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An analysis of problems encountered in the preparation of a regional health and hospital study in British… Morton, Wendy Lynn 1985

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AN ANALYSIS OF PROBLEMS ENCOUNTERED IN THE PREPARATION OF A REGIONAL HEALTH AND HOSPITAL STUDY IN BRITISH COLUMBIA By WENDY LYNN MORTON B.A., The University of B r i t i s h Columbia, 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (Health Planning and Administration) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA January, 1985 (c) Wendy Lynn Morton, 1985 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f tfefaTrt Ote Ave? &p/0£Sf/QlQ<iy The U n i v e r s i t y of B r i t i s h Columbia 1956 M a i n M a l l Vancouver, Canada V6T 1Y3 Date DE-6 (3/81) ABSTRACT I n 1982/83, the author, i n the r o l e of c o n s u l t a n t to the f i r m of Thompson Berwick Pratt and Partners, A r c h i t e c t s and P l a n n e r s , Vancouver, conducted a regional health needs study In the i n t e r i o r of B r i t i s h Columbia for the Board of the Thompson-Nicola Regional Hospital D i s t r i c t (TNRHD). The completed report e n t i t l e d , The Thompson-Nicola R e g i o n a l H o s p i t a l D i s t r i c t  Health and Hospital Study has subsequently been tabled as a public document. T h i s planning thesis i s concerned with the processes of conducting the study which was more complex than o r j g i n a l l y e nvisaged. The n a r r a t i v e d e s c r i b e s the planning model developed by the consultants to f i t the terms of reference which were, i n b r i e f , to assess e x i s t i n g l o c a l h e a l t h s e r v i c e needs and the supply and d i s t r i b u t i o n of health resources i n the region, and to p r o j e c t f u t u r e requirements through 1991. In attempting to develop the model i t was r e a l i z e d that the Thompson-Nicola Regional H o s p i t a l Board had l i m i t e d powers to i n i t i a t e a study f o r a l l health and h o s p i t a l providers i n the region. The Board's planning mandate was l i m i t e d by s t a t u t e , and t h i s l i m i t a t i o n i s explored. Co-operation among l o c a l providers was achieved through persuasion. The M i n i s t r y of H e a l t h (MOH) had funded 60 per cent of the project, thereby i n d i c a t i n g to l o c a l groups that i t supported the Board's planning approach. The M i n i s t r y of Health's concern f o r r a t i o n a l planning has already been expressed i n other ways (e.g. The B r i t i s h Columbia Hospital Role and Funding Studies) although p l a n n i n g i s s t i l l ad hoc r a t h e r than part of a c l e a r M i n i s t r y p o l i c y . The l a c k of integration among providers made i t d i f f i c u l t to determine need and demand f o r h e a l t h s e r v i c e s i n the r e g i o n . There were s p e c i f i c problems of d e f i n i t i o n of need, and s p e c i f i c and recurrent problems of data c o l l e c t i o n and a n a l y s i s because of the l a r g e number of independent data r e s o u r c e groups i n v o l v e d . Problems i n s e l e c t i n g and a p p l y i n g models of analysis were also experienced. N e v e r t h e l e s s , a model of h e a l t h s e r v i c e s needs and resource requirements was constructed. The t h e s i s concludes by summarizing study problems and underlying issues, and recommending f i r s t steps for resolving issues, or modifying t h e i r e f f e c t s . Suggestions as to who has the power to do this are made. < i v TABLE OF CONTENTS PAGE ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES ' i x LIST OF FIGURES x ACKNOWLEDGEMENTS x i SECTION A INTRODUCTION CHAPTER I BACKGROUND AND RESEARCH FOCUS 1 The Thompson-Nicola Regional Hospital D i s t r i c t Study 1 Study Terms of Reference 1 Thesis Research Focus 3 Problem 3 Questions 4 Thesis Research Design 5 Method 5 Format 5 SECTION B INTERPRETING THE THOMPSON-NICOLA REGIONAL HOSPITAL DISTRICT STUDY'S TERMS OF REFERENCE V PAGE CHAPTER II DETERMINING THE PARAMETERS AND PURPOSE OF THE STUDY, AND DEVELOPMENT OF THE STUDY PLANNING MODEL 8 Introduction 8 Determining The Parameters of The Study 9 Determining The Purpose of The Study . . . 10 The Study Within The Context of The Health Services Planning L i t e r a t u r e 11 Development of The Thompson-Nicola Regional Hospital D i s t r i c t Study Planning Model 14 SECTION C ORGANIZATIONAL ISSUES COMPLICATING DEVELOPMENT OF THE STUDY CHAPTER III LOCAL HEALTH AND HOSPITAL GROUPS AND THE THOMPSON-NICOLA REGIONAL HOSPITAL DISTRICT STUDY 17 Introduction 17 Evolution and Powers of Regional Hospital D i s t r i c t s 17 The Thompson-Nicola Regional Hospital D i s t r i c t Board 22 IV ORGANIZATION OF HEALTH SERVICES AT THE FEDERAL, PROVINCIAL (B.C.) AND LOCAL LEVELS 24 Introduction 24 Health Services at The Federal Level 24 Health Services at The P r o v i n c i a l Level (B.C.) 25 v i PAGE Health Services at The Local Level 27 V MAJOR FEDERAL AND BRITISH COLUMBIA HEALTH-RELATED LEGISLATION. 41 Introduction 41 Federal Health-Related L e g i s l a t i o n 41 B r i t i s h Columbia Health-Related L e g i s l a t i o n 50 VI ATTEMPTS BY THE BRITISH COLUMBIA GOVERNMENT TO IMPROVE SYSTEM INTEGRATION 6 5 ' Introduction v65 The B r i t i s h Columbia Hospital Role and Funding Studies 66 F i n a n c i a l Re-Structuring of Programs 69 A Proposal f o r Regionalization of Health Services i n B r i t i s h Columbia « 7 4 ' SECTION D INTEGRATING THE INFORMATION FOR A NON-INTEGRATED SYSTEM CHAPTER VII RECURRENT PROBLEMS IN THE COLLECTION AND ANALYSIS OF STUDY DATA 8 2 Introduction -82 A v a i l a b i l i t y of Data 8 2 R e l i a b i l i t y of Data 8 3 P o t e n t i a l f o r Bias i n The C o l l e c t i o n and Analysis of Data . . . 8 ^ v i i PAGE VI I I SPECIF IC PROBLEMS COMPLICATING DEVELOPMENT OF A COMPREHENSIVE INFORMATION BASE 94 I n t r o d u c t i o n 94 I d e n t i f i c a t i o n of T e c h n i q u e s f o r D e t e r m i n i n g Need f o r H e a l t h S e r v i c e s 94 I d e n t i f i c a t i o n of S e r v i c e A r e a C h a r a c t e r i s t i c s 1QP D e t e r m i n a t i o n of The S u p p l y of H e a l t h S e r v i c e s and Re sou rce s i n The R e g i o n 104 SECTION E ESTIMATION OF HEALTH'SERVICE NEEDS AND RESOURCE  REQUIREMENTS FOR THE THOMPSON-NICOLA REGIONAL HOSPITAL DISTRICT CHAPTER IX MODELLING ISSUES AND MODELS OF ANALYSIS 114 I n t r o d u c t i o n 1 1 4 B e d - R e s o u r c e E s t i m a t i o n Models and T h e i r L i m i t a t i o n s l~l-5 S e l e c t e d B e d - R e s o u r c e E s t i m a t i o n Models 121 A c u t e I n - p a t i e n t Beds 121 E m e r g e n c y / O u t p a t i e n t S e r v i c e s 135 I n t e r m e d i a t e and E x t e n d e d C a r e Beds 139 N o n - h o s p i t a l H e a l t h C a r e Programs 1^2 M e d i c a l and N o n - m e d i c a l H e a l t h Ca re P e r s o n n e l - l ^ 2 M o d e l l i n g of The H e a l t h Ca re System i 4 4 v i i i SECTION F CONCLUSION PAGE CHAPTER X SUMMARY AND RECOMMENDATIONS 146 Introduction 146 Summary of Identified Problems and Underlying Issues 147 Major Themes Identified 154 Success of The Thompson-Nicola Regional Hospital District Study Given Limitations 1 5 5 Recommendations 156 Conclusions 160 BIBLIOGRAPHY 1 6 2 APPENDICES I BRITISH COLUMBIA HEALTH ASSOCIATION SUMMARY OF HOSPITAL ROLE STUDY, 1979 (DRAFT DOCUMENT) 1 6 9 II DEPARTMENT OF NATIONAL HEALTH AND WELFARE (HEALTH AND WELFARE CANADA) EMERGENCY DEPARTMENT CLASSIFICATION SCHEME, 1975 1 7 6 i x LIST OF TABLES TABLE PAGE I. Organization of P r o v i n c i a l Health Services ( B r i t i s h Columbia, 1983) 28 I I . Major Federal and B r i t i s h Columbia Health-Related L e g i s l a t i o n , 1984 42 I I I . B r i t i s h Columbia Hospital Program's Suggested Suitable Acute Care Hospital Occupancy Rates, 1982 131 X LIST OF FIGURES FIGURE PAGE 1. Elements of The Health Planning Process 12 2. The Thompson-Nicola Regional Hospital D i s t r i c t Study Planning Model, 1983 15 3. B r i t i s h Columbia Regional D i s t r i c t s , 1984 18 4. B r i t i s h Columbia Min i s t r y of Health Organizational Chart, 1982 . 26 5. Expenditure by P r i n c i p a l Categories i n the B r i t i s h Columbia Ministry of Health f o r F i s c a l Year 1981/82 70 6. Proposed Health Regions f o r B r i t i s h Columbia, 1981/82 78 7. Attitudes of Special Interest Groups Toward Health P o l i c y Issues, 1981. . . . 91 8. Local Health Services Administrative Geographic Boundaries, 1983 106 xi ACKNOWLEDGEMENTS I n a c k n o w l e d g i n g t h o s e who h a v e h e l p e d me i n p r e p a r a t i o n o f t h i s t h e s i s , I must f i r s t of a l l e x p r e s s my g r a t i t u d e t o my p a r e n t s who showed me t h a t d i f f i c u l t g o a l s c a n be a t t a i n e d . T o D r . A n n e C r i c h t o n , D e p a r t m e n t of H e a l t h Ca re and E p i d e m i o l o g y , my mentor and f r i e n d th roughou t the program, and t o the two o t h e r members of my c o m m i t t e e , D r . H e n r y H i g h t o w e r , D e p a r t m e n t o f C o m m u n i t y a n d R e g i o n a l P l a n n i n g , a n d D r . C o u r t M a c k e n z i e , D e p a r t m e n t o f H e a l t h C a r e a n d E p i d e m i o l o g y , f o r t h e i r r e s p e c t i v e r o l e s as a d j u d i c a t o r and e d i t o r . To the team at Thompson B e r w i c k P r a t t and P a r t n e r s , a n d t o D r . M o r t o n W a r n e r , f o r t h e i r s u p p o r t and c o l l a b o r a t i o n i n the s t u d y , and f i n a l l y t o my husband, J o h n , whose a u d i t i n g of t h i s work and e v e r g r o w i n g f a m i l i a r i t y w i t h the u n d e r l y i n g i s s u e s has no t made h im anx ious f o r more. 1. SECTION' A INTRODUCTION CHAPTER I BACKGROUND AND RESEARCH FOCUS The Thompson-Nicola Regional Hospital D i s t r i c t Study I n 1982, the c o n s u l t i n g f i r m of Thompson Berwick Pratt and Partners, Architects and Planners, Vancouver was commissioned to prepare a r e g i o n a l h e a l t h and h o s p i t a l study i n the i n t e r i o r of B r i t i s h Columbia. This writer was the p r o j e c t c o - o r d i n a t o r and c h i e f author of the s t u d y which was e n t i t l e d , The Thompson-Nicola Regional Hospital D i s t r i c t Health and Hospital  Study. The p r i n c i p a l c l i e n t was the Board of the Thompson-Nicola Regional Hospital D i s t r i c t (TNRHD). The B r i t i s h Columbia M i n i s t r y of H e a l t h (MOH) played a fundamental role i n a s s i s t i n g the Board with the formulation of- the study's terms of reference, and authorizing funding to be cost-shared with the Board on a 60 per cent (MOH) : 40 per cent (TNRHD Board) basis. The study was c a r r i e d out but f e l l s hort of the i n v e s t i g a t o r ' s hopes due to numerous problems encountered. Therefore, the major question for th i s t h e s i s i s : Why were these problems encountered i n the course of preparing  The TNRHD Health and Hospital Study? Study Terms of Reference In b r i e f , the study's terms of reference were to assess e x i s t i n g l o c a l 2 . h e a l t h s e r v i c e s use, and the supply and d i s t r i b u t i o n of health resources i n the TNRHD, and to project future r e s o u r c e requirements through 1991. The study was to take approximately s i x months. The detailed terms of reference provided to the consultants were as follows: "1. General I d e n t i f y area to be served, together w i t h p e r t i n e n t f e a t u r e s that may a f f e c t health care or a c c e s s i b i l i t y ; this to include geographic f e a t u r e s : highways, t r a n s p o r t a t i o n s e r v i c e s , c l i m a t i c and the general economy of the D i s t r i c t . 2. Population (a) I d e n t i f y i s o l a t e d , as well as major centres of population within s c h o o l d i s t r i c t s ( l o c a l h e a l t h a r e a s ) w i t h i n the r e g i o n a l h o s p i t a l d i s t r i c t . (b) Display population trends c o v e r i n g 1966, 1971, 1976 and 1981 census p e r i o d s according to age group (0 - 14 paediatric, 15 -44 female, 15 - 60 t o t a l , 65 and over, 70 and over), w i t h i n school d i s t r i c t , within regional h o s p i t a l d i s t r i c t . E s t imate p o p u l a t i o n growth over the next ten years and provide supportive data. 3. External Factors I d e n t i f y health care needs supplied to other regions and health care normally obtained from other regions. 4. Current and H i s t o r i c a l Health Care Records (a) I d e n t i f y e x i s t i n g health care services and f a c i l i t i e s and g i v e dates when established or b u i l t . (b) Display f i v e years ' h o s p i t a l i z a t i o n experience by major h o s p i t a l s e r v i c e , together w i t h percentage occupancy rates and average length of stay figures f o r each f a c i l i t y i n the region. (c) Display the incidence of h o s p i t a l i z a t i o n frequency ( r a t e s ) f o r the years 1966, 1971, 1976, 1981, along with hospital/school d i s t r i c t p a t i e n t r e f e r r a l p a t t e r n s by age group and major service. (d) D i s p l a y f i v e years of recent volume of a l l outpatient/day care services by f a c i l i t y . (e) Display one year of extended care and intermediate care w a i t i n g l i s t volume and p a t i e n t l e n g t h of wait by f a c i l i t y of f i r s t choice and age group (quarterly l i s t s ) . ( f ) Display a p p r o p r i a t e u t i l i z a t i o n of n o n - h o s p i t a l h e a l t h c a r e u t i l i z a t i o n including a l l agencies working under the auspices of the M i n i s t r y of Health (see 5 (e) 0). 5. Future Requirements D i s p l a y f u t u r e u t i l i z a t i o n of h e a l t h care requirements f o r a ten 3. year period and indicate approximate l o c a t i o n . Hospitals: (a) Display future incidence rates, r e f e r r a l p a t t e r n s and estimate h o s p i t a l p a t i e n t day volume. I n d i c a t e the reasons f o r any upward/downward swing i n rates and patient flow patterns. (b) Determine su i t a b l e occupancy rates for major h o s p i t a l s e r v i c e s and c a l c u l a t e bed requirements. (c) Compare study area's beds per 1,000 population with p r o v i n c i a l experience and e x i s t i n g standards. (d) Substantiate any d e v i a t i o n s from the g u i d e l i n e s on h o s p i t a l r o l e s as s e t f o r t h i n the H o s p i t a l R o l e Study based on recommendations of bed and service requirements. Other Health Care Services: (e) Determine requirements for n o n - h o s p i t a l s e r v i c e s . I n c l u d e a l l those agencies operating under the auspices of the M i n i s t r y of Health: i . e . , ( i ) Community Health Services ( i i ) Emergency Health Services ( i i i ) A l c o h o l and Drug S e r v i c e s " (The Thompson-Nicola R e g i o n a l H o s p i t a l D i s t r i c t H e a l t h and H o s p i t a l Study, Terms of Reference, 1983) Thesis Research Focus  Problem I t was the writer's b e l i e f that the development of a r e g i o n a l h e a l t h and h o s p i t a l study would be a worthwhile exercise, and that the completed study would be an i n v a l u a b l e t o o l to policy-makers i n making d e c i s i o n s regarding the present and future a l l o c a t i o n of resources i n the region. I t was assumed t h a t the t a s k of d e v e l o p i n g the study would be straight-forward. The terms of reference had indicated the study components to be c o n s i d e r e d . A model would be constructed i n d i c a t i n g the d i r e c t i o n i n which the study would proceed, data would be c o l l e c t e d , and h e a l t h s e r v i c e needs and r e s o u r c e requirements estimated u s i n g documented models of analysis. I n f a c t , problems were encountered i n i n t e r p r e t i n g the terms of 4. r e f e r e n c e , I d e n t i f y i n g study p a r t i c i p a n t s , c o l l e c t i n g study data, and se l e c t i n g and applying models of analysis. As a r e s u l t , p r e p a r a t i o n of the study was not s t r a i g h t - f o r w a r d , and an all-encompassing approach to the estimation of the region's health service needs and re s o u r c e requirements was not a c h i e v e d , though f u t u r e use p a t t e r n s and reso u r c e needs were estimated to the best of the consultants' a b i l i t y . Because of the b r i e f d u r a t i o n of the s t u d y , t h e r e was l i t t l e opportunity to analyse i n depth why these problems occurred. Certainly, some of the problems were the r e s u l t of this investigator's l i m i t e d experience with regional health and h o s p i t a l studies i n general. However, the m a j o r i t y of study problems appeared to occur as a r e s u l t of two types of underlying issues. The f i r s t concerned systems i s s u e s such as, the l i m i t e d p l a n n i n g powers of the Regional Hospital D i s t r i c t , the organizational complexity of the health care system, funding mechanisms, health-related Acts, p r o v i n c i a l government c o s t c o n t r o l measures, and the l a c k of c o - o r d i n a t i o n and int e g r a t i o n among providers and serv i c e s . The second involved methodological issues, which i n turn appeared to be compounded by systems i s s u e s . I f t h i s assumption is correct, then problems w i l l continue to be experienced i n the process of developing regional health and ho s p i t a l studies u n t i l u n d e r l y i n g issues are resolved. Questions The p r i n c i p a l research question to be addressed i n th i s thesis i s : Why  were problems encountered i n the course of developing the TNRHD study? I f study problems are found to be the r e s u l t of underlying systems and me t h o d o l o g i c a l i s s u e s , the second question to be explored i s : Who has the 5 . power to resolve these issues? Thesis Research Design  Method Research i n t o why study problems occurred has been based primarily on an a n a l y t i c a l and problem-solving approach, rather than a p r e s c r i p t i v e one. Research data has been drawn from: . The TNRHD study terms of reference Personal experience and information from the TNRHD study D i s c u s s i o n s with o f f i c i a l s from the Minist r y of Health, the B r i t i s h Columbia Medical A s s o c i a t i o n , and the C o l l e g e of P h y s i c i a n s and Surgeons of B r i t i s h Columbia . H e a l t h care p o l i c y , c o n f l i c t theory and health services planning l i t e r a t u r e , and Government reports, and federal and p r o v i n c i a l statutes. F ormat Study problems w i l l be i d e n t i f i e d and analysed i n t h i s t h e s i s i n the order i n which they appeared i n the study. Relevant l i t e r a t u r e w i l l be reviewed as part of the analysis of each of the study problems. Chapter II w i l l begin by d e s c r i b i n g the problems encountered at the onset of the study i n defining the purpose and parameters of the study. The study w i l l then be c o n s i d e r e d w i t h i n the context of the h e a l t h s e r v i c e s planning l i t e r a t u r e to determine where the study f i t s i nto the l i t e r a t u r e . A description of the model constructed f o r developing the planning approach to the study w i l l then be given. 6 . The I n i t i a l reluctance of several l o c a l health and h o s p i t a l groups to p a r t i c i p a t e i n the study w i l l be c o n s i d e r e d i n Chapter I I I . The Regional Hospital Board's l e g i s l a t e d planning mandate w i l l be examined i n order to determine the Board's authority to involve hospitals and non-hospital health service groups i n the study. C h a p t e r I V w i l l d e s c r i b e why d i f f i c u l t i e s were ex p e r i e n c e d i n i d e n t i f y i n g study participants and data sources, and how the o r g a n i z a t i o n a l complexity of the health care system compounded th i s problem. Chapter V w i l l i l l u s t r a t e how l e g i s l a t i o n passed by the fe d e r a l and B r i t i s h Columbia governments over time i s , i n part, the cause of the present complex organization of the system. Chapter VI w i l l d e s c r i b e s e v e r a l major attempts by the p r o v i n c i a l government to improve government c o n t r o l over the system; such as the H o s p i t a l Role and Funding S t u d i e s , f i n a n c i a l r e - s t r u c t u r i n g of h e a l t h service programs, and a proposal f o r r e g i o n a l i z a t i o n . S e v e r a l r e c u r r e n t problems were e n c o u n t e r e d i n the process of c o l l e c t i n g and a n a l y s i n g data f o r the study. These problems, i n v o l v i n g a v a i l a b i l i t y and r e l i a b i l i t y of data, and the p o t e n t i a l f o r b i a s i n c o l l e c t i n g and analysing data w i l l be considered i n Chapter VII. Chapter VIII w i l l deal with s p e c i f i c problems complicating development of a comprehensive i n f o r m a t i o n base; such as i d e n t i f y i n g h e a l t h need indicators, securing population projections, and determining the supply of health services and resources i n the region. C h a p t e r IX w i l l be t e c h n i c a l i n nature, i n v o l v i n g an a n a l y s i s of problems experienced i n estimating resource requirements f o r the region. 7. I d e n t i f i e d underlying i s s u e s c o m p l i c a t i n g development of the TNRHD study w i l l be summarized i n Chapter X. The success of the study, given l i m i t a t i o n s w i l l then be assessed. F i n a l l y , u n d e r l y i n g i s s u e s w i l l be c o n s i d e r e d to determine what approaches are needed to resolve these issues or modify th e i r e f f e c t s . Suggestions as to who has the power to do this w i l l be made. 8. SECTION B INTERPRETING THE THOMPSON-NOCOLA REGIONAL HOSPITAL DISTRICT STUDY'S TERMS OF REFERENCE CHAPTER II DETERMINING THE PARAMETERS AND PURPOSE OF THE STUDY, AND DEVELOPMENT OF THE STUDY PLANNING MODEL Introduction The f i r s t problem encountered i n the development of the TNRHD study involved the terms of reference. While e x t e n s i v e , they d i d not s t a t e the o b j e c t i v e s of the study, and many of the statements regarding factors to be considered were not s p e c i f i c . I t was therefore d i f f i c u l t to determine how the study would be used, or the degree of r e s o l u t i o n required i n estimating future resource requirements. The absence of c l e a r study g u i d e l i n e s may have o c c u r r e d because few r e g i o n a l h e a l t h and h o s p i t a l s t u d i e s have been done i n the province. The TNRHD study therefore represented a test-case which would form a precedent f o r the Mi n i s t r y of Health i n assessing the f e a s i b i l i t y of using consultants i n t h i s manner. As such, the terms of r e f e r e n c e would themselves be evaluated following completion of the study. The TNRHD Board had e s t a b l i s h e d a S t e e r i n g Committee to a s s i s t the c o n s u l t a n t s d u r i n g the c o u r s e of the s t u d y . A M i n i s t r y of H e a l t h representative acted as a l i a i s o n with the M i n i s t r y throughout the study. However, i n t e r p r e t a t i o n s of the terms of r e f e r e n c e were l e f t t o the consultants. Determining the Parameters of the TNRHD Study When the terms of reference were examined, i t became e v i d e n t that the many i n d i v i d u a l statements d e a l t with e i t h e r the re g i o n ' s s e r v i c e area c h a r a c t e r i s t i c s or i t s h e a l t h s e r v i c e s and r e s o u r c e s . S e r v i c e a r e a c h a r a c t e r i s t i c s to be c o n s i d e r e d included the region's economic base, i t s environment and t r a n s p o r t a t i o n , and c u r r e n t and h i s t o r i c p o p u l a t i o n c h a r a c t e r i s t i c s and trends. Future population growth was to be estimated f o r a ten year period. The h e a l t h s e r v i c e s and resources category involved i d e n t i f i c a t i o n of h e a l t h s e r v i c e s use i n the r e g i o n , and e s t i m a t i o n of f u t u r e r e s o u r c e requirements through 1991 for the following health services components and sub-components: 1. Acute care services a. Acute inpatient beds b. Emergency/outpatient services 2. Intermediate and extended care services 3. Non-hospital health care programs a. Community health services ( i ) Public health nursing ( i i ) Home nursing care ( i i i ) Long term care program (LTC) (iv ) Mental health 10. b. Alcohol and drug programs c. Emergency health services In addition, health services supplied to other regions, and health s e r v i c e s normally obtained from other regions were to be i d e n t i f i e d . These i n d i v i d u a l h e a l t h s e r v i c e components when grouped together, re s u l t e d i n the requirement to assess the region's t o t a l health care system. The only health care system components excluded from the terms of r e f e r e n c e were h e a l t h s e r v i c e s personnel and voluntary organizations. I t was decided by the consultants that the h e a l t h s e r v i c e s personnel component would be i n c l u d e d , as an assessment of this resource group was considered e s s e n t i a l to a regional health and h o s p i t a l study. Groups to be considered within this group were p h y s i c i a n s , acute c a r e nurses, d e n t i s t s , p h a r m a c i s t s and n o n - h o s p i t a l h e a l t h care p e r s o n n e l . The a v a i l a b i l i t y of diagnostic and treatment c e n t r e s and out-post h o s p i t a l s i n the r e g i o n would a l s o be examined i n conjunction with analysing general practice physician s e r v i c e s . Determining the Purpose of the TNRHD Study T h e r e was no r e q u i r e m e n t i n the terms of r e f e r e n c e to develop recommendations or a plan f o r the region. I t was t h e r e f o r e concluded th a t the purpose of the study was to provide the Regional Hospital Board with a good information base to a s s i s t i t i n making present and f u t u r e r e s o u r c e a l l o c a t i o n d e c i s i o n s . Based on t h i s assumption, i t was decided t h a t r e s o l u t i o n of the question of future resource requirements would take the form of a s e t of f i n d i n g s . These findings would indicate, i n quantitative terms, the mix of resources required i n the region to meet i t s p o p u l a t i o n ' s 1 1 . future health service needs. The Study Within the Context of the Health Services Planning  Li t e r a t u r e A r e v i e w of the h e a l t h s e r v i c e s planning l i t e r a t u r e was done to determine where the TNRHD study f i t s i n t o the l i t e r a t u r e . According to Friedman, planning is "guidance of change wit h i n a s o c i a l system." (1973, 346) A second d e f i n i t i o n indicates that planning involves, " d e c i d i n g how the fu t u r e patterns of a c t i v i t i e s should d i f f e r from the present, i d e n t i f y i n g the changes necessary to accomplish t h i s , and specifying how these changes should be brought about." (National Health Service, 1976, 4) This i s providing that changes are indeed found to be necessary. T a y l o r i n d i c a t e s that i n order f o r pla n n i n g to be e f f e c t i v e , the planning process should involve: development of broad goals and o b j e c t i v e s , c o l l e c t i o n and a n a l y s i s of data, i d e n t i f i c a t i o n of p r i o r i t i e s , development of a plan with a l t e r n a t i v e proposals, s e l e c t i o n of the plan with targets and standards, and implementation, and then e v a l u a t i o n of the p l a n . ( T a y l o r , 1973, 20-28) T a y l o r ' s approach to planning i s shared by many others i n the health services planning l i t e r a t u r e . This author's i n i t i a l uncertainty about the purpose of the study and i t s p l a n n i n g process o c c u r r e d because the TNRHD Board's approach did not corre s p o n d to t h i s g e n e r a l l y accepted procedure. However, the Board's approach d i d c o r r e s p o n d w i t h t h a t of Blum. As shown i n Figure 1, Blum's model of the p l a n n i n g process i s d i v i d e d i n t o f o u r s t a g e s : assessment, a n a l y s i s and design, implementation and evaluation. Each stage contains a number of elements w i t h i n i t . Based on the model, the TNRHD study f a l l s w i t h i n the assessment stage i n v o l v i n g the element of measurement. Blum's 72. Figure 1 Elements of the Health Planning Process EVALUATION, analyzing the outputs, outcomes and impacts occurring as a result of planning. IMPLEMENTATION. obtaining policy commitment to the bureaucratic action on the plan. a. MEASUREMENT, determination of where we are, where we are l i k e l y to be, how we fee l about i t , and what we want. INTERPRETATION OF DATA, identification and selection of wants (problems or goals) and grand ideologic GOALS. d. CREATING THE PLAN, design, analysis comparison and selection among alternative interventions. c. ANALYSIS, understanding nature of specific wants. entire process and i t s elements guided by the prevalent socio-economic p o l i t i c a l outlooks, relevant legislative policies, p o l i t i c a l environment, resources, governmental structure and planning expertise. (BLUM, 1981, 54) 13. assessment stage i s s u b s t a n t i a t e d by MacStravick who indicates that "the determination of needs forms the basis of h e a l t h p l a n n i n g . " (and) " h e a l t h needs are determined within the planning process." (MacStravick, 1978, v i i , 7) Blum's s u c c e s s i v e stages of a n a l y s i s and design, implementation and e v a l u a t i o n were beyond the study's terms of r e f e r e n c e , and would be undertaken by the Regional Hospital Board, and subsequently approved by the M i n i s t r y of H e a l t h . Thus, the B oard's r e q u e s t f o r a comprehensive information base or "needs assessment" f o r the r e g i o n i s supported i n the health services planning l i t e r a t u r e . (MacStravick, 1978, 7) The Board a l s o i n d i c a t e d the study p l a n n i n g approach to be used i n d e v e l o p i n g the needs assessment f o r the r e g i o n . Based on the terms of r e f e r e n c e , f u t u r e h e a l t h s e r v i c e s and r e s o u r c e requirements were to be estimated on the b a s i s of c u r r e n t and h i s t o r i c use of h e a l t h s e r v i c e s , p o p u l a t i o n projections and p r o v i n c i a l standards and guidelines. In adopting this approach, the Board ruled out the use of a "normative or g o a l - s e e k i n g approach" to the e s t i m a t i o n of future requirements. (Blum, 1981, 60) Blum also r e j e c t s this approach on the basis that statements about "what ought to be" need to be modified by standards or norms and the r e a l i t y of r e s o u r c e c o n s t r a i n t s i n order f o r conclusions about future requirements to be both acceptable and f e a s i b l e . (Blum, 1981, 60) The Board i n s t e a d chose what Blum has d e f i n e d as an " e x p l o r a t o r y planning mode." (Blum, 1981, 60) He characterizes this approach as one which " e x p l o r e s the possible futures from current trends, c a p a c i t i e s , and expectations, and designs a desired f e a s i b l e f u t u r e , and a l l o c a t e s resources accordingly." (Blum, 1981, 60) The consultants constructed a study planning model b u i l t on this approach. 14. Development of the Thompson-Nicola Regional Hospital D i s t r i c t Study Planning  Model The m u l t i - f a c e t e d nature of the h e a l t h care system r e q u i r e d the development of a model which would show the components to be c o n s i d e r e d and t h e i r i n t e r - r e l a t i o n s h i p s . As shown i n Figure 2, on the following page, the model developed f o r the TNRHD study was based on a modified economics model. Where p o s s i b l e , each element i n the model was a l l o c a t e d a number. T h i s number r e l a t e d back t o the c o r r e s p o n d i n g statement i n the terms of reference. The consultants' planning approach i s i l l u s t r a t e d i n the model and the steps are outlined below: . Analyse s e r v i c e area c h a r a c t e r i s t i c s of the region and t h e i r e f f e c t on the d i s t r i b u t i o n of health services and resources, and the health of the population. (1, 2a, b) I d e n t i f y the q u a n t i t y , type and d i s t r i b u t i o n of e x i s t i n g h e a l t h s e r v i c e f a c i l i t i e s , personnel and o r g a n i z a t i o n a l u n i t s i n the region, and determine future planned supply. (4a, 5c) . I d e n t i f y and analyse the health service needs of the population. (3, 4a, b, c, d, e, f ) Estimate gaps i n the supply of health services and resources i n the r e g i o n on the basis of i d e n t i f i e d health service needs, and compare these with p r o v i n c i a l standards and guidelines. Estimate h e a l t h s e r v i c e needs f o r 1986 and 1991 on the b a s i s of p o p u l a t i o n p r o j e c t i o n s , and a n t i c i p a t e d changes i n health service needs. (5a, b, e, ) 15, "External Current" Figure 2 The Thompson-Nicola Regional Hospital D is tr ict Study Planning Model, 1983 E C O N O M I C D E V E L O P M E N T (1) P O P U L A T I O N M I X (2o,2b) E N V I R O N M E N T I N F R A S T R U C T U R E "Current" H E A L T H S E R V I C E S I D E M A N D U T I L I S A T I O N - I n f l o w - O u t f l o w (3) -Hospital Experience (4d -Hospital isation Rates (4c) -O.P.D., (4d) - E C U and ICU (4e) - C o m m u n i t y P r o g r a m m e s (4 f ) S U P P L Y FACLITES (4a 5c) M A N P O W E R P R O G R A M M E S 'Analysis" G A P S Distr ibution Type Quantity Future N E E D Fjture Rates (5a,5b) P L A N N I N G A C T I V I T I E S ( 5 , 5 a , 5 e ) 'Supply Constraints" R O L E S T U D Y A N D O T H E R P R O V I N C I A L G U I D E L I N E S (5a) P R O J E C T I O N - Economic - Population Cnanging Externals (5a,5b,5d, 5e) (Thompson Berwick Pratt and Partners, 1983, 5) 16. . Compare p r o j e c t e d r e s o u r c e requirements with e x i s t i n g and planned supply to determine future shortages i n supply. . Compare projected resource requirements with p r o v i n c i a l g u i d e l i n e s and targets. (5c, d) Development of the study was to be done i n two phases. Phase 1 would consist of an analysis of the region's e x i s t i n g health care d e l i v e r y system. A working document would then be prepared, and d i s t r i b u t e d to the R e g i o n a l Hospital Board Steering Committee, relevant M i n i s t r y of Health o f f i c i a l s and h e a l t h care p r o v i d e r s i n the r e g i o n to determine e r r o r s i n f a c t and/or perception i n the document. A meeting with these groups would then be h e l d t o o b t a i n comments and c o r r e c t i o n s r e l a t i n g to Phase 1, and to discuss future health services needs. Phase 2 would involve e s t i m a t i n g f u t u r e h e a l t h s e r v i c e and r e s o u r c e requirements f o r the region. The study would conclude with the preparation and p r e s e n t a t i o n of a f i n a l r e p o r t i n c o r p o r a t i n g Phase 1 and Phase 2 f i n d i n g s . 