First and Foremost in Community Health Centres: The Centre in Sault Ste Marie and the CHC Alternatives 9781487575939

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FIRST AND FOREMOST IN COMMUNITY HEALTH CENTRES : The Centre at Sault Ste Marie and the cue Alternative

The United Steelworkers of America opened Canada's first community health centre in Sault Ste Marie in 1958. The history of that centre provides a unique view of developments in health care delivery in Ontario over the past twenty-five years. As the costs of health care climb, the contribution of present approaches to the overall level of health is called increasingly into question, and discussions of alternative health care systems are now common. Some policy-makers believe that community health centres represent the direction of the future. Lomas considers that conviction in light of the complex issues raised in the Sault Ste Marie experience. He traces the success of the organizers in mobilizing the community and reveals the obstacles they faced, from harassment by local doctors to the reluctance of government to respect the centre's unique position under national health insurance. The same forces that shaped the Sault Ste Marie centre - government attitudes, medical resistance, and community response - will affect the development of alternative health services generally. Lomas questions whether there is a single best alternative. He concludes with an account of related developments in Ontario, which suggests that community health centres are assuming an increasingly important role. is an assistant professor in the Department of Clinical Epidemiology and Biostatistics at McMaster University.

JONATHAN WMAS

JON ATHAN LOMAS

First and Foremost in Community Health Centres:

The Centre in Sault Ste Marie and the CHC Alternative

UNIVERSITY OF TORONTO PRESS

Toronto Buffalo London

©

University of Toronto Press 1985 Toronto Buffalo London Printed in Canada Reprinted in 2018 ISBN 0-8020-5635-0 (cloth) ISBN 978-0-8020-6532-2 (paper)

Canadian Cataloguing in Publication Data Lomas, Jonathan, 1952First and foremost in community health centres Includes bibliographical references and index. ISBN 0-8020-5635-0 (bound) - 978-0-8020-6532-2 (paper) 1. Sault Ste Marie and District Group Health Association - History. 2. Community health services - Ontario - Sault Ste Maire - History. 3. Community health services - Citizen participation. I. Title.

RA450.S28L6 1985

362.1

C84-098940-7

To the memory of John George Barker 1910-82 'Give me John Barker and I can build a health centre in the Sahara Desert.' GLENN wnsoN,

5 January 1981

Contents

Preface

ix

PART ONE

THE CENTRE IN SAULT STE MARIE

1 Sault Ste Marie 3

2 3 4 5 6 7 8

Mobilization 16 The Union as Organizer 36 The Homestretch 49 In Operation 62 The Coming of Medicare 78 A Second Beginning 94 The Government Presence 106

PART TWO

9 IO II 12 13

THE CHC ALTERNATIVE

Medical Attitudes 127 The Role of the Community 137 The Role of Government 150 Evaluation 161 Is There a Best Alternative? 170 Epilogue 177 Notes 183 Interviews 199 Index 201

125

Preface

The introduction of a universal health insurance plan to Canada in the late 1960s enshrined in legislation a particular method of delivering, organizing, and funding primary health services-delivered by physicians located in hospitals, in their individual offices, or sometimes in group practice. Health services are generally organized according to the dictates of the physician rather than according to the desires of the community in which he or she practises; these services are funded by a payment to physicians of a fee for each service they perform. It is a system riddled with disincentives to efficient operation and devoid of any mechanism for making the system and those who operate it accountable to the community's needs. Furthermore, this legislated uniformity has tended to inhibit, or at least make less worthwhile, the exploration of alternative approaches. At a time when the costs of health care and its contribution to our over-all level of 'wellness' are increasingly being called into question, discussion of alternative methods is more important than ever. The probability is that the way we are doing things now can be improved. However, there has been little incentive for, and hence few examples of, alternative approaches in Canada. One notable exception has been the Sault Ste Marie and District Group Health Association. The story of its development, from an idea amongst the northern community's steelworkers to a practical alternative system serving over half the city, is full of lessons and insights and even drama. The account of the Sault Ste Marie achievement, from the late 1950s to 1980, offers a unique opportunity to view developments in health care delivery from a position of practical experience. As policy-makers come to view alternatives such as this as a possible future direction for a health service, then a comprehensive exploration of the issues and events in the association's growth may help in better formulating the exact nature of that future.

x First and Foremost But the association's history provides far more than lessons for the future. It is the story of a social movement which engulfed a community, an example of how the vision of a few can mobilize many towards a single goal. It is a description of the problems and conflicts which can arise from challenging the status quo-a challenge arising from a trade union's and a community's commitment to social change. The Group Health Centre in Sault Ste Marie was born from a trade union's desire for a better community not just for its members, but for all the inhabitants. It is an example of the realization of the potential for social change that lies in all associations. As the organization matured, so too did the people involved, as they learnt the skills of translating ideals into reality, and principles into practice. The Group Health Centre's story provides lessons not only about an alternative health system but also about human co-existence. The pattern of this book reflects these two different aspects. I have divided the text into two parts. The first part tells the history from the emergence of the idea in the late 1950s up to the much-changed circumstances of 1980. The second part places the general issues encountered by the health centre in the broader context of community health centres and the alternative delivery of health care in Canada as a whole. It draws heavily from the first part in providing examples of these more general points. My own involvement with the project started in late 1980 when the board of the association asked me to record the health centre's history. I had already heard many times about the Sault's health centre and welcomed the opportunity to study it further. The association provided me with unfettered access to letters, minutes, contracts, clippings, and so on, and members gave generously of their time during my frequent visits to Sault Ste Marie. I also travelled to other parts of Canada and a number of places in the United States in my search for further documents and interviews with the early participants. I obtained material from the archives of the United Steelworkers of America in Hamilton and Ottawa, Local 2251 uswA in Sault Ste Marie, the Prudential Insurance Company, the Algoma Steel Corporation, the Ontario Medical Association, the Ontario Ministry of Health, the Sault Star, and from the personal papers of I.S. Falk in Connecticut, Ted Goldberg in Detroit and Glenn Wilson in North Carolina. Almost without exception, I received enthusiastic co-operation and assistance. In an attempt to fill the gaps and remove ambiguities inevitably left by reading mere written accounts of events, I interviewed over fifty people in preparation for the book. Many of these interviews were transcribed and excerpts are used frequently in the text to clarify points or ascribe motivations which may not

xi Preface otherwise have been possible. I have tried to reproduce faithfully the passions, disappointments, and atmosphere of the times. Obviously any project such as this, which has had to rely on the individual co-operation of so many people, owes thanks to more names than can be listed here. I owe my greatest debt to the Sault Ste Marie and District Group Health Association itself, for having the insight to know the value that its story holds for others and for the resources which supported me during the writing. The executive director, Fred Griffith, and his staff were an invaluable source of information and ideas. As medical director, Tom Ferrier directed me with care and understanding through the complexities of the medical aspects of the centre and their role in the total scheme of things. Glenn Wilson, the centre's consultant, gave generously of his time and knowledge during extended exchanges in North Carolina and Sault Ste Marie. The board of the association, under the presidency of Jack Ostroski, set a fine example of community voluntarism. John Barker, the real "founder" of the Group Health Centre, provided the bulk of the historical papers upon which the first chapters of the book are so dependent. Tulking at length with this pioneering trade unionist whose commitment to the improvement of the human condition was beyond doubt was a rare experience. His death in 1982 marked the passing of an era in Sault Ste Marie, and I can only be thankful that I had the privilege of capturing his ideas and philosophy during 1980 and 1981. Invaluable help in the researching and editing of the book was provided by Sam Wolfe, John Browne, Debby Capes, Hugh Oliver, Shea Hoffritz, Judy Brioux, and Roy Lomas. The daunting task of typing the manuscript was cheerfully undertaken by Nancy Bishop, Sally Waldes, Lorna Holmes, and Judy Brioux. Finally, BJ Porter, who suffered through the summer as I burnt the midnight oil writing to all hours of the morning, was nothing but supportive and provided me with encouragement and coaxing when I needed it. However, despite all this help and assistance from individuals and organizations, I accept the ultimate responsibility as a scholar and author for all the interpretations, views, and opinions expressed in the book-they are mine and mine alone. This book has been published with the help of a grant from the Social Science Federation of Canada, using funds provided by the Social Sciences and Humanities Research Council of Canada. J.L.

1

Sault Ste Marie

During the evening of 2 December 1957, seven Canadian steelworkers-three from Sault Ste Marie, three from Hamilton, and one from the national office in Toronto-crossed the border to study Philadelphia's two union-sponsored medical clinics. This concept of a clinic had been gaining ground in the United States for some years. Not so in Canada, where only a few group practices of any kind existed, 1 and these were neither consumer- nor union-sponsored. Hospital insurance was still a year away in Ontario and medical insurance more than ten years away. These Canadian union representatives were taking the first steps towards providing their own medicare plan and becoming embroiled in what the Toronto Telegram was later to call their own 'Little Saskatchewan'-a reference to the days of the doctors' strike against the introduction of medicare in that province. Following that December visit to Philadelphia, there were six years of hard endeavour before Canada's first real consumer-sponsored group practice was set up in Sault Ste Marie. Under the stewardship of the United Steelworkers of America, the Sault Ste Marie and District Group Health Association opened on l September 1963. Over twenty years later, the Group Health Centre now ministers to the health of over half the population of the city and its medical staff has expanded from twelve physicians to thirty-three. Its initial $600,000 budget has grown to over $6 million, and government funds have replaced the original consumer premiums. It has commanded the personal attention of countless individuals, from cabinet ministers to coke-oven workers. It has been studied by governments, royal commissions, and the World Health Organization. It has been a model for alternative health care delivery in Ontario and for numerous attempts at replication. It has had experiences which can be found only in a development at the forefront of its field. An alternative it has always been: group practice as an alternative to solo practice; prepayment for health services as an alternative to fees paid at the time of

4 First and Foremost each service; consumer sponsorship as an alternative to private insurance indemnity and to physician-dominated organizations. By definition, an alternative does not ally with the status quo with its capacity for resisting change. It is hardly surprising, therefore, that the history of the Group Health Centre at the Sault is one of conflict and controversy-with other providers, with governments, and within itself. The post-war idealism and spirit of co-operation which marked the 1940s in Canada were accompanied by an absence of any national health insurance. As a consequence, many imaginative schemes surfaced in the form of medical cooperatives, non-profit insurance, or prepayment plans. Trade unions, as an obvious organizational unit, came to play a major role in negotiating and shaping these financial groupings. The purpose of such schemes was always restricted to ensuring that the externally determined costs were reasonably equally distributed throughout the group, not just to the sick. However, Sault Ste Marie saw the first attempt at letting the organization of payment for medical care evolve into the organization of the medical care itself. The steelworkers did not consider this an approach restricted only to one community: they were more ambitious than that. 'We think the significance goes far beyond this one location ... We believe that other Canadian communities will follow suit, and that in the not-too-distant future there will be a coordinated chain of community health centres from one end of Canada to the other.' 2 The first crucial step in this direction came when the visiting steelworkers saw in December 1957 what had been done by the building trades and garment workers' unions of Philadelphia. The members of Local 2251, United Steelworkers of America (uswA), returned to Sault Ste Marie two days later totally convinced of the value of such a plan as 'the only way in which we can secure the most advantages from modern medicine.' 3 One member of that committee was John Barker, the tall and commanding local staff representative in Sault Ste Marie. An ex-pipefitter in his forties, with clear memories of the days before any welfare plan existed, he was particularly stirred by the Philadelphia visit. Years later he recalled that one thing which really impressed him was the Sidney Hillman clinic. 'They were garment workers and their fingers used to get all gnarled up with arthritis from the needle treads, and they used to, on their way home, drop in and immerse their hands in wax, hot wax. And this enabled them to continue making a living; otherwise they couldn't have worked the next day. And that was the thing, I think, that impressed me the most.' It was Barker's energies and commitment to the idea which were to be the driving force behind years of organizing and planning which followed. His organizing zeai combined with the knowledge of experts and consultants from across the continent to realize what many referred to as 'Barker's dream.'

5 Sault Ste Marie SAULT STE MARIE -THE CITY

'Isolated', 'frontier-like', 'rugged'-this was Sault Ste Marie in 1957. As with most of the northern settlements of Ontario, the dual forces of natural resources and water access had determined the city's location. It lies on the St Marys River, which connects Lakes Superior and Huron, close to both the iron ore deposits of Wawa and the thousands of square miles of forest to the north. The narrows of St Marys River between the two lakes were first converted to a shipping route in 1789 by the construction of a small canal and locks. The potential of the narrows as a power source was harnessed by an American entrepeneur, Hector Clergue, who propelled Sault Ste Marie into the twentieth century with remarkable energy and characteristic over-confidence. Clergue started railroads, sawmills, mines, and finally a steelplant, all using the power generated from the river. But by 1903 the whole enterprise was bankrupt, unpaid workers were rioting, and the company had to be kept afloat by the sale of stock to the public. It was not until the mid 1930s that the Maritime financier, Sir James Dunn, consolidated the steelmaking of the Sault into the Algoma Steel Corporation and thus provided the city with a more assured economic future. From this time on, the community showed more and more of the characteristics of a city with a single major industry: the economic monopoly and power of the company, 4 the response of the workers in the form of a strong union, clear class and ethnic distinctions, opposing political outlooks, and periods of boom and bust all followed. In the case of Sault Ste Marie, however, the steel needs of the Second World War and the economic reconstruction that followed brought prosperity to the city, and rarely did the community suffer economically, although that could not always be said of the workers. In 1946 the union president, John Barker, took the entire Algoma workforce out on a three-month strike; which led to reasonable, and later very good, wage levels and established the union as a force to be reckoned with in the community. s The president of one of the locals in the immediate post-war period commented, 'At that time ... up to the late 1950s, what you were developing in the mill was a strong union feeling, an aggressive feeling right across the board ... Things were argued out and real passion was put into what was going on ... Any meeting you had in those days was really a union meeting and union things were really gone over.' 6 Strong organizations and strong individuals therefore took the city into the 1950s. The geographic location of the city has surely also had its influence on those who live within it. As one author put it, 'It is as if the harsh unyielding nature of the country is matched by men who love those very qualities.' 7 Those who chose to live there were not the sort who needed the pamperings of cosy

6 First and Foremost southern life. This holds true not only for the working man of the Sault but also for those in the professions- the lawyers, accountants, and doctors-who opened their practices in this emerging northern town. The Sault was an extremely isolated community in the 1950s: over 400 miles to both Toronto and Thunder Bay, Sudbury 190 miles down the highway. The city had no airport until July 1961. Ferry transportation was all that was available to cross the river until the international bridge to the States was opened in 1962. The Trans-Canada and other highway systems in place today were hardly conceived of, never mind built. Road transportation north of the city ended a meagre 78 miles away at Montreal River until the highway extension opened in September 1960. In this isolated community many of the facilities, services and amenities were in fact monopolies; there were no alternatives available just down the road. However, the isolation also resulted in a clearly defined population, relatively uninfluenced by outside sources and reasonably open to organization. The city's economic prosperity was such that for a number of years in the late 1950s and '60s it had the highest per capita income of any city in Canada. People were being attracted in larger and larger numbers. From a population of just over 48,000in 1955, the city grew to nearly 70,000 by the time the health centre opened in 1963. 8 Such growth was reflected in the size of the workforce at Algoma Steel, which grew from 5,800 employees in 1957 to 7,500 by 1963, and in the growing size and importance of the steelworkers' union. 9 However, despite its growth, the Sault retained certain characteristics of a small town: management and union representatives might sit on opposite sides of the negotiating table, but it was probable that the individuals concerned had attended the same school together; a limited repertoire of cultural and artistic events ensured that close-knit ties developed between those with such tastes; the cocktail party circuit would recycle the same people through the various settings; the labour council and union halls perpetuated contact between many of the same citizens over prolonged periods. Sault Ste Marie was approaching the 1960s as a city undergoing a major change; the strong individual leadership from people like Hector Clergue and Sir James Dunn was being exchanged for a more equal representation among the emerging community forces. MEDICAL SERVICES IN THE SAULT

The medical community serving the growing and changing population of Sault Ste Marie was also undergoing its own transformation in the 1950s. Greater specialization, the introduction of newer technologies, and increased expectations from patients meant that the single doctor practising from his own office

7 Sault Ste Marie had become part of a larger medical 'system': the family doctor would refer his patients to other solo practitioners who were 'specialists', rather than caring for all their problems himself. In the period from 1956to 1960, the ratio of general practitioners to specialists in the Sault dropped from 2.6: 1 to 1.6: I. Even so, the city was slower than many others in responding to this change: for instance, in Sudbury that same ratio was 0.9: 1 by 1960. The physicians were also slow in recognizing some of the natural implications of such a change. They steadfastly maintained independent solo practices, each with its own office and staff, despite obvious gains which could be achieved by banding together under one roof. There was talk in the mid 1950s of building a Medical Arts Building, but the logistics of such an operation appeared to be overwhelmed by the strong preferences for solo practice which had developed over the years. One consequence was that, as referrals became more common, the patient was having to spend more time and energy pursuing medical treatment-visits to the hospital for X-rays or tests, to another doctor for the specialist report, and back to the family doctor for the final word. On the subject of group practice, a background paper for the 1964 federal Royal Commission on Health Services stated: medical services of comparable quality can be provided at a lower real cost in a group setting than they can under conditions of solo practice. These gains can be attributed to the fact that the practice is organized to take advantage of specialization and division of labour, to use capital equipment efficiently, and to avoid the costly misuse of time that many solo practitioners fall heir to. Costs are lower, too, by virtue of lighter hospital utilization where ambulatory patients can be treated in group practice offices for many procedures which otherwise would require hospitalization ... Even though the advantages of group practice appear to be substantial for the doctor, for the patient, and for society ... a minority of doctors in private practice today are working in groups. Why? Some doctors are too individualistic; financial backing is required in some instances; there is a great lack of information on group practice; and there may be several minor fears that inhibit physicians from interesting themselves in group practice. 10

The slow influx of specialists to the Sault, the individualistic nature of the doctors practising there, the lack of incentive, and indeterminate fears all helped reinforce the traditional structuring of medical care in solo practices. It was clear, however, that some changes had to be made and, as the above paper later pointed out, one inevitable consequence of maintaining solo practice was increased hospital use. It became obvious that expansion of the hospitals would be necessary. The two hospitals in Sault Ste Marie represented a division which existed in

8 First and Foremost the health services across the province at that time: one was Catholic- the General; the other was Protestant-the Plummer Memorial. The latter had the only elected board, as the General was run by the sisters of the Grey Nuns of the Cross and even went as far as to have the chief of the medical staff as chairman of their hospital board. These two hospitals provided 338 beds between them, but an expansion to nearly 450 beds was required. The hospitals sat side by side in the downtown area of the city but had operated very much as independent institutions, almost in competition, until this expansion became necessary. Owing to pressure from the Algoma Steel Corporation, which refused a checkoff from employees without a joint appeal, they had to co-operate in their fundraising. The $8 million campaign was extremely effective, and by 1962 new wings were opened. For the doctors as well as the patients, this was a significant improvement in physical plant and equipment. The money for this expansion came partly from government and partly from the normal donors of the community-the corporations, especially Algoma, professional groups, and the steeiworkers. The steelworkers were the economic backbone of the city and it was their money that provided the bread and butter of medical practice in the area. They were the ones who were most able to pay and who provided the income security for many of the doctors' practices, sub~ sidizing the care of indigents and the less well-off whose bills frequently went unpaid. Partly because of this, medical fees were higher in Sault Ste Marie than in most other cities in Ontario. As the city with the highest per capita income in the country, it could afford fairly high prices. But there was also a shortage of doctors, and some relief from the pressure of demand might have been provided by the higher prices. The city's physical isolation, preventing easy access to competition, was a further influence, as was the fact that doctors in solo practices had high average overheads. Whatever the reasons, the fact was that by 1961 citizens had to pay $4.80 for an office visit, although most of the insurance plans at the time, including the steelworkers', were reimbursing only $2.00! By contrast the same office visit would cost only $3.70 in Sudbury or $3.75 in Toronto. An appendectomy in the Sault cost $126.25, in Sudbury $108.75, and in Toronto $117.50 11 In their quest to obtain prices such as these, the local doctors had a taken major step in 1958 by opting out, en masse, of the doctors' own non-profit insurance plan called Physicians' Services Incorporated (PSI). By opting out they were declaring that the fee schedule, paying 90 per cent of the Ontario Medical Association's rates, was unacceptable. The PSI schedule was, in fact, a very generous one compared to others, but despite this the local doctors objected to PSI's retention of the 10 per cent for 'administration.' Concerted action of this

9 Sault Ste Marie kind on the part of the doctors required a certain loyalty to the local medical society. The Sault Ste Marie Medical Society had imposed an effective structure on the doctors despite the fact that they were 'fairly vocal. You have to recognize, you know, that northern Ontario is a frontier, and people who go to the frontier are generally people that don't sit comfortably in the more organized society. They tend to be the people who are a little rebellious.' 12 At this time, local medical monopolies were common, partly because there was no centralized bargaining for fees between the provincial medical association and the government. Consequently, the local medical societies were highly autonomous and established not only their own fees but also their own individual character. This still happens today, as exemplified recently in Manitoba during a work 'slowdown' by the province's doctors. The interpretation of 'slowdown' varied among medical societies: 'In such towns as Selkirk and Beausejour, doctors agreed to leave their offices closed. In Winnipeg they agreed to take fewer phone calls. In Morris doctors only took emergency calls; and in Thompson they refused to complete patient discharge forms. In the town of Dauphin doctors took long weekends. In Brandon, doctors did all of the above.' 13 1\venty years ago the Saut Ste Marie Medical Society was undoubtedly one of the Brandons of Ontario. The doctors were rebellious and independent, aware of the economic worth of their patients, slow to incorporate the new ideas of organization in medicine, strong on defending the old values, but willing to arrogate professional decisions of the whole to only a few. There was, however, one major obstacle in their path for the delivery of good medical care in the city-a serious shortage of doctors. While most of the physicians were undoubtedly competent practitioners, they were plagued throughout the 1950s and early '60s by a shortage of manpower which meant the city as a whole was not receiving the amount of care it needed. In 1956 there was one physician for every 1,400 people in Sault Ste Marie, while province-wide the average was one for every 850 or so. Neighbouring Sudbury had a ratio of 1 : 831 at this time, and by 1958 was at 1: 697, while the Sault remained at 1: 1,400. 14 One of the steelworkers recalled that, 'At that time there was signs up ... it was quite common to see signs in doctors' offices, "Sorry, No New Patients," after a certain date, because doctors had more patients than they could handle.' 15 Although the shortage was across the board, it was particularly severe among specialists. Certified specialists were difficult to come by in a country that was suffering from a shortage of doctors everywhere. The output of the medical schools had not kept pace with the increased use of medical services, and the country at large was relying heavily on the immigration of foreign doctors, and the incoming doctors were more likely to locate in the larger, better-equipped urban centres than a northern community like the Sault.

IO First and Foremost A number of events in Sault Ste Marie conspired to exacerbate the shortage. The successful negotiation of a welfare plan for the local steelworkers in 1951 had increased the demand for medical care, the costs of which would now be at least partly covered by the insurance carrier. The mushrooming population in the city, many of which were also to be covered by welfare plans, inevitably increased city-wide needs even further. Finally, the introduction of government hospital insurance in January 1959 placed further stress on the situation. The local medical society did not, however, respond to the crisis as well as it should have. Between 1955 and 1959 only four new physicians arrived, while the population grew by 8,000. Some of the difficulty might have been alleviated if a more organized system of coverage for off-hours had been arranged, but the fierce defence of solo practice made this difficult. One of the Algoma Steel managers described the situation this way: 'It was extremely difficult ... to see any of the better doctors ... They made appointments, but didn't keep them. You went there and there were 25 people in the waiting room ahead of you, and you just had to wait your turn. You really couldn't get a doctor at night, you couldn't get a doctor on Sunday. Nobody made housecalls.' 16 In October 1958 the city council passed a motion requesting that a listing of the doctors on call at night and weekends be posted for the public. In July 1959 the local paper, the Sault Star, reported on the death of a young baby whose father blamed the local doctors because they were not available at the time his son took an overdose of aspirin. In reporting the story, the newspaper obtained the following comment from a hospital spokesman: 'We have had many complaints from the public about difficulty in contacting the members of the medical profession. Off the cuff, the medical association must give more consideration to this problem.' 17 In 1959, the society did attract nine new physicians, but by this time the population growth alone required at least that many, and none were left to address the increased demand brought about by other factors. This prompted an editorial comment in the Sault Star: 'At the rate of heart attacks and other forms of collapse among the profession in the last few years it would seem they have not been taking more than their share of time off. Perhaps the fact of the matter is the Sault needs more doctors.' 18 As a result of this shortage medical care in the city became, by necessity, more and more sickness-oriented with little time left for preventive care. Annual check-ups and immunizations were rising in popularity at this time, but in the Sault the pressures on doctors did not allow them to respond to such demands. One organization which had felt particularly strongly about this omission was the local steelworkers union.

11 Sault Ste Marie THE UNION

Sault Ste Marie is what might be called a 'union town.' As in its closest neighbour, Sudbury, the majority of the workforce are union members. In the Sault, the giant amongst the city's unions is Local 2251 of the United Steelworkers of America (uswA)-employees of the Algoma steelplant. This union had emerged in 1942 from an amalgamation of the Algoma Steelworkers Union (organized in 1935) and the Steelworkers Organizing Committee (founded in 1940). They organized well in advance of the other main steel plant in the province-Stelco in Hamilton-which did not achieve full union status until 1946. Even in the early days as a company union, the employees of Algoma Steel were a progressive group: in 1937 the executive was discussing group insurance coverage for better health benefits. They already had a reputation within the Canadian labour movement. John Barker, president of 2251 in 1946 and later to become staff representative in the Sault, recalled that '2251 was the first large local of the Steelworkers west of Sydney, Nova Scotia. It was recognized as a strong union. We had the 1943 strike, and again in 1946, which gained us a lot of recognition in the labour movement.' One member of Barker's executive in 1946 was Bill Mahoney, an astute politician and a committed union activist. At that time Mahoney was recording secretary in 2251, but in 1947 he left the local steelworkers for the national office, where he became assistant to the national director and, in 1957, national director, both influential positions in the steelworker organization. His presence in the national office for over twenty years meant that more attention was paid to the Sault local than might otherwise have happened. The United Steelworkers of America were organized on three levels: international, national, and by district. The international office, located in Pittsburgh, was the most distant and left the Canadian part of the union-the national office in Toronto-with a large degree of autonomy. The International was represented by the director of district 6 (Ontario and West), 19 also located in Toronto. He reported directly to the International and appointed the local staff representatives. Although everything theoretically went back to the International, in practice it was more a tripartite system exchanging information and resources in a reasonably autonomous fashion. The district 6 office was most concerned with the day to day workings of the union. The national office, which had its own research department, took a slightly larger perspective, with help and direction coming from the International. Contract negotiations and broad policy were more their concern.

12 First and Foremost Despite some occasional stress between the elements, an Algoma steelworker could certainly feel that he was a member of a large and widespread brotherhood. The 1940s and '50s witnessed 'the feeling of belonging to a union that embraced steelworkers in the United States and Canada. This feeling can only be appreciated by those who lived through it ... sharing problems, sharing solutions, and the knowledge that someone in a distant area who works on a similar job is thinking of how to improve his or her lot and willing to share their ideas with you.' 20 Within this larger whole, 2251 retained high recognition in these post-war years. Barker moved from the presidency of the local to be the area staff representative in 1947. In this position he was responsible for many of the innovations of the local union. He was a modest man with incredible amounts of energy and dedication. He commanded the respect not only of his fellow unionists but also of management and of many in the community at large. One of Algoma's negotiators from those days thought that none 'of the other locals had people of the calibre of John Barker. You know, when John Barker said he was going to do something, he was bloody well going to do it ... many, many things I've disagreed with John Barker on, but you cannot get away from the fact that he's an honest, hard-working, sincere, loyal sort of person, and he's worked his butt off for a lot of these people.' 21 He was a man who had to have a cause; and when things were quiet in the union, he looked outside, as when in 1952 he was an unsuccessful Co-operative Commonwealth Federation (ccF) candidate in the federal election. When he was induced to talk about himself, he alluded to this need for action: 'My wife used to say this to me: "You got nothing to do, eh?" If I was lagging or not feeling good, she'd say, "Nothing doing at work today?" It was when things were exciting that I always felt good, and I was always on the go, anyway.' During those first ten years-1947-57-when Barker was staff representative, 2251 succeeded in introducing the first co-operative wage study for office workers, started its own credit union, and negotiated steadily improving wages and benefits for the workers. These things, of course, were not done by one man alone, and there were many other hard-working unionists in the local- Woodcock, Ferris, Bradley, Lepage, and Krmpotich-who were again and again identified with significant achievements for their members. The director of district 6, Larry Sefton, had quickly come to recognize the strength of the local in Sault Ste Marie and provided them with the support and encouragement they needed to put their ideas into practice. The most important of these was the welfare plan. The union negotiated hard to achieve its welfare package, meeting only as much resistance from the company as could be expected from a public corporation which did have to turn a

13 Sault Ste Marie profit. The 'small-town syndrome' can be seen in the comment of an Algoma company official: 'Industrial relations at Algoma have been somewhat more harmonious than in other basic steel plants ... I sat across from union employees and two of the guys grew up in the same neighbourhood I did. A couple of us were in the same class-another one just ahead of me. It's pretty hard to fight forever with somebody you know well.' 22 In such an atmosphere, 2251 negotiated the first welfare agreement in 1951. A non-contributory pension plan, one of the first of its kind in Canada, provided a maximum of $60 per month on retirement. Group life insurance up to $1,000 was obtained, along with an accidental death and dismemberment indemnity of$1,000. Additionally, $30 a week for a maximum of 13 weeks was provided as sickness benefit. Finally, hospital and medical costs were covered, with some strict financial limits. For each specific operation or procedure, the plan paid a set amount; if the doctor charged more, the employee had to pay it. Also, no costs were covered for doctor's care until the third visit, unless it was a hospitalization or accident. The company's contribution to all this was $2.27 per month for each employee, the remainder to be made up by the employee himself, including any cost of entitling his dependents to medical benefits under the plan. Employees started by paying $2.27 a month if they were single, the same as the company, but $5.75 if they were married. This presented no major problems for the first few years of the plan. When it was time to renegotiate in 1955, the plan showed a surplus of$50,000and the premiums had remained the same. At this renegotiation, monthly contributions were not increased for single employees, but married premiums went up to $6.21. The company also agreed to pay 0.02 cents per hour worked by all employees in addition to their monthly contribution of $2.27 per employee. There were some nominal increases in sickness benefits and elsewhere, and the carrier was changed to the Prudential Insurance Company, but the over-all increasing costs of care meant that benefits were not improved. Unchanged also was the need for employees to pay out significant amounts on top of the premium to cover things like extra doctors' fees, costs for the first two visits to the doctor's office, medical costs of dependents, any sums over the ceilings defined in the plan, and the purchase of all drugs, prostheses, eyeglasses, other insurance plans, and so on. It was very disturbing, therefore, when in 1956 the welfare plan showed a deficit of nearly $24,000. At first this was covered by the previous year's surplus but by 1957, with an $82,000 deficit, things looked grim. Premiums had to be raised by 67 cents for single and $1.93 for married employees, and even these 30 per cent increases did not cover the entire increased cost. The costs of the plan were no longer being shared 50/ 50 with the company: the adjustments

14 First and Foremost meant that employee contributions for the limited plan benefits alone amounted to cover 60 per cent of the total premium. The 2251 president, Bob Collins, wrote in his newspaper column: 'I think we must agree that we are experiencing some financial difficulties ... A Welfare Plan of Group Insurance like ours must have as much money paid in as paid out. We must understand that there is no risk involved by the insurance company who only administer[s] the plan for us and the company for a retention fee!' 23 In this same column, the hospital part of the plan was named as the culprit for rising costs: 'several contributing factors ... outpatient services have run exceptionally high ... a prevalency of confinements for purely diagnostic purposes ... The duration and frequency of the confinements have not only been considerably higher than normal, but have shown a continued increase.' 24 Given the fact that the plan strictly limited amounts payable for doctors' fees but not for hospital costs, this analysis was not surprising. But it did ignore a number of crucial factors. Doctor costs were rising just as much, but the plan's fixed payment for these passed the burden directly to the employee. Additionally, much of the increased hospital cost came from increased admission and referral to the hospital by those same doctors-'a prevalency of confinements for purely diagnostic purposes.' In 1959 hospital costs were transferred to the Provincial Hospitalization Plan, but despite their removal, the re-establishment of 50 I 50 cost-sharing for the total premium, and little improvement in the nature of benefits, the 1959 single employee contribution still had to be increased by over 20 per cent to $3.64. Therefore, in the eight years since the introduction of a welfare plan, the cost to the employee had risen by 60 per cent, he had received no real extra benefits, and the entire hospital part was now covered elsewhere. Furthermore, his outof-pocket expenses were rising and the Provincial Hospitalization Insurance had raised his expectations. It was no wonder that he had the feeling of running as fast as he could just to stand still. The union was also concerned with fully comprehensive care, regardless of cost, as was exemplified by two actions in these late 1950s. First, a suggestion that the welfare plan's financial difficulties be solved by using co-payment or user fees for each service, rather than by raising premiums, was rejected by the members because of the possibility that it might have further discouraged people from seeking care when it was needed. Second, under its own auspices, the union initiated a massive tuberculin immunization program in 1957 and stressed the value of the preventive approach to health. It is clear, therefore, that the efforts to institute comprehensive medical benefits were being constantly frustrated. Not only were the costs increasing for a package of constant or shrinking benefits, but the shortage of doctors, exacer-

15 Sault Ste Marie bated by increased demand through hospital insurance and the existence of the welfare plan itself, seriously undermined even access to care. It did not take much time for the union to realize that it was not going to achieve its goal of comprehensive care within the commercial insurance approach. An alternative approach was definitely needed.

