i s not compatible with  r e d i s t r i b u t i o n theory,  compatible with current evaluation  studies.  This nor i s i t  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 a n d a l t e r n a t i v e s s u c h as substitution  Butter  ( B u t t e r 1967) a n d r e d i s t r i b u t i o n m u s t be  (1967) i l l u s t r a t e s  attempt to estimate She  this  i n her c r i t i q u e of Fein's  making use o f an a n a l y t i c a l  to develop estimates  cites  t o previous  of future  methods, i t f a i l s  requirements.  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 h e s p e a k s  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 This  i s combined w i t h  a model t o d e a l w i t h  the i n a b i l i t y o f researchers the e n t i r e health  manpower m a r k e t i n p a r t i c u l a r . not  allow  h a v e b e e n made i n t h e U n i t e d  in  nature,  Hansen  N a v a r r o 19 6 9 ) .  States  research. to devise  system and t h e h e a l t h (19 70)  states this  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 .  ( Y e t t 19 75,  ones  framework f o r t h e s t u d y o f h e a l t h  manpower a n d 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  (19 73)  (1967)  the future requirements f o r physicians.  argues t h a t although h i s study i s s u p e r i o r  Hall  considered.  does  Some a t t e m p t s  t o d e v e l o p such a model  These models have been e c o n o m e t r i c  e x a m i n i n g t h e p r o b l e m a t a macro l e v e l .  Lipscome  - 53 -  et  a l . . (1976) h a v e 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  to the problem a t a micro l e v e l with Reservation  of Arizona.  almost non-existent  with, the p o s s i b l e e x c e p t i o n (.1977) .  Butter  of the V i s i o n  (1967) d e s c r i b e s  i s because i t i s derived  which e n t a i l s  to estimate  and measure.  f r o m t h e demand f o r h e a l t h  a v a r i e t y o f heterogeneous s e r v i c e s  2.  care,  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 non-labour  the  f u r t h e r when s h e p o i n t s o u t t h a t t h e 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 This  Indian  Canadian attempts i n t h i s area are  C a r e T a s k F o r c e i n B.C. difficulty  t h e Papago  approach,  with  inputs.  Questions r e :  Usefulness of Health  Manpower P r o j e c t i o n s  H a n s e n ( 1 9 7 0 ) , 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 , raises questions  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 which flow  f r o m them.  abundance o r a s h o r t f a l l  He c o n c l u d e s  that  o f p h y s i c i a n s , who r e q u i r e many  years lead time f o r t r a i n i n g ,  Hiestand  projections  w h i c h p r e d i c t e d e i t h e r an o v e r -  t o o c c u r i n 19 75.  the possible exception  a somewhat u s e l e s s  recommendations  His examination of physician  t o t h a t d a t e showed e s t i m a t e s  with  of policy  attempts a t p r o j e c t i o n s are  effort.  (1976) i n d i c a t e s f u r t h e r p r o b l e m s i n h e r e n t  i n the  process through the r e l a t i v e l y short period o f time.in  which  - 54 -  demand f o r manpower may s h i f t . British  T h i s p r o b l e m became e v i d e n t i n  C o l u m b i a i n 19 78 when L o n g Term C a r e P r o g r a m 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 grew p h e n o m e n a l l y o v e r n i g h t .  In this  o f workers  instance projections  could  n o t h a v e p r e d i c t e d e v e n 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.  Sorkin  (19 77)  points out that inadequate f i n a n c i a l  resources  l i m i t t h e number o f manpower g r o u p s w h i c h c a n be s t u d i e d a n d 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 made.  p r o j e c t i o n s c a n be  The m a j o r i t y o f n a t i o n a l a n d p r o v i n c i a l s t u d y  efforts  have been devoted 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  nurses.  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 u t h o f manpower r e s e a r c h  general  has r e s u l t e d i n a  l a c k o f s o p h i s t i c a t i o n i n the 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 : absence o f a s o l i d Hiestand  1976, M e i j a  methodological corporate by B a d g l e y  Butter  a n a l y t i c a l base 19 7 9 ) ;  attempts  The  ( B u t t e r 1967, H a l l 1973,  the supply  o r i e n t a t i o n o f most  ( H a l l 19 7 3 ) ; a n d t h e f a i l u r e t o i n -  a l l necessary elements i n t o design  (discussed  earlier  1971).  (196 7) h a s i d e n t i f i e d t h e a b s e n c e o f a s o l i d  analytical  - 55. -  b a s e as a m a j o r w e a k n e s s i n a t t e m p t s Hall  (.1973) h a s  to project  requirements.  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  of projections 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 m e t h o d - t h e p o p u l a t i o n r a t i o method-is  Hall  most o f t e n based  (19 73)  upon i n a d e q u a t e  data.  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 m e t h o d s , 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 t o o much e m p h a s i s on t h e s u p p l y s i d e o f  the  equation.  He  attributes this  to the e x i s t e n c e of the  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 . illustrates  Anderson  avail-  (1976)  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  h e a l t h manpower d a t a b a s e i n B r i t i s h C o l u m b i a . r e v i s e d by M a n n i n g more e x a g g e r a t e d  the  T h i s document,  ( 1 9 7 9 ) , shows t h a t t h e s i t u a t i o n has  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  become  additional  s u p p l y d a t a w i t h o u t a n i n c r e a s e i n demand o r n e e d i n f o r m a t i o n . Reports  produced, n a t i o n a l l y  ( A z i z 19 74)  supply information with l i t t l e Few  show a p r e d o m i n a n c e o f  a t t e n t i o n t o demand a s p e c t s .  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 in-house  exist.  However, t h o s e w h i c h  s h o u l d be a c k n o w l e d g e d  At the p r o v i n c i a l d e s c r i p t i o n s and  do t a k e r e q u i r e m e n t s  ( A z i z 1973,  level, accounts  I m a i 1974,  o f manpower s u p p l y .  into  Ahamad  o n g o i n g manpower e f f o r t s  level account  1969).  focus  These a r e  u s u a l l y encapsulated i n annual or biannual p u b l i c a t i o n s .  upon  - 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) .  Studies which address requirements u s u a l l y involve the establishment  o f a s p e c i a l committee charged w i t h  of c o l l e c t i n g  v a s t amounts o f demand d a t a  question. Royal  At a n a t i o n a l l e v e l  C o m m i s s i o n on H e a l t h  Medical  P r o v i n c i a l l y , the  (1977) and t h e A d v i s o r y  Manpower ( 1 9 7 9 ) had t h i s m a n d a t e .  each f u l f i l l e d  examples are t h e  (1964) and t h e N a t i o n a l  C o m m i t t e e on P h y s i c i a n Manpower ( 1 9 7 5 ) . V i s i o n Care Task F o r c e  t o address the  two c l a s s i c  Services  t h e mandate  C o m m i t t e e on  The d e g r e e t o w h i c h  i t varies.  Summary Chapter three  reviewed  the f o u r major r a t i o n a l  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  planning their  limitations.  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  method c a n be u s e d was e x a m i n e d a l o n g  ratio  with the l a c k of  s o p h i s t i c a t i o n o f t h e method.  The  h e a l t h n e e d s method was p r a i s e d f o r i t s l o g i c  ability  to provide  and i t s  maximum g o a l s ; h o w e v e r , t h e f a c t t h a t i t  i g n o r e d e c o n o m i c 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 did  n o t add t o i t s p o p u l a r i t y .  data  E c o n o m i c demand a p p r o a c h e s 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 a n d were c o n s i d e r e d too r e q u i r e d extensive  Service simple  t o be u s e f u l , h o w e v e r , t h e y  data.  target approaches,although l o g i c a l to use,rely  h e a v i l y upon d e s i r e s  T h r e e m a j o r p r o b l e m s were a s s o c i a t e d planning  i n h e a l t h manpower.  The  usefulness  care  general  with  than  fact.  a l l rational  in isolation  from the  system i n g e n e r a l .  of projections  view of l a g time i n education  The  rather  M o s t s t u d i e s were c o n d u c t e d on  h e a l t h manpower a l o n e and g e n e r a l l y dynamics o f the h e a l t h  and r e l a t i v e l y  i n general  was q u e s t i o n e d i n  and s y s t e m  changes.  l a c k o f s o p h i s t i c a t e d methodology does n o t s e r v e  t o e n h a n c e t h e a p p e a l o f any o f t h e methods u s e d .  Two t h i n g s  become i m m e d i a t e l y a p p a r e n t when r e v i e w i n g  h e a l t h manpower m e t h o d o l o g y . unique., E a c h i n c o r p o r a t e s in other  Firstly,  no method i s i n i t s e l f  some v a r i a b l e s and t e c h n i q u e s  methods.  S e c o n d l y , no one method i s p e r f e c t . r e l a t i v e l y new a n d r e q u i r e  existing  A l l methods a r e  development.  found  - 58 It  -  i s h o w e v e r , many o f t h e d i f f i c u l t i e s  t o problems  i n accurately  O t h e r s s u c h as p o l i t i c a l  noted above w h i c h  lead  p r o j e c t i n g future requirements. i n f l u e n c e s w i l l be d i s c u s s e d  later.  - 59 -  Footnotes  1.  H a l l , T. E s t i m a t i n g R e q u i r e m e n t s a n d S u p p l y : Where do we s t a n d ? PAHO C o n f e r e n c e o n H e a l t h Manpower P l a n n i n g , S e p t e m b e r 19 73, O t t a w a .  2.  ibid.  - 60 -  CHAPTER 4  HEALTH MANPOWER PLANNING STRUCTURES I N CANADA  The  priority  f o r h e a l t h manpower p l a n n i n g  ably over the past f i f t y years. planning  activities  has changed  The r a p i d e v o l u t i o n o f manpower  i n the early seventies  brought about a  p r o l i f e r a t i o n o f c o m m i t t e e s and s t r u c t u r e s as w e l l a s able  fragmentation.  Some a r e f o r m a l l y e s t a b l i s h e d  others  hoc  ventures.  This  section w i l l  consider-  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. committees w h i l e  consider-  c a n be c o n s i d e r e d  focus on t h e formal  nothing  committee  on-going more t h a n ad  structures  e s t a b l i s h e d i n government o v e r t h e p a s t t e n y e a r s .  It will  begin with  ventures  a b r i e f overview of s i g n i f i c a n t planning  p r i o r t o 1970. and  Itwill  then review formal  structures  provincial structures with particular attention to B r i t i s h  Columbia.  Although t h e major concern of t h i s  bureaucratic  chapter w i l l  be  s t r u c t u r e s , the 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.  national  a l s o be a d d r e s s e d .  A c t i v i t i e s P r i o r t o 1970  Planning  i n t h e h e a l t h manpower f i e l d  1970's r e s t e d p r i m a r i l y w i t h  p r i o r t o t h e 1960's a n d  the professions.  Government  lacked  - 61 -  interest i n this activity, responsibility  p r i m a r i l y b e c a u s e i t had  f o r funding.  a great extent  still  Planning  a c t i v i t i e s were, and t o  are, .scattered, resting with professional  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 , institutions,  little  l i c e n s i n g bodies  educational  and a v a r i e t y o f o t h e r  agencies.  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 of physician  The  first  shortages.  s i g n i f i c a n t attempt a t planning i n t h i s  found i n Saskatchewan w i t h d o c t o r s s y s t e m i n 1914. 1  a c t i o n was t a k e n pose o f paying the  questions  i s t o be  the i n i t i a t i o n o f the municipal  Faced w i t h a d i r e shortage  of physicians,  t o allow m u n i c i p a l i t i e s t o levy f o r the pur-  the s a l a r y of a doctor,  f r e e market.  area  Although  as a p l a n n i n g / r e c r u i t m e n t  thus i n t e r f e r i n g  t h e p l a n h a d a number o f m e t h o d , i t was  reported  with  shortcomings,  t o be  r e l a t i v e l y successful."^  I t was n o t u n t i l t h e R o y a l  Commission on H e a l t h  Services i n  19 64 t h a t g o v e r n m e n t b e g a n t o a d d r e s s t h e i s s u e o f t h e i m m i g r a n t p h y s i c i a n and o f t h e n e e d f o r C a n a d i a n schools  to begin  medical  t o meet t h e demands o f t h e c o u n t r y :  The C o m m i s s i o n ' s c h i e f c o n c e r n w i t h m e d i c a l education i s the capacity o f the medical schools 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 e x p a n d i n g demands r e s u l t i n g f r o m 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 p e r s o n s who w i l l h a v e t h e i r h e a l t h s e r v i c e s prepaid through extension o f p r e p a y m e n t 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 m e e t C a n a d a ' 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 to t r a i n p r o f e s s i o n a l h e a l t h for the developing n a t i o n s .  Based upon J u d e k 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 1  recommendations c o n c e r n i n g insurance money be  the e s t a b l i s h m e n t  personnel  and  of a health  scheme, t h e C o m m i s s i o n recommended l a r g e amounts devoted to the t r a i n i n g of p h y s i c i a n s .  a c c o m p l i s h e d by  the p r o v i s i o n of d i r e c t grants  e x i s t i n g schools  and  e s t a b l i s h new  the shortcomings of t h i s course c o r r e c t e d the  to  facilities.  has  increased  Time h a s  o f a c t i o n , s i n c e i t has  The  T a s k F o r c e on  address shortages  the c o s t of medical  care.  the Costs  i n 19 69  of Health  to  be  expand  current physician surplus/distribution  and  shown not  problems  attempted  to  w h i l e r e c o m m e n d i n g 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. of educational  T h i s was  of  facilities  W h i l e recommending e x p a n s i o n  t o d e c r e a s e dependency upon i m m i g r a n t  p h y s i c i a n s , t h e T a s k F o r c e a l s o recommended t h e d e v e l o p m e n t o f auxiliary by  physicians.  planning,  The  personnel  i t has  to undertake tasks then being  Although  y e t t o see  fruition in practice.  r e p o r t was  the  establish-  1 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, h e l d  i n O t t a w a i n O c t o b e r ; 1969.. foundation  out  a s i g n i f i c a n t advance i n r a t i o n a l  most s i g n i f i c a n t outcome o f t h i s  ment o f t h e  carried  This conference  laid  the _  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.  Federal  Coordination  Efforts  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' s p o n s o r e d b y t h e  Department o f N a t i o n a l H e a l t h o f U n i v e r s i t i e s and C o l l e g e s  (1969-80)  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 Canada.  Objectives of the  3  Conference 1.  w e r e t o s e c u r e a g r e e m e n t on g u i d e l i n e s  Planning the  2.  for:  the delivery of t o t a l health services  next decade.  D e t e r m i n i n g t h e numbers a n d q u a l i t y o f h e a l t h  3.  during  required  f o r these s e r v i c e s .  Planning  the education  of the required  manpower  manpower.  Among t h e o u t c o m e s o f t h e C o n f e r e n c e was a r e c o m m e n d a t i o n  that  planning  that  g r o u p s be e s t a b l i s h e d i n a l l h e a l t h d e p a r t m e n t s ,  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 that l a r g e r provinces  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 health  services.  A s e c o n d n a t i o n a l c o n f e r e n c e h e l d i n O c t o b e r 19 71, h a d a s 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 p r o g r a m s for the purpose o f promoting f l e x i b i l i t y , adapta b i l i t y and c o o r d i n a t i o n . The  results of this  c o n f e r e n c e w e r e more s i g n i f i c a n t  those o f i t s predecessor. Health  than  By May o f 1972 t h e F e d e r a l / P r o v i n c i a l  Manpower C o m m i t t e e h a d b e e n c r e a t e d w i t h  sub-committee t o examine H e a l t h  a technical  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 1972  a d o p t e d by  t h e C o m m i t t e e i n November o f  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 h o u s e  manpower 2.  3.  To  information.  develop:  a)  a l i s t of e s s e n t i a l health occupations w i t h s c o p e s o f p r a c t i c e and a n a t i o n a l of nomenclature of t i t l e s ,  b)  a n a t i o n a l inventory of h e a l t h s e r v i c e s personnel by q u a l i f i c a t i o n , p l a c e o f w o r k , and f i e l d o f employment,  c)  a national inventory i n s t i t u t i o n s f o r the  d)  n a t i o n a l standards f o r the a c c r e d i t a t i o n of t r a i n i n g programmes f o r t h e r e c o g n i t i o n o f qualifications.  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  other  To  determining  that  migration  i d e n t i f y n a t i o n a l manpower i m b a l a n c e s as  to develop general national basis  t o numbers,  u s e f u l on  f o r the development, d i s t r i b u t i o n  a  and  manpower.  To m o n i t o r n a t i o n a l and be  and  t y p e s o f p r a c t i t i o n e r s , and  g u i d e l i n e s t h a t w o u l d be  u t i l i z a t i o n of health  m a t t e r s as may  reflect  factors.  g e o g r a p h i c d i s t r i b u t i o n and  5.  together standard  of approved t r a i n i n g essential health occupations,  health services requirements, production,  4.  of  r e g i o n a l trends  e v i d e n c e d by  various  a r r a n g e m e n t s , t h e e x p a n s i o n and r o l e s of h e a l t h workers, the  i n health health  a l t e r a t i o n s of  emergence o f new  f o r workers, the changing h e a l t h  services the categories  needs o f g e n e r a l  or  - 65 -  particular population  g r o u p i n g s and t h e 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 g o v e r n m e n t s as t h e y m i g h t 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 a n d 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 cooperation activities  considered  regardshealth  and t o p a r t i c i p a t e i n such t o be m u t u a l l y  manpower p r o d u c t i o n  The t e r m s o f r e f e r e n c e w e r e n o t a m b i t i o u s , Committee b a s i c a l l y  advantageous as  and u t i l i z a t i o n .  describing the  as a n i n f o r m a t i o n e x c h a n g e m e c h a n i s m  t h a n one w h 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  I n May o f 19 73,  other  rather  role.  t h e Committee developed and r e l e a s e d  a  'Health  Manpower D e v e l o p m e n t P r o g r a m f o r C a n a d a ' d e s c r i b i n g t h e C o m m i t t e e ' s o b j e c t i v e s , g o a l s a n d methods 1973/1974  ( A p p e n d i x G) ..  1 9 7 4 / 1 9 7 5 , and 1 9 7 5 / 1 9 7 6 .  still done. its  year  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 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 C o m m i t t e e a t t e m p t e d an a m b i t i o u s year of operation.  