17. SECTION C ORGANIZATIONAL ISSUES COMPLICATING DEVELOPMENT OF THE STUDY CHAPTER III LOCAL HEALTH AND HOSPITAL GROUPS AND THE THOMPSON-NICOLA REGIONAL HOSPITAL DISTRICT STUDY Introduction During i n i t i a l discussions with several health and h o s p i t a l groups i n the r e g i o n , attempts were made to e l i c i t t h e i r co-operation i n developing the study. Some reluctance was encountered on the part of a few who f e l t the TNRHD Board did not have a mandate to p l a n f o r then. C o n f u s i o n over the B o a r d ' s p l a n n i n g mandate can be t r a c e d to the e v o l u t i o n of r e g i o n a l d i s t r i c t s , followed by the s e t t i n g up of r e g i o n a l h o s p i t a l d i s t r i c t s and t h e i r boards. Evolution and Powers of Regional Hospital Boards Reg i o n a l p l a n n i n g was f o r m a l l y introduced i n B r i t i s h Columbia by the Regional D i s t r i c t Act passed i n 1966. Under t h i s A ct, the p r o v i n c e was d i v i d e d i n t o 28 regional d i s t r i c t s , each headed by a regional board. A 29th r e g i o n a l d i s t r i c t was s u b s e q u e n t l y added. F i g u r e 3 i l l u s t r a t e s the geographic boundaries of the d i s t r i c t s , i n c l u d i n g the TNRHD. Re g i o n a l d i s t r i c t s have been assigned a r b r i t a r y numbers as o f f i c i a l numbers do not c u r r e n t l y e x i s t . Figure 3 British Columbia Regional Districts, 19&+ 18. DISTRICTS 23 AIbernl-Clayoquot 51 Bulk ley-Nechako 17 Capital 41 Carl boo 45 Central Coast 11 Central Fraser Val 03 Central Kootenay 35 Central Okanagan 39 Columbia-Shuswap 25 Comox-Strathcona 19 Cow Ichan Valley 13 Dewdney-Alouette 01 East Kootenay 09 Fraser-Cheam 53 Fraser-Fort George ley 15 Greater Vancouver 49 KItlmat-Stlkine 05 Kootenay Boundary 43 Mount Waddlngton 21 Nana i ox3 37 North Okanagan 07 Okanagan-SI miIkameen 55 Peace R lver -Uard 27 PowelI River 47 Skeena-<Jueen Charlotte 31 Squamish-UIlooet 57 St lkine 29 Sunshine Coast 33 Thompson-Nicola (Ministry of Health, 1983) 1 9 . Each r e g i o n a l d i s t r i c t b o a r d c o n s i s t s of r e p r e s e n t a t i v e s from m u n i c i p a l i t i e s or unorganized areas w i t h i n the r e g i o n a l d i s t r i c t . The purpose of the board i s to provide a forum where j o i n t decisions can be made r e g a r d i n g the planning and co-ordination of developments which a f f e c t more than one municipality or unorganized area. ( C o l l i e r , 1970, 12) "The number of representatives each municipality has, and the number of votes each representative has on regional matters i s c a l c u l a t e d by d i v i d i n g the p o p u l a t i o n of the area by a 'voting u n i t . ' This f i g u r e i s s p e c i f i e d i n the l e t t e r s p a t e n t and v a r i e s between d i s t r i c t s . R e p r e s e n t a t i v e s from e l e c t o r a l areas are e l e c t e d d i r e c t l y , w h i l e r e p r e s e n t a t i v e s f r o m m u n i c i p a l c o u n c i l s a r e appointed by the c o u n c i l . " ( C o l l i e r , 1970, 13) A d d i t i o n a l r e g i o n a l planning l e g i s l a t i o n was enacted i n 1967 with the passing of the H o s p i t a l D i s t r i c t A c t . Under the Act, 28 ( c u r r e n t l y 29) regional h o s p i t a l d i s t r i c t s were formed with, "the a f f a i r s of each regional h o s p i t a l d i s t r i c t managed by a board comprised of the same r e p r e s e n t a t i v e s of the m u n i c i p a l i t i e s and unorganized areas who form the board of the r e g i o n a l d i s t r i c t . " (Hospital D i s t r i c t Act, R.S.B.C. 1979, Chapter 178) The geographic boundaries of regional h o s p i t a l d i s t r i c t s are i d e n t i c a l w i t h those of regional d i s t r i c t s . The purposes of a regional h o s p i t a l board, "are b a s i c a l l y to e s t a b l i s h , acquire, construct, enlarge, operate and maintain h o s p i t a l s ; to grant a id f o r those purposes; and to act as an agent of the pr o v i n c e i n r e c e i v i n g and d i s b u r s i n g monies granted out of the H o s p i t a l Insurance Fund." ( M i n i s t r y of H e a l t h Annual Report, 1980, 114) R e g i o n a l h o s p i t a l d i s t r i c t s and t h e i r boards were established as a r e s u l t of the p r o v i n c i a l government's concern over r i s i n g health care c o s t s i n the 1960 's. R e s p o n s i b i l i t y f o r the delivery of health services had been delegated to s o c i e t i e s , with the f u n d i n g of h o s p i t a l o p e r a t i n g c o s t s the r e s p o n s i b i l i t y of the province. With the passing of the Hospital Insurance V 20. and Diagnostic Services Act i n 1957, the f e d e r a l government agreed to share with the provinces the cost of operating h o s p i t a l s . A c c o r d i n g to C r i c h t o n , Lawrence and Lee, a h o s p i t a l construction and manpower plan had been developed by consultants i n 1949. However, d e s p i t e this plan, " h o s p i t a l s were being b u i l t when the government decided to accede to p o l i t i c a l pressures." (Crichton, et a l . , 1984, 89) "The p r o v i n c i a l h o s p i t a l a s s o c i a t i o n ( l a t e r the B.C. H e a l t h Association) (BCHA) had been formed b e f o r e World War I I to b r i n g h o s p i t a l s together i n a consortium to work on t h e i r problems, and, where necessary, to exert pressure on government. A f t e r government began to fund the hospitals ' operating costs, the association found this l a t t e r r o l e had f i n i s h e d . Government r e q u i r e d a b a r g a i n i n g agent to act on i t s behalf i n contract negotiation, and the BCHA was persuaded to take on this r o l e . " (Crichton, et a l . , 1984, 89) By the 1960's, despite matched funding from the f e d e r a l government, "an a d d i t i o n a l p r o v i n c i a l government vote (was required most years) to keep the hospitals out of debt, and hospitals began to depend on d e f i c i t f i n a n c i n g , r a t h e r than c a r e f u l budgeting." (Crichton, et a l . , 1984, 89) Thus, h o s p i t a l o p e r a t i n g d e f i c i t s , combined wit h i n c r e a s e d demands f o r c a p i t a l f u n d i n g prompted the p r o v i n c i a l government to e s t a b l i s h regional h o s p i t a l boards i n 1967 as a form of buffer group which would c o n t r o l over acute and extended care h o s p i t a l s , thereby r e l i e v i n g pressure on government. (UBC Health P o l i c y Study Group, 1982, 64) Boards have had l i t t l e success i n c o n t r o l l i n g h o s p i t a l costs for two reasons. F i r s t , they are p o l i t i c a l bodies, and t h e i r r o l e h i s t o r i c a l l y has been one of responding to the demands of their constituencies. Thus, while the Hospital D i s t r i c t Act allows boards to 'operate' h o s p i t a l s (thereby g i v i n g them a u t h o r i t y to e x e r t pressure on hospitals to control operating costs), boards, because of t h e i r p o l i t i c a l nature "have primarily concerned 21 . themselves with the f i n a n c i n g of c a p i t a l debts and pla n n i n g of h o s p i t a l construction." (Long Range Planning Branch, 1974, 7) Secondly, under the terms of the Hospital D i s t r i c t Act, h o s p i t a l s may choose to act independently, as, "Nothing i n the Act s h a l l operate to require an owner or p r o p r i e t o r of a h o s p i t a l to accept or receive any f i n a n c i a l or other assistance from a d i s t r i c t , or to have recourse to or approval from a d i s t r i c t i n order to claim or request financing or f i n a n c i a l a s s i s t a n c e from the government of Canada or from the M i n i s t r y of Health, and the financing of any ho s p i t a l may be continued on the same b a s i s as i f t h i s A c t had not been enacted." ( H o s p i t a l D i s t r i c t Act, R.S.B.C. 1979, Chapter 178) Thus, under the terms of the Act, regional h o s p i t a l boards t e c h n i c a l l y have l i t t l e authority to finance, operate or plan ho s p i t a l s i n t h e i r regions, and h o s p i t a l boards i n the THRHD could have withheld t h e i r co-operation i n the study. Nothing i n the Hospital D i s t r i c t Act gives the regional h o s p i t a l board the a u t h o r i t y to plan f o r non-hospital health care programs i n i t s region. Local or union boards of health have r e s p o n s i b i l i t y f o r community h e a l t h s e r v i c e s (except i n remote areas where the regional h o s p i t a l d i s t r i c t board i s the a d m i n i s t r a t i v e body), while the a l c o h o l and drug program, and emergency h e a l t h s e r v i c e s are each co-ordinated and administered by a zone c o-or dinat or/adminis t r a t o r . Regional h o s p i t a l boards, then, have l i t t l e a u t h o r i t y to c o - o r d i n a t e and p l a n f o r e i t h e r health or h o s p i t a l groups i n t h e i r regions. However, no other regional group has o v e r a l l r e s p o n s i b i l i t y f o r the c o - o r d i n a t i o n and planning of l o c a l health services e i t h e r . 22. The Thompson-Nicola Regional Hospital Board The TNRHD Board adopted a leadership r o l e i n commissioning the study d e s p i t e i t s l i m i t e d p l a n n i n g mandate f o r hospitals, and complete lack of planning mandate for non-hospital health care programs. However, because the Mini s t r y of Health had approved and funded 60 percent of the study, i t s i n f l u e n c e was instrumental i n convincing health and h o s p i t a l groups i n the region to p a r t i c i p a t e i n the study. I t i s probable that the Board and M i n i s t r y of Health's d e c i s i o n to employ a c o n s u l t i n g f i r m to develop the study was i n f l u e n c e d by the following f a c t o r s : F i r s t , the Board did not have the technical support s t a f f a v a ilable to undertake a large study, and the number of M i n i s t r y of H e a l t h s t a f f a v a i l a b l e to compile and analyse data, and prepare a r e p o r t was l i m i t e d due to government r e s t r a i n t . Secondly, both the M i n i s t r y of H e a l t h and the Board were being f a c e d with demands f o r increased spending i n the region, and the employment of a consulting f i r m would p r o v i d e a method of r e s o l v i n g c o n f l i c t s among regional groups over scarce resources. According to the UBC Health P o l i c y Study Group, "the c o n s u l t a n t r e p r e s e n t s a new form of b u f f e r g r o u p . . . t h e 'independent' c o n s u l t a n t (and h i s / h e r attendant f i r m ) who w i l l resolve c o n f l i c t s with 'neutral data' and judgement." (UBC H e a l t h P o l i c y Study Group, 1982, 73) The UBC Study Group i n d i c a t e s that the advantages of these "buffer groups" are that: "(1) They appear unbiased towards any group; (2) they w i l l act as c o n s u l t a n t s , thus no one w i l l have to do what they suggest (and) those employing these consulting firms can ignore a response that i s not i n l i n e with preconceived n o t i o n s , or a l t e r n a t i v e l y , present w i t h p r i d e 'independent' support for preconceived notions; and (3) such firms do not have a stake i n the health s e r v i c e p r o v i s i o n per se - they do not stand to lose money i f recommendations are made to 23 . close beds, remove services, e t c . ; t h e i r only stake i s i n c o n t i n u e d study, thus f u r t h e r employment." (UBC Health P o l i c y Study Group, 1982, 73) F i n a l l y , i n approving a consultant to do the study, the M i n i s t r y of H e a l t h c o u l d accomodate r e g i o n a l i n i t i a t i v e s while maintaining some c o n t r o l ; and, at the same time t e s t the f e a s i b i l i t y of u s i n g c o n s u l t a n t s to develop regional planning information. The planning process does not end once the consultants have completed a "needs assessment" f o r the r e g i o n . As i n d i c a t e d i n Blum's model of the planning process, Figure 1, page 12, development of goa l s and a plan, and implementation and e v a l u a t i o n of the p l a n s t i l l remain. These tasks may prove d i f f i c u l t f o r the Board, given i t s l i m i t e d p l a n n i n g powers, and the f a c t t h a t i t i s not r e p r e s e n t a t i v e of a l l h e a l t h p r o f e s s i o n a l s and administrators i n the region. CHAPTER IV ORGANIZATION OF HEALTH SERVICES AT THE FEDERAL, PROVINCIAL AND LOCAL LEVELS Introduction Development of the study f i r s t r e q u i r e d i d e n t i f i c a t i o n of a l l l o c a l health and h o s p i t a l groups i n the region, and t h e i r f e d e r a l and p r o v i n c i a l c o u n t e r p a r t s . The consultants had requested that a l i s t be supplied at the beginning of the study i n d i c a t i n g the l o c a l , p r o v i n c i a l and f e d e r a l c o n t a c t fo r each of the health services components and sub-components. This l i s t was never provided. I d e n t i f i c a t i o n of study p a r t i c i p a n t s , and f e d e r a l and p r o v i n c i a l resource groups proved d i f f i c u l t and time-consuming. I t became e v i d e n t t h a t numerous h e a l t h s e r v i c e s groups would have to be c o n t a c t e d i n order to develop a comprehensive i n f o r m a t i o n base f o r the r e g i o n . Necessary t o i d e n t i f i c a t i o n of these groups was knowledge of the way i n which health services were organized at the f e d e r a l , p r o v i n c i a l and l o c a l l e v e l s . T h i s had to be worked out for the next stage of the study. Health Services at the Federal Level The a d m i n i s t r a t i v e a u t h o r i t y r e s p o n s i b l e for.health services at the fe d e r a l l e v e l i s the Department of N a t i o n a l H e a l t h and Welfare under the M i n i s t e r of N a t i o n a l H e a l t h and Welfare. The Department i s divided into a number of branches, f i v e of which involve health: The Health Programs Branch administers f e d e r a l f i n a n c i a l programs, including the Hospital Insurance and Diagnostic Services Program, the M e d i c a l Care Insurance Program, and the F e d e r a l - P r o v i n c i a l F i s c a l Arrangements and Established Programs Financing Act. The Health P r o t e c t i o n Branch i s r e s p o n s i b l e f o r e n f o r c i n g p a r t s of f e d e r a l laws d e a l i n g with food and drugs. The Canadian Fitness and Amateur Sports Program i s administered by the Department's Fitness and Amateur Sport Branch. The Medical Services Branch "provides or arranges health treatment, e d u c a t i o n and assessment s e r v i c e s f o r p a r t i c u l a r c a t e g o r i e s of people" including r e g i s t e r e d Indians. (Soderstrom, 1978, 190) The Long Range H e a l t h P l a n n i n g Branch "develops new ideas and approaches f o r improving health as well as e f f i c i e n c y with which health services are p r o v i d e d . " (Soderstrom, 1978, 191) T h i s B r a n c h was r e s p o n s i b l e f o r the p r e p a r a t i o n of A New Perspective on the Health of Canadians (Lalonde, 1974). From these descriptions i t was determined that c o n t a c t s h o u l d be made with the Medical Services Branch, and the Long Range Health Planning Branch to i d e n t i f y health treatment provided f o r r e g i s t e r e d I n d i a n s i n the TNRHD, and to determine f e d e r a l directions i n health promotion/protection programs. Health Services at the P r o v i n c i a l Level (B.C.) The TNRHD study c o i n c i d e d with a major reorganization of the Minis t r y of Health's operations i n 1981/82. "Key to the reorganization was the realignment of v a r i o u s programs int o three major p o l i c y f i e l d s - Preventive Services, Community Care S e r v i c e s and I n s t i t u t i o n a l S e r v i c e s , each headed by an assistant deputy minister." (Ministry of Health Annual Report, 1981, i v ) Each p o l i c y f i e l d was further sub-divided i n t o a number of a d m i n i s t r a t i v e u n i t s which were responsible f o r i n d i v i d u a l programs. According to Mi n i s t r y of Health sources, this reorganization was done i n an attempt to r a t i o n a l i z e the health care system administratively. Figure 4 i l l u s t r a t e s the f i n a l i z e d Figure 4 Br i t i s h Columbia Ministry of Health Organizational Chart, 1982 Medical SLTVICL-* Commiuion Emergency Health Service) Commission |\ec. Director lultrriul Audit Medical Advisory Cum mi I DEPUTY MINISTEJt Policy and Resource AlltKjliun Committee Alcohol and Drug Com mission Furrnioc Psychiatric Service* Commission Director Information Service* Director Executive Service* Senior IVpuiy Minister Assistant D M Preventive Services Assistant D M . Community Care St-rvirrv Assistant D M . Institutional Services Director lvg.ll Service* w i Direitor I ' i i M i u ijt Service* Ix.. Dir.il.> IVl^.MIIU-l Servi.v* M.iii.i^i-iiti-ni Into System* l\ec. Director Planning Policy and Legislation Director Management Service* lixec. Director Central Service* Director Mc-dual Ser vii Pl.ui lii.ee. Director Health Promotion Provincial Health Obiter Av.isl.uti D M. Vancouver Uureau Director Denial Health Service* Sr Director Clinical Ser v. Director Public 11, alii. Inspection Director Nutrition Director I'uhlic IL-allh Nur*ing Din.h.r l:|>i.leii>i»logy Dirciit.r Sjvech and (tearing l:\ev. Oi rector Mental Health Service* L\ec Director A l a 1)4.1 Jlld Drug Program* Exec. Director I lok nilal Programs lixec. Director Emergency Health Service* Exec. Director Long Term/ I lome Care (Adapted from Ministry of Health Annual Report 1982, M i n i s t r y of Health organizational chart. W h i l e t h e r e a l i g n m e n t of programs may have p r o d u c e d a more a d m i n i s t r a t i v e l y r a t i o n a l system, i d e n t i f i c a t i o n of M i n i s t r y of H e a l t h resource groups remained d i f f i c u l t . Table I has been developed to i l l u s t r a t e the o r g a n i z a t i o n a l complexity of the health care system at the p r o v i n c i a l l e v e l . The M i n i s t r y of Health p o l i c y f i e l d i s i d e n t i f i e d f o r each of the study's h e a l t h s e r v i c e s components and sub-components. The M i n i s t r y of H e a l t h a d m i n i s t r a t i v e u n i t r e s p o n s i b l e f o r the o v e r - a l l d i r e c t i o n and c o n t r o l of each h e a l t h s e r v i c e s program i s then given. Where applicable, i d e n t i f i e d p r o v i n c i a l health groups outside the M i n i s t r y of Health are a l s o shown. These administrative units, and health groups became the consultants ' health services data sources at the p r o v i n c i a l l e v e l . Health Services at the Local Level The way i n which h e a l t h services are organized at the l o c a l l e v e l was found to be even more complex than at the p r o v i n c i a l l e v e l . Many of the h e a l t h s e r v i c e s components and sub-components are c o - o r d i n a t e d and administered by a l o c a l M i n i s t r y of H e a l t h a d m i n i s t r a t i v e u n i t . I n some c a s e s , the a d m i n i s t r a t i v e u n i t i s a l s o r e s p o n s i b l e f o r p r o v i d i n g the s e r v i c e . In other cases, a separate non-profit or private (for p r o f i t ) group has r e s p o n s i b i l i t y f o r a d m i n i s t e r i n g and/or p r o v i d i n g the s e r v i c e . I n addition, the administrative j u r i s d i c t i o n s f or several of the health service components and sub-components are geographically d i f f e r e n t . Table I Organization of Health Services at the Pro v i n c i a l Level ( B r i t i s h Columbia, 1 9 8 3 ) TNRHD STUDY HEALTH SERVICE P R O V I N C I A L H E A L T H S E R V I C E S O R G A N I Z A T I O N COMPONENTS AND SUB-COMPONENTS M I N I S T R Y O F H E A L T H OTHER HEALTH SERVICES CROUPS POLICY FIELD ADMINISTRATIVE UNIT 1. Acute Care Services a) Acute Care Hospitals b) Diagnostic and Treatment Centres c) Outpost Hospitals a) I n s t i t u t i o n a l Services b) I n s t i t u t i o n a l Services c) I n s t i t u t i o n a l Services a) H o s p i t a l Programs b) Hospital Programs c) H o s p i t a l Programs a) British,Columbia Hospital A s s o c i a t i o n b) c) Canadian Red Cross A s s o c i a t i o n 2. I n s t i t u t i o n a l Intermediate and Extended Care Services a) Intermediate Care b) Extended Care c) Intermediate and Extended Care Services i n Acute Care Hospitals a) I n s t i t u t i o n a l Services b) I n s t i t u t i o n a l Services c) I n s t i t u t i o n a l Services a) LTC Program b) Hospital Programs c) H o s p i t a l Programs — 3. Non-Hospital Health Care Programs a) Community Health Services (1) Public Health (11) LTC/Home Care (111) Mental Health b) Alcohol and Drug Services c) Emergency Health Services a) (1) Preventive Services (11) I n s t i t u t i o n a l Services (111) Community Care Services b) Community Care Services c) I n s t i t u t i o n a l Services a) (1) Health Promotion, Public Health Nursing and School Health Services (11) LTC Home Care Program (111) Mental Health Services b) Alcohol/Drug Programs c) Emergency Health Services ---4. Medical Services Management Operations Medical Services Plan (1) B.C. College of Physicians and Surgeons (11) B r i t i s h Columbia Hedlcal A s s o c i a t i o n (111) Health Manpower Research Unit (a research unit f o r the MOH) (c) W. L. Morton, 1985. 1. Acute Care Services Acute care inpatient and emergency/outpatient services are provided by acute care h o s p i t a l s , diagnostic and treatment c e n t r e s , and outpost h o s p i t a l s . Each acute care h o s p i t a l i s owned and operated by a hospital society, and administered by a local hospital board. The Hospi ta l board is responsible to the Hospital Society. A hospital administrator is responsible to the board for the day to day administration of the hospital apart from medical care which is given by staff admitted to pr ivi leges under h o s p i t a l by-laws. Department heads are responsible to the administrator for the provision of non-medical acute care services. Diagnostic and Treatment Centres may, "be owned and operated by a local society, by the regional h o s p i t a l d is t r i c t or by a general hospital located elsewhere." (B.C. Hospital Programs, 1980, 1) Functions include: elective outpatient procedures, minor surgery, emergency services, patient holding services f o r emergency pat ients , physicians ' o f f i c e prac t ice and public health services. Administration of a Centre may be performed by: an on-s i te administrator , by a "shared" administrator ( i . e . , one who is responsible for another agency), or by a nurse-in-charge. At least one physician must be on s t a f f and be located i n the immediate v i c i n i t y of the Centre. The Centre i s staffed by at least one registered nurse, and graduate nurse coverage must be provided whenever there are patients i n the Diagnostic and Treatment Centre. (B.C. Hospital Programs, 1981, 1-2) While acute care hospitals, and diagnostic and treatment centres operate independently, they are organized according to regional hospital d is t r i c t s , 30. of which there are 29 i n the province. As indicated i n the previous chapter, the regional h o s p i t a l board i n each region shares r e s p o n s i b i l i t y with the M i n i s t r y of H e a l t h f o r the c a p i t a l f u nding of acute c a r e h o s p i t a l s and diagnostic and treatment centers i n the region. Operating c o s t s are funded by Hospital Programs. Outpost h o s p i t a l s are operated and funded by the Red Cross Association. They are small 3 bed hospitals located i n i s o l a t e d communities, and are generally the only f u l l - t i m e health resource i n the area. Services are provided by one or two f u l l - t i m e nurse p r a c t i t i o n e r s . Beds contained i n outpost h o s p i t a l s were o r g i n a l l y used as inpatient beds. With improved t r a n s p o r t a t i o n , they are now c l a s s i f i e d and used as "holding beds" (Wightman, 1984) 2. I n s t i t u t i o n a l Intermediate and Extended Care Services I n s t i t u t i o n a l intermediate and extended care services form part of the LTC program continuum of care for that segment of the population who cannot l i v e without h e l p because of h e a l t h r e l a t e d problems but do not warrant acute care h o s p i t a l treatment. (Ministry of Health Annual Report, 1982, 52) Intermediate care services are provided i n non-profit and p r i v a t e ( f o r p r o f i t ) community care f a c i l i t i e s , and i n acute care h o s p i t a l s . Extended care services are provided i n non-profit extended care h o s p i t a l s , combined i n t e r m e d i a t e and extended care non-profit community care f a c i l i t i e s , and i n acute care h o s p i t a l s . Each f a c i l i t y has i t s own a d m i n i s t r a t o r . Although p r o v i n c i a l a d m i n i s t r a t i o n and r e s p o n s i b i l i t y f o r o p e r a t i n g c o s t s of community and i n s t i t u t i o n a l s e r v i c e s i s d i v i d e d between the LTC program (intermediate care services) and Hospital Programs (extended care s e r v i c e s ) , 31 . c o - o r d i n a t i o n and a d m i n i s t r a t i o n of s e r v i c e s at the l o c a l l e v e l i s the r e s p o n s i b i l i t y of the LTC administrator working from the community health u n i t . •=-There are 17 p r o v i n c i a l h e a l t h u n i t s and 5 m u n i c i p a l u n i t s i n the p r o v i n c e . However, a c c o r d i n g to M i n i s t r y of H e a l t h sources, need f o r i n s t i t u t i o n a l i n t e r m e d i a t e and extended care s e r v i c e s i s determined by school d i s t r i c t . There are 92 school d i s t r i c t s i n the province. E l i g i b i l i t y f o r intermediate and extended care services i s determined by l o c a l LTC Assessment s t a f f who consult when necessary with an Assessment Team composed of i n t e r d i s c i p l i n a r y representatives. The Assessment procedure establishes the l e v e l of care required by the applicant. 3. Non-Hospital Health Care Programs Included under this category are community health services, the alcohol and drug program, and emergency health services, a) Community Health Services These include public health nursing, home nursing care, the LTC program and mental h e a l t h s e r v i c e s . (While not dealt with i n the study, community health services also include physician consultation through the medical health o f f i c e r , public health inspection; dental h e a l t h s e r v i c e s , n u t r i t i o n , e pidemiology, s p e e c h and h e a r i n g services, etc.) A l o c a l or union board of health i s responsible for the o v e r a l l a d m i n i s t r a t i o n of community h e a l t h s e r v i c e s at the l o c a l l e v e l , except i n remote areas where a d m i n i s t r a t i o n of community h e a l t h s e r v i c e s i s handled by a regional d i s t r i c t board. A l o c a l board of health i s made up of the co u n c i l of a municipality. Union boards of h e a l t h c o n s i s t of r e p r e s e n t a t i v e s from i n d i v i d u a l m u n i c i p a l i t y boards of health, which together make up a h e a l t h d i s t r i c t . L o c a l boards of health may choose to j o i n together to form a metropolitan baord of health (eg. Vancouver Metropolitan Board of Health). Organization of community health services technical o p e r a t i o n s i s the r e s p o n s i b i l i t y of a medic a l h e a l t h o f f i c e r appointed by a l o c a l or union board of health, and Minis t r y of Health l o c a l program a d m i n i s t r a t o r s f o r each of the community h e a l t h s e r v i c e s . The medical health o f f i c e r i s responsible to the l o c a l or union board of h e a l t h f o r programs, the M i n i s t r y of Health f o r budgets, and the p r o v i n c i a l h e a l t h o f f i c e r f o r p r o v i n c i a l h e a l t h s t a t u t e s . The me d i c a l h e a l t h o f f i c e r i s g e n e r a l l y a s a l a r i e d physician with the cost of his/her salary shared between the l o c a l m u n i c i p a l i t y (s ) and the M i n i s t r y of Health. The administrative j u r i s d i c t i o n f or public health nursing, home n u r s i n g c a r e and the LTC program i s the community h e a l t h u n i t . Mental health i s organized a c c o r d i n g to mental h e a l t h u n i t s , the boundaries of which are i d e n t i c a l with those of the 22 community health units i n the province. ( i ) Public Health Nursing As outlined i n the East Kootenay H e a l t h S e r v i c e s Review Report 1981, the o v e r a l l goal of the D i v i s i o n of Public Health Nursing i s , " t o a s s i s t i n d i v i d u a l s and f a m i l i e s i n the attainment of an optimum l e v e l of h e a l t h and f u n c t i o n i n g , to assess and evaluate community health needs and services, and to promote the development and appropriate use of resources r e q u i r e d to meet these needs. Five main programs have been developed i n order to a t t a i n t h i s goal: P e r i n a t a l , P r e s c h o o l , School Health, A d u l t , and Community Care F a c i l i t i e s L i c e n c i n g . " (East Kootenay Health Services Review Team, 1981, 74) The maternal and c h i l d h e a l t h programs are g i v e n the g r e a t e s t emphasis. P u b l i c h e a l t h nursing services are funded d i r e c t l y by the Minis t r y of He a l t h . S e r v i c e s are p r o v i d e d by p u b l i c h e a l t h nurses, and s u p e r v i s e d by a l o c a l Ministry of Health public health nursing administrator. P r e v e n t i v e s e r v i c e s f o r R e g i s t e r e d I n d i a n s l i v i n g on r e s e r v e s come under the auspices of Medical Services, Health and Welfare Canada. S e r v i c e s are pr o v i d e d through Community H e a l t h C e n t r e s and i n c l u d e s c r e e n i n g f o r t u b e r c u l o s i s , immunization, pre and post natal classes, counselling and group education, ( i i ) Home Care/Long Term Care The Home Care/LTC program provides for a range of s e r v i c e s f r o m home s u p p o r t and p e r s o n a l c a r e to i n t e r m e d i a t e and extended care l e v e l s e r v i c e s . The primary aim of the program i s , " t o permit those who q u a l i f y f o r benefits to remain i n the i r own homes, among t h e i r own f a m i l i e s , f o r as l o n g as i s d e s i r a b l e and p r a c t i c a l . " ( M i n i s t r y of H e a l t h Annual Report, 1982, 52) The Program p r o v i d e f o r e i t h e r Home Support Care or I n s t i t u t i o n a l Care. Home support i n c l u d e s home n u r s i n g c a r e , 34. homemaking and housekeeping s e r v i c e s , meals-on-wheels, and v i s i t s by s o c i a l workers, p h y s i o t h e r a p i s t s and n u t r i t i o n i s t s when needed. I n s t i t u t i o n a l C a r e may be p r o v i d e d i n an Intermediate care f a c i l i t y , group home, extended care h o s p i t a l , or i n LTC beds located i n acute care h o s p i t a l s . Adult day care i s also a component of the Program and can meet a c l i e n t ' s need f o r s o c i a l i z i n g and recreation together with s p e c i f i c care such as n u t r i t i o n a l c o u n s e l l i n g , n u r s i n g s u p e r v i s o n and b a t h i n g a s s i s t a n c e . ( K a l l s t r o m et a l , 1981, 7-10) A d u l t day c a r e may be p r o v i d e d i n community c a r e f a c i l i t i e s and/or acute care h o s p i t a l s . A p p l i c a t i o n t o the program may o r i g i n a t e f r o m the applicant, or his or her family, a phys i c i a n , or the f a c i l i t y i n which the a p p l i c a n t i s c u r r e n t l y r e s i d i n g . E l i g i b i l i t y i s determined by a l o c a l LTC a d m i n i s t r a t o r and LTC Assessment s t a f f who c o n s u l t when necessary w i t h an i n t e r d i s c i p l i n a r y Assessment Team. (Eredics, 1982) ( i i i ) Home Nursing Care Program The home n u r s i n g c a r e program i s a component of Home Care/LTC Home Support S e r v i c e s . A c c o r d i n g to the East Kootenay Health Care Services Review Report, August 1981, the ph i l o s o p h y of the Home Nursing Care Program i s to provide comprehensive nursing c a r e t o i l l or handicapped persons whose p h y s i c a l , s o c i a l and emotional needs can be met i n the home s i t u t a t i o n . (East Kootenay Health Care Review Team, 1981, 97) 35 . The Home Care Program, "provides or co-ordinates patient care with p h y s i c i a n s , Long Term Care, mental h e a l t h , Public Health Nursing, n u t r i t i o n i s t s , Human R e s o u r c e s , H o m e m a k e r s , Meals-on-Wheels, acute care and extended care h o s p i t a l s as well as other community a g e n c i e s . " (East Kootenay Health Care Review Team, 1981, 97) The Home N u r s i n g C a r e Program c o n s i s t s of two major components, both of which require a physician r e f e r r a l : . General Program T h i s c a t e g o r y a p p l i e s to p a t i e n t s at home f o l l o w i n g a normal term of h o s p i t a l i z a t i o n , or those who need some professional assistance but do not require h o s p i t a l i z a t i o n . . Hospital Replacement Program In order to q u a l i f y f o r this program, the patient must have an e a r l y h o s p i t a l d i s c h a r g e with a s p e c i f i e d number of h o s p i t a l days r e p l a c e d , or be admitted to the program i n l i e u of h o s p i t a l i z a t i o n . The program not only enables the patient to be cared for i n his or her home, but i s a c o s t - e f f i c i e n t a l t e r n a t i v e to acute care h o s p i t a l i z a t i o n . ( M i n i s t r y of Heal t h Annual Report, 1980, 70) Home n u r s i n g c a r e s e r v i c e s are funded d i r e c t l y by the M i n i s t r y of H e a l t h . S e r v i c e s are p r o v i d e d by home care nurses under the supervision of a M i n i s t r y of He a l t h home nursing care administrator, ( i v ) Mental Health The o v e r a l l goal of mental health services i s , " t o p r o v i d e e f f i c i e n t and e f f e c t i v e care to residents with mental h e a l t h problems r e g a r d l e s s of where the r e s i d e n t s l i v e or t h e i r income l e v e l . " ( M i n i s t r y of Health Annual Report, 1982, 38) S e r v i c e s are c a t e g o r i z e d a c c o r d i n g t o t h r e e m a i n demographic groups (children, adults, and the e l d e r l y ) and "are o r g a n i z e d i n t o s e v e r a l major program groups: P r e v e n t i v e , emergency, acute, r e h a b i l i t a t i o n and maintenance." (Ministry of Health Annual Report, 1982, 38) The Mental Health D i v i s i o n has established p r i o r i t i e s regarding the types of c l i n i c a l services g i v e n , with s e r v i c e s d i r e c t e d to the most s e r i o u s l y i l l i t s f i r s t p r i o r i t y . (Ministry of Health Annual Report, 1982, 39) Mental health services are provided by M i n i s t r y of H e a l t h mental h e a l t h s t a f f , community care boarding homes, sheltered w orkshops, a c u t e h o s p i t a l o u t p a t i e n t and p s y c h i a t r i c f a c i l i t i e s , s p e c i a l care units i n extended care hos p i t a l s , and private mental h o s p i t a l s . Mental h e a l t h s e r v i c e s p r o v i d e d i n h o s p i t a l s are funded by Hospital Programs. Mental health s t a f f s a l a r i e s , and annual grants to private agencies are funded by the Mental Health Services D i v i s i o n . Mental health services are co-ordinated by a l o c a l Mental Health Services D i v i s i o n program administrator. Alcohol and Drug Programs A l c o h o l and Drug Programs are r e s p o n s i b l e f o r four types of treatment services: Outpatient counselling services - These services are provided i n a f a c i l i t y owned or l e a s e d by a p r i v a t e agency. While the d u r a t i o n of treatment i s dependent upon i n d i v i d u a l needs, the average length of treatment i s from 2 to 6 months. . D e t o x i f i c a t i o n - Treatment i s p r o v i d e d i n a d e t o x i f i c a t i o n c e n t r e , or an acute care h o s p i t a l . The average length of stay i s from 4 to 5 days, but can extend up to 2 weeks. . Supportive or recovery homes - Recovery homes provide a group l i v i n g environment f o r r e f e r r e d substance abuse patients f o r up to 3 months. P a t i e n t s may cont i n u e to r e c e i v e o u t p a t i e n t counselling services while r e s i d i n g i n the home. . R e s i d e n t i a l treatment centres - Treatment i s provided on an inpatient basis and consists of an intensive 28 day r e s i d e n t i a l treatment program with i n d i v i d u a l and group therapy involved. In addition to these four treatment s e r v i c e s , an I n f o r m a t i o n Services D i v i s i o n i s responsible f o r preventive programs, and a P r o f e s s i o n a l Development D i v i s i o n provides seminars on alcohol and drug abuse on r e q u e s t . (B.C. A l c o h o l and Drug Programs, 1980, 1-2) P r e v e n t i o n programs and seminars on alcohol and drug abuse are provided and funded d i r e c t l y by the Minis t r y of Health. A l l other a l c o h o l and drug s e r v i c e s p r o v i d e d i n the TNRHD a r e s u p p l i e d by p r i v a t e agencies which are subsidized annually by the M i n i s t r y of H e a l t h . These p r i v a t e a g e n c i e s have been established by non-profit s o c i e t i e s who i n turn appoint a chief executive o f f i c e r to administer the ser v i c e . 38. Alcohol and drug s e r v i c e s are c o - o r d i n a t e d at the l o c a l l e v e l by a M i n i s t r y of Health program administrator. Services are organized i n the province according to 5 regional zones. A regional director i s responsible for the o v e r a l l administration and co-ordination of services i n each zone. c. Emergency Health Services The Emergency H e a l t h S e r v i c e s Commission i s responsible f o r ambulance and air-evacuation, and the medical aspects of d i s a s t e r p l a n n i n g t h r o u g h o u t B r i t i s h Columbia. As of A p r i l , 1983, the Commission operated 350 ambulances from 160 c e n t r e s around the province." (Ministry of Health Annual Report, 1982, 51) "Residents of B r i t i s h Columbia are b i l l e d at $25.00 per c a l l f o r up to 40 km and 26 cents per km over that, w i t h a $162.00 maximum. There i s no extra charge f o r a i r ambulance s e r v i c e or f o r t r a i n e d e s c o r t s where these are approved prior to the journey." (Ministry of H e a l t h Annual Report, 1982, 52) Emergency health services are organized on the basis of 7 regions i n the province, each of which i s administered by a Minis t r y of Health zone co-ordinator. 