2

Mobilization

AN IDEA IN SEARCH OF A LOCATION

By the late 1950s pressures for a new approach to medical care were building from many different directions in Canada. Political parties, unions, and organized consumers were all expressing dissatisfaction with the current organization and were experimenting with alternatives. The ccF, the historic party of the left in Canada, was calling into question the effectiveness of the assortment of insurance plans which covered some of the people some of the time for some of their care. In Saskatchewan, the only province with a ccF government, the first forays into the territory of government-run medical insurance were being made in what ultimately became a long and hard-fought battle with the doctors. Federally, things had been moving cautiously since the late 1940s, but the first steps were now being taken towards government-run insurance with a hospitalization plan, excluding doctors' services. The unions, with a keen interest in these developments, were unanimous in pressing for the involvement of the government in the nation's medical care. In the meantime, many unions took steps of their own to hurry things along. A number of the northern mining communities experimented with different ways of paying for medical care. As nearly all residents of such areas were with the same employer, it was not too difficult to arrange plans which spread the cost of medical care across the entire community, or at least the working section thereof. International Nickel (INCO) in Sudbury had been running a medical clinic for the miners and their families since 1941. This plan had some forwardthinking elements - a prepaid sum each month covered all care, and the doctors practised as a kind of group, though they were not prevented from also running private solo practices outside the clinic. Even in the clinic they were paid with fees for each service, hence orienting care towards treatment of sickness

17 Mobilization rather than encouraging preventive care. Also, the clinic was run entirely by the company, with no input from the employees. There were other areas in the north with notable plans. Timmins-Porcupine, Kirkland Lake, and Thunder Bay all had prepaid medical plans organized for, if not by, particular unions. Kirkland Lake's, for example, was started in 1943 by local doctors and the township council and was soon expanded to cover all employees of the local mines as well. A visiting steelworker researcher described the plan: 'The mines' plans ... provide comprehensive services ... There is no fee billed by the doctors whatsoever. The plan is paid for entirely by a capitation fee ... doctors practice through two organized medical centres and practice on a group practice basis ... The plan as I understand it has worked exceptionally well ... involving better than 14 or 15,000, which is probably over 7511/o of the population.' 1 On paper, at least, this plan was administered by the employees. The rules and regulations stated that it would be administered by a medical plan committee composed of eight elected employee members and one member appointed by the company. 'The duties of this committee are to administer the funds entrusted to them in accordance with the rules and regulations of the Plan and to promote understanding of the plan.' 2 However, communications from the local representative indicated that employee involvement was in fact small: 'The Mines Medical Plan is administered by an administrative secretary ... and a Central Mines Medical Committee, made up of one delegate from each Mine Medical Committee. In most cases this has been a management representative ... the employee representatives have not shown the interest in the plan they should have done.' 3 The Kirkland Lake plan was certainly more advanced than Sudbury's, with no fees for service, with group practices, and with comprehensive prepayment. However, it is clear from the rules and regulations that prevention was not stressed and that the consumers' role, which they did not perform very well, was restricted to administering the funds. The plan, like many in the north, had grown largely out of the need of doctors to have a secure income at a time when private insurance was rare. The willingness of consumers to band together and guarantee the doctor a fixed sum each month, in exchange for care whenever they needed it, was a welcome financial relief for the doctors in those early 1940s. Similar situations existed elsewhere in Canada. Some municipalities paid a local doctor an annual retainer-collected through taxes-to guarantee care for the local population. In Saskatchewan this scheme was adopted on a regional basis in 1946 by the Swift Current area. All doctors in the region received their income through the local tax collection, although they maintained complete autonomy over their individual practices. Again, the major role of organization was for financing alone: 'The area had been chosen because it was

18 First and Foremost economically depressed and there was a shortage of doctors. Doctors practising there had many unpaid accounts.' But even this significantly improved the level of local care: 'The number of doctors in the region increased from 19 in 1946 to 41 in 1960, during which time the size of the population remained static.'4 South of the border in the United States, things had progressed somewhat further, with many prepaid plans run by consumer boards with integrated facilities and the group practice of medicine. The Americans had already begun to respond to the development of increased specialization and technology in medicine and had also seen some of the gains to be had from an emphasis on prevention. The American developments have been described in a 1960 Ontario Medical Association report by two officers dispatched to the American Medical Association in Chicago to appraise these plans: The earliest union health centre was organized in 1913 but this was the sole union venture in this field for some thirty years ... the introduction of a 'hold the line' order on wages by the U.S. government as an anti-inflation measure ... permitted voluntary welfare agreements between employers and the unions for the provision of fringe benefits ... The costs of such benefits were not classified as wage increases ... This in turn led to the preoccupation of unions with ... health centre activities. There are now some sixty of these in operation ... such centres have become relatively prominent during the past ten to twenty years. They collect premiums ... and frequently enter into contracts with organized groups of physicians to provide medical care to subscribers ... Perhaps the two best known examples of the community type are the Health Insurance Plan of Greater New York (H.I.P.) and the Kaiser Foundation Plan in California ... A considerable number of union members and their dependents have comprehensive health benefits through contracts with such plans. These usually combine group practice with prepayment ... The emphasis is on preventive medicine ... [and] on specialists rather than on general practitioners. This may have something to do with the fact that ... most plans stress the importance of complete examination and early treatment ... Most plans have a Board of Directors or Trustees ... the Boards are controlled numerically by consumer representatives. Thus there is a lay domination and any interference in medical matters which might result therefrom is counteracted only by the general desirability of unions to maintain the favour of the profession and their respect for the doctors' abilities in professional matters. 5

The scope of some of these plans can be seen in statistics from the news-letter of the Kaiser Foundation, which show that in 1957, for their plan alone, there were 317,000 subscribers having 1,429,000 office visits. 6 The effectiveness of the plans was demonstrated by significantly lower hospitalization rates in comparison with those of traditional insurance subscribers.

19 Mobilization In certain instances in the United States, however, consumers had come to play an active role in the organization of medical care and had been extremely successful. This burgeoning phenomenon led in 1959 to the amalgamation of the Group Health Federation of America with the American Labour Health Association to form the Group Health Association of America (GHAA). The GHAA became the rallying point for all those interested in this 'alternative' delivery of medical care. Its goals were: l / prepayment of the cost of medical care, 2/ group practice of medicine, 3 / comprehensive health care of high quality under the direction of qualified professional personnel, 4/ control of policy and administrative functions by or in the interest of consumers of health services. 7 The United Steelworkers of America had been taking particular note of these developments, and in the 1950s they took on the cause of comprehensive care for their members. A reflection of this was the hiring of Isadore (lg) Falk by the international office in Pittsburgh. A consultant to the Welfare Department, Dr Falk, (not a physician but a doctor of philosophy) had experience in organizing prepaid group practice and had been a life-long proponent of such an approach. He was a major participant in the U.S. government's Committee on the Costs of Medical Care of 1932, which had recommended prepaid group practice as the most appropriate form of health delivery for the States. His many studies in the field of health care delivery had won him much respect. A veteran of struggles with local state medical societies who adamantly opposed the prepaid group practices, he was a highly articulate individual who could, and frequently did, command a meeting by his impressive rhetoric. At the national office in Toronto, the Canadian Steelworker Research Department had their own lg Falk-much younger, much less experienced, but equally zealous and more than willing to learn. In 1954 Ted Goldberg started parttime with the research department and soon drifted into health benefit negotiation. His keenness took him down to the States to attend conventions of the pre-GHAA health organizations and he was one of the founding members at the 1959 GHAA inaugural meeting. At these meetings he started to talk with men like Falk, whom he regarded as somewhat of a mentor, and he brought back GHAA ideas to the uswA national office in Toronto. He read voraciously and started to lobby the national director to get things moving in this direction. So enthusiastic was he that in 1957 he had begun a PhD dissertation in the area of welfare benefits, as well as now working full-time in the Steelworker research department. He was very ambitious, and he applied later for a deputy-ministerial post in the Ontario Ministry of Health. He is currently, chairman of the Department of Health Administration at the University of Toronto.

20 First and Foremost It was as a result of his lobbying the Steelworkers that their initial 'feelers' were put out in 1957. Bill Mahoney, the national director, requested that the major Canadian locals establish a committee to investigate organizing union health centres for their membership. The three main locals were 1064 in Sydney, Nova Scotia; 1005 in Hamilton at Stelco; and Algoma Steel's 2251 in Sault Ste Marie. These three locals had always gathered regularly in Toronto at what were called 'Basic Steel' meetings. As it turned out, the Sydney local did not respond to Mahoney's request, so the appointed health centre committee contained representatives only from Hamilton and the Sault. It was this committee which, after a first meeting in Toronto, visited the union health centres in Philadelphia at the close of 1957. Heading the committee was Ted Goldberg, and accompanying him were the Lisson brothers, John and Bill, plus John Shipperbottom from Hamilton, and a contingent of three from Sault Ste Marie: the president of the local, Bob Collins, who left the union after 1957 and eventually joined management at Algoma; the vice-president, Les Woodcock, who still sits on the board of the health centre; and John Barker. The latter three were very interested in any new approach to health care: 1957 was the very year in which they had been forced to raise the premiums to their members to cover their welfare plan deficit. The severe shortage of doctors in their community, the constant extra-billing by the doctors, and the inability to improve the scope of benefits of their plan despite steeply rising payments were all good reasons for this interest. The importance of this committee in setting in motion the machinery of alternative delivery for Sault Ste Marie cannot be overestimated. Les Woodcock said later, 'I was interested in helping them [the members] resolve the problems that they had, but I never, in my own mind, connected it with - that the union should get into establishing a health centre. That never really entered my mind, I don't think, until I went to that meeting in Toronto.' Woodcock was a quiet man who was in and out of office in the local over many years. Although neither a great politician nor an initiator, once convinced he really took the ball and ran with it. Like Barker, he was one of the strong contingent from Local 2251 who helped ensure success for some of its pioneering endeavours. He was certainly convinced of the need for a health centre in the Sault after the Philadelphia visit: 'I was really eager about it then. I think there was only one person who was more convinced or more converted than I was and that was John Barker ... Once we came back from this Philadelphia trip, we knew that that was the right way to go.' By January 1958 Ted Goldberg had written a report on their trip recounting impressions, outlining the structure of Philadelphia's centres-salaried doctors, administration by lay boards, comprehensive coverage- and concluding with

21 Mobilization detailed proposals for action in Canada. While mentioning both Hamilton and Sault Ste Marie as possible locations, Goldberg obviously favoured Hamilton at this time: 'The advantages of starting in Hamilton are obvious. It is the much larger city; there is a greater number of union members; there are more medical specialists to draw from; and it is closer to research and teaching facilities.' 8 Barker reacted quickly to this portion of the report, firing back a letter to Goldberg: Your proposed report is very factual and in general is acceptable to me. On page 15 however, you state the advantages of starting in Hamilton are obvious. I agree with this only on the basis that there could be greater participation, and thus lesser cost per member and the availability of specialists. A large number of our members have to travel to the Hamilton and Toronto area for such services. Therefore the greater need for such a clinic is in Sault Ste Marie, where services such as it would provide are not available. There is also the possibility of greater pressure being brought to bear on the medical profession because without the business of union members, there would not be sufficient other business for them in this area. 9

Barker continued his crusade through 1958, and as momentum built for the idea of a union health centre in Canada, he continued to press for Sault Ste Marie as the location. Momentum certainly did build, the idea striking a chord within the steelworkers. In April 1958, the committee's report provoked a major resolution at their Winnipeg national convention. The resolution bemoaned the absence of government-organized medical insurance and stated that until such time as it was introduced Be it resolved that a major goal of our collective bargaining programs will be to establish for our members and their families- laid-off members as well as pensioners -employerpaid health security programs encompassing all areas of necessary medical attention; and Be it further resolved that such a program shall be established on economically sound and medically advanced principles; and

Be it finally resolved that in such locations where our membership is ofsufficient size to make it practicable ... immediate steps to be taken to develop organizations ofMedical Care Centres through which comprehensive health benefits would be provided on the basis of group medical practice. 10

Similar resolutions were passed in September 1958 by the International Steelworkers' constitutional convention and later by their wage policy committee. lg Falk had been set to work by the international in Pittsburgh to 'under-

22 First and Foremost take the investigation of the possibilities of alternative arrangements [covering] all the programs established by other labour unions, and the development of fully pre-paid medical care plans utilizing group practice medicine.' 11 Back in Canada it was obvious that there was a general desire on the part of unionists to establish medical centres. Goldberg had also started to branch out beyond the steelworkers. Attempts began in early 1959 to co-ordinate the development of a union health centre in Toronto by 55 labour groups there. A ten-man executive was formed, a potential membership of 500,000 estimated, and finally a one-year research and planning phase proposed. 12 Meanwhile, Barker was at work establishing the Sault as the logical location for the first centre. Like most converts, he had become even more zealous than the converter, Goldberg. The resolution in Winnipeg signalled definite approval from Mahoney, as national director, for the idea, but the location was still unresolved. Hamilton was undoubtedly a good location, but Barker's perception that the Sault was the more needy and his overpowering commitment to the idea didn't leave Hamilton with much hope. It was also the case that Barker had a certain amount of special influence with Mahoney. Goldberg himself commented, 'John Barker had a hell of a lot more influence on Bill Mahoney's decision than I did.' The politics of deciding between Hamilton and the Sault, plus a lengthy strike at Stelco in late 1958, delayed the final decision for some time. But Barker finally got his reward in mid 1959: in a letter to him Mahoney expressed the view 'that Sault Ste Marie offers the ideal opportunity for establishing a health program which would be the model which other localities could copy. Not only because of geographical factors and concentration of union members, but also because we have a strong, united and energetic local there, the situation at the Sault gives the greatest assurance of success for the program.' 13 So, eighteen months after that visit to Philadelphia, the idea of a union health centre at Sault Ste Marie had taken a major step forward. THE CAT AMONG THE PIGEONS

Contracts between the union and Algoma were negotiated every three years, and the last one had been signed in 1958. The impending opening of the contract negotiations for 1961 now took on special significance. Mahoney emphasized this in his letter to Barker: 'Time is of paramount importance. It will be necessary to have all the details worked out before we start negotiations for the renewal of the contract.' The 1958 resolution, which had been reaffirmed in 1959 and would be again in 1960, made it clear that welfare benefits were going to be a major part of these renegotiations. But before this, the members had to be

23 Mobilization sounded out, data collected on current services, and projections and decisions made about total costs, extent of benefits, and the size and nature of the staff; then all this had to be organized for the contract talks. The first step was to arrange a seminar at which the union members could be apprised of events and educated about what would be involved in setting up their own health centre. On 14 and 15 October 1959, the standing committee members and delegates of departments for all the steelworker locals crowded into the old union hall on Thompson Street for a workers' health school. Mahoney himself attended, and guest speakers included the director of an American union health centre and a health planner from western Canada. Planned by Goldberg and organized by Barker, the intensive two-day session diagnosed current problems, surveyed solutions, and finally convened as working groups to settle on strategy. Union members holding any kind of office participated, and they were impressed and excited by what they heard. They were solidly behind Barker and they adopted, unanimously, the following resolutions:

a I that the Local Union undertake to develop a new comprehensive health program at the Soo; b I that the program start with Local 2251, then extend to other uswA local unions and ultimately be made available to the community as a whole; and c I that a committee be appointed to plan the development of the new program. 14

By January 1960, some firm steps were being taken. The members of 2251, encouraged by the response to the health school, passed a motion to 'deduct from each member who so authorizes, 50¢ per day, for deposit into the Health Centre Building Fund, until sufficient moneys have been deducted to pay their portion of such building, and that the Local start the fund with a contribution of $5,000 from the Local Treasury.' 15 The company agreed to do this check-off for one year only, starting in May 1960. This would force the union to provide signed authorizations again the next year if they wanted it continued. Luckily there were International union elections at the time, which facilitated the signing of 3,800 authorizations. It was also at this time that the health centre committee was established with Woodcock, Barker, and the new president of 2251, John Ferris, as the members: they were to investigate what steps would be necessary to establish the centre. The next important move was to get some expert advice. A month after the check-off motion, near the end of February, lg Falk's experience was brought to bear on the problem when he made a three-day visit to the Sault after a request to the International from Mahoney. Falk was accompanied by Goldberg and J.J. Senturia, the International's insurance consultant. The two hospitals,

24 First and Foremost the steel company, the local doctors, and the insurance carrier - Prudential-were all visited and interviewed at length. Discussions took place with the union local, and within ten days a comprehensive report had been prepared by Falk. The local doctors, hospitals, and company were impressed by the obvious breadth of knowledge, comprehensiveness of inquiry, and general professionalism of these visitors. If they had not taken the union seriously before, they surely would now. Falk's report fully supported the local union's opinion that a health centre was needed. With regard to the insurance scheme he concluded that 'the benefits are uneven ... grossly inadequate for all other major elements of medical care ... Some of the inadequacies depend on the limited size of the cash reimbursements, leaving residual charges to be met by the family ... fees are many times the size of the insurance benefits ... other inadequacies result from the noncomprehensive scope of the benefits ... no control of the quality of care being received ... and the very nature of a limited cash indemnity plan.' 16 He also costed out roughly the proposed health centre: 'Local Union 2251 realizes that the program it proposes would cost much more than the $42 per employee estimated for the present group welfare plan health benefits ... It has also been pointed out to the Local Union, however, that the operating costs of the contemplated program may not be much more than the sum of a) the amounts being spent under the group welfare plan, and b) the amounts already being spent through individual out-of-pocket expenditures ... to cover residual charges ... and pay for non-insured costs.' He laid out a developmental plan which stressed the immediate need to do 'surveys of steelworker family experiences with personal health services, including fees and charges incurred, and insurance benefits received, in the course of a stated recent period of time ... Preliminary design of a direct-service group-practice prepayment plan to meet local needs.' Finally, Falk demonstrated his experience in these matters by trying to involve the local doctors at this early stage: 'The outlines of a development plan were presented to some leading local physicians, including some officers of the local medical society, and discussed with them at some length. They were not prepared to express any definitive opinions on it- for themselves or on behalf of other local physicians or of the medical society.' Some interesting things emerged in Falk's report: the intention, from this early stage, was eventually to make the health centre available to the entire community; the union was aware that the cost for comprehensive care was probably going to be greater than current expense; the need for extensive preliminary study, and hiring of someone to do this, was outlined; and the union sincerely wanted to include local doctors in the plan. However, as Falk well knew, organized medicine was unlikely to be very co-

25 Mobilization operative. In fact, with plans going ahead in the Sault, Toronto, and Hamilton (the Sault's being the most advanced), organized medicine was decidedly on the defensive. A taste of what was to come could be found up in Kirkland Lake where the community's 18-year-old prepayment plan was about to be ended by the local doctors. On 1 February 1960, the local paper had reported 'the principal of prepayment has drawn fire from the Ontario Medical Society through its local body, the Kirkland District Medical Society. "Unethical", was the description ... in a letter from the medical men ... The doctors will withdraw by May from the present arrangement.' 17 Although Goldberg visited Kirkland Lake at the request of the two steelworker locals there, the national steelworker office did little to try to save the plan, and by June the plan was fee-for-service with a commercial insurance carrier. Back in the Sault, the local doctors did not take long to decide upon their stance. Shortly after their February meeting with Falk, Senturia, and Goldberg, the president of the Sault Ste Marie Medical Society wrote to Barker informing him that 'the union-sponsored clinic as presently proposed constitutes a closed panel system which is directly opposed to our afore-mentioned statement of policy. Accordingly, the members of our society are unanimously opposed to the introduction of any such system in this community and will refuse to participate in such an undertaking.' 18 The union was not surprised, but was far from convinced that this really was an unanimous feeling. Barker reported to the district 6 director, Larry Sefton, 'At some future date, we will endeavour to attend a meeting of the medical profession to explain our objectives and our desire for their participation.' 19 Five days after the letter to Barker, the Sault doctors took the issue to the public by publishing a full-page advertisement in the 2 April issue of the Sault Star. In their 'Statement of Policy' they asserted the following principles: (1) Freedom of choice of physicians

(2) (3) (4) (5)

Payment of physicians on a fee-for-service basis Preservation of the system of family practice Maintain and preserve the present high standard of medical care and public health Continue to provide care for those in unfortunate circumstances

They proclaimed their opposition to the 'closed-panel system' of the unionsponsored clinic and their refusal to participate in it. The advertisement established what would be the medical society's public reasons for opposition. They didn't like the fact that, unless referred, health centre patients could use only health centre doctors. They wanted total free choice of physicians by patients. They didn't like group practice which, they said, would interfere with the

26 First and Foremost unique doctor-patient relationship which came from continuous care under the same family physician for years. This was the thrust of the public argument, but principle 5 -the continuance of care for those in unfortunate circumstances- hinted at a deeper cause for their opposition. As Arthur Wishart, a local lawyer, chairman of the Plummer hospital board (and later attorney general of Ontario), noted: 'There was a feeling amongst the doctors ... that the health centre was being sponsored by the union, the steelworkers, that it would expand into other paid workers and employees to serve them and that these people were people who were always going to be able, qualified and capable of paying for medical charges. The doctors had a fear that they were going to be left with those less able to look after themselves. They were concerned it was going to touch their pocketbooks very severely. There was a fear there that gave rise to a resentment.' Besides the potential loss of income, there were two other, covert, reasons for opposition. First, the whole idea was connected very much with the left side of the political spectrum -after all, the ccF was its major political proponent. One officer of the medical society commented: 'A doctor is generally a tory and a unionist is not. This was a socialist idea, socialized medicine.' 20 Second, a feeling of resentment arose at criticism of the existing medical care. Another medical society officer put it this way: 'The union began to say things about the medical care of the community which, in my view, was a deliberate attempt to create the feeling in their membership that they were getting less than good care ... And that created a lot of hurt, anguish, disappointment, and difficulty for the doctors in the community. There's no question about that.' 21 This interaction of economics, politics, and emotions in their attitude proved to be a potent combination which maintained medical society opposition for a long time into the future. The first public volley fired by the medical society on 2 April was answered by the steelworkers, who took out their own full-page advertisement two weeks later. (The Sault Star was doing well from the dispute!) The union pointed out that the doctors' position did not alleviate the problems of medical care which existed. They did not think all doctors were in opposition, and they reaffirmed their commitment to the health centre plan with a promise to make it available to the general public in the future. They concluded by stressing their responsible approach and their wish to co-operate with the medical profession at all levels. The following Saturday the medical society, in a further full-page advertisement, expanded on its criticism of the closed-panel system by running a comparison with the present system. Opposition was reiterated and the audience it was trying to reach was identified when it said: 'Although it is beyond our

27 Mobilization power to decide a policy for the local union members, we feel that our accumulated knowledge of medical care may be of help to the union members in preventing their executives from leading them into a very unhappy and costly experiment.' This was the last of the full-page advertisements ... for a while. The dispute reached further afield when, at the May 1960 meeting of the Ontario Medical Association, the situation precipitated a resolution 'to study and clarify the statement of policy of the OMA as applied to the operation of "closedpanel" clinics sponsored by lay groups.' 22 (In fact the OMA had implicitly been supporting closed panels, where participants could see only panel doctors, for many years by doing nothing about management plans like INco's in Sudbury. The differences in the Sault plan were that a union was involved and the doctors would not be paid fees for service.) The OMA also then decided that mediation of the dispute was required and proposed a meeting with the union. This meeting was arranged for July in Sault Ste Marie: international, national and local union people were to attend, along with officers of the local medical society. 23 At this time a bitter election campaign was being fought by the CCF in Saskatchewan against doctors who opposed the ccF plan for government medical insurance. It was not surprising, therefore, that the national press took up the Sault dispute. The Toronto Telegram published a story saying that Sault Ste Marie had been turned into a 'Little Saskatchewan' by the fight over prepaid medical care between Canada's largest union, the United Steelworkers, and the local medical association. 24 The OMA meeting took place just over two months after the last of the fullpage advertisements, but the national press stories, coupled with Barker's periodic appearances on local radio and television, had kept the issue alive. Additionally, Goldberg had made a fairly provocative presentation to the Canadian Medical Association meeting in Banff during June, when he criticized current medical care organization in Canada and advocated prepaid group practice with a lay board. He concluded by saying somewhat wishfully, or maybe it was wistfully, 'I am sure that labour can look forward to nothing but cooperative understanding from organized Canadian medicine.' 25 It was on 8 July 1960, in the Mid-City Motel, in the Sault that the OMA, as the medical society's negotiator, met with the union - but what transpired was little more than a description of the proposed program. The OMA president, WW. Wigle, set the stage by saying that 'the OMA Executive had come to Sault Ste Marie to listen to the union proposals, and had no formal policy to present at this time'. 26 The OMA were most interested to find out if'the union was committed to this course of action.' This was obviously related to their later desire 'to know the response of the union representatives to a hypothetical plan which could be run by the doctors and built around a modified PSI with ancillary ser-

28 First and Foremost vices and all aspects covered as desired by members.' They seemed to be responding to the threat of competition from the union by presenting the possibility of an improved insurance package which addressed the cost concerns. For the union's part, they were intent on impressing on the OMA that it was the new way of organizing the medical care which most attracted them to the plan, and not so much the cost of the care, although this was obviously a consideration. 'Mr. Goldberg considers that ... in private practice it appears that many decisions have been made on non-medical grounds. For example, many tests are performed in hospital because this was the only place where insurance would cover them.' The meeting broke up with plans for another consultation in the near future-after the OMA had made further investigations, had established a clear policy, and had worked out details of their alternative comprehensive insurance plan. By January 1961, the OMA council had approved a policy on closed-panel clinics sponsored by lay groups. On 23 February, the OMA, the union, and the Sault medical society convened in Toronto for further discussion. A week before the meeting, a statement made by the oMA's parent body- the Canadian Medical Association-was not encouraging. An editorial in their journal expressed its opposition to union health centres with salaried doctors. The oMA's lengthy policy statement did, however, try to take into account all sides of the issue. It considered not only the rights of physicians under closedpanel plans, but also the rights of the plan's participants. It concluded that, while the OMA certainly didn't like closed panels, 'the Ontario Medical Association ... believes that the operation of a closed panel clinic need not contravene the Code of Ethics or Statement of Policy of the Association.' 27 The careful inclusion of the words 'need not' allowed them some flexibility, but exploration of the policy in the meeting revealed an OMA which was not directly opposed to the Sault plan. To quote from the minutes: 'Mr. Mahoney asked whether we couldn't say the two systems (Health Centre and private practice) could live side by side and we could find out which is the better. Dr. Sawyer, Dr. Wigle, Dr. Bruce Lockhart and others pointed out that this was exactly the thinking of the Council of the OMA and the profession.' The OMA appeared, therefore, to be tolerating the union clinic as an experiment in the delivery of medical care. Even with regard to the issue of freedom of choice of physician, the OMA seemed to come down on the union's side. They felt that as long as members of the plan had chosen, by free vote, the closed panel of doctors, then the individual's freedom of choice was being respected. As regards the individual's 'freedom to choose the method by which he will pay for or prepay his medical care,' they

29 Mobilization stated that 'initially the individual should be able to exercise this freedom of vote. Thereafter, as a member of a group he would be subject to the will of the majority and could exert his freedom only by vote or by leaving his place of employment.' 28 In other words, individuals could relinquish their right to have a constant choice between all available physicians by making a periodic choice to receive care from a specific group of physicians. The OMA also declared that it would be offering a more comprehensive insurance plan to the Sault in the near future. The union came away feeling reasonably pleased and in March, when the OMA policy became public, the press interpreted it as favourable to the union. Bill Mahoney was quoted in a Toronto Globe and Mail article entitled 'oMA to Cooperate in Labour Medical Plan' as saying, 'the OMA has taken a statesmanlike approach to the question. We hope to work with the OMA in a development of our health centres.' 29 The Sault medical society was less than pleased. It did not feel that the OMA had represented it very effectively. The Sault vice-president at the time, Dr Arthur Scott, commented on the OMA in a later interview: 'They had a very jaundiced view of the private practitioners in. Sault Ste Marie. In fact ... I had the feeling that they wouldn't mind if the rebellious doctors in the Sault got their come-uppance, and that maybe they deserved exactly what the union was about to give them ... I had very little confidence that the OMA would do anything for us in this struggle ... and, indeed, their conclusion was that this was an interesting sociological experiment that should proceed.' 30 This tension between the Sault medical society and the OMA would continue for some time. However, the OMA's apparent support for the union did not last long. By May 1961 the provincial medical association was back-tracking. It declared publicly that 'it does not approve of closed-panel clinics. This step [the public declaration] was taken ... because following a January meeting of the OMA Council, some newspaper headlines left the impression that approval was given to the closed panel now being planned in Sault Ste Marie.' 31 It also approved for publication and use in the Sault a small pamphlet on closed-panel clinics, 'Choose Your Own Doctor,' which included the statement: 'closed panel clinics could endanger the welfare of a community ... increase the cost of medical service [and] are alien not only to the best practice of medicine but also to the democratic rights of free people.' It was clear where the oMA's ultimate sympathies lay, even if its support of company-run closed panels like INco's prevented it from establishing clear policy opposition to the steelworkers. The OMA's attempted solution to the medical care problems in the Sault also demonstrated its lack of sympathy for the union's

30 First and Foremost goals. Despited being told that the organization of comprehensive care was the union's main aim, the OMA proposed a simple extension of the existing insurance arrangement-a solution which centred on cost, not organization. Nevertheless from the union's perspective, a victory had been achieved. Its plan had not been declared unethical, and an agreement was reached that conflicts be resolved in private, and not in the pages of the press. EDUCATION AND INFORMATION