f o r the f i s c a l  Many o f t h e t a s k s  work p l a n listed  fori t s first  f o r that year are  o n t h e 19 80/19 81 w o r k s c h e d u l e a n d h a v e y e t t o b e The C o m m i t t e e h a s u n d e r g o n e v e r y  eight year,  nineteen  a b l e changes', d i d o c c u r . Committee r e g a r d i n g  meetings'lifetime.  few c h a n g e s  during  H o w e v e r some n o t e -  I n 19 76 d i s c u s s i o n s b e g a n w i t h i n t h e  its inability  to effect policy.  t h r e e y e a r s were then spent r e v i e w i n g t h e C o m m i t t e e . New t e r m s f i n a l l y  Two o r  t h e terms o f r e f e r e n c e f o r  received approval  by b o t h t h e  - 6,6 -  Committee i t s e l f Ministers  and i t s p a r e n t b o d y , t h e C o u n c i l o f D e p u t y  i n 1979.  The o u t c o m e 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 igation. A s e c o n d c h a n g e b r o u g h t a b o u t i n J u n e 19 79 was t o t r a n s f e r t h e chairmanship  o f t h e 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 t h e p r o v i n c e s . t o b e o n a one y e a r  rotating basis.  This Chairmanship  I t resulted  was  from a b e l i e f  b y t h e C o m m i t t e e t h a t t h e r e was a l a c k o f commitment b y t h e f e d e r a l g o v e r n m e n t t o h e a l t h manpower p l a n n i n g a n d t h a t t h e n e e d s o f t h e p r o v i n c e s and t h e C o m m i t t e e a s a w h o l e , m i g h t b e 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. b e e n b u t one p r o v i n c i a l c h a i r m a n .  C.  t h e r e has  I n 19 80 t h e t i m e came f o r  t r a n s f e r o f the p o s i t i o n t o another reluctance t o accept  To d a t e  province, but there i s a  the r e s p o n s i b i l i t y .  C o l l a b o r a t i o n b e t w e e n 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 ,  the j u r i s d i c t i o n a l  o v e r l a p s b e t w e e n h e a l t h manpower a n d e d u c a t i o n became 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 representatives  apparent. education  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 t h e C o u n c i l o f M i n i s t e r s o f Education western  attended  t h e m e e t i n g s a s an o b s e r v e r .  p r o v i n c e s were t h e f i r s t  f o l l o w e d soon a f t e r by O n t a r i o .  The f o u r  t o send d u a l r e p r e s e n t a t i o n , 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  pro-  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 w h i c h r e c e n t l y d i d so  ( J u n e 19 8 0 ) .  I n A p r i l 1974  the Western Post-Secondary C o o r d i n a t i n g  requested  formation  the  committee.  The  o f a H e a l t h Manpower R e q u i r e m e n t s Sub-  Western Post-Secondary Coordinating  comprised of senior o f f i c i a l s ministries with  i n the  from post-secondary  four western provinces.  I t has  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  Committee i s education  been charged  coordinating  secondary t r a i n i n g requirements i n the western  d e s i r e t o e x a m i n e , and  coordinate health personnel  programs i n the west.  The  f o r h e a l t h and  one  r e p r e s e n t i n g the department  a t i v e s on  The  i n each p r o v i n c e .  of the one  closely  federal/provincial  u s u a l l y s a t on t h e  the  training two  responsible  the other r e p r e s e n t i n g the department  s u b - c o m m i t t e e ' s a c t i v i t i e s so  activities  from  sub-committee i s comprised o f  for post-secondary education this  post  provinces.  F o r m a t i o n o f t h e H e a l t h Manpower S u b - c o m m i t t e e a r o s e  senior o f f i c i a l s ,  Committee  The  responsible focus  approximated  committee, t h a t  of  the  represent-  other.  g e n e r a l mandate f o r the sub-committee i s t o promote c l o s e  l i a i s o n and  c o m m u n i c a t i o n i n t h e h e a l t h manpower f i e l d on  W e s t e r n Canada b a s i s . functions  are:.  S p e c i f i c a l l y , the  sub-committee's  a  -  This  6.8  -  a)  to determine the personnel;.  t r a i n i n g needs f o r h e a l t h  b)  to develop i n t e g r a t e d planning f o r the d e l i v e r y of 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 r e c o m m e n d a t i o n s t o t h e W e s t e r n C a n a d a Secondary C o o r d i n a t i n g Committee.  Committee p o s s e s s e s a f a r s t r o n g e r  care  Post-  mandate t h a n d i d  f e d e r a l c o m m i t t e e as w e l l as some c o n s e n s u s b e t w e e n t h e vinces the  c o n c e r n i n g t h e p r o b l e m s a t h a n d and  pro-  the o b j e c t i v e s  of  process.  I n W e s t e r n Canada t h i s  sub-committee has  f o c u s f o r manpower p l a n n i n g  D.  the  Health  Manpower P l a n n i n g  In February of  19 72  and  Structures  Columbia  the Honorable  the r e g u l a t i o n s of  to address requirements f o r  i n c e n t i v e programs.  to f u l f i l l  and  crisis  i t s e n t i r e mandate.  It-'s  physicians,  surpluses,  distribut-  The u r g e n c y o f  s h o r t a g e problem d i c t a t e d t h a t the Committee devote i t s to shortage questions  Mr.  the  Manpower C o m m i t t e e .  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 to shortages, i o n a l p r o b l e m s , and  in British  the M i n i s t e r o f H e a l t h ,  established a Medical  o v e r a l l m a n d a t e was  central  coordination.  Ralph Loffmark, i n accordance w i t h Hospital Act,  emerged as t h e  the energies  s i t u a t i o n s rather than attempt  - 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  year brought w i t h i tthe necessity o f developing  that  a provincial  h e a l t h manpower c o m m i t t e e 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 D e v e l o p m e n t P r o g r a m : 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 t o 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 b y t h e e n d 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 d e v e l o p m e n t programs ( P r o v i n c i a l Program).  Priority  f o r the establishment  o f p r o v i n c i a l manpower c o m m i t t e e s  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 . 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 ,  were q u i c k l y e s t a b l i s h e d . accorded  committees  I n other p r o v i n c e s , the low  meant t h a t f o r m a l s t r u c t u r e s w e r e s l o w  Some p r o v i n c e s very  avail-  priority  h e a l t h manpower p l a n n i n g a n d u n a v a i l a b i l i t y o f  resources  and  Where r e s o u r c e s w e r e  still  i n emerging.  do n o t h a v e manpower p l a n n i n g  committees  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 c o m p o n e n t s .  Appendix  D d e s c r i b e s t h e n a t i o n a l a n d p r o v i n c i a l c o m m i t t e e s t r u c t u r e s as t h e y w e r e i n 19 78.  British  C o l u m b i a 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  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 c o m m i t t e e , t h e H e a l t h Manpower W o r k i n g Group i n 19 72.  to a  establishing  -  The  70  "  c r e a t i o n o f t h i s Committee began the demise o f the  pro-  v i n c i a l M e d i c a l Manpower C o m m i t t e e e s t a b l i s h e d i n 1972 Minister of Health. disbanded  and  By  l a t e 1973  .thatcommittee  i t s f u n c t i o n s assumed by  had  by  the  been  t h e H e a l t h Manpower  W o r k i n g Group.  In  i t s e a r l y d a y s t h e W o r k i n g G r o u p was  t h r e e D e p u t y M i n i s t e r s o f H e a l t h -H e a l t h and  Mental  C o m m i s s i o n and  Health -the  comprised  of  the  H o s p i t a l Insurance,  Chairman o f the M e d i c a l  a r e p r e s e n t a t i v e from the M i n i s t r y of  Public  Services Education.  T h i s m e m b e r s h i p has b e e n a l t e r e d numerous t i m e s o v e r t h e year h i s t o r y o f the Committee. o f H e a l t h has  v a r i e d due  Ministry,  the p r i o r i t y  and  planning at various  In  Representation  from the  i t has  p l a c e d upon h e a l t h manpower  times.  r e s e n t a t i o n t o the W o r k i n g Group.  requested T h i s was  to provide  matters.  that  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  At the request of the C o l l e g e of P h y s i c i a n s  S u r g e o n s , an o b s e r v e r was Group m e e t i n g s . e d i n 1978.  rep-  to f a c i l i t a t e  c o m m u n i c a t i o n w i t h t h e Manpower Needs C o m m i t t e e o f and  Ministry  to 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 the  19 74 t h e M i n i s t r y o f L a b o u r was  Ministry  eight  labour and  sent from the C o l l e g e to Working  This practice, i n i t i a t e d  i n 1975, was d i s c o n t i n u -  .  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 W o r k i n g G r o u p  accepted  i n 19 73, w e r e as 1. To  follows:  advise  Departments*-and M i n i s t e r s on m a t t e r s  t o h e a l t h manpower p r o d u c t i o n , patterns  attrition,  relating  migration,  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-  graphic l o c a t i o n ; 2. To  recommend on  contracts  the conduct o f research  and  to  arrange  f o r n e c e s s a r y d e v e l o p m e n t s t u d i e s done  out-  s i d e the 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 o n m a t t e r s p e r t a i n i n g t o  the F e d e r a l / P r o v i n c i a l Health 4. To  r e c e i v e r e p o r t s and  arising  from expert  advise  Manpower C o m m i t t e e ; on  appropriate  c o m m i t t e e s and  action  professional  committees e s t a b l i s h e d independently  to deal with  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 W o r k i n g G r o u p as o u t l i n e d i n i t s t e r m s  r e f e r e n c e was  weak.  Any  ability  i t would have to f u n c t i o n  an e f f e c t i v e p o l i c y / p l a n n i n g c o m m i t t e e was i t s mandate b u t  of  t o be  found not  as in  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 during  the  l a t e 1970's l e f t o n l y one  ministry, with the  first  a number o f a s s i s t a n t d e p u t i e s .  i n a s e r i e s of events which r a d i c a l l y  membership o f the Committee. teeth  deputy m i n i s t e r i n each  By  1978  T h i s change altered  the Committee  b o t h i n t e r m s o f i t s m e m b e r s h i p and  was  the  lacked  i t s mandate.  At  that  - 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 the 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 n e w l y e d 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 structure.  The  1.  follows:  Reference 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  i n g t h e g r o w t h , d e v e l o p m e n t and power i n t h e 2.  i t s organizational  r e v i s e d t e r m s o f r e f e r e n c e o f t h e H e a l t h Man-  power W o r k i n g G r o u p a r e a s Terms o f  develop-  To  regard-  c o n t r o l o f h e a l t h man-  Province.  establish priority  i n t h e P r o v i n c e and  areas  f o r h e a l t h manpower r e s e a r c h  to arrange  f o r this research to  be  conducted. 3.  To  a d v i s e t h e D e p u t y M i n i s t e r o f H e a l t h on  appropriate  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  in  t h e a r e a o f h e a l t h manpower. 4.  To  address  or respond  t o s p e c i f i c manpower  concerns,  c o n s u l t i n g w i t h expert committees, p r o f e s s i o n a l associations,  the M i n i s t r i e s of Labour, Education  U n i v e r s i t i e s , Science agencies 5.  To  or Ministries  & C o m m u n i c a t i o n and as  other  necessary.  r e c e i v e r e p o r t s addressing s p e c i f i c concerns  t a k e a c t i o n where n e c e s s a r y  and  or advise the  and  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  these  concerns. 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  w i t h , and  recommend a c t i o n t h r o u g h  to discuss  the Deputy M i n i s t e r  - 73 -  on m a t t e r s  of inter-ministerial  concern  regarding  h e a l t h manpower. 7.  Through t h e chairman and/or h i s appointees,  to pro-  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 t h e P r o v i n c i a l Ministry of Health to federal/provincial, 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  inter-  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 8.  o f concern  and a p p r o p r i a t e  action.  To r e v i e w p r o p o s e d h e a l t h manpower l e g i s l a t i o n f o r i t s implications regarding the 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 D e p u t y M i n i s t e r o f any 9.  concerns.  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 ,  licens-  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 b e aware o f , a n d w h e r e n e c e s s a r y ,  assess  proposed  h e a l t h c a r e p r o g r a m s f o r i m p l i c a t i o n s f o r h e a l t h manpower a n d , w h e r e n e c e s s a r y , Health o f these 11.  advise the Ministry o f  implications.  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 personnel.  I n o r d e r t o c l a r i f y membership on t h e 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 W o r k i n g G r o u p s h a l l r e p o r t t o t h e D e p u t y M i n i s t e r o f H e a l t h a n d s h a l l be r e s p o n s i b l e t o him f o r meeting i t s terms o f r e f e r e n c e .  2.  Membership a)  o n t h e W o r k i n g Group s h a l l c o n s i s t s o f ;  S i x r e p r e s e n t a t i v e s from the M i n i s t r y 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 n e e d s . 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 t h e 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 their respective jurisdictions. T h e s e s i x r e p r e s e n t a t i v e s s h a l l be d r a w n f r o m 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 Serv 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 C a r e S e r v i c e s , P r e v e n t i v e a n d S p e c i a l Community Service's.-.'-,;The c h a i r m a n w i l l be a p p o i n t e d b y t h e D e p u t y M i n i s t e r f r o m 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.  3.  b)  One r e p r e s e n t a t i v e e a c h f r o m t h e M i n i s t r y o f E d u c a t i o n , a n d t h e 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 a n d Communica 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 of those M i n i s t r i e s .  c)  A s many a s two r e p r e s e n t a t i v e s f r o m t h e M i n i s t r y o f L a b o u r , 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. T h e s e r e p r e s e n t a t i v e s s h o u l d b e knowledgeable 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)  S u c h 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) a s a r e n e c e s s a r y f r o m t i m e t o t i m e .  Representation  from t h e S e c r e t a r i a t s h a l l be  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 . retariat  appointed  A member o f t h e S e c -  s h a l l a c t as S e c r e t a r y o f t h e W o r k i n g 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 C o m m i t t e e .  - 75 -  E.  The H e a l t h Manpower R e s e a r c h  Unit  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 t h e Committee. support  I n a l l provinces but B r i t i s h Columbia  i s p r o v i d e d by g o v e r n m e n t p l a n n i n g o r r e s e a r c h  this  divisions.  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 maintained  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  I n B r i t i s h C o l u m b i a , t h e H e a l t h Manpower R e s e a r c h  Ministry.  U n i t was  e s t a b l i s h e d a t the U n i v e r s i t y o f B r i t i s h Columbia t o provide the required support.  T h i s u n i t was u n i q u e i n t h a t a l t h o u g h  receiv-  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 maintained  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 R e s e a r c h  U n i t was h o u s e d 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  & D e v e l o p m e n t , a d i v i s i o n c r e a t e d i n 19 71  with the o v e r a l l mission of: stimulating s c i e n t i f i c enquiry i n t o issues of h e a l t h i n p o p u l a t i o n g r o u p s , ways i n w h i c h h e a l t h s e r v i c e s c a n 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 w h i c h i n s t i t u t i o n s s h o u l d respond.  The U n i t became t h e f o c u s o f f e d e r a l / p r o v i n c i a l a n d 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 the province.  A d a t a b a s e 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  institutions.  The m a j o r p u r p o s e o f t h e U n i t was t o i n t r o d u c e t o t h e manpower planning process, 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 t h e H e a l t h Manpower W o r k i n g G r o u p , 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  statistical  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 w o r k h o w e v e r h a s a l s o b e e n p r o v i d e d f o r v a r i o u s divisions i n the University, the Federal/Provincial  Committee  and o t h e r manpower c o m m i t t e e s , as w e l l a s f o r l i c e n s i n g  bodies  and a s s o c i a t i o n s .  F.  O t h e r G o v e r n m 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 i n B r i t i s h Columbia  In  the past t e n years  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  of a v a r i e t y o f s t r u c t u r e s to address h e a l t h care w h i c h h a v e 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  delivery, 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 Centre  (B.C.M.C.) f o r t h e p u r p o s e s 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 a r e a o f h e a l t h manpower i n t h e p r o v i n c e brought t o the f o r e f r o n t .  were  An E d u c a t i o n C o m m i t t e e 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 a s s e s s take on t h e r e s p o n s i b i l i t y power p r o d u c t i o n supported  n e e d s f o r h e a l t h manpower a s w e l l a s f o r e d u c a t i o n a l p l a n n i n g a n d man-  i n Vancouver.  The E d u c a t i o n  C o m m i t t e e was  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  f u n d e d t h r o u g h .the C e n t r e  B.C.M.C,  and r e p o r t e d t o t h e P r o v i n c i a l  C o u n c i l s e t up u n d e r t h e B.C.M.C. A c t .  Confusion arose.  over  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  Both t h e P r o v i n c i a l C o u n c i l and t h e H e a l t h  Manpower  W o r k i n g 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 W o r k i n g Group h a d c o o r d i n a t i n g l i n k s that ministry. more c l o s e l y  to senior o f f i c i a l s i n  In practice, the Provincial Council  related  t o E d u c a t i o n w h i l e t h e W o r k i n g G r o u p r e l a t e d more  closely to Health.  B o t h t h e P r o v i n c i a l C o u n c i l a n d t h e H e a l t h Manpower W o r k i n g G r o u p w e r e 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 mining  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 u n i t s supporting t h e senior bodies  Linkages six  deter-  and development  occurred.  b e t w e e n t h e s t r u c t u r e s w e r e t e n u o u s , d e p e n d e n t upon  i n d i v i d u a l s who c o m p r i s e d a n u n o f f i c i a l  d i r e c t o r a t e through  interlocking  c r o s s membership on committees.  