4. Medical Treatment Services Medical services are p r o v i d e d by a combination of f e e - f o r - s e r v i c e , s a l a r i e d and sessional physicians. Fee-for-service physicians are reimbursed by the B r i t i s h Columbia Medical Services Plan for services insured under the Plan. Payment f o r uninsured services i s made to the physician by the patient d i r e c t l y . S a l a r i e d p h y s i c i a n s are reimbursed by t h e i r program or agency (hosp i t a l ) , which are i n turn funded by the M i n i s t r y of H e a l t h . S e s s i o n a l physicians are usually private practice physicians who contract to a program or agency for a given amount of time. By way of example, a dermatologist or r a d i o l o g i s t would contract to work 1 or 2 days a week at a small community h o s p i t a l . A session i s defined as 1/2 day or 3 1/2 hours. (Ralff, 1984) Physicians providing community health s e r v i c e s , and a l c o h o l and drug programs and emergency health services are generally s a l a r i e d or sessional physicians, and are r e s p o n s i b l e to the program d i r e c t o r i n V i c t o r i a f o r services rendered. P h y s i c i a n s are l i c e n c e d by the College of P h y s i c i a n s _ a n d Surgeons w h i c h has the r i g h t to revoke any physician's l i c e n c e . Hospitals grant p h y s i c i a n s h o s p i t a l a d m i t t i n g p r i v i l e g e s which are retained as long as the physician abides by h o s p i t a l by-laws. Physicians providing s e r v i c e s i n h o s p i t a l s may be a mixture of f e e - f o r - s e r v i c e , s a l a r i e d and sessional physicians. S a l a r i e d physicians, such as the program direct o r f o r a h o s p i t a l renal unit, are paid out of the h o s p i t a l ' s g l o b a l budget which i s i n turn funded by Hospital Programs. I n s u r e d acute h o s p i t a l s e r v i c e s p r o v i d e d by f e e - f o r - s e r v i c e physicians are paid f o r by the Medical Services Plan. The BCMA orga n i z e s i t s members by s p e c i a l t y i n the province according to 5 administrative zones. The Medical Services Plan has adopted the BCMA's zones f o r b i l l i n g purposes. Once i t was e s t a b l i s h e d how l o c a l health services were organized, i t was t h e n p o s s i b l e t o a p p r o a c h a l l r e l e v a n t f a c i l i t y and p r o g r a m a d m i n i s t r a t o r s , co-ordinators, and the medical health o f f i c e r , and ask f o r t h e i r assistance i n developing the study. According to Foulkes (1 974), "the present range of h e a l t h " s e r v i c e s 40. p r o v i d e d i n B r i t i s h Columbia i s both broad and varied, and i n many aspects, of high q u a l i t y . " (Foulkes, 1974, Tome Two, 1) However, t h i s author agrees wi t h Foulkes that, given the number of fed e r a l , p r o v i n c i a l and l o c a l groups i n v o l v e d , as w e l l as d i f f e r i n g f u n d i n g mechanisms, and d i f f e r i n g administrative j u r i s d i c t i o n s , i t i s "no wonder that the t o t a l enterprise has been l a b e l l e d a 'non-system' of health services delivery." (Foulkes, 1974, Tome Two, 3) 41. CHAPTER V MAJOR FEDERAL AND BRITISH COLUMBIA HEALTH-RELATED LEGISLATION Introduction The p r e s e n t complex o r g a n i z a t i o n . ; of the h e a l t h care system and accompanying lack of co-ordination among providers and services appeared, i n part, to stem from l e g i s l a t i o n governing the system's h e a l t h s e r v i c e s and r e s o u r c e s . In order to test t h i s assumption, i t was necessary to review the l e g i s l a t i o n . Acts and t h e i r r e g u l a t i o n s e s t a b l i s h the a u t h o r i t y r e s p o n s i b l e f o r a d m i n i s t e r i n g , funding and p r o v i d i n g the s e r v i c e , and designate each authority's administrative j u r i s d i c t i o n . Major fe d e r a l and B r i t i s h Columbia A c t s g o v e r n i n g each of the s t u d y ' s h e a l t h s e r v i c e s components and sub-components are shown i n Table 2. D e s c r i p t i o n s of the Acts and t h e i r regulations follow. A. Federal Health-Related L e g i s l a t i o n 1. Health Services a. The B r i t i s h North America Act (BNA Act), 1867 "Government i n v o l v e m e n t i n h e a l t h care s e r v i c e s i n 1867, at confederation, was minimal. Fo r the most part the i n d i v i d u a l was compelled to r e l y on h i s own r e s o u r c e s , and those of his family group, and h o s p i t a l s were a d m i n i s t e r e d and f i n a n c e d by p r i v a t e c h a r i t i e s and r e l i g i o u s organizations. The o n l y s p e c i f i c r e f e r e n c e s to h e a l t h i n the d i s t r i b u t i o n of l e g i s l a t i v e powers under the B r i t i s h North America Act 1867 a l l o c a t e to Parliament j u r i s d i c t i o n over quarantine and the establishment and maintenance of marine h o s p i t a l s , and to p r o v i n c i a l l e g i s l a t u r e s j u r i s d i c t i o n over the establishment, maintenance and management of h o s p i t a l s , asylums, c h a r i t i e s and c h a r i t a b l e i n s t i t u t i o n s i n and f o r TABLE II Major Federal and B r i t i s h Columbia Health-Related L e g i s l a t i o n , 1984 HEALTH SERVICES COMPONENTS AND SUB-COMPONENTS 1. Health Services MAJOR HEALTH - RELATED LEGISLATION FEDERAL PROVINCIAL (B. C.) ° B r i t i s h North America Act (BNA Act) 0 BNA Act ° F i n a n c i a l Administration Act 2. Acute Care Services a) Acute Hospitals and Diagnostic and Treatment Centres ° Department of National Health and Welfare Act " National Health Grants (now terminated) 0 Hospital Insurance and Diagnostic Services Act • Health Resources Fund (now terminated) ° Federal-Provincial F i s c a l Arrangements and Established Programs Financing Act (EPF Act) ° Canada Health Act 0 Hospital Act 0 Hospital Insurance Act ° Hospital D i s t r i c t Act 0 Hospital D i s t r i c t Finance Act 3. I n s t i t u t i o n a l Intermediate and Extended Care Services a) Intermediate Care* b) Extended Care ° EPF Act ! 0 Community Care F a c i l i t y Act ° Hospital Act ° Hospital Act ° Hospital Insurance Act * No LTC / Home Care Act has yet been l e g i s l a t e d . TABLE II (Cont'd.) Major Federal and B r i t i s h Columbia Health-Related L e g i s l a t i o n , 1984 HEALTH SERVICES COMPONENTS AND SUB-COMPONENTS MAJOR HEALTH - RELATED LEGISLATION FEDERAL PROVINCIAL (B. C.) 4. Non-Hospital Health Care Programs a) Community Health Services (i ) Public Health ( i i ) Community Health Services (Registered Indians) ( i i i ) Mental Health (iv) Long Term Care/ Home Nursing Care Services* b) Alcohol and Drug Programs c) Emergency Health Services ° Department of National Health and Welfare Act ° Department of National Health and Welfare Act ° EPF Act ° Health Act 0 Health Act ° Mental Health Act ° Community Care F a c i l i t y Act ° Health Act 0 Hospital Act 0 Community Care F a c i l i t y Act 0 Alcohol and Drug Commission Act ° Community Care F a c i l i t y Act ° Health Emergency Act 5. Medical Services ° Medical Care Act 0 EPF Act ° Canada Health Act 0 Medical Services Act ° Medical Services Plan Act 1981 ° Medical P r a c t i t i o n e r s Act * No LTC / Home Care Act has yet been l e g i s l a t e d . <£)W. L. Morton, 1985. 44. the p r o v i n c e , other than marine h o s p i t a l s . I n 1867 t h i s l a t t e r r e f e r e n c e probably was meant to cover most health care s e r v i c e s . Since the provinces were assigned j u r i s d i c t i o n g e n e r a l l y over a l l matters of a merely l o c a l or private nature i n the province, i t i s probable that this power was deemed to cover health care, w h i l e the p r o v i n c i a l power over municipal i n s t i t u t i o n s provided a convenient means f o r dealing with such matters. Thus p r o v i s i o n of h e a l t h care s e r v i c e s has t r a d i t i o n a l l y been acknowledged as p r i m a r i l y a p r o v i n c i a l r e s p o n s i b i l i t y . But a measure of r e s p o n s i b i l i t y i n health matters has been expressed over the years i n many f e d e r a l programs and policies..."(Canada Year Book, 1980-81, 171) The Department of National Health and Welfare Act, 1944 F e d e r a l r e s p o n s i b i l i t y f o r a number of h e a l t h s e r v i c e s was formalized with the passing of the Department of National Health and Welfare Act i n 1944. This Act extablished the Department of National Health and Welfare (Health and Welfare Canada). Under the provisions of the Act, the Department, " i s responsible f o r the o v e r a l l promotion, preservation and r e s t o r a t i o n of the h e a l t h of Canadians, and f o r t h e i r s o c i a l s e c u r i t y and s o c i a l w e l f a r e . " (Canada Year Book, 1980-81, 171) The Department i s d i v i d e d i n t o a number of b r a n c h e s w i t h r e s p o n s i b i l i t y f o r health protection, medical services, and health services and promotion and "these branches act i n c o n j u n c t i o n w i t h other f e d e r a l agencies and with p r o v i n c i a l and l o c a l s e r v i c e s . " (Canada Year Book, 1980-81, 171) Hospital and Medical Services Although p r o v i n c i a l governments have primary j u r i s d i c t i o n over h e a l t h s e r v i c e s i n Canada, f e d e r a l p a r t i c i p a t i o n i n p r o v i n c i a l h o s p i t a l and medical programs i s governed by a number of A c t s . They i n c l u d e : the N a t i o n a l H e a l t h Grants, 1948 (now e x p i r e d ) , the 45. Hospital Insurance and D i a g n o s t i c S e r v i c e s Act, 1958, the H e a l t h Resources Fund, 1965 (now expired), the Medical Care Act, 1966, the F e d e r a l - P r o v i n c i a l F i s c a l Arrangements and E s t a b l i s h e d Programs Financing Act (EPF Act), 1977, and the Canada Health Act, 1984. The f e d e r a l government in t r o d u c e d the National Health Grants program i n 1948 as part of i t s post-war reconstruction measures. "Under this program the federal government provided grants to the provinces to b u i l d h o s p i t a l s , improve public health, p r o v i d e more t r a i n e d manpower, and improve cancer, mental health and medical r e h a b i l i t a t i o n s e r v i c e s . Prime M i n i s t e r S t . L a u r e n t i n d i c a t e d t h a t i t was a '...fundamental prerequisite to a nationwide system of h e a l t h i n s u r a n c e ' (Gelber, 1959)." (Soderstrom, 1978, 158) The p r o l i f e r a t i o n of hospitals and health units today i s the r e s u l t of the l a r g e number of f a c i l i t i e s c o n s t r u c t e d with the a i d of matching grants under t h i s program between 1948 and the program's termination i n 1970. In a l a t e r move to increase the supply of h e a l t h manpower i n Canada, the federal government established the Health Resources Fund Program i n 1966. "Under this program,... the federal government share(d) with the p r o v i n c i a l governments the cost of planning, acquiring, c o n s t r u c t i n g , r e n o v a t i n g and equ i p p i n g f a c i l i t i e s (e.g. schools and h o s p i t a l s ) which (were t o ) be used e i t h e r to t r a i n people i n h e a l t h p r o f e s s i o n s or to conduct health research." (Soderstrom, 1978, 154) The program was terminated i n 1980. A number of f a c t o r s c o n t r i b u t e d to the development of the Hospital Insurance and Diagnostic Services Act, and the Medical Care A c t . However, the over-riding factor appears to have been the high 4 6 ' . cost of private hospital and medical fees i n the 1950's and 60's leading to hardship for some individuals, and a consequent protest from the public that they be freed from the c r i p p l i n g costs of heal th care . This protest was in the form of electing governments that would e f f e c t change . The f e d e r a l L i b e r a l p a r t y made implementation of "universal health care" part of i ts platform, and passed the Hospital Insurance and Diagnostic Services Act i n 195 8, and the Medical Care Act i n 1966. Support for welfare state type health services has continued to occur as the public (through voting behavior) has opted for increased state intervention. (Taylor, 1978, 44) Rising health care costs in the 1970's and early 80's became a matter of increasing concern for both the federal and provincial governments. In an attempt to cont ro l health care c o s t s w h i l e maintaining present levels of service, the federal government passed the Federal-Provincial F i s c a l Arrangements and Established Programs Financing Act i n 1977, and the Canada Health Act i n 1984. a) Hospital Insurance and Diagnostic Services Act, 1958 Under the p r o v i s i o n s of the A c t , the M i n i s t e r of Nat ional Health and Welfare is empowered to enter into agreements with the provinces to share i n the c o s t of providing hospital and diagnostic services. In order to be e l i g i b l e , each p r o v i n c e must agree to f i v e b a s i c principles : "comprehensiveness of services; universal a v a i l a b i l i t y of coverage to a l l e l i g i b l e r e s i d e n t s ; no b a r r i e r s to reasonable a c c e s s i b i l i t y of c a r e ; p o r t a b i l i t y of b e n e f i t s ; and p u b l i c a d m i n i s t r a t i o n of the p r o v i n c i a l program. No direct charge i s to be l e v i e d to p a t i e n t s , t h e r e b y r e m o v i n g f i n a n c i a l b a r r i e r s to care which exist e d p r e v i o u s l y f o r many r e s i d e n t s . " (Canada Year Book, 1980-81, 169) The o v e r a l l f e d e r a l c o n t r i b u t i o n to a l l provinces i s 50% of the national cost of the insured services but, " t h e d i s t r i b u t i o n among p r o v i n c e s r e f l e c t each province's c o s t s f o r i n s u r e d s e r v i c e s i n an i n v e r s e r a t i o so that low-cost provinces r e c e i v e more than 50% of the c o s t s and h i g h - c o s t provinces l e s s than 50% of the costs. This i s an incentive f o r a p r o v i n c e to keep i t s costs below the national average." (H a l l , 1980, 4) The provinces can r a i s e t h e i r portion of insurable costs as t h e y w i s h " p r o v i d e d t h a t a c c e s s t o s e r v i c e s i s not i mpaired." (Canada Year Book, 1 980-81, 169) B r i t i s h Columbia's share of the cost of insured services i s r a i s e d through general income tax (8'p~er cent, 1983), and per diem h o s p i t a l user charges. -Medical Care Act, 1968 The M e d i c a l Care Act was enacted by Parliament i n 1966, and made e f f e c t i v e on July 1, 1968. "In addition to the comprehensive p h y s i c i a n s ' s e r v i c e s w h i c h must be p r o v i d e d as i n s u r e d s e r v i c e s by p a r t i c i p a t i n g provinces, the Medical Care Act empowers p r o v i n c i a l governments to include any a d d i t i o n a l health s e r v i c e s under terms and c o n d i t i o n s w hich may be s p e c i f i e d by the L i e u tenant-Governor-in-C ounc i l . " (Canada Year Book, 1980-81, 170) E l i g i b i l i t y conditions governing f e d e r a l p a r t i c i p a t i o n i n each p r o v i n c i a l plan i s again based on the p r i n c i p l e s of u n i v e r s a l i t y , p o r t a b i l i t y , comprehensiveness of services •48. and public administration of the program. The M e d i c a l c o s t - s h a r i n g f o r m u l a d i f f e r s from the Hospital Insurance formula, " i n t h a t i t i g n o r e s i n d i v i d u a l p r o v i n c e ' s costs. A l l p r o v i n c i a l expenditures f o r insured medical services f o r insured persons are tabulated and the n a t i o n a l average per c a p i t a i s c a l c u l a t e d . One half of the amount i s paid to each p r o v i n c e i n r e s p e c t of the number of insured persons i n i t s population. The e f f e c t of t h i s change i s to r e d u c e the percentage c o n t r i b u t i o n of high c o s t provinces and to increase i t f o r low c o s t p r o v i n c e s . " ( H a l l , 1980, 7) Under the Act, "each p r o v i n c e may determine how i t w i l l finance i t s medical insurance plan - through premiums, s a l e s tax, o t h e r p r o v i n c i a l r e v e n u e s or by a combination of methods." (Canada Year Book, 1980-81, 170) In B r i t i s h Columbia, the medical services plan i s f i n a n c e d through general income tax, and premiums. The F e d e r a l - P r o v i n c i a l F i s c a l Arrangements and Established Programs Financing Act (EPF), 1977 P r i o r to 1977, f e d e r a l c o n t r i b u t i o n s to h o s p i t a l and medical insurance plans were based on t i e d c o s t - s h a r i n g agreements with the p r o v i n c e s as i n d i c a t e d i n the two previous Acts. Through enactment of the EPF ACT i n 1977, the f e d e r a l government s h i f t e d from cost-sharing to block funding of the established programs. E s t a b l i s h e d programs a r e h o s p i t a l i z a t i o n , m e d i c a r e , and p o s t - s e c o n d a r y education. Certain extended health c a r e s e r v i c e s are a l s o included under the EPF Act. Total f e d e r a l contributions, 49. "take the form of the transfer of a predetermined number of t a x p o i n t s , and r e l a t e d e q u a l i z a t i o n and cash payments (which) are based on the c u r r e n t e s c a l a t e d v a l u e of the 1975-76 f e d e r a l c o n t r i b u t i o n f o r the provinces i n question." (Canada Year Book, 1980-81, 170) Federal contributions then, "are based on the do l l a r equivalent of what cost-sharing w o u l d h a v e y i e l d e d , b u t w i t h o u t e n f o r c i n g the requirement on the provinces to spend a dollar f or every d o l l a r the Government of Canada contributes." (Canadian Bar Association, 1981, 7) C r i t i c i s m has been r a i s e d t h a t under the agreement "federal block-funding could be used to replace p r o v i n c i a l funds p r e v i o u s l y spent on health and education." (Canadian Bar Association, 1980, 7) According to Emmett H a l l i n h i s r e p o r t , Canada's N a t i o n a l P r o v i n c i a l Health Planning f o r  the 1980's, the a l l e g a t i o n that f e d e r a l health d o l l a r s are being d i v e r t e d by the provinces i s unfounded. ( H a l l , 1980, 11) Canada Health Act, 1984 While mechanisms f o r funding the p r o v i n c i a l c o s t s of m e d i c a l and h o s p i t a l i n s u r e d plans have been l e f t to the p r o v i n c e s , f e d e r a l p a r t i c i p a t i o n i n the programs i s c o n t i n g e n t on the p r i n c i p l e s of u n i v e r s a l i t y , p o r t a b i l i t y and comprehensiveness of services being upheld. Thus, the i s s u e s of h o s p i t a l u s e r f e e s , premiums f o r m e d i c a l insurance, and e x t r a - b i l l i n g by p h y s i c i a n s have become po i n t s of c o n t r o v e r s y between the federal government and the provinces. I n an attempt to discourage these practices, 50. the federal government passed the Canada Health Act i n June of 1984. The Act permits the federal government to withhold $1. i n grants to the provinces f o r every $1. patients are forced to pay f o r t h e i r h o s p i t a l and medical charges. While the B r i t i s h Columbia government does not allow p h y s i c i a n s to e x t r a - b i l l , the B.C. Health Minister argues that, " d i r e c t c h a r g e s f o r h o s p i t a l i z a t i o n and m e d i c a l insurance are an i n t e g r a l part of health care funding i n B r i t i s h Columbia, and that t h e i r abandonment would force drastic cuts i n service or a corresponding g e n e r a l tax increase." (Palmer, 1984, 5) Under the Act, "any p r o v i n c e can receive the revenues that have been withheld, simply by making i t s system comply with the new r u l e s . " (Cruickshank, 1984, 3) • B r i t i s h Columbia has chosen not to accept the fe d e r a l government's o f f e r . B. B r i t i s h Columbia Health-Related L e g i s l a t i o n 1. Health Services a. F i n a n c i a l Administration Act, 1981 (S.B.C. Chapter 15) The F i n a n c i a l A d m i n i s t r a t i o n A c t i s a d m i n i s t e r e d by t h e M i n i s t r y of Finance and e s t a b l i s h e s the authority for spending i n the province. The Act consolidates a number of F i n a n c i a l A c t s , and o v e r r i d e s a number of others. A detailed description of the Act i s p r o v i d e d i n C h a p t e r VI, i n the s e c t i o n e n t i t l e d , F i n a n c i a l Re-structuring of Programs. Hospitals A c c o r d i n g to B a i n b r i d g e , the enactment of the H o s p i t a l Insurance Act i n 1952 occurred as a r e s u l t of the floods of 1947, "which so over-taxed the m u n i c i p a l i t i e s that pressure was brought to bear on the p r o v i n c i a l l e g i s l a t u r e to impose the S o c i a l S e r v i c e s and M u n i c i p a l A i d Tax which subsequently p r o v i d e d the revenues f o r a h o s p i t a l i n s u r a n c e p l a n . " (Bainbridge, 1980, 28) Costs of the i n s u r e d p l a n were shared with the f e d e r a l government f o l l o w i n g enactment of the H o s p i t a l I n s u r a n c e and D i a g n o s t i c Services Act i n 1958. Hospitals were formally c l a s s i f i e d according to their operation and o r g a n i z a t i o n with the passing of the Hospital Act i n 1960. The Hospital Act a l s o e s t a b l i s h e d the powers of h o s p i t a l boards. As p r e v i o u s l y i n d i c a t e d , the f e d e r a l government's N a t i o n a l Health Grants program provided matching grants for h o s p i t a l c o n s t r u c t i o n . Because m u n i c i p a l i t i e s were c o n s i d e r e d too small to share i n the cost of funding c a p i t a l projects, h o s p i t a l improvement d i s t r i c t s , set up on the basis of major water courses, were established by the p r o v i n c i a l government under the Water Improvement Act. (Bainbridge, 1983) The h o s p i t a l improvement d i s t r i c t s were absorbed into what became regional h o s p i t a l d i s t r i c t s with the passing of the H o s p i t a l D i s t r i c t A ct i n 1 967. The H o s p i t a l D i s t r i c t Act, and the Hospital D i s t r i c t Finance Act together e s t a b l i s h the mechanisms through which regional h o s p i t a l d i s t r i c t boards share i n the c a p i t a l f u n d i n g of h o s p i t a l s as designated under the Hospital Act. Details of each Act are described below. 52. a. Hospital Insurance Act (R.S.B.C. 1979. Chapter 180) This Act determines benefits for h o s p i t a l services and establishes funding regulations. The Act authorizes the, "establishment of the H o s p i t a l Insurance Fund, from which grants are made to h o s p i t a l s toward operating expenses and c a p i t a l c o s t s . Grants are also made to regional hospital d i s t r i c t s . " (Ministry of Health Annual Report, 1980, 113) Under the Act, ( i ) "Every permanent resident who has l ived i n Br i t i sh Columbia during the statutory waiting period is entit led to hospital insurance benefits. ( i i ) Operating grants to public general h o s p i t a l s are based on approved annual b u d g e t s ; for accounting purposes , per diem r a t e s are used f o r m e d i c a l l y necessary in-patient care rendered to qual i f ied B r i t i sh Columbia residents who are s u f f e r i n g from an acute i l l n e s s or i n j u r y , and those who r e q u i r e a c t i v e convalescent, rehabilitative and extended hospital care. The payment made to a hospital by Hospital Programs from the Hospital Insurance Fund amounts to the per diem rate approved f o r that p a r t i c u l a r h o s p i t a l minus the co-insurance charge paid to the hospital by the patient. ( i i i ) A wide range of i n - p a t i e n t and out-pat ient benefits is provided under the Act . (iv) Qualified persons who are temporarily absent from Bri t i sh Columbia are entit led to certain benefits during a period which ends at midnight on the last day of the twelfth month following the month of departure. (v) In addition to the payments toward operating costs paid to h o s p i t a l s as-descr ibed above, h o s p i t a l s and regional h o s p i t a l d is t r i c t s receive grants of up to 60 per cent of approved c o s t s of c o n s t r u c t i o n or a c q u i s i t i o n of h o s p i t a l f a c i l i t i e s , one-third of the cost of minor movable f a c i l i t i e s , 75 per cent of the cost of major diagnostic equipment, and 100 per cent of the cost of (that) equipment which r e s u l t s i n proven savings i n o p e r a t i n g c o s t s . The province may also provide additional f i n a n c i a l assistance i n respect of the approved cost of equipment for f a c i l i t i e s which have been designated by the Minister as provincial referral .53. centres." (Ministry of Health Annual Report, 1980, 113) The H o s p i t a l Programs branch of the M i n i s t r y of H e a l t h operates under the authority of the provisions of this Act. Hospital Act (R.S.B.C. 1979, Chapter 176) This Act, " c o n t r o l s the o r g a n i z a t i o n and operation of hospitals which are c l a s s i f i e d as follows: ( i ) Public h o s p i t a l s : Non-profit h o s p i t a l s caring primarily f o r acutely i l l persons. ( i i ) Private h o s p i t a l s : T h i s c a t e g o r y i n c l u d e s s m a l l hospitals, most of which are operated i n remote areas by i n d u s t r i a l concerns primarily f o r t h e i r employees, and l i c e n c e d nursing-homes which are not under h o s p i t a l insurance coverage. ( i i i ) R e h a b i l i t a t i o n and extended-care h o s p i t a l s : These n o n - p r o f i t hospitals are primarily f o r the treatment of persons who r e q u i r e l o n g - t e r m r e h a b i l i t a t i v e and extended h o s p i t a l c a r e . " ( M i n i s t r y of H e a l t h Annual Report, 1980, 114) Under the Act, every h o s p i t a l except hospit a l s owned by the Province or by Canada, s h a l l , " ( i ) make p r o v i s i o n f o r the r e p r e s e n t a t i o n of t h e P r o v i n c i a l government and the board of the r e g i o n a l h o s p i t a l d i s t r i c t on the board of management of the h o s p i t a l . ( i i ) have f u l l c o n t r o l of the revenue and expenditure of the h o s p i t a l vested i n i t s board of management. ( i i i ) have a p r o p e r l y c o n s t i t u t e d board of management and by laws, rules or regulations thought necessary by the m i n i s t e r f o r the a d m i n i s t r a t i o n and management of the h o s p i t a l ' s a f f a i r s and the p r o v i s i o n s of a h i g h standard of care and treatment f o r p a t i e n t s , and the c o n s t i t u t i o n and by-laws, r u l e s or r e g u l a t i o n s of a h o s p i t a l are not e f f e c t i v e u n t i l approved by the minister." (R.S.B.C, 1979, Chapter 176) The Minister however, 54. "may exempt a h o s p i t a l from making p r o v i s i o n f o r the r e p r e s e n t a t i o n of the board of the r e g i o n a l h o s p i t a l d i s t r i c t on the board of management of the h o s p i t a l , i f he i s s a t i s f i e d that, ( i ) the board of the regional h o s p i t a l d i s t r i c t does not wish to have representation; or ( i i ) the h o s p i t a l has not r e c e i v e d a i d under the Hospital D i s t r i c t Act." (R.S.B.C, 1979, Chapter 176) The society that owns or operates the h o s p i t a l cannot e x e r c i s e i t s borrowing powers, or make any s t r u c t u r a l a l t e r a t i o n s , or reduce or i n c r e a s e the number of beds w i t h o u t p r i o r a p p r o v a l of the M i n i s t r y of H e a l t h . (R.S.B.C, 1979, Chapter 176) The H o s p i t a l A c t i s a d m i n i s t e r e d by the H o s p i t a l Programs branch of' the M i n i s t r y of Health. The A s s i s t a n t Deputy Minister of I n s t i t u t i o n a l Services i s also the Chief Inspector of Hospitals f o r B r i t i s h Columbia under the Act. c. Hospital D i s t r i c t Act (R.S.B.C. 1979, Chapter 178) "The H o s p i t a l D i s t r i c t Act p r o v i d e s a mechanism f o r financing the c a p i t a l c o s t of h o s p i t a l b u i l d i n g s and equipment. The Act provides f o r the d i v i s i o n of the p r o v i n c e i n t o l a r g e d i s t r i c t s t o enable r e g i o n a l p l a n n i n g , development, and f i n a n c i n g of h o s p i t a l p r o j e c t s under a formula which permits s u b s t a n t i a l f i n a n c i a l assistance from the p r o v i n c i a l government. Each r e g i o n a l h o s p i t a l d i s t r i c t i s , s u b j e c t t o the requirements of the Act, able to pass c a p i t a l expense proposal by-laws a u t h o r i z i n g debentures to be i s s u e d c o v e r i n g the t o t a l c o s t of one or more h o s p i t a l projects. Once a c a p i t a l expense p r o p o s a l by-law has been approved by the Lieutenant-Governor-in-Council, the d i s t r i c t i s able to proceed to arrange both temporary financing and long-term financing on a favourable basis. The long-term f i n a n c i n g i s p r o v i d e d by the R e g i o n a l H o s p i t a l D i s t r i c t s F i n a n c i n g A u t h o r i t y (see below), which purchases d e b e n t u r e s i s s u e d by the v a r i o u s -55. districts as required. Each year the p r o v i n c i a l government pays through Hospital Programs from the Hospital Insurance Fund a portion of the principal and interest payments required on the debentures issued by the Regional H o s p i t a l D i s t r i c t s ' F i n a n c i n g Authority i n accordance with section 22 of the Act. The balance of the p r i n c i p a l and interest requirements are raised by the d i s t r i c t through taxation. Under the s h a r i n g arrangements the province pays annually to or on behalf of each di s t r i c t 60 per cent of the approved net cost of amortizing the d i s t r i c t s ' borrowings for hospital construction projects after deduction of any items which are the d i s t r i c t s ' responsibility, such as provision of working c a p i t a l , funds for hospital operations, etc. The a f f a i r s of each regional h o s p i t a l d i s t r i c t are managed by a board comprised of the same representatives of the municipalities and unorganized areas who form the board of the regional district (incorporated under the Municipal Act) which has the same boundaries as the regional hospital d i s t r i c t . The board of each r e g i o n a l h o s p i t a l d i s t r i c t i s responsible for c o - o r d i n a t i n g and e v a l u a t i n g the requests or funds from the h o s p i t a l s w i t h i n the district, and for adopting borrowing by-laws subject to approvals and conditions required under the Act, i n respect to either single projects or an over-all program for hospital projects in the d i s t r i c t . The purposes of a r e g i o n a l h o s p i t a l d i s t r i c t , as described i n section 20 of the Act, are b a s i c a l l y to acquire, c o n s t r u c t , enlarge, operate and maintain hospitals; to grant aid for these purposes; and to act as an agent of the province in receiving and disbursing monies granted out of the Hospital Insurance Fund. In o r d e r to e x e r c i s e these powers, that board i s authorized, with the approval of the Minister, to raise by t a x a t i o n an amount not exceeding the greater of $200,000 or the product of one-quarter of a m i l l on the assessed value of lands and improvements within the d i s t r i c t . " (Ministry of Health Annual Report, 1980, 114) Hospital D i s t r i c t Financing Act (R.S.B.C. 1979, Chapter 179) "The Hospital D i s t r i c t Financing Act establishes an authority to a s s i s t i n the f i n a n c i n g of h o s p i t a l projects, medical and health f a c i l i t i e s , community human :56. resources and health centres, and any other community, regional, or p r o v i n c i a l f a c i l i t i e s f o r the s o c i a l improvement, welfare and benefits of the community or the general public good approved by the Minister of Health. The f i n a n c i n g a u t h o r i t y purchases s i n k i n g f u n d debentures issued by regional hospital construction projects. The financing authority obtains i t s money by marketing i t s own debentures. The raising of funds by a p r o v i n c i a l authority helps ensure a better market and, on average, a lower interest rate." (Ministry of Health Annual Report, 1980, 116) 3. Intermediate and Extended Care F a c i l i t i e s According to Bainbridge, by the 1960's, both the federal and provincial governments were becoming concerned with the often inappropriate use of acute care hospitals to deal with the needs of the handicapped and the e l d e r l y . Private hospitals and long term care f a c i l i t i e s were charging whatever rate they f e l t the market could bear, while services provided by non-profit organizations were only marginally adequate. (Bainbridge, 1980, 28-2 9) In 1965, "the federal and p r o v i n c i a l government came to an agreement on funding extended hospital care in British Columbia. The c r i t e r i a for admission to such hospitals was very rigidly defined." (Bainbridge, 1980, 29) By the la t e 1960's and early '70's, homemaker s e r v i c e s provided by non-profit s o c i e t i e s , together with home nursing care services provided by the provincial government's health units, the V.O.N, and municipalities began to deliver more care i n the home. However, emphasis throughout the system was s t i l l on institutional care. People who were not e l i g i b l e for extended care, but who needed varying degrees of non-acute institutional assistance were categorized as 'intermediate care'. Large numbers of these p a t i e n t s were "causing bottlenecks i n the acute hospitals from where discharge was a l l but impossible." (Bainbridge, 1980, 29) At the same time, " n e g o t i a t i o n s f o r the t e r m i n a t i o n of the f e d e r a l / p r o v i n c i a l c o s t - s h a r i n g agreements were i n an advanced stage and extended h e a l t h options were included i n the proposals brought to the table by the f e d e r a l government. The convergence of a l l these f o r c e s c u l m i n a t e d i n an acceptance by the B r i t i s h Columbia government of a program of l o n g term c a r e t h a t was to d e a l not o n l y w i t h 'intermediate care', but also with the provision of an ent i r e range of p r e v e n t i v e low-cost a l t e r n a t i v e s e r v i c e s f o r the i n f i r m and handicapped, p a r t i c u l a r l y the aged." (Bainbridge, 1980, 30) The long term c a r e program came into e f f e c t on January 1, 1978. No formal l e g i s l a t i o n was s p e c i f i c a l l y enacted f o r the program. Instead, "the P r o v i n c i a l Adult Care Licencing Board, e s t a b l i s h e d under the Community Care F a c i l i t y Act i s the organizational body responsible to the M i n i s t e r of H e a l t h f o r the l i c e n c i n g and i n s p e c t i o n of community care f a c i l i t i e s p a r t i c i p a t i n g i n the program, recommending app r o v a l of the c o n s t r u c t i o n of new lo n g term f a c i l i t i e s i n the various communities, and l i a i s o n with other programs that may have d e s i r a b l e imput to the long term care program." (Ministry of Health Annual Report, 1980, 65) The f a c i l i t i e s l i c e n c e d under this Act include both p r i v a t e and n o n - p r o f i t community care f a c i l i t i e s with benefits accruing under a r e s i d u a l clause i n the Hospital Act. The Community Care F a c i l i t y A c t i s a d m i n i s t e r e d by the M i n i s t r y of H e a l t h ; the P r o v i n c i a l Adult Care Licencing Board i s comprised of representatives from the Minis t r y of Health. Extended care f a c i l i t i e s are administered and operated under the H o s p i t a l Act and the H o s p i t a l Insurance Act, under the d i r e c t i o n of the Ministry of Health. 4. Non-Hospital Health Care Programs a. Community Health Services ( i ) Public Health Public health services are governed under the He a l t h A c t . 