Meanwhile the union was busy encouraging workers to sign authorizations for check-off, collecting initial data on current services and costs, searching for a qualified consultant for the project, and educating its members. The dispute with local doctors helped to keep the issue alive. Stewards and union activists talked about the health centre with members whenever possible. However, the union was in a tactically difficult position. It didn't want to stir things up too much, but at the same time it had to convince its members of a need for the health centre. It was, therefore, careful not to criticize any individual physician's care, and to emphasize that everyone had the same goal - high-quality medical care. As Barker said: 'I don't think we were ever critical of the quality of the care that the local physicians gave to any patient. We were critical of the lack of numbers of them and the fact that we had to wait so long for health care-and the fact that every time we negotiated a contract to provide care, and negotiated sufficient money to do it, we were quickly confronted with extra billing. These were the things that we were critical of.' It was inevitable, however, that individual unionists would not walk this tight line as carefully as the officers, and undoubtedly rumours circulated - some people probably encouraged them. Medical society doctors had to take some lumps. One of the doctors recounted that 'during the time that these talks were going on, I came out to find my car painted in the driveway one morning- obscene words painted on the side of the car.' 32 These incidents were not common, but they served to fuel the doctors' opposition and added to their impression that the union was out to get them. This polarization increased the degree to which union members identified the health centre as 'our project' and certainly helped to increase support within the ranks. However, it also meant that a visit to the local doctor's office became as much a political event as a medical consultation. This particularly affected the women, traditionally the supervisors of the family's medical care: it was they who frequently found themselves being harangued by their local doctor whenever the family required care. This presented a problem for the union which, through its need for signed

31 Mobilization authorizations for check-off, had contact with the employees but not with their families. To involve the women, tea parties were held in order to encourage discussion of the health centre, but these were not very successful, and a more effective method had to be found. This was done under the supervision of Glenn Wilson, the new project consultant on the health centre team. The search for a project consultant had taken Barker down to a meeting of the Group Health Association of America in Columbus, Ohio, in 1960. There he met Wilson, the organizer of the conference, who was already well versed in the type of plan the local proposed. He had spent time in Pennsylvania with the United Mineworkers Welfare and Retirement Fund and, along with a radical young physician, Tom Ferrier, had been instrumental in setting up the Russelton Medical Clinic there. Wilson and Barker had a lengthy talk over a drink or two and found that they got on very well. Wilson was the type of person who aroused strong emotions - you either gravitated to him or avoided him. Armed with facts and figures he could out-think, out-manouevre, and finally convince the right people of the right way. Goldberg said of him: 'Glenn is much more of a detail man than I am ... that's where Glenn shines. He knew what needed being done and he kept at it and kept at it until it got done.' He was deft at seeing through to what a project needed. There was no doubting his fierce loyalty. His commitment to Barker and others can be seen in that he found himself in the Sault, rather than at home, for ten of his daughter's birthday parties in a row. He was efficient and hard-working, and he had just a touch of the slave-driver in him. After talking to Barker, Falk and Goldberg recommended to the national office that Wilson be hired as the main co-ordinator in the Sault and he was seconded from the national office part-time (he was also starting on a similar project in Cleveland). The Sault's health centre was becoming a real co-operative effort within the union. The International was providing Falk. Mahoney at the national office gave his own time, he committed resources, and he provided first Goldberg and then Wilson. Sefton allowed Barker to spend much of his time on the health centre and enthusiastically supported the endeavour. At the local level, John Ferris's 2251 was joining with other area steelworkers in locals 4509 and 5595 and committing many man-hours to the project. Wilson's first major task was to plan and implement a household survey in the Sault which would provide information on the current level and cost of the steelworkers' medical care, and incidentally bring the union into more effective contact with the wives of its members. As part of his PhD research, Goldberg had already constructed a questionnaire for Hamilton steelworkers so that he could compare two welfare plans in that city. These same questions were modified by Wilson in the fall and winter

32 First and Foremost of 1960 and amended by Falk; the survey was ready by January 1961. These household surveys not only brought contact with the wives, they also encouraged the members who were to do the survey to become more involved. Nearly a hundred volunteers contributed hours of their own time. One canvasser recalled, 'I ran my canvass on a one-to-one basis or a family-to-one basis and I made the appointments ahead of time and I would see two or three families a night ... They would worry about the calibre of medical aid. Whether they would get a bunch of young doctors just out of college ... the cost never seemed to be a factor as I reflect.' 33 In the three-month survey, over 650 steelworker families described how much they had spent on medical care in the previous year, and what they had spent it on. They also gave details about their dependants and other demographic data. The results were tabulated by April 1961. They were not scientifically accurate, depending as they did on people's recollections of information from the previous year, but they left little doubt that there was a problem. It was revealed that less than 40 per cent of doctor costs were met by the welfare plan. The average steelworker was spending over $50 a year for doctors outside insurance coverage. Less than 18 per cent of total health charges were paid for by insurance. Also, interestingly, the survey revealed an average of 3.25 dependants per employee, although current insurance coverage definitions produced an average of only 2.6. The current welfare plan was obviously defining dependants too stringently. All this information was to be very useful in persuading Algoma of the need for the health centre when contract negotiations started later in the year. 34 Meanwhile, Wilson had worked out preliminary figures for the cost of putting up a building. The calculations suggested that $800,000 would be needed. With 6,000 union steelworkers in the Sault, each would have to contribute $135-the original rough estimate by Barker had been $150. Canvassing for check-off, which had to be renewed in May 1961, could now be done with an actual target figure. When the new authorizations were signed, they were no longer for 50¢ but for $1, $2, or $3 per weekly pay. Three thousand eight hundred workers had signed the first check-off, but the renewals numbered only 2,400, which suggested that grassroots canvassing ·had lost some momentum. This was hardly surprising given the other work being done. Barker was seeking out possible sites for the health centre, arranging for an information booklet for members, as well as organizing and speaking at meetings. Goldberg was initiating talks with lawyers to work out the legal structure of the health centre, continuously co-ordinating everyone's efforts, and contributing to discussions about the operating budget. In addition to supervising the survey, Wilson was putting together a detailed operating budget for use in the contract negotiations. Significant input was coming from Falk for this. Mahoney, Sefton, and Barker

33 Mobilization were starting to investigate areas of common ground with Algoma for the forthcoming negotiations. As it turned out, these negotiations dragged on right through the summer of 1961 and finally went to conciliation in the fall, when the health centre issue was to be raised fully for the first time. The major points to be decided were l I What level of premium was required to provide the comprehensive benefits that members had been promised? 2/How extensive should coverage be in both breadth of services and extent of dependents covered? 3 / How large was the population to be served and, therefore, how big should the staff of the health centre be? 4/Should there be a dual choice where union members could vote for which plan they wanted- the present Prudential or the new health centre -and then receive their voted choice? 5 I Could they arrange for a check-off with no need for yearly renewals to raise the $135 building fee from each member? The question of the level of premium was really decided by outside market forces. In July 1961, the promised OMA counter-proposal came in the form of a PSI insurance scheme which was very comprehensive for those days. The threat of the health centre had certainly provoked an attractive package-offered only in Sault Ste Marie-which became the costing guide for the health centre. Falk and Wilson proposed a monthly premium of $7.90 compared to Ps1's $9.05. The current welfare plan at Algoma-Prudential's-had a premium far lower than this but provided much less coverage. Negotiations, however, had to produce an increased company contribution to the welfare plan, which would make up the dollar difference between the old plan and what the new health centre needed. The required increase turned out to be at least three cents per employee-hour worked bringing the total company contribution to a minimum of seven cents per employee-hour worked. 3 5 This was the figure which the union took into negotiations. The question of the extent of coverage had been answered by Barker and others who had already promised that retired workers and all types of dependants would be covered. The promise of comprehensive coverage meant that, unlike the PSI plan, there were no limits on coverage for doctors' services, and the additional services of physiotherapy, optometry, vaccination, and preventive health were included. The size of the health centre population was assumed in the calculations to be the 6,000 uswA members and their dependants (approximately 19,500 people). This included the 5,000 or so in Algoma's Local 2251, plus a few hundred

34 First and Foremost in their office workers' Local 4509; additionally, a recently opened German company, Mannesmann Tube, had just over 400 in their Local 5595; a couple of other small locals brought the total up to 6,000. By including all the potentially eligible members in the calculations, the union assumed that the company would agree to all union members' welfare payments going to the health centre. Under the other option - dual choice-each member would indicate which plan he wanted for his and his family's health care. He would then be covered under whichever plan he had chosen, with his premium paid by the company to whichever plan he had selected. The traditional union pattern was to have the majority vote count for all, and this seemed to be its position as negotiations were approached. Goldberg certainly had this idea in mind when he wrote to Falk and Wilson: 'At the moment we do not expect any real opposition from the company on the health plan, but we must be prepared to meet it if it does come. The company may try to keep their contribution to the new plan low, or may try to insist on dual choice.' 36 However, Wilson and Falk favoured the idea of dual choice, as they foresaw that having members in the health centre who did not want to be there could cause problems. They also saw the advantage of members actually choosing the health centre plan. As Wilson later put it, it was important 'that all health insurance for everybody in 2251 is cancelled as of some date ... [then] you must make a choice or you have nothing.' Nevertheless the brief for negotiations reflected the traditional union viewpoint: 'It is proposed that once a majority of the union members signify their desire to join such a program the Algoma Steel Company pay on behalf of all employees in the bargaining unit the agreed upon money for health services to the consumer sponsored medical care plan.' 37 Thus, going into negotiations in the Sault on 14 November 1961, the union wanted at least seven cents an hour for welfare benefits, majority vote instead of dual choice, guaranteed check-off for the $135 building fee, and a set date when company payments for the health centre would start. For their part, Algoma were willing to distribute the negotiated increase to wherever the union desired, so they had no major opposition to the health centre idea. However, they wanted to make sure that the proposed plan would work. As one negotiator said: 'We knew that if we agreed to this package and it didn't work out, we weren't going to be able to walk away ... we believed our position was to ensure that it was as viable as possible, not out of any altruistic motive, but because we didn't want to get caught holding the goddam bag.' 38 After the usual long hours of negotiation, on 27 November a memorandum of understanding was signed which met nearly all the union's demands and, in some cases, exceeded them. 1\vo periods were established-one to the end of 1962

35 Mobilization and the other starting l January 1963. In 1962 there was to be a nominal increase in company welfare contributions, but essentially things were to be left unchanged for that year. Then, in 1963, the company's contribution would increase to 7.8 cents per employee-hour actually worked. The health centre would be recognized by the company as of 1963, but Algoma required a dual-choice election. 'Members of plan [are] to be split into two groups-the Clinic Group and the Insured Group. Each employee will be required to choose the Group to which he wished to belong at an election to take place under neutral conditions with full information on the alternatives to be given employees in advance. The company's position will be strictly neutral; it will be concerned only to see that each employee is given full opportunity to make a free choice.' 39 The opportunity to transfer from one alternative to the other one had to be provided once every year, i.e., annual dual choice. Finally, a check-off which would be in operation until any member who had authorized it had paid the full $135 building fee was agreed to. The company had clearly recognized the union's goal of starting the health centre. They had also recognized that it would cost more money than the current welfare plan, and had greatly increased their contribution by four cents per employee-hour worked. That this increase was at the expense of an improvement in the hourly base-rate pay structure is evidence of just how committed to the idea the union was. In the three years before this contract the base rate had improved by 24 cents an hour; in the three years following, the improvement was 28 cents an hour; but for this contract period, it increased only 9.5 cents an hour. The union was willing to forgo a larger increase in order to get the money into the welfare plan. Although this would probably now give the health centre enough operating funds, it would also put more money into the Prudential plan, which could then offer a better package. The opening of the health centre was set for late summer 1963. The details of the dual-choice election were carefully worked out during and after negotiations, with the ever-suspicious Barker making sure that it would be a fair process. The election was planned for September l 962- just over nine months away-and this became the new target date for health centre activities. Since the first seminar in October of 1959, then, there had been a gradual build-up to the conclusion of this agreement. The members had been educated and mobilized, opposition from the local doctors was at least out of the public eye, money for the capital funds was starting to come in, an impressive team of consultants was gathered together, and detailed operational budgets were established. The job now was to convince the members that the way to vote in the September 1962 dual-choice election was for the health centre.

3

The Union as Organizer

ORGANIZATION PAYS OFF

At a major organizational meeting of the local in December 1961, just a few weeks after the contract was signed, it was unanimously agreed that 'there would have to be a stepped up campaign to sign people for capital check-off.' 1 It was also suggested that such a campaign should ~e 'co-ordinated with announcements regarding the purchase of land for the Centre, the hiring of architects and so on.' The union was aware of the need for speedy action and clear organization: 'a timetable should be developed and insofar as it can be foreseen the work that must be done should be assigned to a specific person to be accomplished.' 2 A clear organizational structure did start to emerge. Falk acted as the consultant, proferring sage advice from a distance, and using his contacts in the search for a medical director and an architect. Wilson was involved on a day-to-day basis- he visited the Sault frequently, kept an eye on the timetable, planned rather than organized events, and used his expertise in dealings with architects and contractors. Goldberg, in the national office, acted more in the capacity of overall co-ordinator, and became directly involved when union-style organization was required: he took most of the responsibility for arranging the legal structure of the health centre. Barker was in the thick of it all, ever-present in the city, seeking a building site, organizing the canvass of members, and, with Wilson, dealing with day-to-day business. Because of their close on-the-spot involvement, Barker and Wilson came to play increasingly important roles in the setting-up of the centre, particularly as time pressures often made collective decisions impossible. By January 1962, Barker had finalized a check-off authorization for the $135 building fee which did not require yearly resigning- it was good until the full

37 The Union as Organizer sum was paid. This check-off became the barometer by which the future success of their endeavour could be forecast. A progress report written in February noted that, 'The program to get 4,000 members of local union 2251 signed up has been launched ... We should all keep in mind that we are not only raising our necessary capital funds but we are really determining how many we will get on dual choice. It seems to me highly unlikely that a person will agree to put in $135 and then not select the Health Centre.' 3 The sign-up campaign, which began in earnest on 1 February, was a highly organized affair, designed to add to the 2,400 members already on check-off. The union produced lists of those not yet signed up, and volunteer canvassers equipped with questionnaires and brochures made house-to-house calls. A team of fifteen women worked on the telephones, calling the wives of steelworkers who had not yet signed up. A crucial element in this was John Barker's ability to select to do the canvassing people who were most likely to influence the members. A letter which Barker sent to all the members as part of the campaign indicates the kind of approach that the canvassers took. Comparing the current welfare plan with the proposed health centre, he said: We have provided for you having a choice of the type of medical and surgical coverage you desire ... You may be covered by the Group Health centre, where there is no limit to the amount of coverage, where there is no additional cost, where you and your dependents may get treatment or care as often as necessary with no charge for any calls, from and including the first visit. Where you will receive, after being retired at normal retirement age, free medical and surgical care ... You will also be able to have coverage in case you happen to be laid-off, by paying the premiums. This you cannot do under our present type of welfare plan ... Your dependants are anyone residing with you for whom you can claim income tax exemptions, regardless of age. You will have a greater choice of doctors in the Group Health centre than you presently have. At present, for the Soo and district, there are approximately 42 doctors or one for each 1,400 people, while in the Health centre we expect to have ... one doctor for each 1,000 people. Each person will have their choice of the doctors as their personal physician or family doctor ... you will have available other doctors who specialize in whatever might be wrong with you. If you have a condition that cannot be taken care of by the Health centre staff, someone will be brought in ... or you will be sent to wherever it is necessary to have it taken care of. We hope Steelworkers will take advantage of this opportunity, to me this is the greatest individual endeavour we have ever undertaken. 4

38 First and Foremost Free coverage after retirement proved to be a powerful selling point in the era when retirement frequently meant hardship. The canvass of the members was more than a mere sales exercise. It was a real dialogue in which canvassers listened as well as informed. They carried back their fellow steelworkers' comments to the union hall, and these comments helped to shape the final form of the health centre. The campaign was not announced publicly, as it was an internal union affair. However, care was taken to keep news of the health centre's progress in the public eye. The first step in this progress was marked by the announcement, on 6 February, that land had been purchased and an architect Jerome Markson, hired. Markson had been involved in planning the Bayview Hospital in Toronto and had received awards for work in Elliot Lake. Initially he was consulted to help find an architect but, after discussions with Wilson, it was decided that he was the best person for the job. He was hired to do the preliminary design work and specifications for a site selected by Barker. Wilson sent him a long memo setting the tone for the kind of health centre that was required: The word 'health' is used instead of medical in a deliberate sense. The entire program is expected to be a pleasant place where people in the Soo can receive personal attention ... A 'clinic' insofar as it means a place where the 'worthy poor' are queued up on benches for the beneficence of doctors, is exactly what we oo Nor WANT .. • It is expected that doctors at the centre will freely consult with one another ... total staff, doctors, nurses and technicians and others will develop into a team. The design of the centre will ... encourage this free exchange among members of the team.'

Barker's selected site, on the advice of Falk and Wilson, was located close to the two city hospitals- right across the street in fact. An offer to purchase this plot on the corner of Simpson and Queen was submitted at the start of February, but it was subject to the rezoning of the land from residential to light commercial use, a process which could take at least ninety days. Design work had to go ahead before the planning committee decision was reached. Things went reasonably smoothly, with initial approval by the city council planning committee and a swift call for public hearings in early summer. The purchase of the land and building was to be financed by loans secured with the promise of funds from the $135 building fee check-off. By March, a month after the sign-up campaign began, the check-off authorizations had increased to about 3,500-nearly 3,000 from Local 2251, 100 from the Algoma office workers, and almost all of the local at the Mannesmann

39 The Union as Organizer Tube Company. None the less, Wilson stressed how important it was to keep things happening: 'We cannot afford to let the current drive bog down ... If the drive bogs down in the next week or so, we must institute new measures.' 6 As it happened, they did not have to worry. The local doctors emerged from their public silence on 2 March and their action obviated the need for any 'new measure' on the part of the union. Obviously concerned at what now seemed to be the inevitability of the health centre, they released a statement which became front-page news in the Sault Star. The article, with the headline 'Doctors Won't Enter Union Health centre,' included this statement by the Sault medical society: The position of the local doctors of Sault Ste Marie today is exactly the same as it was last year ... Briefly- the Sault Ste Marie Medical Society feels that medical practice as proposed in the union clinic is not in the best interests either for the union members and their families or the community at large. The Medical Society feels that the concentration of responsibility for provision of medical care in a non-medical organization such as a union is a backward step and can only result in deterioration of the quality of medical care provided to the community ... members of the Medical Staff will not be joining the staff of this clinic. The position taken ... is in full agreement with the policy of the Ontario and Canadian Medical Associations.

This story was quickly picked up by Toronto papers and appeared across the province on 3 March. Goldberg immediately contacted the OMA to see if they knew about the statement, which had broken the nearly two-year agreement of silence. They had no knowledge of it. He therefore told the OMA that 'I hope you can appreciate the fact that our members in the Sault feel they now have to answer this unwarranted attack.'' The steelworkers answer took the form of a full-page advertisement in the Sault Star of 6 March, with the title 'An open letter to the doctors of Sault Ste Marie.' The advertisement provided the union with an opportunity to educate its members further, and this it did in detail. It defended group practice, using examples like the world-renowned Mayo Clinic in the United States. It reiterated that the union would not run the health centre; rather, 'a board of directors similar to the board of a hospital will establish policy ... the fact that the union had no intention of telling doctors how to practise medicine has been made clear to everyone'. As well as reporting the progress of the plans for the centre, it criticized the local doctors for not increasing their numbers, not attracting qualified specialists, and for extra-billing their patients. However, it still did

40 First and Foremost not rule out local doctor involvement: 'Once again we invite qualified local physicians who are truly concerned with the public interest to join us in this program.' This exchange gave the sign-up campaign a welcome fillip. Education and interest were also helped by outside events. The prime minister, John Diefenbaker, had appointed Justice Emmet Hall to the Royal Commission on Health Services in 1961, and by early 1962 public hearings were being reported in the press. Much of Hall's early activity was devoted to isolating inadquacies in coverage provided by most commercial insurance plans. Throughout Canada the health insurance debates raged, with conferences, seminars, and public meetings all decrying the absence of adequate health protection for the population. At the same time in Saskatchewan, the doctor's strike, which would rack that province in July 1962, was building up, and many local communities were starting to prepare for the provision of their own medical care in the anticipated absence of Saskatchewan doctors. Against such a background events in the Sault generated wide interest and were extensively covered - articles appeared, for example, in the national news magazine Macleans on 27 March and in the April issue of Canadian Doctor. In April Barker received a standing ovation when he reported to the Steelworkers' national policy conference in Vancouver that 'a total of 4,247 members have joined the Health centre and signed payroll deductions for the $135.00 membership fee. New members are joining the Health centre at the rate of more than 200 each week. Because of the good response to the membership drive, the board of the Health centre has decided to build for 6,000 families rather than the more than 4,200 already signed.' 8 The search for an executive or medical director had been led by Falk since the early days of 1960. A major consideration was that a Canadian should fill the post, although finding one with appropriate qualifications and experience was not easy, there being no facilities equivalent to those planned for the health centre anywhere in Canada. Falk wrote to one American university professor 'about the preference for a Canadian physician to run the Sault project if he could be found; and otherwise searching for someone from the USA to be Medical Director. A Canadian preference is not vital, but I am sure that many aspects of the work, especially recruitment of staff and initial organizational work with various groups, would be much easier for a Canadian physician than for someone south of the border.'9 From 'south of the border', Wilson had already brought in Tom Ferrier, his old colleague from the days of the Russelton Clinic in Pennsylvania. Ferrier had been medical director there and then assistant to the administrator of the United

41 The Union as Organizer Mine Workers' welfare and retirement fund, of which Russelton was a part. He had visited the Sault early in 1962, got on well with the people, and was very well qualified. He was, however, an American. The most promising Canadian candidate was George Morrison, who came from a small group practice in Fort William. He wrote in April expressing interest, and on I May he visited the Sault. He had nothing like the experience of Ferrier but had worked in group practice, had a lot of sympathy for the union's goals, and, most important, was a Canadian. He was the subject of much discussion by the health centre organizers attending a GHAA meeting in Washington on 13 May. The main purpose of this meeting, attended by all the major participants in the project and the medical directors from two major U.S. programs, was to discuss thoroughly the architect's plans. The planning was reaching its final stages, with space for at least eighteen doctors and possible expansion for up to twenty-five; the centre would be capable of serving 25,000 patients. Final approval for the site's rezoning had not yet been obtained, but a few days earlier, on 8 May, the city council had recommended approval to the final authorizing body, the Ontario Municipal Board. As the appointment of a medical director was considered an urgent priority, the participants also took the opportunity to discuss this. Not all of them had met Morrison, so it was decided to invite him to the first full board meeting of the Sault Ste Marie and District Group Health Association, due to take place in Toronto on 27 May. For some time now, Goldberg had been thrashing out the details of incorporation, the composition of the board of directors, and the nature of government requirements for providing insured medical care. By the end of May these details were well enough established to warrant this first meeting of the board. The Sault Ste Marie and District Group Health Association was going to be a non-profit corporation run by a board, largely of steelworkers but including up to three members of the local community, to be selected by the steelworkers on the board. The inclusion of three community members was important if the union was to fulfil its promise that the health centre would not be uniondominated and would eventually open its doors to groups in the rest of the community. The first meeting was, however, composed entirely of steelworkers, as it was not yet decided who the community members would be. The participants knew that a decision had to be made on a medical director, and that the choice was more or less between the American, Ferrier, and the less experienced Canadian, Morrison. The feeling of all was that a Canadian was needed, and it was unanimously agreed to offer Dr George Morrison the position of medical direc-

42 First and Foremost tor. One week later, on 3 June, Morrison accepted the offer and all that remained was to arrange a contract. Despite the gruelling timetable, events seemed to be falling into place. THE BUBBLE BURSTS

The day after Morrison's acceptance, the insurance carrier Prudential published details of its new welfare plan in the Sault Star-this was to be the alternative to the health centre in September's dual-choice vote. This new insurance policy took the wind somewhat out of the union's sails. Because the extra welfare contributions paid by Algoma went not only to the health centre but also to the Prudential plan, the union local had been worried about the new scheme Prudential would offer. Competitive it certainly was. Instead of coverage from the third doctor's call, it was now from the first . Dependants, although still narrowly defined, would be covered for medical as well as surgical costs. The issue of preventive care, raised by the union, was addressed by allowing one medical check-up each year. And, as Prudential took pains to point out, all of this would 'let you keep your present family doctor ... definitely go into effect on January 1, 1963 [and] all at the same low monthly charge you now pay with no membership.' 10 It was one of the best welfare packages to be found anywhere in the country at the time. On top of this, the local doctors had met in May to discuss the matter of extrabilling over the plan's provisions. They decided that they had little choice, and informed Prudential that 'all the members of the Society present indicated that they intend to accept the amounts provided by the Plan as payment in full for services rendered to those covered by the Plan, except in very unusual circumstances.' 11 It was not an outright pledge, but it was a vast improvement over the widespread extra-billing of prior days. Without so much as a brick in place, the health centre was already having a major effect, if not on the organization, then at least on the cost of the Sault's medical care. The year before in December 1961, the medical society had decided that the 20 per cent fee increase announced by the OMA for 1962 would not go into effect, as fees in the Sault had already been raised in 1959. The previous summer the OMA had also offered the competitive PSI plan for a limited time, only in the Sault-their response to the union's conflict with the local doctors. In Toronto the OMA, having heard about the dual-choice requirement, felt that it was time to try again. The minutes oftheoMA Council for January 1%2 stated: 'It is now understood that, at the insistence of the management at Algoma Steel, each worker must be given a free choice of whether to participate in the clinic

43 The Union as Organizer program or in a separate insurance program ... At this date we have not heard that the company to underwrite the insurance aspect has been arranged. At any rate, this development is encouraging, particularly to the Sault doctors. PSI will make another approach in the Sault as a result of these recent developments.' While all this was very beneficial for the population of Sault Ste Marie, it was exactly what Barker and others in the union had feared. It was clear that such improved welfare programs were worthy competitors for dual choice. The difference between the actual benefits and cost of the health centre package and those of its rival were not going to be so great: the health centre would give greater dependant coverage, include some extra services, have no ceilings on cost, provide the convenience and advantage of group practice with the services all under one roof, and cover retirees free, but it would require a $135 membership fee as well; the Prudential improvements advertised on 4 June and the fee-cutting response of local doctors established an attractive dual-choice alternative. Such developments made it essential that another event be announced, to show that concrete progress was being made. The obvious move was to report the hiring of the medical director, Morrison. However, his acceptance depended on first establishing his contractual relationship to the Sault Ste Marie and District Group Health Association. Much discussion had already taken place about the relationship of the doctors to the health centre's board. Barker, Woodcock, and others had been much influenced by what they had seen in Philadelphia, where each doctor was under individual contract to the union board. Wilson and Falk were more familiar with the format of large prepaid group practices like those in California, wher~ all the physicians formed an autonomous partnership and the board contracted with the partnership for the provision of the subscribers' medical needs; it would be difficult, however, to construct a partnership before the doctors knew each other or knew how the program worked. Therefore the letter of contract sent to Morrison in mid-June stated that 'the only practical plan at the outset is to retain the medical director, and then to retain each additional staff physician through an individual contract as the recruitment proceeds ... after ... the Group Health Association has had a year or two of actual and effective operation ... it will consider a shift to the pattern of contract with a partnership.' The union tried to speed things up so that they could announce Morrison's appointment at the opening of their new union hall on 17 June, when local dignitaries and most of the members would be present. A model of the health centre on display attracted much attention and praise. Fred Griffith, the local director of the Welfare Federation, or United Way, spoke with Wilson and remembers that, 'He and I got into a great argument about would it work,

44 First and Foremost wouldn't it work, why was it necessary, all sorts of things,' unaware that two years later he would become the centre's administrator! However, the event passed with no mention of Morrison. It transpired that he had submitted the contract letter for comment to the College of Physicians and Surgeons of Ontario-the disciplinary and rule-making body of the doctors. The College expressed concern at the proposed individual contracts, and warned Morrison that the plan was radical although, they agreed, not illegal. Morrison himself was starting to have doubts: he wasn't sure if he was really an administrator, his wife was concerned about the conflict with the local doctors, and the OMA was sending a deluge of adverse literature and comment about closed-panel plans. He started to stall while his lawyer made further investigations. By the time of the board meeting on 20 July, the union was close to the end of its tether - it desperately needed a medical director well before the dual choice on 14 September. The next day Morrison finally admitted that he had been scared off, and he turned down the offer of appointment. The board had lost their medical director with only six weeks left before dual choice. They decided to allow one more week, until 30 July, to find a suitable Canadian candidate. That week in July, however, brought another blow to the health centre's aspirations. Having held public hearings on the proposed rezoning by-law for the planned site, the Ontario Municipal Board decided that 'In view of the opposition to this application and after consideration of the proposed parking requirements, the Board does not feel that it should approve this by-law.' 12 The chairman of the Plummer Memorial hospital, Arthur Wishart, had opposed the rezoning application on behalf of a local physician and the hospital itself. Was a situation going to arise like that in the United States where many union groups had been forced to build their own hospitals when the local ones refused privileges to the group doctors? Architect's plans had been prepared for this site, tenders had been called to remove the house that was on the property-and now the rezoning had been turned down. This was a major setback, and Barker released a statement saying, 'We are frankly shocked at the decision and can only conclude that the board made their decision on some grounds other than the facts that were presented at the board hearing.' 13 He continued, however: 'There are any number of other properties both inside and outside the city that can be used for our health centre. We will be prepared to call for tenders on the centre in the near future.' A few days later the 30 July deadline expired, with no suitable Canadian candidate, for the post of medical director. Things looked bleak indeed as August began.

45 The Union as Organizer THE DUAL-CHOICE ELECTION

On 30 July, efforts to bounce back from adversity started by sending an offer to Ferrier in Pittsburgh. He was, in fact, just returning from Saskatchewan, where he had been helping to place the volunteer physicians arriving as substitutes for the doctors on strike against the introduction of medicare to that province. He was well experienced in dealing with that kind of conflict, as in the early 1950s he had been the founding medical director-with help from Wilson and the United Mine Workers-at the Russelton Medical centre. He had often experienced conflict both with the local Allegheny medical society, and with the state medical society after his move to the area office of the United Mine Workers' welfare and retirement fund in 1957. By now he was becoming disenchanted with the mine workers, who had lost some of their initial crusading zeal and were becoming more political than medical; he was consequently attracted to the obvious energies being devoted to the Sault program. Over twelve years' experience with union-sponsored group practice had taught him many lessons about the need for pragmatism, and fostered in him a dedication to the efficient delivery of medical care. He was a supporter of group practice, of consumer sponsorship, and of alternative methods of remunerating physicians rather than the fee for each service, because he saw these as the best ways of delivering medical care. It was this belief which gave rise to his socialism, not the other way round. He was soft-spoken and unassuming, but very experienced. The clouds over the health centre program at the start of August started to disperse when Ferrier accepted the position of medical director. Contract details and a starting date had still to be worked out, but Ferrier was already aware of the board's attitude. The sun even started to shine through the clouds when, on 2 August, Barker found a suitable site to replace the one across from the hospitals. It was located in Turentorus township, which in 1964 was to be incorporated into the city, and seemed to be ideally situated to take advantage of the city's expansion. The new site, formerly a chicken farm, was much larger than the old one, but would not necessitate major changes to the architect's drawings. On 3 August an agreement to purchase was signed, but nothing was yet announced publicly. On the same day, the concerns about local hospital opposition evaporated with the publication of a letter by Arthur Wishart. He explained his appearance at the Municipal Board hearings: 'the impression seems to have gone abroad that the Plummer Memorial Hospital opposed the establishment of the medical health centre. This impression is entirely contrary to the fact of the matter ...