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  occurred.  Little  - 78 -  The d e m i s e o f B.C.M.C. i n 1975 b r o u g h t w i t h i t t h e d e m i s e o f its  Education  G.  Education/Health  Overlapping  Committee.  C o m m i t t e e s i n B.C.  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  con-  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 t h e 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 a n d approving  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 .  C o m m i t t e e a c t e d as a r e p l a c e m e n t  f o r t h e B.C.M.C.  Committee a f t e r t h e change i n government.  Again  This Education overlapping  r e p r e s e n t a t i o n b e t w e e n t h i s C o m m i t t e e a n d t h e H e a l t h Manpower W o r k i n g Group  occurred.  The C o m m i t t e e c o n t i n u e d  to 'exist' u n t i l  19 78.  The f u z z i n e s s  o f i t s mandate a n d t h e power o f v e t o o f t h e M i n i s t e r o f E d u c a t ion over  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  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 i n g education study  a nursl-  i n the province.  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 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  (1977).  Advisory  decision to establish  the C o u n c i l s , c r e a t e d by t h e C o l l e g e s and P r o v i n c i a l Act  signif-  Institutions  These C o u n c i l s , t h e 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 a n d t h e Management A d v i s o r y C o u n c i l w e r e  79 -  meant t o . c o m p l e m e n t 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 earlier  (1963) u n d e r s e p a r a t e  legislation.  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 a p p r o v e a n d c o o r d i n a t e between p r o v i n c i a l  years  funding  universities.  The r o l e o f t h e A c a d e m i c C o u n c i l i s t o r e v i e w p r o g r a m p r o p o s a l s for  academic programs i n c o l l e g e s and t h e B r i t i s h C o l u m b i a I n -  s t i t u t e o f Technology, approving This c o u n c i l i s supported Education/Health  o r denying  f u n d i n g f o r same.  i n the health occupations  Sub-committee which reviews  by an  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 a n d 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 suitability.  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 Health.  Linkages  b e t w e e n t h e H e a l t h Manpower W o r k i n g G r o u p ,  the M i n i s t r y o f Education committee a r e maintained  and t h e E d u c a t i o n / H e a l t h through  membership o f t h e W o r k i n g  Group C h a i r m a n a n d C o o r d i n a t o r o f h e a l t h p r o g r a m s of Education) attempt  H.  on t h e E d u c a t i o n / H e a l t h  t o keep t h i s  Sub-  (Ministry  S u b - c o m m i t t e e i n an  from o c c u r r i n g .  H e a l t h Manpower C o m m i t t e e s 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 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 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 , a n a s s o c i a t ion  r e p r e s e n t i n g t h e h e a l t h manpower e m p l o y e r s 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 c o m m i t t e e (Terms o f R e f e r e n c e  '.  Appendix E ) .  The r e a s o n s f o r i t s c r e a t i o n w e r e b a s e d o n 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 r o c e s s a n d an a t t e m p t t o p u t o n a s t a n d i n g  planning  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 , administrators  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  Chairman o f the Health the  linkage with  with the  Manpower W o r k i n g G r o u p , who  provides  t h e Working. G r o u p .  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 planning  f o r t h e i r own p r o f e s s i o n  of Physicians  i s n o t new.  The B.C.  a n d S u r g e o n s a n d t h e B.C. M e d i c a l  Association  h a v e m a i n t a i n e d a j o i n t manpower c o m m i t t e e f o r many M a j o r n a t i o n a l and p r o v i n c i a l c o m m i t t e e s have been i n t h e p a s t t o a d d r e s s t h e manpower q u e s t i o n p r o f e s s i o n o r s e r v i c e area.  In recent  Nursing  few o r no t i e s  to existing  standing  manpower o r  among  i n t h i s respect  other  education  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  has been a l e a d e r  bodies.  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 therapists.  a  structures.  groups w i t h  committees b e i n g  established  of a specific  y e a r s however, i n t e r e s t has i n c r e a s e d  occupational  years.  These have been committees w i t h  l i m i t e d mandate and t i m e frame w i t h manpower p l a n n i n g  College  and  occupational  The m a i n f u n c t i o n o f t h e s e c o m m i t t e e s h a s b e e n t o  - 81 lobby  government.  However b e c a u s e 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 r a t h e r than w i t h  the formal  government. Because t i e s questionable, chapters  directly  they w i l l  with  the Health M i n i s t e r  manpower p l a n n i n g  t o the. e x i s t i n g  committees.of  structures are  be d i s c u s s e d • w i t h i n t h e f o l l o w i n g  concerned w i t h p l a n n i n g . i n s p e c i f i c  disciplines.  Summary Responsibility responsibility  f o r h e a l t h manpower p l a n n i n g 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 t h e e d u c a t i o n  The  first  initiation  planning  sector.  of s i g n i f i c a n c e occurred  of the municipal  doctor  system.  c o n t r i b u t i o n t o the H a l l Commission important  The  move i n t h e a r e a  i n 1914 w i t h t h e Judek's  (1964) was t h e n e x t  of medical  T a s k F o r c e on t h e C o s t o f H e a l t h  recommended an i n c r e a s e  h a s a l w a y s been a  manpower  Services  planning.  (1969)  i n t h e use o f a u x i l i a r y p e r s o n n e l  more c o s t e f f e c t i v e method o f h e a l t h c a r e d e l i v e r y . manpower p l a n n i n g 1972 has  as a  The f e d e r a l  s t r u c t u r e a s we now s e e i t was e s t a b l i s h e d i n  as a r e s u l t o f t h a t committee's Report.  The c o m m i t t e e  a weak mandate a n d has" s u f f e r e d froni'a" l a c k o f f o r m a l  reporting relationships. reference  provided  I n 1979 a r e v i s i o n o f t h e t e r m s o f  a s t r o n g e r mandate b u t t e n d i f f e r i n g  a g e n d a s and s e t s o f p r i o r i t i e s w i t h i n  provinces.  - 82 -  Regional  planning  efforts  i n t h e w e s t have r e s t e d w i t h t h e  Western Post-Secondary Health  Manpower C o m m i t t e e w h i c h  e s t a b l i s h e d t o address t h e needs of the e d u c a t i o n has  a stronger  In B r i t i s h Medical replaced  issues  rather  than n a t i o n a l  Columbia the f i r s t planning  Manpower C o m m i t t e e e s t a b l i s h e d by t h e H e a l t h  education  and  ones.  i n 1972.  I t was s o o n  Manpower W o r k i n g Group a c o m m i t t e e  health  Government  Officials.  c o m m i t t e e s have b e e n e s t a b l i s h e d  the p a s t s i x y e a r s t o address i s s u e s were i n t e n d e d  It  s t r u c t u r e was t h e  c o m p r i s e d o f D e p u t y M i n i s t e r s and S e n i o r  Several  sector.  mandate t h a n i t s n a t i o n a l c o u n t e r p a r t  addresses r e g i o n a l  was  of mutual concern.  a s 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  over  These planning.  J u r i s d i c t i o n a l problems have caused the demise o f the m a j o r i t y of these committees. from  overlap  T h o s e w h i c h have s u r v i v e d  problems".  still  suffer  - 83 -  Footnotes  1.  T a y l o r , M., H e a l t h I n s u r a n c e a n d C a n a d i a n 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 C o m m i s s i o n on H e a l t h S e r v i c e s , O t t a w a , 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 C a n a d a , O t t a w a , 1969.  4.  H a c o n , W. Canadian P u b l i c Health 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 C a n a d a , O t t a w a , 1971..  6.  Minutes of the Third Meeting of the F e d e r a l / P r o v i n c i a l Manpower C o m m i t t e e , O t t a w a , November 23, 19 72.  7.  H e a l t h Manpower D e v e l o p m e n t P r o g r a m , G o v e r n m e n t o f C a n a d a , O t t a w a , May 1 9 7 3 , 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 o l u m b i a , V a n c o u v e r , 19 7 1 .  Government o f Canada, Manpower, G o v e r n m e n t o f  Association  Journal,  Manpower, G o v e r n m e n t o f Health  - 84 -  CHAPTER 5  MEDICAL MANPOWER PLANNING I N CANADA  It i s appropriate  t h a t a n 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 g r o u p s i n C a n a d a b e g i n the  by a d d r e s s i n g  s e r v i c e c o n t r o l l e r s of the h e a l t h care  pattern leaders  Traditionally sponsible  f o r o t h e r h e a l t h manpower  i n the nineteenth  century,  f o r t h e i r own p l a n n i n g .  physicians  maintained  standards,  q u a l i t y and f e e s e t t i n g .  p h y s i c i a n manpower, d e l i v e r y systemard t h e occupations.  p h y s i c i a n s were r e -  Through  registration,  c o n t r o l o f admission to the profession, J o h n s o n (1972) c a l l s  this  type o f control, 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 . In t h e 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 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 . volved  i n the establishment  Recommendations concerning  contained  f o rmental h e a l t h ,  L a t e r t h e y became i n -  of hospitals.  i n t h e H a l l Commission Report  health insurance  and p h y s i c i a n s h o r t a g e  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  (19 64)  initiated  planning.  H o w e v e r , s i n c e r e i n t e r e s t by g o v e r n m e n t b e g a n much e a r l i e r , i n Saskatchewan.  The m u n i c i p a l  i n C h a p t e r 3, i s p r o b a b l y  doctors'  scheme o f 1914 o u t l i n e d  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 . p h y s i c i a n manpower s u p p l y  Attempts to increase the  l e d to the establishment of h o s p i t a l s  to a t t r a c t physicians to underserviced areas.  I n the years  that  f o l l o w e d a n d m o s t e s p e c i a l l y t h e 1 9 4 0 ' s , p h y s i c i a n manpower a n d the p o s s i b i l i t y o f shortages N a t i o n a l H e a l t h Grants were asked  became a p r i o r i t y  a n d i n 1948 when  came i n t o b e i n g , p r o v i n c i a l  governments  t o e x a m i n e a n d r e p o r t o n b o t h manpower a n d h o s p i t a l s .  Concentrated  i n t e r e s t i n p l a n n i n g b y g o v e r n m e n t came o n l y when  t h e r e s p o n s i b 1 1 1 t y .for p a y m e n t became t h e i r s u n d e r h e a l t h . insurance.  U n d e r t h i s new scheme g o v e r n m e n t f e l t  i t had a  m o r a l 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 a n d 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 h a d t o b e  provided.  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 both t h e demand f o r s e r v i c e , a n d i t s c o s t u n d e r 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  social'  j u s t i c e w i t h e c o n o m i c g r o w t h , t h e s e new c o r p o r a t e  planners  w e r e f o r c e d t° e x a m i n e t h e s e r v i c e p r o v i d e d .  gatekeepers  The  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 with a shortage t h e a d v e n t o f t h e new M e d i c a r e  o f p h y s i c i a n manpower due t o scheme i n t h e s i x t i e s ,  f o c u s s e d o n s u p p l y i n g s u f f i c i e n t manpower t o m e e t demand.  Questions  of immigration  mechanisms,increased t r a i n i n g ,  planning  growing  and i t s a l t e r n a t i v e  supply  a n d o f s u b s t i t u t i o n came t o t h e  - 86 -  forefront.  A.  I m m i g r a t i o n v s Home  Trained  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 r e a c h e d alarming  proportions  physicians and  by t h e m i d s i x t i e s .  e x c e e d e d C a n a d i a n g r a d u a t e s b y 14% i n new r e g i s t r a n t s  comprised approximately  country  By 19 67 i m m i g r a n t  25% o f a l l a c t i v e p h y s i c i a n s  (Task F o r c e on C o s t o f H e a l t h  Services).  was n o t u n i q u e t o p h y s i c i a n s , a n d i n f a c t i t i s w h i c h t i e s h e a l t h manpower p l a n n i n g ning  The  i n general,  with  This  i n C a n a d a t o manpower p l a n -  common p o l i c i e s  linking  'brain-drain' of trained physicians  own n e e d s .  both.  from B r i t a i n and o t h e r  L a t e r , however, e x c e s s i v e  become a s e r i o u s physician Health  problem.  immigration  Service  situation  immigration  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 her  i n the  immigration  n o t meet was t o  Britain's contribution to  were o f t e n  i n that country.  'refugees'  from t h e N a t i o n a l  T h e y w e r e unhappy w i t h  t h e way  t h a t s y s t e m h a d w o r k e d a n d h a d come t o C a n a d a t o d e v e l o p careers  u n d e r an e n t r e p r e n e u r i a l  system.  This  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 time t o t i m e c o n f l i c t s have s p l i t  Dependency on i m m i g r a n t p h y s i c i a n s As d e s c r i b e d  their  of i t .  From  the ranks o f t h e p r o f e s s i o n .  created  i n C h a p t e r One, p r o f e s s i o n a l s  a d d i t i o n a l problems. immigrating  to this  - 87 -  c o u n t r y q u i t e o f t e n d i d s o as one s t e p p i n g s t o n e i n t h e i r professional career. they  emigrated  Once e s t a b l i s h e d i n t h e w e s t e r n  to.greener  pastures  i n the United States.  Many o t h e r s who u s e d t h e 'have n o t ' p r o v i n c e s s u c h Maritimes or B r i t i s h  As  world,  as t h e  as a p o i n t o f e n t r y q u i c k l y migrated west t o O n t a r i o Columbia.  t h e supply o f p h y s i c i a n s reached  p o r t i o n s , numbers o f i m m i g r a n t s  adequate and s u r p l u s  pro-  b e g a n t o become a b u r d e n  because o f t h e c o s t s they generated.  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 n e w l y 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,  training  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 . f e l t t h a t home g r o w n p e o p l e may t e n d t o s t a y i n a n a r e a and m i g h t b e more r e a d y  to live  i n r u r a l areas.  graduates  from Canadian medical  Medicare,  w i t h o n l y 769 g r a d u a t e s  19 62  longer  Numbers o f  s c h o o l s grew s l o w l y p r i o r t o i n 1945 i n c r e a s i n g t o 838 i n  ( R o y a l C o m m i s s i o n o n H e a l t h S e r v i c e s , 19 6 4 ) .  number h a d i n c r e a s e d s u b s t a n t i a l l y 1,754 i n 1 9 8 0 .  I t was  By 19 70  this  t o 1,071, t o 1,565 i n 1 9 7 5 ,  and  an e s t i m a t e d  ( H e a l t h Manpower I n v e n t o r y , 1 9 7 8 ) ,  B.  Physician Substitutes  The  m a l d i s t r i b u t i o n and t h e apparent  shortage  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 a s t o t h e u s e o f p h y s i c i a n s u b stitutes .  The c o n c e p t  had been popular i n o t h e r c o u n t r i e s f o r  - 88 -  centuries  i n t h e form o f f e l d s h e r s , d o c t o r s '  such types o f p e r s o n n e l .  assistants or other  The e c o n o m i c 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,  Golladay  19 7 3 ) , h o w e v e r a c c e p t a n c e i n t h e w e s t h a s n o t become a (Badgley  Badgley  reality  1971) .  (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  assist-  a n t s a n d 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 s e e n a s a s o l u t i o n to physician shortage, a theory Jeffers  (1974) .  I t was a b o u t 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  areas that discussions the United  a l s o p u t f o r t h by  began.  The f i r s t  t r a i n i n g program f o r  S t a t e s b e g a n 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 b y  a number o f o t h e r s  i n the years which followed.  the Task F o r c e on t h e C o s t o f H e a l t h held to discuss  S e r v i c e s , a c o n f e r e n c e was  the role of physician  ( 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  As a r e s u l t o f  a s s i s t a n t s i n Canada  t o the Physician,  w h e r e s u p p o r t was g i v e n by p h y s i c i a n s ,  1971),  n u r s e s 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 t h e 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 c o n c e p t . H a r t . ;Scarrow, . i n a s u r v e y c o n d u c t e d i n B r i t i s h received  a p o s i t i v e i n d i c a t i o n from t h e medical  t h a t a u x i l i a r i e s w o u l d be u s e f u l .  Sackett  Columbia, profession  a n d Chambers  (19 77)  have a t t e s t e d t o t h e success o f these p r a c t i t i o n e r s ! .  However, t h e i s s u e s  regarding  t h e number o f p h y s i c i a n s  grew.  s u b s t i t u t i o n b e g a n t o change a s P h y s i c i a n a s s i s t a n t s were  :  -  p e r c e i v e d as w e a k e n i n g t h e (Roemer 19 79) (Berki  and  19 7 2 ) .  required  not  l o w e r i n g the  that worker  has  medical  This threat  available  an  function,  the  but  these workers  also  a  transfer  ( B a d g l e y 19 7 1 ) .  met  of  an  unwanted  occupational  quashed i t s growth.  with similar frustrations  r o l e , meeting with strong  b a s e d upon the  i t is  nurse p r a c t i t i o n e r s  adequate supply or  Role i s not  physicians  r o l e of  number o f  to provide service.  feels there i s a shortage t r a i n i n g of  practitioner  opposition  When t h e  more l i k e l y as  a s t o p gap  i s two  to practice  edged.  onto h i s  professional  his technical  Secondly, the  creating  a loss  reason f o r  t u r f by  expertise  occurs.  the  physician the  ( I m a i 19 7 4 ) .  what q u a l i t y c a r e  quickly  The  n u r s e p r a c t i t i o n e r has physician  The  the —  a  the  are question  intrusion  aura created  begins to diminish  i n revenue f o r the  concern.  r e s e n t s the  nurse.  the  m e a s u r e t h a n when  i n c e r t a i n geographic areas.  Primarily  profession  to advocate  surplus of p h y s i c i a n s e x i s t  q u e s t i o n , i t m a t t e r s not  general  nurse p r a c t i t i o n e r i s able to d e l i v e r or i f physicians unwilling  in  profession.  i s most o f t e n  practitioners  general  income o f the  effectively  attempting to develop her from the  of  faced with introduction  Nurse.Practitioner  the  upgrading the  only a transfer  g r o u p h a v e C o u n t e r e d and The  -  r o l e of  In a d d i t i o n ,  of p r i v i l e g e to  Physicians  of  89  by  when t h i s potential definite  of  - 90 -  Recently, attempts  h a v e b e e n made t o i n t r o d u c e n u r s e - m i d w i v e s  i n t o C a n a d a as a f o r m 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 h a v e b e e n by t h e m e d i c a l similar  C.  thwarted  p r o f e s s i o n , t h i s one seems t o b e f o l l o w i n g  a  route.  