donald t. fraser memorial lecture: the health services troika—where is it going?

DONALD T. FRASER MEMORIAL LECTURE: The Health Services Troika—Where is it Going?Author(s): MILTON BROWNSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 58, No.9 (SEPTEMBER 1967), pp. 385-390Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41984089 .

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Canadian Journal of

PUBLIC HEALTH

VOLUME 58 SEPTEMBER 1967 NUMBER 9

DONALD T. FRASER MEMORIAL LECTURE

The Health Services Troika -

Where is it Going?1

MILTON BROWN,2 O.B.E., M.D., B.Sc.(Med.), D.P.H., F.C.C.P.

To accomplish great things we must not only act but dream, not only plan but also believe. Let us believe and let us act.

Anatole France

Nothing will ever be attempted if all possible objections must first be overcome. Samuel Johnson

T WAS greatly honoured when Ernest Watkinson, President of the University

of Toronto School of Hygiene Alumni, in- vited me to give this lecture and at the same time it made me feel just a little more humble, first because I had the great privi- lege of knowing Donald Fraser as a friend and of being a member of his department for some years, and second because of joining that group of distinguished lec- turers who have preceded me.

Dr. Donald Cameron, in the inaugural Donald Fraser lecture, outlined superbly Dr. Fraser's many attributes and attain- ments, but to those of you who did not know Donald Fraser a brief word-picture will be of interest. He was a gifted scholar who from his early youth was trilingual,

lPresented at the 58th annual meeting of the Cana- dian Public Health Association held in Ottawa, April 25-27, 1967. 2Professor and Head of the Department of Public Health and Preventive Medicine, Associate Director of the School of Hygiene, Assistant Director of the Connaught Medical Research Laboratories, University of Toronto, Toronto 5, Ontario.

being fluent in English, French, and Ger- man, a master of English prose, a scientist who made numerous contributions, particularly in the control of communicable disease by active immunization, a stimulat- ing teacher, a devotee of physical fitness, and above all a great friend and humani- tarian who always lent a hand to anyone who came his way. Little wonder he is revered and honoured in the form of an annual lecture conceived and brought into being by a host of friends across the country headed by that inimitable pair, Doctors Baillie and Mather, two of his greatest admirers.

In considering a topic for this address there were three areas I thought appropriate. First, I might have discussed the recent and pending developments in immunization which have progressed so rapidly since his time and second, the changing curricula for the undergraduate medical student and for the graduate spe- cializing in modern public health, another

385



386 CANADIAN JOURNAL OF PUBLIC HEALTH Vol 58

rapidly changing area. I decided to examine with you the troika of our health services as of today, knowing full well that recently enacted legislation when promulgated will add another element to the already many- faceted health service. In using the word troika, described in the Oxford dictionary as a vehicle drawn by a team of three horses abreast, I had in mind the three major areas involved in providing health services, namely the hospital, organized medicine or physicians' services, and public health or the health department. No offence is intended to those of you in the voluntary health agencies as I am using the word public health as all-inclusive, embrac- ing both the official and voluntary agencies.

The influences or factors which have created our present dilemma are well known, ( 1 ) and include the rapid development of prepaid medical care schemes, universal compulsory hospital services, the explosive advances in medical treatment and preventive services, changing modes of medical practice, and, not the least, a rapidly growing population, a buoyant economy and an affluent society with all its stresses and strains.

There seems to be a consensus that the health services troika should be co-ordinated; the difficulty is in deciding how and by whom it should be co-ordinated. The scientific and technological revolution of our times has sharply focussed attention upon the gaps in services provided. The critical issues are philosophical issues; that is, can methods of meeting the new chal- lenges be carried out democratically, by whom and from what value system?

It seems paradoxical that man can be projected into outer space and returned safely, satellites can be orbited, rockets can be landed on the moon and yet we have difficulty in coming forward with a plan for the co-ordination of a total health service. Man masters mechanical devices but fails when it comes to interpersonal relationships, which is the keystone of our dilemma.

By Whom Will Co-ordination Be Effected?

As indicated, there are at least three organizations or bodies that might be charged with this responsibility - (a) the hospital, (b) organized medicine, (c)

public health. It should be noted that co-ordination is the term employed, not necessarily direction, as these organizations are well-established entities and vigor- ous guardians of their respective roles or what they consider their roles.