46 First and Foremost My submission was directed solely to the question of the proposed location which I felt would create a serious traffic and parking problem ... It was on these grounds alone that the proposed site-not the health centre-was opposed ... I stated openly ... that the hospital would welcome to its staff qualified medical personnel serving the clinic centre.' 14 It looked after all as if the health centre doctors would have no major difficulties gaining privileges at the Plummer hospital. Falk, however, had not been kept well-informed of these changes, and on 9 August he called Goldberg to find out what was happening. He was shocked to discover that a new site away from the hospitals had been selected and an American appointed as medical director. It was he who had pressed for a site next to the hospitals and for a Canadian director, and he undoubtedly took the reversals as a slight. On 17 August he formally resigned from the project: 'I have become concerned that I may find myself embarrassed professionally, in my work in this field in general, by actions and decisions taken without my knowledge (to say nothing of without my participation) at the Sault ... I should not any longer personally seem to share responsibility for the success or failure of the project.' 15 Falk had spent a vast amount of time seeking a Canadian medical director, and he felt his credibility had been devalued by the appointment of an American. Furthermore, he felt usurped by Wilson (the two did not talk to each other for some years after this), considering that he had enough stature not to have to play second-fiddle to a newcomer. The loss of Falk, while obviously disappointing, occurred at a hectic time when there was little opportunity to dwell upon it. Detailed written outlines of the health centre option were being prepared for the official publicity for the dual-choice vote. Over one hundred stewards and canvassers were putting on a final push, and the telephoning to wives was being completed. As 14 September drew nearer, the sense of momentum gathered. To stress that the health centre was eventually going to be a community-wide project, Barker announced that two non-steelworkers had agreed to serve on the board. They were both 'men of the cloth,' -one a local Protestant, Dean F.F. Nock, the other a Catholic, Monsignor J.J. O'Leary. The addition of such reputable local citizens was a feather in the cap of the health centre board. The next step was to release the architect's final drawings in order to provide the members with a plan of what would be inside this fancy modern building, a model of which they had already seen. This was done on 14 August, together with a public announcement that a new site had been found. Although the location was not yet made public, the Sault Star gave good coverage to this development.

47 The Union as Organizer By 22 August details of Ferrier's contract had been finalized, and a signing ceremony was arranged for that evening. The national director, Bill Mahoney, returned to his native Sault Ste Marie to give an address and make the announcement. Press attendance was good as pictures were taken and the location of the new site disclosed, and the impression given was that of a successful project just tying up a few loose ends. Ferrier went back to Pittsburgh but was to return by I September to start hiring doctors. Radio and press coverage ensured that the steelworkers were being left in no doubt that the health centre was not only a viable proposition but the only proposition. The local medical society could not match this kind of orchestrated campaign. As the president later recalled, 'We're beaten before we start with those guys, they're organized and we're not.' 16 Despite the fact that the advertisements for the Prudential option urged steelworkers to consult their local doctors about which plan to choose, few of them did. The doctors had been clearly identified as being in opposition to the union, and their potential influence was consequently devalued. The OMA, while certainly not supporting the health centre, had not given the medical society clear support. What local doctors did have in their favour was the natural reluctance of anyone to leave their current doctor. The medical society exploited this feeling by stressing in their official publicity for dual choice that no local doctors would join the health centre, and advising steelworkers to 'weigh carefully the following- on one hand you are committed to a clinic not yet built, to doctors who are not yet chosen -whereas on the other hand you can remain with your family doctor whom you have grown to know and trust.' 17 The appointment of Ferrier was crucial in answering the criticism of 'doctors who are not yet chosen.' He was not only chosen but also well-qualified and experienced. To answer the criticisms of 'clinic not yet built,' there had come the declaration of a site on 22 August followed by an official sod-turning on 6 September. The old chicken shack on the site was burnt, a huge billboard reading 'Future Site of the Group Health Centre' was erected, and a speaker's platform was put up for the day's proceedings. The guest speaker was Dr John Hastings, a professor of public and preventive medicine at the University of Toronto and a World Health Organization fellow, who spoke about the advantages offered by group practice in medicine. 18 The next day, just one week before the dual-choice vote, the Sault Star had a front-page picture of John Barker turning the first sod, with another article inside covering the visit of John Hastings. On 13 September, the day before the vote, a large advertisement calling for 'Tenders for Construction of Group Health Centre' appeared in the paper, as

48 First and Foremost the carefully orchestrated campaign surged on to its conclusion. By then a total of 4,853 local steelworkers had signed check-offs for the $135 building fee, but this was not a guarantee that they would choose the health centre option. It was crucial that enough steelworkers should vote for the health centre to ensure at least 12,000 patients, including dependants, otherwise the operation might not be financially viable. That meant getting nearly 4,000 (or over 60 per cent) of the local steelworkers. Similar dual-choice votes in the United States had never produced a figure like this, the most successful achieving around 25 per cent. 19 Furthermore, the competitive Prudential plan was one of the best welfare plans offered in the country at the time, being matched against what was, after all, an experiment. It was an emotional experience for some of those steelworkers as they approached their pay windows, knowing that this was the day they would have to make a decision about an issue that had overshadowed everything else in the union for two years. Some had wives back at home who were adamant in demanding that the family retain their present doctor. The steelworker had to weigh this against feelings of commitment to his fellow unionists, a desire to be part of what he sensed was a progressive innovation, and the economic reality of having already paid the $135 building fee on check-off. When the votes were counted, nearly 65 per cent of the steelworkers were in favour, with 4,363 opting for the health centre. Within Algoma, 73 per cent of the production workers of local 2251 gave a resounding affirmation of the plan, while the office workers voted nearly 50 per cent in favour. This was added to the 437 out of 443 workers at Mannesmann Tube, Local 5595, who had almost unanimously supported the health centre at their own vote back in July. Including dependants, there would be between 12,000 and 15,000 patients at the new Group Health centre-a more than adequate financial basis to work on. There had obviously been some over-penetration in persuading steelworkers to sign the $135 check-off, as nearly 500 unionists who had been convinced enough to sign did not finally opt for medical coverage with the health centre. This, however, was a reflection of the enormous success the union had had originally in selling the health centre idea and the improvements in the local medical care which the threat of the health centre had caused.

4

The Homestretch

NORMALIZED RELATIONS ARE THE AIM

In just under two years, the local union had taken the membership's resolution at a health seminar and turned it into a near reality. It had weathered the storm of initial protest from local doctors and achieved recognition of its idea from the company. It had then convinced a significant portion of the community to participate in the social change. The local doctors, however, remained totally alienated. This was inevitable, given the economic threat that the health centre posed and the fiercely individual entrepreneurial instincts of the doctors. Such a situation would not make it easy for Ferrier to find the doctors needed to staff the health centre. It was certainly in the health centre's interests, now that dual choice was out of the way, to try to normalize relations with the local doctors and decrease the hostility of the medical establishment in the city. The rental of an office downtown was a symbolic break with union facilities. The Sault Ste Marie and District Group Health Association now had its own address and hired its first employee-an assistant to the medical director. 1 Meanwhile, Ferrier set about placating local animosities. Through the telephone, personal visits, and group meetings, he conversed with just about every one of the forty or so members of the medical society. He found few who were more then coldly polite and many who implied, or openly demonstrated, hostility. None was interested in joining the health centre staff, if only because they knew all further referrals from fellow practitioners would cease immediately. After a meeting with the executive of the medical society, Ferrier concluded 'I didn't really expect to and did not find a crack in the lines [of opposition] at the executive committee level this early in the game.' 2 He had, however, demonstrated to the Sault doctors that he was largely interested in good medical care not

50 First and Foremost politics. His conciliatory tone, which nevertheless was laced with a firm resolve that plans would go ahead despite their actions, moderated the opposition of some of the less hostile doctors. But it turned up no one for the health centre staff. Ferrier's encounters with local doctors also gave him a better knowledge of the environment into which health centre doctors would be arriving. The dualchoice numbers indicated a need for twelve or thirteen physicians by September 1963 when the centre would open - providing one doctor for about every 1,000 subscribers. Ferrier's search encompassed nearly all the medical schools in Canada. He had to find doctors trained in traditional medical schools (and therefore generally imbued with the traditions of solo practice) who were willing to brave the obvious local conflict and work in a setting which had not received the general approval of organized medicine. The president of the medical society predicted that 'the doctors they'll get will be young graduates, misfits, and a few true believers in this kind of medicine.' 3 Ferrier was helped, however, by having Dean Nock and Monsignor O'Leary- non-steelworker members-on the health centre board. Furthermore, he could also highlight the advantages offered by group practice: 'The family physicians will have available to them fulltime consultants in the basic medical and surgical specialities. The Health Centre will maintain excellent out-patient laboratory and X-ray facilities available to all group physicians ... A competent paramedical and administrative staff will free the physicians from the burden of administration and business tasks and allow full time devotion to the practice of high quality medical care. Physician income will approximate what can be earned in private practice.'4 The difficulties facing Ferrier were compounded by the problem of attracting doctors to practise in the northern city at a time of a general shortage of doctors and given their desire to remain in the better-equipped southern cities. The medical society had already encountered this problem, as Ferrier reported after talking to one of their leaders: 'He [the local doctor] didn't know how I, or we, would be successful in recruiting the number of doctors needed, since they had been unsuccessful in getting doctors, particularly general practitioners, to come to the area and practise.' 5 When hiring was finally completed by April 1963, twelve doctors, out of over one hundred applicants, were engaged to start work in September of that year. Five, plus Ferrier himself, were to be general practitioners and the rest specialists. Three or four had experience with, or a keen interest in, group practice. These included the former president of a Victoria, BC, hospital department of surgery, Simon Marinker; a graduate of London University, he became chief of surgery at the health centre. His previous positions included the chairmanship of the General Surgical Section of the Canadian Medical Association (BC Division),

51 The Homestretch and such reputable qualifications did much to confirm the status of the health centre. Most of the other physicians were graduating from residency programs in particular specialities or internships. A few were British and two were natives of Sault Ste Marie. In general, they probably did not have a good idea of the nature of the group practice they were entering-after all, there were few examples to guide them. Their individual motivations were as varied as those in any group: some wanted group practice; others desired the regular hours of salaried employment; most were attracted by the promise of a modern well-equipped building; and maybe a few liked the consumer-sponsorship aspects of the plan. Ferrier had not gone out of his way to stress the local conflict-why make the recruitment task even harder?-so a number did not fully appreciate the extent of local hostility. The medical director was, in fact, doing everything in his power to be conciliatory to local doctors while not compromising the aims of the program. An exchange in February 1%3, is an illustration of this. Ferrier received a letter from Walter .2.aharuk, the medical society president: 'To obviate present and/or future misunderstandings by the Group Health Association, the Sault Ste Marie Medical Society reiterates its original statement of policy- that none of the local doctors in private practice will join the Union Clinic on a full or part-time basis. This clearly denotes that consultative and other assistance will not be available.' 6 His reply oozed conciliation: 'In order to obviate present or future misunderstandings by the Sault Ste Marie Medical Society ... I am pleased to report to you that each and every member of the Group Health Centre staff, and the staff as a whole, will provide any consultative service or other assistance which may be required or requested by any physician or any patient in need of such service.'7 Ferrier did, however, submit the original letter to the College of Physicians and Surgeons for comment, pointing out that the withdrawal of consultation and assistance was dangerously close to professional misconduct. The college, which is ultimately responsible for keeping order amongst the province's doctors, produced a most unsatisfactory reply. Its first contact with Ferrier, although friendly, had been to request a review of proposed contracts with doctors. It responded to .zaharuk's letter by addressing both Ferrier and .zaharuk 'In order to avoid situations in which the College might be called upon to intervene, the Executive Committee asks that the College receive the cooperation of its members in avoiding acts of professional impropriety.' 8 It was this same executive committee which called Ferrier before it later in the year on charges of professional impropriety for using the names of health centre doctors on a subscriber newsletter-this was considered advertising. None the less, Ferrier replied to the College registrar's warning to him and .zaharuk that, 'It was once again a pleasure to visit and talk things over with you during my most recent

52 First and Foremost visit to Toronto. I would, once again, like to express my appreciation for the form and content of the request sent by you.' 9 At the national level, the Canadian Medical Association had moderated its position somewhat, as the inevitability of the health centre became apparent. Nevertheless, an article in the January issue of its journal, while trying to present a fair picture, was critical of the union's approach: 'The whole community must be concerned about the orientation of such a centre to a small number of participants rather than to the general community ... The union clinic will be bringing in additional doctors who will duplicate existing skills and to some degree supplant them.' 10 A long letter of response from Ferrier pointed out that time and goodwill would 'indeed be required to heal what appears to have been a breach in our medical community. We accept our major responsibility to provide an endless measure of both.' 11 In situation after situation, Ferrier found himself being studiously polite to those who felt or presented hostility. He was determined to concentrate on the delivery of good medical care and achieve normalized relations. ISOLATION OF THE MEDICAL SOCIETY

While the primary concern of the local doctors probably centred on the loss of their best-paying patients to the group health centre, their public arguments grew more sophisticated. They had already expressed concern about the effect of defecting steelworkers on their own ability to care for the remaining indigents. They also regarded the union as the employers of the doctors at the centre (the presence of Dean Nock and Monsignor O'Leary on the centre's board was a mere smokescreen to them) and this ran directly contrary to their instincts as independent entrepreneurs: 'When the union hired doctors to work for them, one assumed that those doctors concurred with the basic philosophy of the employer. If you take a man's money you owe him loyalty.' 12 This role of the union as a third party in the doctor-patient relationship was perceived as being very different from the presence of a commercial insurance carrier -all they did was pay the bill. 13 The sacrosanct doctor-patient relationship would undoubtedly suffer from this intrusion -all of their training and prior experience told them this was inevitable. They also felt that the group practice aspect would further spoil this relationship: 'I can't see many of them [steelworkers] being satisfied with the kind of assembly line treatment they'll get at the centre. The doctors they'll get ... will pull out as soon as they have paid off their debts and saved some money to establish themselves ... Not many will stay long enough to establish any kind of personal relationship with their patients.' 14 However, the two main arguments the society came to settle on were the

53 The Homestretch absence of freedom of choice for subscribers, and the detrimental effect on recruitment of physicians to the city as a whole. A motion at the north central Ontario meeting of the OMA in September 1962 put it this way: 'The only way practice within the Union Clinic would meet with the approval of doctors in OMA District 9 would be if a health insurance plan were developed whereby all steelworkers and their families would have free choice to attend either the union clinic or a doctor of their choice outside the union clinic for any or all illnesses paid for under the plan.' 15 That dual choice would take place every year was not enough to satisfy the local doctors. The local doctors also claimed difficulties in recruiting new physicians. The 1961 president of the society, Arthur Scott, described their situation: 'We had recognized a need for more doctors, and we were recruiting specialists and general practitioners in the community, but once the concept that a clinic might start, and take all the steelworkers out, nobody would come there to practice because there were so many other communities in Ontario in those days that needed them just as much as we did. We lost our competitive position in the market for recruiting.' A related concern was the community's ability to support sub-specialities in the future: 'We had an isolated community, with no help for miles around, and we needed certain sub-specialities which could only be supported by the whole community. And if you divide the community into two parts, neither one is large enough to support the sub-speciality.' It was certainly true that few new physicians came to Sault Ste Marie in the years 1959 to 1963, and this increased the doctor shortage. This in turn further demonstrated the need for the health centre, and the irony of this situation served only to raise the local doctors' annoyance even more. The situation was exacerbated when the local doctors perceived that they were somehow being blamed for the doctor shortage, whereas they felt it was the union's fault: 'By the time that they [the health centre] did open their doors, there were not enough doctors in the community; but they were part of the cause of that, rather than the solution of that.' The local doctors' hackles were further raised by the union's implied criticisms. Its open letter in the Sault Star of March I962 had included inflammatory statements like 'Specialists in the Group Health Centre will not be physicians who have designated themselves as specialists ... Once again we invite all qualified local physicians.' Comments like this provoked strong emotional opposition to the union; the offer of staff places for local doctors was like rubbing salt into the wounds. As Zaharuk commented: 'Why should the solo practitioners move from the known to the unknown - their's was an "experimental" plan.' All this helps to explain why the medical society opposition came to be car-

54 First and Foremost ried out with such vehemence. Unfortunately for them, the vehemence and emotion tended to take them overboard in both their claims against the centre and their tactics in opposition. When, in January 1963, the health centre board passed a motion opening the health centre to interested non-steelworker groups, it could no longer be claimed that the community at large was not eventually going to benefit. When in April the two 'men of the cloth' were joined on the board by a prominent Tory businessman, Ian Hollingsworth, claims of union domination were hard to maintain. When Ferrier made it clear, in his reply to Zaharuk's letter, that they would freely refer patients to local specialists not represented at the health centre, the restriction of sub-specialities argument no longer held. The hiring in early 1963 of doctors with years of experience, like the chief of surgery, Simon Marinker, meant that it was no longer accurate to describe the health centre staff as 'young graduates.' As Ferrier's skill at low-key conciliation, undeniable experience, and stature came to be known in the community, it became more difficult to portray the health centre as socialist hordes taking over local medical care. The medical society was left only with the issue of the lack of free choice, which the health centre, with its philosophical commitment to fiscal responsibility for the medical care of a defined population, was not going to relinquish easily, beyond the provision of yearly dual choice. Furthermore, neither the PSI plan nor the improved Prudential plan would pay for visits to a specialist unless they were referrals from the general practitioner - i.e., even under the doctors' own plan (PSI), patients were not covered if they 'freely chose' to get care directly from a specialist. Some of the actions of the local doctors did not serve them well either. Arthur Wishart, president of the Plummer hospital board at the time, recalled events surrounding the granting of hospital privileges in 1963: 'There were some occasions when we were urged that they [group health centre doctors] shouldn't be given privileges. I paid no attention to that, I had no attitude, no different treatment because a doctor served the group health centre ... I couldn't quite appreciate their [the local doctors'] attitude. I could understand it but I couldn't agree with it.' As an influential member of the legal profession in the city, Wishart can be said to have represented the general feeling of other local professionals. At Algoma, too, the company managers were continually being subjected, on an informal level, to pressure from the medical society. The doctors complained so much and for so long that Algoma people lost any initial sympathy they may have had for their plight. One executive of the time remembered the attitude of the medical profession in the city as 'very, very bad downtown ... I would go as far as to say that there was hysteria on the part of many of the doc-

55 The Homestretch tors ... I would even go as far as to say that some of the doctors' wives were more hysterical than the doctors ... Any time you went to a cocktail party somebody would nail you and say, "You know, you guys have got to stop this".' 16 Within the hospitals the non-physician staff, especially nurses, came under pressure from the doctors not to apply to the group health centre for jobs. Ferrier 'spoke to the Registered Nurses ... at their recent meeting, in the sanctity of Westminister Church because the association had been denied the use of the Public Health Centre, the General Hospital and the Plummer Hospital, as a result of physicians' complaints. Approximately fifty nurses, however, turned out to the "clandestine" meeting.' 17 The attempts to block a new avenue of career development for nurses in the city alienated a number of them. For some it firmed their resolve not to be intimidated; others succumbed to the pressure. Even some of the steelworkers and their families who were going to be transferring to the health centre in September 1963 were similarly alienated by doctors intent on pointing out all the evils of care by 'union-employed' doctors. When some of the union canvassers went overboard with their criticisms of local doctors, they were disowned as not being representative of the public position of the union. Similarly, the most vociferous local doctors probably did not represent the views of all their medical society colleagues either. The difference, however, was that, while the union canvassers held no sway in union affairs, these vociferous local doctors were the leaders of the medical society. They could 'influence' doctors who might be sympathetic to the centre by threatening to cease referrals from their colleagues. Renegades quickly moved into line! The medical society's aim was to make things as uncomfortable as possible for the 'union' doctors. Besides planning the exclusion of the new doctors from their society, they concocted a plan for social ostracism. Ferrier described the events of a medical society meeting, after details of it had been passed on to scare a potential health centre doctor who was visiting: 'At that meeting there was discussion of plans to freeze out Health Centre physicians by social ostracism. It was recommended that physicians refuse to talk to Group Health Centre physicians in the hospital ... that physicians in private practice "walk out or walk away" when Health Centre physicians enter.' 18 The medical society's leaders regarded the health centre doctors as the most vulnerable element of the 'union clinic.' They were far more accessible to the local doctors than the union itself, and in the local leaders' eyes, were the combat warriors of the union. As such, they were to become the lightning rods of the health centre down which the medical society could flash all the frustrated hostilities that had built up against the union over the years of development. Unfortunately the vigour and zeal with which they set about this task alienated most other potentially sympathetic groups in the community. Their

56 First and Foremost real effectiveness came to be restricted to those areas where they had significant influence- the College of Physicians and Surgeons, the OMA, their own medical society, and the local hospitals. The health centre doctors must have come to realize how great the struggle for acceptance was going to be when, one week before their opening day, they were given their tour of the Plummer hospital by the janitor! THE EFFECTS OF RESTRICTIVE LEGISLATION

Since early 1960, when Goldberg first called in the lawyers, there had been discussion of legal matters. An incorporated structure had to be established, board composition decided, and the contractual relations with doctors worked out. During 1963, in the months preceding the opening, it was necessary to satisfy provincial regulations for prepaid health insurance agents. A path also had to be found through the forest of archaic regulations governing the delivery of all aspects of medical care in the province, none of which had taken into account the kind of plan which now existed in the Sault. Central to their thinking on these issues was the 'Carruthers case' of 1956, in which the Carruthers Clinic Limited had been found guilty of practising medicine as a corporation, contrary to the Medical Care Act. 19 Consequently, when the Sault Ste Marie and District Group Health Association became incorporated on 15 June 1962, it was made clear that they would 'give to the Medical Director and his staff absolute autonomy over patient treatment and all related medical matters, reserving to itself only administrative and accounting matters within the proper competence of lay persons. 20 This distinction was meticulously maintained throughout contractual matters involving the association and was clearly expressed in the agreement with the medical director and the contracts with individual doctors. Although Barker, Woodcock, and other unionists had developed a clear idea of the doctors as salaried employees after their visit to the Philadelphia health centres, this would have presented legal problems in Canada. The doctors were, therefore, under individual contract to the medical director, although still on salary. After a reasonable period of familiarity, all the doctors would be expected to form a partnership, and contracts would then be negotiated between the partnership and the association. This was the model of large U.S. prepaid groups like Kaiser Permanente. The composition of the board represented both the steelworker sponsors and the local community. Since loan guarantees for the capital costs were being made by the steelworkers (until all the $135 check-offs were paid), the Canadian national director, Mahoney, the district 6 director, Sefton, and the national office

57 The Homestretch researcher, Goldberg, were appointed to protect their interests. With the exception of Algoma's office workers 21 - Local 4509-each of the union locals which had significant numbers of their members as subscribers had members on the board. The posts were to be filled not with specific people but with union officebearers: the president, the vice-president, and recording secretary of Local 2251 plus the president of Local 5595 at Mannesmann Tube. John Barker sat as president. Finally, the three community representatives- Dean Nock, Monsignor O'Leary, and Ian Hollingsworth-completed the eleven-person board. The process of non-profit incorporation required that the board of directors be defined as one and the same as the members of the association. Ironically, this meant that none of the board could obtain their care at the health centre! 'The Provincial Secretary's Department has taken the position that in the case of prepaid medical and hospital plans, subscribers to the particular plan cannot be members of the corporation which administers it, since the benefits received would be "in the nature of a gain". ' 22 The ruling was not particularly harmful to PSI or other third-party organizers of health insurance, but it was directly contrary to the idea of consumer-sponsored organizations. They could organize, but not partake of, the health care they needed. As it happened, the board effectively ignored this ruling, but the legal restriction did prevent a broadening of the association's membership to include significant numbers of the consumers. The board's attempt to be actively involved in organizing a pharmacy within the health centre ran up against similar difficulties: 'It is, of course, quite clear that the present corporation cannot itself operate a pharmacy ... The Pharmacy Act requires that the majority of the directors of a corporation which operates a pharmacy shall be pharmaceutical chemists.' 23 The association's attempts to involve consumers actively in the provision of their own health needs was once again frustrated by the existing legislation. The pharmacy problem was finally solved by an independent leasing arrangement to pharmacists, with less control over its operation than was optimally desirable by the association. Again, when it came to the area of tax exemptions for medical equipment, the board discovered that legislation was so worded as to allow exemptions for hospitals or charitable institutions but not for something like the health centre-Le., although it was a non-profit corporation, it did not qualify as a charitable organization. As these legislative anomalies accumulated during the months leading up to the opening, the board became aware of the need for a forum in which it could express its concerns. Such a forum became available when, on 13 January 1963, the Ontario premier, John Robarts, made his first announcement in what was to be the province's long road to medicare. Robarts was preparing 'to introduce

58 First and Foremost medical health insurance legislation at the next session, then refer it to a committee for study. "We don't intend to pass it at the next session," he said.' 24 Barker immediately sent a letter to Robarts: 'We find it hard to believe that your government would knowingly set up legislation in a way which would deprive doctors of their freedom to choose their own method of payment or deprive citizens of their freedom to choose their own method of securing health care services .... I would appreciate your assurance that the government's proposed health insurance legislation will not prevent our plan from providing services and receiving benefits under the legislation.' 25 It is not known if Barker ever received such an assurance, but in June 1963 Bill 163, 'An Act Respecting Medical Service Insurance,' made it clear that few concessions would be made for a plan like the one in the Sault. It is much to the credit of the association that, despite its preoccupation with preparations for opening day, it found time to put together a brief to the committee studying the bill, the Hagey committee. The arguments put forward in this brief were to surface again and again in dealings with the government, whose policies were to be a major impediment to the development of prepaid consumer-sponsored group practices. Bill 163 was based on the belief that only doctors, not consumers or non-profit insurers, would organize the care to be provided. The brief pointed out that the legislation failed to make the distinction between 'arrangements for the actual provision of medical care or services, and arrangements under which the only obligation assumed is that of reimbursement or payment for the cost of such services when rendered by others.' 26 Asecond major concern was the requirement that subscribers should have complete freedom to obtain services 'wherever rendered' and the insurer would always be obliged to pay for them. The Association responded: 'Unlike an insurer, who can reimburse with equal facility physicians and others throughout the province, an organization which provides the actual services can only do so in the physical area it is equipped to serve.' Similarly, they pointed out that if their services had to be provided to anyone and everyone, they would not be able adquately to control their costs or standards: 'Based as it is upon the existence of physical plant and the agreement of a specific group of physicians, the service we make available can only meet the exacting standards we have set for ourselves if the number seeking it is not excessive. These provisions have been based on specific assumptions about the number of patients to be served.' The passage of Bill 163 as it stood would have caused major problems for the health centre in its early years of development. What in fact transpired was a series of delays which put off medicare's introduction in the province for a further six years. However, this exposure to government thinking just prior to the opening in 1963 was a foretaste of the issues and impediments that the as-

59 The Homestretch sociation would have to face in the future. The government's attitude was that they would only pay for, but not organize, health services, that responsibility for a defined population would not be allowed, and that everyone should be free to get their care wherever and whenever they wanted. BUILDING THE CENTRE

The successful outcome of the dual-choice vote in September 1962, started a rush to complete the building-which at the time was no more than a vacant plot of land. The timetable was tight, with less than a year to build, equip, and staff the entire project. By October the contractor had been hired, and the final capital cost settled in the region of $810,000. The number of subscribers paying the building fee was set at 4,600 by the end of the year, which would produce only $620,000. Additional groups had to be found to bring the total to 6,000 subscribers and contribute to the total amount required. Hence in January, once construction had actually started, the board passed a motion making the centre available to other interested labour groups in the city. It was agreed that, allowing for some future expansion, the building should be designed to handle about 25,000 subscribers. This was considered by Wilson and the others to be close to the maximum size at which warm, personalized care could still be maintained alongside the advantages of group practice. Loan guarantees at the Toronto-Dominion Bank from the United Steelworkers of America provided the capital monies to tide the health centre over until the extra subscribers were actually enrolled and the current subscribers fully paid up. Goldberg reported the centre's progress to the annual GHAA meeting in October in a paper with the title 'Breakthrough in Canada.' This was Goldberg's last major contribution to the project's development, as the following February, just after completion of his Ph.D., he left the uswA to move to the United Auto Workers in Detroit. He was replaced at the steelworkers and on the health centre board by Gordon Milling, another experienced and committed supporter of prepaid group practice. Goldberg's contribution had been enormous, but his loyalty was more to the concept of reformed health delivery than to the steelworkers per se. Construction had actually got underway in October and proceeded throughout the winter. The company had been officially notified that the centre would open on I September and that Prudential's coverage of their subscribers would cease as of that date. As the building started to take shape, all the hopes and aspirations of the members and leaders of the union came to be identified with the blossoming structure. It certainly did look attractive; the

60 First and Foremost three-storey skylighted edifice rising on the edge of the city impressed even Zaharuk. In March, when only the basic structure and walls were pushing through the snow, he commented, 'We agree on just one thing. It's going to be a beautiful building.' 27 However this beautiful building suffered a set back just over a month later. When the spring thaw came at the end of April, work suddenly stopped at the site. The east wall had subsided badly as the ground around the foundations thawed out. Concrete poured into frozen soil had given way with the onset of spring. A crack went cleanly through the whole wall. Nevertheless 'the show must go on,' and now there was even more pressure to meet the September deadline. The administrator who had been hired, Frank Silversides, arrived on 1 May, the day after the wall collapsed. He faced a hectic four months of preparations: he received instructions from Ferrier about equipment and medical suite organization; Wilson communicated concerns about every other aspect of the building and about the hiring of non-medical personnel; meanwhile, the board involved him in the finances and community liaison tasks. Silversides, originally a hospital administrator in sleepy northern Manitoba, had to adjust to this frantic new pace. And it was not as if these events could unfold out of the public eye. The local and national press were well primed by now for what they perceived as a dramatic confrontation going on in Sault Ste Marie. At the start of June, with the wall collapse repairs just finishing and the contractor fighting to get back on schedule, the Canadian Broadcasting Corporation did a full radio documentary on the health centre. CBC television followed suit near the end of August. These programs predictably dwelt on the controversy: the television program opened with the comment that 'since its inception, this health centre had met with stiff opposition from the local medical society, 28 and continued with questions about divided families and strife amongst neighbours. Ferrier maintained his position of conciliation in these broadcasts and would not be interviewed except to deliver a prepared statement in which he took great pains to play down the conflict. The local medical society took the opportunity to relay once again their concerns about the health centre. It was in this supercharged atmosphere that the issue of hospital privileges started to cause concern again for the health centre. Rumours about medical society attempts at excluding health centre doctors from the hospitals prompted applications for privileges to be sent in during May and June. Final clearance was not actually obtained from both hospitals until 30 August, just one day before opening! Heated exchanges between the architect, the contractor, and Wilson marked these final weeks of preparation. Despite the problems, the contractor

61 The Homestretch had still guaranteed access to the building by mid August and an opening on 1 September. It was clear, however, that things would be far from complete by that time-construction would continue around the doctors, but the opening deadline would be met. The dedication of the doctors and staff, who were willing to operate in such surroundings, was praised by Wilson: 'Another medical group, another medical director, could have delayed it [opening] until October or November ... any self-respecting physician could have abdicated-you can't provide medical care in a building with carpenters, everybody running around. But they did.' They rushed headlong into opening day, actually two days later than planned, with time only to clear the debris to allow the lines of waiting steelworkers to enter the long-promised centre. The Sault Star of 3 September reported that 'Officials hurried to open the centre today ... to do so, the doors were opened before everything was ready. Mud still graces the doorway.' The official opening was set for 4 October, when things would be finished. Now the thirteen doctors and thirty three other members of staff had to process 15,000 new patients and iron out all the wrinkles. On 4 October, at the official opening, the steelworkers found time to congratulate themselves. The International president of the uswA, David McDonald, described the Sault centre as 'only the first of many to follow as the Steelworkers seek to solve some of our most pressing health problems by ourselves.' 29 Besides the accolades for the new concept, the building itself came in for much praise. 'The modern design of the structure was the outstanding feature which impressed touring groups the most ... Its bright modern atmosphere seemed to reflect the type of treatment which will be given there.' 30 This building gained high architectural honours for Markson, the architect, including the Massey Medal for one of Canada's twenty most outstanding designs of the early sixties.

