Doctors in Canada: the changing world of medical practice // Review
Blishen, Bernard R
Canada’s system of universal public health insurance has been one of the nation’s most successful and over – whelmingly popular public programs. The program works very well, especially when compared to most other systems throughout the world. It has been successful in equalizing access to health care services and has managed to contain expenditures on health care for an extended period of time. The public health insurance program has also played an important role in nation – building with its emphasis on equality among the citizens of Canada.
At present, the health care policy agenda in Canada is being driven by a set of interrelated issues, none of which is particularly new or unique to Canada. These issues are in the areas of cost control, demographic change in the population, the proliferation of technology, manpower planning, and improving the efficiency of health care delivery. The four books considered here provide a variety of analyses of these issues and the health care market from a number of different perspectives, namely political, historiographical, sociological and economic.
In Federalism and Health Policy: The Development of Health Systems in Canada and Australia, Gwendolyn Gray provides us with a well – researched, well – presented and detailed comparison of the development of health care policy in two federal systems. In the process, Gray examines the validity of two competing theories of federalism, the “orthodox” and the “revisionist” theories. The first theory, attributed to James Madison, suggests that the division of power in a federal state restricts the extent to which government can intervene effectively in economic and social policy; in this sense federalism would act as a barrier to change. The second theory, associated primarily with Pierre Trudeau and Alan Cairns, suggests that the division of power in a federal system contributes to the expansion of government and may, under certain conditions, lead to innovation in policy development.
As her method of analysis, Gray employs a “most – similar system” comparison between Canada and Australia. The main variable under examination is the impact of institutions as major determinants of government activities and policy development. Gray recognizes, however, that while institutions are central to theories of federalism, other factors interact with institutional structures to influence government policy. It is in this context that the development of healthpolicies in Canada and Australia are examined and compared.
Gray provides an historical overview of the development of National Health Insurance in Canada and argues that policy developments in Canada have been quickly advanced by the successful introduction of comprehensive measures at the provincial level that were later adopted nationally. The National Health Insurance program developed from a combination of federal financial support and respect for provincial responsibilities. Gray also argues that centralization of power was not a necessary condition for such social policy reform. She provides examples of this in her examination of the cost – containment policies of Canadian governments after the introduction of National Health Insurance.
During the passage of the Canada Health Act (1984), the federal government was seen to be preserving a popular national program without having to take responsibility for its implementation. It was the provinces’ responsibility to reach agreements with provincial medical associations and to implement the programs.
The federal division of responsibility provided flexibility at both levels of government, a division of responsibility which facilitated the subsequent banning of extra – billing. There was sufficient time for the provinces to decide what action to take to ban extra – billing; they could have accepted lower transfer payments and chosen not to confront the medical profession (129). If there was intense intergovernmental conflict at the time, there was also a degree of flexibility which would not have occurred in a unitary system. A situation had been created in which provincial governments were able to use a variety of strategies and control the timing of their responses in the face of medical opposition. Thus federalism appears to have been one of the major factors that undermined the possibility of a united campaign against the abolition of extra – billing (130).
For Canada, Gray suggests that there is little evidence to support the “orthodox” theory that federal institutions give rise to weak conservative governments. Canada had been successful in developing and preserving a system of universal health insurance despite the decentralized nature of its federal institutions.
Gray states that the major obstacles to policy development in Canada were neither federalism nor institutional arrangements, but rather thefamiliar problems of political opposition, budgetary concerns, and lack of support for new policies. As a result, much of Canadian health policy supports the “revisionist” theory of federalism.
The Australian experience, however, does not entirely support the revisionist theory. There was considerable support of it during the 1940s but subsequently the centralization of constitutional and financial powers and the activist role taken by the federal government severely limited the capacity of the states to undertake independent policies in the area of health. Consequently, revisionist theory is unable to explain the dynamics of Australian federalism.
Gray examines how the early development of health policy in Australia emphasized public provision of services, in particular, public and publicly subsidized hospitals, similar to that of the British system. The experience of Australia during the early 1940s showed that cooperative federalism could be a reality and that centralization of power was not essential to policy implementation, all evidence supporting the revisionist theory of federalism.