58. This Act was passed i n 1891, and re-written several years ago. Health Act (R.S.B.C. 1979, Chapter 161) "The Act e s t a b l i s h e s the a u t h o r i t y of the Minister of Health for the Province of B r i t i s h Columbia to make and i s s u e such g e n e r a l r u l e s , orders and r e g u l a t i o n s as are deemed, necessary for the prevention, treatment, mitigation, and suppression;of disease, including .those rules and regulations r e l a t i n g t o _ v i t a l s t a t i s t i c s , ' organization of health units, and p e r s o n n e l i n s p e c t i o n of h o s p i t a l s , f a c t o r i e s and ind u s t r i a l ; camps, etcj_, s a n i t a t i o n , water q u a l i t y regulations, p o l l u t i o n and nuisance abatement, tuberculosis and venereal disease c o n t r o l , and communicable disease c o n t r o l . Under the Act, the execution of regulations i s assigned to a l o c a l Board of Health, a Union Board of Health or a Regional D i s t r i c t ( i n out-lying areas)." (Department of Health Care and Epidemiology, 1969, A25.3) Local or Union Boards of Health have r e s p o n s i b i l i t y for the s u p e r v i s i n g , c o - o r d i n a t i n g and operating of community health u n i t s . Under the Act, a 'Board' i s responsible for appointing a Medical Health O f f i c e r who i s r e s p o n s i b l e f o r the t e c h n i c a l o p e r a t i o n s under the a u t h o r i t y of the A c t . The Act a l s o establishes the authority of the P r o v i n c i a l Health O f f i c e r , i ) Long Term Care / Home Nursing Care Services No s p e c i f i c l e g i s l a t i o n has been e n a c t e d f o r t h e s e programs. Community care f a c i l i t i e s are licenced and inspected under the Community Care F a c i l i t y Act. The M i n i s t r y of H e a l t h a d m i n i s t e r s the LTC and Home Nursing Care Programs, and both programs a r e f u n d e d e n t i r e l y by t h e p r o v i n c e . L o c a l a d m i n i s t r a t i o n and c o - o r d i n a t i o n l i e s with the Health Units under the d i r e c t i o n of the Medical Health O f f i c e r . I n each health unit, a LTC administrator and Home Nursing 59. Care a d m i n i s t r a t o r are appointed, with program d i r e c t i o n from the Ministry, but these s t a f f are integrated with the s t a f f of p u b l i c h e a l t h and other l o c a l l y based community programs. The LTC administrator i s r e s p o n s i b l e f o r both i n s t i t u t i o n a l and community b a s e d programs. Home Nursing Care s e r v i c e s are co-ordinated with the LTC program. (Bainbridge, 1980, 30) ( i i i ) Mental Health Services Mental health services are governed by the Mental H e a l t h A c t . The Act i s not an administrative act, but was l e g i s l a t e d to e s t a b l i s h the circumstances under which a person may be r e s t r a i n e d i n an a c u t e c a r e or m e n t a l h e a l t h f a c i l i t y . Specif i c a l l y , "The Act enables the Lieutenant-Governor-in- C o u n c i l to e s t a b l i s h and maintain f a c i l i t i e s and services f o r the diagnosis and treatment of mentally d i s o r d e r e d persons and the r e h a b i l i t a t i o n of patients. F a c i l i t i e s include p r o v i n c i a l mental h e a l t h f a c i l i t i e s , p r i v a t e mental hospitals and any public h o s p i t a l or part of a p u b l i c h o s p i t a l as a psychiatric u n i t . The Act also permits the l i c e n c i n g by the L i e u t e n a n t - G o v e r n o r - i n - C o u n c i l of community care f a c i l i t i e s according to regulations under the Community Care F a c i l i t y Act. The Act i s admi n i s t e r e d by the M i n i s t r y of H e a l t h . R e g u l a t i o n s include the establishment of a director f o r each p r o v i n c i a l mental health f a c i l i t y . Under the Act, the L i e u t e n a n t - G o v e r n o r - i n - C o u n c i l may f i x per diem charges for care, treatment and maintenance p r o v i d e d i n a p r o v i n c i a l m e n t a l h e a l t h f a c i l i t y . The Act a l s o includes s p e c i f i c rules f or admission by c e r t i f i c a t i o n or v o l u n t a r y admission, review, procedures which can be i n s t i t u t e d on demand a f t e r three months of admission, and r e g u l a t i o n s f o r t r a n s f e r , d i s c h a r g e and l e a v e . " ( D e p a r t m e n t of H e a l t h Care and Epidemiology, 1969, A.25.11) Mental health services have a l o o s e a s s o c i a t i o n with the p u b l i c h e a l t h system, w i t h mental h e a l t h c l i n i c s sometimes 60. l o c a t e d adjacent to community h e a l t h u n i t s , and sometimes s e p a r a t e ; b. Alcohol and Drug Programs The A l c o h o l and Drug Commission was e s t a b l i s h e d by the p r o v i n c i a l government i n 1973 under the Alcohol and Drug Commission A c t . Under the p r o v i s i o n s of the Act, the Commission i s empowered to, "operate programs, enter into agreements with, or prov i d e f i n a n c i a l or o t h e r a s s i s t a n c e t o any m i n i s t r y of government, h o s p i t a l , agency, u n i v e r s i t y or p e r s o n to operate programs, f o r study i n g , researching, diagnosing, treating, r e h a b i l i t a t i n g , counselling, following up, caring or providing other services f o r a l c o h o l i c s or drug u s e r s , ( a n d ) , c o n d u c t , or a r r a n g e and f u n d , p r o g r a m s f o r the d i s s e m i n a t i o n of i n f o r m a t i o n about a l c o h o l i s m and drug abuse." ( A l c o h o l and Drug Commission Act, R.S.B.C. 1979, Chapter 13) I n l a t e 1980, the p r o v i n c i a l government r e o r g a n i z e d the f u n c t i o n s which were performed by the Alcohol and Drug Commission. Treatment programs and support s e r v i c e s became a branch of the M i n i s t r y of Health under the t i t l e Alcohol and Drug Programs, and a new Commission was appointed to serve as an a d v i s o r y body to the p r o v i n c i a l government. "The Commission c o n s i s t s of a chairman drawn from the e x e c u t i v e l e v e l of the M i n i s t r y of H e a l t h , and s e n i o r o f f i c i a l s of the M i n i s t r i e s of Education, Human Resources, Labour, the A t t o r n e y - G e n e r a l , Consumer and C o r p o r a t e A f f a i r s and T r a n s p o r t a t i o n and Highways, as well as the Insurance Corporation of B.C." ( M i n i s t r y of H e a l t h Annual Report, 1980, 74) c. Emergency Health Services P r i o r to J u l y 1, 1974, ambulance s e r v i c e s were p r i v a t e l y or 61. municipally owned. On Ju l y 1, 1974, the p r o v i n c i a l government formed the Emergency Health Services Commission with r e s p o n s i b i l i t y f o r the planning and funding of ambulance and a i r evacuation services i n the p r o v i n c e . The Commission was e s t a b l i s h e d under the Emergency Services Act. With consol i d a t i o n of p r o v i n c i a l statutes i n 1979, the name of the A c t was changed to the He a l t h Emergency A c t . The Commission comprises f i v e members, one of whom i s a p p o i n t e d Chairman. (Ministry of Health Annual Report, 1980, 201) While the primary concern of the Commission since i t s inception has been to provide ambulance service throughout the province, i t also has the powers and authority: "To provide emergency health services i n the province; To e s t a b l i s h , equip, and operate emergency h e a l t h c e n t r e s and s t a t i o n s i n areas of the province that the Commission considers advisable; To a s s i s t h o s p i t a l s , o t h e r h e a l t h i n s t i t u t i o n s and a g e n c i e s , m u n i c i p a l i t i e s and other o r g a n i z a t i o n s and persons, to provide emergency health services, and to t r a i n personnel to provide services, and to enter into agreements or arrangements for that purpose; To e s t a b l i s h or improve c o m m u n i c a t i o n s systems f o r emergency health services i n the Province; To make ava i l a b l e the services of medically trained persons on a continuous, c o n t i n u a l , or temporary basis, to those residents of the Province who are not, i n the o p i n i o n of the Commission, adequately s e r v i c e d with e x i s t i n g health services; To r e c r u i t , examine, t r a i n , r e g i s t e r and license emergency medical a s s i s t a n t s ; To perform any other function r e l a t e d to emergency health services as the Lieutenant- Governor i n Council may order. The Commission also has the r e s p o n s i b i l i t y for the medical aspects of disaster planning, as well as r e s p o n s i b i l i t y f o r the maintenance, i n s p e c t i o n , replacement and storage of Federal emergency medical supplies which are s t o c k p i l e d i n various locations around the Province." (Ministry of Health Annual Report, 1980, 201) 4. Medical Services H e a l t h - r e l a t e d acts of l e g i s l a t i o n governing medical services are: the Medical Services Act, the Medical P r a c t i t i o n e r s Act and the Medical Services Plan Act. a. Medical Services Act (R.S.B.C. 1979, Chapter 255) "On J u l y 1, 1968, the Government e s t a b l i s h e d the M e d i c a l S e r v i c e s P l a n of B r i t i s h Columbia, which i s administered and operated i n accordance w i t h the M e d i c a l S e r v i c e s A c t and r e g u l a t i o n s , under the s u p e r v i s i o n of the M e d i c a l Services Commission. The Commission i s empowered to f u n c t i o n as the p u b l i c authority, appointed by the Government of the Province, to be responsible to the Minister of Health i n r e s p e c t of the a d m i n i s t r a t i o n and operation of the plan established under the regulations. The Medical Services Plan of B r i t i s h Columbia provides p r e p a i d medical coverage upon uniform terms and c o n d i t i o n s f o r a l l r e s i d e n t s of the P r o v i n c e and t h e i r d e p e n d e n t s . I n s u r e d services under the plan are paid for insured persons regardless of age, s t a t e of health, or f i n a n c i a l circumstances, provided the premiums f i x e d by the Commission are paid. Payment f o r the s e r v i c e s p r o v i d e d i s made, on a f e e - f o r - s e r v i c e b a s i s , according to a t a r i f f of fees approved or p r e s c r i b e d by the Commission or on a s a l a r i e d , sessional, or contract basis at l e v e l s approved by the Commission. The Medical Services Plan provides insurance coverage f o r a l l m e d i c a l l y required services rendered by medical p r a c t i t i o n e r s , i n c l u d i n g o s t e o p a t h i c p h y s i c i a n s , i n B r i t i s h Columbia, and c e r t a i n s u r g i c a l p r o c e d u r e s of d e n t a l s u r g e o n s where n e c e s s a r i l y performed i n a h o s p i t a l as p r o v i d e d under the Medical Care Act (Canada). U n t i l March 31, 1977, funds were received from the Government of Canada under shared-cost programs. Commencing A p r i l 1, 1977, these programs were replaced by transfers to the Province under new F e d e r a l - P r o v i n c i a l f i s c a l arrangements, and the P r o v i n c e now provides the e n t i r e Government c o n t r i b u t i o n to the Medical Services Plan." (Ministry of Health Annual Report, 1980, 186) I n addition to payment f o r the above s e r v i c e s , a d d i t i o n a l b e n e f i t s , when rendered i n the p r o v i n c e , are provided without extra premium by the province. A l l payments are paid only at a t a r i f f of f e e s approved by the -63Y C o m m i s s i o n and i n c l u d e c h i r o p r a c t i c , n a t u r o p a t h i c , o r t h o p e d i c s , physiotherapy, podiatry, optometry, and orthodontic s e r v i c e s . ( M i n i s t r y of H e a l t h Annual Report, 1980, 188) Payments for these add i t i o n a l benefits are l i m i t e d to a s p e c i f i e d amount per patient per year. Under the Act, c e r t a i n s p e c i a l i z e d services are excluded f o r each of the above s e r v i c e s . b. Medical P r a c t i t i o n e r s Act (R.S.B.C. 1979, Chapter 254) ( T h i s Act empowers the C o l l e g e of P h y s i c i a n s and Surgeons to e l e c t a Council with r e s p o n s i b i l i t y f o r r e g u l a t i n g i t s members, determining professional q u a l i f i c a t i o n s and experience required f o r conditions for r e g i s t r a t i o n , e s t a b l i s h fees f o r r e g i s t r a t i o n , keep r e g i s t e r s , provide the basis f o r r e g i s t e r i n g members of the College i n the province as s p e c i a l i s t s i n the f i e l d of medicine or surgery, etc. (R.S.B.C. 1979, Chapter 254) c. Medical Services Plan Act, 1981 (R.S.B.C. 1979, Chapter 18) Under t h i s Act, u n t i l the B r i t i s h Columbia Medical A s s o c i a t i o n and the Medical Services Commission, "have agreed to a renewal, amendment or replacement of the agreement, or a renewal, amendment or replacement of i t has been s e t t l e d by a r b i t r a t i o n under t h i s Act, i n s u r e d services s h a l l continue to be p r o v i d e d under the p l a n i n accordance wi t h the r a t e a p p l i c a b l e f o r those s e r v i c e s under the agreement and plan on March 15, 1981. No medical p r a c t i t i o n e r p a r t i c i p a t i n g i n the plan s h a l l , f o r an i n s u r e d s e r v i c e rendered i n respect of an insured person, seek compensation by means of balance b i l l i n g , e x t r a b i l l i n g or e x t r a charging, or demand or receive any payment other than a payment under the agreement and p l a n at the rate applicable f o r that service on March 15, 1981." (Medical S e r v i c e s P l a n Act, 1981, R.S.B.C. 1979, Chapter 18) As has been shown, the development of health services i n Canada can be 64. r e g a r d e d as an i n c r e m e n t a l f l o w of events, b e g i n n i n g at the time of Confederation, and evolving to the present. Separate Acts governing h e a l t h and h o s p i t a l groups have been passed at v a r i o u s times i n response to changing p r i o r i t i e s being placed on health and health services. As a r e s u l t , B r i t i s h Columbia h e a l t h and h o s p i t a l groups tend to r e l a t e to d i f f e r e n t administrative groups, have d i f f e r e n t f i n a n c i a l bases, and d i f f e r e n t primary service area geographic boundaries. This has r e s u l t e d i n the present complex organization of the health care system. Because h e a l t h s e r v i c e s have developed over time, Acts pertaining to one health service often contain amendments governing other health s e r v i c e s . As a r e s u l t , the l e g i s l a t e d mandate of each h e a l t h s e r v i c e group, and i t s r o l e i n r e l a t i o n to other groups i s often not c l e a r l y defined. This makes i t d i f f i c u l t f o r groups to respond i n a comprehensive manner, and r e s u l t s i n the present lack of co-ordination among providers and s e r v i c e s . The l e g i s l a t e d powers of the Ministry of Health to improve c o n t r o l and i n t e g r a t i o n of the system have been l i m i t e d by these A c t s , as has the a u t h o r i t y of the TNRHD Board to i n v o l v e groups i n i t s r e g i o n i n the development of a health and h o s p i t a l study. Major attempts by the p r o v i n c i a l government to improve control and i n t e g r a t i o n of the system are described i n the following chapter. 65. CHAPTER VI ATTEMPTS BY THE PROVINCIAL GOVERNMENT TO IMPROVE SYSTEM INTEGRATION Introduction The Task F o r c e on the C o s t s of H e a l t h Care, 1969 s i g n a l l e d the beginning of a new era i n Canadian health system o r g a n i z a t i o n . The f e d e r a l programs were begun separately f o r p o l i t i c a l reasons. Now they were about to be handed over to the p r o v i n c e s - though this took some years to achieve (1977). The provinces which had picked up the t i e d grants from Ottawa now had to accept t h a t they were r e s p o n s i b l e f o r health service organization within t h e i r boundaries, and began to think about streamlining. They did not contemplate changing the l e g i s l a t i o n , but changing the financing of programs which was to a l t e r t h e i r balance. The s e t t i n g up of regional h o s p i t a l d i s t r i c t s had, i n f a c t , preceded t h i s g e n e r a l attempt to get o p e r a t i o n a l c o n t r o l by f o c u s s i n g f i r s t on c a p i t a l spending and i t s control ten years before the government of B r i t i s h C o l u m b i a began to work on i n c r e a s i n g a c c o u n t a b i l i t y f o r o p e r a t i o n a l spending. The Hospital Role and Funding Studies, to be described below, were the f i r s t i n a s e r i e s of moves to improve government con t r o l over the operating system. The M i n i s t r y of Health o r g a n i z a t i o n a l c h a r t shown i n Chapter IV, page 26, i l l u s t r a t e s a l a t e r move to restructure the flow of money to the service delivery i n s t i t u t i o n s . The M i n i s t r y of Health's c o n s i d e r a t i o n of ' r e g i o n a l i z a t i o n ' as a p o s s i b l e mechanism for integrating health services delivery and planning at the regional l e v e l w i l l then be described. 6.6. The B r i t i s h Columbia Hospital Role and Funding Studies By the mid 1970's, " i n s t i t u t i o n a l and h o s p i t a l program costs were consuming n e a r l y 85 percent of the p r o v i n c i a l health budget, (and) the B r i t i s h Columbia government was worried about both the s i z e of the health budget and the no-end i n sight increases." (Campbell et a l , 1981, 14) R e g i o n a l h o s p i t a l boards were part of the problem as boards were involved with expansion of h o s p i t a l f a c i l i t i e s i n response to l o c a l . c o n s t i t u e n c y and h o s p i t a l demands. In an attempt to control h o s p i t a l costs, p r o v i n c i a l government p o l i c y s h i f t e d from program development to an emphasis on cost containment. At the same time, the B r i t i s h Columbia H e a l t h A s s o c i a t i o n ' s r o l e as b a r g a i n i n g agent f o r the government ended with the separation of labour r e l a t i o n s i n t o the Health Labour Relations Association. "This freed the BCHA to undertake another b u f f e r i n g function, namely the renegotiation of h o s p i t a l funding." (Crichton et a l , 1984, 90) I n conjunction with the p r o v i n c i a l government's s h i f t to cost containment, "the s e n i o r deputy minister of health asked the association to form a j o i n t Task Force with his o f f i c i a l s to f i n d a more r a t i o n a l b a s i s f o r f u n d i n g than the e x i s t i n g b a r g a i n i n g process, which favoured strong and bold i n d i v i d u a l negotiators." (Crichton et a l , 1984, 90) However, i t became c l e a r that the development of a Funding Study "presumed a c a t e g o r i z a t i o n of hospitals and s e r v i c e s . Consequently the H e a l t h M i n i s t r y began, i n addition, a Hospital Role Study." (Campbell et a l , 1981, 2 7) As a r e s u l t of a reorganization within the M i n i s t r y of Health i n 1979, the J o i n t Funding Study subsequently became a simple M i n i s t r y of H e a l t h funded Finance Study. The H o s p i t a l Role and Funding Studies were done i n 67. tandem and were involved i n developing a uniform s t a t i s t i c a l and f i n a n c i a l i n f o r m a t i o n base upon which to base a cost management system f o r h o s p i t a l s . (Pallan, 1983) Because each h o s p i t a l d e f i n e s i t s r o l e d i f f e r e n t l y , Phase 1 of the H o s p i t a l Role Study was e s s e n t i a l l y interested i n e s t a b l i s h i n g guidelines f o r a n a l y s i n g acute h o s p i t a l p r o f i l e s . A p r o f i l e was d e f i n e d as the combination of various care functions and l e v e l s of service which the acute h o s p i t a l was c u r r e n t l y providing. Standards were then developed to be used i n determining each h o s p i t a l ' s r o l e , or the combination of care functions and l e v e l s of s e r v i c e which the acute h o s p i t a l s h o u l d be p r o v i d i n g . ( M i n i s t r y of H e a l t h , 1979, 4) Standards included such factors as: s i z e of community to be served, need f o r services, t r a v e l time between one h o s p i t a l and another, et c . A c l a s s i f i c a t i o n t a b l e or 'service matrix' was then developed f o r the purpose of describing each acute h o s p i t a l ' s p r o f i l e and r o l e . The t a b l e c o n s i s t s of seven care functions and s i x l e v e l s of s e r v i c e . Care functions i n c l u d e o b s t e t r i c s , p a e d i a t r i c s , d e n t i s t r y , medicine, r e h a b i l i t a t i o n , s u r g e r y and p s y c h i a t r y . The s i x l e v e l s of service were divided into three groups; Community services involving l e v e l s A, B and C; R e f e r r a l s e r v i c e s c o n s i s t i n g of l e v e l s D and E; and P r o v i n c i a l services, l e v e l F. (Ministry of H e a l t h , 1 979, 1-13) A summary of the H o s p i t a l Role Study, i n c l u d i n g descriptions of care functions and l e v e l s of s e r v i c e , was compiled by the BCHA, and i s provided i n Appendix I . The methodology f o r implementing Phase I of the Hospital Role Study was c o n t a i n e d i n a document e n t i t l e d , H o s p i t a l Role Study, Phase 2. In 1981, 68. a f t e r a series of public meetings, and submission of b r i e f s from v a r i o u s groups i n the p r o v i n c e , an Addendum to Phase 1 was prepared. I t contained a d d i t i o n s and r e v i s i o n s to the o r g i n a l document and a r e v i s e d s e r v i c e m a t r i x . Phase 1, together with the Phase 1 Addendum were to be used to: s t a n d a r d i z e acute h o s p i t a l s , a c t as a p r e d i c t a b i l i t y measure, as a long-range planning t o o l , and also, by d e f i n i t i o n , as a p r o v i n c i a l planning constraint i n l i m i t i n g the expansion of h o s p i t a l f a c i l i t i e s . ( P a l l a n , 1983) The H o s p i t a l Role and Funding S t u d i e s together were to provide a l o g i c a l s t r a t e g y f o r g u i d i n g the c a p i t a l and o p e r a t i o n a l development of acute hospit a l s i n the province for the following f i f t e e n years. However, i n l a t e 1981, the MOH p l a c e d the Hospital Role and Funding Studies "on hold." Underlying t h i s d e c i s i o n was the M i n i s t r y of H e a l t h ' s c o n c e r n that there would be d i f f i c u l t i e s i n implementing the s t u d i e s . According to standards established i n the Hospital Role Study, many of the s m a l l e r h o s p i t a l s would be r e q u i r e d to reduce t h e i r care functions and/or l e v e l s of service, and this would be d i f f i c u l t to e n f o r c e . Conversely, new r o l e s would be proposed f o r other h o s p i t a l s , and monies f o r a d d i t i o n a l services were not a v a i l a b l e . The government f e l t that the t i m i n g was not r i g h t p o l i t i c a l l y to implement the studies. (Pallan, 1983) There were also problems i n that the studies had been done by a planning department but were to be implemented by an operating department which did not necessarily agree with the planning department's conclusions. Both s t u d i e s are important p l a n n i n g documents i n t h e i r attempt to organize and r a t i o n a l i z e acute hospitals i n B r i t i s h Columbia. At present, hospit a l s i n a regional d i s t r i c t are i n c o m p e t i t i o n with one another f o r 69; expansion of t h e i r f a c i l i t i e s . Agreement as to each hospital's r o l e i n the region would do much to reduce competition, and would al l o w f o r a g r e a t e r degree of regional s e l f - s u f f i c i e n c y i n the area of budgetary c o n t r o l s . F i n a n c i a l Re-Structuring of Programs I n B r i t i s h Columbia, health care has accounted f o r some 30 per cent of the p r o v i n c i a l annual budget s i n c e 1978/79, and r e p r e s e n t s the l a r g e s t budget of any p r o v i n c i a l m i n i s t r y . Costs of providing health care services have grown by 282 per cent between 1975 d o l l a r s spent and 1984 e s t i m a t e d expenditures, with h o s p i t a l costs representing approximately 50 per cent of the Ministry of Health's t o t a l annual budget. Figure 5 on the following page i l l u s t r a t e s the most recent available figures f o r expenditures by p r i n c i p a l category i n the M i n i s t r y of Health. (Ministry of Health Annual Report, 1982, 85) Some of the factors which have l e d to an increase i n health care costs include: an aging population, r a p i d advances i n medical technology, a change i n disease trends, and an increase i n the supply of physicians. By 1980, p r o v i n c i a l government revenues were declining as a r e s u l t of a worsening economy. In an attempt to c o n t r o l r i s i n g h e a l t h care c o s t s , the B r i t i s h Columbia government began a series of moves designed to, " c o n s o l i d a t e government f i n a n c i a l a u t h o r i t y , c o n t r o l ' p u b l i c bodies ', change the s t y l e of administration within the Ministry, and contain h o s p i t a l expenditures." (Campbell et a l , 1981, 28) The f i r s t step i n achieving greater f i s c a l c ontrol over M i n i s t r y of H e a l t h a c t i v i t i e s occurred i n 1981. Cabinet consolidated f i n a n c i a l control with the Ministry of Finance, thereby increasing the power of the Treasury Board over Figure 5 Expenditures by Principal Categories in the Ministry of Health For Fiscal Year B r i t i s h Columbia 1981/82 OTHER: FORENSIC $6.2 million ADMINISTRATION SS4.2 million PREVENTIVE SERVICES 948.1 million EMERGENCY HEALTH SERVICES $45.2 million TOTAL HEALTH SERVICES IN 1981/82 - S2.328 MILLION (Ministry of Health Annual Report, 1982, 85) 71. Health as well as other M i n i s t r i e s . (Ryan, 1982, 9) This move towards centralizing control was reinforced with the passing of a new F i n a n c i a l Administration Act in July of 1981. The Act is administered by the Ministry of Finance, and under the Act, the Ministry of Health, and a l l other m i n i s t r i e s , are accountable to the Finance Ministry for spending. The Act consolidates a number of financial Acts, and over-rides a number of others. At this time major changes were also occurring within the Ministry of Health. "In January 1981, there was a change of both the Minister and the Deputy Minister of Health i n B r i t i s h Columbia." (Ryan, 1982, 1) This resulted i n a major re-organization of the Ministry i n 1981/82 as shown in Figure 4, Chapter IV. This re-organization was an attempt to rationalize the system administratively, and at the same time re-structure the flow of moneys to the service delivery institutions. Prior to the re-organization, proposed expenditures f o r the f o l l o w i n g year were voted on i n the l e g i s l a t u r e for each Individual program, e.g., emergency health services. Following the passing of each separate vote, The Ministry of Health could neither alter the vote, nor transfer dollars from one vote to another (i.e., from one program to another) without going back f o r approval to the legislature. (Munroe, 1984) With the r e - o r g a n i z a t i o n of the Ministry of Health, programs of s i m i l i a r type were placed under one policy area, e.g., I n s t i t u t i o n a l Services, and one vote. The Ministry of Health vote structure consists of 5 separate votes for proposed expenditures as follows: 72. Vote No. 44 M i n i s t e r ' s O f f i c e - T h i s vote p r o v i d e s f o r the O f f i c e of the Minister of Health, including the minister's s a l a r y and expenses and those of the immediate s t a f f . 45 Management Opera t i o n s - T h i s vote p r o v i d e s f o r the ministry's a d m i n i s t r a t i o n and support s e r v i c e s . Sub-votes are taken f o r C e n t r a l A d m i n i s t r a t i o n , Support S e r v i c e s , and S p e c i a l Care Services Grants. 46 M e d i c a l S e r v i c e s Commission - T h i s v o t e p r o v i d e s f o r the development and administration of p o l i c i e s and programs under the M e d i c a l S e r v i c e s P l a n i n c l u d i n g payment of i n s u r e d s e r v i c e s . Sub-votes i n c l u d e : Administration, the Medical Services Plan and the Dental Plan. 47 Preventive and Community Health Care Services - The p o l i c y areas of P r e v e n t i v e S e r v i c e s and Community Health Care Services have been combined under one vote which pr o v i d e s f o r the s e r v i c e d e l i v e r y , program management, p o l i c y development and planning r e s p o n s i b i l i t y f o r P r e v e n t i v e and Community Care Programs. Sub-votes are taken f o r : Preventive Services, Vancouver Bureau, V i t a l S t a t i s t i c s , Forensic P s y c h i a t r i c Services, Alcohol and Drug, and Mental Health. 48 I n s t i t u t i o n a l S e r v i c e s - T h i s vote p r o v i d e s f o r the s e r v i c e d e l i v e r y , program management, p o l i c y development and planning r e s p o n s i b i l i t y f o r i n s t i t u t i o n a l , acute and c o n t i n u i n g p a t i e n t c a r e programs. Sub-votes i n c l u d e : H o s p i t a l Programs, Long Term 73. Care and Emergency Health Services. (Province of British Columbia, 1984, 105-115) No change was made in the way in which programs were basically funded. Programs whose operating costs had previously been funded d i r e c t l y such as pr o v i n c i a l government hospitals, and Ministry of Health staff salaries for preventive services, mental health, long term care/home care, emergency health services, and alcohol and drug programs continued to be funded in this manner. Programs whose operating costs had been funded i n d i r e c t l y through grants to hospitals, non-profit or private agencies operating alcohol and drug programs, mental health boarding homes and long term care f a c i l i t i e s continued to be funded in this way on a budget basis. However, with the new vote structure, while monies could not be moved between votes, dollars could be transferred between sub-votes within a vote, i . e . , between long term care and hospitals, and between sub-sub-votes (activity levels), thereby giving the Ministry of Health greater f l e x i b i l i t y i n a l l o c a t i n g dollars within a vote. (Munroe, 1984) The new F i n a n c i a l Administration Act gives the Treasury Board the authority to l i m i t the amount of any approved appropriation. (Financial Administration Act, 1981, S.B.C. Chapter 15) Ideally, the Ministry of Health would like to have total control of a l l moneys with f l e x i b i l i t y to move dollars between votes. This has not met with Treasury Board approval. The Ministry's a b i l i t y to move dollars between those programs under one vote has, however, served to further discourage co-ordination and integration of programs, as programs are i n competition with one another to retain control over their approved program budgets for the year. -.74. The program to r e c e i v e the c l o s e s t s c r u t i n y under the new M i n i s t r y re-organization was h o s p i t a l s . Hospital costs contribute most to health care spending and h o s p i t a l c o s t s are the f a s t e s t growing component of health expenditures. I n 1981/82, the p r o v i n c i a l government decided that, " a l l h o s p i t a l s should be asked to cut back. A d m i n i s t r a t i o n was informed th a t they must p l a n r e d u c t i o n s , (and) that no d e f i c i t f i n a n c i n g would be p e r m i t t e d i n the f u t u r e , but they would be allowed to keep any savings made i f they could turn over acute to long-term beds." (Crichton et a l , 1984, 90) I n conjunction with t h i s approach, the p r o v i n c i a l government i n t r o d u c e d g l o b a l budgeting. Previously, hospitals had been provided with an operating budget f i g u r e at the b e g i nning of each y e a r . W i t h g l o b a l b u d g e t i n g , h o s p i t a l s were g i v e n q u a r t e r l y budgeting guidelines, and issued a monthly report i n d i c a t i n g each hospital's performance. (Munroe, 1984) The M i n i s t r y of Health overcame i t s l i m i t e d l e g i s l a t i v e powers over h e a l t h and h o s p i t a l groups through the use of i t s funding powers. The f a c t that the M i n i s t r y approved and funded 60 per cent of the TNRHD study was a s t r o n g m o t i v a t i o n f o r programs i n general, and h o s p i t a l s i n p a r t i c u l a r to c o - o p e r a t i v e with the c o n s u l t a n t s i n d e v e l o p i n g the s t u d y . However, i n c r e a s e d M i n i s t r y c o n t r o l over f u n d i n g of programs has not r e s u l t e d i n improved co-ordination and i n t e g r a t i o n among providers. A Proposal f o r Regionalization of Health Services i n B r i t i s h Columbia The lack of a co-ordinated and integrated approach to h e a l t h s e r v i c e s d e l i v e r y and planning at the regional l e v e l prompted the Ministry of Health i n 1981 to consider the concept of regional i z at i o n of h e a l t h s e r v i c e s f o r B r i t i s h Columbia. Planning for a regional structure f o r health programs was 75. begun under the direct control of the Ministry, and a draft paper outlining the regionalization plan was circulated later that year to senior managers in the Ministry. Although the regionalization proposal was not accepted for implementation, the approach outlined i n the proposal for r e g i o n a l i z i n g health care programs w i l l be b r i e f l y described below. Information from secondary sources has been used as a copy of the draft plan could not be obtained from the Ministry of Health. According to Kaminsky, "the concept of r e g i o n a l i z a t i o n of health services has been discussed and written about a great deal since It was introduced i n the Dawson Report i n Great B r i t a i n i n 1920. While there is no consensus as to a definition of this term, the s a l i e n t points with which most health care planners would agree include: 1. a method of structuring health care on a geographical basis, at an intermediate l e v e l (e.g., between l o c a l and p r o v i n c i a l or state levels), 2. the intent of such a structures being the optimal allocation and use of health care resources." (Kaminsky, 1982, 4-5) Various forms of regional s t r u c t u r e s have been adopted In A l b e r t a , Saskatchewan, Manitoba, Ontario, Quebec and New Brunswick, as well as in Britain and New Zealand. Based on the findings of Malcolm (1981), Ryan has i d e n t i f i e d a number of factors which have led to the development of these new structures: "1. Growth in health expenditures. 2. Surplus of medical manpower. 3. U n c e r t a i n t y about the scope and nature of p r o f e s s i o n a l accountability. 4. Inequalities i n the distribution and balance of health services between geographic areas as well as between high and low status 7 6 . services, and between institutional and community care. 5. Fragmentation and lack of co-ordination of care (accentuated and perpetuated by i n s t i t u t i o n a l and h i e r a r c h i c a l systems of management, with each agency competing both for resources and the provision of services. 6. Lack of effective community involvement (although many current problems are l i f e s t y l e related)." (Ryan, 1982, 110, adapted from Malcolm, 1981, 5) Based on articles by Van der Zwaan (1980) and Saward (1976), Kaminsky indicates that existing regional structures can be categorized according to two general models of regionalization: "the direct patient care model, and the planning and coordinating model. The former Is characterized by i t s emphasis upon client needs and c i t i z e n participation. It therefore implies radical changes to our current health care organizational system .The planning and c o o r d i n a t i n g model, however, is (a less r a d i c a l ) i d e o l o g i c a l departure from present practice, in that i t is focussed on service providers rather than clients, and Its chief concerns are efficiency and cost control." (Kaminsky, 1982, 5) Regional structures can also be c l a s s i f i e d according to the way in which services are organized and resources allocated. "At this point i n time, there is no province i n Canada whose Health Ministry reports both a regional structure and a regional method of resource allocation." (Kaminsky, 1982, 23) Instead, various combinations exist involving "resources allocated on a r e g i o n a l b a s i s without" the e x i s t e n c e of a formal r e g i o n a l o r g a n i z a t i o n , " h e a l t h care organized on a regional basis without a corresponding "allocation of resources according to regional boundaries," or conversely, "the absence of regionalization, both from an organizational as well as a resource allocation perspective." (Kaminsky, 1982, 6-7) In B r i t i s h Columbia, m i n i s t r i e s such as the Ministry of Highways, Municpal Affairs, Environment and Forests, Lands, Parks and Housing, and the Ministry of Human Resources have a l l regionalized i n varying degrees. The Ministry of Health, while having, "some l i m i t e d r e g i o n a l i z a t i o n , i . e . , public health units, and regional hospital d i s t r i c t s for hospital c a p i t a l expenditures, remains an anomaly in that there is no overall government policy on a regional approach to the delivery of health services." (UBC Health Policy Study Group, 1981, 60) Under the Social Credit government, a proposal for r e g i o n a l i z a t i o n of health services i n B r i t i s h Columbia was begun in mid-1981. Ryan indicates that the stated objectives of the Regional Health Plan were as follows: "1. To improve the efficiency and effectiveness of the health care system. 2. To improve accountability of the health care system at a l l levels. 3. To improve equity within the health care system. 4. To maintain and improve the quality of health services." (Ryan, 1982, 18) Ryan states that, "these objectives r e f l e c t the present philosophy of the senior managers i n health, which are cost containment ( e f f i c i e n c y and effectiveness) and cost control (accountability)." (Ryan, 1982, 18) B r i t i s h Columbia's Regionalization Proposal would therefore appear to correspond more cl o s e l y with the planning and c o o r d i n a t i n g model of reg i o n a l i z a t i o n , as opposed to the direct patient care model, with i t s emphasis on citizen participation. The British Columbia Regionalization Proposal recommended the formation of seven health regions as shown in Figure 6. "The rationale behind the setting of the boundaries was largely pragmatism. Each region required a large enough population (minimum approximately 200,000) to serve as a planning unit for comprehensive health services. As well, there was a desire to minimize the amount of disruption of current service units (e.g., Health Units and Regional Hospital D i s t r i c t s ) . In essence then, most regions were formed by combining e x i s t i n g smaller s e r v i c e d e l i v e r y or Figure 6 Proposed Health Regions for B r i t i s h Columbia, 1981/82 I (Ryan, 1984, 4) 79, administrative components." (Kaminsky, 1982, 14) Each region was to have a regional manager who would "be responsible f o r program d e l i v e r y w i t h i n that geographic area." (Ryan, 1982, 3) Regionalization of health services was to involve three stages. In the f i r s t phase (involving approximately 3 years), the regional manager would have direct authority for only those programs in the region operated directly by the M i n i s t r y , such as preventive s e r v i c e s , mental h e a l t h , e t c . Responsibilities would include: "1. Overall regional planning for such services. 2. Overall budget development, allocation and monitoring. 3. Development of r e g i o n a l p o l i c i e s (to be c o n s i s t e n t with provincial policies) and having Imput to provincial policies. 4. Implementation and interpretation of province wide policies. 5. Provision of regional support services, including personnel, finance, planning and administration. 6. Overall need determination for the region. 7. Development of program structure to f i t regional needs. 8. Monitoring of program effectiveness, efficiency, and equity -based on policies and minimum standards that are developed by Program ADM'S." (Ryan, 1982, 5) For programs funded through the Ministry of Health but provided through non-government agencies such as hospitals, long term care, private health providers, etc., the role of the regional manager would involve: "1. D i r e c t planning of s e r v i c e s where no planning c a p a b i l i t y currently exists and l i a i s o n and coordination with e x i s t i n g planning bodies. 2. L i a i s i n g with such agencies in order to improve the coordination between government services and non-government services. 3. Monitoring compliance with overall provincial standards re l a t e d •80. to service delivery, management and programs." (Ryan, 1982, 5) According to Pallan (1983), regional hospital d i s t r i c t s would be included in the second phase of the plan, and would be funded through the larger 'region." This phase would involve approximately 5 years. Hospitals and a l l indirectly funded community health care programs would be included i n the Regional Health Plan in the third phase of the plan. (Pallan, 1983) This phase would involve approximately 10 years, and at the end of this period, r e g i o n a l i z a t i o n of health services would have been accomplished, with a l l programs organized on a regional basis, and dollars allocated according to regional boundaries. The Regionalization Proposal did not indicate what the structure and processes f o r planning would be i n accomplishing these goals. (Ryan, 1982, 6) The Regionalization Proposal was placed "on hold" i n 1982. According to Pallan, two major factors contributed to the decision not to proceed with the Regional Health Plan. One of the government's reasons for considering r e g i o n a l i z a t i o n was the concern over rising health care expenditures, and the consequent need to promote cost containment and control. Regionalization had been presented as an efficiency measure. However, r e g i o n a l i z a t i o n of other B r i t i s h Columbia ministries had cost more than anticipated, and Treasury Board was worried about the costs to be incurred i n r e g i o n a l i z i n g the large and complex Health Ministry. Secondly, r e g i o n a l i z a t i o n implies decentralized decision-making. However, the present Social Credit government, i n an e f f o r t to contain costs, has emphasized increased centralized decision-making, and centralized c o n t r o l . This philosophy i s incompatible with the d e c e n t r a l i z e d 81. decision-making approach proposed i n the Regional Health Plan. (Pallan, 1983) The commissioning and development of the TNRHD study occurred during the period when the Ministry of Health was considering the p o s s i b i l i t y of reg i o n a l i z i n g health services i n B r i t i s h Columbia. While i t is not known whether the TNRHD study was i n any way related to the r e g i o n a l i z a t i o n investigation, the study may have represented a test-case for the Ministry to use in assessing the f e a s i b i l i t y of planning for health services on a regional basis. The B r i t i s h Columbia Hospital Role and Funding Studies, and the financial re-structuring of programs and Regionalization Proposal were a l l attempts by the provincial government to improve control and integration of the system. As indicated, neither the Hospital Role and Funding Studies nor the Regionalization Proposal have been accepted for implementation. The financial re-structuring of programs, while presumably giving the government increased control over i t s efforts to contain costs, has served to further discourage co-ordination and integration among providers in the region. These provincial government attempts to improve control and integration of the system did not address the underlying issue of standing legislation. The continuing absence of a rational approach to the organization and supply of services, combined with the lack of integration among providers l e d to problems in both the collection and analysis of data for the TNRHD study. 