5

In Operation

THE DOCTORS ARRIVE

For the 4,500 steelworkers who pledged their $135 and their monthly premiums, the local union officers who had given so freely of their time, the national and international union with their support, the consultants with their expertise, and the Sault community representatives serving on the board- for all of them the health centre had a degree of ideological significance. For some the ideology was no more than the provision of good medical and preventive care through the efficient use of group practice in modern facilities. For others it was the economic imperative of reduced costs and decreased hospitalizations brought about by prepaid group practice with salaried doctors. Still others were impelled by the opportunity provided by consumer sponsorship to involve patients in organizing their own care. A few were motivated by all these considerations. Whatever their viewpoint, they certainly all regarded the health centre as very different from the mechanisms of medical care delivery found almost everywhere else on the continent at this time. Among the dozen or so doctors who arrived at the health centre in the fall of 1963, there were few with such strong ideological motivations. With the exception of Ferrier and, to some extent, Marinker, none really had any strong beliefs that this was the way to deliver medical care-although some would certainly develop such beliefs. Many came from traditional settings or traditional training and were attracted most of all by the modern facilities and the absence of the administrative burdens of solo practice. At the health centre the general practitioners had the convenience of X-ray and laboratory facilities, and specialists 'on site'; the specialists had these facilities plus a ready-made referral population; none of them had to bother about billing patients- their salary was paid automatically.

63 In Operation However, although the consumer-sponsored prepayment plan in which they were engaged offered economic and professional advantages for the doctors, it was not entirely congruent with the values instilled in most of them during their training. The fact that they were identified as 'employees of the steelworkers' was a major concern. Another, encouraged by the Sault medical society, was the so-called restriction of free choice of doctors imposed by the health centre. Much of the early non-medical activity of the group doctors was directed toward altering the health centre's structure to bring these non-congruent elements more into line with their professional outlook and values. Initially, however, the doctors had little time to consider such niceties of practice. The doctors had now supplanted the union and the board as the front-line contacts with the subscribers. It was they who suddenly had the responsibility of meeting all the expectations that had been raised by first the union and then the board. The first months were marked by an extremely heavy workload, with the new patients choosing among the particular doctors, and effective appointment, referral, and nursing procedures being established. The patients who wanted house calls for even minor ailments, physicals every month, appointments immediately, and all manner of unreasonable demands, had to be educated and mollified. And the mechanisms for operating an effective group practice had to be refined. One of the main pitfalls of all forms of large group practice is a tendency, perhaps a necessity, to drift away from personalized care, as the patient's identification with one particular doctor becomes clouded by specialist referrals, visits to other doctors when his is not available, and high rates of turnover among general practitioners. The health centre was no exception, and before long concern was expressed about personalized care: 'A lengthy discussion was held and several adverse opinions were voiced, particularly concerning loss of personal contact between doctor and patient.' 1 In contrast, by 1966 'it was felt that in order to maintain cohesiveness of the group some de-emphasis of personalized practice should take place and that referrals from a physician to other physicians should be through departments rather than through individual physicians. It is hoped in this way to avoid groups practising within the group.' 2 The arrangement of all appointments through a central area provoked similar controversy. Some doctors wanted the more personalized approach of individual scheduling by each doctor. As was pointed out, however, central appointments were necessary in order to 'avoid chaos, assure an equal distribution of workload and patient load, [and] avoid development of private practice within group practice ... In this connection, it must be re-emphasized that it is impossible to combine all of the advantages of group practice with all of the advantages of private solo practice and each physician must decide for himself whether he is, in fact,

64 First and Foremost dedicated to and interested in group or solo practice. 3 The attitudes bred by traditional medical training died hard for some, particularly the specialists who seemed more concerned than the general practitioners with maintaining their individuality. Originally, the medical group was administered by Ferrier plus a three-person executive appointed by him; future plans were for the medical staff to elect this executive. However, in March 1964 two things prompted a majority of the group to vote to disband the executive structure and require all decisions to be made by the medical staff en masse. The first cause was the emerging desire for an individual voice which was being suppressed by the oligarchic executive structure. The second was uneasiness at the potential power of the medical director. Ferrier's overloaded schedule meant that he did not always pay due regard to the niceties of democracy. This would not have been so serious if there had not been a parallel suspicion that he was rather close to being a 'creature of the board.' He was employed by them, and so he was in the position of representing the board to the medical group, while simultaneously representing the medical group to the board. This introduced a significant degree of ambiguity to his role. Thus, the entire medical group was to have a hand in all the decisions, until a solution to these problems could be found. It was at this time that the idea of a partnership under contract to the board was revived. The partnership would elect an executive and the medical director, and the latter would represent their interests in dealings with the board. Progress towards this goal was accelerated by the taunts of the medical society, who regarded them as 'union employees.' Another of the society's taunts, questioning the professional stature of the group doctors because of the absence of feefor-service payment, encouraged some of the group to seek a partnership agreement with the board which would provide them with a fee for each service they performed, rather than salaried remuneration. Between 1964 and 1966, the details of this partnership arrangement were being worked out. For Barker and the other original unionists on the board, this was all a far cry from the Philadelphia centres they had visited. The concept of the doctor as employee, in which they firmly believed, had already been diluted by the requirement for doctor independence, as dictated by the Carruthers case and other legislation. Now the professional outlook of their own doctors was threatening to dilute it even further. Furthermore, Wilson, who continued as consultant after the opening, knew that the partnership idea was necessary, and had been actively encouraging it, partly to bring the Sault into line with the proven success of the American prepaid-care model. As regards fee for service, Barker's opposition was religious- such a form of payment would be heresy: 'Fee for service is completely contrary to democracy. It is the closest thing to

65 In Operation

dictatorship I think there can be and there's conflict of interest connected with it in every case ... It shouldn't be allowed. It should be illegal.' With Barker as president, then, it is not surprising that the less progressive doctors lacked complete trust in the board. This lack of trust surfaced in concrete form during the development of the partnership concept in late 1965. A small group of the doctors questioned the accounting of the association and felt that a year-end financial surplus, for the distribution to the doctors, was in fact understated. An independent audit was requested and meetings were held at which general frustrations of these doctors were vented, but no accounting anomaly emerged. However, this dispute was symptomatic of the difficulty that some of the doctors had in allowing an outside body-the board of the association -to be involved in their professional lives. These were the very doctors who were having trouble making the concessions required by group practice and who had disbanded the executive. By the summer of 1966 they had all left. The accounting dispute again brought to the fore the concerns about Ferrier's dual role and his status as an employee of the board-was he really protecting the medical group's interests? The arrival of a new administrator, Fred Griffith, in late 1964 had alleviated some of Ferrier's administrative burden and made it far easier for him to relinquish some of the board responsibilities and become the head of the medical partnership. After the signing of a partnership agreement in early 1966 the doctors were called the Algoma District Medical Group. They had an elected executive and medical director (Ferrier) and required one year's associate status before the full income benefits of partnership became available. They were no longer employees either of the board or of Ferrier. The next step was to establish the relationship between the newly formed partnership and the association. With their own partnership as a stable base to work from, the doctors now sought changes that could only be provided by the board in a mutually negotiated medical services agreement. There were some who still wanted to be paid fee for service, but this was intially dismissed by the board: 'We said, quite emphatically and, we trust, quite clearly, that, if the physicians expected the Board to pay the Medical Group on a fee-for-service basis ... it was totally unacceptable to the Board, and that it would, in fact, destroy group practice.'4 Other conditions desired by the board for the medical services agreement were that: Both parties enter into an exclusive agreement; The initial nomination of a new physician by the partners be subject to approval by the Board; The hours of service be arranged by mutual consent;

66 First and Foremost All non-physician personnel remain employees of the Association; Dr T.A. Ferrier will represent the partnership of physicians. s

All of these elements, except board approval of new physicians, were incorporated into the final agreement. In addition, with the proviso that health centre subscribers take precedence, the doctors were allowed to take on non-subscriber fee-for-service patients. The medical group had moved that bit further towards the values of their physician colleagues, and the board had known enough to allow slight erosion of their original concept to promote their own doctors' professional self-image. During 1966 the doctors had clearly established independence from 'steelworker control' and introduced an element of fee-for-service remuneration into their practice. They also turned their attention to that apparent absence of free choice of doctor for the health centre subscribers. As at the outset, dual choice, between the Prudential plan and the health centre, took place once each year. Within the health centre, subscribers could choose any one of the group's general practitioners as their family doctor. Although the board always encouraged dual choice, some subscriber groups could not negotiate it and were forced by employers to have either all members or none covered at the health centre. Griffith recalled how free choice operated in these groups for the people who did not want to receive care at the health centre: 'In Mannesmann Tube ... the company said, "It's 100 per cent to the health centre." This meant that there were a small number of people there, seven or eight employees, who we simply could not treat, we couldn't treat them as captives. We said you go, we know who you are, you go and get care where you want and we'll pay the bill.' Numerous references in board minutes to the desire for dual choice and aversion to 'captives' corroborates this attitude. If it had not been for serious criticism from doctors outside the group, most of the group doctors would probably have been quite happy with the provisions for free choice. Talking of what attracted him to the centre, one of the doctors said, 'I thought the idea of annual dual choice was a marvellous one. I can think of nothing more wasteful than so-called free choice of doctor ... It's capricious, it's wasteful, and I think it can be very, very dangerous.' 6 However, a series of incidents surrounding anaesthetic coverage in the city brought the issue to a head in the latter half of 1966. Ferrier had always believed that anaesthetists should not have to be included in their group-they should be hospital-based. The problems with the local medical society had, however, necessitated the inclusion of two anaesthetists. With the imminent departure of one of them, the idea of a city-wide 'Anaesthesia Associates' was mooted by Ferrier. This would require open co-Operation and the instigation of normal referral

67 In Operation patterns from the medical society. The society, still hostile to the group, saw this as a chance to bring up the free-choice issue as a bargaining tool in exchange for Anaesthesia Associates. Hence, in August 1966, after some initial exchanges, the chief of staff at the Plummer hospital made a proposal which would guarantee the necessary free exchange of referrals if the following policy were approved: 'Participation by medical staff members in the direction of patients to specific doctors by an insurance underwriter, with loss of benefits to the insured if he does not comply, will be interpreted as contrary to hospital policy. Deliberate breach of hospital policy is incompatible with staff membership.'7 Underneath the jargon, this was a simple threat to remove hospital privileges from health centre doctors if all subscribers continued to be restricted to the group doctors for insured coverage. Pressure was building to loosen up the dual-choice provision even further, if not disband it entirely in favour of total free choice. That same month the executive of the health centre's board responded to a request from their medical group by recommending a policy change, later called 'interselection choice', which stated 'the Association will make arrangements for any subscriber or dependant to receive care from a physician of his choice if he is dissatisfied with the service, for any reason, at the Group Health Centre.'8 The board required only notification from a subscriber that he was going to do this and a guarantee that he would not select the health centre at the next dual choice. On 25 August Ferrier and Griffith were called to a clandestine evening meeting of the medical advisory board of the Plummer to thrash out the issue. It seemed that inter-selection would be enough to precipitate the formation of Anaesthesia Associates: the medical society president said that 'if the Board of the Association interpreted their policy as it had been described at the meeting then there should be no more problems among the physicians.'9 However, the Sault medical society met on 30 August and in a 2-to-1 vote opposed this move, reversing themselves and preventing any further progress on the issue. One interpretation was that the society had decided that Anaesthesia Associates should be blocked because it might save money for the health centre. The medical society communicated its official conclusions to the association saying that group doctors were responsible for providing all care to the centre's patients and the medical society would provide none. Ferrier had to search for new anaesthetists for the group and the board was left with an 'inter-selection' policy on its books, although it had not been announced publicly. Spurred on by the actions of the local medical society and by their own desire to be accepted by their medical colleagues outside the centre, the group doctors had succeeded in moving the board another step closer to the traditional form of practice. The tension between the group doctors' desire for normalcy and acceptance, and the board's commitment to principles of innovative alternative delivery, was to be

68 First and Foremost the trademark of board-director relations well into the future. Ferrier was the fulcrum in this relationship. He clearly sympathized with the basic philosophy of the board, and this sympathy was certainly greater than that which he had for his own doctor's philosophy. Nevertheless, he respected the doctors' viewpoints, appreciating the strength with which their professional values were held. He was committed ultimately to good medical care, and for that you needed good doctors; it was unfortunate but apparently inevitable that few of these doctors shared his progressive view of health delivery. He found himself defending both the aims of the board to the doctors, and the doctor's right to professional integrity to the board. He walked a tightrope between idealism and realism which represented an everpresent tension in the development of the centre. THE REALITIES OF RUNNING THE HEALTH CENTRE

During the planning stages the board had had a certain licence to plan according to its ideals; later, however, the realities of economics and the desires of their own doctors had introduced an inevitable element of pragmatism. These first years could be characterized unkindly by the zealot as retreat from the ideals, but they ought rather to be regarded as a reasonable response to the economic and professional imperatives of the times. The role of Barker and other unionists on the board was to be the 'conscience' of the association, reminding their colleagues of the founding principles and the commitments to subscribers. Barker's degree of involvement diminished once the excitement of organization had passed its peak. Both he, as president, and the rest of the board were willing to leave the everyday running of affairs to Ferrier, Wilson, and the administrator Griffith, and to heed their advice on those occasions when pragmatism was the order of the day. The long hours of exchange Barker had had with Ferrier and Wilson during the planning phases, and his resultant conviction of their joint dedication to a common goal, made it easier for him to relinquish control. It was not long before similar confidence was built up in relation to the new administrator Griffith, who took over from Silversides in November 1964. He was a native of the Sault but arrived at the health centre from Saskatoon where he had been running the city's United Appeal campaign since 1962. He was a man of quiet energy, always looking for a challenge but approaching it in a more contemplative way than Barker. If he had a failing, it was his unwillingness to delegate responsibility for any of his tasks, as long as their novelty still held some fascination for him. He had administrative skills and experience with boards, but no real knowledge of medical care delivery, although he soon acquired a wealth of experience in that

69 In Operation area. He was not a radical zealot with preconceived notions but rather an administrator with a keen eye for actions necessary to ensure an organization's survival and growth. 'We have taken, in everything we've done, a very pragmatic approach. Now this doesn't mean you forget your goals, it just means that sometimes you've got to get across the creek on three or four stepping stones instead of one long jump.' Griffith could blend nicely with the new pragmatism of Wilson and Ferrier. The process of sorting the wheat from the chaff started early. Economic realities very quickly eroded the idea that fees for service should be completely absent from the health centre. It was not long before the association realized that the workmen's compensation board, insurance companies covering physicals, and so on would only pay on a fee-for-service basis. Furthermore, the need to have enough patients to expand medical staff, and the mounting desire of the doctors to have some fee practice, to have a diversity of patients, and to see professionally the people they were seeing socially, meant that, before long, the fee-for-service component found a place in the health centre. However, its place was always subordinate to the prepaid subscriber care. Initially the fee patients had to pay the $135 sponsor fee like everyone else; later this was altered, with the doctors paying 10 per cent of their fee to the association in consideration of the $135; and in January 1968 the $135 fee was made optional for everyone. To retain some incentive for people to pay it, contributions ensured free coverage at retirement. This decision was made just before the dual choice period of 1968, to try to induce more people to transfer to the health centre and thereby preclude the necessity for a premium increase. It did not turn out to be a successful ploy as only seventeen steelworkers chose to move from Prudential to the centre, while sixty-eight moved the other way. At Algoma Steel small numbers had been transferring from one to the other in each yearly dual-choice vote. The health centre population grew by attracting new subscriber groups-school janitors, city employees, and other non-steelworker locals- and fee patients, but not from increases in subscribers at Algoma. Besides the required payment of $135, there were other factors that deterred growth within the Algoma workforce. As Griffith pointed out, 'We started out with too deep a penetration into Algoma Steel. People, I think, came here with some ... feelings that this was going to be the absolute answer to all their problems. Well, there were people with unpleasant diseases that weren't cured [and] people discovered that they couldn't get a housecall at four in the morning ... We also had the situation where the husband maybe had made the decision without consulting his wife and children. So over the first year or so people started to sort themselves out.' A general shortage of doctors also dictated a cautious growth in the subscriber population. Additionally, the imminent arrival of medicare discouraged extra groups from

70 First and Foremost enrolling at the health centre. Premier Robarts announced in 1965 that medicare would be a centennial project starting in July 1967. Griffith commented, 'We would go to a union and say, "This is the story, this is what we are trying to do." The answer would be "The government is taking everything over; this union, this local, has always been for national health insurance-medicare-and all of our problems are going to be solved then." So we ran into the situation where people weren't going to take the gamble of changing carriers .. People don't differentiate payment of service from delivery of service.' Medicare did not, in fact, start until October 1969, but its ever-present possibility permeated the 1960s, inhibiting the health centre's expansion and exploration of other areas. Part of the reason why the board, in 1966, had been willing to respond to pressure from their own doctors and from the medical society for inter-selection was the probability that total free choice of doctors would be part of the medicare legislation. There is no doubt that the board, or at least Barker as president, felt duped by the fact that inter-selection was policy and yet neither the normal referral patterns among the city's doctors, required for Anaesthesia Associates, nor medicare had materialized. It is interesting that, when Barker was asked for clarification of the inter-selection policy by Griffith in early 1967, he managed to use the absence of public proclamation of the policy to backtrack on it: 'The Policy Statement [of inter-selection] was intended to apply only to subscribers and their dependants who were in groups without any dual choice ... who were unable to change programs between annual selection periods.' 10 This restricted the policy to only a handful of the subscribers and alleviated some of Barker's mounting concerns about erosion of basic principles. He never fully accepted the idea that the doctors now ran the medical and related care of the health centre as an independent group, and he was rarely happy with the concessions that were made. It was important to show that, despite this, the health centre was achieving its goal of excellent comprehensive care delivered in an efficient fashion with no extra charges. After all, they were being viewed by more than just the citizens of Sault Ste Marie-the International Steelworkers, other unions, governments, and political parties all had an interest in their program. Besides the family medical care with basic specialties, the health centre was providing physiotherapy; laboratory, X-ray, emergency, and pharmacy services at low prices with free injectable drugs; annual check-ups; and optometry-all organized under one roof and at a level of premium competitive with more restricted commercial insurance coverage. One real measure of economic efficiency was the level of hospital utilization by their patients. Very early on, Ferrier put figures together to look at this question. With data from the government's Hospital Services Commission he showed what a positive effect their existence was having on care in the Sault. 11 The study was picked up in 1966 by Donald C. MacDonald, the leader of the New Democratic

71 In Operation Party in the Ontario Legislature, and used in support of the NDP's desire for the extension of group practice: 'Under the Sault plan ... the annual hospitalization rate per 1,000 population covered was 680, compared to 1,400 for the general population in the community ... It is obviously too early to draw hard-and-fast conclusions from the Sault experience but a hospital utilization rate of 680 per 1,000 persons, as compared with about 1,850 [per 1,000] for persons throughout the whole Ontario population, is such a staggering achievement that its implications for cutting our hospital bill should be explorerd.' 12 This challenge was taken up, and in October that year Dr John Hastings visited the Sault with a proposal to do a comprehensive study, jointly supported by the World Health Organization and the Ontario government. This was the same Hastings who had been the speaker at the sod-turning ceremonies prior to dual choice in 1962. Based at the University of Toronto with a team which included a leading light of the Group Health Association of America-Dr Fred Mott-he gained cooperation from the local doctors and spent nearly four years comparing the utilization of services by the centre's steelworker subscribers and the downtown doctors' steelworker patients. This study was unique (and still is today) in that the two sample groups consisted entirely of steelworkers and were therefore highly comparable; the only major difference lay in their medical care delivery system. Because hospitalizations were not part of the benefits paid for by the health centre (they were covered by the government's Ontario Hospitals Services Commission), there were no direct financial incentives for decreasing subscribers' rates of hospitalization. By contrast, previous studies in the United States had been with health centres whose premiums covered both doctors' and hospitals' care, giving rise to clear financial advantages from decreasing hospitalizations. The results showed that the Sault's consumer-sponsored prepaid group practice did indeed reduce the demands on the local hospital facilities, partly by greater use of their own diagnostic facilities. The study concluded, 'although the group practice had no financial incentive to economize on inpatient care, its rate of hospital utilization was lower by about a quarter.. .it appeared that the group practice placed somewhat greater emphasis on health protection against the investigation and treatment of disease, but utilization of both laboratory and radiologic services was certainly higher in the population served by the group practice.' 13 These findings did reassure the association that they were achieving their goals. Moverover, 'the co-ordinated chain of health centres from one end of Canada to the other' began to seem more than just an extravagant hope: Goldberg had been generating interest within the United Auto Workers and by 1968 a plan was well underway for a similar health centre at St Catharines in southern Ontario. Some further reassurance came from a modest increase in the number of patients attending the centre and the consequent increased size of medical staff.

72 First and Foremost Although the Algoma employees' involvement had not increased, other groups had joined and, with the addition of the fee patients, over 20,000 people were using the centre by the end of the 1960s. The number of doctors had expanded from thirteen to twenty, although no new specialties had been added. Prospects for further growth were, however, limited by the constraints of a building which had originally been planned for no more than 25,000 patients. The board was obviously pleased with this growth, which contrasted well with some of the community health centres which had sprung up in Saskatchewan after the 1962 doctor strike. These fee-for-service centres were experiencing difficulties in doctor-board relations far more serious than those encountered in the Sault. Wilson and others attributed the Sault's endurance to the non-political nature of the association's board, as well as to their dedication to the goal of medical care delivery. Ferrier had convinced everyone that the assurance of 'good medical care' should take precedence over everything. DEVELOPMENT UNDER DURESS

With the opening of the centre, the task of handling the physicians' opposition passed squarely from the board and union to the health centre doctors. Of most concern was the behaviour of local doctors downtown, but more subtle pressures were applied by both the OMA and the College of Physicians and Surgeons. It was not surprising that health centre doctors pressed for some policy changes by the board. They felt that these changes would soften the perception of themselves as black sheep of the medical world, in which they suffered many indignities and encountered many obstacles in their everyday work. It was not unusual for group practices to experience some opposition from their local colleagues. The situation was particularly exacerbated in the Sault, however, first by the union sponsorship, and second by the protracted development period in which deep-seated hostilities-with emotional, political and financial roots-had been allowed to ferment. On 14 December 1963, just three months after the centre had been opened, the local doctors had taken the unprecedented step of placing a warning notice in the Canadian Medical Association Journal: 'The Sault Ste Marie Medical Society has established an information service to advise doctors contemplating practice in the area on matters of local importance. The establishment of a consumer-sponsored clinic in the Soo has given rise to certain misunderstandings within the profession, and newcomers in their own interest should investigate the situation before making commitments.' In these early years the health centre doctors found themselves almost universally excluded - from the local medical society, from hospital committees (par-

73 In Operation ticularly at the Plummer hospital), from almost any referrals from downtown physicians, from social, cultural, and recreational organizations in the city, and generally from any decision-making regarding local medical matters. On an official level everything possible was done to make the health centre doctors feel like second-class citizens. In 1965, applications from several health centre doctors for membership in the local medical society were greeted with identical letters of rejection: 'I regret to inform you that no motion was received from the floor approving your application in the local Society and accordingly your membership requirements have not been met at this time.' 14 When concerns were expressed about the validity of the society as an OMA affiliate, given such a non-representative membership, the OMA reply indicated an unwillingness to intervene: 'Reverting to its autonomy as an independent society, the Sault, as in the case of any other society, may set out membership requirements, etc. and remain an affiliate of the OMA.'IS

Referrals from downtown doctors to the health centre were virtually nonexistent, despite the fact that the health centre doctors did make referrals to them. In 1973 a survey of the situation concluded that 'only 2-3% of referrals by solo practitioners appear to be in the direction of physicians in group practice.' 16 To make things even worse the health centre doctors could not participate in their patients' care once they had referred downtown. As Ferrier pointed out in a draft letter to the OMA: 'The Medical Society has made a ruling whereby patients referred by us for operative surgery cannot have any of our members act as surgical assistants or anaesthetists, regardless of the patients' wishes.' 17 The greater necessity for referral in surgery, as opposed to general practice, and the surgeons' constant contact with the hospital, meant that they were more in the front lines than their non-surgical colleagues. On a social level, however, few escaped the acrimony. There were numerous instances of hostility. One health centre doctor recalled that 'in church, a [downtown] doctor's wife left an organization because my wife was asked to become a member.' 18 Ferrier felt compelled to write to the society when 'a member of [the] society ... attacked Mrs. Ferrier publicly with a verbal assault of extreme viciousness and followed this with a physical assault on Dr R.G. Martin and myself.' 19 The real target of these incidents was the Group Health Association in general, not the individual doctors, but as one disgruntled health centre doctor put it, 'some of these [medical society] physicians have said that we should not take the insults, segregation, and efforts to destroy this program in a personal way. Perhaps I am being overly sensitive but I have taken each and every affront personally.' 20 Of the society's leadership he said that there was 'a hard

74 First and Foremost core who refuse to be realistic. It seems to me that this hard core within the local society have climbed out on the end of the limb and do not want to lose face.' This appeared to be an accurate portrayal of the medical society strategy. The original grounds for opposition were gradually eroded, both because they were based on misconceptions about the program and because of the changes introduced at the request of the group's doctors: with fee-for-service patients and non-steelworker groups as subscribers, it could no longer be claimed that membership was restricted to union members; free coverage of retirees, responsibility for Children's Aid Society orphans, and care of the local treaty Indians more than countered complaints of not taking care of the city indigents; and the establishment of a partnership effectively squashed accusations that they were employees of the association's board or of the steelworkers. The medical society was left clinging to the issue of the apparent lack of free choice for health centre subscribers. This, they claimed, was the last remaining barrier to normal relations. Yet the introduction of inter-selection in 1966, the insistence by the association that the government's new Ontario Medical Services Insurance Plan be available to all groups who did not have formal dual choice, and the group doctor's willingness to refer to society physicians, all failed to satisfy the society's definition of free choice. It seemed as if the medical society didn't really want to have that last remaining barrier removed-all of the previous forecasts of doom would have gone by the board and the limb upon which they sat would have crashed to the ground. The society had, however, made one self-fulfilling prophesy. They had warned that the centre would have difficulty in retaining family doctors, and would therefore not establish good doctor-patient relationships. The group did have a high turnover of doctors: Ferrier noted early in 1968 that, 'of the twenty members of the medical group starting January 1st, 1968, seven are considering staying with the program for the immediate future, eight are leaving or have left, and five are undecided.' 21 The feelings of many of the departing doctors were expressed in a particularly articulate letter of resignation by one of the early general practitioners: 'A disgraceful situation exists in this city. I am referring to the manner in which certain physicians in Sault Ste. Marie, under the banner of the local medical society, have treated the Group Health centre staff ... It is possible that I would have remained here indefinitely had it not been for this situation, but I do not choose to spend my life in an atmosphere of hate, vindictiveness and paranoid delusions.' 22 Others in the group reacted more stoically; they liked the community, believed or had come to believe in the program, and were determined to stay. Meanwhile the board was trying for conciliation, but the elusive 'last barrier to normal relations' seemed always to move one step ahead of where they had just reached.

75 In Operation The board's hands were tied- these were, after all, largely medical matters and therefore outside their domain of responsibility. They had no influence over the two matters that concerned their doctors most-exclusion from the medical society and the absence of normal referral patterns. Where they could, they helped, without compromising the program's principles-the introduction of inter-selection was one such instance. Much of the time, though, they were reduced to standing by and witnessing the adverse effects the situation had on their doctors. By mid 1968 the entire situation had started to come to a head. The Association and its doctors had made conciliations beyond the point of reasonableness, and yet the local boycott remained unchanged. Now it appeared that the anaesthesia issue would re-emerge. Ferrier noted in May that, 'We are facing, as of July 1st, a critical situation with regard to anaesthesia. Both anaesthetists will by then have left. No replacements have been located.' 23 In other words they would have to rely on the medical society doctors to provide anaesthesia to their patients. In preparation for this, Ferrier wrote to the society on 28 June reiterating the health centre's policy with regard to free choice of doctor-Le., inter-selection. The communication was acknowledged but nothing further was said- that is, not until 22 July, when the society's president called to inform Ferrier that a resolution had been passed which barred society doctors from accepting referrals from the health centre except in emergencies. Until that time anaesthesia had been provided for health centre patients by an anaesthetist who had left the group to go downtown, and by one from the society who had sympathy with the group. By 5 August, however, one of these individuals had gone on vacation and the other had been 'persuaded' not to provide any further assistance. The medical society leaders had effectively ensured that no health centre patient could receive surgery except in an emergency. This proved too much, even for the conciliatory health centre, and on 8 August, with the board's definite approval, Ferrier issued a warning to the society's officers that court action was underway: 'The Group Health Association and the Algoma District Medical Group have been advised by their solicitor and have commissioned their solicitor to prepare a writ to stop you from preventing any and all anaesthetists from providing our patients, or any patients in the hospital, with anaesthesia in elective procedures as well as emergencies.' 24 Despite the warning, the boycott continued into a second week and by 19 August the health centre solicitors wrote to the OMA advising them that legal action was about to begin. A hurried set of exchanges followed, and a hold was put on the legal action. By the end of the month it had been agreed that the matter could be dealt with more effectively by the College of Physicians and Surgeons than

76 First and Foremost in the public forum of the courts. With the health centre using an extremely liberal definition of'emergency', together with some clandestine arrangements, limited surgery was resumed. However, the anaesthetists who provided the help found themselves with fewer and fewer referrals from their society colleagues until it became clear that the College had laid professional misconduct charges against seven of the medical society doctors. The health centre managed to find an interim anaesthetist of their own by the end of the year, and the immediate crisis was alleviated, if not over. The aftermath lasted well over a year. The medical society's view was that the health centre had committed itself to providing all care to its own patients and that they had been unable to discharge this responsibility: 'The Group Health Centre agreed to provide their own services etc.... but then the anaesthetists left. The case meant that the Group Health Centre should not have sympathy when they don't deliver what they say they will. So they can damn well provide their own anaesthetist.' 25 The group doctors could find no reason to excuse the solo doctors' behaviour: 'It is beyond belief and beyond the patience or charity of the Group ... We ask that the Discipline Committee of the College of Physicians and Surgeons of Ontario investigate.'26 The college took the view that this investigation should also be used to 'clarify the matters that are at the root of the problem and to bring forth proposals that will aid in resolving these issues. The committee looks for a settlement that will bring about normal professional relations between the two groups of doctors.' 27 The group doctors seized the chance to try to press home their advantage. They were willing to drop their complaints and, at the college's insistence, to introduce full free choice if medical society membership was opened to all, and if normal referral patterns were instituted. The college's sympathies seemed to lie more with the medical society's attempt to obtain a 'free and unfettered choice of any physician' than with the group's desire for a single representative medical society. Negotiations laboured on throughout 1969 with little progress. By October, however, the introduction of medicare had made free choice of the law of the land. So in January 1970 Ferrier and Marinker attended a Toronto meeting at the offices of the college, where an agreement was finally signed. The body of this agreement concerned the guarantees of free choice and assurances that a public announcement to this effect would be made. At the end of the agreement it was declared that, 'There shall be inaugurated a normal medical referral and consulting practice [and that] there shall be formed forthwith a medical organization known as the Algoma District Medical Academy, which shall be the only and the official branch of the Ontario Medical Association in the District of Algoma.' 28 The group doctors had conceded only that which they were now legally required to pro-

77 In Operation vide-free choice-and had finally obtained the recognition they had so long desired. While the Sault medical society had influenced the way the group scheme had evolved-increasing their turnover, enforcing the hiring of anaesthetists, encouraging free-choice provisions, and so on -so too had the group doctors heavily influenced medical development downtown. By 1964 a large medical arts building housed nearly all the solo doctors under one roof right between the hospitals-not quite group practice but at least doctors grouped together. An efficient city-wide on-call procedure was established for evenings and weekends. Recruitment of sub-specialties was speeded up. The Hastings study for the World Health Organization had shown that the solo physicians too had reduced their own hospital utilization below the expected average, even if it still did not match the health centre's. Competition from the health centre pharmacy had lowered drug costs across the city. And finally extra-billing had been virtually eliminated. With the establishment of a single medical society and the promise of normal interdoctor relations, the centre doctors had at last come of age in the medical community and could perhaps now receive some of their rightful credit for these improvements in medical care in the Sault.