I suggest we look at the changing roles of these organizations in the hope of deciding upon a logical and reasonable ap- proach to co-ordination.

The Hospital Heretofore, and quite understandably,

the hospital has been an inward-looking organization with little concern for the problems of the surrounding community. This is a generalization, for one is mindful of the situation in Newfoundland where the hospital in the outlying areas is the center of a unified health service. But the role of the hospital has changed markedly in the last decade. It is now offering the community new services and is rapidly becoming a community health center. People are more hospital-minded than ever before and are turning to the hospital for a wide variety of services not previously included in its role. The following are some examples:

Home Care - There is a wide variety of home care plans, some community based, but a great many are hospital based, and at present serve chiefly to reduce the length of hospital stay and thus release beds for more acute cases. In one province the Hospital Services Commission has a pilot project operating a home care plan in several urban areas.

Emergency Department - Minor Sick- ness - The traditional role of the so-called emergency department has changed signifi- cantly. Patients go directly to this department rather than the local physician for all manner of non-emergency conditions. This apparently is not just a local situation but has become a pattern throughout a good part of North America, particularly in the urban centers. The precise reason for this new pattern of care is not clear. It is possibly due to the increased demand for local physicians' services which results in large practices and patients' difficulty in getting appointments. By going directly to the hospital they are assured of immediate treatment at any time on any day of the



September 1967 DONALD FRASER LECTURE 387

week. To meet this situation, various plans have developed; in some instances full-time staff have been employed on salary by the hospital and in other places local practi- tioners rotate in the emergency department on a fee for service basis.

Family Care or General Practice Clinics - In a few urban centers, especially in the teaching hospitals, family care or general practice clinics staffed by general practi- tioners are being set up. These are separate from outpatient departments and offer comprehensive care to all members of the family. In some instances these clinics have admitting privileges and provide domicili- ary care in case of emergency.

Family Planning Clinics - In urban centers hospitals have established these clinics and in some instances co-operate with the local health department.

Poison Control Center - This service is now established in strategically located hospitals in most centers throughout the country. While set up with encouragement and support from the Food and Drug Directorate of the Department of National Health and Welfare, poison control centers offer a service to the entire community. Where local health departments have co- operated in the follow-up of cases admitted to these centers, a useful health education program has been developed.

Mental Health - In some provinces a pattern has developed whereby the one- time community mental health clinics operated in health departments are being or have been moved into the hospital, another evidence of the trend toward using the hospital as the community center.

Rehabilitation - While originally the physical medicine departments of hospitals serviced hospital patients only, more and more these departments are offering outpatient services and services to the community at large. In one Canadian city an active hospital is devoted entirely to rehabilitation, and caters to the whole community.

Private Physicians' Offices in Hospital - As a matter of economy of time and effort for physicians, hospitals have made available suites for the use of private prac- titioners. In other instances groups of

physicians have under a co-operative plan erected office buildings in close proximity to a hospital. These are but some of the trends which have developed in making the hospital more and more of a community health center. While they are not to be found in all areas of the country, nevertheless they could be taken as an index of the present developments.

A suggested example of the role of the hospital in future was put forth by the president (4) of the Hospital Review and Planning Council of Southern New York, as follows:

"The Hospital Council believes that the future planning for the health-facility needs of New York City should center on the development of 'medical service centers' which would concentrate many of the community's health functions in one complex. Each service center should have as its nucleus a modern general hospital with a minimum of 400 beds, and with a well-equipped and staffed department of rehabilitation medicine; should provide suitable programs and facilities for providing necessary ambulatory services to its community; should provide for posthos- pital care, including extended-care services; should provide the base for operation of organized home-cāre programs; should undertake appropriate commitments in research and medical education; and should include facilities for housing activities of governmental and voluntary health agencies and suitable offices for private physicians and group-practice units."

Health Department Housed in the Hos- pital - In a few of the large urban centers in the United States, sections of the health department are located in the hospital and in isolated instances the hospital adminis- trator has become the local medical officer of health. This could be a portent of the future. In one province some years ago, in planning for the overall health services, provision was made for the health department to be housed in the hospital. There are arguments for and against housing the health department in the hospital, but the future may see at least a closer working arrangement.