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 sulted  from the 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 the growth i n technology personnel.  t o curb  immigration,  and t h e i n c r e a s e d use o f  paramedical  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  quickly  moved f r o m 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 to apply r a t i o n a l planning t o the  problem, b u t were f r u s t r a t e d methods s u c h  i n t h e i r attempts.  as t h o s e d e v i s e d by Lee and Jones  Rational (19 3 3) w e r e com-  p l e x and o p e n t o much c r i t i c i s m b y 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 j u d g e m e n t as t o c o n s u m e r n e e d a n d t h e manner o f c a r i n g f o r those needs, p r o v i d e d t h e medical  profession with a  knowledge base which r a t i o n a l p l a n n e r s  difficult  pute.  found  to d i s -  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 -  ing f o r the supply of physicians i s the r o l e of the medical community.  Arguments c o n c e r n i n g o w n e r s h i p and c o n t r o l o f  p h y s i c i a n data bases, levels.  continue at both  n a t i o n a l and  provincial  The  first  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 C a n a d a ,  and t h e o n l y n a t i o n a l s t u d y f o r t h e s e v e n t i e s , a r o s e f r o m t h e 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 .  The N a t i o n a l  C o m m i t t e e o n P h y s i c i a n Manpower was i n i t i a t e d i n 1971 b y 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 g o v e r n m e n t s , who b e l i e v e d t h e y w o u l d n o t b e a b l e t o i m p l e m e n t r e c o m m e n d a t i o n s made b y 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 the Cost o f H e a l t h Care, in  The  t h e Committee found  a t u r b u l e n t ; and u n c e r t a i n  i t s e l f operating  environment.  f e d e r a l government found i t s e l f w i t h o u t funds  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  and w i t h t h e  n e i t h e r the f e d e r a l nor  p r o v i n c i a l g o v e r n m e n t s knew w h e r e t h e y  stood.  To c a r r y o u t t h e w o r k o f t h e C o m m i t t e e an e l a b o r a t e s y s t e m o f e x p e r t p h y s i c i a n c o m m i t t e e s was e s t a b l i s h e d a n d a c o m p l e x m e t h o d o l o g y 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 : population ratios  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  t i m e t h e p a r e n t b o d y 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 suggested passed  t a r g e t s f o r 1981 h a d a l r e a d y b e e n r e a c h e d ,  i n some p r o v i n c e s .  t a r g e t s as r e a s o n a b l e .  and s u r -  Other p r o v i n c e s would not accept the  P r o b l e m s 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  over  t h e m i x o f g e n e r a l i s t s a n d s p e c i a l i s t s w h i c h w o u l d 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 of the r e p o r t have y i e l d e d little  fruit  and  Canada has  yet to e s t a b l i s h a physician :  p o p u l a t i o n r a t i o w h i c h meets w i t h  Question  over the v a l i d i t y  consensus.  o f the Committee's recommendations  has  not r e s t e d s o l e l y w i t h government.  has  disagreed  The  o v e r many r e c o m m e n d a t i o n s , and  t h o s e w h i c h s u g g e s t e d r e d u c e d work l o a d s ers  (Geekie  profession  19 7 6 ) .  most  particularly  for general  Recommendations c o n c e r n i n g  itself  the  practition-  establish-  ment o f a n a t i o n a l d a t a b a s e , b r o u g h t o u t t h e w o r s t f e a r s physicians concerning  the c o n t r o l o f government.  Medical A s s o c i a t i o n expressed ing  the doctors'  w o r k i n p h y s i c i a n manpower p l a n n i n g  doctors Garner  and  The  Canadian  views t h a t  continu-  s h o u l d be  not by o u t s i d e g r o u p s , e s p e c i a l l y t h e  (19 76)  quotes the p r e s i d e n t of the Ontario  A s s o c i a t i o n as  of  done by government. Medical  saying:  'We h a v e t o p l a y t h e manpower game - i t ' s t h e o n l y game i n t o w n ' . A s t a t e m e n t s u c h as t h i s b r i n g s t o t h e dictional  f o r e f r o n t the  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.  juris-  I s i t the  r o l e o f g o v e r n m e n t t o p l a n f o r t h e number o f d o c t o r s who be  allowed  to p r a c t i c e ?  The  number t o be  funded?  r o l e o f t h e p r o f e s s i o n , b a s e d upon t h e i r c l i n i c a l r  advise  g o v e r n m e n t o f how  d e l i v e r adequate s e r v i c e . m e n t s n e v e r Can  many p h y s i c i a n s w i l l be  generation.  i s i t the  expertise,, to required  Examining i t r e a l i s t i c a l l y ,  o b t a i n f i n a n c i a l c o n t r o l because  r e t a i n power o v e r demand  Or  will  to  govern-  physicians  To d a t e t h e o n l y o u t c o m e o f t h e r e p o r t h a s b e e n much d i s c u s s i o n concerning 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 data 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 h a s 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. It i s currently its  t h e i n t e n t o f CM.A.  own d a t a f i l e ,  t o e s t a b l i s h and c o n t r o l  providing, subject to negotiation, analyses  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  either i n  conjunction with p r o v i n c i a l medical colleges or medical  plans.  A u t h o r i t y t o do s o i s p r o v i d e d u n d e r p r o v i n c i a l m e d i c a l  acts  and  insurance  agreements.  Immigration has p r o v i d e d another planning.  General concern  eign medical graduates The  as t o t h e l a r g e p e r c e n t a g e  l e d to a desire to c u r t a i l  s i g n i f i c a n c e o f t h e problem  1973,  focus f o r n a t i o n a l p h y s i c i a n of for-  immigration.  varied across the country.  In  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  medical graduates  whereas Saskatchewan and Newfoundland  exper-  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% a n d 6 3 % r e s p e c t i v e l y (Roemer & Roemer 19 7 7 ) .  The s h o r t a g e s y s t e m w h i c h  still  e d i n many p r o v i n c e s a t t h a t t i m e 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 immigration.  exist-  I n 19 75 t h e  ( B r i t i s h Columbia) C o l l e g e of P h y s i c i a n s  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 the of f o r e i g n t r a i n e d physicians.  and  registration  B a s e d p a r t i a l l y upon t h e  plus of p h y s i c i a n s i n the m e t r o p o l i t a n  a r e a s and  unsuccessful  the College set  f e e n e g o t i a t i o n s i n 19 74,  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 C a n a d i a n c i t i z e n s w e r e t o be . a l l o w e d  full  sur-  p r i m a r i l y upon  graduates.  registration  about Only with  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 t e m p o r a r y r e g i s t r a t i o n and  a  requirement to p r a c t i c e i n a designated  In  May  19 76,  underserviced  t h e Human R i g h t s C o m m i s s i o n o f B r i t i s h  area.  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;  It  not . u n t i l r e v i s i o n s to the g e n e r a l  criteria  i n 19 77,  immigration  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.  law  and  Then f i g u r e s f o r  i m m i g r a n t p h y s i c i a n s d r o p p e d f r o m o v e r 1,00 0 t o j u s t o v e r per year w i t h i n three years. do  so because o f f a m i l i a l  Many o f t h o s e  ties  was  200  currently entering,  r a t h e r t h a n as p a r t o f t h e w o r k  a l l o c a t i o n s e l e c t i o n procedure.  D.  P h y s i c i a n Manpower P l a n n i n g  P r i o r t o t h e New a t t e n t i o n had ment.  In B r i t i s h  Columbia  D e m o c r a t i c P a r t y c o m i n g t o power i n 1973,  b e e n 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  Under t h e S o c i a l C r e d i t ' s twenty y e a r  b e e n t h e o r d e r o f t h e day. t h a t p a r t y not to  plan.  littl govern  r e i g n shortages  I n a d d i t i o n , i t was  the s t y l e  of  had  I t was 1972  o n l y under p r e s s u r e  the Honourable  from the medical  community t h a t i n  Ralph Loffmark, the M i n i s t e r of  e s t a b l i s h e d a M e d i c a l Manpower C o m m i t t e e f o r t h e  Terms o f r e f e r e n c e not  province.  f o r t h e work of t h e committee l a c k e d  a l l o w i n g i t t o do o t h e r  Health,  than e x t i n g u i s h bush f i r e  teeth shortage  situations.  M e d i c a l Manpower C o m m i t t e e  Terms o f  Reference  1.  The C o m m i t t e e 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 graduates from B r i t i s h Columbia, o t h e r p r o v i n c e s o f C a n a d a and f r o m o t h e r c o u n t r i e s .  2.  The C o m m i t t e e w i l l r e v i e w t h e p r e s e n t and f u t u r e d i s t r i b u t ion of doctors. Sources of information 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 the Dominion Bureau of 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 f r o m d o c t o r s and c o m m u n i t i e s . R e c o r d s w i l l be d e v e l o p e d f o r f o u r a r e a s w h e r e m e d i c a l manpower p r o b l e m s may e x i s t ("designatedareas" (a) A r e a s w i t h no  doctor  (b) A r e a s w i t h o n l y one  at a l l ; doctor,  unable to get  (c) A r e a s w i t h one o r two d o c t o r s , n e e d i n g one order to p r o v i d e improved s e r v i c e ; (d) A r e a s w i t h a n e e d f o r a s p e c i f i c  relief; more i n  specialist.  3.  The C o m m i t t e e 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 , s u c h as l a c k o f f a c i l i t i e s , l a c k of adequate remuneration, etc.  4.  The C o m m i t t e e w i l l s t u d y t h e n e e d s o f v a r i o u s b r a n c h e s o f 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 surpluses i n different d i s c i p l i n e s . I t w i l l record the needs o f c e r t a i n areas 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 s u r g e o n s w i l l be reviewed, together w i t h those of other 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 f r o m w h a t has b e e n 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 , t h e C o m m i t t e e 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 t h e 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  basic  training;  (b) d o c t o r s who  have had  specialist  training;  (c) d o c t o r s who a r r i v e i n B r i t i s h C o l u m b i a f r o m provinces or other countries; (d) d o c t o r s who  are 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 t h e practice; (f)  other  facilities  available for  medical  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 requirements i n other provinces;  (g) t h e n e e d f o r p e r i o d i c r e l i e f designated areas.  and  f o r doctors working i n  6.  The C o m m i t t e e 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 of 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 m e a s u r e s , w h i c h c o u l d be c o n s i d e r e d a c c e p t a b l e , and w h a t d e g r e e o f G o v e r n m e n t , 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 ( s u c h 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 , paramedical p e r s o n n e l , etc.) would be f e a s i b l e .  7.  I n i t s work t h e 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 , the 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 S u r g e o n s , t h e B.C. Medical 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 B r a n c h o f t h e D e p a r t m e n t 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 m a n d a t e ,  the Committee d i d  n o t c o n s i s t o f s t r o n g p r o f e s s i o n a ' l — o r o t h e r members. I t i s 1  a s u r p r i s e t h a t i n 19 73 t h e n e w l y f o r m e d p r o v i n c i a l  Health  Manpower W o r k i n g G r o u p , 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 servants  t o o k o v e r t h e r o l e o f p h y s i c i a n manpower  civil  planning.  not  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 C o l u m b i a h a s  contained several s i g n i f i c a n t policy/planning ventures, of which double  s h o u l d be a d d r e s s e d .  three  The f i r s t was t h e d e c i s i o n t o  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 b y 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 H o n o u r a b l e 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 The  Columbia.  s e c o n d was t h e 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  study the p r o v i s i o n o f v i s i o n care s e r v i c e s i n the province. The  third,  t h e e s t a b l i s h m e n t i n 1 9 7 8 , 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 study t h e requirements  for physician  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 t h e m e d i c a l s c h o o l was  made b y 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 Ministry of Education or Health. In fact, r a t i o n a l health planners both p r o v i n c i a l l y move. youth  and f e d e r a l l y , have d i f f i c u l t y  defending the  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 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  than a h e a l t h one. expressed  Columbia  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  i n t h e T a s k F o r c e o n t h e C o s t o f H e a l t h S e r v i c e s and  f o u n d s u p p o r t when B.C. e n r o l m e n t those across the country. nature, r e c e i v e d minimal from t h e p r o f e s s i o n .  f i g u r e s were compared w i t h  The move, t o t a l l y p o l i t i c a l i n support  from t h e c i v i l  s e r v i c e and  C o n d e m n a t i o n came f r o m 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 -  physicians.  I n a d d i t i o n , t h e move s e t b a t t l e l i n e s  the M i n i s t r i e s o f Health  and E d u c a t i o n ,  between  once a g a i n b r i n g i n g t o  the  forefront the j u r i s d i c t i o n a l overlaps  between t h e two.  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 . has  n o t been accomplished a t a p o l i t i c a l  It  This  l e v e l , but rather  w i t h i n the bureaucracy.  The  V i s i o n Care Task Force e s t a b l i s h e d w i t h  of examining  'the p r e s e n t v i s i o n care  t h e o v e r a l l mandate  system i n B r i t i s h  Columbia,  t o a p p r o x i m a t e i t s c o s t , a n d t o recommend any c h a n g e s 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  provide  2 b e t t e r , more e f f i c i e n t c a r e  The  a t the lowest  cost.  1  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  planning  c o m m i t t e e r e s t s i n t h e f a c t t h a t f o r t h e f i r s t t i m e a l l comp o n e n t s o f a s e r v i c e a r e a met t o d i s c u s s Membership on t h e Committee i n c l u d e d  their  future roles.  representatives  from a l l  aspects o f the 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 ,  optometrists  and  from  o p t i c i a n s - as w e l l a s g o v e r n m e n t r e p r e s e n t a t i o n  Health  and  Negotiations  Education.  u l t i m a t e l y centered  around i s s u e s o f economics  and  turf, with  the ophthalmologists  attempting  the  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 a n d more c o s t e f f i c i e n t  to hold  onto  s y s t e m was p r o p o s e d ,  - 9 9-  the m i n o r i t y r e p o r t submitted bargaining,  Advisory  C o m m i t t e e on M e d i c a l  19 78 b y t h e p r e s e n t  Manpower p r e s e n t s  f a i l u r e of r a t i o n a l planning.  the medical  yet a  Established i n  and c h a i r e d by a  t h e H o n o u r a b l e Mr. W e s l e y B l a c k , t h e  Committee on M e d i c a l  especially  i n B.C.  Minister of Health,  former M i n i s t e r of Health,  manpower p l a n n i n g  little  from i t .  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  Advisory  and subsequent  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  further action arising  The  by t h e p h y s i c i a n s  Manpower f o u n d i t s r o o t s i n t h e Rationalization of physician  i n the province,  h a d become  impossible,  i n t h e wake o f t h e d e c i s i o n t o d o u b l e t h e s i z e o f school.  The t i m e was l o n g o v e r d u e 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 a n d 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 C o m m i t t e e was  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  comprised  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, t h e M e d i c a l  Association,;  the Health  Advisory  and  A s s o c i a t i o n , the Health  the Medical  Services  Education  Commission.  a n a l y s i s and d e l i b e r a t i o n s .  Committee  I t - s p e n t two y e a r s i n i t s  The r e s u l t was  sixty-seven  recommendations c o v e r i n g n o t o n l y  issues of medical  but  care d e l i v e r y system.  o f a l l aspects  o f the medical  scope o f i t s recommendations and t h e p o l i t i c a l o f them h a v e l e d t o c o n f u s i o n To d a t e ,  and r e l u c t a n c e  t h e r e p o r t has been r e l e a s e d o n l y  minimal a c t i o n r e s u l t i n g .  manpower, The  i m p o r t o f most  f o r future action.  f o r discussion with  I t i s unlikely that action w i l l  be  - .1.00 -  forthcoming.  E.  Summary  Each o f t h e p l a n n i n g r a t e two p o i n t s .  e f f o r t s d e s c r i b e d above s e r v e  Firstly,  t h e nature, o f m e d i c a l  ning i s such, t h a t although ional planning it.  should occur,  manpower p l a n -  i t i s the prime arena i n which i ti s the area  nature  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 him w i t h  b a r g a i n i n g power b o t h w i t h g o v e r n m e n t a n d w i t h o t h e r 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. control costs w i l l  ability  a l w a y s be t h w a r t e d  t o g e n e r a t e h i s own demand.  health  by the p h y s i c i a n ' s  Secondly;  planning/  outside 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 . both s t u d i e s o r i g i n a t e d w i t h these  from an i n a b i l i t y medicine.  Impetus  structures, but primarily  o f .the s y s t e m t o a p p l y r a t i o n a l  techniques  to  R e c o m m e n d a t i o n s e v o l v i n g f r o m t h e r e p o r t s w e r e met  with equal d i f f i c u l t y future action.  channels.  and an i n a b i l i t y  t o soundly  a d v i s e on  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  a t i o n s has o c c u r r e d formal  great  Attempts by government  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  for  a n y hope  o t h e r manpower c a t e g o r i e s .  power c o n t r o l h e l d b y t h e p h y s i c i a n , p r o v i d e  to  rat-  least receptive to  M e d i c a l manpower i s s u e s n e e d t o be r e s o l v e d b e f o r e  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 The  to i l l u s t -  recommend-  d i r e c t l y with the M i n i s t e r , again  bypassing  -  101  -  Footnotes  1.  