6

The Coming of Medicare

THE BOARD ON THE BRINK OF MEDICARE

The focus during the sixties was very much on the events and actions of the health centre's medical group. The crisis surrounding anaesthesia was a primary instance of this focus. It had been the decision of the group's doctors to resolve the issue through the College of Physicians and Surgeons. Despite the board's unanimous support for the doctors, many of its members would have preferred an open court action. As long as the issue was lodged with the college, the board of the association had no say over the matter. Although this was ostensibly a medical issue, and therefore beyond the purview of the board, it was obviously rooted in many of the principles espoused by the board-consumersponsorship, responsibility for a defined population, dual choice rather than totally unrestricted free choice, salaried doctors rather than fees for service, and so on. By the late 1960s the frustration of this and other instances of alienation from decisions about the health centre had started to take its toll on the board's enthusiasm and interest in the centre. Its decisions seemed no longer to be about innovative health delivery but more about matters more like the 'number of paper clips required.' Barker, who by 1969 had been involved for ten years with the centre, was still president of the board. He above all others felt the frustration. At a Canadian Labour Congress conference in December 1969, he displayed his feelings in the opening words of his talk, 'Community Health Centres in Canada and How They Function': 'It's easy to tell you how health centres function in Canada-whether they are in Saskatoon, St Catharines or in Sault Ste Marie -they function with difficulty .' 1 Symptomatic of the decreasing energy of the board was their neglect to institute searches to fill vacancies on the board. In late 1967 it became no longer necessary to have two representatives from the

79 The Coming of Medicare national steelworkers, as the steelworker-guaranteed loan was paid off and an increase in local involvement was desired. Therefore Mahoney and Sefton left. Monsignor O'Leary resigned at the same time. These three positions had still not been filled by 1970, leaving a board of eight people, six of whom were steelworkers. External forces which inhibited expansion were another cause of the board's lack of enthusiasm. College restrictions on advertising prevented active solicitations for new subscribers. 2 Furthermore, the attempts to normalize relations with the local doctors occupied much of the medical group's energies that might otherwise have been directed at program expansion and development. The board showed little interest in developing the program partly because of their relationship to the group doctors and partly because of the general waning enthusiasm. After six years the board was having trouble coming to terms with the continual demands for dilution of the program's principles. They failed to appreciate Ferrier's difficulty in finding doctors who were not only willing to come to Sault Ste Marie, but who also had the correct 'philosophy.' Added to this was their concern at the absence of any orientation for the doctors even after they had arrived. Griffith asked in a letter to Barker, 'ls the Medical Group really interested in our program? Are they aware of the program? Do they, as part of their professional development in the Centre, get any sort of training in the concepts of consumer-sponsored prepaid group practice, or have we by default allowed ourselves to slip into just another group practice?' 3 Even the imminent emulation of their program by the United Auto Workers' fledgling St Catharines Community Health Foundation failed to fire enthusiasm. Ted Tulchinsky, the medical director at St Catharines, and the other leading light, Goldberg, had both cut their teeth on alternative health plans in the Sault. Nevertheless there was a feeling that St Catharines was headed for failure. A Ministry of Health official, who later dealt with both centres, said, 'St Catharines set up a clinic in an area where they had one doctor for five hundred people-they were an over-doctored area. The union didn't set that up because they thought it was needed; they wanted a Centennial project.' 4 The attempts in Toronto and Hamilton had already petered out without getting off the ground, and the addition of a further failure threatened to harm the health centre concept irreparably. The board's general disenchantment and their diminishing role was putting a greater load on the shoulders of Griffith, Ferrier, and to a lesser extent Wilson. Early in 1969 the administrative side was enlarged by appointing Griffith as executive director and placing a young Englishman, John Harwood, in the post of administrator. The expansion was needed because of natural growth, increasing fee-for-service work, and the general decline in board involvement. For much

80 First and Foremost of the time administrative staff found themselves presenting the board with situations which should have been dealt with far earlier. It was not until 1968, for instance, that the agreement reached with the medical group in 1966 was passed as a motion of the board. Despite the administrators' pleas, a premium increase had not been instituted until 1968 when the association was well into deficit on operating expenses. Pressing space problems had been incessantly brought to the board's attention by Griffith, but little or no planning for an extension to the building was made. As Wilson wrote, 'As problems arose they were let go until they reached crisis proportions. When the institution seemed to be on the verge of collapse, a series of frantic and sometimes acrimonious meetings were held. Just as soon as the worst of the fire was put out, it was business as usual until another crisis developed.' 5 To be fair to the board, much of decision-making was made more difficult by the uncertainty as to when medicare would be introduced and what form it would take. However, it became clear that Ontario would have a universal provincial health insurance scheme by late 1969. The various bills which had been introduced, the committees which had reported, and the nature of the plans already in force in other provinces, gave a good idea of the basis for the legislation: it would pay doctors a fee for each service, it would not allow any coverage besides the government's, it would not involve itself in organization but only in payment for services, and patients would be free to choose any doctor they liked. Without special provisions, the entire prepaid dual-choice program at the Sault would become illegal. To avoid this the board would have to be reduced to the role of landlord, maintaining the building for their fee-for-service doctors. Alternatively, the board could lobby the government to ensure that the Sault plan could still survive under their medicare legislation with special provisions. For this reason an alliance was formed with the emerging St Catharines group, which was due to go into operation during 1969. Tulchinsky and Goldberg, accompanied by Griffith and others from the Sault, made extensive representations to the government, requesting special provision for their schemes. The association at the Sault had already laid the groundwork with its briefs to various committees of inquiry on the subject during the 1960s. 6 The concern of the two schemes was that they would be required to accept anyone, and, conversely, their subscribers would be free to use other doctors at their expense. They worried that the premiums would be collected by the government, and therefore any direct ties the subscribers felt to the health centre would be removed. They wanted to be paid the established premiums for both medical and hospital care of their patients, so that the savings they knew would be made on the hospital side could be redirected towards more comprehensive care in the centre. But most of all they wanted to avoid being forced to pay their doctors fees for service,

81 The Coming of Medicare which they saw as encouraging the treatment of sickness rather than the promotion of health. In the Sault there were two additional concerns. The first one was that legally any fee-for-service income had to go directly to their doctors. At that time, the group doctors' fee income from their fee-for-service, workmen's compensation, and insurance claims was supplemented to reasonable earnings levels by the association's income from subscriber premiums. The doctors depended on the association for a significant portion of their income. Thus the subscriber premiums represented the board's 'leverage' over the running of the program. Enforced fees for service would send the monies directly to the medical group. The board certainly did not want the doctors, whom it currently regarded as adversaries, suddenly to gain free rein over the entire program. Second, it had promised free coverage for its retirees, but was unsure how it would provide this under medicare; unless the legislation stipulated it, the board would have no source of funds to pay for such care. The board, however, was not well prepared to cope with these problems. Its gradual disenchantment, the consequent overloading of the administrative staff, and its poor or non-existent relations with its doctors, all seemed to be more than enough to retard preparations for medicare's arrival. The strong union component on the board introduced a further ironic block to facing the problems which medicare could bring. The union movement had historically been the strongest of voices in favour of national medicare: the original steelworker resolutions for health centres had even been prefaced by 'until such time as national health.insurance is introduced.' Were they really to believe that this cause for which they had fought so hard was actually a threat to their own prepaid group plan? To complicate matters further, around the time of medicare's introduction, the unionists on the board were unable to keep up their board involvement. The steelworkers of 2251 went on strike against Algoma, and this became the primary focus of their energies. Nevertheless consultations with the government took place throughout the summer of 1969, with Griffith and the new administrator, Harwood, carrying the major share of the Sault's responsibility. St Catharines, through Goldberg, started talks with the Hospital Services Commission about consideration for the savings in hospital use by the plans. Tulks with the Ministry of Health centred on an alternative payment scheme to fees for service. The alternative which was most favoured would pay a set amount to the health centre each month for the care of each patient. This was effectively prepayment, with the money coming in whether the patient used the centre or not that month. Capitation, as it was called, would allow prospective budgeting, the practice of preventive care, use of non-physicians, and many other innovations. Significant

82 First and Foremost progress was made in this direction, and by October, when medicare was to start, a reasonable proposal was thrashed out. The board now had to accommodate the medical group's desires within this proposal before they could feel confident signing such an agreement with the government. With the poor board-doctor relations, with the anaesthesia issue not yet resolved and motivating the group's doctors to seek more concessions from the board, and with time pressures building, this did not promise to be an easy exercise. The insecurity, bitterness, and despair of the association and its officers was probably at its highest point ever at this time. On I October, just before the government proposal was to be aired in front of the board and doctors, and on the day medicare started across the province, Griffith pleaded in a letter to Barker, 'I must bring to your attention again in the most urgent terms possible the necessity of immediate board action in dealing with the financial crisis facing the Association ... The Board has not met for 6 months and unless they rapidly deal with these and other problems the affairs of the Association will be unmanageable.' The board responded with a plan to meet on 22 October, and to include representatives of the medical group at the meeting. The meeting was to be in Toronto as the strike negotiations which were taking place there involved a large number of the board. The members of the board regarded the meeting as an opportunity to utilize the special provisions offered by the government to re-establish some control over the centre's direction. Certainly there was finally a realization that medicare would bring significant changes. The board wanted to ensure that these changes would continue to mark them out as an exemplary prepaid group practice, not 'just another group practice'. THE MEDICAL GROUP'S MOOD

By the end of the 1960s, the medical group regarded the board as a distant entity which acted as an obstacle to the doctors' aims for the program. The incessant harassment by the local medical society had taken its toll: not only had it worn down the resistance of the group members who had remained, but it had also ensured that replacement doctors could not be guaranteed to have sympathy for the alternative delivery concepts of the board. There was very little communication between these doctors and the board, and hence a failure to grasp each's motivations. The group's feelings were summarized by Ferrier in 1968: 'The remoteness of the Board of the Group Health Association is felt very keenly. Its members are looked on as absentee landlords who cannot possibly understand all the problems and needs of our physicians.'' The anaesthesia crisis, which could have served to unite the two interests

83 The Coming of Medicare against a common foe, had only exacerbated things. The group just wanted to use the occasion to lift the weight of hostility off their backs, while the board felt it was time to teach the medical society a lesson with court action. Their respective motivations were entirely different, although the board did vote wholehearted support for the medical group's course of action. The medical group was most concerned with establishing an environment in which its members could prosper and thrive and concentrate all their attention on practising medicine in the way they had been taught. The fact that the types of specialty available within the group had not been expanded, that there was no stability in general practitioner care, that they were excluded from positions on hospital committees and restricted in the breadth of programs they could start, all irked them. Members were disturbed that any new equipment to serve the entire city could not easily be located at the centre, because downtown doctors refused to make referrals to them. This presented almost a moral obligation to avoid location of new services at the health centre, otherwise all nonsubscribers would be deprived of their use. The group's main aim was to bring about conditions which would prevent this and other examples of restriction on their practice. The medical group decided that specific incentives were required to encourage doctors to stay longer. The partnership formation had been the first step in this direction, and in 1968 the one-year eligibility period was extended to two years. However, this was still not enough of an incentive. Income levels, especially for some of the specialists, were probably below those of the solo practitioners, and increases were required to maintain a competitive position. Some moves in this direction were taken by the board in 1968, but the doctors still felt that 'benefits to subscribers have come at their social, professional and financial expense and that is not appreciated either in any tangible or intangible way ... they know they have been accepting less income than they could have received in solo practice in the area.' 8 It was thought that attractive incomes were particularly important in order to procure rare specialists for the centre and thereby expand services and increase their independence from local doctors. A further incentive was sought through a pension plan or some other tax-free deferred income plan which would be provided by the association and only available after a few years' service. The board was slow to react to this need for incentives, but the doctors' group instituted some changes on its own to reduce the rate of turnover. By late 1968, in an attempt to take physician productivity into account, the doctors were operating under a productivity points scheme. In addition to their basic salary (i.e., their 'drawing account' with the partnership), they received additional monies depending on the workload: 'The basic method is a point system for

84 First and Foremost different services such as call duty, house calls, surgical assists, etc. It has been noted for example that the physicians have shown more acceptance of increasing their workload ... The system does allow for jockeying in terms of points and it may become too contentious.'9 Although this accounted for less than 10 per cent of a doctor's income it did have elements of some fee for each service, which pleased many in the group while leaving some of the board disturbed but resigned to the plan. The doctors had clearly identified fee-for-service payment as a desirable change for them. Not only would such payments come directly to them, rather than payment coming via the association, but fees for service would help to legitimize the group in the eyes of their medical colleagues and thus improve the medical environment for them. These feelings burgeoned in 1969 during the intense search for normalized relations which had been precipitated by the anaesthesia boycott. The negotiations to resolve the boycott also increased the group doctors' desire to institute unequivocal free choice for the subscribers. This was part of a general feeling that further concessions had to be made to improve working relations. Ferrier stated to the board: 'Since we cannot have our own hospital and full range of specialists rendering us totally independent of the local medical profession, we must reduce the barriers between the two medical groups.' 10 The group doctors' attitude to the local doctors was not, however, always one of conciliation. Another desired change, which was partly determined by the local problems, was expansion. If the centre could become big enough, the group would not only support all specialists but would either subsume, or make itself independent of, the local doctors. As medicare approached, this feeling grew. One of the doctors recalled, 'At that point there was disagreement, at least with the board, over expansion. They were still emotionally wedded to the idea of the steelworker clinic ... whereas a group of physicians particularly wanted to see this thing keep expanding. My personal desire was to keep the thing expanding until we were the only significant medical presence in the Sault, and I would like to see us gradually take over the whole practice of the Sault.' 11 Because of the absence of any real education of doctors in the program's goals and the lack of communication from the board, the doctors' view of the situation was somewhat one-sided. The questions of the philosophy, economic efficiency, and nature of the health centre were not seriously considered by the doctors. As Griffith pointed out in a paper commissioned by a federal project on community health centres, 'physicians see their responsibilities in terms of an individual patient who needs medical care and that this can best be supplied in a situation in which they have personal and professional autonomy.' 12 Yet a major function of the health centre was to transcend such individual group

85 The Corning of Medicare interests and consider the desires of the subscribers, the requirements for fiscal solvency, and the broader picture of their medical care delivery in the entire system. It was hard for steelworkers, used to incomes of a few thousand dollars a year, to accustom themselves to the idea of paying their doctors over twenty thousand a year as well as fringe benefits like pension plans. Furthermore, while they were not nearly as concerned about the steelworker aspect of the centre as the doctors thought, they did have fears that more expansion would increase the difficulties they were already encountering in maintaining 'warm, personalized and continuous care.' They were even more wary of fee-for-service payment for care, which ran contrary to the most basic of their principles: 'On a fee-forservice basis ... the Sault Ste Marie centre ... would be destroyed ... It would penalize us very greatly to do services of a preventive nature. Preventive medicine doesn't pay as well as surgery [under fee-for-service] . Doctors would be tempted to concentrate on the more lucrative procedures.' 13 Additionally, as doctors would be the only ones allowed to charge a fee and have it paid by the government, it would severely discourage the use of allied health workers in a team approach. It would also undermine any remaining influence that consumer sponsorship had over the direction of the program. Finally, although the board inevitably became resigned to the onset of 'free choice' with rnedicare, it was not yet prepared for the complications this would cause for their operation. Griffith's role as executive director was to act as the buffer between these contrasting desires of the board and the medical group-not a rewarding task. Ferrier's position in all this was also not easy. He knew that some of the requested changes might jeopardize the program's goals. However, as medical director he had a parallel responsibility to represent the consensus of his medical group, and to ensure that there would be physicians to deliver care at the centre. To have gone against the consensus might have resulted in the loss of physicians from the program. He therefore knew how important it was for the board to listen to the medical group's requests. While the Sault and St Catharines developed special provisions with the government in the summer of 1969, the medical group was formulating its own ideas. The group reacted to the proposed capitation 'experiment' by comparing it with fees for service. In late June they concluded that 'It is our considered opinion that we would be unable to keep a small group of physicians sufficiently dedicated to accept the political risks and financial disadvantage necessary to conduct such an experiment. Numerous experiments in the provision of services can still be carried out ... with the program essentially working within the free choice fee-for-service scherne.' 14 For the British doctors in the group, many of whom had fled the capitation-based National Health Ser-

86 First and Foremost vice, the very mention of the word 'capitation' raised emotional barriers, even though Canada's would be a totally different system. Despite this, the government negotiations continued with a proposal to introduce capitation along with 'bonus' payments for every hospital day saved by the group compared to the provincial average. The medical group conducted its own discussions, and it became clear that some members were adamantly opposed to anything but fees for service while others recognized the dangers this posed for the integrity of their group practice. Over all, however, there was the fear that if they went into capitation, while all the rest of the province was on fees for service, they would once more be marked as the black sheep of the province's doctors. As a prelude to the planned board meeting in Toronto on 22 October 1969, Ferrier communicated these feelings to Griffith: 'A consensus has been arrived at based on substantial discussion ... Method of payment rather than free choice is now considered by many to be fundamental to acceptability on the part of the local medical profession. Acceptability at this time is essential for provision of cross coverage, particularly in the provision of anaesthesia ... An adequate trial of fee-for-service of some months is mandatory ... Further dialogue at this time will not influence this decision.' 15 Thus, the medical group and the association approached the crucial board meeting in Toronto with almost opposite goals for medicare's role in the health centre. The board, including the steelworker members who were already testy from the prolonged stike negotiations, wanted to seize the chance to re-exert control and mark out the centre as an exemplary alternative. The doctors, sickened by the never-ending conflict with the medical establishment, wanted to slip into the normal fee-for-service system and lead peaceful, unhampered medical lives. MEDICARE'S INTRODUCTION AND ITS IMMEDIATE CONSEQUENCES

On 1 October 1969 the Health Services Insurance Act of Ontario became law, and health coverage for the entire population was provided under the Ontario Health Services Insurance Plan (0HSIP). Hospital coverage continued to be provided through the Ontario Hospital Services Commission (oHsc). It was now illegal to have any competing insurance plans and, other than being an agent to collect 0HSIP premiums, the insurance role of the Group Health Centre had come to an end. No agreement had yet been reached on medicare's special provisions for the health centre. However, the legislation had, as a result of lobbying from the Sault and St Catharines, left room for such special arrangements: 'The Minister may enter into arrangements for the payment of remunera-

87 The Coming of Medicare tion to physicians or practitioners rendering insured health services to insured persons on a basis other than fee for service.' 16 The capitation proposal was thus cleared as legal. Along with the proposed payments for reductions in hospitalization, it formed the basis of the alternative payment scheme to be discussed at the board meeting with the medical group representatives on 22 October. The board wanted to accept the proposal and believed it would provide enough income to support the program, especially if significant reductions in hospital use could be achieved. Griffith had calculated that the current programs and practice of the doctors were unlikely to be financially supportable under fees for service. Nevertheless the doctors were convinced that they must have fees for service. This meeting in Toronto proved to be a cathartic exercise with few punches pulled. One board unionist recalled events: 'I had my lunchpail in my hand, going out to work for 3 o'clock, and then the phone rang and they say, "Can you be on the train this afternoon? There's a board meeting in Toronto ... it's an emergency meeting.'' And that's when the medical profession at that building [Group Health Centre] started to kick up their heels a little more, you know. There was maybe some justification for it, too, because of some of the things that hadn't been signed. But it was a very emotional meeting. Dean Nock, at the time, he spoke out very vehemently against the things they were trying to do ... And it was pretty much that thinking around the board ... The meeting went on from about 7 o'clock to pretty near twelve that night ... So after the meeting, there was kind of an airing, you know, things seemed to take on a little better perspective.' 17 The meeting seemed to have at least a temporary positive effect on relations and paved the way for a compromise to be worked out a few days later. Ferrier, Wilson, and Griffith had been working hard to sway the doctors towards capitation. To this end a series of comparisons had been done demonstrating that better income levels could be achieved under the alternative payment scheme rather than fees for service. This income argument did prove to be persuasive for the medical group, and on 30 October Ferrier was able to tell the board that the group was agreeable to 'prepayment [from government] with the Algoma District Medical Group billing the Group Health Association on a fee-forservice basis.' 18 The association and the medical group signed a memorandum of understanding, which embodied this approach and cleared the decks for an agreement with the government. In practice the doctors never actually billed fees for service to the association, but in theory this was the procedure, which was so important for them in their search for legitimacy. The series of events surrounding medicare heralded a new balance in board-

88 First and Foremost doctor relations: the doctors were recognized as independent partners along with the association in the health centre venture. The medicare legislation had confirmed the view that doctors, not consumers, were the primary decisionmakers in health care and thus helped legitimize the doctors' demands for more control. It was agreed that 'a policy committee consisting of the executive of the Board of Directors and the executive of the medical group shall meet at least quarterly to review the policy of the two organizations and to provide such policy clarification as is required.' 19 This 'joint executive,' as it was called, was the final recognition that the doctors of the health centre were in no way employees of steelworkers or anyone else and, furthermore, were equal partners with the board in determining the policy directions of the health centre. There was now, on paper at least, a basis for significant physician involvement in the running of the centre. The doctors had progressed from initially being employees of Ferrier, through established independence as a medical group, to partnership with the association on the joint executive. Although the association, through the board, retained the legal responsibility, it had started the process of formalizing shared policy responsibility with the doctors. Shortly after this, in December, the one-year agreements were signed with the Ministry of Health and OHSC, and the Group Health Centre's second stage of development, as a government-funded alternative, was begun. The government's commitment to allowing them to continue as an alternative was, however, far from total. The Conservative premier, John Robarts, had not been a willing supporter of medicare for Ontario, introducing it only because of its guaranteed federal dollars. He was careful to offend neither the doctors nor the insurance industry with the scheme. He maintained that the government's role was only to pay for services not to organize them. Organized medicine, the OMA in particular, had got the fee-for-service payment it wanted. Capitation payment for the Sault and St Catharines was very much the exception under the act. The much-touted 'free choice' was also part of the act: 'This Act shall not be administered or construed to affect the right of an insured person to choose his own physician or practitioner, and does not impose any obligation upon any physician or practitioner to treat an insured person.' 20 No exceptions to or exemptions from this clause were entertained, presumably for fear that the government might be seen to be going beyond payment and interfering with the delivery or organization of care. It was this provision in the act that caused continuous difficulties for the Sault and the eventual demise of St Catharines. The effect of the free-choice guarantee was to discourage economic accountability in the delivery of an individual's care. Previously the health centre had known for whom it liad responsibility, i.e., those who paid it a premium. It had

89 The Coming of Medicare also had some control over the use of services outside the health centre for which it had to pay, by reimbursing only those initiated through referrals from health centre doctors. 21 It had therefore been possible to finance the centre accurately by subtracting the controlled cost of the outside services from all the subscribers' premium income and have left the budget for running the centre. A competitive premium for a competitive level of service could then be established. After medicare such fiscal and program planning was far more difficult, if not impossible. The centre still had the premium income ($4.60 per person per month at the inception of medicare), although it was now paid as a capitation sum by the government. But out of this sum the centre was supposed to pay for services used by its patients outside the health centre, whether on referral from the health centre or not. The fact that patients had the legislated right to see any doctor at any time meant that the health centre was potentially fiscally responsible for a patient's fifth, sixth, or even twentieth outside doctor's opinion on the same episode of illness. With the 15,000 or so steelworkers who had been subscribers since 1963 this was no major problem, as they had come to regard the centre as the primary location for their care. However, the freedom of choice provision encouraged many new patients to use the centre too. These people had no historical commitment to using the centre exclusively and, furthermore, they paid their premiums to the government, not the health centre; this effectively discouraged any loyalty. Many of these patients received only a small portion of their care at the centre and the rest downtown. If the association took them in under capitation they might well lose money on them after paying their feefor-service bills downtown. The difficulty was further compounded by the refusal of the government to allow 'split contracts,' i.e., an entire family had to be enrolled en masse. Therefore if only the husband used the health centre while the wife and children went downtown it was unprofitable to put the family on capitation. If they were all put on fees for service, the centre could charge them for the care obtained from group doctors and have no responsibility for the care delivered elsewhere. Therefore, there was little incentive in these early days to put people on capitation. The consequence was a very fast growth in the proportion of fee-for-service patients, as unprofitable capitation enrollees were transferred to this method of payment and new patients started. Between 1969 and 1972 the capitation population actually fell from just over 18,000 to 15,400, while the actual population served reached 35,000. Hence, the proportion of income from fees for service grew from 18 per cent of the total in 1969to over40percent of the total in 1972. Despite the attempts to control the level of outside service costs by a massive transfer to fees for service, the cost per enrollee for outside services

90 First and Foremost climbed from 45 cents a month in 1969 to $1.50 in 1972. The free-choice provision of medicare was making financial planning at the centre a nightmare. As the association pointed out in one submission to the ministry, 'In direct violation of good medical and administrative practice we are still being required to be responsible for services over which we have absolutely no medical or fiscal control.' 22 The government, with its concentration on payment and aversion to the organization of care, was fast nullifying any possibility of providing innovative care through the capitation scheme. The Ministry of Health seemed unable to grasp the interaction of payment incentive with organizational elements. What the health centre wanted was 'the provision of a voluntary enrolment option for all citizens of the Province who live within the medical service area of the Group Health Centre. Each year individuals or families would have the opportunity of enrolling ... or discontinuing their enrolment ... We would argue that free choice includes the concept of the right of the individual to choose his medical care system, including the right to choose community health centres ... Government is currently denying the citizens free choice in that they have only the opportunity of choosing the individual physician.' 23 They were, in essence, asking for a return to the dual-choice system. The proposal, however, fell on deaf ears. The failure of OHSIP to provide free coverage for retirees was an additional cause for concern. The health centre program had always promised premium waiver or free coverage for its retired subscribers; however, there was no consideration for such payments in their capitation sum from government. Many board members recalled how vital this promise had been in the original signup campaign in 1962, and felt that to remove this provision was unconscionable. However, in May 1970, seven months after medicare's start, they could no longer carry the cost of paying their retirees' premiums. After much soul-searching the board advised retirees 'with great regret ... June will be the last month we can pay your premiums to the government.' 24 From that time until 1972, when the government did start premium waiver for the over-65s, the pensioners were forced to pay their own way. This was indicative of the massive change brought about by medicare at the centre: the board had been forced to discard one of the central promises made at the start of the venture. Similarly, the association had always used the broad definition of dependant as anyone who could be claimed for income tax purposes. The medicare legislation restricted the definition to the immediate dependants-another blow to the integrity of the centre's funding principles. The association had been forced to become just another cog in the far larger wheel of a government-paid health insurance scheme, albeit a unique cog. It

91 The Coming of Medicare was lucky enough in these early days to have in the Ministry of Health some people who were sympathetic to its aims, but this could not alter the fact that it was a very small part of a system oriented to fee-for-service payment and free choice. It was inevitable that the fee-for-service system would determine the overall direction of care. The centre's capitation sum was, in fact, calculated on the basis of equivalent fee-for-service cost, despite the omission of preventive and non-physician expense in this figure. The nature and quantity of data for health planning was determined by fee- for-service needs. The mentality and approach of ministry personnel were shaped by the concept of a fee-for-service structure. The Sault and St Catharines were doomed to be thorns in the side of the feefor-service status quo. The situation became even worse in 1972 when OHSIP (medical care) and oHsc (hospital care) were combined into the single Ontario Health Insurance Plan (OHIP). 0HSIP had sensibly introduced an individual identifier for each person or family, but 0HIP took the insurance approach of identifying only the policyholder, i.e., the head of the family. This precluded any consideration of individual utilization and calculation of costs per capita by age, sex, geographic location, and so on. The OHIP data base became a bill-paying system for fee claims from doctors, and health planning was severely hampered without information on each individual's use of the system. The accurate capitation sums and hospital utilization figures needed to fund alternatives like the Sault could be obtained only through individual identifiers, but yet again the government seemed to see a responsibility only to pay bills, not to plan the delivery of care. The fact that the centre had served over 20,000 people's health needs before 1969 meant that the ministry had a responsibility to fund it under medicare. There was no guarantee, however, that they would understand how to fund it! Although it was true that the introduction of medicare, through the OHSC contract, had allowed the Sault to gain a financial incentive for its more prudent use of hospitals, even here the government's approach demonstrated a lack of understanding of the concept. The idea was a good one. For every hospital day less than the provincial average utilization, the centre would receive $32 as consideration for the hospital expense that was not being incurred. As the provincial average was around 1,300 hospital days per 1,000 people, and the World Health Organization study had showed that the Group Health Centre used fewer than 1,000 hospital days per 1,000 people, significant income was potentially available from the scheme. However, the provincial average was not really a fair comparison for the Sault in northern Ontario, where hospitals were commonly more used than their counterparts in the south. The best comparison would have been with the non-health-centre patients in the Sault, but the ministry did not have such data. That provincial average persisted until 1972 when an arbitrary

92 First and Foremost adjustment of 5.7 per cent was introduced as a northern Ontario allowance. The free-choice provision also had an effect in this context. With no exclusive control over their patients' hospital use, the health centre doctors were far less able to keep down hospital utilization. If they told a patient he didn't need a tonsillectomy, the individual could go to an outside doctor where the payment of a fee for the service might encourage performance of the operation and cause the increase in hospital use anyway. 25 The lack of accountability of patient to centre and centre to patient worked directly against controlling appropriate hospital use. Consequently, in the first year, 1969-70, there was a hospital saving of only 145 days per 1,000 people and a consequent income of eighty thousand dollars instead of the possible two or three hundred thousand dollars. Furthermore, the ministry clearly failed to grasp the need for timely payment of these incentive sums to the health centre. If the doctors were to be encouraged to maintain reduced hospitalization, then the incentive had to be paid close to the period on which it was based. This did not happen after the first year. The association complained: 'Although a hospital incentive was negotiated the incentive was paid so far after the performance that it had no impact. In one instance the final settlement was received about four years after the period during which the performance was measured.' 26 These problems did not represent any kind of conspiracy on the government's part to destroy the alternative concept. Rather, they exemplified the difficulty they had in understanding the goals and needs of such programs when surrounded by an insurance-oriented, fee-for-service system. The consequence for the Sault was a continual feeling of insecurity and the need for Griffith and others to spend a great deal of time dealing with the ministry. As the issues became more complex, so the need for 'experts' increased, and the board could play a less active part. Its reduced role, with which it did not seem entirely unhappy, was to emerge at politically opportune times to confront the government and otherwise to leave the nitty-gritty to Griffith, Harwood, and Wilson. The siege mentality which had developed as a result of opposition from the local medical society and organized medicine was now further encouraged by the less purposive, but no less destructive, attitude of the ministry. All was not gloom, however, for the health centre after the introduction of medicare. Generally, there was now some incentive to use all resources appropriately. Specifically, the centre did have a fiscal incentive, however poorly structured, to decrease hospital utilization, something that was not available before 1969. The deadlock in relations between the doctors and the board had at last been broken. Things were still far from perfect but the doctors felt happier with the natural opening-up and availability of the centre to all the citizens of Sault Ste Marie. The massive growth in fee-for-service care, coupled with the establish-

93 The Coming of Medicare ment of a joint executive, enabled the group doctors to feel that they were close to being traditional professionals with fee practices and individual autonomy. They were also represented in the newly formed combined local medical society- the Algoma West Academy of Medicine-which had supplanted the Sault Ste Marie Medical Society after the conclusion of the anaesthesia crisis in 1970. Hospital committee positions were becoming available to them although there was still no normal referral pattern from their solo practice colleagues. The freechoice provision had very much contributed to the group doctors' feeling of final liberation from the 'steelworker' label and was encouraging to them because of the far larger patient population it provided. The question of whether to expand or not, something the board had never really decided upon, was now assured and this would certainly increase their prestige and influence. The board and administration were left to grapple with the mechanics of the inevitable expansion within the context of unknown commitments to and from their new government paymasters who had replaced the former subscribers. The influx of new patients-none of whom had paid a $135 building fee, none of whom paid premiums directly to the health centre, and none of whom necessarily felt any obligation towards the centre-made the job of maintaining the atmosphere of a 'community' health centre all the more difficult. As Barker acknowledged, the introduction of medicare had made the whole idea of community health centres a more difficult proposition to sell: 'People generally, working people generally, don't have any concept of what the actual cost is now ... if somebody else pays-as long as they don't have to shovel out the money themselves- they seem to forget the fact that they have to pay for it. So that once they're getting their health care paid for by medicare, what the hell -you couldn't interest them in some other kind of form.'