During the 1950s and 1960s, the implementation of voluntary health insurance significantly changed the nature of Australian health policy. The trend toward public provision of services was reversed and private medical practice became prevalent. The centralization of power allowed the federal government to determine the nature of the health care system while taking very limited responsibility for health insurance arrangements. The federal government was able to control indirectly the provision of medical services within hospitals and the rate at which states were able to expand other health services.
Health policies during the 1970s and 1980s in Australia alternated between voluntary and compulsory health insurance. The main policy initiatives were all undertaken at the federal level of government; the states played a very small role in the whole process. The centralization of power in Australia, at least in relation to health, gave the federal government a level of policy freedom similar to that found in unitary systems, another reason why the revisionist theory has very little applicability in post – war Australia. As in Canada, however, evidence from Australia shows that the division of power can be used to impede as well as to promote the development of social policies, depending upon the political persuasion of the parties in power.
The conclusion of Gray’s study is that it is difficult to isolate the independent effects of federal institutions from a vast array of other factors. The Canadian experience is that social programs can be implemented in a highly decentralized political system and that national standards can be developed and preserved. In Australia, by contrast, a public health insurance system has not been established as a permanent component despite the high level of centralization. Overall the evidence tends to suggest that revisionist theory may be a more useful guide to the operation of the federal state. Divided federal power gives rise to the coexistence of a number of activist governments, and it may operate as an expansionary rather than a contradictory force. Nevertheless one must be careful not to give too much explanatory power to the institutional variable.
Gray emphasizes that other factors such as political parties, party competition, elections, ideologies, ideas, interest groups, public opinion, and economic factors all affect policy development. Institutions are just one among many factors that may have an effect on policy outcomes. The way in which federal institutions operate depends on the particular set of arrangements in operation at a given time and on the existing interaction of historical, social, and political factors. As a result, she claims that there is no one theory of federalism that is universally applicable or acceptable. She emphasizes that Trudeau, Cairns, and Banting were not writing about the dynamics of federalism, but rather about the dynamics of Canadian federalism (214).
The book is appealing in many respects. It provides a well – documented historical account of the development of health policy in both Canada and Australia and is a rich source of information in this regard. The book also details information about the similarities and differences in policy development and health services between the two countries. The book will be of use to both those interested in the area of health policy and those interested in comparative politics and federalism.
Canadian Health Care and the State: A Century of Evolution, edited by C. David Naylor, is a collection of essays that grew out of a seminar series on “Medicine and the Welfare State” organized by Professor Pauline M.H. Majumdaor of the Institute for the History and Philosophy of Science and Technology at the University of Toronto. The essays examine the nature of state involvement in the health care field as the Canadian welfare state emerged, and as such provide an informal social history of Canada’s health care system.
The first four essays are medical historiographies depicting the early involvement of the state in the field of medicine. The first paper (by Colin D. Howell) entitled “Medical Science and Social Criticism,” is concerned with state intervention in the market place, and examines the career of medical doctor Alexander Peter Reid, a leading figure in the profession of medicine during the late nineteenth century in the Maritimes.
Howell protrays Reid as a tireless advocate of closer links between the medical profession and the state, who continually encouraged and demanded greater involvement at all levels of government. Reid was of the belief that urban and industrial growth had caused major social upheaval and argued for a greater role for the medical profession in social and economic reform. Their involvement contributed to the medicalization of concerns that previously had been the jurisdiction of the family, church and other government institutions such as criminal justice, and represented an early step in the direction of both modern medicine and the capitalist welfare state (18). Reid had an optimistic view of the state, and a strong belief in social responsibility of the profession, that would eventually achieve widespread acceptance.
Reid was convinced that applying scientific and therapeutic principles to these social problems would cure the irrationality of modern urban and industrial society. He argued for an alliance between the state and the scientific professions to regulate excessive competition in the marketplace and to provide the “respectable” poor with appropriate protection from exploitation and disease. Reform involved the reconstruction of the existing capitalist system in accordance with principles of scientific management, state regulation, efficient production and cooperative enterprise, constituting a partial critique of the excessively competitive marketplace (28).
Desmond Morton’s contribution, “Military Medicine and State Medicine: Historical Notes on the Canadian Army Medical Corps in the First World War 1914 – 19,” and Terry Copp’s on “The Development of Neuropsychiatry in the Canadian Army (Overseas) 1939 – 43,” describe the experiences of doctors in the Canadian Army during the First and Second World Wars. Both address the experiences of medical practitioners under state control.