G a r n e r , J . , " C o n f e r e n c e i n CMA House C o n c l u d e s P h y s i c i a n s Have t o P l a y t h e Manpower Game". C a n a d i a n 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 ) , O c t o b e r 1 9 7 6 , 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 C o l u m b i a , O c t o b e r , 1977.  - 102-CHAPTER 6  MANPOWER PLANNING I N 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 concern i n the f i e l d ,  h a v e s t i m u l a t e d t h e most p l a n n i n g a t t e n t i o n  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 . and o c c u p a t i o n s h a v e b e e n s l o w t o a d d r e s s  both  Other p r o f e s s i o n s  t h e i r own manpower  p r o b l e m s 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 e n e r g y  t o these other  areas.  P l a n n i n g f o r t h e most p a r t h a s n o t f o c u s s e d o n numbers. 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 ,  Questions  and a c c r e d i t a t i o n .  o f numbers h a v e o n l y r e c e n t l y a c h i e v e d  because immigration o f f o r e i g n t r a i n e d workers prime concern. percentages  Instead  significance  h a s become o f  Foreign t r a i n e d personnel account  f o r high  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 nurses  i n B.C., t o name j u s t a f e w .  the mushrooming e f f e c t o f t e c h n o l o g y new t y p e s o f h e a l t h w o r k e r s ,  Concern as t o  and t h e p r o l i f e r a t i o n o f  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 occupations 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 disputes 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 workers  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 m e t h o d s . i s b e c o m i n g most e v i d e n t  This  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  craft  workers, r e c r e a t i o n aides, a c t i v i t y  aides, occupational  therapy  aides, physiotherapy  t h e r a p i s t s a n d a new  breed  of remedial  a i d e s , massage  gymnasts a r e a t t e m p t i n g  to f i l l  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 . of p r a c t i c e f i e l d s  gaps i n s e r v i c e A lack of d e f i n i t i o n  through l i c e n s u r e o r r e g i s t r a t i o n  often  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 b y e x i s t i n g w o r k e r s a futile effort.  I n some i n s t a n c e s , s u c h as d i e t e t i c s ,  demand.is d e c r e a s i n g  the  b e c a u s e o f an i n a b i l i t y on t h e 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 d e f e n d 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 and  as a  priority  t h e r e f o r e few h a v e 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 p h y -  sicians  that this  f u n c t i o n should  W i t h few e x c e p t i o n s , planning  This  have seen p l a n n i n g  a notable  one, e f f o r t s i n  have r e s t e d w i t h government and w i t h  chapter  illustrating nursing,  nursing being  remain w i t h i n the p r o f e s s i o n .  will  examine f i v e h e a l t h o c c u p a t i o n a l  a d i f f e r e n t planning  climate.  pharmacy, d e n t i s t r y , d i e t e t i c s ,  occupational  A. N u r s i n g  academics.  They  areas,  include  physiotherapy  and  therapy.  Manpower  The r o l e o f n u r s e s i n t h e h e a l t h c a r e  f i e l d has undergone  each  - 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 The s e n s e o f m i s s i o n with  so o f t e n a t t r i b u t e d t o them h a s  a sense o f m i l i t a n c y r e p l a c i n g i t .  health occupation,  Nightingale. faded,  M o r e t h a n any  other  t h e r o l e o f the nurse has always evolved  r e l a t i o n t o that of the physician.  Any r o l e c h a n g e h a s b e e n  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 physician territory.  Some a n a l y s t s  i t i n f r i n g e s upon carry the  infringement  a n a l o g y t o e x t r e m e s a n d s e e t h e r o l e o f t h e n u r s e a s no necessary.  Levi  (19 80)  longer  h a s 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 -  f o r m e d by t h e n u r s e i s n o t c a r r i e d o u t by some o t h e r worker.  in  She r e f e r s t o t h e n u r s e as b e i n g  health  'functionally  redundant'.  Movement t o w a r d s more r e s p o n s i b l e  r o l e s , s u c h as  by t h e n u r s e p r a c t i t i o n e r , h a s b e e n met w i t h successful opposition  from the m e d i c a l f i e l d .  n u r s e s t o assume t h e s e more r e s p o n s i b l e routes  - registration/licensuretactics,  standards of p a t i e n t care  Planning  E f f o r t s by  r o l e s have taken education  various  requirements,  a n d s a l a r y demands.  i s due t o a f e a r o f t h e numbers  lack of c l a r i t y  was  f o r c e f u l and  o f n u r s i n g manpower by g o v e r n m e n t h a s b e e n m i n i m a l .  Possibly this  team.  exemplified  involved or a  as t o t h e r o l e o f t h e n u r s e i n t h e h e a l t h  At the national l e v e l ,  a Nursing  care  Requirements Committee  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  Health  Manpower C o m m i t t e e o r t h e N a t i o n a l C o m m i t t e e on  - 105--  P h y s i c i a n Manpower.  Instigated  at the request of the nursing  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 a n e a r l y d e m i s e .  Lack o f  agreement on o b j e c t i v e s and upon m e t h o d o l o g y , w i t h i n t h e p r o f e s s i o n , brought completed.  Attempts  t h e s t u d y t o a n e n d b e f o r e i t s w o r k was h a v e n o t b e e n 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 nursing study.  At the p r o v i n c i a l  level,  few a t t e m p t s h a v e b e e n 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 . (19 79)  The K e r m a c k s  o n 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  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 a t t e m p t e d n u r s i n g e d u c a t i o n system.  this issue i n  to r a t i o n a l i z e the  Conducted under t h e auspices o f the  M i n i s t r y o f Education, t h e report gained l i t t l 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 n u r s i n g from a i d e l e v e l  support i n the  a l a d d e r i n g concept i n  t o b a c c a l a u r e a u t e l e v e l based  d i f f e r e n t r e q u i r e d competencies. willing  Report  t o accept t h i s concept  upon  The H e a l t h M i n i s t r y was u n -  until  i t felt  thoroughly i n v e s t i g a t e d - a process which  i t had been  could take years. In  a d d i t i o n , K e r m a c k s recommended r e p e a l i n g t h e P s y c h i a t r i c  Nursing  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 altogether.  T h i s l a t t e r r e c o m m e n d a t i o n was m o s t  unacceptable  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 nurses 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  The  institutions.  u n a c c e p t a b i l i t y o f t h e K e r m a c k s R e p o r t t o H e a l t h , was  -  probably  106 -  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  of Education  t h a n 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  a l w a y s s e e n h e a l t h manpower a s i t s t e r r i t o r y , relates to nursing - a f i e l d a training  they  maintained  i t appears t h a t u n t i l r e c e n t l y the  p r o f e s s i o n has n o t f u l l y  nurses'  f o r which i t has always  as i t  responsibility.  Within nursing i t s e l f ,  numbers.  especially  has  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  I n f a c t , numbers more o f t e n t h a n n o t h a v e b e e n u n d o i n g r a t h e r t h a n h e l p i n g them t o a c h i e v e  appear t o l a c k u n i t y w i t h i n the ranks.  success,  as  On t h e 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 , b u t i s t h i s n e c e s s a r i l y the  case?  Although  hidden  w i t h i n o t h e r g u i s e s , an u p w a r d 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 occupational areas, members f o r m i n g occurred  has always o c c u r r e d .  a pyramid e f f e c t  I n most  occurs w i t h less  t h e b a s e by v i r t u e o f numbers.  skilled  T h i s has n o t  i n n u r s i n g w h e r e t h e more h i g h l y t r a i n e d n u r s e s  a much l a r g e r p r o p o r t i o n o f t h e n u r s i n g p o o l t h a n do P r a c t i c a l Nurses  with approximately  Licensed  (LPN) and R e g i s t e r e d P s y c h i a t r i c N u r s e s  L i c e n s e d p r a c t i c a l nurses  form  (RPN).  are found a t the base o f the pyramid  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 f o u n d i n t h e g r a d u a l p h a s i n g of 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 .  out  Neither  - 10,7 -  f i e l d h a s grown o v e r t h e p a s t few y e a r s a n d i n f a c t , e a c h h a s e f f e c t i v e l y b e e n 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 registered nurses.  The a u t h o r o f t h e K e r m a c k s R e p o r t ,  herself  an R.N.-, h a s p u t f o r t h t h e r e c o m m e n d a t i o n c o n c e r n i n g t h e d e m i s e of  the p s y c h i a t r i c nurse.  base,  The r e c o m m e n d a t i o n h a s a r a t i o n a l  i n that psychiatric nursing i s the only nursing specialty  trained, i n a separate stream, training one  and changing  i t to specialty  f o r r e g i s t e r e d nurses, i s extremely l o g i c a l .  However,  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 aiming t o achieve.  As  R.P.N.'s a n d L.P.N.'s g r a d u a l l y d e c r e a s e  masters to  and d o c t o r a l l e v e l  i n c r e a s e , the pyramid  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 b a s e .  movement t h r o u g h to  nurses  and b a c c a l a u r e a t e ,  t h e system  jelly-like  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  h e a l t h manpower p l a n n i n g .  Manpower (19 77)  This  begins  A l b e r t a ' s Task Force on N u r s i n g  recommended t h a t by 19 81, t h e b a c c a l a u r e a t e  d e g r e e b e c o n s i d e r e d as m i n i m a l f u r t h e r s h u f f l e upwards?  requirement  f o r nurses.  Although not c l e a r l y  A  ..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  B.  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 . .'.  : Pharmacy. Manpower  Pharmacy i l l u s t r a t e s from t h a t observed  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  i n nursing.  I n n u r s i n g i t was shown t h a t  - 108 -  power r o s e f r o m w i t h i n t h e p r o f e s s i o n i n c h a n g i n g b o t h t h e l e v e l of  worker  a n d 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 f r o m 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 h a s  not i n t e r v e n e d i n the process e i t h e r a t a n a t i o n a l o r a provincial level,  leaving the school,  i n conjunction with  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 e x p a n d as i t saw f i t .  Polglase  (19 79) h a s d e s c r i b e d how c o n c e r n h a d grown i n t h e m i d -  s i x t i e s over t h e d e c l i n i n g enrolment 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. p e r c e n t a g e o f U.B.C. g r a d u a t e s  i n the Faculty of  The g r a d u a l d e c l i n e i n t h e  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  t h e C o l l e g e o f P h a r m a c i s t s f r o m 8 1 . 6 % i n t h e 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 t h e h a r d  w o r k o f t h e Dean o f P h a r m a c y , t h e s c h o o l h a d s t a r t e d o n a p e r i o d of  growth.  B e t w e e n 19 70 a n d 19 77, t h e s c h o o l ' s e n r o l m e n t  grew  f r o m 221 t o 3 6 1 .  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 s y s t e m  f o r drugs  t o c e r t a i n groups  u n d e r t h e N.D.P.  g o v e r n m e n t , 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,  h o w e v e r , h a s l e v e l e d o f f a n d c o n c e r n now c e n t e r s a r o u n d  a  s a t u r a t i o n o f t h e market.  Government has n o t d i r e c t e d p l a n n i n g e f f o r t s manpower.  t o pharmacy  However, s e v e r e b u d g e t 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 the system to the 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 s l o w growth o f pharmacy a i d e s . currently  pharmacists i s evident I t i s b e l i e v e d t h a t many  c a r r i e d o u t by p h a r m a c i s t s ,  p h a r m a c i s t s has  t r a i n i n g programs i n t h i s exists, month  led to a reluctance field.  t r a i n i n g approximately  To  the  program  60 p e o p l e p e r y e a r i n a  three  course.  Dental  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  had  be  to e s t a b l i s h aide  d a t e o n l y one  C.  until  Saturation of  the  tasks  could quite r i g h t l y  assigned toithese l e s s e r t r a i n e d workers. m a r k e t by  in  Manpower  r e c e n t l y , been l e f t  little  o f d e n t a l manpower  to the market p l a c e .  Government  has, has  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, b e c a u s e a  t h i r d p a r t y payment s y s t e m d i d n o t fession, similarly  to the medical  exist.  The  dental  p r o f e s s i o n , i s the  progatekeeper  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 t h e y deem i t necessary.  The  o n l y r e s t r i c t i o n on  of surfaces  i n which to place  p r a c t i t i o n e r s has  been l e f t  s e r v i c e d e l i v e r e d was dentists' personnel.  t h i s s e r v i c e , i s the  fillings.  C o n t r o l o f numbers  t o t h e p r o f e s s i o n and  of  because  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  advantage to encourage the development of D e n t a l A s s i s t a n t s and  number  to  the  auxiliary  H y g i e n i s t s h a v e 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 venture i n t o d e n t a l care for  c h i l d r e n a n d B.C.'s s t u d y o f p o s s i b l e p r o v i s i o n  similar  lines  (Evans  19 7 5 ) ,  government c o n c e r n has  along really  b e g u n 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 , the a r r i v a l of Denticare p l a n s . t h i r d p a r t y s y s t e m has  Although the impact of  not y e t been determined,  s u c h a p r o g r a m r a i s e s many q u e s t i o n s (Evans  The  d e n t a l p r o f e s s i o n h a s , u n t i l now,  with  this  the c o s t of  & W i l l i a m s o n 1976) .  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 g r o w i n g 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 vincial policy  government l e v e l s , towards  dentists.  as t o t h e o p e n d o o r i m m i g r a t i o n As  i t currently exists, points for  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 a r e . a c o m p o s i t e o f pictures.  Those p r o v i n c e s w i t h "needs"  sway t h e p o i n t s a l l o c a t e d . s u c h t h a t B.C.  f o r an o c c u p a t i o n c a n  M i g r a t i o n p a t t e r n s i n Canada a r e  q u i c k l y becomes t h e r e c i p i e n t o f i m m i g r a n t s  gain entry to a  t h e f e d e r a t i o n and human r i g h t s to  who  'needy' p r o v i n c e , a n d 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 t h e w e s t .  difficult  provincial  The  nature of  l e g i s l a t i o n make t h i s  factor  control.  R e g i s t r a t i o n m e c h a n i s m s and c o n t r o l o f t h e s i z e o f t h e d e n t a l school  ( 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), h a v e b e e n  - Ill  more o r l e s s t h e o n l y t h e p r o f e s s i o n and  -  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  g o v e r n m e n t i n B.C.  until  19 80 w i t h g r o w i n g c o n c e r n a b o u t numbers and Denticare,  the C o l l e g e of Dental  recently.  Early in  the promise  of  Surgeons e s t a b l i s h e d a  standing  c o m m i t t e e on d e n t a l manpower t o a d d r e s s numbers i s s u e s . this  D.  c o m m i t t e e i s f u n c t i o n i n g i s unknown.  D i e t e t i c Manpower  Never of primary provides i t s own  own  study  i m p o r t a n c e t o manpower p l a n n e r s ,  o f i n t e r n s h i p p o s i t i o n s and planning,  Faced w i t h  a d e s i r e t o be  a  perceived  involved i n  the 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  of the requirements f o r D i e t i t i a n s  enormity  dietetics  a d i f f e r e n t approach to p r o f e s s i o n a l involvement i n p r o f e s s i o n ' s manpower p l a n n i n g .  shortage its  How  o f t h e t a s k , and  i n Canada.  i t s questionable  a  The  usefulness, l e d to  the 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 to examine the  feasibility  a n a t i o n a l study.  D e v e l o p m e n t , 1980)  Findings  ( H e a l t h S e r v i c e s R e s e a r c h and  indicated that d i e t i t i a n s ,  u n l i k e those  f e s s i o n a l s m e n t i o n e d p r e v i o u s l y , had their identity  and  t e r r i t o r i a l claims.  r o l e as h o s p i t a l d i e t i t i a n s , f i e l d o f p r a c t i c e and i n new  and  they had  defend adequately  emerging areas.  f o r t h e m s e l v e s has  failed  pro-  to s t r u g g l e w i t h  Beyond t h e i r  traditional  f a i l e d to define  their  the need f o r d i e t i t i a n s  Their i n a b i l i t y  l e d to a great  health  of  to carve  out  deal of infringement  space  upon  - 112  t h e i r t e r r i t o r y by supervisors,,  -  l e s s e r t r a i n e d p e o p l e s u c h as  d i e t a r y aides  and  dietary technicians.  recommended t o t h e C a n a d i a n D i e t e t i c A s s o c i a t i o n e n g a g i n g i n manpower p l a n n i n g profession able  and  believed  E.  I f t h i s i s not  final  t r e a t e d as  gaining  majority  of  t r a i n i n g and by  growth of  be  phased  the  out.  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 but  for various  licensure.  been  political  increasing significance.  f o r e i g n t r a i n e d p e o p l e f o r many trained, lured  promises of higher  T h e s e w i l l be  have years. by  wages.  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  a d i s c u s s i o n of the  the  near f u t u r e , i t i s  gradually  these have been B r i t i s h  s h o r t a g e s i n C a n a d a and  Separate issues  to  that i t i s  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  b o t h b e e n d o m i n a t e d by The  addressed i n the  a f r i n g e a r e a i n the p a s t ,  P h y s i o t h e r a p y and  was  O c c u p a t i o n a l T h e r a p y Manpower  example p o i n t s  r e a s o n s i s now  It  i t should define  c o n t i n u e d need and  t h a t such a p r o f e s s i o n w i l l  P h y s i o t h e r a p y and  This  activities,  service  that prior  i t s f i e l d o f p r a c t i c e i n s u c h a way  adequately to defend the  profession.  food  examined f i r s t ,  common m a n d a t e f o r p l a n n i n g  to followed  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 diploma  - 113 -  l e v e l b o t h i n B r i t a i n and Canada.  Membership i n t h e Canadian  Physiotherapy A s s o c i a t i o n has u n t i l diploma. and  19 77, r e q u i r e d o n l y a  I n 19 79, i n a n e f f o r t t o c u r t a i l  foreign immigration  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 o n a minimum o f a b a c c a l a u r e a t e d e g r e e membership.  