7

A Second Beginning

THE CHALLENGE OF EXPANSION

With the province-wide free-choice provision, a major task for the health centre following the introduction of medicare was how best to handle the consequent increase in patient use of their facilities. By 1972, just three years after medicare, a number of patients using the centre for at least some services had increased by a staggering 93.8 per cent over pre-medicare days. However, free choice meant that by no means all of these people used the health centre exclusively. The increase in visits to the physician, a better indicator of the real demand, was a more reasonable but still substantial 28 per cent. By 1980 patients using the centre for some services numbered well over 50,000 and visits to physicians had increased 94 per cent compared to 1968. The problem was how to handle this expansion and still adhere to the original principles and goals of the program. The potential difficulties were clear. Could effective group practice be maintained as the number of doctors increased and interchange amongst all of them became more difficult? Would warm, caring attitudes be present in a staff numbering 145 by 1977, compared to 47 in 1968? Would the flexibility of capitation funding be translated into new programs substituting appropriate non-physician manpower for traditionally physiciancontrolled work? Could consumers still identify it as 'their' community health centre when it was becoming so large and there was no longer any direct financial commitment? Finally, could the structures of the board, the administration, and the medical group develop appropriately to take account of a transformation into a multi-million dollar enterprise? In 1971 Griffith reassured the subscribers to the health centre that 'the Group Health Centre is still owned and operated by the people who put it up in the first place. It's still your Centre and even with all the changes we've had to make

95 A Second Beginning as things changed around us we still have the same aims as in the days when you started it. How well we can meet these aims depends on how strong you make us.' 1 The association was always keen to ensure that the services it provided were meeting the requirements of its patients. In 1973 it commissioned a study of the consumers' view of care in the city, to compare the solo-practice doctors with the group health centre. This wide-ranging questionnaire study found that 'consumers of care at the Group Health Centre perceive greater accessibility of certain diagnostic services, perceive the waiting time to see the doctor to be shorter, and find the locational convenience (with regard to parking) of the Health Centre to be more desirable ... [However] patients who predominantly use the solo practitioners reveal consistently more positive attitudes towards physicians in general ... Patients of solo practitioners evaluate the general personal concern ... for their welfare more positively than do patients of the Group Health Centre.' 2 Such findings generated debate as to whether the necessary expansion should take the form of an addition to the present building or whether it would be better to set up satellite clinics which could keep the small, more personalized element to the fore. The idea of satellite or 'off-shoot'-centres was well established in the United States, where prepayment plans used them extensively. There was serious doubt, however, about their feasibility in a city the size of Sault Ste Marie, where you could go almost anywhere in twenty minutes. The question was raised of how few doctors could staff such satellites and still be considered a 'group.' There was also the factor of increased overheads in separate centres-would they include X-ray, laboratory services, and so on? If they didn't have these services, then patients would have to come to the main McNabb Street site anyway for this allied care. The only real advantage to be found was the assurance of more personalized care. A number of factors eventually led to the decision to expand the original premises: land became available immediately adjacent to the centre, offering a perfect opportunity for building there; discussion of plans for the addition of dental care to the centre's services indicated a need for more space at the central facility; the agreements with the government, signed only on a yearly basis, were not providing as much money as originally anticipated and hence the smaller capital commitment of an addition, rather than satellites, was economically more attractive. The insecurity of government payments caused a delay in the start of new construction, but by 1973 the commitment for a $900,000 addition was made. The surplus space was to be rented out until dentistry came on stream or a further increase in patient numbers necessitated its direct use for the centre. The extension opened in the summer of 1974 and provided potential space for the care

96 First and Foremost of at least 50,000 patients. Inevitably, this expansion did give rise to concern about the centre's ability consistently to maintain warm personalized care. A major worry was that the original $135 sponsors - the 'founders' of the centreshould not become part of any dissatisfied group. On a number of occasions the board deliberated ways to provide something extra for these people but failed to find anything substantial that they could do for them. The expansion aroused the local solo-practice doctors to overt opposition once again. On numerous occasions doctors who had agreed to join the group, or were about to agree, reneged at the last minute, citing pressure from solo practitioners. Ferrier noted that 'with the commencement of construction of the new building, local political problems have become much worse. The solo practitioners have out-recruited the Group this year and have secured six new general practitioners. Two members of the Medical Group were on the executive committee of the General Hospital; however, following elections there are none.' 3 By this time the centre and its doctors had learned to pay scant attention to such opposition: most of the veterans knew that the making of concessions to remove the 'last barrier to normal relations' had reached a point of diminishing returns, while newer doctors, who were largely unaware of the past difficulties, were able to put up with the harrassment which was less intense than before. Nevertheless, there were still areas in which the local doctors significantly affected the health centre- their attempt to expand to outlying districts being a case in point. One of the chronic problems of health care in northern Ontario is how to ensure adequate medical and dental coverage for the small communities and settlements far away from large concentrations of people. The Group Health Centre, with its ready-made administrative structure, was an ideal organization to facilitiate this kind of care. The project seemed to offer an opportunity for the board to become involved and motivated by an exciting new venture. Two attempts were made. The first was precipitated in 1972 by a request for help from St Joseph's Island. Wilson and Griffith visited the Island and started plans for health centre involvement. However, it did not take long before the local Sault doctors moved in, and in early 1973 Griffith wrote to the Red Cross Hospital on the island: 'While we welcome an opportunity to work with anyone who has something to offer in the way of meeting the problems of the people of the island, we do not want to discover that we are working at cross purposes with either your Board or with any other group who may be involved.' 4 With neither a strong commitment to the idea nor the unqualified support of doctors, board, and government, the plan soon fell through. The second major thrust involved a more comprehensive approach in 1979 to attract government funding for nurse practitioner coverage with physician back-up in a number of the communities to the north of the Sault, starting with

97 A Second Beginning Wawa. The consumer orientation of the centre could be seen clearly in Wilson's preliminary proposal; 'It is assumed that the long-term solution to the problem of health manpower practitioners for the remote communities is either trained nurse practitioners or other specially trained personnel and, most importantly, personnel who are indigenous to the area to be served.' 5 The proposal included a teaching program for nurse practitioners at the local Sault College. This time it was a combination of the board's cautious approach and the local doctors' intervention which scuttled the plan. Wilson commented sarcastically about the problems of remote areas: 'The answer to the Northlands is for Fred and I to go there and talk about doing something. Then the government or the local doctors will do it ... Fred and I went ahead going down to St. Joe's Island. Next thing you know, the government is in there doing something with the local medical society ... Then we get involved with people in Wawa ... The next thing you know the local doctors are out there providing consultation.' There was far more success with the development of innovative programs within the centre, although these brought their own internal problems. The capitation system of payment meant that a broader range of personnel could be employed to address the health needs of patients. Under fees for service, payment was only forthcoming for services largely performed by doctors. With capitation, a set amount for each person's care was paid and the centre could spend it on providing services they thought necessary in addition to doctor's care. The first area in which this added flexibility was utilized was in an expanded role for nurses. The traditional role of the nurse was only just beginning to be challenged at this time, and the centre was quick to see the value of a more imaginative use of nursing personnel. Ferrier trained some nurses to do physical examinations and staff a health evaluation unit within the centre. At the same time, Griffith and Wilson, the latter now at the University of North Carolina, arranged to have places available for the training of family nurse practitioners who would be able to handle much of the basic work of a family doctor. However, problems emerged on two fronts, prompted, surprisingly, by the nurses themselves: they were nervous about the college rules on such added responsibility and they were concerned about not getting more pay in line with their increased role. Therefore in 1973 they withdrew services from the evaluation unit, restricted themselves to normal duties, and started the process of unionization. Wariness of innovation seemed to be no less a characteristic of the nurses than it had been of the doctors. A solution to these problems was found, the program got back on track in 1975, and the concepts of expanded-duty nurses and of family nurse practitioners became an integral part of the program. This did not mean that either the local doctors or even some of the health centre doc-

98 First and Foremost tors demonstrated ready acceptance, but persistence managed to allay most of their fears. It was not difficult to convince most of the family doctors of the value of a program which removed from them the burden of the more trying aspects of emergency or on-call care. From the economic perspective, it meant that more patients could be handled without automatically having to hire more doctors. The main obstacle to be overcome was the fear of reprisals from the disciplinary colleges of nurses and doctors. The use of non-traditional nurses at the health centre involved some risk-taking by Ferrier and the other doctors; nevertheless, they were willing to accept these risks. Further advantage was taken of the flexibility of the capitation system with the introduction in 1974 of a counselling service for the centre's patients. Repeated studies had revealed a small number of patients using a very significant percentage of services. It was possible that counselling might teach some of these people more appropriate use of the facilities and might also more appropriately address their problems. 'A particular population of 1 per cent use almost a quarter of the hospital days ... Possibly this is the group who are so ill that their utilization is appropriate-or is it a population where special efforts should be made to modify utilization? ... Certainly our very modest study of appropriate intervention with high utilizers of service ... indicates significantly lower utilization and dependency on drugs following counselling. The study indicates that we are accomplishing excellent results for the patient and at the same time reducing utilization.' 6 The additional service was another economic plus for the centre and also removed some arduous labour from the shoulders of the doctors. However, its full potential was not explored for fear that animosities and acrimony would be aroused among the local solo practitioners and possibly put an end to even the limited use of the services. The search for more economic modes of delivery also resulted in the introduction of a day-surgery unit in the new building; this could potentially save hospital utilization and therefore increase income through the government incentive scheme. Unfortunately, its use was never very great because the centre's doctors were largely unable to break out of their traditional practice pattern of using the hospital. Griffith was forced to conclude in 1977 that 'the surgery is used to such a limited extent that justification of the cost is doubtful.' 7 Expansion in the area of purely medical programming did, however, advance at a significant rate. For many years, the centre had the only properly qualified cardiologist in the city, and he was one of the few health centre doctors to receive referrals from the solo practitioners. Special coronary care programs were instituted at the hospitals and some recognition was gained for this health centre contribution to the city. The arrival in 1974 of a specialist in cancer treatment afforded the opportunity to develop pioneering oncology programs in the city.

99 A Second Beginning A mental retardation program, speech therapy, a detoxification halfway house, a nutritionist, psychiatric services by family practitioners were all added. Most of these programs, while of exemplary medical worth, were notably of a type acceptable to traditional medicine. Besides the building expansion of 1974, the major new project for the board occurred when they moved into dental care in the mid 1970s. Since the early days of the centre, the inclusion of dental care had been an aim. The new building provided the space for dentistry, and planning started in earnest in 1974. Consultants were hired, the facility planned, and dental directors interviewed before it became clear that once again the legal and political climate was not favourable to community health centre innovation. For financial more than philosophical reasons, the centre wanted to make its dentists employees of the association, as the dentists already were at the St Catharines centre. However, the regulations governing all the health professions were at the time (1975) in the process of being redrafted under the new Health Disciplines Act. The original draft of the regulations made it entirely ethical for a dentist to be employed 'as an employee or agent of government, agency of government, university, hospital, community health centre or any similar facility ... [or] a duly qualified medical practitioner.'8 However, just as the Sault's plans were announced, the 'community health centre' provision was removed. The centre therefore resorted to the 'medical practitioner' section, and proposed employment of dentists by Ferrier in order to maintain them within the organization. It was not long before that portion of the regulations mysteriously disappeared, and suddenly the dentists could only be contracted with separately for their services. 9 The regulations were approved by the Minister of Health, with little regard for the resulting inability of the health centre to incorporate dentistry into the program as an integrated non-fee-for-service component. Ministerial approval was granted, despite the strong protests and representations received from the Sault, St Catharines, and other groups. The new facilities were finally opened in October 1976: the dentists operated on a fee-for-service basis, leasing space from the association, with all non-dentists as employees of the centre-a similar arrangement to that with the physicians, except for the fee-for-service component. Between 1976 and 1980 the dental service expanded to six dentists with a growing demand for services. Given the obstacles placed in the path of the centre in its quest for more rational health delivery, it is surprising that any innovation at all was achieved. Yet, despite all the problems, a great deal was achieved: pioneering utilization of nursing personnel, an impressive array of 'health' services under one roof, group-practice dentistry, some highly qualified medical specialists, and connections with provinicial, national, and foreign teaching institutions-all these reinforced the view of the Group Health Centre as more than just a run-of-the-mill

100 First and Foremost medical practice. However, continuously paddling upstream produced a weariness which, in Wilson's words, prompted the question, 'Why should the Sault, which has always broken so much ground, get further and further apart from the rest of the social system? We're in enough trouble being where we all are.' The irony of the situation was that most of the innovations and reforms being attempted in the Sault were, at the same time, being recommended to the government by various task forces and inquiries. Unfortunately, the Ministry of Health did not appear to be willing to create an environment conducive to such changes. Expansion and innovation require a firm commitment; they can spring only from a solid base of principles and a united resolve on the part of the innovators to achieve known goals. One of the centre's biggest problems was the absence of any recognized planning body where long-term goals could be established and translated into short-term action. This would have provided a solid base and united resolve, able to withstand the reticence of the health centre doctors, and the animosity of the local medical community, and the lack of government understanding. The joint executive committee formed in 1970 would have been an ideal such forum, but this body became bogged down in financial negotiations between the doctors and the association and rarely ventured into health planning. The centre was hampered by a failing common to developing organizations: it was naturally slow to discard the homely structures of a small community facility in favour of more formal linkages appropriate to a large business enterprise. It is possible, with the benefit of hindsight, to analyse where, ideally, things might have been different, and how a united resolve might better have been achieved. STRUCTURAL SHORTCOMINGS

The arrival of medicare coincided with a greater feeling of security in the medical group: the government legislation had clearly established physicians as the health system's 'gatekeeper'; and the local situation had become at least ostensibly normalized, with the single Algoma West Academy of Medicine integrating the group and solo doctors into one medical structure. Although normal referral patterns from the solo doctors to the group had not ensued, and there was still harassment of potential new group doctors (and existing ones), the increased personal contact through the academy and the appearance of group doctors in staff positions at the hospital put much of this below the surface. As the group emerged from its 'siege mentality' and grew significantly in numbers (33 by 1980), two main effects were apparent- the gradual traditionalization of practice and

101 A Second Beginning a growing desire to increase the power of the medical group in all health centre matters. As for the board, its waning enthusiasm and, following the introduction of medicare, increasing preoccupation with government negotiations, meant that it started to become a more distant management body for the health centre. The doctors had become less and less aware of the original aims and purpose of the board; certain aspects, consumer sponsorship for example, which had been so important in the establishing of the centre, began to lose their significance. The board's role was gradually redefined as chiefly the financier of the health care provided at the centre. This was certainly how the medical staff had come to regard the board: 'The only time we're aware of it is ... when they start talking money. The rest of the time we're not really interested in what they're doing.' 10 Certainly, the procurement of funds did seem to overshadow other aspects of the board's role during the 1970s. This shift in emphasis was reflected in a change at the head of the board. In August 1973 John Barker resigned as president after ten years in the post. He had overseen the growth of the largest consumer-sponsored group practice in the province. This he had done with a keen sense of when to stand back and allow pragmatism t take precedence over his principles. His work with the centre earned him many accolades, including an honorary doctorate from Laurentian University. He continued to sit on the board, a champion of the original principles and a reminder of the original steelworker sponsorship. After a brief spell with Woodcock (another of the originals from Local 2251) as president, Phil Bostelaar, the vice-president offinance at Mannesmann Tube, took over in 1975. Bostelaar was a softly-spoken man with an air of relaxed competence and a strong commitment to the centre. He was the first non-steelworker president of the board, and it was no coincidence that he was an expert in financial matters. His appointment highlighted the changing balance between the board's financial preoccupations and the steelworker involvement, which was gradually diminishing. By this time the composition of the board was six steelworkers and five others, a majority which still obtained in 1980. Bostelaar noted that, 'while the nature of the institution changes every year from the strictly union to a real community thing, the composition of the board is not reflective of this.' One of the board's chief problems was that its members did not always have time to devote themselves constantly to the affairs of the health centre. The six steelworker members, for instance, sat on the board solely by virtue of the official union positions they held, and these union commitments necessarily limited the time they had to devote to board matters. Lack of time meant that the board adopted a generally reactive response to their task: when confronted with a situation, they could and did often come to a quick decision, but all too often Griffith

102 First and Foremost was left to 'ad-lib' on general policy matters when attending government or medical group meetings. The absense of any general policy was felt particularly in the matter of maximization of income from the government. This income came in ever-changing ways, with uncertain conditions, varying incentives, and different degrees of timeliness, and the board found it difficult to establish a formula for splitting the funds between the association and the medical group. With no established formula for distribution, each year this painful exercise had to be worked through anew at the joint executive. This left little time for discussions with the doctors. How to squeeze the maximum return out of the various economic incentives included in the government contract was a financial question which fell under the board's jurisdiction; yet the number of referrals to outside doctors and the number of hospital admissions, both crucial influences on the size of the budget, were matters under the control of the doctors. Clearly, these issues should have been approached jointly, but the lack of communication between the board and the doctors meant that this was never done. The danger that the medical group and the board would each pursue separate courses and, sometimes, mutually exclusive goals, was very real. The shortcomings did not lie with the board alone. For various reasons the doctors themselves were not well motivated to discuss matters either. As their numbers had grown, the difficulties of maintaining a cohesive, interacting group had increased. At the end of 1977, Ferrier reported to the board that 'as the Group gets larger it becomes more difficult to keep communication and loyalty with the Group ... an almost uniform complaint was that there is poor communication between the specialist and general practitioner ... some general practitioners have stated that if communication doesn't improve they will deal with specialists not in the Group.' 11 The use of outside specialists by the general practitioners would have resulted in direct cost to the health centre, which had to pay for the outside services of any patient for whom it received a capitation payment from the government. In effect they would be paying for the service twice-once to make sure it was available to the group, and then again for the use of that specialty outside the group. It was clear that the general practitioners had little understanding of the financial consequences of their proposed action, or, if they did, their individual practice style took precedence. Here was an example of how the lack of board-doctor communication resulted in their working towards separate goals. The system of productivity points introduced in the late 1960s presented a similar case. Originally this payment mechanism - akin to fees for service- had accounted for 10 per cent of doctors' incomes, but by the mid '70s it had grown to nearly 25 per cent. It had also become a more sophisticated count of each

103 A Second Beginning service performed by each doctor and was constructed around the oMA's fee schedule. Parallel with its growth in importance was a desire by the administration and board for a decrease in hospital utilization, in order to maximize the incentive payments from the government in consideration of reduced hospitalization. This incentive never really seemed to yield anything like its full potential. This was not so surprising given the obvious countervailing force of productivity points that would actually reward the doctor financially for an admission to hospital. The association was not opposed to the productivity points scheme per se, but it was concerned that it should not develop to the extent where it would negate the value of the hospital incentive payment. The attitudes within the medical group were obviously not being shaped by the philosophies of the board and association. With no formal communication from the board itself, the medical group members were left to develop their practice philosophies pretty well as they pleased. In this atmosphere it became quite possible as the 1970s progressed, for some of the group, particularly specialists, to develop as essentially solo practitioners within the health centre. As one specialist commented: 'When I came here it rapidly became apparent that the physicians in the Group Health Centre, although they practised as a group in their referral patterns and things like that ... were still really independent physicians for most of the time and had a completely free hand, particularly the specialists, in how they wanted to organize themselves.' 12 The medical group was, however, quick to unite on matters of financial concern in its dealings with the association. There was the continual lingering distrust of having non-physician entities-the administration and board-controlling the physical details of their practice, i.e., the office space, support services, nurses, and equipment. Throughout the medical group's minutes allusions can be found to attempts at increasing the role of the doctors in the overall control of the health centre. In 1973 it was recorded that 'the medical group must get up the strength to take over some administrative aspects, consider replacement of some members of the Board or to persuade them that a joint venture is sound.' 13 At one time the question was 'raised ... of Mr Griffith becoming an employee of the Group instead of the Association.' 14 For most of the 1970s, however, the barriers to effective communication among board, administration, and doctors forestalled serious discussion of this underlying desire for greater control on the part of the doctors. This and many of the other issues that failed to receive full attention were ideal items for consideration at the joint executive, the committee which had emerged from the last major crisis during medicare's introduction. Composed of the board and the medical group's executive, with Griffith having ex-officio status, this was the natural seat of joint consultation and communication between the two. Unfor-

104 First and Foremost tunately the yearly deliberations on the distribution of income between the association and group had come to occupy most of this committee's time, and what little was left over was occupied by the planning of a tax-deferred sabbatical-leave plan for the doctors. There really was no other forum for constructive exchange among board members, administration, and doctors. This left a heavy burden on the shoulders of Ferrier as medical director and Griffith as executive director; communication between them often became the only mode of interchange between the parties. This channel may well have been effective in the days of the self-contained, small facility of the early years, but expansion and the passage of time had put many obstacles in their path by the 1970s. In the early years Ferrier was actually penalized by spending time on administrative duties. In 1972 the executive was keen to 'arrive at some decision about [Ferrier's] income. In order to keep up with the rest of the group he has had to do more practice in order to receive productivity. As a result of this, he finds his work as Medical Director suffers.' 15 By the end of 1972 it was agreed to pay him a modest supplement in consideration of the duties, but the fact still remained that all the administrative complexities of running a large medical group fell to one person on a very part-time basis. Furthermore, Ferrier himself had an almost pathological reluctance to introduce administrative assistance for the task: 'I'm sure that I could justify having an assistant physician in the medical group to deal with all these communications, memoranda and meetings and soon discover I need a second. I would spend the whole time [on this] and stop doing medical practice ... there's a tendency to build an empire.' Ferrier was also showing signs of wear and tear after years of being embroiled in the stresses and strains of the pioneering centre. His enthusiasm for the task tended to wax and wane with the prevalence of crises. During his 1978 tenure as chairman of the joint executive, he failed to call a single meeting of the committee, which only served to inhibit communication channels further. Dedication to the introduction of new programs like the use of nurse practitioners also required significant time (as well as use of persuasive powers over some fellow physicians). Over all he was not always as diligent as he should have been in passing information from the board down to the rest of the medical group, which was particularly unfortunate given the absence of any other real method of communication between the two. Another unfortunate aspect of leaving Ferrier and Griffith as the main seat of exchange between the parties was that Ferrier's attitudes did not always represent accurately the attitudes of medical group members. It was easy for Griffith, who had years of dealings with the essentially sympathetic Ferrier, to be misled on the degree to which the doctors did or did not support a particular issue. Griffith, however, was also not well tuned to the need to ensure that all

105 A Second Beginning the doctors were made aware of general association policy and needs. The years of assertively defined areas of responsibility between the two made him leery of over-stepping any sacred boundaries, and he developed an over-reliance on Ferrier as the messenger. The periodic waning of board enthusiasm, and the constant attention demanded by government contract negotiations, also limited the available time for exchanges with Ferrier. The situation was, therefore: a joint executive tied down by income distribution and strict financial matters; the two senior officers heavily occupied and tiring somewhat in their task after nearly twenty years at the helm; and to complete the picture, a board and a medical group who were unwilling to recognize the need for greater administrative aid to facilitate communication and decisionmaking in the health centre. This isolated development of the two main components of the centre would not have been so serious if the respective developing objectives and goals had been congruent. They were not. A confrontation between the doctors and the board seemed inevitable. It came in 1980, when the board made a series of decisions about new programs and facilities on which the medical group felt that they should have been consulted. The moot points were ostensibly the expansion of dentistry, the development of a new vision and eye-care centre, the hiring of a patient relations officer, and the writing of a history; but these really served only as a cover for the real issue at stake: a re-evaluation and restructuring of the centre which would give the doctors a larger say in the running of their own affairs. After a series of acrimonious confrontations, Ferrier wrote to the new board president, Jack Ostroski, in 1980: 'I accept at least equal responsibility with Fred Griffith for allowing responsibility and authority to be confused and for overlooking lines of communication and for inappropriate executive action ... The latest unilateral action [of the board) ... will have to serve as a raison d'etre for a perhaps painful re-evaluation of our administrative structure.' 16 The ensuing discussions resolved things by investing the joint executive with increased powers. It was made the seat of interaction, and this decision made totally explicit the enlarged role of the medical group in approving all major aspects of health centre development in partnership with the association. For some this represented the inevitable compromise required when two pipers who are responding to different tunes come to play together. However, to the still feisty Barker the new agreement was not 'intent on establishing a relationship between the Medical Group and Board of Directors but an agreement which has whittled away authority from the Board of Directors since day one.' 17 After seventeen years of successful operation since 1963, the critical choices which had to be made still seemed to come down to pragmatism versus principles.

8 The Government Presence

THE PARALLEL CHC MOVEMENT

In October 1969, on the introduction of medicare, there were only two health centres in the entire province of Ontario which could reasonably be identified as having developed from community organizations-those in the Sault and St Catharines. However, during the early 1970s a series of forces contrived to produce a few companions for these two pioneers and provoke more than a few reports, commissions, and studies in support of the concept. The forces came from two clearly identifiable directions. First there were the activists of the sixties-a mixture of the 'crunchy granola' set, committed trade unionists, and progressive local politicians, fierce supporters of the right of communities to have a significant say in their own affairs. For them, community health centres (CHcs) were more than places for the delivery of care- they were representative of a significant voice for the community. On the other side there were governments (federal and provincial), a handful of progressive physicians, and some planners who viewed CHCS primarily as a cost-containment and rationalization device in health services and only secondarily as voices of the community. This was, of course, an entirely predictable attitude from the government, who had maintained all along that their role was to pay for services, not to organize them. Government insurance had been introduced for hospital care in 1959, without the accompaniment of insurance for medical care. The historical effect had been to bias care unduly towards expensive in-patient service delivery. The experiences of the Sault, with its decreased hospitalization of patients (as reported by the World Health Organization study), of Saskatchewan's community health centres, and of the prepaid group practices in the United States, showed to the governments that cost-savings could be made through community health cen-

107 The Government Presence tres. If, however, they intervened to establish such centres themselves, it would have been seen as the direct involvement of the government in the organization of care. The fragile alliance between government and doctors under medicare could have been destroyed. It was, therefore, fortunate for them that some community organizations were independently planning such centres, enabling government at least to test the waters without being too provocative. The community aspect of the centres had received little more than this disingenuous support from all the provinces except Saskatchewan and Quebec. In Saskatchewan, which had had medical service insurance since 1962, CHCS emerged after the crisis of 1962 and were given reserved approval only as fee-for-service facilities. In 1971 the option of line-by-line budgets, rather than fee-for-service, was offered to them for the first time. In Quebec, where the local community ties were historically very strong, the remarkably progressive CastonguayNepveu Commission had proposed in 1969 a community-based approach to the province's entry into medicare. 1 In Ontario the integrity of its pre-existent cHcs in the Sault and St Catharines had been maintained, but by 1970 only tentative moves had been made to encourage further development. In 1971 the Conference of Health Ministers, organized by the federal government, requested a full investigation of cHcs and their possible role in future health services. As the federal government provided fifty cents of every health dollar, but had little control over the way each province spent it, it had an obvious interest in exploring and encouraging approaches which would reduce, or at least contain, costs. John Hastings from the University of Toronto was appointed chairman of what became known as the Community Health Centre Project. (Hastings had spoken at the 1962 sod-turning ceremony at the Sault and had been the principal investigator in the World Organization study there.) He chose a twentyperson committee which included John Barker and Ted Tulchinsky, who had spent time at both the Sault and St Catharines. Barker and Tulchinsky were definitely the reform element of a committee which represented a broad crosssection of the health interests of the time. Commenting on what he perceived to be his role on the committee, Barker said, 'As far as I was concerned, it was to argue against payment from fee-for-service-eliminate the fee-for-service.' The final report was delivered to the health ministers in July the following year. Regarding fees for service, it said, 'There are difficulties in reconciling the planning and administrative interests of the system and the team approach- both essential for the success of the community health centre-with the present feefor-service payment system ... Some committee members feel that any fee-forservice payment system is incompatible with the objectives of the community health centre and the health services system.'2The report recommended develop-

108 First and Foremost ment and evaluation of 'payment mechanisms alternative to the present form of fee for service; development by the provinces ... of community health centres ... in a fully integrated health services system; [and] funding of community health centres through global or block budgets given by the province to the district level.' It laid out objectives for such a reorganized system and placed particular stress on the CHC as a site of integration for social services as well as health services. It also envisaged 'the reduction by provincial governments of acute general hospital in-patient bed facilities; the development ... of less costly and more appropriate alternatives to acute hospital in-patient care; [and] the review and modification ... of existing provincial legislation and regulatory measures ... to allow for flexibility and innovation in service provisions.' While a broad spectrum of interests was covered by the report this was largely because of its studious avoidance of specifics and adherence to generalities. Nobody could argue with the general thrust of better-organized, less costly and higher-quality care, but the contentious question of specific measures required to achieve this was side-stepped. The difficulties of reconciling cttcs with the principle of free choice of physician as required by medicare, were not specifically addressed. Nor was there any consideration of the need for CHC responsibility for all aspects of its patient care-hospital, preventive, palliative, and curative. Neither the transition from in-patient care to less costly alternatives nor the steps required to establish an enrolled population were laid out. In its attempt to paint an idealized health system in broad brush strokes, the report failed to shed light on many of the real impediments to change which the Sault and others had already experienced. The report did serve, however, to stimulate further interest in cttcs, although the provinces were still far from committed to a line of development which could put them on a direct collision course with traditional medicine. The ambivalence in Ontario was demonstrated in October 1972, only three months after the release of the report, when promised capital funding for a CHC in Ottawa was withdrawn. The health minister, Dr Richard Potter, 'questioned the success of two other experimental community health clinics-one in Sault Ste Marie, the other in St Catharines. And he asked why taxpayers throughout the province should have to pay to start up such a clinic in the Ottawa area when there are already hundreds of health clinics established by doctors themselves.'3 The protests of unfair competition from the OMA seemed to be enough to overcome any feelings of responsibility to aid communities financially to provide for and organize their own health services. 4 This was an ominous portent. Nevertheless, mindful of the potential cost-savings available, Ontario was willing to dabble in the waters of cttcs behind the scenes. Before the Hastings report had come out, the province had provided operational funds, through a variety

109 The Government Presence of different departments and mechanisms, to nine disparate heterogeneous centres in addition to the Sault and St Catharines. s A few had a true community base, others were isolated physicians seeking an alternative method of funding, while still others were affiliates of a particular hospital or university. None of them fitted the description of the wide-ranging CHcs of the Hastings report- integrated social and health services under one roof -nor did they represent any coherent model or models developed by the govenment. As a result of the Hastings report, a few progressive individuals within the Ontario Ministry of Health proposed, in September 1973, the setting up of a special group- the Program Development and Implementation Group (PDIG)- to develop a model or models for the health centre and alternative payment concepts. However, the Sault and St Catharines, as large, well-established premedicare facilities, did not come within the scope of this new group-responsibility for them lay with the Special Projects Branch of the ministry. Thus, the PDIG was presented with a mish-mash of pre-existing small alternatives but had no responsibility for the two largest and, in the Sault's case, most successful alternatives in the province. As one member of the PDIG said, 'The Deputy [Minister] had said that we were not to be confined by what had been set up at the Sault or St Catharines ... they were both pre-medicare plans ... the approach [to other centres] had really been patchwork pieces to that point.' 6 The government's real intent was made explicit when they included in the PDIG's mandate an examination of the alternative payment schemes available to doctors in hospital emergency rooms and chronic care facilities. It was alternative payment which was the focus, not community involvement. The PDIG was directed by John Aldis, a physician with first-hand knowledge of alternative delivery and experience at the now defunct Ontario Health Services Insurance Plan. They had inherited heterogeneity, and they encouraged it by signing alternative payment contracts with everything from local drop-in centres to traditional solo-physician practices. Their intention was to encourage many options and models and then see which ones survived and appeared to be the most promising for future development. They followed the Hastings recommendation that 'enough community health centres ... be introduced into the system to allow effective evaluation of their impact on the process of health services delivery,' but they lumped in the Community-sponsored health centres with all the other alternatives and didn't regard them as a separate model. The group's progress was impeded by opposition from outside the government and from within the ministry. The situation was exacerbated by the lack of wholehearted support from the government itself. There was never any formal cabinet approval of what they were trying to do-in fact, the cabinet turned down a PDIG request for an official announcement and invitation for groups