82. SECTION D INTEGRATING THE INFORMATION FOR A NON-INTEGRATED SYSTEM CHAPTER VII RECURRENT PROBLEMS IN THE COLLECTION AND ANALYSIS OF STUDY DATA Introduction A number of s p e c i f i c problems were encountered in the process of developing the study, involving the c o l l e c t i o n and analysis of data, and s e l e c t i o n and application of study models of analysis. However, throughout the period of the study, three major problems in the collection and analysis of data occurred regularly. These were, availability of data, r e l i a b i l i t y of data, and the potential for bias in the collection and analysis of data. Availability of Data General d i f f i c u l t i e s encountered in obtaining data occurred as a result of a number of f a c t o r s . No central data r e g i s t r y existed for accessing information at the p r o v i n c i a l l e v e l . Instead, as previously noted, data sources were dispersed among many health and non-health administrative units, each responsible for the information pertinent to i t s own operational ac t i v i t i e s . Once requests had been made to the appropriate administrative units for population, manpower and health services use data, r e t r i e v a l was often delayed as government r e s t r a i n t programs had l e f t i n s u f f i c i e n t manpower available to process requests. Data, when received, was often in raw form, 83. and converting i t to useable form cost the consultants money from a l i m i t e d budget which could have been applied to data analysis. According to Alford, d i f f i c u l t i e s in obtaining data may also stem from the reluctance of various data sources to disclose information. For example, "Professional monopolists, who tend to be s t r a t e g i c a l l y located i n data-gathering and processing positions have no incentive to release information to outside groups who might challenge their power to define their own work." (Alford, 1973, 160) There was some evidence of this attitude during the data collection stage. Reliability of Data As the study progressed, the consultants began to q u e s t i o n the r e l i a b i l i t y of the data collected. I t was found that reported s t a t i s t i c a l data based on use of a specific service varied between the service's l o c a l and p r o v i n c i a l administrative u n i t . By way of example, the number of surgical day care procedures reported by local acute hospitals differed from that reported by the Research Division of Hospital Programs; and, st a t i s t i c s provided by the l o c a l Union Board of Health for LTC waiting l i s t s , and numbers of patients i n intermediate and extended care beds differed from those supplied by the Long Term Care program and Hospital Programs i n Victoria. D i s c r e p a n c i e s were sometimes the r e s u l t of dif f e r e n t reporting mechanisms, use of a different denominator upon which to base calcu l a t i o n s , or merely more up to date information based on l o c a l knowledge. In each case, a decision had to be made based on evaluation of the advantages and disadvantages of using one set of data over another. Problems in developing a reliable Information base also occurred due to 84. the overlapping of services. For example, the problem of long term care patients occupying acute care beds created d i f f i c u l t i e s i n analysing acute care bed needs. The overlapping of mental health needs into alcohol and drug, and emergency h e a l t h s e r v i c e s r e f l e c t e d a m u l t i - d i s c i p l i n e involvement, and there were consequent data r e l i a b i l i t y and analysis problems. The Potential for Bias in the Collection and Analysis of Data During the data collection stage, i t became apparent that a number of vested i n t e r e s t groups existed, each with i t s own pa r t i c u l a r bias. The existence of these special interest groups created a potential situation for the consultant/planner to become co-opted by a p a r t i c u l a r group, thereby influencing the kind of data collected, and the analysis of that data. A l f o r d has divided special Interest groups involved in the American health care system into three categories: 1. "Professional monopolists," consisting of biomedical researchers, physicians in private practice, salaried physicians and other health occupations, "who share an interest i n maintaining professional autonomy and control over the conditions of their work, and thus w i l l , when that autonomy is challenged act together i n pursuit of that interest." (Alford, 1973, 133) 2. "Corporate rationalizers," consisting of ho s p i t a l administrators, public health o f f i c i a l s and medical school o f f i c i a l s , "whose organizational interests often require that they compete with each other for power and resources (but who) share an i n t e r e s t i n maint a i n i n g and extending the control of their organizations over the conditions of work of the professionals whose a c t i v i t i e s are key to the achievement of organizational 8 5 . goals." (Alford, 1973, 133) 3. The community population, constituting, "a set of interest groups which are externally heterogenous with respect to their health needs, and a b i l i t y to organize their needs into effective demands, (but who) share an interest in maximizing the responsiveness of health professionals and organizations to their concerns for accessible, high quality health care." (Alford, 1973, 133) Government is "not an independent power standing above and beyond the competing interest groups," but is instead a vested i n t e r e s t group which, i n Canada, is i n turn composed of a number of diverse groups at the local, provincial and federal l e v e l s , each with i t s own program bias. (Alford, 1973, 164) Thus, in Canada, government is also included in the "corporate rationalizer" group. Alford indicates that neither "professional monopolists" nor "corporate rationalizers" have a "stake in the co-ordination and integration of the entire system toward the major goal of easily accessible, inexpensive, and equal health care." (Alford, 1973, 145) Bailey states that competition among groups may be, "endemic in society due to the simultaneous desire for i n v a r i a b l y scarce resources, and to the existence of incompatable interests." (Bailey, 1975, 75) Competition among groups in B r i t i s h Columbia has escalated over the l a s t several years due to the provincial government's emphasis on rationing of health services and resources in the face of rising health care costs. According to Strauss, factors underlying a conflict situation include: the identity and number of groups involved, the number and complexity of the issues, the relative balance of power exhibited by each group, the notion of 86. their respective stakes in the issues, and the v i s i b i l i t y of the transaction to others. (Strauss, 1973, 3) Some examples of issues which i l l u s t r a t e current areas of conflict between special interest groups include: the federal government's enactment of the EPF Act i n 197 7, and the Canada Health Act in 1984, restriction of physician b i l l i n g numbers by the provincial government, the introduction of global budgeting for hospitals and the LTC program, physicians' reluctance to consider physician substitutes, and the issue of funding for health prevention/promotion programs. 1. The Federal-Provincial F i s c a l Arrangements and Established Programs  Financing Act, 1977 As noted in Chapter V, in the section entitled, Federal Health-Related Legislation, enactment of the EPF Act i n 1977 created dissension between the provinces and the federal government. Conflict has intensified since the re-negotiation of Established Programs Financing i n 1982. At that time, the federal government changed the EPF formula to reduce its transfer payments, and shift part of i t s deficit back to the provinces. (Ministry of Health, 1984, 13) "In order to maintain services, provinces could either raise taxes or cut back services." (Ministry of Health, 1984, 14) While the British Columbia government chose to raise taxes through the introduction of a B.C. H e a l t h Care Maintenance Tax, d i s s e n s i o n over f e d e r a l - p r o v i n c i a l responsibility for health services funding continues. 87. 2. Canada Health Act, 1984 As described i n Chapter V, i n the s e c t i o n e n t i t l e d F e d e r a l Health-Related L e g i s l a t i o n , enactment of the Canada Health Act in 1984 created problems between the federal government and the province over the issues of hospital user fees and premiums for medical insurance. Inherent in both the f e d e r a l and p r o v i n c i a l government's position is a degree of internal conflict, as the goal of limiting costs conflicts with the goal of maintaining and/or increasing the quality and quantity of health services. 3. Restriction of Physician B i l l i n g Numbers With increased emphasis being placed on cost reduction, the form of physician remuneration, and the number of physicians practicing i n B r i t i s h Columbia is being c l o s e l y s c r u t i n i z e d by the p r o v i n c i a l government. As indicated i n Chapter V, i n the s e c t i o n e n t i t l e d , B r i t i s h Columbia Health-Related Legislation, the Medical Services Plan Act, 1981 was passed to prevent physicians from extra-billing. Some health-care analysts argue that future health care costs cannot be lowered as long as physicians are paid on a fee-for-service basis which rewards them for the volume of work performed. Instead, they advocate remuneration in the form of a salary. Given the vested interests of both the provincial government and physicians, resolution of this issue is unlikely in the short-run. The ratio of total physicians-to-population has increased i n B r i t i s h Columbia from a r a t i o of 1 physician per 545 persons in 1974 to 1 per 479 persons in 1980, to 1 per 461 persons in September of 1984. (UBC Health 88. Manpower Research Unit, 198A). As a result, British Columbia has the highest physician-to-population ratio in Canada. Concern over the increasing supply of physicians i n B r i t i s h Columbia caused the p r o v i n c i a l government to introduce l e g i s l a t i o n i n 1983 r e s t r i c t i n g b i l l i n g numbers for new physicians. "To prevent the government from passing the b i l l , doctors reluctantly agreed to appoint representatives to 28 regional medical manpower committees and a provincial committee whose task was to limit the number of b i l l i n g numbers given out by British Columbia." (Hannant, 1984, 4) However, as physicians point out, while new physician b i l l i n g numbers are being restricted, enrollment in the University of British Columbia's medical school has grown, but, this i s a Ministry of U n i v e r s i t i e s , Science and Communications jurisdictional area and not the Ministry of Health's. 4. Introduction of Global Budgeting As i n d i c a t e d i n Chapter VI, i n the section e n t i t l e d , F i n a n c i a l Restructuring of Programs, the p r o v i n c i a l government i n 1981/82 informed hospitals in the province that no further deficit financing would be allowed in the future. In conjunction with this decision, the government Introduced global budgeting. Conflict over this decision persists as hospital boards have not shared the Finance Ministry's goal of inexpensive health care, though they are being educated to consider the matter more carefully. One of the problems is the relationship of physicians to hospital boards since they generate much of the expense. 8 9 . 5. Issue of" Physicians'Substitutes Physicians i n the past have fought to retain their historic t e r r i t o r i a l rights over s p e c i f i c areas of h e a l t h c a r e . T h e i r p o s i t i o n has been reinforced by a powerful medical association and the Medical Practitioners Act, which enables physicians to regulate their own a c t i v i t i e s . According to Evans, a number of studies have been done, "which indicate that the level of work which is now being done by p h y s i c i a n s i n p r i m a r y c a r e . . . c o u l d be done by p h y s i c i a n substitutes." (Evans, 1981, 20:23) and that this possibility creates, "an enormous untapped potential for lowering the costs of medical care while h o l d i n g constant, or i f anything increasing, the quality...which would enable (the system) to get by with very significantly fewer numbers of physicians." (Evans, 1981, 20:23) Physicians, for the most part have rejected these conclusions. 6. Funding for Health Prevention/Promotion Programs A f i n a l i l l u s t r a t i o n of conflict among special interest groups involves the issue of funding for health prevention/ promotion programs. In a brief to the Special Committee on Federal-Provincial F i s c a l Arrangements, the Canadian Health Coalition stated that, i "to look at health care primarily in terms of present hospital and medical care i s a narrow pers p e c t i v e . . . a n d has l e d to the development of a very expensive p h y s i c i a n / i n s t i t u t i o n i l l n e s s -oriented care system." (Canadian Health Coalition, 1981, 29:116) This 'medical model ' approach to health care has occurred partly because of, "advances in medical technology (which) have called for greater specialization of f a c i l i t i e s , equipment and personnel...The cost of specialized equipment, "f a c i l i t i e s , as "well as the people needed to provide this has led; to a concentration of resources within 90. hospitals." (British Columbia Health Association, 1984, 6) In 1974, the federal government issued a policy statement en t i t l e d , "A New Perspective on the Health of Canadians." (Lalonde Report) The intent of the paper was to redirect interest away from high technology medical care to low technology health prevention/promotion programs. (UBC Health Policy Study Group, 1982, 30) While Lalonde's "health f i e l d concept" has generally been well received, corresponding support in the form of funding for British Columbia health prevention/promotion programs has not occurred because, "the main spenders within the Ministry have h i s t o r i c a l l y been the less c l o s e l y c o n t r o l l e d i n s t i t u t i o n a l and medical service areas, (and) the losers i n e v i t a b l y continue to be the d i r e c t l y funded preventive and community services, which have less fat to spare." (UBC Health Policy Study Group, 1982, 43) Many of the positions taken by groups in the foregoing discussion are r e f l e c t e d i n the attitudes shown by special interest groups toward health policy and planning issues. The chart shown in Figure 7 on the following page has been developed by the UBC Health P o l i c y Study Group, and illustrates the potential areas of c o n f l i c t between various groups and organizational units involved in the health care system. During the development of the TNRHD study, i t was found that participating groups and organizations expressed attitudes which supported the UBC Health Policy Study Group's conclusions. Specifically, Ministry of Health bureacrats were concerned with c o n t r o l l i n g costs; providers with i n c r e a s e d autonomy and services; i n s t i t u t i o n s - care; community and preventive health services - maintenance and health prevention/promotion; p o l i t i c i a n s - public relations; and comsumers - quality and availability of services and resources. 91. Figure 7 Attitudes of special interest groups toward health policy issues, 1981 H E A L T H P O L I C I E S o >» 0 0 o 3 r i O S P E C I A L I N T E R E S T C R O U P S Efficiency c o > Equality of condition* Provincial $ control Accounlabilii; the Province High tcchnolc Standards of i o 1/1 w « C Ci Cn Professional monopoly Corporate Planners Politicians 9 9 9 + + + + 9 -Top Managers + 9 9 + + - 9 9 -Health Planners + + + + 9 + + + -Health Entrepreneurs and Workers • Physicians and Surgeons (fee-for-service) + 9 9 - - + + + + Hospital Service Workers 9 9 9 - 9 + + + + Hospital Trustees 9 9 9 - - + + -Hospital A d m i n . (C .E .O. ' s ) + + 9 - - + + 9 -Public Health Workers, (incl. Doctors) 9 + + - 9 - 9 + + Consumers Taxpayers + + + + + + + + -Patients + + + - 9 + + + 9 + = positive attitude - = negative attitude § » "motherhood," or neutrality * = Two forms: minimal standards and equitable distributions • • = Attitudes vary according to party NOTE: This chart xas developed in Novtinber, 1981 and recent events have tended to make the participants harden their positions with an attendant increase in potential and actual conflict. (U.B.C. Health Policy Study Group, 1981, 77) Wants and needs have always exceeded the supply of health services and resources made available. However, given the present structure of the health care system, and increased cut backs i n funding, competition for scarce resources is guaranteed. As a r e s u l t , planning of a health and hos p i t a l study becomes a very p o l i t i c a l process as each group attempts to influence the kind of data collected in the hope that the study outcome w i l l be in i t s favour. How then does the planner maintain o b j e c t i v i t y i n the course of c o l l e c t i n g and analysing data? One approach is to i d e n t i f y models of analysis to be used in the study prior to collection and analysis of data. In practice, this approach may have problems as a number of models of analysis selected for the study had to be discarded due to d i f f i c u l t i e s i n obtaining required data. A second approach involves determination of the planner's role prior to beginning the study. Bailey has indicated that the role of the planner, " i s that of a broker within a competitive decision-making arena...if conceived as a dealer in the possible and not just the published." (Bailey, 1975, 86) Because planning takes place i n a competitive p o l i t i c a l - b u r e a u c r a t i c environment, each conflict of interest group has imput into the study. Final decisions are the planner's but these decisions need to be just i f i e d or negotiated i f they are to stick. Used together, these approaches can assist in forestalling and limiting the influence of vested interest groups on the c o l l e c t i o n and analysis of data. I t i s c l e a r from the foregoing discussion that general problems 93 . encountered, Involving a v a i l a b i l i t y and r e l i a b i l i t y of data, and the potential for bias i n the c o l l e c t i o n and analysis of data, occurred as a result of the organizational complexity of the system, combined with a lack of i n t e g r a t i o n among providers. Specific problems experienced i n the collection and analysis of study data w i l l be addressed i n the following chapter. 94. CHAPTER VIII SPECIFIC PROBLEMS COMPLICATING DEVELOPMENT OF A COMPREHENSIVE INFORMATION BASE Introduction The development of a comprehensive study data base f i r s t required i d e n t i f i c a t i o n of a method for determining need for h e a l t h s e r v i c e s . A l t h ough no single method was found, a number of techniques were identified which partially measured need as outlined in the literature. The planning approach described in Chapter II was then used to develop the study. The f i r s t tasks involved identification of the region's service area characteristics, and determination of its supply of health services and resources. Problems encountered in carrying out these tasks w i l l be discussed in the second half of this chapter. Identification of Techniques for Determining Need for Health Services According to Zimmer and Berg, "the data area most central and germinal to the regional planning and monitoring processes i s that required for the estimation of 'need' for health services. This i s also the most d i f f i c u l t data requirement to f u l f i l l (as) even the d e f i n i t i o n of need i s controversial." (Zimmer and Berg, 1975, 158) The term 'health services' includes both environmental and personal health services. As previously indicated, the consultants were asked to consider only personal health services. Kohn and White define personal health services as, " a l l transactions between physicians, dentists, nurses, pharmacists, and other formally and informally recognized health care personnel, and the individuals who seek or require their services." (Kohn et al, 1976, 3) The provision of health services, involving health manpower, f a c i l i t i e s and organizational units in varying degrees of formal and informal organization can be viewed as a system. (Kohn et al, 1976, 3) MacStravick has divided need for personal health services into three categories: "1. Health maintenance/promotion needs requiring health services presumed to benefit people who are i l l , by improving or protecting their health. 2. Acute episode needs involving specific events such as onset of illness or Injury, which al t e r the physiological or mental state of individuals such that their functions are impaired or they represent a threat to others. 3. Chronic c o n d i t i o n needs which engender unique sets of maintenance needs." (MacStravick, 1978, 58) No single method exists for determining need for these three categories of health services. Instead, six techniques for partially identifying need for health services are documented in the literature: 1. Health Status as a Measure of Need for Health Services According to De Miguel, the health status of a population is an i n d i c a t i o n of how w e l l the h e a l t h care system i s meeting i t s population's health service needs. However, De Miguel points out that because the health care system is an 'open system', health status is a product of many things i n addition to health services. (De Miguel, 1974, 7) For example, high unemployment l e v e l s as a r e s u l t of a recession may produce a lowered health status in one portion of the population. Improvement i n that population's health status is more 96. l i k e l y to be achieved through reducing high levels of unemployment than i n providing additional health services. Health status then represents only a partial measure of a population's need for health services. The Ontario Council of Health indicates that one should be able, "to measure the health of the community within its region, and as a by-product of the measurement process, identify areas in which the application of additional health resources w i l l produce net health benefits." (Ontario Council of Health, 1978, D-3) The problem l i e s in determining how to measure health status. Ideally, "The determination of the health status of a community (should) be a simple deduction based on need as derived from v i t a l and health service consumption s t a t i s t i c s . However, the r e s u l t s Indicate past met demand and do not take into account the over-use or misuse of services; nor can they show undetected or unmet need." (Ontario Council of Health, 1977, 12) Thus, in practice, health status is d i f f i c u l t to measure. According to Kaminsky, "Attempts have been made to develop a combined index or summary indicator of morbidity, mortality, d i s a b i l i t y and functional status. The quest for a health status equivalent to that of the economists's GNP has sparked the interest and imagination of numerous people." (Kaminsky, 1981, 75) However, to date, no "epidemiology plus" index has been developed which represents a satisfactory measure of the populations's health status or need for health services. (Kaminsky, 1981, 75) Instead, a number of i n d i v i d u a l health status indicators are currently used to measure the general health of the population. These, "surrogate measures of need include: death rates/mortality, m o r b i d i t y r a t e s f o r r e p o r t a b l e d i s e a s e s , d i s e a s e incidence/prevalence, l i f e expectancy and disability." (Ontario Council of Health, 1978, A-5) External Factors Affecting Need for Health Services Determination of the need for health services i n a region can also be a s s i s t e d through an a n a l y s i s of the region's service area characteristics. Major areas for consideration include: the region's economic base, i t s environment and transportation routes, and its population c h a r a c t e r i s t i c s . The economic base w i l l influence what h e a l t h s e r v i c e s and resources the region can support over time. Topography, dispersion of communities, transportation routes, distance and enviromental hazards a l l involve the issue of accessibility. And population size and mix, and age and sex c h a r a c t e r i s t i c s w i l l a f f e c t the type and quantity of health services and resources required in the region. MacStravick indicates that certain demographic c h a r a c t e r i s t i c s are linked to the need for specific health services, with age generally the most important demographic determinant. (MacStravick,, 1978, 78) By way of example, the need for preventive health maintenance services such as immunization can be analysed on the basis of age cohorts. Need for acute diagnostic services can be determined on the basis of individual age groupings. For example, the Research Division of Hospital Programs analyses need for acute care services according to five age/diagnostic service categories: 0-14 (paediatrics), 15-69 (medical/surgical), 15-44 (maternity), and 70 years and over (medical/surgical). The 70 years and over category is identified separately, as according to the Ministry of Health, this group requires proportionately more hospital services than do the 15-69 age group. (Selwood, 1982) ; 98. Need for chronic maintenance services such as long term care i s generally associated with the 65 years and over population. And on the basis of need for specific long terra care services, the 65 and over population can i n turn be partitioned into three groups: the 65-74, 75-84, and the 85 years and over population. A fourth group consisting of a small proportion of the population under age 65 require long term care services. (Selwood, 1982) Demand as an Indicator of Need for Services The most common technique for i d e n t i f y i n g need for services is "analysis of demand based on what is actually sought and obtained by consumers." (Zimmer and Berg, 1975, 159) Demand for health services can be measured by analysing use of health services over time on the basis of patient admissions, separations, patient days, occupancy rates, net referral patterns based on patient flow patterns, etc. However, "assessment of u t i l i z a t i o n attempts to identify the proportion of actual health services use which r e f l e c t s r e a l need and appropriate resources, but assumes no need exists which does not result in u t i l i z a t i o n . " (MacStravick, 1978, 71) Areas of unmet need occurring due to a shortage of providers, or the inab i l i t y of users to access services remain unidentified, as do areas of undetected need or misuse of service. Thus, demand measured by use of health services represents only a p a r t i a l measure of need f o r services. Program Performance as an Indicator of Need This technique is used primarily in the area of health maintenance 99. services and involves evaluation of a program's performance in order to determine areas of need for additional program services. An example of the use of this technique involves determining the number of pre-school and school-age immunizations done as a proportion of the total number of pre-school and school-age children located in the program's primary service area. The percentage of immunizations given is then compared against the program's stated objective in order to identify the extent of need for additional immunization i n the target population. This technique is also used in i d e n t i f y i n g need for additional pre-natal c o u n s e l l i n g s e r v i c e s , p o s t - n a t a l home v i s i t s , and well-baby examinations. (Crane, 1982) 5. Need for Services Based on Professional Assessment I d e n t i f i c a t i o n of s p e c i f i c areas of unmet need can be assisted through discussions with health care providers. (Zimmer and Berg, 1975, 159) However, while providers are a valuable source of imput, each group has its own inherent program bias. As a r e s u l t , each group's perception of areas of unmet need may be unrealistic. 6. Use of Public Opinion Surveys and Questionnaires as an Indicator of  Need Consumer-perceived needs sometimes described as "wanted services" can be i d e n t i f i e d through the use of detailed questionnaires and surveys of samples of the target population. (Zimmer and Berg, 1975, 159) Questionnaires and surveys, while valuable techniques for 100. e l i c i t i n g information, are time-consuming and expensive. Once techniques for partially identifying need for health services had been determined, a descision was made to employ five of the six methods in the study. They included: i d e n t i f i c a t i o n of service area c h a r a c t e r i s t i c s , determination of the population's health status, analysis of demand based on use of health services, program performance measured against s t a t e d o b j e c t i v e s , and i d e n t i f i c a t i o n of provider-perceived need for health services. Use of public opinion surveys and questionnaires were excluded from the study. Specific health status and demand indicators to be employed in the study would be defined by selected quantitative models of analysis. Before selecting study models of analysis, i t was f i r s t important to develop a working knowledge of the region. Problems encountered i n o b t a i n i n g population s t a t i s t i c s and identifying the supply of health services and resources in the region w i l l now be addressed. Identification of Service Area Characteristics According to MacStravick, i d e n t i f i c a t i o n of the "constituency" or population whose health needs are to be determined forms the basis of health services planning, and the geographic area containing the defined population establishes the basis upon which need for e x i s t i n g and f u t u r e h e a l t h services and resources is analysed. (MacStravick, 1978, 12) While the terms of reference c l e a r l y indicated that the study's "constituency" and the geographic area to be considered comprised the resident regional population 101. and the TNRHD, i t was less clear whether need for existing and future health services and resources was to be estimated for the region's four school d i s t r i c t populations as well. To resolve this uncertainty, i t was decided that need would be estimated for (1) the TNRHD resident population, and (2) each of the four school district resident populations. Within these defined populations, need for s p e c i f i c health services and resources would be determined on the basis of relevant age groups associated with use of specific health services. Service area characteristics were therefore identified for each school d i s t r i c t and the r e g i o n . I n f o r m a t i o n on topography, dispersion of communities, distance between communities, and current and proposed economic developments was readily available from the region's economic development o f f i c e r , and the B r i t i s h Columbia Ministry of Industry and Small Business. Climatic data was obtained from Environment Canada, Atmospheric Environment S e r v i c e s , C l i m a t i c Data and Records Department. Information on transportation routes and environmental hazards was provided by the B r i t i s h Columbia Ministry of Transportation and Highways. Population as a major determinant of need for health services was the most important component of service areas characteristics to be considered. In addition to h i s t o r i c and current population sta t i s t i c s , access to the most recent population projections was desirable in order to provide a best estimate of future requirements. 1981 federal census data by region were available when the study commenced. However, the Br i t i s h Columbia Ministry of Industry and Small Business ' breakdown of federal data by school d i s t r i c t was delayed due to cut-backs i n provincial government staff. As a result, 102. population projections normally developed by the Ministry, and private p r o v i n c i a l agencies on the basis of school dis t r i c t data were also delayed. Rather than base estimates of future requirements on previous population projections, i t was decided that the study period would be extended by several months until population projections had been developed and made available. The c o n s u l t a n t s obtained h i s t o r i c school d i s t r i c t and regional population statistics for the 1971 and 1976 census years from the Ministry of Health. 1981 s t a t i s t i c s , when made available, were obtained from the Ministry of Industry and Small Business. Each of the three years' population statistics were grouped according to age categories associated with use of s p e c i f i c health services. As previously indicated, age/health services categories consisted of: 0-14 (paediatrics), 15-69 (adult medical/surgical), 15-44 female (maternity), 70 years and over (adult medical/surgical), and 65-74, 75-84 and 85 years and over (long term care). Population variables selected for analysis included: the number and distribution of persons in the region and each school district, the age-sex d i s t r i b u t i o n , and growth trends. B i r t h rates, death rates and natural increase were also examined for each school d i s t r i c t and the r e g i o n over time. Based on an analysis of these variables, a profile of each school district population and the regional population was developed i n order to id e n t i f y changes in population characteristics. The results of the analysis were to used in subsequent planning stages of the study to determine h i s t o r i c and current incidence/prevalence rates for specific health service categories, manpower to population r a t i o s , use rates, net r e f e r r a l rates 103. based on patient flow, etc. Future requirements for health services and resources were expected to vary depending upon the size and mix of population in each school d i s t r i c t and the region. Given this assumption, the consultants decided to use two sets of population projections in order to indicate to decision-makers the possible range i n health services and resources required in 1986 and 1991. Population projections were obtained from two separate research groups, each of whom had based their figures on di f f e r e n t growth projections. Growth P r o j e c t i o n A population projections were provided by the Ministry of Health's Hospital Program's Research D i v i s i o n . Growth P r o j e c t i o n B population projections were obtained from B.C. Research, the technical operation of an independent non-profit industrial research organization, the British Columbia Research Society. Both the Research D i v i s i o n of Hospital Programs, and B.C. Research emphasized that their figures were projections;.rather than forecasts. The distinction between the terms, 'forecast' and 'projection', and s i m i l i a r planning terms such as 'prediction' and 'estimation' have been examined by 0 'Brien in the health services planning literature. While a l l four terms are used to describe a "quantitative state i n the future", 0 'Brien indicated that only the terms, 'forecast' and 'prediction' have a probability attached to the l i k e l i h o o d of the future state occurring. (O'Brien, 1980, 21) The term, 'projection' has no probability attached, and is instead conditional, with statements regarding the future containing a significant subjective element. (O'Brien, 1980, 21) 'Determination' or 'estimation' of the future takes the process a step further. The forecast or projected future i s 104. modified "by altering factors which are amenable to adjustment." (0 'Brien, 1980, 22) For example, projected requirements for health services are modified on the basis of anticipated changes, or intervention in health services use patterns. P o p u l a t i o n p r o j e c t i o n s obtained from Hospital Programs and B.C. Research had been developed by f i v e year age cohorts f o r each school d i s t r i c t . However, neither group would make available the assumptions underlying their p r o j e c t i o n s , s t a t i n g that they were u n w i l l i n g to 'pronounce' on the l i k e l i h o o d of projects going ahead i n each school di s t r i c t . This created d i f f i c u l t i e s in identifying where population growth would occur, and which communities and health services would be affected. To deal with this problem, the consultants developed assumptions regarding anticipated areas of future growth from information obtained on current and proposed developments in each school d i s t r i c t . Population projections were then compiled according to age/health service categories for each school district, and summed for the region. The percentage change in growth between 1981 and 1986, and 1986 and 1991 was determined for each age/health service category. The result s of this analysis would be used i n l a t e r planning stages of the study to determine future requirements for health services and resources. Determination of the Supply of Health Services and Resources in the Region The next task i n developing a working understanding of the region involved identification of the quantity, type and di s t r i b u t i o n of existing and planned f a c i l i t i e s , manpower and organizational units in each school 105. d i s t r i c t and the region. This inventory was to involve only those health services and resources contained within the TNRHD geographic boundaries. However, as indicated i n Chapter IV, in the section e n t i t l e d , Health Services at the Local Level, the administrative jurisdiction for several of the study's health service components and sub-components differed from that of the THRHD. On closer examination, i t was found that the geographic boundaries of these administrative j u r i s d i c t i o n s extended beyond the boundaries of the r e g i o n . This c r e a t e d some confusion between the consultants and the providers in determining which health services and resources to exclude from the study. Conversely, i t was important to know what major r e f e r r a l services were located w i t h i n the component's or sub-component's primary service area but outside the boundaries of the region. It was therefore necessary to c l a r i f y the jurisdictional boundaries of each health service before proceeding to develop a health services and resources inventory for the region. Ministry of Health maps outlining primary service area geographic boundaries were of limited use. Each map was done to a different scale, and could not be overlaid to determine the over-all picture. A common mapping scale for each of the health service's administrative jurisdictions might be a f i r s t p r i o r i t y for the Ministry. The map provided in Figure 8 has been developed by this author to i l l u s t r a t e the problem of over-lapping geographic boundaries. As indicated, TNRHD boundaries differ from those of the community health unit, emergency health services, alcohol and drug programs, and the B.C.M.A. In discussions with Ministry of Health staff, i t was learned that administrative geographic boundaries for other M i n i s t r i e s Figure 8 Loca l Health Serv ices Administrative Geographic Boundaries, 1983 THOMPSON-NICOLA REGIONAL HOSPITAL DISTRICT COMMUN I TY HEALTH DISTRICT No. 6 \L SOUTH OKANAGAN HEALTH UNIT EMERGENCY HEALTH SERVICES, r l REGION 4 riSH COLUMBIA MEDICAL ASSOCIATION, ZONE 5 K ALCOHOL AND DRUG PROGRAM, , ZONE 3 © W.L. Morton, 1985 107. such as Human Resources, Environment and Forests, and Lands, Parks and Housing are different again. Data collection and analysis problems occurring as a result of differing health service j u r i s d i c t i o n a l boundaries w i l l be described i n the relevant sections below, and i n the following Chapter entitled, Modelling Problems and Models of Analysis. 