to maintain  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 a s 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 predicament  f o r they were  satisfied  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 graduates.  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  diploma people took advantage o f f e r e d and e v e n t u a l l y Shortages  o f upgrading courses which  were  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 .  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 h a s y e t t o b e 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 T h e r a p y ,  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 achieve equal  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 d a t e t h e i r q u e s t h a s b e e n  unsuccessful.  Both 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 a d v e n t o f L o n g  Term C a r e a d d e d t o t h i s p r o b l e m b o t h f r o m 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 h a v e b e e n made i n  - 114 -  the p a s t t o i n c r e a s e enrolment training  facilities.  of existing  An i n t e r e s t i n g  schools or to  improve  s i t u a t i o n has begun t o  occur 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 Persons  by t h e U n i t e d N a t i o n s .  S i n c e 1978 a n d 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 h a n d i c a p p e d  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 a s i n t o s t u d i e s o f manpower t o s e r v i c e t h e n e e d s o f t h e s e people.  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 , h a s  been l a u n c h e d a t t h e 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  study  s p e c i f i c t o p h y s i o t h e r a p y a n d o c c u p a t i o n a l t h e r a p y manpower. Studies o f t h i s type are p o l i t i c a l l y - l i k e the handicapped  F.  i n vogue and p r a c t i t i o n e r s  - a r e s a y i n g " I t ' s my  turn".  Summary  T h i s c h a p t e r has examined f i v e 'honrational" approaches manpower p l a n n i n g t h r o u g h t h e e x a m p l e o f f i v e groups.  to health  professional  I t b e g a n w i t h an e x a m i n a t i o n o f t h e p l a n n i n g o f n u r s -  ing  manpower a n d t h e a b i l i t y  of the profession  and  r e c o g n i t i o n through t h w a r t i n g t h e growth  'to gain status  o f lower  level  nursing personnel.  S e c o n d l y , p h a r m a c y 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 P h a r m a c y t o i n c r e a s e e n r o l m e n t , f o r e i g n immigrants  prevent  f r o m s p o i l i n g t h e 'pharmacy e c o l o g y ' o f t h e  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 m a r k e t .  - 115 -  Dentistry provided has  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  used t h e s u b s t i t u t i o n o f lower  level auxiliaries  toi t s  members' f i n a n c i a l b e n e f i t a s w e l l a s t o c o n t r o l i t s own manpower m a r k e t .  D i e t e t i c manpower i s t h e s t u d y o f a manpower g r o u p i n d a n g e r 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 a n d of a c l e a r r o l e .  Although  interested i n pursuing  a rational  p l a n n i n g framework t h e ground work has n o t been l a i d  to allow  t h e m t o do t h i s .  Finally,  discussion of physiotherapy  and o c c u p a t i o n a l  therapy  manpower h a s r e v e a l e d two f r i n g e g r o u p s who, u n t i l r e c e n t l y , and  i n spite of shortages,  attention.  The p o l i t i c a l  study o f these  groups . as  have r e c e i v e d l i t t l e  planning  c l i m a t e h a s now become r i p e f o r t h e the I n t e r n a t i o n a l year o f the D i s -  a b l e d i s upon u s .  With t h e exception o f n u r s i n g , a l l four areas c h a r a c t e r i s t i c o f being overlooked 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  and  none o f t h e s e  t h e common  by government i n p l a n n i n g  than planning a t t e n t i o n o f a research  In  share  attempts  rather  variety.  f i e l d s has r a t i o n a l p l a n n i n g been  considered  a l l h a v e a t t e m p t e d t o i n c r e a s e t h e i r power a n d numbers  through  negotiation.  Some h a v e b e e n more s u c c e s s f u l t h a n  others.  - 116  Nursing  has  received  accorded p h y s i c i a n s . as t h e  little The  -  a t t e n t i o n i n comparison to  r e a l i t y a p p e a r s t o be  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  those professions health pyramid.  and This  o c c u p a t i o n s which form the f a c t o r a l o n e may  r o c k e t i n g cost of h e a l t h  care.  that  that  physicians,  exclusion base of  account f o r the  of  the  sky-  - 117 CHAPTER_7  TOWARDS IMPROVEMENTS IN HEALTH MANPOWER PLANNING  The  purpose o f t h i s study  a)  t o review  b)  t o describe  c u r r e n t h e a l t h manpower p l a n n i n g  i n context,  manpower p l a n n i n g B r i t i s h Columbia. p r o f e s s i o n a l areas  c)  to critique planning  was t h r e e f o l d :  methodogies.  t h e g r o w t h and c h a n g e s i n m e d i c a l  i n Canada w i t h  s p e c i a l reference t o  The manpower i s s u e s were a l s o  of f i v e other  health  explored.  t h e C a n a d i a n and B r i t i s h C o l u m b i a n manpower  processes using  c u r r e n t m o d e l s a n d recommend  changes t o t h e 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 review  was made o f s i x h e a l t h  p r o f e s s i o n a l g r o u p s and how r a t i o n a l p l a n n i n g place  has n o t t a k e n  i n s p i t e o f g o v e r n m e n t ' s d e s i r e t o ..plan.  were e x a m i n e d planning  i nlight  of past  and p r e s e n t  These groups  bureaucratic  structures.  I t was r e a l i z e d  that health professions  and o c c u p a t i o n s  than p h y s i c i a n s  receive l i t t l e  a t t e n t i o n from  planning  other  government because they a r e n e i t h e r t h e gate keepers t o t h e  - 118 h e a l t h care  s e r v i c e s y s t e m n o r do t h e same c o s t f a c t o r s  t o them t h a t a p p l y  to physicians.  These p r o f e s s i o n s  apply  have b e e n  s l o w t o a d d r e s s t h e i r own manpower p r o b l e m s and when t h e y done s o i n m o s t i n s t a n c e s negotiation  Issues  rather  t h e a p p r o a c h h a s been one o f  than r a t i o n a l p l a n n i n g .  f o r t h e s e g r o u p s have o f t e n  centered  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 t h a n on n u m b e r s . of  immigration,  now n e c e s s i t a t e disputes  have  Questions  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 t h a t numbers be e x a m i n e d .  a r e g r o w i n g between v a r i o u s  Jurisdictional  l e v e l s o f w o r k e r and  i s exaggerated  i n occupational  practice field  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 n o t  this  a r e a s where d e f i n i t i o n o f t h e  exist.  Nursing  has p r o v i d e d  an i n t e r e s t i n g e x a m p l e o f a p r o f e s s i o n  has attempted 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 s o h a s 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 pyramid. 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 training  i n requiring  profession  sanction  i n a c q u i r i n g from the m e d i c a l Movement  r o l e s s u c h as e x e m p l i f i e d  p r a c t i t i o n e r h a v e been met w i t h opposition.  functions, nurses  f o r new and e x p a n d e d r o l e s .  t o w a r d s more r e s p o n s i b l e  Although  increased  l e v e l s to perform t r a d i t i o n a l nursing  h a v e been l e s s s u c c e s s f u l  which  f o r c e f u l and  by t h e n u r s e  successful  - 119  Attempts at r a t i o n a l planning  -  i n n u r s i n g h a v e been  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  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 o v e r l a p s have negated  On  the s u r f a c e there  manpower p l a n n i n g . occupation how  R.N.  come t o g r i p s  jurisdictional  recommendations.  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 However, t h e upward m o b i l i t y o f  i n t h e p a s t number o f y e a r s  l e a d s one  to  g o v e r n m e n t has  s a t b a c k and  done  Through  a second model of n e g o t i a t i o n , but  that of n u r s i n g .  I n pharmacy p r e s s u r e  the e d u c a t i o n  resulted in a gradual  i t not been f o r budget c u t b a c k s  resulted  and  Within  the  this  one  unlike  power f r o m w i t h i n  s e c t o r l e d t o a p e r i o d of growth during  This  the  nothing.  Pharmacy p r o v i d e s  resulted.  question  i n f a c t have a l m o s t caused  d e m i s e o f t h e L.P.N, as t h e b a s e l e v e l w o r k e r .  had  the  s have been a b l e t o f o r m a f a r l a r g e r p o r t i o n of  n u r s i n g p o o l t h a n L.P.N.'s and  sixties.  fruitless  the  f l o o d i n g of the market a severe  problem would  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  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  and have  has  aide  programs.  Until  r e c e n t l y p l a n n i n g f o r d e n t a l manpower has f  the m a r k e t p l a c e . s y s t e m h o w e v e r has  The  been l e f t  to  i n t r o d u c t i o n o f a t h i r d p a r t y payment  led to governmental i n t e r e s t  in control.  - 120 The  dental profession  controlling The  t o d a t e h a s been s u c c e s s f u l i n  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  reasons.  a d v e n t o f d e n t a l p l a n s , h o w e v e r / m a y l e a d t o an e a s i n g  this  up o f  situation.  Dietetics  i s the s t o r y of a p r o f e s s i o n concerned with  dwindling  numbers.  U n l i k e n u r s i n g , pharmacy o r d e n t i s t r y , t h e y  have f a i l e d  to struggle with  territorial  claims.  their field  o f p r a c t i c e and t h e r e f o r e  need f o r c o n t i n u e d  i t s own  their  Dietitians  existance.  identity  and w i t h  have been u n a b l e t o d e f i n e adequately defend the  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 w o r k e r s h a v e been s u c c e s s f u l i n t a k i n g many t r a d i t i o n a l d i e t e t i c  jobs  over  because o f the l a c k o f  def.in.it i o n .  Physiotherapy  and O c c u p a t i o n a l  Therapy  illustrate  p r o f e s s i o n c a n g a i n s i g n i f i c a n c e b a s e d upon atmosphere r a t h e r than r a t i o n a l e . occupations Despite  Disabled' are  t o place  i t took  The s h o r t a g e o f t h e s e two  Chapter 5 s p e c i f i c a l l y the h e a l t h care  system.  to illustrate  manpower p l a n n i n g  years.  'The I n t e r n a t i o n a l Y e a r o f t h e  e m p h a s i s on t h e s h o r t a g e .  now commencing i n t h i s  serves  political  h a s b e e n a w e l l - k n o w n f a c t f o r many  many p l e a s  how a  Planning  efforts  area.  addresses the p h y s i c i a n as gatekeeper t o Each o f t h e p l a n n i n g  two p o i n t s .  First,  i s such, that although  efforts  the nature  described  of medical  i t i s the prime arena  - 121 in which r a t i o n a l planning receptive to i t . before  any  Issues  hope can  be  should  i t is'the groupleast  held  for rationally  resolved  addressing  planning  other health occupations.  The  o f t h e p r o f e s s i o n i s s u c h t h a t t h e k n o w l e d g e and  h e l d by  the p h y s i c i a n p r o v i d e  b o t h w i t h g o v e r n m e n t and occupational will  occur  o f s e r v i c e c o n t r o l must be  e i t h e r f o r p h y s i c i a n o r any nature  -  groups.  a l w a y s be  h i s own  him  bargaining  power,  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  A t t e m p t s by  thwarted  with great  control  by  government t o c u r t a i l  the p h y s i c i a n ' s a b i l i t y  costs  to generate  demand.  Secondly, planning illustrated,  and  occurred  d e c i s i o n making i n a l l i n s t a n c e s outside  h e a l t h manpower s t r u c t u r e s .  the e s t a b l i s h e d Impetus f o r  o r i g i n a t e d w i t h i n these  s t r u c t u r e s , but  initiated  inability  rational  b e c a u s e o f an techniques  concerning  to medicine.  r e c o m m e n d a t i o n s has  M i n i s t e r , again  bypassing  What i s t h e r o l e o f t h e m e d i c a l planning?  I t has  .government.  of the system t o  occurred  by  apply  physicians  d i r e c t l y with  the  channels.  p r o f e s s i o n i n i t s own  of the  manpower. ,,  t h i r d p a r t y s y s t e m t h i s was  However, i t i s q u e s t i o n a b l e  responsibility  were p r i m a r i l y  o b v i o u s l y b e e n q u i t e i n v o l v e d i n t h e .past.  to the establishment legitimate.  many s t u d i e s ,  Bargaining  formal  bureaucratic  should  be  that  Prior  probably  sole  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  the  - 122 -  Federal  and p r o v i n c i a l p l a n n i n g  fourth chapter issues placed  Federal  have f a i l e d before  involvement  questionable,  s t r u c t u r e s as d e s c r i b e d  adequately  t o a d d r e s s t h e manpower  them.  i n h e a l t h manpower p l a n n i n g  with the provinces  interference.  i n the  h a s a l w a y s been  r e l u c t a n t t o accept  The f e d e r a l g o v e r n m e n t h a s t e n d e d t o p o r t r a y i t s  r o l e on t h e f e d e r a l / p r o v i n c i a l c o m m i t t e e a s one o f c o o r d i n a t i o n and  as s u c h they  national  concern.  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 o f  Ten d i f f e r e n t  and  priorities  assist  The  t i g h t e n i n g of immigration  s c e n e r i o s , s e t s of problems  in this.  l a w s and t h e a p p l i c a t i o n o f z e r o  p o i n t s t o p h y s i c i a n s a s an o c c u p a t i o n a l c a t e g o r y of  immigration  h a v e been t h e o n l y a c c o m p l i s h m e n t s o f t h e  f e d e r a l government t o date. of r a t i o n a l p l a n n i n g , and  f o r purposes  T h e s e moves came n o t a s t h e r e s u l t  b u t r a t h e r as t h e r e s u l t o f b a r g a i n i n g  n e g o t i a t i o n b o t h w i t h p r o v i n c i a l g o v e r n m e n t and t h e  profession.  Initial  made t o t a l l y  i n isolation  generally  changes  i n general  immigration  from the h e a l t h f i e l d  and a p p l i e d  t o a l l immigrants, 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 d e v e l o p m e n t and i m p l e m e n t a t i o n o f h e a l t h manpower h a s t e n d e d t o o c c u r the  rational structure.  inability  l a w s were  This occurs  t o develop l i n k s with  with the p r o f e s s i o n s .  outside  i n the area  o f t h e bounds o f  because of the s t r u c t u r e ' s  s e r v i c e areas or t o negotiate  - 123 -  G o v e r n m e n t 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 t h e y e x i s t , operate  almost  planning structures.  totally  outside of other health s e r v i c e  M e m b e r s h i p on t h e P r o v i n c i a l  Health  Manpower W o r k i n g G r o u p , f o r many y e a r s , h a s n o t been a t a policy-making  l e v e l . T h i s h a s 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 t h e 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  m e m b e r s h i p may c h a n g e t h i s p i c t u r e , a s more s e n i o r representatives are c u r r e n t l y being appointed area.  However, u n l e s s b r i d g e s c a n be b u i l t  negotiation,  this  Implementation,  too w i l l  be a w a s t e d  o r f o r that matter  o f t e n has a r i s e n f r o m s e r v i c e a r e a s rational planning structure. Task Force  Report,  from each s e r v i c e  to facilitate  effort.  i n i t i a t i o n of s t u d i e s , q u i t e r a t h e r than  In the cases  and t h e i n i t i a t i o n  from the  of the V i s i o n  o f t h e Long Term C a r e  P r o g r a m a n d i t s need f o r Homemakers and Long Term C a r e and  Care  the C h i l d r e n s ' Dental Health Study,  a l l manpower  Aides  areas'  n e e d s were d e c i d e d o u t s i d e o f f o r m a l g o v e r n m e n t h e a l t h manpower structures.  Government has f a i l e d  t o o v e r c o m e many j u r i s d i c t i o n a l  These o c c u r p r i m a r i l y  b e t w e e n t h e M i n i s t r i e s o f H e a l t h and  Education  who a r e r e s p e c t i v e l y  overlaps.  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 , a n d t h e c a l i b r e o f manpower t r a i n e d .  The  Education  a  s e c t o r has t a k e n  the perogative of i n i t i a t i n g  - 124 t r a i n i n g program or a l t e r i n g existing will  -  t h e numbers o f s t u d e n t s  in  t r a i n i n g programs, without c o n s u l t a t i o n with those  eventually hire  these poeple.  The  c r o s s i n g of j u r i s d i c t i o n a l boundaries s i z e of a medical  most b l a t a n t  was  o r  the d o u b l i n g of  the  s c h o o l by t h e M i n i s t e r o f E d u c a t i o n a t a  when a s u r p l u s o f p h y s i c i a n s was  acknowledged.  who  I t i s not  time the  o n l y example,however, pharmacy p r o g r a m s , d e n t a l a s s i s t a n t p r o g r a m s and  n u r s i n g p r o g r a m s h a v e a l l grown w i t h o u t  consultation with formal structures. w i t h numbers o f p e o p l e students for c l i n i c a l  e x p e r i e n c e . The  experience.  occur w i t h the M i n i s t r y of  Labour  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  Human R i g h t s ' L e g i s l a t i o n . c o n d i t i o n s and jurisdiction  continued  I s s u e s of u n i o n s , wages,  a p p r e n t i c e s h i p programs a l l f a l l  of Labour.  students working  The  M i n i s t r y o f H e a l t h has' y e t  acknowledge a r e s p o n s i b i l i t y f o r  Jurisdiction difficulties both  only  t r a i n e d , but a l s o w i t h the placement of  to decide whether i t w i l l p r o v i s i o n of student  Problems a r i s e not  Conflict  in hospitals  3 was  the  has  L a b o u r f o r many y e a r s .  t o review the f o u r major r e s e a r c h  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 from o t h e r areas  within  ( e s p e c i a l l y L.P.N.'s),  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 .  isolation  working  o v e r payment o f wages t o  b e t w e e n H e a l t h , E d u c a t i o n and  purpose of Chapter  and  The  fact that  are conducted  these  mostly  of the h e a l t h c a r e system  in  have,to  c e r t a i n e x t e n t , b e e n t h e c a u s e o f t h e f a i l u r e o f many p l a n n i n g  a  - 125 efforts.  Much o f  t h i s has  -  r e s u l t e d f r o m a l a c k o f an o v e r a l l  health policy.  Questions regarding  the  o v e r a l l usefulness  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 changes which c o u l d  of h e a l t h  the  occur i n a short period  manpower  l a r g e number o f of  time.  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 inability  a p p r o p r i a t e l y t o r e s o l v e even the  problems. reviewing  Two  things  and  become i m m e d i a t e l y a p p a r e n t when  u n i q u e , each i n c o r p o r a t e s  t e c h n i q u e s found  is perfect.  an  l e a s t complex  e x i s t i n g h e a l t h manpower m e t h o d o l o g y .  method i s i n i t s e l f  to  i n other  A l l methods a r e  methods. relatively  First,  some v a r i a b l e s  S e c o n d l y , no new  no  and  one  method  require  development.  