From these examples it is readily ap- parent that the hospital already has become a community health center serving



388 CANADIAN JOURNAL OF PUBLIC HEALTH Vol.58

a variety of areas which hitherto were outside its activities.

Organized Medicine - Physicians' Services - Medical Association

Organized medicine has urged that the voluntary lay and physician-sponsored medical care schemes, together with the commercial companies, be charged with the responsibility of supplying physician care. In one province this is the situation at the moment. Under the newer government schemes of supplying medical care, complete maternal and child health care, including immunization and prenatal and postnatal care, is covered. In some schemes periodic health examinations are included. If the practising physician accepts the new challenge and offers this complete service, then public health will be relieved of one of the major portions of its present program, which will call for a reappraisal of its role in the community. Organized medicine has become more and more community minded and has formed committees for the study of maternal and child welfare, the prevention of accidents, perinatal deaths, public health problems and medical aspects of traffic accidents. Educational material on these subjects has been pre- pared for the public by provincial medical societies and distributed through the physician's office. In some provinces outstanding leadership has been provided by organized medicine, particularly in the field of the prevention of accidents, perinatal and maternal mortality.

There is an increased awareness on the part of the medical profession of the problems of the community and there are numerous examples of a readiness to give leadership in solving the complex problem of a complete health service. Public Health - Health Department

The role of the health department has changed and some departments have accepted the new challenge. The following are some examples.

Home Care - Of the various approaches to this service, whether through the hospital, the voluntary organization or the health department, it seems natural that the health department would be the co- ordinator because of its knowledge of the community and its administrative ability.

But there is no unanimity of opinion on this point as in some areas the health department has pioneered in providing this service, whereas in others it has not been considered within its orbit. Surely this is an area where the public could be con- vinced of the role of the health department, and a contribution made to the economic aspect of health care by demonstrating the saving and improved service that home care offers.

Mental Health - Regardless of where mental health clinics are located, in the hospital or the community, the health department could be the co-ordinating agency. Otherwise a somewhat parallel organization will be set up leading to further fragmentation, duplication, and demands on already extremely limited skilled personnel.

"Preventicare" Mass Screening - Pre- symptomatic Detection of Illness - Mass screening, while advocated as a means of dealing with the chronic diseases, has not been widely accepted. There are notable exceptions in which health departments have carried out successful projects and the practice should become more widely accepted. The recently introduced term "preventicare" gives a different perspec- tive to "mass screening". The U.S. Public Health Service (5) has established a trailer caravan service equipped to carry out a battery of tests. Until the etiological agents or disturbed biochemical reactions are elu- cidated the most rewarding means of con- trolling the chronic diseases rests on early detection. It is too time-consuming to have practising physicians take on this work, but it is an area the health department quite properly should develop.

Shortage of Health Personnel - The acute shortage of all categories of health personnel calls for the most efficient use of such personnel. This necessitates a change in the concept of the roles of the various members of the health team. The nursing profession has shown leadership in this area by introducing less highly trained personnel for the routine tasks. An editorial in a recent issue of the Journal of the College of General Practice (6) suggests that the public health nurses could be spe- cial assistants to physicians in the care of



September 1967 DONALD FRASER LECTURE 389

patients in the office and home. This new role has been instituted by the Montefiore Hospital group (4) in New York City, where the physician's attitude changed from "hesitant compliance to active participation". This offers a challenging concept to the health department.

If that portion of Winslow's definition of public health "through organized community effort" is to be meaningful, surely it is natural to look to the health department to co-ordinate community health services. In order to play this role a change in attitude or outlook is necessary. The oft-heard remarks when it is suggested the newer problems should be taken on are "that is not public health" or "how will the staff take on anything new when they are already fully occupied?" Surely the quoted statement of the professional colleague of the 1965 president of the A.P.H.A., (2) "that public health is an anachronistic dinosaur being increasingly limited in its power and activities because it has lost its ability to change" will not be allowed to go unchallenged.

There is an understandable reluctance to take on the newer problems such as the chronic diseases, accidents, care of the aged, home care, etc. because of the lack of specific direction or organization. But surely this is not sufficient excuse. The health department is the organization sup- posedly in a position of administrative ability. Co-ordination by planning and organization is the difficulty in coming to grips with these problems. Thus, the first requisite is a plan. This should not be left to the local health department but must be organized on a provincial basis. This demands leadership from the central au- thority. In fairness to public health, the role it is to play should be spelled out and if that role is to co-ordinate our modern health services then the staff and financial support should be forthcoming.