1. Acute Care Services Overlapping j u r i s d i c t i o n a l boundaries were not at issue i n determining the supply and lo c a t i o n of acute care f a c i l i t i e s as hospitals are organized under regional hospital d i s t r i c t s . The TNRHD was found to contain a regional referral hospital and four community hospitals with a combined total of 479 acute care beds. Statistics were obtained from Hospital Programs showing the historic rated bed capacity for each institution, and it s major diagnostic service categories for the period 1976 to 1981. The range of possible diagnostic services to be considered included: paediatrics, medical/surgical, maternity, r e h a b i l i t a t i o n and p s y c h i a t r y . H o s p i t a l Program's 'rated bed' statistics as opposed to the TNRHD h o s p i t a l s ' 'beds set up' figures were used i n the study as hospital bed numbers tended to fluctuate between services, depending upon current demand. Rated bed s t a t i s t i c s were analysed f o r each i n s t i t u t i o n and the region to determine reductions or increases in bed supply over time. Acute care providers at each hosp i t a l were asked to provide a description of their f a c i l i t i e s indicating date when built, services provided within each diagnostic service category, the number of 108. p r a c t i c i n g physicians by specialty, and the supply of registered nurses. These hospital descriptions, together with the completed analysis of service area c h a r a c t e r i s t i c s , and s t i l l to be obtained health service use statistics, would be used in analysing current and historic use of acute inpatient services. In requesting a description of each f a c i l i t y , i t was explained to providers that the r e s u l t i n g i n f o r m a t i o n would also a s s i s t i n developing a hospital p r o f i l e for each f a c i l i t y using guidelines established in the British Columbia Hospital Role Study. (A detailed summary of Hospital Role Study guidelines is provided in Appendix 1.) As Indicated i n Chapter VI, e n t i t l e d , Attempts by the P r o v i n c i a l Government to Improve System Integration, the Ministry of Health decided not to go ahead with the British Columbia Hospital Funding and Role Studies i n late 1981. Despite this f a c t , the study's terms of reference specified that the consultants "substantiate any deviations from the guidelines on hospital roles as set forth in the Hospital Role Study." (TNRHD Study Terms of Reference, Chapter 1, ) Several of the smaller hospitals in the region indicated a reluctance to be cl a s s i f i e d according to Hospital Role Study guidelines, perhaps in the belief that the results would demonstrate a need for a reduction in care functions or levels of service. Co-operation among providers was achieved when i t was explained that determination of each hospital's p r o f i l e would assist in establishing how self-sufficient the region and each school district was in meeting its population's health service needs. Emergency and outpatient services were also analysed in the region 109. and found to be physically combined i n each of the f i v e acute care f a c i l i t i e s . While the range of available services varied at each hospital, emergency/outpatient services could be divided into two major categories: true emergency services and ambulatory care/outpatient s e r v i c e s . True emergency s e r v i c e s were p r o v i d e d i n the emergency/outpatient department. Ambulatory care/outpatient services referred to services for ambulatory patients which were scheduled through the emergency/outpatient department, and provided either within the department, or i n various locations throughout the h o s p i t a l . Services provided within the department included treatment services, medical and surgical day care programs and specialty c l i n i c s . Examples of s e r v i c e s provided outside the department were radiology and laboratory services. 2. Intermediate and Extended Care Beds The concept of a multi-level intermediate/extended care f a c i l i t y has not yet been implemented in the region. Instead, intermediate care beds were provided in non-profit and private intermediate care f a c i l i t i e s , and acute hospitals. Extended care beds were located in non-profit extended care hospitals, and acute care f a c i l i t i e s . I d e n t i f i c a t i o n of the supply of existing and planned intermediate and extended care beds in these f a c i l i t i e s proved time-consuming due to the problem of differing administrative jurisdications. As indicated in Chapter IV, in the section entitled, Local Health Services, intermediate and extended care services are co-ordinated at the local level by a long term care 110. administrator, and organized on the basis of the community health unit. I n V i c t o r i a , the long term care program has a d m i n i s t r a t i v e r e s p o n s i b i l i t y for intermediate care services only. Extended care services are administered by Hospital Programs and organized according to regional h o s p i t a l d i s t r i c t s . I n f o r m a t i o n requested by the consultants on the number of intermediate and extended care beds in the region and each school d i s t r i c t yielded conflicting information. Rated bed figures provided by the community health unit's long term care administrator were used following confirmation with local f a c i l i t y administrators. The region was found to contain a t o t a l of 266 intermediate care beds, 180 r e g u l a r extended care beds, and 25 special (chronic behavioral disorder) extended care beds in 1982. The majority of these beds were concentrated i n the TNRHD's regional centre - Kamloops. Senior Ministry of Health administrators Indicated that although intermediate and extended care services are co-ordinated at the local l e v e l according to community health units, need f o r s e r v i c e s i s determined by school d i s t r i c t . Non-Hospital Health Care Programs As i l l u s t r a t e d i n F i g u r e 8, page 106, primary service area jurisdictional boundaries for community health services, and alcohol and drug programs, and emergency health services extend beyond the boundaries of the region. Where relevant, major r e f e r r a l services 111. located within the programs' j u r i s d i c t i o n a l boundaries but outside TNRHD boundaries were identified such as the alcohol and drug program's residential treatment centre located i n Kelowna, B r i t i s h Columbia. However, the major focus was on i d e n t i f y i n g the quantity, type and d i s t r i b u t i o n of primary health services and associated personnel available i n each school d i s t r i c t and the region. Data was obtained from the medical health o f f i c e r , l o c a l program administrators and co-ordinators, and senior Ministry of Health administrators. 4. Medical and Non-Medical Health Care Personnel The degree to which people are able to obtain health care in their community is largely dependent upon the a v a i l a b i l i t y of health care personnel i n that community. Types of manpower to be considered were physicians by specialty, dentists, pharmacists and registered nurses. According to Hsu, the supply of medical and non-medical health care personnel, " i s commonly estimated by counting actual numbers of health manpower occupational personnel. Allowance can be made for variations in individual workloads, retired personnel, etc. by e s t i m a t i n g F u l l - T i m e Equivalent (FTE)) numbers. Further refinement is possible by disaggregating a health manpower group into s p e c i a l i t i e s (eg. physicians by specialty)." (Hsu, 1982, 5) Information on the supply of active health personnel, by group and spe c i a l t y is compiled annually by the Health Manpower Research Unit at the University of British Columbia in a document e n t i t l e d , R o l l C a l l . However, these s t a t i s t i c s are only available by region, and have not been determined on the basis of Full-Time Equivalents. 112: I n an a t t e m p t t o o b t a i n i n f o r m a t i o n b y s c h o o l d i s t r i c t , t h e c o n s u l t a n t s c o n t a c t e d each g r o u p ' s p r o f e s s i o n a l a s s o c i a t i o n . B.C.M.A. f i g u r e s c o u l d not be u s e d as the a s s o c i a t i o n o r g a n i z e s p h y s i c i a n s i n t h e p r o v i n c e a c c o r d i n g t o a d m i n i s t r a t i v e z o n e s . As shown i n F i g u r e 8^ page 106, Z o n e 5 e x t e n d s b e y o n d t h e b o u n d a r i e s o f t h e T H R H D . I n f o r m a t i o n was e v e n t u a l l y o b t a i n e d f r o m a document e n t i t l e d , The  M e d i c a l D i r e c t o r y , w h i c h i s c o m p i l e d a n n u a l l y b y t h e C o l l e g e o f P h y s i c i a n s a n d S u r g e o n s of B .C . T h i s document l i s t s each p h y s i c i a n i n the p r o v i n c e by name, b i l l i n g number, s p e c i a l t y and p l a c e of r e s i d e n c e . S t u d y i n f o r m a t i o n o b t a i n e d i n a n a n a l y s i s o*f s e r v i c e a r e a c h a r a c t e r i s t i c s was u s e d t o d e v e l o p a l i s t o f c o m m u n i t i e s i n e a c h s c h o o l d i s t r i c t . T h e number of p h y s i c i a n s b y s p e c i a l t y i n e a c h c o m m u n i t y was d e t e r m i n e d f rom The M e d i c a l D i r e c t o r y , and t o t a l l e d f o r each s c h o o l d i s t r i c t . These numbers were s u b s e q u e n t l y amended' as t h e y w e r e f o u n d t o i n c l u d e r e t i r e d p h y s i c i a n s , and p h y s i c i a n s who no l o n g e r l i v e d i n the community. Da t a on the number of p h a r m a c i s t s , d e n t i s t s and r e g i s t e r e d n u r s e s i n each community and each s c h o o l d i s t r i c t was n o t a v a i l a b l e f r o m e a c h g r o u p ' s p r o f e s s i o n a l a s s o c i a t i o n , and was i n s t e a d d e t e r m i n e d f rom l o c a l h e a l t h and h o s p i t a l a d m i n i s t r a t o r s . As a g e n e r a l r u l e , t h e d e g r e e o f a c c e s s i b i l i t y t o p r i m a r y c a r e p r a c t i t i o n e r s ( those t h a t r e p r e s e n t the e n t r y l e v e l t o the h e a l t h c a r e s y s t e m ) Is more i m p o r t a n t than a c c e s s i b i l i t y t o s p e c i a l i s t p r o v i d e r s . I n a d d i t i o n t o d e t e r m i n i n g the s u p p l y of g e n e r a l p r a c t i c e p h y s i c i a n s i n each community, the c o n s u l t a n t s i d e n t i f i e d the number and l o c a t i o n o f c o m m u n i t y c l i n i c s , o u t p o s t h o s p i t a l s , a n d d i a g n o s t i c and t r e a t m e n t 113. centres in each school d i s t r i c t . This completed the inventory stage the study. 114. SECTION E ESTIMATION OF HEALTH SERVICE NEEDS AND RESOURCE REQUIREMENTS FOR THE THOMPSON-NICOLA REGIONAL HOSPITAL DISTRICT CHAPTER IX MODELLING ISSUES AND MODELS OF ANALYSIS Introduction Estimation of current and future need for health services and resources i n the TNRHD f i r s t required identification and selection of specific models of analysis to be used in the study. Selected models of analysis would i n turn define the type of health services use data to be collected for each of the study's health service components. Numerous models of analysis have been documented in the literature involving "methodologies in actual use, and those suggested or designed on a more or less theoretical basis." (Zimmer et al, 1975, 167) Most abundant are planning models for estimating acute bed requirements. However, there appears to be no consensus on an ideal acute bed estimation model which has technically feasible application, and according to Zimmer and Berg, " i f the methodology i s ' u n s e t t l e d ' i n the h o s p i t a l bed area, i t is a l l but non-existent in most other areas." (Zimmer et al, 1975, 167) D i f f i c u l t i e s were therefore encountered i n s e l e c t i n g resource estimation models for use in the study as a result of problems with models of analysis in general. Once these problems had been identified, i t was then possible to make a decision to go in a certain direction and select specific 115. models of analysis for each health service component. A description of documented resource estimation models and their limitations w i l l be given, followed by a discussion of major modelling problems encountered in applying selected models of analysis. Bed-Resource Estimation Models and Their Limitations 0 'Brien indicates that, "many of the bed planning, predication or determination models are not exclusive to their own branch of planning. The word 'bed' can be replaced by the generic term 'resource'. The type of bed planning model, therefore describes a general approach to the distribution of resources either in the present or the future." (O'Brien, 1980, 38) Bed-resource planning models vary from the simple bed-to-population r a t i o method to "the more complex methods which attempt to acknowledge and incorporate the many factors which may be associated with the u t i l i z a t i o n of a bed." (O'Brien, 1980, 38) O'Brien has done an extensive literature review of this subject, and based on the observations of Donabedian, Navarro and MacStravick, has developed a c l a s s i f i c a t i o n schema c o n s i s t i n g of the following six major types of bed-resource planning models: 1. Utilization 2. Multiple Factor 3. Distributional Analysis 4. Non-Formal and Consensus 5. Standards 6. Multiple Methodology 116. 1. Utilization "This method entails the use of a bed-related ut i l i z a t i o n rate such as admissions, separations or patient days expressed as a use rate per thousand population. The resultant rate is then manipulated by standards through the use of simple mathematics. The use rate may be past, current or predicted." (O'Brien, 1980, 39) Typical formulae include: . Total required beds =beds per thousand current population x projected population Total required beds = rate x standard 365 x standard . Total required beds = admissions per thousand current population (projected) x population x average length of stay 365 days x occupancy rate (O'Brien, 1980, 40) The disadvantages of this model are numerous. According to Zimmer and Berg, "this method considers only demand as reflected by u t i l i z a t i o n and not need, assumes a l l beds are homogeneous and that the area is a 'closed system, ' and makes no allowance for future changes in need, socio-economic status or medical technology." (Zimmer et al, 1975, 168) However, 0 'Brien indicates that ".the changing perspective of many planners from the aggregate to the s p e c i f i c needs of populations has led many to refine their methods." (O'Brien, 1980, 41) Various refinements include: use of age-sex groupings and bed categories, population projections based on anticipated changes in socio-economic factors, incidence rates for s p e c i f i c diseases, consideration of catchment populations, and referral rates based on patient rate of flow, etc. "These refinements are being added to the simple formulas which 117. continue to survive because no superior method as yet has been found." (O'Brien, 1980, 41) 2. Multiple Factor Analysis This method involves estimation of bed requirements through analysis of current health services use data, and demographic and socio-economic variables. (Zimmer et a l , 1975, 168) The use of multiple regression is c h a r a c t e r i s t i c of t h i s method, "although s i m u l a t i o n has a l s o been experimented with, and queuing theory has been adapted for solutions to both c r i t i c a l numbers of beds and waiting l i s t s . " (O'Brien, 1980, 42) O'Brien indicates that the need for a large, available and s p e c i f i c set of data, together with an intimate knowledge of the hospital or service to be studied, limits the use of this approach to local settings such as hospitals or c l i n i c a l settings. (O'Brien, 1980, 43) 3. Distributional Analysis "This model assumes that there is a pattern to the presentation of patients for admission and that the pattern can be described by a distributional curve. In simple terms, the c r i t i c a l number of beds is adjusted which insures that the beds w i l l be over-filled on one to five days out of a hundred. The adjustment i s a multiple of the standard deviation and the insurance is a probability that the beds delivered w i l l not be exceeded (patients turned away) given the patterns of admission each day." (O'Brien, 1980, 43) The poisson-. d i s t r i b u t i o n technique is normally the method of choice. "Beds are calculated from one type of information: the mean average da i l y census." (O'Brien, 1980, 43) The poisson technique is best suited to service beds which do not have electives or which contain a lower percentage of electives. (O'Brien, 1980, 43) 118. 4. Non-Formal and Consensus "Non-formal methods are those which do not apply conventional or m a t h e m a t i c a l methods." ( O ' B r i e n , 1980, 44) D e t e r m i n a t i o n of provider-perceived need based on discussions with professional providers is an example of a non-formalized approach to estimation of bed requirements. The technique can be formalized through use of a process c a l l e d the delphl technique which involves "an original l i s t i n g of variables which is passed to a group for consensus. Through a process of repetition and refinement, a f i n a l l i s t of variables i s proposed which has consensus of a l l members." (O'Brien, 1980, 45) Conversely, "a meeting of planners and administrators at which a bed rate is decided through observation and discussion" i s an example of a non-formalized consensus approach. (O'Brien, 1980, 45) As previously mentioned, the disadvantage of these methods is that they are highly subjective. 5. Standards Use of this method i s two-fold. First, the use of standards overlaps with previous models because the basic formulae involve the choice of, for example, an occupancy, length of stay or wait, or a bed-related use rate standard. (O'Brien, 1980, 45) Secondly, standards are used as a method of evaluating the existing quantity of beds in a defined area as well as assessed future bed requirements. This is done by: a) comparing the existing quantity of beds per thousand population to a desired bed-to-population standard or guideline, and b) comparing assessed future bed requirements per thousand population 119. to a desired bed-to-population standard or target. Standards and guidelines for use in basic formulae, and as measures of performance have been developed on a province-wide basis at the pr o v i n c i a l policy level. Underlying the use of standards is a rationing process as cost i s c l e a r l y related to resource supply. The disadvantage of provincial standards and guidelines is that they make no allowance for variations i n l o c a l health needs due to regional pecularities of climate, economic base, distance, population characteristics, etc. Thus, a standard or guideline which is desirable for one region may be inappropriate for another. A second problem is that provincial standards and guidelines have been developed independently for individual organizational units without taking into account the a v a i l a b i l i t y of other resources. For example, guidelines for intermediate and extended care bed-to-population ratios have been developed without considering availability of mental health boarding homes, home care services, private f a c i l i t i e s , etc. However, given that "a community may define i t s needs unreal i s t i c a l l y , demanding the highest quality of services available twenty-four hours a day," provincial standards and guidelines, as supply constraints, provide an element of realism to the whole resource needs assessment process. (Bugbee, 1970, 54) 6. Multiple Methodology Based on the l i t e r a t u r e , "a number of writers have resorted to different means in solving their problems." (O'Brien, 1980, 46) For example, a conventional u t i l i z a t i o n model would be used to calculate requirements for one bed category, while d i s t r i b u t i o n a l a n a l y s i s would be a p p l i e d i n 120. estimating needs for a second bed category. The key advantage of this approach, " i s tied more to the f l e x i b i l i t y i n approaching bed d i s t r i b u t i o n problems, not to mention the p o s s i b i l i t y of comparing various methods within a study." (O'Brien, 1980, 47) Once the advantages and disadvantages of each general type of resource estimation model had been i d e n t i f i e d , the consultants could proceed in selecting an appropriate model for each of the study's health s e r v i c e components. Before describing each model, i t i s necessary to recall the general study framework into which each model of analysis was incorporated. The f i r s t two study tasks, involving i d e n t i f i c a t i o n of service area characteristics, and determination of the supply and distribution of health services and resources i n the region had been completed. Remaining tasks included: . Analysis of current and historic use of health services. . Estimation of gaps or a surplus i n existing resource supply on the basis of analysis of health services use data, and comparison with provincial standards and guidelines. . Projection of health services use to 1986 and 1991 on the basis of h i s t o r i c trends, and a n t i c i p a t e d changes i n health service use patterns. . Estimation of future resource requirements. . Comparison of estimated resource requirements with existing and planned supply to determine future shortfall. Comparison of estimated resource requirements with provincial resource targets. 121. Selected Bed-Resource Estimation Models Acute Inpatient Beds A v a r i a t i o n of O'Brien's 'utilization model' was chosen for estimating current and future acute bed requirements. The selected acute bed planning model was based on a model employed by the B r i t i s h Columbia Hospital Program's Research Division with some modifications. Factors leading to the decision to use this model included: greater availability of data for model variables, fewer measurement problems given data a v a i l a b i l i t y , and the potential for greater acceptance of study results given s i m i l i a r i t y of planning methodology. Two other models described i n O'Brien's six-part c l a s s i f i c a t i o n schema were incorporated Into the model design. They were: the non-formal provider-perceived need model, and standards. The model was designed for estimation of current and f u t u r e bed requirements at the school d i s t r i c t and regional level for the following major age/diagnostic bed c a t e g o r i e s : 0-14 ( p a e d i a t r i c s ) , 15-69 ( m e d i c a l / s u r g i c a l ) , 15-44 female (maternity), and 70 years and over (medical/surgical). Current and future requirements for psychiatric and r e h a b i l i t a t i o n beds were analysed on the basis of total population needs as available use data was not age specific. 1. Analysis of Current Acute Bed Requirements a. Hospital Use Trends and Patterns Major variables analysed for each age/diagnostic bed category were: 122. incidence of hospitalization, hospital workloads, net referral patterns based on patient flow patterns, patient inflow/outflow p a t t e r n s , occupancy rates and average length of stay (ALOS). Data for each of these variables was obtained from the Research D i v i s i o n of Hospital Programs. (i) Incidence of Hospitalization S t a t i s t i c s on the number of units of service attributed to residents of each school d i s t r i c t in the region for acute care services obtained both within and outside the school d i s t r i c t and the region were obtained for 1971, 1976 and 1981. Measures of units of service were hospital cases and patient days by age/diagnostic service category. The incidence, or number of cases and p a t i e n t days per 1000 resident population was calculated using the following formulae: Incidence rate (cases by age/diagnostic service category) = number of resident cases by school dis t r i c t for census year 1000 Incidence rate (patient days by age/diagnostic service category) = number of resident patient days by school d i s t r i c t for census year 1000 C a l c u l a t e d school d i s t r i c t i n c i d e n c e r a t e s f o r each age/diagnostic s e r v i c e category were added to determine regional incidence rates for each bed category. Rates were analysed to i d e n t i f y changes in diagnostic service morbidity rates over time. Factors which might a f f e c t h o s p i t a l i n c i d e n c e rates 123. i n c l u d e : a change i n populat ion mix, changes i n m e d i c a l p r a c t i c e , an increase or decrease i n heal th care programs provided outside the inpatient setting, increased control over use of h o s p i t a l beds, and the success of the long term care program i n moving inappropriately placed patients from acute beds. An increase or decrease i n the prevalence of disease occurring as a result of an epidemic, or advances i n medical technology would also affect Incidence rates. ( i i ) Hospital Workloads Hospital workload s ta t is t ics for each acute hospital i n the region were obtained for the period 1976 to 1981, and analysed to determine changes in hospital use over time. Fluctuations In the number of cases and patient days may be considered to r e f l e c t only var ia t ions in demand, when in fact a decrease in hospital use may be the result of a reduction in bed supply, or i n medical or non-medical heal th care personnel . H o s p i t a l workloads were t h e r e f o r e examined i n r e l a t i o n to each hospital 's historic rated bed capacity for each diagnostic bed category, and a v a i l a b i l i t y of manpower over time. ( i i i ) Net Referral Patterns A community h o s p i t a l ' s catchment area for p r o v i s i o n of general ized services i s u s u a l l y assumed to be the s c h o o l d i s t r i c t i n which the h o s p i t a l i s located, and i ts "service constituency" - the resident population w i t h i n the catchment 124. area. (MacStravlck, 1978, 15) A regional hospital may operate both as a community hospital providing generalized services for residents within i t s school d i s t r i c t , and as a r e f e r r a l hospital providing specialized services for the larger regional service constituency. Patient inflow/outflow patterns can occur as follows: Patients can seek their acute care services outside their school d i s t r i c t but within the region either at another community hospital, or at the regional referral hospital. Patients can obtain services outside the region either at another community hospital, or at a regional or p r o v i n c i a l referral hospital. . Patients from outside the region can seek services within the region either at a community h o s p i t a l , or at the regional referral hospital. Factors leading to the decision to seek care outside the resident's school d i s t r i c t or the region may include: lack of available resources in the defined catchment area, preference, chance due to travelling, proximity to hospital of choice, or necessity in order to obtain specialized services. Net r e f e r r a l patterns, or the net e f f e c t of inflow and outflow patterns were determined by age/diagnostic service category for each school district and the region for 1971, 1976 and 1981 using the following formulas: Net referral rate (%) (cases) = 12-5. Hospital volume (resident volume minus outflow plus inflow) resident hospital volume (obtained everywhere) ^ ^0 Net r e f e r r a l rate (%) (patient days) = Hospital volume (resident volume minus outflow plus inflow) resident hospital volume (obtained everywhere) Changes i n r e f e r r a l patterns may occur as a r e s u l t of changes i n existing patterns of care, a s h i f t i n the number of g e n e r a l p r a c t i t i o n e r s v e r s u s s p e c i a l i s t s , changes i n a hospital's rated bed capacity or a new hospital coming on l i n e , (iv) Inflow/Outflow Patterns While net r e f e r r a l patterns are a v a l i d planning t o o l f o r estimating acute bed requirements, they do not indicate the actual percentage of hospital cases and associated patient days coming into or leaving a school d i s t r i c t or region. They merely i n d i c a t e the net e f f e c t of flow. Thus, i t i s d i f f i c u l t to evaluate how s e l f - s u f f i c i e n t the reg i o n i s i n meeting i t s population's needs, or what share of the market each h o s p i t a l i s actually s a t i s f y i n g . Patient inflow and outflow patterns were therefore analysed by service as a basis for determining: . The c a p a b i l i t y of the region to s a t i s f y I t s r e s i d e n t s ' acute care service requirements. . The c a p a b i l i t y of each community hospital i n the r e g i o n to meet i t s catchment population's g e n e r a l i z e d acute care needs. . The number of non-resident p a t i e n t s seeking acute care 126. services within the region. 1981 patient inflow data by service was compiled for each school dis t r i c t and the region on the basis of patient's place of residence. Each patient's residence was identified according to a school d i s t r i c t within the region, or significant school districts outside the region. Patient outflow data by service was sorted by school d i s t r i c t and region according to the hospital at which the patient was treated. Hospitals providing care were either identified separately, or grouped depending on hospital volume. Ideally, inflow/outflow patterns would have been compiled on the basis of a morbidity p r o f i l e of each patient indicating what s p e c i f i c service was being sought within each diagnostic service category. Data at this l e v e l of d e t a i l were not available, and would have required a degree of analysis which was beyond the scope of the study. Tables illustrating inflow and outflow patterns by service were provided for decision-makers to use in assessing current hos p i t a l use patterns. Once patterns had been i d e n t i f i e d , consideration could be given to ways of reversing high outflow patterns. However, there was f i r s t a need for agreement on what constitutes a reasonable level of patient inflow and outflow f o r each school d i s t r i c t and the region. No quantitative p r o v i n c i a l guidelines have been developed as measures of performance for evaluating inflow, outflow or net referral patterns. Underlying the development of guidelines are the 127. issues of equity and health care as a "universal right" versus the f e a s i b i l i t y of providing a l l services i n a region or a J school d i s t r i c t . In practical terms, this involves concordance on what constitutes reasonable access to services, and what type and quantity of resources can be r e a l i s t i c a l l y provided at the s c h o o l d i s t r i c t and r e g i o n a l l e v e l s to s a t i s f y accessibility/availability/coverage c r i t e r i a . The British Columbia Hospital Role Study addresses several of these questions. As indicated in Chapter VI, Hospital Role Study c r i t e r i a developed for use in assessing each hospital's role, or the combination of care functions and l e v e l s of service which the hospital should be providing included: size of catchment population, h i s t o r i c use of hospital services, distance to other f a c i l i t i e s , availability of manpower, etc. Each hospital in the region was assessed according to these c r i t e r i a , and i t s hospital role determined. The f a c i l i t y ' s hospital profile, or combination of care functions and levels of service which the hospital was currently providing were then examined to i d e n t i f y any deviations from Hospital Role Study guidelines. Recommendations on approaches for r a d i c a l l y a l t e r i n g hospital profiles in order to conform with Hospital Role Study guidelines were beyond the consultants' mandate. Instead, the detailed tables i l l u s t r a t i n g existing inflow/outflow patterns were provided for decision-makers to use in assessing hospital 128. use patterns in the l ight of Hospital Role Study guidelines. I t was also suggested that co-operat ion among hospitals in the region regarding each f a c i l i t y ' s role could serve to decrease unnecessary duplication and/or fragmentation of services in the region. (v) Occupancy Levels Occupancy levels by diagnostic service were determined for each hospital and the region for the period 1976 to 1981 using the following formula: Occupancy rate (%) = actual patient days available patient days X 100 Where: Available patient days = rated capacity x 365 days. Rates for the 15 to 69, and 70 years and over age groups were combined to determine total adult m e d i c a l / s u r g i c a l occupancy r a t e s . Rated beds for each service were then summed, and occupancy rates were c a l c u l a t e d for each h o s p i t a l and the region. Low occupancy rates can be?an indication of surplus capacity due to such factors as high bed to catchment population rat ios , lack of available manpower, high net outflow patterns or l i t t l e i l l n e s s . An increase i n occupancy rates may occur as a result of closure of rated beds, an increase i n the a v a i l a b i l i t y of manpower, an epidemic or an increase in population to the area. Occupancy rates also tend to fluctuate according to season. (vi) Average Length of Stay (ALOS) Current and h i s t o r i c average length of stay, measured by 129. patient days was c a l c u l a t e d by d i a g n o s t i c s e r v i c e f o r each h o s p i t a l and the region using the following formula: Average length of stay = patient days cases Average length of stay was analysed to determine differences i n h o s p i t a l use over time and between f a c i l i t i e s . V a r i a t i o n s i n average length of stay over time may be the r e s u l t of a change i n medical p r a c t i c e such as the p r e s e n t p r a c t i c e of d i s c h a r g i n g m a t e r n i t y p a t i e n t s e a r l i e r . I n discussions with providers, i t was found that average length of s t a y at a r e g i o n a l or p r o v i n c i a l r e f e r r a l h o s p i t a l f o r s p e c i a l i z e d treatment i s , i n g e n e r a l , longer than that at a community h o s p i t a l f o r g e n e r a l i z e d treatment. In a d d i t i o n , r u r a l patients, faced with long distances to t r a v e l may remain i n h o s p i t a l longer than patients l i v i n g c l o s e to a treatment f a c i l i t y , or with access to community health support s e r v i c e s . Length of h o s p i t a l stay i s also r e l a t e d to age. I t was found t h a t p a t i e n t s i n the 70 years and over age group averaged longer lengths of stay than did the 15 to 69 age group. Lack of a l t e r n a t i v e s to acute care i n the community may i n t u r n n e c e s s i t a t e f u r t h e r time b e i n g s p e n t i n the acute c a r e f a c i l i t y . b. Comparison with P r o v i n c i a l Standards and Guidelines Following analysis of h o s p i t a l use trends and p a t t e r n s i n the region, quantitative guidelines were used as benchmarks i n comparing 130. the supply and demand of e x i s t i n g acute beds against Ministry of Health suggested acute bed-to-population r a t i o s , and su i t a b l e occupancy rat e s , ( i ) Acute Bed Ratios Acute b e d - t o - p o p u l a t i o n r a t i o s were determined f o r the region, and compared against Hospital Programs ' acute bed r a t i o guidelines (1982) to i d e n t i f y shortages or a s u r p l u s i n the supply of acute beds i n the region. . Total acute beds = 4.25 beds per thousand population . P s y c h i a t r i c beds = 0.25 beds per thousand population . R e h a b i l i t a t i o n beds = 0.25 beds per thousand population While these guidelines are useful as a gross measure of the need f o r acute beds i n the region, they have some l i m i t a t i o n s : Hospital Programs' guidelines have been developed f o r use on a r e g i o n a l b a s i s only, and do not take into account the s p e c i a l needs of the p o p u l a t i o n , the mix of h o s p i t a l types i n the r e g i o n , or the net e f f e c t of p a t i e n t inflow and outflow. As well, estimated acute bed requirements c o u l d only be compared with t o t a l , p s y c h i a t r i c and r e h a b i l i t a t i o n bed-to-population guidelines, because quidelines f o r medical/surgical, m a t e r n i t y and paediatric r a t i o s have not been developed, ( i i ) Suitable Occupancy Rates Occupancy r a t e s have been shown to increase with h o s p i t a l s i z e , and, " i f actual occupancy was used as a b a s i s f o r t r a n s l a t i n g bed u t i l i z a t i o n Into bed needs, almost twice as many beds 131. would be required in under 25-bed hospitals as opposed to 500-plus-bed institutions." (MacStravick, 1978, 132) Thus, based on productivity alone, large i n s t i t u t i o n s are preferable to smaller institutions. However, MacStravick points out that, "Creating more large i n s t i t u t i o n s would reduce users access to them. Studies have shown that u t i l i z a t i o n of hospitals tends to decrease as distance from the h o s p i t a l i n c r e a s e s . ( C o n v e r s e l y ) , Making care more d i r e c t l y accessible would increase u t i l i z a t i o n of smaller hospitals, making even more beds n e c e s s a r y to meet needs." (MacStravick, 1978, 133) Recognizing that there is a relationship between size of hospital and occupancy rates, Hospital Programs ' have developed suitable occupancy rate guidelines on the basis of size of service provided: TABLE III British Columbia Hospital Programs ' Suggested Suitable Acute  Hospital Occupancy Rates by Service, 1982 Service Suggested Occupancy Rates (%) Adult Medical/Surgical Under 50 beds 70 - 80 50 99 beds 80 83 100 - 199 beds 83 85 200 - 2 99 beds 85 87 300 beds and over 87 90 132. TABLE III Br i t i sh Columbia Hospital Programs ' Suggested Suitable Acute Hospital Occupancy Rates by Service, 1982 (con't) Paediatric and Maternity Suggested Occupancy Rates (%) Under 15 beds 70 15 - 30 beds 75 30 beds and over 75 - 85 Occupancy rates by service at each hospital in the region were compared against Hospital Programs' suggested suitable occupancy rates by service in order to obtain a rough i n d i c a t i o n of actual beds r e q u i r e d based on eff ic ient use of beds and s taff . Through this method, the patient day volume by service at each hospital was divided by 365 to obtain the average daily census (ADC) for the 1982 year. This was repeated for each of the previous two years . The ADC for each of the three years was then averaged to give a three year average ADC. Suggested suitable occupancy rates shown in Table III were appl ied to the three year average ADC to determine each h o s p i t a l ' s bed needs by service. Calculated bed requirements were then compared against the existing number of rated beds by service at each hospital to identify gaps i n supply based on provincial guidelines. Based on the consultants ' analysis of hospital use trends and patterns, and comparison with p r o v i n c i a l g u i d e l i n e s , the region and each school dis t r ic t were found to be well served with total acute beds. However, there 133. was a need for some re-deslgnation of rated beds between services. In practice, a r e - a l l o c a t i o n of beds between s e r v i c e s may r e s u l t i n an undesirable mixing of services. Potentially re-assignable beds may also be inappropriate given their location within the hospital. Based on discussions with hospital providers, there appeared to be s u f f i c i e n t f l e x i b i l i t y for re-assignment of beds given the overall surplus of beds at each hospital. 