Has  r a t i o n a l planning  failed.  Marmor, as was  2 argues t h a t r a t i o n a l planning process.  Organizational  i s valuable  p r o c e s s and  stated  but  e a r l y on  Excessive  w i t h o u t due  care  manpower p l a n n i n g  D o n n i s o n has the  a t t e n t i o n has  to these'other into overall  the  resulted in  been p a i d t o 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 and  the  i n t e g r a t i o n of  planning.  s a i d t h a t t h e more c l o s e l y l i n k e d t h e  r a t i o n a l p l a n n e r are  in  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 failure.  i n Chapter  t o the i d e o l o g i e s of the  concepts decision  of  - 126 -  maker t h e more l i k e l y  t h e p l a n has o f acceptance.  a l s o f o r h e a l t h manpower p l a n n i n g . accomplished  without  This i s true  Good p l a n n i n g c a n n o t be  o v e r a l l i n t e g r a t i o n i n t o the health  care  system.  C h a n g e s 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 ideology of the Canadian w e l f a r e balancing social  j u s t i c e w i t h economic development.  The power o f t h e m e d i c a l  p r o f e s s i o n m u s t be r e a l i z e d a n d 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 planning  state,  any u s e f u l  occurs.  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 t e m p e r e d a n d n e g o t i a t e d if  we a r e t o s e e a n y p l a n s r e a c h  fruition.  - 127 -  BIBLIOGRAPHY  - 128 -  Bibliography Ahamad, B. A P r o j e c t i o n o f Manpower R e q u i r e m e n t s b y O c c u p a t i o n i n 19 75. C a n a d a and i t s R e g i o n s , D e p t . 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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Ministry of H e a l t h , P r o v i n c e o f B r i t i s h Columbia, V i c t o r i a , March, 1979 . R e p o r t o f t h e Community H e a l t h C e n t r e P r o j e c t t o t h e C o n f e r e n c e o f H e a l t h M i n i s t e r s , V o l . 1-3. H e a l t h a n d W e l f a r e , C a n a d a , O t t a w a , 19 72. R e p o r t o f t h e N a t i o n a l A d v i s o r y C o m m i s s i o n on H e a l t h Manpower, V o l . 1, U.S. G o v ' t P r i n t i n g O f f i c e , W a s h i n g t o n , 1967. R e p o r t o f t h e N a t i o n a l C o m m i t t e e o n P h y s i c i a n Manpower - R e q u i r e m e n t s f o r P h y s i c i a n s i n C a n a d a , V o l . 1-3, Ottawa : Health and W e l f a r e , 1976. 1  - 136  -  R i c h m o n d , A. A s p e c t s o f t h e A b s o r p t i o n and A d a p t i o n o f I m m i g r a n t s . Manpower and I m m i g r a t i o n , O t t a w a , 19 74. R o b e r t s o n , H. R o c k e . H e a l t h C a r e i n C a n a d a : A Commentary. 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XVI ( 3 ) , F a l l 1979, pp. 2 5 9 - 6 3 .  in  Roemer, R. and Roemer, M. H e a l t h Manpower P o l i c y U n d e r N a t i o n a l Health Insurance the Canadian Experience, Department of• H e a l t h , E d u c a t i o n and W e l f a r e , W a s h i n g t o n , 1977. R o y a l C o m m i s s i o n on D o m i n i o n - P r o v i n c i a l R e l a t i o n s . G o v e r n m e n t o f C a n a d a , O t t a w a , 1940. R o y a l C o m m i s s i o n on H e a l t h S e r v i c e s . O t t a w a , V o l . 1-2, 19 64. ~  Government o f Canada,  S c h e f f l e r , R.M., Y o d e r , S.G., W e i s f e l d , N., and " 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 : 19 8 0 ' s . " I n q u i r y , V o l . XVI ( 3 ) , F a l l 1979,  Ruby, G. Issues f o r the 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 Hygienist Viewpoint". American J o u r n a l of P u b l i c H e a l t h . January, 1972, V o l . 62 ( 1 ) , pp. 54-56. S c h o n f e l d , H., H e s t o n , J . F . and F a l k , I . "Number o f P h y s i c i a n s Required f o r Primary Medical Care". 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 ) , M a r c h 19 72, pp. 5 7 1 - 7 6 . S e c o n d 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. W e l f a r e C a n a d a , O t t a w a , 19 71. S h i l l i n g t o n , C.H. The T o r o n t o , 19 72.  Road t o M e d i c a r e  H e a l t h , and  i n Canada.  Del  Graphics  - 137 -  Shuman, L . J . , Y o u n g , J . P . , a n d N a d d o r , E. "Manpower M i x 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 1 9 7 1 , p p . 1 0 3 - 1 1 9 . S o r k i n , A l a n L . H e a l t h Manpower, A n E c o n o m i c P e r s p e c t i v e . L e x i n g t o n B o o k s , D.C. H e a t h a n d Company, T o r o n t o , 1 9 7 7 . S p a u l d i n g , W. B. a n d S p i t z e r , W.O. "Implications o f Medical Manpower T r e n d s i n O n t a r i o 19 6 1 - 7 1 " . . O n t a r i o M e d i c a l R e v i e w , V o l . 39 ( 9 ) , S e p t e m b e r 1972,' p p . 5 2 7 - 5 3 3 . S p o o n e r , S.A. a n d M e i l i c k i , C. H e a l t h Manpower P l a n n i n g a n d Utilization: Information Bases~and P l a n n i n g Models. Edmonton, M a r c h 2 2 , 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 P r o g r a m s 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 C a r e Manpower i n t o U n d e r Serviced Areas. 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 . a n d Brown,,G.D. " M a r k e t S t r u c t u r e A p p r o a c h 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 , Contexts, Processes and S o c i a l O r d e r . 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 t h e 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 a n d W e l f a r e C a n a d a , O t t a w a , V o l . 1-3, 1 9 6 9 . 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 a n d C a n a d i a n 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 C a n a d a . McGill, 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 P o l i c y , New Y o r k , P a n t h e o n B o o k s , 19 7 0 .  to Social  T o m p k i n s , 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 C a r e R e n d e r e d b y 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 Certification. H e a l t h M a n p p w e r * P o l i c y D i s c u s s i o n Paper: S e r i e s , R o b e r t Wood J o h n s o n F o u n d a t i o n , M i c h i g a n , May 19 74, No. M9. T r o p m a n , 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 o n S o c i a l P o l i c y . Y o r k , Pergamon P r e s s , 1976. U.S. D e p a r t m e n t o f H e a l t h , E d u c a t i o n a n d W e l f a r e . P l a n n i n g P r o c e s s , V o l . 1, W a s h i n g t o n , 19 76.  Health  New Manpower  - 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 S u p p l y o f H e a 1 1 h Ma np ow e r . DHEW (HRA) 7 5 - 3 8 , W a s h i n g t o n , 1 9 7 4 .  U.S.  D e p a r t m e n t 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' M o d e l s - Volume 1. M o n o g r a p h s a n d D a t a f o r H e a l t h R e s o u r c e s 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.  D e p a r t m e n t 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 M o d e l s - V o l u m e I I . M o n o g r a p h s a n d D a t a f o r H e a l t h R e s o u r c e s 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) 7 5 - 1 9 , May 1974.  V i s i o n Care Task Force Report. B r i t i s h Columbia, October  Ministry o f Health, Province o f 1977.  Warham, J . T h e C o n c e p t o f E q u a l i t y i n S o c i a l P o l i c y . o f B r i t i s h C o l u m b i a , 1974, p p . 1-127. Watkins,  K.  University  S o c i a l C o n t r o l , Longman, L o n d o n , 19 75.  W e r n e r , J . L . , L a n g w e l l , K.M. B u d d e , N.W. "Designation o f P h y s i c i a n Shortage Areas: The P r o b l e m o f S p e c i a l t y Variations". I n q u i r y , V o l . X V I ( 1 ) , 1979, p p . 31-3.7. W i l d a v s k y , A. " D o i n g B e t t e r a n d F e e l i n g W o r s e : 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 K n o w l e s , J.H. D o i n g B e t t e r and F e e l i n g W o r s e : H e a l t h i n t h e U n i t e d S t a t e s . W.W. N o r t o n & Co., 1977, p p . 1 0 5 - 1 2 3 . W o 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: . 1960.  The O r g a n i z a t i o n ,  Y e t t , D.E., D r a b e k , L . , I n t r i l i g a t o r , M.D., a n d K i m b e l l " H e a l t h Manpower P l a n n i n g : An E c o n o m e t r i c A p p r o a c h " . 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, p p . 134-147. Y e t t , D., D r a b e k , 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 Microeconometric Model o f the h e a l t h care system i n the 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, p p . 413. ~  139 -  22,000 T o t a l P o p u l a t i o n and R u 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)  "20, 000 18,000* 16,000 14,:000 12,000 10,000' 8,000 6, 00 0 4, 000  U  2,000  1871 Source:  1881  1891  1901  1911  1921  1931  1941  1951  1961  P e r s p e c t i v e s Canada - 1974, Government o f C a n a d a , O t t a w a , T a b l e  1:1  -  ,141 -  APPENDIX  - 142  -  Marmor's Frames o f  The  Rational Actor  Within  Model:  t h i s m o d e l , g o v e r n m e n t i s t h o u g h t o f as  rational actor. choices  The  nation  ' v i e w e d as  g o a l s and  purposes'.  what g o a l  a nation  and  that  in light  reasonable  'The  basic  choice  The  of  and  policy  r a t i o n a l d e c i s i o n maker.  are  Rational  i s pursuing of  that goal  action  u n i t of a n a l y s i s  the  strategy.  i n s u c h work i s t h e  of  national showing action  most  government's  1  Process Model  outputs of o r g a n i z a t i o n s  s t a n d a r d s of b e h a v i o r under the  Marmor,  actions  i s i n t e r p r e t e d as  a c t i o n was  the  one.  Organizational  are  C h o i c e s and  i n f o l l o w i n g a c o u r s e of the  "the  i s u n d e r s t o o d as  means c a l c u l a t e d t o a c h i e v e  U n d e r t h i s m o d e l what r a t i o n a l p o l i c y acts  a single  occurences of n a t i o n a l p o l i t i c s are  of domestic a c t o r s "  a c t i o n of the the  Inference  analysts  functioning  call  choices  according  o r g a n i z a t i o n a l process  and  to model.  T.R. The P o l i t i c s o f M e d i c a r e , A l d e l i n e , C h i c a g o , pp 95 - 125.  1973  - 143  -  'The b a s i c u n i t o f a n a l y s i s i s t h e o r g a n i z a t i o n , and t h e f o c a l concepts  include routine behaviour  procedures, biased organizational  information, incremental  perspective?  The B u r e a u c r a t i c  standard  Politics  operating c h a n g e , and  1  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  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  policy  bargaining  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 t h e n a t i o n a l g o v e r n m e n t .  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 v i e w and s e t s o f struggle f o r t h e i r choice  o f outcomes  priorities  u s i n g t h e power a t t h e i r  disposal.  'The b a s i c u n i t o f a n a l y s i s i s t h e d e c e n t r a l i z e d game p l a y e d by r e l a t i v e l y  autonomous  concepts include bargaining  actors.  The  bargaining focal  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).  1  - 144 -  APPENDIX C  - 145 -  HEALTH MANPOWER DEVELOPMENT PROGRAM, CANADA A S t a t e m e n t A p p r o v e d by 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 C o m m i t t e e 1 May 1973 Obj e c t i v e : To i m p r o v e and m a i n t a i n , t h r o u g h t h e 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 c o n c e r n e d 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 o f 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 t h e d e l i v e r y of 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 . G o a l s a n d M e t h o d s - F i s c a l Y e a r 19 75/74 1.  Organization (a) G o a l  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 b a s e d on 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 C o m m i t t e e (The C o m m i t t e e ) w i t h t h e n e c e s s a r y a u t h o r i t y a n d a b i l i t y t o u n d e r t a k e h e a l t h manpower d e v e l o p m e n t programs.  (b) M e t h o d  (See Annex A) (i)  (ii)  (iii)  (iv)  (v)  The w o r k i n g c a p a c i t y o f t h e 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 i m p r o v e d to a l e v e l t h a t i t c a n undertake t h e t a s k s a s s i g n e d by The C o m m i t t e e . The w o r k i n g r e l a t i o n s h i p s b e t w e e n t h e H e a l t h Manpower D i r e c t o r a t e , D.N.H. & W. a n d t h e n a t i o n a l agencies concerned with the development o f h e a l t h manpower w i l l be i m p r o v e d t o a l e v e l t h a t t h e 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 C o m m i t t e e . 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 t o p e r f o r m t h e f u n c t i o n s o f D i r e c t o r o f H e a l t h Manpower (Provincial Director). 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 acquire the 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 t o 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 D e v e l o p m e n t P r o g r a m s ( P r o v i n c i a l Program). The w o r k i n g r e l a t i o n s h i p s b e t w e e n P r o v i n c i a l D i r e c t o r s and t h e p r o v i n c i a l a g e n c i e s c o n c e r n e d w i t h t h e d e v e l o p m e n t o f h e a l t h manpower w i l l be i m p r o v e d t o a l e v e l t h a t p e r m i t s t h e i m 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 (vi)  (vii)  (viii)  2.  The C o m m i t t e e w i l l meet a t l e a s t t w i c e i n t h e y e a r t o e n s u r e 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 collaboration. The C o m m i t t e e w i l l c o n t r i b u t e t o and p a r t i c i p a t e i n t h e Pan A m e r i c a n C o n f e r e n c e on H e a l t h Manpower D e v e l o p m e n t t o be h e l d i n O t t a w a , September 10 - 14, 1 9 7 3 . The C o m m i t t e e w i l l r e a c h a g r e e m e n t on g o a l s t o be a t t a i n e d d u r i n g t h e f i s c a l y e a r 1974/75.  Information  System  (a) G o a l  To c o n t i n u e t h e d e v e l o p m e n t o f a s y s t e m 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 a n d t o d e v e l o p a H e a l t h Manpower D a t a Bank.  (b) M e t h o d (i)  (ii)  (ii.i)  (iv)  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 cooperation with Provincial D i r e c t o r s , p r e p a r e a n d p u b l i s h t h e "Canada H e a l t h Manpower I n v e n t o r y 1 9 7 3 " by M a r c h 3 1 , 1 9 7 4 . 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 s h o w i n g 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 t h e M e d i c a l M a r k e t i n g Systems tapes and w i l l attempt t o 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 a n d occupational therapy l i s t i n g s . 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 " b y M a r c h 3 1 , 1974. 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 d e v e l o p t h e H e a l t h Manpower D a t a 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 C o m m i t t e e . 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 a n d S p e e c h Therapists 5. P h y s i o t h e r a p i s t s a n d Occupational Therapists 6. Pharmacists 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 . Laboratory & R a d i o l o g i c a l Technicians 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 terminology.  Requirements (a)  Goal  To c o o r d i n a t e and make r e c o m m e n d a t i o n s c o n c e r n i n g t h e p r o v i n c i a l and o v e r a l l r e q u i r e m e n t s f o r physicians of a l l kinds, nurses, pharmacists, a d m i n i s t r a t o r s and f o r t h e 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 F o r c e s e t up by t h e D.N.H. & W. H e a l t h Manpower C o o r d i n a t i n g C o m m i t t e e 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 t h e N a t i o n a l P h y s i c i a n Manpower C o m m i t t e e and t h e 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 t h e o v e r a l l r e q u i r e m e n t s for physicians of a l l kinds. The C o m m i t t e e 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 a n d f r o m 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 a g r e e m e n t on r e c o m m e n d a t i o n s f o r o v e r a l l requirements.  (ii)  N u r s e s - The Committee w i l l r e v i e w t h e recommendations a r i s i n g from a study c a r r i e d o u t by t h e C a n a d i a n N u r s e s ' A s s o c i a t i o n u n d e r c o n t r a c t t o D.N.H. & W. t o e s t i m a t e the r e q u i r e m e n t s f o r n u r s e s and n u r s i n g a s s i s t a n t s i n Canada o v e r t h e n e x t 5 y e a r s in conjunction with the reports of p r o v i n c i a l s t u d i e s t o r e a c h a g r e e m e n t on r e c o m m e n d a t i o n s for o v e r a l l requirements.  (iii)  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 C o m m i t t e e w i l l r e v i e w t h e recommendations a r i s i n g from a s t u d y c a r r i e d o u t by t h e C a n a d i a n C o l l e g e of Health Services Executives under c o n t r a c t t o D.N.H. & W. t o p r e p a r e a p r e l i m i n a r y forecast of requirements f o r health 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 t h e n e x t 7 y e 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 c o m p l e t e f o r e c a s t s as n e e d e d .  (iv)  (v ) :  4.  - 148 D e n t a l Manpower - The Committee w i l l r e v i e w t h e recommendations a r i s i n g from a study c a r r i e d out by D r . D. IV. L e w i s a n d M r s . B . I . Brown o f t h e U n i v e r s i t y o f T o r o n t o u n d e r c o n t r a c t t o D.N.H. & W. to e s t i m a t e t h e r e q u i 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 t h e 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 t h e 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 t h e g e n e r a l employment o f t h e r a p i s t s . O t h e r H e a l t h Manpower - The C o m m i t t e e w i l l e x a m i n e methods a n d p r i o r i t i e s f o r d e t e r m i n i n g requirements f o r o t h e r h e a l t h manpower.  Supply (a) Goal  (b)  To r e v i e w t h e 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 t h e a g r e e d r e q u i r e m e n t s a n d t o 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 i m b a l a n c 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 p h y s i c i a n s and n u r s e s .  Method (i)  (ii)  (iii)  (iv)  (v) (vi)  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 f u r t h e r s t u d i e s t o d e t e r m i n e methods of improving migration f o r e c a s t s . The C o m m i t t e e w i l l r e v i e w t h e r e p o r t s on t h e s t u d y u n d e r t a k e n b y A.U.C.C. w i t h D r . Rocke R o b e r t s o n as t h e c h i e f i n v e s t i g a t o r , a n d f u n d e d t h r o u g h t h e N a t i o n a l H e a l t h Grant Program t o determine t h e t o t a l planned outputs o f a l l Canadian H e a l t h Sciences 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 t o e s t i m a t e t h e i r maximum o u t p u t c a p a c i t i e s . 