What is needed is a plan and while planning is given an unpopular connota- tion in some quarters, without it little progress will be made.

Comprehensive Health Planning Federal Participation - In order to

grapple with this complex problem central planning is necessary. One could liken the problem to that which existed in this

country prior to 1948. At that time the Government of Canada introduced an overall scheme for health insurance which has been introduced by stages. The success of that scheme to date undoubtedly has been due to the leadership given at the federal level. It would seem that the time has arrived when federal leadership should be provided once again to bring about co-ordination of the many-faceted health service. The type of leadership could consist of fiscal arrangements with the provinces as in 1948.

Health Services Planning Body - The constitutional polemic is at such a fever- pitch that the actual planning would of necessity be carried out at the provincial level. This should not exclude any province which wished to seek assistance in the planning process from requesting the research facilities of the federal department. If a province decides to do the planning this would necessitate the setting up of a board or council with representatives from the consumer public, health professions and government. The board should be provided with a full-time research or resource staff and secretarial assistance. It would be the task of this board to search out a workable solution which would consist in the first instance of dealing with the philosophical issues of the value system to be used, the goals to be attained and the means of achieving them. This does not mean that any particular group would be expected to make undue sacrifices, but the spiralling costs of health services have made the tax-conscious public demand more efficient planning. No business or industrial organization would succeed in the present age without good planning.

Local or Regional Advisory Body - In the more populated and larger provinces it would be advisable to have regional bodies set up on a basis similar to the central body, smaller of course, not to duplicate the work but as a two-way system to pass recommendations to the central body and to adapt general policy to the local situation.

Jurisdictional Areas - As a result of advances in the means of transportation and communication, it is necessary to rearrange the jurisdictional areas. Health services



390 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 58

traditionally are organized within political boundaries established years ago when the tempo of life was much slower, and are not in keeping with the modern flow of people and services. There are metropoli- tan areas whose health services still function on the old divisions. In some areas, because of differences in the system of grants, a large city health department and an adja- cent county health department are admin- istered quite separately in separate offices in the same city where they could be more efficiently and economically operated as a single unit. Smaller health units should be combined into larger areas, which would result in a more efficient administrative arrangement.

Co-ordination to prevent overlapping and fragmentation and to promote a more efficient use of skilled personnel is urgent. Whatever agency takes on this role will be breaking new ground and it will require intensive study and research as to the best method of attacking the problem. It may be necessary to have pilot projects before a plan is given general application.

The decisions taken and the plans brought into use may cause untoward reactions, even controversy. This would not

be something new in the health field as one is reminded of the struggles associated with the introduction of pasteurization of milk, chlorination of water supplies, tuber- culosis control, fluoridation of water, and many other measures which engendered great controversy yet brought unbounded benefit to the community. In this respect, George James (3) says "public health which so long prided itself on objec- tivity must learn to live increasingly with controversy, bitter controversy, subjective human-value controversy but relevant controversy and hence intensely useful controversy."

A great challenge to co-ordinate our health services awaits the members of the health troika. Public health with its administrative background in co-ordinating community health activities would seem to be in a position to give leadership in this task. It is generally agreed that unless public health gives determined leadership in bringing about co-ordination it will be relegated to a minor role in community affairs.

If you have a fraction of the faith that I have in public health to fulfil this task then you will rise to the occasion.

REFERENCES 1. Roemer, Milton L.: "Changing Patterns

of Health Service. Their Dependence on a Changing World." Annals of the Ameri- can Academy of Political and Social Science, 1963, March, p. 44.

2. Metzler, D. F.: Amer. J. Public Health, 1966, 56: 161.

3. James, George: Public Health Rep., 1965, 80: 579.

4. National Forum on Hospital and Health

Affairs: Hosp. Top., 1966, 44: 41. 5. Linder, Forrest E.: Sci. Amer., 1966,

214: 21. 6. Editorial: J. Coll. Gen. Pract. Canada,

1966, 12: 31. 7. Report of the National Commission on

Community Health Services. "Health is a Community Affair." National Health Forum, May 9-11, 1966.



donald t. fraser memorial lecture: the health services troika—where is it going?

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