2. Estimation of Future Acute Bed Requirements Estimation of acute bed requirements for 1986 and 1991 f i r s t required the development of a number of assumptions regarding anticipated changes i n use of hospital services. Variables considered for each a g e / d i a g n o s t i c service category were: incidence rates, referral rates, ALOS and occupancy rates. Given budget r e s t r a i n t s , i t was doubtful that major new programs would be introduced i n the short-run. I t was t h e r e f o r e assumed that incidence rates for each service would continue to decline, but at a decreasing rate. In the absence of major attempts at reversing high outflow patterns i n each school d i s t r i c t , i t was assumed that historic referral rates would continue with a s l i g h t increase i n inflow to the regional hospital, and a s l i g h t reduction in outflow from the community hospitals. ALOS was expected to remain r e l a t i v e l y constant. H o s p i t a l Programs' suggested occupancy rates for each diagnostic service were assumed to be re a l i s t i c , and were employed in the bed estimation formula. As previously mentioned, po p u l a t i o n p r o j e c t i o n s to be used i n estimating future resource requirements were based on two separate growth projections in order to indicate to decision-makers the possible range i n 134. requirements for acute beds for each age/diagnostic bed category, and total beds. The bed estimation formula used i n c a l c u l a t i n g age beds f o r each diagnostic service for 1986 is given below. Calculations for each step were done by school d i s t r i c t , and summed for the r e g i o n . Calcula t ions were repeated for estimation of 1991 bed requirements using 1986 figures as a base, and 1991 population projec t ions , and estimated 1991 incidence and referral rates. Steps: . Estimated school dis t r ic t patient days (1986) = estimated incidence x 1986 projected school d is t r i c t pop. (A & B) rates (days) 1981 school d is t r i c t population . Estimated hospital days (1986) = estimated school dis t r ic t x estimated referral patient days (1986) rates (days) . Estimated acute bed requirements (1986) = estimated hospital days (1986) x suitable occupancy rates 100 Estimated acute bed requirements were compared against the supply of existing and approved rated beds in each school d i s t r i c t and the region to Ident i fy areas of under or over supply of beds i n 1986 and 1991. Future h o s p i t a l workloads were analysed on the basis of H o s p i t a l Role Study guidelines to assess changes in existing hospital prof i les . Estimated bed requirements were then compared against the fo l lowing Hospi ta l Program's ' acute bed ratio targets for 1986 and 1991: . Total acute beds = 4.25 beds per thousand population, and, 4.0 beds per thousand population (1991) 135. . Psychiatric beds = 0.25 beds per thousand population (1986 and 1991) . Rehabilitation beds = 0.25 beds per thousand population (1986 and 1991) Based on the analysis of existing and approved rated beds against estimated future requirements, and comparison with provincial targets, i t was determined that the region would be well served with beds in 1986 and 1991 with some re-designation of rated beds between services. Based on i n d i v i d u a l school dis t r i c t requirements, several additional beds were found to be required at two of the community hospitals by 1991. No change i n hospital profiles was indicated for either 1986 or 1991. Emergency/Outpatient Services A v a r i a t i o n of O'Brien's u t i l i z a t i o n model was orginally selected for estimation of current and future use of emergency/outpatient services. However, during the process of collecting data, i t was found that statistics on use of services could only be obtained from each hospital for the major categories of true emergency services, and ambulatory care/outpatient services. U t i l i z a t i o n data for i n d i v i d u a l programs provided within each emergency/outpatient department, and programs scheduled through each emergency/outpatient department were not available with the exception of day care surgery s t a t i s t i c s . In addition, data on use of services, measured by v i s i t s for emergency/outpatient services, and procedures for day care surgery were not available by age, or patient place of residence. 136. Due to data un-availabillty problems, the following methods were used i n a n a l y s i n g c u r r e n t use of s e r v i c e s , and e s t i m a t i n g f u t u r e emergency/outpatient services use: 1. Analysis of Current and Historic Use of Emergency/ Outpatient Services a. True Emergency Services and Ambulatory Care/Outpatient Services . The percentage annual change in use of emergency/ outpatient services was analysed for the period 1976 to 1981 for each hospital, and for the region. . A u t i l i z a t i o n rate based on v i s i t s per 1000 p o p u l a t i o n was c a l c u l a t e d f o r t r u e emergency s e r v i c e s , and ambulatory care/outpatient services for each hospital and the region. The f i v e emergency/outpatient departments i n the r e g i o n were c l a s s i f i e d according to the Department of National Health and Welfare's Emergency Department C l a s s i f i c a t i o n Scheme. The c l a s s i f i c a t i o n scheme consists of four categories in descending order of complexity, "each of which has certain minimum c r i t e r i a for medical personnel, t e c h n i c a l support and o r g a n i z a t i o n a l configuration." (Department of National Health and Welfare, 1975, 5) A description of minimum c r i t e r i a required for each category is provided In Appendix I I . Each of the f i v e emergency/ outpatient departments in the region was assessed according to these c r i t e r i a , and assigned to a category on the basis of l e v e l of care i t was capable of providing. Department workloads were then evaluated to determine the l e v e l of care which each department was currently 137. providing, b. Day Care Surgery . The number of day care surgery procedures performed at each h o s p i t a l between 197.6 and 1981 was a n a l y s e d to determine changes i n the annual volume of day care surgery performed over time. . The annual volume of day care surgery performed at each h o s p i t a l was determined as a percentage of the t o t a l surgery ( i n p a t i e n t and day care) performed at each h o s p i t a l . The annual volume of t o t a l surgery performed at each h o s p i t a l was c a l c u l a t e d as a percentage of the volume of t o t a l surgery performed at a l l hospitals i n the region. 2. Estimation of Future Use of Emergency/Outpatient Services a. Ambulatory Care Programs I n the absence of s t a t i s t i c s on use of ambulatory care programs, discussions were held with h o s p i t a l providers to determine need f o r future day care programs and s p e c i a l t y c l i n i c s at each h o s p i t a l . b. Day Care Surgery The f o l l o w i n g assumptions were made regarding use of day care surgery i n 1986 and 1991: The volume of t o t a l s u r g e r y p e r f o r m e d at each h o s p i t a l as a percentage of the t o t a l volume of surgery performed i n the region would remain at the 1981 l e v e l . . The number of day care surgery procedures performed at each h o s p i t a l as a percentage of the volume of t o t a l s u r g e r y performed at each 138. h o s p i t a l would i n c r e a s e s l i g h t l y r e f l e c t i n g h i s t o r i c trends occurring prior to 1981. Future day care surgical volumes at each h o s p i t a l were derived using the following calculations: . 1986 estimated total TNRHD surgical procedures (inpatient and day care) = 1981 total TNRHD x 1986 TNRHD population surgical procedures projections (A & B) 1981 TNRHD population . 1986 estimated individual hospital total surgical procedures = 1986 estimated total x 1981 % distribution of total TNRHD surgical proc. surgical days by hospital . 1986 estimated surgical day care procedures by hospital = 1986 estimated total x estimated % of day care surgical procedures procedures to be performed by hospital by hospital 1986 i n d i v i d u a l hospital day care procedures were summed to determine the volume of day care procedures estimated to be performed i n the region i n 1986. Calcula t ions were repeated using 1986 figures as a basis for determining 199.1 surgical day care volumes. c. True Emergency and Ambulatory Care/Outpatient Service On the basis of current and historic trends, u t i l i z a t i o n rates f o r true emergency services , and ambulatory care/outpatient services were expected to remain relat ively constant i n 1986 and 1991. Based on this assumption, v i s i t s f o r t rue emergency s e r v i c e s , and ambulatory care/outpatient services were estimated for 1986 using the f o l l o w i n g f ormulae: 139. 1986 estimated true emergency v i s i t s by hospital = 1981 true emergency x 1986 school d i s t r i c t v i s i t s by hospital pop, projections (A & B) 1981 school dis t r i c t pop. . 1986 ambulatory care/outpatient v i s i t s by hospital = 1981 ambulatory care/ x 1986 school dis t r i c t outpatient v i s i t s by pop, projections (A & B) hospital 1981 school d is t r i c t population Estimated 1986 v i s i t s for each hospital were summed for the region. Calcula t ions were repeated using 1986 f i g u r e s as a b a s i s f o r estimating 1991 v i s i t s . Estimated true emergency v i s i t s , and ambulatory care/outpatient v i s i t s f o r 1986 were summed to determine t o t a l e s t i m a t e d emergency/outpatient v i s i t s for each hospital , and the region. This was repeated for 1991. . Existing emergency/outpatient department prof i les were assessed on the basis of estimated future workloads to identify possible changes in each department's level of care category i n 1986 and 1991. Intermediate and Extended Care Services I d e a l l y , estimation of intermediate and extended care bed requirements would be based on consideration of the following variables: Current and historic population stat is t ics for the 65 to 74, 75 to 84 and 85 years and over age groups by school d i s t r i c t . Population projections by age group and school dis t r i c t for 1986 and 1991. . Morbidity incidence and prevalence rates by age group and school 140. dis t r ic t for intermediate and extended care services. Active admission waiting l i s t s by age group ( inc luding f a c i l i t y of f i r s t and second choice). . Length of wait by the p a t i e n t ' s place of residence (produced quarterly) by age group. . Total length of stay by age group for each f a c i l i t y . Number of long term care patients in acute care beds. Number of patients c u r r e n t l y i n one long term care f a c i l i t y but waitl isted for another. Simulat ion or queuing techniques described in the f i r s t part of this chapter under the heading, " M u l t i p l e Factor A n a l y s i s " could be used i n analysing data for each of these variables. Consideration of these models ceased when i t became impossible to obtain active and complete information on waiting l i s t s , and length of wait and stay by age group and patient place of residence. Intermediate and extended care bed requirements were estimated instead on the basis of the bed-to-population rat io technique, M i n i s t r y of Health intermediate and extended care guidelines, and provider-perceived need. Bed requirements were determined on the basis of the t o t a l age 65 and over population, as M i n i s t r y of Health bed- to-populat ion guidelines were not developed for the 65 to 74, 75 to 84, and 85 years and over i n d i v i d u a l age groupings. 1. Analysis of Current Intermediate and Extended Care Bed Requirements Current bed- to-populat ion rat ios were determined on the basis of the 1 4 1 . number of intermediate care beds, and the number of extended care beds available per 1000 population age 65 years and over for the region and each school d i s t r i c t . Intermediate and extended care bed ratios were compared against the LTC program's and Hospital Programs' bed ratio guidelines to assess beds available against provincial standards. The guidelines set out by the LTC program are 40.4 intermediate care beds per 1000 population aged 65 years and over. A small proportion of the 19 to 65 age group also require f a c i l i t y placement. When this group is considered, the suggested r a t i o of intermediate care beds to population is 40.9 beds per 1000 population aged 65 years and over. Hospital Programs' suggested ratio of extended care beds to population is 25 extended care beds per 1000 population 65 and over. Bed needs for the 19 to 64 age group have been incorporated into this guideline. Intermediate and extended care bed requirements based on suggested bed-to-population guidelines were compared against the supply of existing intermediate and extended care beds to identify areas of under or oversupply. Estimated Future Intermediate and Extended Care Bed Requirements LTC and Hospital Programs' bed ratio guidelines were applied to 1986 and 1991 p o p u l a t i o n projections (Growth Projections A and B) to determine intermediate and extended care bed requirements by school district and region for 1986 and 1991. Estimated bed requirements based on provincial guidelines were compared against the supply of existing and approved intermediate and extended 142. care beds i n the region and each school d i s t r i c t to i d e n t i f y gaps i n the quantity and d i s t r i b u t i o n of beds i n 1986 and 1991. Non-Hospital Health Care Programs The problem of over-lapping program j u r i s d i c t i o n a l boundaries created d i f f i c u l t i e s i n e s t i m a t i n g r e s o u r c e needs f o r n o n - h o s p i t a l h e a l t h c a r e programs. As shown i n F i g u r e 8, page 10,6, a d m i n i s t r a t i v e boundaries f o r community health services, alcohol and drug, and emergency h e a l t h s e r v i c e s extend beyond the geographic boundaries of the TNRHD. A r t i f i c i a l boundaries, i d e n t i c a l w i t h t h o s e of the r e g i o n were e s t a b l i s h e d f o r each of the programs. However, s t a t i s t i c s on use of each program were not a v a i l a b l e by p a t i e n t p l a c e of r e s i d e n c e with the r e s u l t that the p r o p o r t i o n of use a t t r i b u t a b l e to the TRNHD p o p u l a t i o n c o u l d n e i t h e r be i d e n t i f i e d or p r o j e c t e d . Thus, re s o u r c e s necessary to meet estimated need for services could not be cal c u l a t e d . A v a i l a b l e use s t a t i s t i c s f o r each program were a n a l y s e d to o b t a i n an i n d i c a t i o n of demand f o r s e r v i c e s . However, g i v e n data a v a i l a b i l i t y problems, use of a quantitative model f o r e s t i m a t i n g e x i s t i n g and f u t u r e r e s o u r c e requirments was r u l e d out. I n s t e a d , discussions were held with relevant health care providers at the l o c a l and p r o v i n c i a l program l e v e l s to determine areas of c u r r e n t and f u t u r e need f o r a d d i t i o n a l s e r v i c e s and resources i n each school d i s t r i c t and the region. Medical and Non-Medical Health Care Personnel Determination of current and future manpower requirements was found to 143. be even more d i f f i c u l t than i d e n t i f y i n g the supply of manpower i n each school dis t r i c t , and the region. According to Hsu, "These d i f f i c u l t i e s stem from data a v a i l a b i l i t y and measurement problems associated with need, want, demand, u t i l i z a t i o n (or some combination of these indicators ." (Hsu, 1982, 6) Hsu also points out that, given current budgetary constraints, estimation of supply based on need, or historic demand may be unrealistic as, "what we can afford may be the de facto determinant." (Hsu, 1982, 6) As a r e s u l t of r i s i n g health care costs, various government agencies and groups have attempted to develop standards for appropriate h e a l t h manpower-to-population r a t i o s . Agreement on desirable manpower levels for each health manpower group has proved d i f f i c u l t to reach because of the number of groups involved - each with their own legitimate interests and goals. As Ytterberg, Crichton and Stark point out, " responsibil i ty for manpower planning is i l l - d e f i n e d . Many groups are interested, but no one authority has emerged." (Ytterberg et a l , 1983, 53) In the absence of strong models of analysis for project ing health manpower requirements, estimation of medical and non-medical manpower needs was based on the simple manpower-to-population ratio technique, and regional comparisons. The r a t i o of health manpower (by group and s p e c i a l t y ) per 10,000 population in the THRHD was determined from the UBC Health Manpower Research Unit 's Roll Cal l s ta t is t ics for the 1976 to 1981 period. . The TNRHD rate for each manpower group by specialty was compared with the average rate for the combined non-metropolitan areas, and for B r i t i s h Columbia to identify existing under or oversupply of manpower 144. in the region. . In the absence of desirable manpower-to-population r a t i o guidelines, 1981 TNRHD manpower rates (by specialty) were modified by 1986 and 1991 population projections (Growth projections A and B) to provide an estimation of future manpower requirements. Where TNRHD manpower rates f e l l below the average rate for a l l non-metropolitan areas, the non-metropolitan rate was used i n estimating f u t u r e supply. The manpower figures provided in the study were approximations only, as the supply of h e a l t h care personnel i n an area i s a function of the marketplace. Modelling of the Health Care System MacStravick has indicated that the need for specific health resources must be determined i n r e l a t i o n to the need for other health resources to ensure an appropriate mix of resources in the region. (MacStravick, 1978, 25) Underlying this approach is the requirement for an analytical model capable of simulating the health care system. Such a model would enable the planner to measure int e r r e l a t i o n s h i p s between services and programs, identify duplications or gaps in the system, and determine the consequences of delivering services in one way as compared to another. In this manner, future health service needs, and resources necessary to meet estimated needs could be determined on the basis of an all-encompassing approach. One barrier to this approach is that information related to one health service component i s not e a s i l y aggregated with information from other sources. Secondly, the organizational structure of the health care system, 145. combined with The Ministry of Health's current funding policies , discourages c o - o r d i n a t i o n among health prevention/promotion groups, acute care service organizations and chronic maintenance service groups. F i n a l l y , i t has been demonstrated that there are r e a l methodological problems associated with bed-resource estimation models for individual components of the health care system, and, i n general , even simple standards and guidelines do not take into account the avai labi l i ty of other resources. Recognizing the need for a comprehensive approach to the p r o v i s i o n of heal th care s e r v i c e s , an Advisory Group of the Ontario Council of Health recommended the development of a s imulat ion model capable of estimating p r o v i n c i a l health requirements for the over-65 population. The idea was discarded when i t was determined that the project would cost $3 mi l l ion over five years. (Horsburgh, 1983) Thus, the task of developing a model capable of simulating the entire health care delivery system may be unrealist ic , and i t is not known whether the results would just ify the expense. Conversely, resource requirements estimated by aggregating individual components produce a less than optimum solution. 146. SECTION F CONCLUSION CHAPTER X SUMMARY AND RECOMMENDATIONS Introduction P r e p a r a t i o n of the TNRHD H e a l t h and H o s p i t a l Study was not, as orginally envisaged, a simple matter of construct ing a planning model, developing a comprehensive information base, and estimating health service and resource requirements using documented models of a n a l y s i s . Instead, as has been shown, numerous problems were encountered in developing the study as a result of a complex set of interlocking and overlapping issues i n the health care system. A further complicating factor was that the author had no power to resolve underlying issues, but could only attempt to cope with the problems. In this f i n a l chapter, major underlying issues i d e n t i f i e d as having complicated the study w i l l be summarized. The success of the TNRHD study, given limitations w i l l then be analysed. F i n a l l y , the summarized issues w i l l be considered to identify what approaches are necessary to resolve these issues, or modify their e f f e c t s , and to determine who has the power to do this . 147. Summary of Major Problems and I d e n t i f i e d Underlying Issues 1. The TNRHD Study Terms of Reference The f i r s t problem encountered was that the terms of r e f e r e n c e were u n c l e a r . As a r e s u l t , t h i s c r e a t e d problems at the onset of the study i n determining i t s purpose and parameters. The underlying i s s u e here was that few s t u d i e s of this type had been done i n B r i t i s h Columbia, and none of the participants, including the consultants, the Regional Hospital Board or the M i n i s t r y of H e a l t h understood the complexity of such a study. Fuzziness i n the terms of reference caused problems throughout the study. 2. Organizational Issues The i n i t i a l r e l u c t a n c e of s e v e r a l h e a l t h and h o s p i t a l g r o u p s t o p a r t i c i p a t e i n the study was the second study problem. Upon examination of the Board's l e g i s l a t e d planning mandate i t became c l e a r that the Board had l i m i t e d powers to i n i t i a t e a study for a l l health and h o s p i t a l providers i n the region. However, the Ministry of Health had funded 60 per cent of the study, thereby i n d i c a t i n g to l o c a l groups that i t supported the Board's approach. Because each of the groups was dependent on Ministry funding, t h i s gave the Board, and by e x t e n s i o n , the c o n s u l t a n t s , power by proxy, and convinced l o c a l groups to p a r t i c i p a t e i n the study. T h i r d l y , the absence of a l i s t i n d i c a t i n g the l o c a l , p r o v i n c i a l and f e d e r a l c o n t a c t f o r each of the study's components and sub-components c r e a t e d delays i n developing a comprehensive i n f o r m a t i o n base f o r the region. The process of i d e n t i f y i n g a l l l o c a l health and h o s p i t a l groups, and t h e i r p r o v i n c i a l and f e d e r a l c o u n t e r p a r t s p r o v e d d i f f i c u l t and time-consuming due to the o r g a n i z a t i o n a l c o m p l e x i t y of the health care 148. system. Health and h o s p i t a l groups are administered and co-ordinated by separate a d m i n i s t r a t i v e u n i t s , w i t h s e r v i c e s o f t e n p r o v i d e d by another separate non-profit or private group, have d i f f e r i n g f i n a n c i a l bases, and d i f f e r i n g administrative geographic boundaries. The major u n d e r l y i n g c a u s e of the h e a l t h care system's present organizational complexity was t r a c e d back to l e g i s l a t i o n which had been passed over time by the f e d e r a l and p r o v i n c i a l governments i n response to changing p r i o r i t i e s being placed on h e a l t h and h e a l t h s e r v i c e s . Separate Ac t s governing each of the h e a l t h and h o s p i t a l groups provided a p a r t i a l e x p l a n a t i o n f o r the systems's present complex o r g a n i z a t i o n , and the accompanying lack of co-ordination and i n t e g r a t i o n among providers. I n r e v i e w i n g f e d e r a l and B r i t i s h Columbia health-related Acts, i t was also discovered t h a t because h e a l t h and h o s p i t a l groups were a l l under separate l e g i s l a t i o n , t h e i r a b i l i t y to improve co-ordination and i n t e g r a t i o n of the system was l i m i t e d by t h e i r l e g i s l a t e d powers, and this a f f e c t e d t h e i r willingness to co-operate. A c t s a l s o l i m i t e d the Regional H o s p i t a l Board's powers both to involve i t s e l f i n h o s p i t a l a f f a i r s , and to i n i t i a t e a study for a l l health and h o s p i t a l providers i n the region. S i m i l a r l y , i t was found that M i n i s t r y of H e a l t h powers to improve system i n t e g r a t i o n were bounded by terms of l e g i s l a t i o n , and the i r r a t i o n a l i t i e s of the system. A further c o m p l i c a t i n g i s s u e which c r e a t e d problems throughout the study was The M i n i s t r y ' s response to r i s i n g health care costs. P r o v i n c i a l government attempts to control health care expenditures and improve system i n t e g r a t i o n i n c l u d e d the H o s p i t a l Role and Funding S t u d i e s , and the f i n a n c i a l r e - s t r u c t u r i n g of programs and R e g i o n a l i z a t i o n P r o p o s a l . As 149. i n d i c a t e d , n e i t h e r the H o s p i t a l R o l e and F u n d i n g S t u d i e s nor the Regionalization Proposal was accepted for implementation. The passing of the F i n a n c i a l Administration Act, and the f i n a n c i a l r e - s t r u c t u r i n g of programs, wh i l e presumably g i v i n g the government i n c r e a s e d f i n a n c i a l c o n t r o l over programs, served to further discourage system in t e g r a t i o n . However, none of t h e s e measures attempted to address the u n d e r l y i n g i s s u e of s t a n d i n g l e g i s l a t i o n . The complex organization of the system required that numerous groups be contacted i n the process of developing the study. Each group was found t o have i t s own program bias, and the existence of these vested i n t e r e s t groups c r e a t e d a potential s i t u a t i o n f o r the planner/consultant to become co-opted by a p a r t i c u l a r group, thereby influencing the kind of data c o l l e c t e d , and the analysis of that data. A number of u n d e r l y i n g i s s u e s have served to r e i n f o r c e the vested interests of each h e a l t h p r o v i d e r group. F i r s t , d i s s e n s i o n between the f e d e r a l government and the p r o v i n c e s over r e s p o n s i b i l i t y f o r funding of health services i n t e n s i f i e d with r i s i n g health care costs. Their attempts to deal with these costs through l e g i s l a t i o n and f i n a n c i a l r e - s t r u c t u r i n g of programs c r e a t e d uncertainty among these groups. Because these groups have l i t t l e power under e x i s t i n g l e g i s l a t i o n , and because there i s no p r o v i n c i a l long-range plan, they are forced to compete with each other for funding. As a r e s u l t , each group sought to influence the k i n d of data s u p p l i e d i n the hope that the study outcome would be i n i t s favour. These r i v a l r i e s , when added to the standing l e g i s l a t i o n issue of f e r a s u f f i c i e n t e x p l a n a t i o n f o r the lack of co-ordination and i n t e g r a t i o n encountered among providers. 150. The foregoing systems issues created problems both in developing a comprehensive information base for the region, and estimating need for heal th services and resources. In addition, methodological issues added a further set of complications. 3. Development of a Comprehensive Information Base Development of a comprehensive information base was f i r s t complicated by the problem of finding a method of measuring need for health services. No single method was found to exist, and each of the techniques outlined in the l i t e r a t u r e , such as use of h e a l t h s t a t u s i n d i c a t o r s , service area characteristics, program performance, demand, professional assessment, and use of public opinion surveys had l i m i t a t i o n s , and therefore represented only partial measures of need for health services. The underlying issue here is the absence of a comprehensive operational method for measuring need for health services. The second problem concerned the absence of a central data registry. As a r e s u l t , numerous data sources had to be contacted to obtain information due to the oganizational complexity of the system. The third problem concerned data a v a i l a b i l i t y . Delays in obtaining data such as population projections by school dis t r ic t occurred due to government cut-backs in staff as a result of r i s ing health care c o s t s . The reluctance on the part of a few to supply information to the consultants involved the problem of vested interest groups, and their concern over retention of their roles given government restraint programs. D i f f i c u l t i e s in securing accurate and complete information also were encountered such as the problem of 151. i d e n t i f y i n g the number of Full-Time Equivalent medical and non-medical health care personnel in each school district and the region. The underlying issue here is the absence of a sound and integrated provincial data base. Development of a comprehensive information base was also complicated by the problem of differing administrative geographic boundaries for several of the study's health service components and sub-components because of the way i n which health s e r v i c e s have d e v e l o p e d over t i m e . M i n i s t r y of H e a l t h maps outlining each program's primary service area geographic boundaries were of limited use as each map was done to a different scale. Problems of data r e l i a b i l i t y were also encountered. For example, s t a t i s t i c s obtained from the l o c a l LTC administrator on the number of intermediate and extended care beds in the region d i f f e r e d from those supplied by the LTC program and Hospital Programs in V i c t o r i a . The way i n which intermediate and extended care services are organized at the local and p r o v i n c i a l l e v e l s , combined with the lack of a co-ordinated and integrated data base were the underlying issues here. 4. Estimation of Health Service and Resource Requirements Specific problems encountered in estimating need for health services and resources included d i f f i c u l t i e s in identifying appropriate bed-resource estimation models, applying selected models of analysis, and estimating need for s p e c i f i c health resources i n r e l a t i o n to need f o r other h e a l t h resources. No ideal bed-resource estimation model was found to exist, and identification of appropriate models of analysis from the literature proved d i f f i c u l t given each model's documented limitations. The underlying issue 152. here is the lack of comprehensive operational models for estimating need for health services and resources. Once models of analysis for each of the health service components and sub-components had been selected, each model in turn defined the specific data required for estimation of need for that component or sub-component. However, data availability and measurement problems created d i f f i c u l t i e s in applying bed-resource estimation models, and i n several cases, selected models of a n a l y s i s had to be d i s c a r d e d and r e p l a c e d with simple bed-to-population ratio models. The same systems iss u e s which complicated development of a comprehensive base also complicated data availability and measurement. For example, a number of requests to programs for information were refused, possibly due to budget cut-backs, or to an often encountered reluctance to supply data. Further, data pertaining to specific health status and demand indicators had either not been co l l e c t e d , or was incomplete due to an inadequate data base. As a result, determination of need for health services and resources, was, in general, estimated on the basis of available health services use data. Problems in measuring data occurred because of differing administrative geographic boundaries, different reporting mechanisms, and overlapping of services because of the way in which health services have developed over time. The foregoing d i f f i c u l t i e s encountered in estimating need for health services and resources were compounded by problems relating to provincial standards and guidelines which could not be r e a d i l y adapted to l o c a l circumstances. While standards and guidelines were found to provide an 153. element of realism to the whole needs assessment process, many of the guidelines had been developed without taking into account the availability of other health resources. Problems in estimating current and future resource requirements also occurred because of the lack of well developed guidelines. For example, age specific bed-to-population r a t i o guidelines had not been developed for es t i m a t i n g p s y c h i a t r i c and r e h a b i l i t a t i o n bed requirements, or for determining intermediate and extended bed requirements for the 65-74, 75-84, or 85 years and over age groups. No guidelines existed for evaluating acute h o s p i t a l i n f l o w , o u t f l o w or net r e f e r r a l p a t i e n t patterns, or physician-to-population r a t i o s . Deficiencies i n e x i s t i n g p r o v i n c i a l standards and guidelines is the underlying Issue here. 5. Modelling of the Health Care System Estimation of need for s p e c i f i c health resources in relation to the need for other health resources was the f i n a l problem. No model was found to exist with the ab i l i t y to simulate the health care system. One i d e n t i f i e d b a r r i e r to the development of such a model was cost. Development of a simulation model also requires a co-ordinated and integrated data base. Lack of a co-ordinated data base resul t s from the lack of cooperation among providers due to the organizational complexity of the system, combined with current Ministry of Health funding policies. Lack of an integrated data base stems from d i f f i c u l t i e s i n aggregating information due to the diffe r e n t reporting mechanisms used by each of the health services groups. The absence of some form of "epidemiology plus" index for use as a common measure by 154. these groups is the underlying issue here. Major Themes I d e n t i f i e d From the foregoing, two major themes become apparent. The f i r s t c o n s i s t s of SYSTEMS ISSUES i n v o l v i n g : 1. HEALTH - RELATED ACTS 2. ORGANIZATIONAL COMPLEXITY OF THE SYSTEM 3. FUNDING MECHANISMS 4. PROVINCIAL GOVERNMENT COST CONTROL MEASURES 5. LACK OF CO-ORDINATION AND INTEGRATION AMONG PROVIDERS AND SERVICES 6. LIMITED PLANNING POWERS OF THE REGIONAL HOSPITAL BOARD These have resulted in the lack of rational comprehensive approaches both to the supply of services, and the demand for them. The second comprises METHODOLOGICAL ISSUES including: 1. LACK OF A SOUND AND CO-ORDINATED DATA BASE 2. ABSENCE OF A COMPREHENSIVE METHOD FOR MEASURING NEED FOR HEALTH SERVICES 3. DEFICIENCIES IN PROVINCIAL STANDARDS AND GUIDELINES 4. LACK OF APPROPRIATE RESOURCE - ESTIMATION MODELS These represent a number of s t a t i s t i c a l voids which are compounded by SYSTEMS ISSUES. The problems created by these SYSTEMS and METHODOLOGICAL ISSUES made i t impossible for the consultants' to develop a comprehensive and co-ordinated needs assessment for the region. Because health services and resource needs could not be determined on the basis of an all-encompass ing approach, the 155. regional health services plan to be developed from the needs assessment w i l l be l e s s than optimal. I n order that planning f o r h e a l t h s e r v i c e s and resources be done on a comprehensive and co-ordinated basis, underlying SYSTEMS and METHODOLOGICAL ISSUES must f i r s t b e resolved, or t h e i r e f f e c t s modified. Success of the Thompson-Nicola Regional H o s p i t a l D i s t r i c t Study, Given  Limitations The following results suggest the success of the study: 1. A detailed and descriptive data base for the TNRHD, along with models of analysis needed to update study figures was provided. 