During the First World War about half of Canada’s active medical practitioners were in a new environment dealing with problems very different from those they had confronted in civilian medicine. Their patients were young men afflicted with sexually transmitted diseases and physical and mental battle scars. Morton describes the problems faced by medical practitioners during this time of state control. Placed in medical services with a clear hierarchy, they now experienced salaried remuneration and a related socioeconomic change. Their outlook contributed to an expanded role for the state during peacetime. Dealing with such social – medical problems as tuberculosis and venereal disease enhanced the medical profession’s understanding of preventive medicine and hygiene. Returning medical practitioners adapted their military experience to new fields such as industrial medicine, occupational disease and industrial hazards.
It was thought that the experience with state – controlled medicine during the war would inevitably lead to the extension of social and health insurance for the entire population. The acceptance of state health insurance, however, would take a very long time. Returning soldiers were a conservative influence given their experience with both military life and its particularly aggressive form of socialized medicine. Physicians soon forgot their brief encounter with state – run medicine, at least until the Depression, when their incomes again ran short of private increases (58).
Copp describes the development of neuropsychiatry in the Canadian Army overseas during the Second World War. The army’s neuropsychiatric practice, with its emphasis on joining psychiatry with neurology and general medicine in a single central institution, was unique. This wartime experience proved to be one of the most successful interactions between the medical profession and the state, and was an important development in the profession of psychiatry in Canada. Like Morton, Copp does not explore, however, the practice of military medicine during peacetime, nor the extent to which physicians in the military practiced medicine differently from their civilian colleagues.
In “A Necessary Nuisance: Social Class and Parental Visiting Rights at Toronto’s Hospital for Sick Children, 1930 – 1970,” Judith Young explores the role of the state in a different light, investigating the effects of socialized medicine and of changing medical attitudes on class distinctions. Young focuses on the early history of Toronto’s Hospital for Sick Children. Visiting policies reveal that poor and working – class parents had limited access to their children in public wards compared to those parents whose children were in private or semi – private wards. With the introduction of private insurance plans and the eventual implementation of state – sponsored health insurance, however, the distinction between public and private patients gradually became less obvious. With the spread of insurance, all families eventually had equal visiting rights, accommodations and contact with physicians. Young’s study sheds light on the formulation of hospital policy and the impact of pre – payment plans on patients and families, as well as on the broader issue of class prejudices in health care.
The last four articles in this series bring an historical perspective to bear on a range of topics. The essay “Socialism and Social Insurance in the United States and Canada” by Stephen J. Kunitz provides an American’s perspective on the similarities and differences in the two countries’ approaches to socialism and social insurance. Kunitz emphasizes Canada’s radically different approach in state sponsored pre – payment health insurance, and offers a number of familiar hypotheses to explain the contrasts in ideology and social structures between the two nations. America has been able to implement a program of health insurance for the poor and aged, but has made very little progress in public reorganization of the health services market place. Although this limited form of public health insurance has provided a basis for government involvement in health care, whether the United States will ever achieve a national health insurance program remains debatable given American distrust of socialism.
The essay “The Canadian Health Care System: A Development Overview” by Eugene Vayda and Raisa Deber examines the developments that have led to the present health care system. In the provision of universal health insurance the government has used blunt instruments for cost containment policies, rather than attempting to modify the organization of the system. In reviewing the development of the present system, Vayda and Deber express a number of concerns about its future. They cite the focus on technology, the aging population, the restructuring of the federal system and the federal government’s desire to reduce its contribution to health care as important issues, all of which may make it more difficult for the provinces to afford their share of the national health insurance program.
In the penultimate essay “Making Canada Safe for Sex: Government and the Problem of Sexually Transmitted Disease in the Twentieth Century,” Jay Cassel provides an historical review of government measures to control sexually transmitted disease. From 1917 to 1983, the largest part of public expenditure on sexually transmitted diseases was on medical measures; there has been limited expenditure on public education programs, individual patient counselling, and funding for research.
Cassel cites the government’s continued belief that medical science will find ways to eliminate such diseases as a major reason why government measures of control have not been very successful: they have failed to deal effectively with the social dimension of sexually transmitted diseases. Cassel claims that the most successful measures will be those aimed at directly eliminating the disease while remaining sensitive to human realities. This means acknowledgement of sexual diversity, epidemiologically based information, candid communication and education, and adequate medical facilities.