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 r e c o m m e n d a t i o n s on a method o f u p d a t i n g a n n u a l l y t h e i n f o r m a t i o n on t h e o u t p u t c a p a c i t i e s . The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on t h e extent t o which t h e f l o w o f immigrant p h y s i c i a n s and n u r s e s a n d t h e o u t p u t s o f o u r m e d i c a l a n d n u r s i n g s c h o o l s must be c h a n g e d a n d how t h i s s h o u l d be a c c o m p l i s h e d . The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on methods o f r e d u c i n g t h e a t t r i t i o n o f h e a l t h manpower. The C o m m i t t e e w i l l o f f e r a d v i c e t o t h e H e a l t h R e s o u r c e s A d v i s o r y C o m m i t t e e on f u t u r e commitments f r o m t h e H e a l t h R e s o u r c e s Fund t o w a r d s t h e c o n 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  -  Quality (a)  Goal  (b)  Method  To r e a c h a g r e e m e n t on methods f o r e n s u r i n g t h a t t h e h e a l t h manpower g r a d u a t i n g f r o m o u r e d u c a t i o n a l i n s t i t u t i o n s are of 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 t h e needs o f C a n a d i a n communities.  (i) (ii)  (iii)  (iv)  The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on r e s e a r c h p r i o r i t i e s . The C o m m i t t e e w i l l a s s i s t t h e 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 to 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)  Actions which educational i n s t i t u t i o n s and g o v e r n m e n t s c o u l d t a k e t o i m p r o v e t h e 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 of the e d u c a t i o n a l p r o c e s s and on t h e t y p e s o f c o m p e t e n c e 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 settings.  The C o m m i t t e e w i l l a s s i s t D.N.H. & W. i n the t a s k of 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 N u r s e s f o r Community S e r v i c e i n O t t a w a , November 13 - 16, 1973. The p u r p o s e o f t h e 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 c o n s e n s u s 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 n u r s e s 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 .  The C o m m i t t e e 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 o r l o c a l h e a l t h manpower c o n f e r e n c e s .  Distribution (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 t h e 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 a r e a s and t o i n a u g u r a t e new programs.  .6  - 150 (b)  -  Method (i)  (ii)  Goal  (b)  Method  The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on the i n a u g u r a t i o n o f new p r o g r a m s t o i m p r o v e t h e d i s t r i b u t i o n o f h e a l t h manpower.  (iii)  The C o m m i t t e e w i i l r e v i e w t h e a d v a n t a g e s and d i s a d v a n t a g e s o f l i m i t i n g t h e l i c e n s e s of p h y s i c i a n s f o r purposes of ensuring better geographical d i s t r i b u t i o n , better 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 c o m p e t e n c e .  (iv)  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 t h e p r o v i n c e s and w i t h i n C a n a d a , The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on what must be done i n t h e fields of:  P r o d u c t i v i t y and (a)  The C o m m i t t e e w i l l r e v i e w t h e r e c o m m e n d a t i o n s 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 t o D.N.H. & W. t o e v a l u a t e t h e e f f e c t i v e n e s s o f 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 underseryiced 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 .  (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)  Recognition  of educational  credits.  Utilization  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 t h e p r o d u c t i v i t y and u t i l i z a 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 community h e a l t h s e r v i c e s .  (i)  (ii)  The C o m m i t t e e w i l l r e v i e w t h e v a l u e and t h e 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 e x p a n d the r o l e o f the nurse i n p r i m a r y h e a l t h care s e r v i c e s and t h e e f f o r t s made t o e x p a n d t h e r o l e s o f t h e n u r s e i n h o s p i t a l and s p e c i a l i s t services. The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on what s h o u l d be done t o t r a n s f e r f u n c t i o n s of other 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 personnel 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 .  - 151 -  Research (a)  Goal  (b)  Method  To r e a c h a g r e e m e n t 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 a n d t o i n a u g u r a t e high p r i o r i t y projects.  (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 p d a t e 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 3 1 , 1 9 7 3 .  (ii)  The C o m m i t t e e r e c o g n i z e s t h e 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 .  (iii)  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 o n t h o s e p r o j e c t s l i s t e d • i n Annex B w h i c h a r e m a r k e d w i t h a s t a r .  (iv)  (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 t h e N a t i o n a l H e a l t h G r a n t P r o g r a m W i l l be p r e p a r e d b y D.N.H. & W. a n d d i s t r i b u t e d t o members o f The C o m m i t t e e . Project reports w i l l also be d i s t r i b u t e d when a v a i l a b l e . The C o m m i t t e e w i l l make r e c o m m e n d a t i o n s on f u t u r e research p r o j e c t s f o r support by t h e N a t i o n a l H e a l t h Grant Program.  - 152 — Health  Manpower Development Organisational  Program Rase  ANN F- X A  -  Canada  - 153 ANNEX B RESEARCH PROJECTS HEALTH MANPOWER Requirements *1. *2. *3. *4. 5. |  Requirements f o r p h y s i c i a n s o f a l l k i n d s . Requirements f o r nurses. Requirements 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 . Requirements f o r d e n t i s t s / t h e r a p i s t s . Examination o f new h e a l t h d i s c i p l i n e s l i k e l y to be r e q u i r e d f o r new h e a l t h programs.  Supply and A t t r i t i o n  r  ! ] I  *6. *7.  I  *8. |. . .• i j  :  9. 10.  A n a l y s i s of d i s c r e p a n c i e s between p r o j e c t i o n s of h e a l t h manpower supply and estimated requirements. A n a l y s i s o f data on the supply, d i s t r i b u t i o n and e d u c a t i o n a l requirements of nursing personnel . ... A n a l y s i s o f a t t r i t i o n of nurses, composition o f new i n f u s i o n i n t o the nursing ranks and the career patterns o f nurses. A n a l y s i s o f supply and requirements f o r p h a r m a c i s t s , A n a l y s i s o f a t t r i t i o n i n a l l d i s c i p l i n e s except nursing. •  j Distribution *11. |  E v a l u a t i o n o f programs f o r the d i s t r i b u t i o n o f h e a l t h manpower i n t o underserviced areas. A n a l y s i s o f medical graduates by l o c a t i o n and f i e l d of p r a c t i c e . A n a l y s i s o f job vacancy surveys to determine f u n c t i o n a l and geographic demand p a t t e r n s f o r h e a l t h manpower. A n a l y s i s of the p a t t e r n o f emigration o f Canadian medical graduates to the U.S.A. 1965/70. A n a l y s i s o f f o r e i g n medical graduates by s p e c i a l t y and by p r o v i n c e .  *12. *13. *14.  ' !  *15.  ! Applicants *16. *17. 18.  '  A n a l y s i s o f medical school a p p l i c a n t s enrollments. A n a l y s i s o f nursing school a p p l i c a n t s enrollments. A n a l y s i s o f a p p l i c a n t s and enrollments a l l d i s c i p l i n e s except medicine and  and and in nursing. .2  -.154  -  Education *19. *20. *21. 22.  C a p a c i t i e s of h e a l t h sciences e d u c a t i o n a l institutions.. A p p r a i s a l of teaching i n the h e a l t h s c i e n c e s . R e v i s i o n of the survey of u n i v e r s i t y programs to prepare nurses f o r expanded r o l e s . E v a l u a t i o n of the q u a l i t y of graduates i n the l i g h t of community requirements.  Employment *23. *24. 25. 26. 27. 28.  A n a l y s i s of o c c u p a t i o n a l employment surveys produced by S t a t i s t i c s Canada. Comparative a n a l y s i s o f f i n a n c i a l rewards f o r h e a l t h manpower. A n a l y s i s of the employment of nurses. A n a l y s i s of the present u t i l i z a t i o n o f nurses. A n a l y s i s of the f u n c t i o n s of a l l h e a l t h manpower. A n a l y s i s o f the b a r r i e r s which prevent the b e t t e r u t i l i z a t i o n of nurses.  * A l r e a d y i n c l u d e d i n work p l a n s , c o n t r a c t s or N a t i o n a l H e a l t h Grant p r o j e c t s of the Department o f N a t i o n a l Health and Welfare. • •''  - 155 -  APPENDIX  D  - 156 -  ORGANIZATIONAL  PATTERNS  FOR H E A L T H 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 representatives of the Advisory Committee.  They are reproduced as submitted.  fact that there is less uniformity of style than in the report of  1975.  This explains the  - 158 CANADA The centre of the national structure for health manpower information, development 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 each of the 10 provincial governments,  of the federal government and of  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 manpower 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 regularly included in order to give further dimension to discussions concerning health manpower 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 practice 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 Program,* 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 programs and policies, pointing out favourable and unfavourable influences 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 agencies concerned with each of these disciplines.  Due partly to financial constraints and  monetary obligations, the demands that such committees put on their member organizations, 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 H e a l t h " Manpower D e v e l o p m e n t and - Canada O r g a n i z a t i o n a l Base  Planning  - 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 Committee 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  Federal/Provincial Health Manpower Committee  Professional Associations  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 specialities.  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 personnel 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 personnel 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 applications, 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 comprehensive legislative base for program activity that considers occupational definitions, overlapping fields and specialties, manpower 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. 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.  The  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 policies.  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 representatives 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  -  Federal/Provincial Health Manpower Committee  Administrator Program Development and Evaluation Department of Health  Co-ordinator Health Manpower  Health Manpower Co-ordinating Committee  Technician Subcommittee  Nursing Subcommittee  Physician Services Subcommittee  Professional Associations Department of Education Dalhousie University Health Services Commission Nova Scotia Health Council Nova Scotia Hospital Commission Board - of Registration of Nursing Assistants  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 Information 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 province.  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 C H A R T FOR H E A L T H MANPOWER  Deputy Minister of Health  Director Planning & Evaluation Division  Federal-Provincial Advisory Committee on Health Manpower \  Physician Manpower Committee /  \ /  \  /  :\  /  \  \  Health Manpower Planner  /  /  i i i Nursing Manpower 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 Remuneration) 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 remuneration , working conditions, training of manpower in order to ensure cohesion between the orientations of Social Affairs, manpower 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.) responsible for manpower, training and upgrading matters.  who are  DEPARTMENT OF SOCIAL AFFAIRS  Labour Relations Branch  QUEBEC  Unionized Staff Directorate  Professional Staff Directorate  Executive Staff Directorate  Manpower and Remuneration Directorate  Negotiations  Negotiations  Relations with associations and institutions  Labour relations research  Negotiating body  Negotiating body  Relations with executive staff  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 requirements, 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 administering the Ministry of Health budget for clinical education. Responsibility for health disciplines legislation is assigned to the Health Disciplines 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  Education (Colleges & Universities)  Health  Ontario Council of Health  Minister  Minister  Deputy Minister  Deputy Minister  Health Sciences Education Committee \  \  \ Policy Development and Research Branch  Human Resources Committee  \  \  I  ^ \  Coordinator Health Sciences Education  \ Health Manpower Section  Provincial Review (Education) Committee  Clinical Education Committee  ADM Community Health Services  Health Disciplines Coordinator Medical Manpower Advisory Committee  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 Medical 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 continuing 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 Requirements Sub-Committee.  This Sub-Committee, which reports to the Western Ministers of  Post-Secondary Education, monitors training needs for all Western Canada health personnel 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. post-secondary system, encompasses three major components: stitutes, and community colleges.  The  universities, technical in-  The Saskatchewan concept of community colleges is  different from elsewhere in Canada as these institutions do not offer any ongoing occupational training programs except on a contract basis with universities or institutes. health manpower training, therefore,  All  occurs in either the universities or technical.  institutes. The relationship between the Department of Continuing Education and the universities 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 becomes involved in assessing new program proposals, program revisions and program modifications.  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 personnel 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 manpower 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 disciplines, 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 Education , 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 professional 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 requirements 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-  Interdepartmental  181 ~  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.  mental Committee is made up of four representatives  The Interdepart-  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 definition and resolution of policy matters regarding health manpower training programs and health manpower issues of concern to both departments. reference of the Interdepartmental  More specifically, the terms of  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 :  b.  The Committee will establish priorities and procedures for activities requiring interdepartmental  c.  department.  cooperation.  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 intragovernmental 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 action 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 requirements of national significance.  SASKATCHEWAN:  Health Manpower Development Organization Pattern  Inter-provincial Committees Federal Provincial Advisory Committee on Health Manpower  2.  Department of Health  Provincial Health Professional Associations and Agencies  Western Canada Post-Secondary Health Manpower Requirements Subcommittee  Interdepartmental Committee on Health Manpower & Education  Department of Continuing Education  Saskatchewan Universities Commission  University of Saskatchewan  indicates liaison and discussion  University of Regina  Technical Institute  - 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 Commission.  The Deputy Minister of Health Services acted as Chairman.  reorganization following their last election in 1975,  With the government  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 functions, 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. represented on the Committee are as follows:  Government departments  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. other agencies, associations,  Provision has been made for input from  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 services 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 development 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 PostSecondary 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  Federal/Provincial Health Manpower Committee  Alberta Manpower Committee  Social Services & Community • Health  Alberta Health & Social Services Disciplines Committee  '  1  Advanced Education and Manpower Hospitals and Medical Care  " V \  \  Western Canada PostSecondary Health Man Power Requirements Subcommittee  Professional Associations  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, British Columbia.  Research and Development, Health Sciences Centre, University of  BRITISH COLUMBIA  Ministry of Health  Ministry of Education  Ministry of Labour  4/  Universities Council Health Manpower Working Group  4^  Health . Manpower Research Unit  Manpower Needs Committee  Academic Council  Occupational Training Council  Management Advisory Council  - 189 -  Y U K O N TERRITORY The present health care delivery system in the Yukon is a joint effort development 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 oi Health  Chief Health Insurance . Programs  Chief Health Programs and Standards  1  1  .1  :  1  Health Manpower Development  1  1  Chief Finance and Administration  - 192 -  l  APPENDIX E  - 193 -  B.C. HEALTH ASSOCIATION MANPOWER COMMITTEE TERMS OF REFERENCE  1.  To advise and recommend to the Board o f D i r e c t o r s on H e a l t h Manpower p o l i c y i s s u e s by a)  E n s u r i n g t h a t the employers are i n v o l v e d i n the d e f i n i t i o n o f manpower needs i n the h e a l t h care i n d u s t r y now and i n the f u t u r e .  b)  M a i n t a i n i n g an i n v e n t o r y o f B.C. Health A s s o c i a t i o n ' s and o t h e r agency's r e s e a r c h e f f o r t s i n the h e a l t h manpower field.  c)  I d e n t i f y i n g areas o f h e a l t h manpower r e s e a r c h b e i n g addressed.  n o t now  2.  To recommend t o the Board o f the B.C. H e a l t h A s s o c i a t i o n , t h e e s t a b l i s h m e n t o f ad hoc committees t o 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 p r o g r e s s o f such Committees o r p r o j e c t s r e l a t e d to manpower i s s u e s .  4.  To encourage l i a i s o n v i a r e p r e s e n t a t i o n o f one o f the Manpower Committee members w i t h the H e a l t h Manpower Working Group.  5.  To l i a i s e w i t h the B.C. H e a l t h A s s o c i a t i o n E d u c a t i o n Committee on i s s u e s o f mutual concern.  January 14, 1980  

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