2. Good feedback from the Regional Hospital Board, l o c a l health and hospital groups, and the Ministry of Health suggests that users of the study were very s a t i s f i e d . 3. A prototype model for developing future health and h o s p i t a l s t u dies was developed. 4. There was some breakdown of barriers to communication between competing groups i n the region as groups began to f e e l part of a team with a common objective. Despite the i n a b i l i t y to achieve an all-encompassing approach t o the estima t i o n of need for health services and resources, we conclude that the study was a success, broke new ground, and w i l l serve as a foundation f o r future planning studies. 156. Recommendations The process of planning for health services was complicated by a series of inter-related problems exacerbated by underlying issues. While there are no easy solutions in the short term to resolving these issues, the author believes that the following recommendations w i l l provide an impetus to their resolution. 1. Systems Issues a. Health-Related Legislation ( i ) Health-related Acts should be consolidated under the direction of the Ministry of Health and Health and Welfare Canada, In cooperation with p r o v i n c i a l and l o c a l health services groups. Resulting legislation should clearly delineate each health-related group's mandate, and i t s role In relation to other health-related groups. Lack of cooperation among groups due to the l a c k of w e l l - d e f i n e d and integrated legislation w i l l continue to occur u n t i l e x i s t i n g l e g i s l a t i o n i s revised and consolidated. b. Organizational Complexity of the System (i) The Ministry of Health, i n cooperation with provincial and local health services groups should implement the B r i t i s h Columbia Regionalization Proposal. Organization of health services on the basis of health regions, with resources allocated according to regional boundaries w i l l allow health services to be planned, and resourced allocated in a comprehensive and co-ordinated manner. ( i i ) A l l maps outlining health s e r v i c e s a d m i n i s t r a t i v e geographic 157. boundaries should be drawn to one scale to assist planning groups in identifying areas of overlapping j u r i s d i c t i o n s u n t i l the B r i t i s h Columbia Regionalization Proposal is f u l l y implemented, ( i i i ) The Ministry of Health should place provincial responsibility for extended care services under the j u r i s d i c t i o n of the LTC program. This would eliminate problems of co-ordination of services and data between Hospital Programs and the LTC program in Victoria, (iv) The Ministry of Health should develop a mechanism for improving c o l l a b o r a t i v e planning among health services programs at the provincial level. (v) The Ministry of Health and Health and Welfare Canada should work together toward developing more eff e c t i v e co-ordination of health services information between both levels of government. c. Funding Mechanisms and Provincial Government Cost Control Measures (i) The Ministry of Health, i n cooperation with the Finance Ministry, should prepare f i n a l i z e d budgets for each of the health services programs on a minimum 2 year, and preferably 5 year basis. These budgets should be distributed, to help reduce r i v a l r i e s between competing groups. ( i i ) The Ministry of Health should keep p r o v i n c i a l and l o c a l h e a l t h services groups informed of i t s goals and objectives as priorities change. d. Lack of Co-ordination and Integration Among Providers and Services (i) The Ministry of Health should encourage the formation of a l o c a l Joint Health Services Planning Committee in each regional hospital 158. d i s t r i c t to be comprised of r e p r e s e n t a t i v e s f r o m the r e g i o n a l h o s p i t a l board, union board of health, and each of the l o c a l provider g r o u p s . The J o i n t P l a n n i n g Committee would prov i d e an on-going mechanism f o r h e a l t h s e r v i c e s p l a n n i n g , and c o - o r d i n a t i o n of information at the l o c a l l e v e l , and would act i n an advisory capacity to the M i n i s t r y regarding l o c a l planning concerns u n t i l the B r i t i s h Columbia Regionalization Proposal i s f u l l y implemented, ( i i ) In conjunction with the B r i t i s h Columbia Regionalization P r o p o s a l , a J o i n t P l a n n i n g Committee, c o n s i s t i n g of r e p r e s e n t a t i v e s from the J o i n t P l a n n i n g Committees i n each h o s p i t a l d i s t r i c t s h o u l d be e s t a b l i s h e d i n each health region to a s s i s t the regional manager i n the o v e r a l l planning, and o p e r a t i n g and managing of l o c a l h e a l t h services. e. Limited Planning Powers of the Regional Hospital Board ( i ) The M i n i s t r y of Health, i n c o o p e r a t i o n with acute care h o s p i t a l s , should ensure that regional h o s p i t a l boards, through l e g i s l a t i o n , are given f u l l authority to plan f o r and co-ordinate h o s p i t a l a c t i v i t i e s i n t h e i r r e g i o n s , t h i s to i n c l u d e a u t h o r i t y f o r co-ordinating and evaluating requests f o r c a p i t a l and operational funding of h o s p i t a l s , ( i i ) The regional h o s p i t a l boards should accept o v e r a l l r e s p o n s i b i l i t y f o r the p l a n n i n g and c o - o r d i n a t i n g of h o s p i t a l a c t i v i t i e s i n t h e i r regions. ( i i i ) The M i n i s t r y of Health should implement the B r i t i s h Columbia Hospital Role and Funding Studies. This would a s s i s t the M i n i s t r y and regional h o s p i t a l b o a r d s , and subsequently the r e g i o n a l manager i n the 159. planning and co-ordinating of hospital activities in each region. 2. Methodological Issues a. Lack of a Sound and Co-ordinated Data Base (i ) The Ministry of Health, i n cooperation with l o c a l and pro v i n c i a l health services groups should establish a central data registry to improve co-ordination of and access to health services information. The data base should be maintained, and continually up dated by the Ministry, with data made available to planning groups when requested, ( i i ) The data base should contain information related to health status, health services and health resources for each of the health services components and sub-components, ( i i i ) The Ministry of Health should maintain the data base in such a manner that information pertaining to one region can be compared with that of other regions. b. Absence of a Method for Measuring Need for Health Services (i) H e a l t h and W e l f a r e Canada and the M i n i s t r y of Health, i n collaboration with health services planning groups should work towards developing a comprehensive 'epidemiology plus ' Index for use as a basic and uniform index of need for health services. c. Deficiencies in Provincial Standards and Guidelines (i) The Ministry of Health, in cooperation with health services groups should develop well-defined provincial standards and guidelines for each of the health services components and sub-components. Standards and guidelines for one health services component should be developed 160. in relation to those for other health services components, and should be readily adaptable to local circumstances, ( i i ) If possible, numerical guidelines contained in the B r i t i s h Columbia Hospital Role Study should be used to develop additional quantitative guidelines for use i n assessing acute care hospital inflow, outflow and net referral patterns, ( i i i ) Role studies, similar to the Hospital Role Study should be developed and implemented for non-hospital health care programs, and guidelines quantified. d. Lack of Appropriate Resource-Estimation Models (i) H e a l t h and W e l f a r e Canada and the M i n i s t r y of Health, i n collaboration with health services planning groups should develop appropriate resource-estimation models which have t e c h n i c a l l y feasible application, ( i i ) A l l groups should work together towards developing a comprehensive model of analysis capable of measuring inter-relationships between health services programs, identifying duplications or voids i n the system, and determining the most e f f e c t i v e / e f f i c i e n t manner of delivering health services. Conclusions In this thesis, planning problems encountered in developing a regional health and hospital study i n B r i t i s h Columbia have been researched and analysed. Problems were found to occur due to two major types of underlying issues. The f i r s t consisted of SYSTEMS ISSUES, such as health-related Acts, 161. organizational complexity of the system, funding mechanisms, p r o v i n c i a l government c o s t c o n t r o l measures, l a c k of c o - o r d i n a t i o n and i n t e g r a t i o n among providers and services, and l i m i t e d p l a n n i n g powers of the r e g i o n a l h o s p i t a l board; the second, METHODOLOGICAL ISSUES involving, lack of a sound and c o - o r d i n a t e d data base, absence of a comprehensive method of measuring need f o r h e a l t h s e r v i c e s , d e f i c i e n c i e s i n p r o v i n c i a l s t a n d a r d s and g u i d e l i n e s , and l a c k of a p p r o p r i a t e r e s o u r c e - e s t i m a t i o n m o d e l s . METHODOLOGICAL ISSUES were i n turn found to be compounded by SYSTEMS ISSUES. R e a l i z i n g that there are no easy s o l u t i o n s to t h i s complex s et of i n t e r - r e l a t e d problems and i s s u e s , the author has l i s t e d a s e r i e s of recommendations which she believes w i l l provide f i r s t steps on the road to t h e i r r e s o l u t i o n , thereby paving the way f o r r a t i o n a l p l a n n i n g i n the future. 162, BIBLIOGRAPHY Alcohol and Drug Commission Act. R.S.B.C. 1979, C. 13. Alford, Robert R. "The P o l i t i c a l Economy of Health Care: Dynamics without Change." Politics and Society, Winter 1973, 127-164. Bailey, Joe. " C o n f l i c t Theory." Social Theory f o r Planning. London: Routledge and Paul Kegan, 1975, 73-87. Bainbridge, Jack. "British Columbia's Long Term Care Program: The F i r s t Two Years." Health Management Forum, Summer, 1980, 28-36. Bennett, James E., and Jacques Krasny. "Health Care i n Canada." The  Financial Post, March 26 - May 7, 1977, 1-20. Bice, T., and C. Kerwin. "Governance of Regional Health Systems." The  Regionalization of Personal Health Services. Ed. E. Saward. New York: Prodist, 1976. Blum, Henrick L. Planning for Health. New York: Human Sciences Press, 1981. British Columbia Alcohol and Drug Programs. Fast Facts III. Vancouver: n.p., 1980, 1-2. B r i t i s h Columbia Health Association. Brief by the British Columbia Health  Association to the Canadian Medical Association on Allocation of Health Care  Resources. Unpublished paper. Vancouver, 1984. British Columbia Health Association. Summary of Hospital Role Study. Draft Document. Vancouver: British Columbia Health Association, 1979. B r i t i s h Columbia Hospital Programs. Diagnostic and Treatment Centres. Unpublished paper.-Ministry of Health, Victoria, 1981, 1-2. Bugbee, George. "Changing the Role of Trustees." Hospitals J.A.H.A., 44 (February 1970): 54. Campbell, Alan, et a l . Changing Strategies i n B r i t i s h Columbia Health  Management. Vancouver: University of British Columbia Press, 1981. The Canadian Bar Association. Submission on Established Programs Financing. Ottawa: n.p., 1981. Canadian Health C o a l i t i o n . Submission. The Federal-Provincial F i s c a l  Arangements. 23-29. Ottawa: Queen's Printer for Canada, 1981, 29:116. The Canadian Institute for Advanced Research. Final Report of the Task Force  to Review Primary Health Care. Toronto: The Canadian Institute for Advanced 163. Research, 1982. Charron, K. "The Canadian Experience." Regionalization and Health Policy. Ed. E. Ginsberg. Washington, D.C: HEW, 1977. Chen, M. "Measuring Need for Health Services, a Proposed Model." Medical  Care XVII, No. 2 (1979): 210-214. Collier, Robert W. Regional Planning. Vancouver, B.C.: Centre for Continuing Education, University of B.C., 1970. Community Care F a c i l i t y Act. R.S.B.C. 1979, C. 57. Crichton, A. Health Policy Making. Ann Arbor, Mich.: Health Administration Press. 1981. Crichton, Anne, Jean Lawrence, and Susan Lee. The Canadian Health Care  System. Vol. 1. Ottawa: Canadian Hospital Association, 1984. Cruickshank, John. The Globe and Mail, National ed., August 10, 1984, 3. De Miguel, Jesus M. "A Framework for the Study of National Health Systems." Inquiry. Supplement to XII, No. 2. New Haven: Yale University, June 1974, 10-24. Department of Health Care and Epidemiology. Health Services Systems and  Demography, Jersey, British Columbia. Vancouver: Department of Health Care and Epidemiology, 1969. Department of N a t i o n a l Health and Welfare. Emergency Department  Classification Scheme. Ottawa: n.p., 1975. Detwiller, L. F. The Consequences of Health Care Through Government. Sydney, Australia: Office of Health Care Finance, 1972. Division of Health Services Research and Development. Roll C a l l . Vancouver: Health Manpower Working Group, Ministry of Health, 1982. Dixon, Maureen. The Organization of D i s t r i c t Health Councils in Ontario. Report on a Research Project Funded by the Ontario Ministry of Health, Demonstration Model Grant 332. London: n.p., 1981. Donabedian, A v e d i s . .. Aspects of Medical Care Administration: Specifying  Requirements for Health Care. Cambridge, Mass.: Harvard University Press, 1970. Donnison, D. "Ideologies and Policies." Journal of Social Policy, 1972, 1:2, 97-117. Dror, Y. "The Planning Process: A Facet Design." A Reader i n Planning 164. Theory. Ed. A. Faludl. Oxford: Pergamon Press, 1973, 323-345. Etzioni, A. "Mixed-Scanning: A Third Approach to Decision Making." A Reader  in Planning Theory. Ed. A. Faludi. Oxford: Pergamon Press, 1973. East Kootenay Health Services Review Team. East Kootenay Health Services  Review Report. Report to the Ministry of Health. V i c t o r i a : Ministry of Health, 1981. Evans, R. Submission. The Federal-Provincial Fiscal Arrangements. 23-2 9. Ottawa: Queen's Printer for Canada, 1981, 20:23. Faludi, Andreas, ed. A Reader in Planning Theory. Oxford: Pergamon Press, 1973. Financial Administration Act. S.B.C. 1981, C. 15. Foulkes, R.G. Health Security for British Columbians. Report to the Ministry of Health, Province of British Columbia. Victoria: Queen's Printer, March, 1974. Friedman, J. "A Conceptual Model for Analysis of Planning Behavior." A Reader in Planning Theory Ed. A. F a l u d i . Oxford: Pergamon Press, 1973, 345-371. Great Britain. D.H.S.S. The National Planning System. London: HMSO, 1976. Glennerster, Howard. Social Service Budgets and Social Policy. London: George Allen and Unwin, 1975, 11-15, 248-259. Hall, Emmett M. Canada's National-Provincial Health Programs for the 1980's. Ottawa: National Health and Welfare, 1980. Hall, P., et a l . Change, Choice, and C o n f l i c t i n Social P o l i c y . London: Heineman, 1975. Hall, Thomas L. "The P o l i t i c a l Aspects of Health Planning." Health Planning:  Qualitative Aspects and Quantitative Techniques. Ed. William A. Reinke. Baltimore, Maryland: John Hopkins University, 1972, 73-91. Hannant, Larry. The Globe and Mail, National ed., Wednesday, September 19, 1984, 4. Harman, C.G., and Ken R. Harman. " D i s t r i c t Health Councils: Should Their Mandate Be Broadened?" Health Management Forum. Vol. 3, No. 1, Spring, 1982. Health Act. R.S.B.C. 1979, C. 161. Health Emergency Act. R.S.B.C. 1979, C. 162. 165. Health and Welfare Canada. A New perspective on the Health of Canadians  (Lalonde Report). Ottawa: Information Canada, 1974. Hospital Act. R.S.B.C. 1979, C. 176. Hospital District Act. R.S.B.C. 1979, C. 178. Hospital District Financing Act. R.S.B.C. 1979, C. 179. Hospital Insurance Act. R.S.B.C. 1979, C. 180. Hsu, David. "Health Manpower Planning." U.B.C. Alumni Association Division  Newsletter. Vancouver: U.B.C. Alumni Association, November, 1982, 5-7. Kallstrom, Liza, and Greg Stump. Extended Care Study: Bed Requirements 1981  - 1986. Vancouver, n. p., 1981. Kaminsky, Barbara. Resource A l l o c a t i o n i n a Regional Structure for the  British Columbia Ministry of Health. M. Sc. Thesis, unpublished, University of British Columbia, 1982. Kohn, Robert, and Kerr L. White. Health Care, An International Study. London: Oxford University Press, 1976, 3. Kohn, Robert. "Emerging Patterns in Health Care." Royal Commission on Health  Services. Ottawa: Queen's Printer for Canada, 1964, 7. Long Range Health Planning Branch. Regionalization of Health Services i n  Canada - A Survey of Developments. Ottawa: Department of National Health and Welfare, 1974. MacStravik, Robert E. Determining Health Needs. Ann Arbor: Health Administration Press, 1978. Malcolm, L., L. Wright, and K. Smith. Evaluation of Service Development i n  North Canterbury. Unpublished paper, Health Planning Research Unit, Christ Church, New Zealand, 1981. Marchak, Maureen P a t r i c i a . Ideological Perspectives on Canada. Toronto: McGraw-Hill Ryerson, 1975, 102-119. Medical Practitioners Act. R.S.B.C. 1979, C. 254. Medical Services Act. R.S.B.C. 1979, C. 255 Medical Services Plan Act, 1981. R.S.B.C. 1979, C. 18. Mental Health Act. R.S.B.C. 1979, C. 256. Ministry of Health. Annual Report 1982. Victoria: Queen's Printer, 1982. 166. M i n i s t r y of Health. Annual Report 1981. V i c t o r i a : Queen's Printer, 1981. M i n i s t r y of Health. Annual Report 1980. V i c t o r i a : Queen's Printer, 1980. M i n i s t r y of Health. B r i t i s h Columbia Hospital Role Study Phase 1. V i c t o r i a : M i n i s t r y of Health, August, 1979. M i n i s t r y of Health. B r i t i s h Columbia Hospital Role Study Phase 1 Addendum. V i c t o r i a : Ministry of Health, 1981. M i n i s t r y of H e a l t h . M i n i s t r y of H e a l t h B r i e f to the Canadian M e d i c a l  Association Task Force on A l l o c a t i o n of Health Care Resources. Unpublished paper. Vancouver, 1984. National Health and Welfare. Task Force on the Costs of Health Care. Ottawa: Queen's Print e r , 1969. Navarro, V i c e n t e . "Methodology on Regional P l a n n i n g of Personal Health Services: A Case Study: Sweden." Me d i c a l Care. V o l . V I I I , No. 5. 1970, 386-394. N a v a r r o , V i n c e n t e . " P l a n n i n g f o r the D i s t r i b u t i o n of P e r s o n a l H e a l t h Services." P u b l i c a t i o n Reports. 84. (July 1969): 573-581. 0 'Brien, Eoin. Predictions on Acute,Care Bed Requirements for Scattered  A r e a P o p u l a t i o n s . M. Sc. T h e s i s , unpublished, U n i v e r s i t y of B r i t i s h Columbia, 1980. Ontario Council of Health. Pata Requirements f o r D i s t r i c t H e a l t h C o u n c i l  Planning. Toronto: Ontario Council of Health, May, 1978. O n t a r i o C o u n c i l of H e a l t h . The P l a n n i n g F u n c t i o n of the D i s t r i c t Health  Council. Toronto: Ontario Council of Health, 1977. Palmer, V. Vancouver Sun. August 15, 1984, 5. Province of B r i t i s h Columbia. Estimates, F i s c a l Year Ending March 31, 1984. V i c t o r i a : Queen's Printer, 1984. P r o v i n c e of B r i t i s h Columbia. Supplement to the E s t i m a t e s , F i s c a l Year  Ending March 31, 1984. V i c t o r i a : Queen's Print e r , 1984. Ryan, P a t r i c i a . Strategies f o r Regional Health Planning i n B r i t i s h Columbia. M. Sc. Thesis, unpublished, University of B r i t i s h Columbia, 1982. Saward, E., ed. The Regionalization of Personal Health S e r v i c e s . New York: Prodist, 1976. Soderstrom, Lee. The Canadian Health System. London: Croom Helm Ltd., 1978. 167. S t a t i s t i c s Canada. Canada Year Book 1980 - 81. Ottawa: Queen's Printer, 1981, 169-172. Strauss, Anselm. Negotiations: Varieties, Contexts, Processes and Soc i a l  Order. San Fancisco: Jossey-Bass, 1978. Taylor, C.E. "Stages of the Planning Process." Health Planning: Qualitative  Aspects and Quantitative Techniques. Ed. W.A. Reinke. Baltimore, Maryland: John Hopkins University, 1972, 20-35. Taylor, Malcolm G. Health Insurance and Canadian Public Policy. Montreal: McGill-Queen's University Press, 1978. Thompson Berwick Pratt and Partners. The Thomspon-Nicola Regional Hospital  District Health and Hospital Study. Vancouver, 1983. U.B.C. Health Policy Study Group. "Current Issues in Health Policy Making for the Government of British Columbia." Health Management Forum. Vol. 3, No. 3. (Autumn 1982): 25-57. Van der Zwann, A. H. " R e g i o n a l i z a t i o n : A L o n g i t u d i n a l Case of Interorganizing." Social Science and Medicare. 15 a. (1980): 41-48. Walker, Mike. "Capital Control Over Health F a c i l i t y Development: Regional Organization In B.C." The Canadian Health Care System. Vol. 3. Ed. A. Crichton. Ottawa: Canadian Hospital Association, 1984. White, K. L. "Resource A l l o c a t i o n : Balancing Needs, Resources and Use." Measurement of Levels of Care. Ed. W.W. Hol l a n d . Copenhagen: WHO Publication, 1976, 441-445. Ytterberg, L. A., A. Crichton, and A. J. Stark. "A Look at Nurse Manpower Planning i n B r i t i s h Columbia." Health Management Forum. Vol. 4, No. 1. (Spring 1983): 53-64. Zimmer, J . , and R. Berg. "Data Needs f o r R e g i o n a l i z a t i o n . " The  Regionalization of Personal Health Services. Ed. E. Saward. New York: Prodist, 1976. PERSONAL COMMUNICATIONS Bainbridge Jack. Policy Development Branch, Ministry of Finance. Personal Interview. October 1983. Crane L. Director, Public Health Nursing, Ministry of Health. Personal Interview. Novermber 1982. Eredies, J. Long Term Care Program Administrator, South Central Health U n i t . 168. Personal Interview. November 1 9 8 2 . Herbert, John. Director of Administration and Support Services, Hospital Programs, Ministry of Health. Telephone Interview. November 1984. Horsburgh, Dagmar. Manager of Administration, Ontario Council of Health. Letter to author. 7 December 1983. Munroe, Ron. Executive Director of Financial Services Division, Ministry of Health. Telephone Interview. November 1984. Pallan, Paul. Policy, Planning and Legislation, Ministry of Health. Personal Interview. October 1983. Ralff, Roy. Medical Services Plan, Ministry of Health. Telephone Interview. November 1984. Selwood, W. Research Division, Hospital Programs, Ministry of Health. Personal and Telephone Interviews. 1982 and 1983. Stal, Joost. Planning and Evaluation of Programs, Medical Services, Health and Welfare Canada. Telephone Interview. February 1983. Wightman, F. Director of Health and Community Services, Red Cross Canadian. Telephone Interview. November 1984. 169. APPENDIX I BRITISH COLUMBIA HEALTH ASSOCIATION  SUMMARY OF HOSPITAL ROLE STUDY, 1979  (DRAFT DOCUMENT) APPROACH USED TO DEFINE HOSPITAL ROLES  THE CONCEPT OF HOSPITAL ROLES: The Hospital Role Study document presents a system for classifying acute care functions of hospitals in the province. (The c l a s s i f i c a t i o n scheme i s not c o n c e r n e d w i t h long-term or extended care f a c i l i t i e s . ) The classification system has two main parts: Hospital Care Functions and Levels  of Service, as illustrated in Table 1. The seven Hospital Care Functions define the general areas of care which most acute and rehabilitative hospitals provide. Specific patient conditions and requirements f a l l into one or more of these seven areas of hospital activity. The six Levels of Service categories define levels of organization and sophistication of resources required to back up the delivery of particular Hospital Care Functions. APPLYING THE FRAMEWORK TO A PARTICULAR HOSPITAL: A Profile of any hospital consists of a combination of the various Care Functions and Levels of Service i t ij3_ providing. For example, after an inventory of existing services in a particular hospital, i t might be found 170, to be providing Community Service Level C in Obstetrics, Pediatrics, Surgery and Medicine; Community Service Level B Rehabilitation Function; and no Dentistry or Psychiatric Functions. By contrast, the Role of a hospital consists of a combination of the various care functions and levels of service the hospital should be providing. For example, the same Hospital, due to workloads, need and service population, should be providing Community Service Level C in Obstetrics, Pediatrics and Rehab i l i t a t i o n ; Referral Service Level D in Medicine and Surgery; and at least a Community Service Level B Psychiatric and Dental Function. TABLE I SUMMARY TABLE TO DESCRIBE HOSPITAL PROFILE OR ROLE: L e v e l s o f S e r v i c e C a r e F u n c t i o n s O b s t e t r i c s P e d i a t r i c s D e n t i s t r v M e d i c i n e Rehab i i i t a t i o n S u r q g r v P s v c M 3f r v Community Services Level A i_evel B • / V rs - rt-Level C J if Seferral Services Level D , -,y v.0 Level E V. Provincial Service Leve1 F TERMS USED IN HOSPITAL ROLE STUDY HOSPITAL CARE FUNCTIONS: The seven categories of Hospital Care functions are: 1. Obstetric and Neonatal function - promotion and maintenance of optimum mental and physical well-being of the woman and child during pregnancy until the end of the perinatal period; diagnosis and treatment of any abnormalities during pregnancy. 2. Paediatric function - encompasses diagnosis and treatment of physical diseases and other i l l health conditions or their symptoms related to patients up to age 15; includes numerous techniques and/or applications unique to this population, although some techniques are used in adult medicine and surgery. 3. Surgical function - diagnosis and treatment of physical diseases and conditions or symptoms by means of operative techniques, in conjunction with administration of anaesthesia when appropriate. 4. General Medical function - diagnosis and treatment of physical diseases and other i l l health conditions or symptoms; promotion and maintenance of optimum mental and physical well-being of the individual. 5. Psychiatric function - diagnosis and treatment of emotional and mental diseases and c o n d i t i o n s or symptoms through administration of medication and specialized therapy. 6. Rehabilitation function - diagnostic and treatment process by qualified personnel to treat problems of the neuro-musculo-skeletal systems (and a s s o c i a t e d mental, emotional and s o c i a l problems) which, unless 172. adequately treated, w i l l permanently and seriously impair functional a b i l i t y . This process is obligatory to enable patients to achieve most effective use of remaining physical and mental assets. 7. Dental function - diagnosis and treatment of diseases and other conditions of the teeth and oral cavity; includes dental restoration, peridontics, oral surgery and orthodontics. IDENTIFIER GUIDELINES: In order to describe the sophistication level of each Care Function, a l i s t of the resources required to support the function was developed. These are called "Identifier Guidelines", and they are used to outline the manpower, equipment, f a c i l i t y , demographic and organizational factors necessary to provide the scope of Care Functions at each Level of Service. Some of the Identifier Guidelines used are: 1. Service Population - the population of the catchment area f o r a hospital service. 2. S e r v i c e Access - the travel time from a place of residence to a hospital service. 3. Service Workload - the volume of work which the service population generates. 4. Health Manpower - number, types, and organization of physician manpower. Number, type, and organization of other practitioners when required for initiating a direct care function. This identifier has not been developed extensively. 5. Ward Type - the organization of bed types for a service. 173. 6. Diagnostic Support - services, manpower, space and equipment which are used to treat physical diseases and mental c o n d i t i o n s f o r t h e i r symptoms. 7. Treatment Support - services, manpower, space and equipment which are used to treat physical diseases and mental c o n d i t i o n s or t h e i r symptoms. 8. Ambulatory S e r v i c e s - a h o s p i t a l based service provided on an outpatient basis. 9. Special Services - teaching and/or research. LEVELS OF SERVICE: Ba s i c a l l y , this other dimension of the matrix describes the levels of organization and so p h i s t i c a t i o n of the resources required to back up the delivery of particular direct care functions. These are grouped by Community Service (three l e v e l s , each of which is distinguished by the scope and sophistication of each direct care function); Referral Service (two levels); and Provincial Service (one level). Community Service Level - A: In small (up to 6,000), isolated communities which may experience a wide variety of problems, but comparatively small workloads. Few medical practitioners (probably one or two) and nursing personnel, but r e q u i r i n g a breadth of knowledge and experience of professionals. Community Service Level - B: In medium-sized communities (up to 18,000) in less populated, semi-rural areas that are frequently 60 minutes or more from a larger f a c i l i t y . Handle a wide variety of problems, but workloads s t i l l 174. s m a l l . More medical s t a f f than "A" (3 to 12), mayber 1 or 2 resident specialists. Community Service Level - C: In larger communities (18,000 to 150,000) -some r e l a t i v e l y isolated, others close to other towns and c i t i e s . Rather complex mixture of workload and s p e c i a l i z a t i o n , larger mix of medical manpower (12 or more physicians, 2 or more specialists). Referral Service Levels - D & E: Referral Service Level D is d i s t i n g u i s h e d from Level E by the size of the service population and the number, type and sophistication of the direct care functions available within each level. The role of the Referral Service in each Direct Care Function w i l l generally be similar, but the depth of backup and the degree of di f f i c u l t y in f u l f i l l i n g this role w i l l vary. Referral Service Level D is recognition that in some parts of the province, because of geographic considerations, r e f e r r a l services i n medicine, surgery, obstetrics and neonatology, and paediatrics must by available, even though the population i s less than usually necessary to support a f u l l referral function. Generally this w i l l be in hospitals serving a population of more than 75, 000 and there w i l l be two or more of each of the general medical specialties represented. Referral Service Level E w i l l be serving a population of over 150,000 and there w i l l be in-depth medical representation in a l l general specialties and relevant sub-specialties. Provincial Service Level - F: The Provincial Service Level contains one of a kind service providing particular specialized care for the population of the entire province. An example would be a spinal cord injury unit. 175. These very specialized services handle relatively small numbers of patients with either high r i s k conditions, a rare problem requiring s p e c i a l i z e d expertise, or where specialty and subspecialty diagnostic and treatment support (ie. two of the "identifier guidelines") is required. According to this d e f i n i t i o n , programs which are Provincial Services and are duplicated elsewhere, when need and workload warrants, should be redesignated to a Referral Service Level. As expertise and indictions increase across the province, some types of treatment or diagnostic techniques i n i t i a l l y designated Provincial Services may rapidly become Referral Services. Others, because of continuing low workload and volume, w i l l remain P r o v i n c i a l Services. This is a summary ONLY. Full reading of the report is recommended. 176. APPENDIX II DEPARTMENT OF NATIONAL HEALTH AND WELFARE (HEALTH AND WELFARE CANADA)  EMERGENCY DEPARTMENT CLASSIFICATION SCHEME, 1975 The determination of cer t a i n minimum c r i t e r i a for medical- personnel, technical support, and organization configuration has f a c i l i t a t e d the categorization of emergency departments by the l e v e l of care they are capable of rendering. The l i s t i n this appendix represents the minimum requirements for emergency units to q u a l i f y for a parti c u l a r category, although specific provincial recommendations w i l l vary. CATEGORY I  Personnel 1. Trained, full-time emergency physician in hospital 24-hours a day. 2. Specialists or senior residents in hospital 24-hours a day: - General Surgery - Anaesthesia - Orthopedic Surgery - Neurosurgery - Internal Medicine - Radiology. On-Call (24-hours a day): - Paediatrics - Plastic Surgery - Obstetrics and Gynecology 177. - Ear, Nose, and Throat - Urology - Psychiatry - Cardiovascular Surgery. 3. Nurses (on duty in unit): - In the Emergency Unit - In the Operating Room - In the Intensive Care Unit - In the Psychiatric Unit - A Poison Control Nurse. 4. Technologists (in hospital 24-hours a day): - Radiology - Laboratory - Blood Bank. Trained personnel to take electrocardiograms i n hospital 24-hours a day. Trained personnel to draw blood and start I.V.'s in hospital 24-hours a day. Organization Minimum c r i t e r i a include: - Emergency unit medical director - Emergency unit committee - Written job descriptions for a l l personnel 178. - Continuing medical education program for physicians, nurses, and paramedical personnel - Practiced disaster plan - Resuscitation team in hospital 24-hours a day - Written audit of records - Written emergency unit policy and procedural manual. CATEGORY II  Personnel 1. Physician on premises 24-hours a day. 2. Specialist on c a l l 24-hours a day: - Surgery - Anaesthesia - Orthopedics - Internal Medicine - Pediatrics - Obstetrics and Gynecology - Opthalmology - Psychiatry - Radiology. 3. Nurses: - On duty in the Emergency Unit - On c a l l in the Operating Room - On c a l l in Intensive Care 179. - On c a l l in the Psychiatric Unit. 4. Technologists on c a l l : - Radiology - Laboratory - Blood Bank. Trained personnel to take electrocardiograms on c a l l . Trained personnel to take blood and start I.V.'s on c a l l . Organization Minimum c r i t e r i a include: - Physician director (not necessarily full-time) - Emergency unit committee - Written job description for a l l personnel - Continuing medical education program for physicians, nurses, and paramedical personnel - Practiced disaster plan - Written audit of records - Resuscitation response system 24-hours a day - Written emergency unit policy and procedural manual. CATEGORY III  Personnel 1. Physician on c a l l 24-hours a day. 180. 2. Physicians with additional training available on c a l l 24-hours a day in: - Surgery - Anaesthesia - Internal Medicine. 3. Nurses on premises 16 hours a day in the emergency unit. Nurses on c a l l 24-hours a day in the emergency unit, i n the operating room and for intensive care. 4. Technologists on premises eight hours a day, on c a l l 24-hours a day. Organization Minimum c r i t e r i a include: - Emergency unit committee function capability - Written job description for a l l personnel - Written emergency unit policy and procedural manual - Resuscitation response system 24-hours a day - Practiced disaster plan. CATEGORY IV  Personnel 1. Physician by phone or radio contact. 2. Specialist by phone or radio contact. 3. Nurses in hospital 24-hours a day. 4. Technologists - none. 181. Organization: - Written emergency unit policy and procedural manual - Resuscitation response system 24-hours a day. Note: The nurses or physicians responsible f o r 24-hour a day coverage must be t r a i n e d and a u t h o r i z e d to undertake the f o l l o w i n g advanced C.P.R. procedures: - I d e n t i f y e s s e n t i a l arrythmias and d e f i b r i l l a t e or otherwise t r e a t when necessary. - E s t a b l i s h an airway by means of: . Intubation . Percutaneous endotracheal needles . ( i f Physicians: cricothyroidotomy or tracheostomy) - Starting I.V. 's 

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