Finally, “Equity in Health Care” by Robin F. Badgley and Samuel Wolfe raises questions about the goals and achievements of Canada’s national health insurance system. Links between low income, limited education and ill health have been historically demonstrated. Canada’s national health insurance program was predicated on the belief that the elimination of economic barriers would provide equality of access to health care and thus lead to equality of health status. In establishing the principle of equality of access, the intent was that class divisions in obtaining care would disappear, with need becoming the main criterion for seeking medical treatment. Once the economic barrier was removed, it was expected that the health of all Canadians, particularly those of low income, would improve.
The authors review a series of studies from the last 20 years that attempted to validate these assumptions. Badgley and Wolfe consider historical, epidemiological and political analyses in exploring how and where Canada’s national health insurance program may precisely have failed that portion of the population it was designed to assist. Their review indicates that many social inequalities in health still exist, and that reducing these inequalities must be a priority for social policy. Badgley and Wolfe outline a number of factors that may exacerbate inequality, such as the changing age profile, changing government structure and changes to financing between federal and provincial governments.
As Naylor points out in his introduction to Canadian Health Care and the State, the social history of medicine cannot offer ready – made solutions to present – day problems. Instead, it illuminates trends and occasionally highlights pitfalls that should be avoided (12). This collection of essays does just that.
Bernard Blishen’s study Doctors in Canada: The Changing World of Medical Practice examines the health care delivery system and the self – regulation of the medical profession, identifying social and political pressures on the medical profession. Blishen begins by defining the profession and the professional – client relationship from a sociological point of view, and discusses two different approaches used by sociologists. The “trait” approach is descriptive, and specifies a set of criteria by which the degree of professionalism can be determined; this approach accepts the claims of the profession itself as to the nature of its work, and overlooks societal pressures that affect it. The “control” approach examines ways in which professionals control their clients and how that control is developed. This approach is further defined by who determines the needs of the consumer and the way in which those needs are to be met.
Collegiate control exists when it is the producer who defines the needs of the consumer; it is the predominant form of occupational control in the medical profession. This producer – consumer relationship is normally on a one – to – one basis, initiated by the consumer and ended by the producer; mediative control, on the other hand, is one in which a third party mediates the relationship between producer and consumer. This thirdparty intervention, from the government for example, may have minimal impact on the profession or it may result in the government employing all practitioners and paying them a salary.
Blishen claims that the crucial element to professional autonomy is the degree to which the profession has control over the producer – consumer relationship. The effectiveness of this control depends on the ability of the medical profession to withstand the pressures for control over the provision of medical care by third parties such as government, hospitals and consumers.
Blishen reviews the historical background on the autonomy of the medical profession, and examines the development of national and provincial regulatory bodies (colleges of physicians and surgeons), which are the principal sources of collegial control in medicine. These bodies foster common interests among practitioners by imposing a monopoly on the field of expertise and by regulating entry into the profession through licensing, although the physician has sole authority in defining the consumer’s needs and the manner in which those needs are met. The power given to the medical profession in the area of the socioeconomic conditions of practice has become accepted as a fundamental feature of professional autonomy.
In examining the changing nature of the profession, Blishen presents data on demographic changes within its membership, the homogeneity of its members, and the distribution and supply of physicians. Homogeneity of social background serves to strengthen the collective response of physicians, while diversity in background tends to weaken professional cohesion and solidarity. Current data on ethnic background, gender, and country of birth suggest this homogeneity may be declining, while the profession also has an increasing proportion of women. The implication is that unless physicians find a new basis to remain a cohesive group, they will have less influence in future policy affecting the delivery of health care.
Blishen emphasizes the development of third – party intervention, the growth in technology and the recognition of consumer interests as major threats to the established autonomy of the medical profession. The development of national health insurance, and government attempts to control costs by intervening in fee – setting and the organization and delivery of medical care, were seen by the profession as threats to its traditional form of collegial control of medical practice. Governments will continue their attempts to control total health expenditures while physicians will continue to protect their autonomy in determining the nature of clinical services they provide and their fees for those services. The ultimate challenge will come when governments realize that their attempts to protect the global public interest in ensuring that resources are used in a technically efficient manner can have only limited success while the present self – administered regulatory codes of the medical profession continue unchanged (144).
Blishen presents data on the growth of medical knowledge and technology that has generated a proliferation of paramedical personnel. Licensing and certification of other health occupations provides a clear indication that they have a distinct role to play in the delivery of health care, posing a serious threat to the physicians’ position. In addition, the rising influence of consumers in the delivery of care has the potential to exert pressure for changes in the organization and practice of medicine. Consumers will challenge traditional collegial control, and subsequently the authority of the physician in defining the doctor – patient relationship.
Blishen provides one perspective on the changing face of the medical profession. He offers a number of reasons for these changes, from both an historical perspective in recounting the development of professional autonomy and statistical data illustrating the changing nature of the profession. His analysis is weakened, however, by the fact that most of the data presented ends in 1983. There are now additional observations that should be considered to see if the changes in distribution of physicians by gender, specialty, etc. still follow the trends that he has outlined in his earlier data.
Although Blishen also raises concerns about the increase in the number of physicians relative to population growth and utilization, he does not provide many suggestions for developing coherent and consistent manpower policies. This is one area in which the performance of the Canadian system is weak and an area in which the data that he has presented could be useful.
The book Restructuring Canada’s Health Services System: How Do We Get There From Here? consists of 36 papers covering a variety of topics on the general theme of health economics. The Canadian health care system hasprovided universal access to medical and hospital services without financial barriers to patients. It is an excellent system which other nations have come to study and emulate. From Canada, we have learned that systems that blend mostly public finance with private medical practice can and do work. Controlling health expenditure through strengthening the hands of public funders as opposed to imposing higher costs on consumers is an approach that is broadly acceptable to the Canadian public. The Canadian health care system has, however, become a victim of its own success. Its performance has illustrated the limits of medical care: there has been too much emphasis on curative care, and existing money could probably be spent more effectively. There is constant rhetoric about the need for restructuring.
This collection of papers, presented at the Fourth Canadian Conference on Health Economics, offers a variety of opinions on how restructuring might be achieved. The proceedings cover a wide range of topics from the utilization of health services to the payment of doctors and hospitals, to managed care, quality of care, health promotion and the economic evaluation of various medical programs. Each article is accompanied by a discussion which reflects a number of current debates within the health care system.
Two articles examine the relationship between utilization and the supply of physicians; they both examine the effects of policies on trends in utilization and levels of service provision by physicians. They stress the need for new strategies to control the supply of physicians.
Another reviews the work of a number of major health commissions and task forces across Canada since 1984. The common themes in commission findings are concerns about increasing health care costs, dissatisfaction with the existing organizational structure in the delivery of health care, and issues of the quality and accessibility of care. In general, their conclusions suggest a redirection of the system in three ways: toward a greater emphasis on disease prevention and health promotion, toward more community – based alternatives, and toward greater accountability.
A number of other articles deal with the economic evaluation of health services. Alternative approaches such as home care programs, cholesterol screening, community care programs for mental illness, and geriatric day hospitals are all evaluated as alternatives to traditional styles of practice. Also investigated is the possibility of combining the financing and delivery of comprehensive health care services for a defined group of the population. In such a system a comprehensive range of services is provided and the delivery of these services organized, monitored and controlled to meet established health care delivery goals. The argument is that such alternatives to fee – for – service provisions can, when appropriately utilized, deliver health services more efficiently and promote a more preventive approach to health that will result in long – term cost savings. Finally, a number of articles review the hospital sector. These articles investigate such issues as governance, prospective payment systems, innovative fundraising for capital projects, the role of technology in the purchase of hospital capital equipment, and hospital competition.
There appears to be a high degree of consensus about goals when it comes to changed patterns of service delivery and funding. These goals include less emphasis on hospital care, more emphasis on outcomes and quality, the need to contain or reduce costs, and greater stress on health promotion and quality of life. Unfortunately Restructuring Canada’s Health Services System gives no clear guidance on how the system will be, or should be, restructured. On the whole the collection does, however, identify some of the major political, social, and economic barriers to restructuring the health services delivery system. The book’s diversity of contributions makes it a useful source of information on the Canadian health care system, both past and present, as well as a guide to the future directions the system might follow.
Copyright Trent University Fall 1994
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