110 First and Foremost to start health centres, presumably out of fear of reprisals from traditional medicine. Capital funding was never really talked about again after the Ottawa incident. Within the ministry, the PDIG was not well received: 'There was a lot of internal resistance to the whole notion of community centres ... There was a general belief that fees for service was what we understood, what we paid for, and that some of this other stuff was really for the birds.' 7 Particular opposition emanated from the Special Projects Branch. They were disdainful of the 'sow the seeds and see what grows' approach of the PDIG. They took the hard-nosed approach of pinpointing models of delivery, then matching and evaluating them against the costs of fee-for-service equivalents. The bottom line for them was which one was cheaper. In 1973 they had started their own detailed cost comparison of the Sault and St Catharines with two similar feefor-service group practices, ignoring the fact that the requirements placed on fee-for-service practice were not as great as the service provisions required of the capitation centres. Thus, while the PDIG was experimenting with options, the Sault was being subjected to the financially rather than conceptually oriented Special Projects Branch, which was happier making the alternative change to fit the system rather than vice versa. The hostile environment surrounding the PDIG made their task difficult. By 1975 they had contracts with twenty-one health services organizations (Hsos), as the centres had come to be known, 8 and another ten were in the development stages. Besides the internal ministry opposition, individual doctors and the OMA were expressing their displeasure at the PDIG's activities. Attempts to start a centre in Brampton, the premier's home riding, brought down an avalanche of concern, and the new minister of health, Frank Miller, received advice from aides who were less than sympathetic to Hsos. Furthermore, initial reports of the inappropriate fee-for-service cost comparison at the Sault were indicating only marginal advantages for the capitation system. The success of the PDIG approach depended on the growth of a very large number of centres so that adequate judgements could be made about what was and was not a viable alternative payment scheme. There was little sense in their grappling with the issues of what data systems the alternatives required, how to define an enrolled population for the centres, what was the best method of evaluation, and so on, before an adequate examination of the field in general had been made. But this was never done, as no more than thirty centres were allowed to start up-and these centres were so varied that there was no way of knowing which aspects of which centres were being effective. In April 1975 Miller called a halt to any further development of Hsos. The reason given was the one being publicly put forward by the OMA- there was not enough evidence of their efffectiveness, and a method of evaluation was lack-

Ill The Government Presence ing. One of the members of the PDIG saw it this way: 'One catch with working with government is there are things that have a higher priority than others. I think this one [PDIG] was generating a lot of concern and flak; weighing it against what we were actually seeing happening out there - the ones that we had on were not developing the way we expected to - resulted in the decision to halt.' 9 The centres already in the development stage were allowed to continue, but no new initiatives were started. In June the Minister of Health asked the Ontario Council of Health to develop a methodology for evaluation of Hsos. It was to be based on comparisons with the fee-for-service system. The hardnosed approach of Special Projects had won out over the PDIG's more liberal attitude, which had at least recognized community input as worthy of consideration. The development of alternatives in Ontario had now been clearly tied to the costs of a fee-for-service system. This was a blow to community-oriented facilities, which all considered their role to be the provision of a broad panoply of health services far beyond those items reimbursed under the fee schedules of medical associations. Now they were being constrained to provide their services at the same cost or less than the fee-for-service sector. The cost rather than community orientation of government was becoming more explicit. Hindsight indicates that PDIG would have done better to select a limited number of models and concentrate on their development. But they did not know at the outset that they would develop so few centres and be so constrained in their operation. In their two-year existence they managed to do little more than establish the need for centres to have enrolled populations (rosters) and begin the difficult process of isolating from the fee-for-service-oriented oHIP- data base the information necessary to budget and evaluate HSOS. They had, however, even with their constrained low profile, generated a lot of interest in community groups, progressive physicians and some teaching hospitals. The PDIG's legacy was thirty or so Hsos, each unique, some run by doctors, some by community boards and others by hospitals, insurance companies, and even boards of trade. The variety was astounding and the only common element was their absence of fee-for-service payment mechanisms and, possibly, their sudden feelings of beleagured insecurity. Throughout this turmoil the Sault had remained firmly under the financeoriented Special Projects people, whose philosophy had now come to dominate the further development of alternative delivery systems in the province. A year after the dissolution of the PDIG, the Sault became, on paper at least, integrated with the other alternatives in the province, or rather the others became integrated with the Sault. In March 1976, the Sault's Special Projects Branch of the ministry, now called the Data Development and Evaluation Branch, was required to 'carry out the methodological strategy for evaluating alternative

112 First and Foremost arrangements to conventional care providing primary health care services.' 10 The task of applying this group's findings to the thirty or more alternatives was given to a new Program Development Branch. Headed by H.I. (Mac) MacKillop, the Data Development people showed clearly in their dealings with the Sault that their main interest was in costcontainment and comparisons with fees for service. They would go only so far in disturbing the status quo for the sake of alternative health delivery. It was MacKillop who stated that 'government is not in the business of providing services; it's in the business of paying for services.' It was obvious, therefore, that any further development of Hsos would be based on cost-saving considerations; Hastings's concept of broad-based CHCS had long ago been left behind. MacKillop's past experience with the Sault, however, and the Sault's successful, although embittered, survival under capitation ensured that the nature of contracts negotiated between them would have a strong influence on the proposed method of operation for all the other Hsos. With Ray Berry leading the Program Development Branch, there was some room for innovative incentives, but only within the confines of costs restricted to equivalent fee-for-service expense. For nearly three years, between 1976 and 1979, with MacKillop acting as the hard-nosed financier, Berry doing the conceptual modelling, and the Sault as a protesting but nevertheless actively negotiating guinea pig, a payment system was devised for the province's Hsos which would not upset fee-for-service physicians, but still provide some incentives for more appropriate care and lowered hospitalization. With such a wide variety of Hsos waiting in the wings for results of these deliberations, Berry's chances of moulding an agreeable consensus were not good, especially given the clear bias against cHcs. By 1978 Berry had full responsibility for the system chosen, a system based entirely on capitation payments for an enrolled population. The size of capitation payments was related to fee-for-service equivalents for the services provided by the Hso. Enrollees could still go outside the Hso for services, but if they did that month's capitation sum for the enrollee was not paid to the HSO- this was called capitation negation. 11 Hence, the free-choice provision was protected for patients, while it was the HSO that suffered with a moderate penalty for the patient's exercise of the provision. The premise of the system was the belief that an Hso would be providing services only to its enrolled population, and any innovations they were able to offer would serve as leverage to attract new enrollees who did not have such innovations within their current doctor's fee-for-service care. This, of course, was entirely incompatible with the belief of many of the community-based Hsos that health promotion, education, and prevention measures for the entire community-whether they attended the centre or

113 The Government Presence not-were their responsibility. The capitation sum included no recognition of this kind of function. It was not surprising, therefore, that many of the Hsos, which had been left to flounder in unaided insecurity during the three years of ministry deliberations, were just not viable under capitation negation. At the beginning of 1978, St Catharines finally collapsed under the burden of excessive outside costs, causing further insecurity in the twenty-six centres that remained. 12 Many of them had received no increases in their global budgets or salaries since 1976 or before. Communication among the centres was almost non-existent. The Sault, however, did attempt to facilitate interchange. In June 1978 the board discussed 'the necessity of educating and organizing the Hsos in order to deal constructively with the Ministry ... It was moved ... that the Executive Director and staff be made available for coordinating and working with other Hsos in order to make a strong proposal to government.' 13 However, the energies and efforts required of most the small Hsos, just to keep going, precluded any organized communication at that time. The main problems for the small, urban community Hsos under the proposed capitation negation were described by Hastings in a retrospective report on cHcs in 1978: 'They serve populations such as the aged, the poor, people discharged from mental hospitals, etc., which are heavier than average users of services. Reimbursement methods based on the prevalent fee-for-service schedule ... rarely take this factor into account ... In provinces, such as Ontario, where premium payment on behaf of the patient is the basis for reimbursement for services provided to him or his family, community health centres with numbers of people on and off public payment of their premiums find that much of the service they provide is ineligible for reimbursement.' 14 The most serious problem was that most of the CHcs, located in cities and having only 3,000 or 4,000 patients, could not survive the monthly negation of capitations. The city environment made the use of outside services and the concomitant negation of capitations not only easy but unavoidable. This was not so for the larger centres like the Sault, or for rural centres where there were not other conveniently available services, or for physician-sponsored HSos with long histories of patient loyalty- these centres could more easily survive the negation of capitation for use of outside services. However, the government was most concerned about salvaging a coherentlyfunded program from the ashes of PDIG. Because of the cost-containment offered by capitation negation the cabinet was happy to approve it in early 1979 as the basis of Ontario's funding of alternatives. This was the first time that any formal government commitment had been made to the alternative delivery concept. The ministry then calculated that thirteen of the twenty-six HSOS were viable

114 First and Foremost under the new system. The Sault was one of the few community-sponsored centres amongst the thirteen; they had also been the first centre to sign a contract under the new funding agreement. cHcs, however, seemed to have outlived their usefulness as cost-containment devices for government, and they were neatly cut loose in August 1979, when the term Hso, and all the policy protection concomitant to it, was restricted to those on capitation negation. When an ambulatory care incentive was introduced (the more appropriate new term for the Sault's old incentive payment for reduced hospitalization) it was made available only to the newly defined Hsos. The remaining ex-Hsos became 'health centres' and were continued on global budgets or salary and overhead arrangements, but with no clear plan for their future other than an expectation that they would eventually become Hsos on capitation. The guidelines for establishing new Hsos provided no capital support or development funds and, in fact, explicitly required applicants to have an existing patient roster. This encouraged the transfer of current physicians' practices into the HSO program but made it almost impossible for a community group to start its own health centre. In other words, the efforts and events at the Sault in the early sixties would no longer be feasible under current government funding for alternatives. The irony is that while the Sault played a significant role as a proselytizer for cHcs, it ended up being used by government as a primary model for the structure of a funding mechanism that would effectively block the further development of cHcs in the province. What Berry had established was an alternative 'funding' mechanism rather than an alternative 'delivery' system. The new payment mechanism overcame some of the worst evils of fee-for-service remuneration, and did encourage a team approach to health delivery and reductions in hospitalization. Given the political constraints, it was a commendable achievement, but it failed totally to encourage consumer participation in delivery of care. THE SAULT'S STRUGGLE WITH THE MINISTRY OF HEALTH

With medicare, the intervention of the government in the affairs of the Group Health Centre disturbed the balance and financial efficiency which had taken years to build. The previous rules of the game became null and void. The problem was that apart from a few basic ground rules the government provided no new ones to replace the old. It took nearly ten years after 1969 for these to emerge., and in the interim things proceeded on a largely ad hoc basis. If the personnel on both sides had remained constant the process might have been quicker, but on the government side there was an ever-changing and, to the Sault, bewildering array of faces.

115 The Government Presence The Sault seemed to be passed on from one branch of the ministry to another, with little regard for continuity of personnel. At each stop they had to educate the new branch in the niceties of their operation and their needs in funding. It was not until 1979 that the health centre achieved anything in the way of stable tenure from the ministry. In the meantime, the Sault survived on a diet of interim contracts and endless negotiations. Griffith, Wilson, and board members who attended meetings with the government were never quite sure whether they were talking to the decision-makers or not. They frequently found themselves negotiating in one year contracts which were applicable to the previous year. Contracts were often being signed only weeks before their expiration, and the negotiations for the next contract period would be underway almost immediately. The Sault felt strongly that the ministry never understood the commitments and responsibilities involved in running the centre from day to day. In 1979 Griffith complained, 'On this side of the agreement we are dealing with professional careers, millions of dollars worth of community assets and we are very clearly at risk in very real terms ... Each day that we are without an agreement raises the anxieties of our employees ... once again we are in the situation of having to tell them we don't know where we stand with the Ministry.' 15 The unsigned contracts, erratic funding, and untimely payments increased the internal stresses at the centre. They showed the ministry's lack of appreciation of the unique problems which accompanied experimentation in alternative delivery of care. Ferrier wrote to Griffith on behalf of the medical group: 'Surely the government must recognize the medical profession is wary, if not downright suspicious, of any method or reimbursement other than fee-for-service. To date the experiment with an alternative method of payment has confirmed the suspicions of those already in favour of fee-for-service and has raised serious doubts among those who are willing to try an alternative.' 16 For much of the time the ministry's approach was essentially arbitrary. Decisions were made more on the basis of how to get enough money to the centre this year to keep it operating, rather than how to build a conceptual payment mechanism that could be used from year to year. In one contract the centre would have to pay for all the outside services of the capitation patients. In the next they would have exemption for three months out of twelve, just because that seemed the best way to get the total required budget to the centre. The ministry just didn't seem to know how to organize payment for care delivered through the Sault health centre. The centre, on the other hand, had a clear picture of how they should be funded. Just as their structure was modelled on the prepaid health plans in the United States, so too did they subscribe to a similar funding framework. They wanted:

116 First and Foremost a clear policy commitment to an alternative payment mechanism; a method of defining and enrolling a patient population for whose health care they had total responsibility; a capitation sum for each enrollee, based on more than the average cost of feefor-service medical billings for all Ontario, i.e. based on a true cost of all the services they delivered, taking into account the age, sex, and health status of their patients, and their unique location, by matching to a comparable group; access to current data defining what services and what costs were incurred by their population of patients and the matched population; an incentive payment for their decreased use of hospitals; long-term contracts to enable program and fiscal planning under true capitation. With a clear picture of what they wanted from the government negotiations, and led by the forceful Wilson and meticulous Griffith, they were in a stronger position than the poorly organized ministry to press home their views. They had years of experience, an advantage not possessed either by negotiators in the ministry, or by most of the newer health centres, and were therefore likely to influence the ultimate direction of the alternative care model. Their capital security (they owned their building and facilities) enabled them to hold out financially against the government for what they thought just-a luxury not afforded to most of the smaller and newest centres. But, ultimately the government held the money and therefore most of the cards! Initially, during the first years when they were dealing with sympathetic officials, the Sault had pressed hard for a dual-choice system to define clearly an enrolled population for the centre. However, dual choice, by locking people in to the centre for a specified time period, was contrary to the moment-tomoment free choice guaranteed in medicare. It became clear that the major policy change required for dual choice was not going to be forthcoming from a government which was still keen not to upset organized medicine. The 'free choice' issue had, after all, been the major weapon used by the local Sault medical society, the OMA, and the college in combatting the centre's development. The Sault did continue to press for dual choice, but the major task was to attempt to make the best of their position under the government's known attitude. To plan programs adequately, the centre had to have a definition of the population for which it assumed responsibility; it needed freedom from the burden of paying the outside services cost of medical 'shoppers,' and a way of calculating the size of the capitation sum. In the first years after medicare was introduced, the upheaval of its introduction, the inexperience of the ministry administrators, and the inappropriateness of its bill-collecting data system retarded significant progress. Positions were established, constraiftts outlined, and tentative systems introduced. There was

117 The Government Presence no method for defining the capitation population - hence the increasing fee-forservice element of the centre. No policy was established towards relief from outside service cost, therefore periodic arbitrary exemptions occurred when the financial burden to the centre became unreasonable. The capitation sum, in the absence of a method for calculation, had become no more than an approved total budget for the centre divided by the number of patients considered to be regular users. Each year a new contract was thrashed out but with no secure framework as a basis for future discussions. But by 1972 the rudiments of a system had started to emerge from negotiations with, as Griffith described them, 'people who seemed to be genuinely interested in trying to develop some sort of an alternative system.' But 1972 saw the amalgamation of the separate hospital and medical plans into OlilP and the unfortunate reorganization of the data base which was so important to funding capitation: individual identification of patients was discarded in favour of family or 'contract' identification. More seriously, 1972 also witnessed the disappearance from the scene of most of those negotiators who had finally been coming to understand the issues at stake. After months of little action, the association saw the horror of a return to square one with new negotiators, and pleaded with the ministry, 'we must have some continuity of contact and planning and find it difficult to accept that we must begin again and work towards the point we had reached ... approximately one year ago.' 17 Despite these pleas the Sault became the responsibility of the new Special Projects Branch of the ministry under MacKillop. Luckily some of the former negotiators were now involved with the PDIG who 'observed' at the new negotiations, although their responsibility was only for the newer centres and not for the Sault. With Special Projects came a greater concern for timely financing but a decreased commitment to the development of appropriate concepts. Contracts that had been left unsigned, financial settlements that had not yet been made, and debts owing were all quickly tidied up. The Sault was nevertheless nervous. They had no real commitment from the ministry and had been surviving on these year-to-year haphazard contracts. Then an unsettling memorandum of November 1972 was leaked to them: an internal ministry committee had talked over both the Sault and St Catharines and concluded that, 'the special status for these clinics should be discontinued after March 1973. They should revert to normal group clinic arrangements within the existing health plans.' 18 And indeed St Catharines was taken off capitation and put on a global budget system in April 1973, and it looked as if the Sault might be forced on to fees for service. There was no contract at all between March and July 1973 while negotiations took place between an extremely defensive association and a ministry which obviously had the upper hand.

118 First and Foremost The negotiations did, however produce some concrete steps towards the Sault's aims and failed to confirm its worst fears generated by the leaked memorandum. A new two-year contract provided a definition of its population: a capitation patient, as defined by the ministry, was anyone who received 60 per cent or more of his services at the centre. Now at least the centre knew for whom it was responsible and could accurately estimate its income and plan accordingly. Also, it was to have its hospitalization rate compared with an adjusted average utilization which took into account the naturally higher rates of the north. It pleased the centre that the contract period was for two years, which allowed for some longer-term planning. All of this, however, was achieved at a price. The capitation sum remained as a per capita expression of a total budget, but only for as long as it took to do a detailed evaluation comparing the cost per patient under the capitation system with cost per patient under a matched fee-for-service clinic. This study requirement was in line with the ministry's developing policy towards the Hsos: 'The economic structures of Health Service Organizations are to be designed to ensure that the cost of providing care to their patients is less than or equal to the corresponding expenditure under the traditional [fee-for-service] system.' 19 There were many pitfalls in the planned comparison. Besides the fact that much of the data required for such a comparison was not now available, there was the fact that many of the additional services provided by, and requirements made of, the Hsos did not apply to fee-for-service practitioners: for instance, 'no similar requirements for such things as accessibility, co-ordination, patient responsibility, determination of need, provision of other services, continuity, quality or even medical necessity has simultaneously been required for the fee system.' 20 How would the study take this into account? Would it take it into account? Furthermore, the fact that the Sault provided its own X-ray, outpatient, and laboratory services obviously increased patient costs compared to a fee-for-service facility which relied on the local hospital for such services. At the fee-for-service clinic the costs of these services were lost in the hospital's budget; at the centre the costs were easily identifiable. Would this be acknowledged? Finally, the age, the sex, and the location of patients, plus a host of other variables, were known to influence patients' use of the system. Would the study carefully match the Sault's population with a truly comparable set of fee-forservice patients? The Sault, however, was not in much of a position to argue. As Griffith commented, 'We had no alternative ... it wasn't explicit but it was implied that if we didn't take part in it-this was our chance to justify ourselves-then we should be fee-for-service.'

119 The Government Presence The comparison study took place between 1973 and 1975; the matched clinic for the Sault was the Glazier group in Oshawa, as well as some solo practitioners in both north and south Ontario. The research did not, unfortunately, manage to avoid many of the pitfalls, most notably the inability to cost out laboratory, outpatient, and X-ray services for the fee-for-service patients. Even so, the results which became available near the end of the 1973-75 two-year contract indicated no real cost differences or hospitalization differences between the Sault and Glazier. Compared to fee-for-service solo practice, both groups demonstrated significant savings in hospital utilization. Just as in the World Health Organization study by Hastings, the savings were around 20-30 per cent. However, the fact that the fee-for-service Glazier group was shown, albeit inappropriately, to be costing no more than the Sault, and reducing hospitalization as much, was politically dangerous to the survival of the capitation alternative. In fact the Sault was not performing at an optimum level with regard to hospital use and control of outside services. Many of the reasons for this could be traced directly back to its erratic and ill-conceived treatment at the hands of the ministry. It had come to despair of ever formulating a reasonable incentive mechanism for reduced hospital use under the ministry's restrictive rules and had negotiated the item out of its 1975-76 contract, with a consequent increase in capitation rate. The interim results of the study probably influenced the health minister's decision in 1975 to halt the PDIG's activities and further HSO development in 1975. But, similarly, the obvious problems unearthed during the study, were probably one reason why the Ontario Council of Health was asked to develop a more appropriate evaluation mechanism for alternative primary care delivery. 21 The whole development of alternative care systems was suddenly put into a holding pattern, and the new Program Development Branch under Ray Berry was created. Once again the Sault found itself dealing with a new group of negotiators, who had different ideas and backgrounds. Time would once more be required to establish their positions and achieve understanding. However, in the first year under the new group the Sault was not even aware that responsibility had been transferred! The daunting nature of Berry's task in integrating the heterogeneous Hsos into a coherent program required so much preparatory work and familiarization with new principles that MacKillop's branch was left to negotiate the contract for 1976-77, while Berry's group sorted itself out. True to MacKillop's form, the contract was signed in a timely fashion. But, other than finally recognizing that there should be some financial limits set on the Sault's liability for outside services, no significant progress was made towards a true capitation sum -no major changes were going to be made when a new group, invested with responsibility for developing a province-wide alter-

120 First and Foremost native payment scheme, would be taking over negotiations in the following year. While little progress was made towards translation of alternative concepts into a funding mechanism, at least MacKillop's background in financial management had produced contracts which were signed on time and gave enough money to run the centre. It was during the time with MacKillop that the centre started the counselling service, expanded the building to go into dentistry, and embarked on the greater use of nursing personnel. Although MacKillop would not stray far from fee-for-service concepts, he did provide some funding stability along with a limited development of concepts. All that went by the board in 1977 when contract negotiations started with Berry's new group. Griffith noted, 'We entered a ''transitional" year preparatory to participating in some as yet undetailed roster reimbursement along with thirty other groups known not as Community Health Centres, but as Health Service Organizations.' 22 The transitional year became two and a half years, and gone were any of the systems developed with MacKillop. A 'bridging' contract, put in place while the specifics of the new funding were worked out, did away with the '60 per cent of services or greater' definition of the capitation population and fixed it arbitrarily at 36,118 people. For two and a half years there was no incentive to increase enrolment at the centre; in fact the arbitrary definition of 36,118 meant that it couldn't increase capitation enrolment under any circumstances. Exemption from the costs of outside services used by their enrolled patients was granted up to a stated limit, but all within the context of a temporary measure. The Sault found themselves in a prolonged holding pattern which the other Hsos or centres had already been in for a year. These years-1977-1979-marked the worst period of all in the centre's dealings with the ministry. It still had no policy commitment from the ministry, and had been left feeling very isolated when St Catharines funding was terminated early in 1978. It didn't really know anything about other Hsos and it was unable to do any long-term program planning. What went on in those two and a half years was the structuring of a new province-wide payment scheme, using the contract negotiations with the Sault as the basis. Berry was interested in building the right conceptual models to produce just enough money for the operation of Hsos and, as the largest, most established and resilient of the centres, the Sault was on the front line. The association was an unwilling participant in a process that did not seem to pay heed to its everyday needs for secure funding and long-term commitment. Nevertheless the Sault had little choice but to participate. Negotiating sessions would involve Griffith, Wilson, Harwood, occasionally Ferrier, and sometimes board members. The local Conservative member of the legislature- first John Rhodes, then Russell Ramsay-would be called in at

121 The Government Presence times to try to break an impasse when it occurred. At one of these negotiating meetings in late 1977, which also included the minister himself, Bishop (previously Dean) Nock confronted the health minister with a demand for the long-sought statement of commitment to the centre. A commitment finally arrived in May 1978, when the minister (Dennis Timbrell) wrote to the Association: 'The Hso Program and the capitation concept are part of this Ministry's commitment to the development of payment mechanisms which will be available as options to fee-for-service medicine. We look forward to your continued participation in this project.'23 With this commitment at least some security emerged, but negotiations dragged on, and the Sault became more aware of the fact that it was negotiating not just its own contract but also the basis of the whole new Hso system. It had become resigned to the inevitable comparison with fee-for-service costs as the basis of funding, but was determined to press home on two issues. First, that the total fee-for-service billings for the province, divided by Ontario's population, was just not an adequate estimate of per capita total cost at the centre. It took no account of the specific mix of income, age, sex, and other variables affecting utilization - and therefore cost- in a specific centre's patient population. The actual total dollars paid to look after such a specific population would likely be very different from some gross provincial average fee-for-service cost. Second, they wanted the costs to be based on up-to-date figures for the fee-for-service system - not on prices based on last year's or the previous year's fee schedule. lwo other issues of concern for the Sault were how to define a population in the absence of dual choice, and how to calculate the saving in hospital utilization. The size of its capitation population was still being arbitrarily held at 36,118, and it wanted to find ways to enrol new individuals and remove individuals who used excessive amounts of outside services. For the ambulatory care incentive it wanted its rate to be compared not with the provincial average but with a comparable group of northern Ontario patients. After the two and a half years of negotiation, the use of current data was the only item left undecided, and a meeting was arranged for November 1979. Phil Bostelaar, the board president at the time, recalled, 'The final meeting with the ministry was here in the Sault and the minister was present himself at the time. It was quite a rough meeting, but that's when it all got resolved. We finally got our point across that their formula wasn't acceptable to us.' Finally, on 3 December 1979, the whole process culminated in a Ministry of Health news release from Sault Ste Marie announcing that The health clinic operated here by the Sault Ste Marie and District Group Health Association is now under a new financial agreement with the Ministry of Health. The new ar-

122 First and Foremost rangement, announced by Health Minister Dennis Timbrell and by Russell Ramsay, MPP for the Sault Ste Marie riding, is the first of its kind under the Ministry's Health Service Organization program and is a precursor to all new HSO arrangements.

After ten years of negotiating there was finally some semblance of a coherent funding mechanism and a promise of continued funding in the future. Concessions had been made on both sides, but the agreement did appear to be workable. The capitation population was to be defined, with certain constraints, by the centre itself, with the requirement that each enrollee sign a form which stated, 'This Hso assumes responsibility for my health care and receives payment each month from OHIP regardless of whether I receive health care services. I am free to choose to go elsewhere for my health care. If I do go elsewhere this HSO may receive a reduced payment from OHIP for me.' The full cost of outside services was not charged to the centre, but a patient's capitation sum was withheld for any month in which he or she used outside services that could have been obtained at the centre. A potential population was thus defined, although the administrative headaches of signing up the 40,000 or more patients who used the centre regularly were substantial. The capitation sum was calculated on fee-for-service costs adjusted for two of the variables requested by the Sault- the age and sex of its population. In addition, consideration was made within the capitation sum for the extra counselling, laboratory, optometry, and physiotherapy services provided by the Association. The capitation fee was not based on present fee-schedule costs, but was related to the OHIP fee levels of the immediately preceding period. Finally, the ambulatory care incentive was to be calculated in comparison with the hospitalization rate of the rest of the Algoma District, not the provincial average. With the Sault's rate at around 1,200 hospital days per 1,000 people for a year and the district at around 2,000 the incentive had potential for significant payments to the centre. In 1980 half a dozen or more other HSos moved to the same system as the Sault's, and the consolidation of the government's program was well under way. A final objective of the association -a multiple-year contract-was achieved by the end of 1980, when it was granted three years of guaranteed funding under its new contract. The business of program planning, unencumbered by endless ministry negotiations, could now begin in earnest. The framework for the funding of alternative delivery systems in the province had finally been worked out. It was far from perfect, restricting as it did the possibilities for the development of new, truly 'community' health centres. Considering the severe political and fee-for-service constraints imposed by the government, it did, however, achieve as many of the initial objectives of those

123 The Government Presence pioneering steelworkers in the Sault as could be expected. The Sault was obviously happy about finally achieving the funding security which had proved so elusive for the previous ten years. However, it shared the concerns of many of the believers in health reform that the Hso program, the program they had been so influential in shaping, was still clearly subordinate to the fee-for-service system. By 1980 the association's initial vision of a province-wide system of prepaid plans, in which the fee-for-service sector would be relegated to the 'alternative' position, still remained on the horizon ... or was it even pie in the sky?

9

Medical Attitudes

One of the most striking aspects of the development of alternative health care structures is the degree of opposition they experience from within the medical profession itself. As was the case with the Group Health Association in the Sault, the opposition emanates from two sources which are not always in concert- the local physicians upon whose turf the alternative springs up, and the medical associations or colleges within whose larger jurisdiction the alternative falls. The nature of the opposition and its motivations are not always the same for both sources, although the public reasons given for such opposition and the ideological stance from which they arise are frequently shared. THE PRETEXTS FOR OPPOSITION

In the Sault, the profession chose three main areas in which to express publicly its concerns about the centre: the restriction on free choice of physician, the threat to an unencumbered doctor-patient relationship, and, later, the absence of evaluative procedures to judge efficacy. It is these same three criticisms, which alternatives in general have been subjected to over the years. In all three areas the profession has chosen to put itself in the role of the protector of the patient's rights, implying that these concerns are raised on behalf of the patients, and are not related to the physician's own self-interest. Closer scrutiny would indicate otherwise. The freedom to choose their physician is not a liberty that is much exercised by the population at large. In the Sault in 1962 over 60 per cent of all the steelworkers were happy to restrict their choice to the physicians working in the health centre. Generally, most specialist visits are not the result of choice but occur on referral from the family doctor to a specific consultant who has privileges in a specific hospital. Most family doctors, especially in the under-doctored areas outside southern urban centres, are

128 First and Foremost chosen because of their geographical availability or the fact that they are open to take more patients. Considered decisions about the quality, philosophies, and expertise of particular physicians tend to take second place to these more mundane matters. However, the maintenance of this freedom ensures that all patients are potential 'customers' for any particular physician, and the entrepreneurial aspects of a private practice are thus maintained. In the Sault it was the economic fear of losing the well-paid steelworker 'customers' which really lurked behind the free-choice criticism. Ironically the profession as a whole has been willing to restrict choice in situations where it is to its advantage. Its own insurance plan of the 1960s PSI would not allow payment for specialist services which were freely chosen by the patient; such services would only be reimbursed when preceded by a referral from another doctor. When they were responsible for the financing of care through PSI, elementary accountability such as restricted conditions on free choice was not only ethical but necessary; under government financing, however, the profession has insisted on the absence of such fiscal control. Nowadays, with fewer funds available from government, the current position of organized medicine is that user fees be instituted, despite the demonstration that such fees discourage people with lower incomes from seeking care. In this context the profession seems unperturbed by the decreased freedom of choice for a particular income group. Finally, the fact that even in 1973 fewer than 5 per cent of the referrals by private practice doctors in the Sault were to Group Health Centre doctors-who represented over 30 per cent of available physician manpower in the city-indicates an unwillingness to practise what they preach in promoting free choice. The second area of attack has been the imposition of a 'third party' on the doctor-patient relationship. This has been seen by physicians as a threat to the quality of care, with the intruding third party dictating on matters outside its expertise. In the case of community health centres like the Sault's, this statement is patently ridiculous-the community board was established for the express purpose of improving the quality of care in line with the needs and desires originally of the steelworkers and later of the whole community. When the third party is an organized version of the individual patients themselves, it is not truly a third party at all, but merely a more visible form of the patient in the doctor-patient relationship. Physicians have been only too willing to allow insurance underwriters third-party status-indeed, through PSI they had introduced insurance underwriters-even though their coverage dictated the nature of medical practice: e.g., the absence of coverage for preventive care and periodic health examinations. It was partly this very restriction that prompted the steelworkers to establish the health centre.

129 Medical Attitudes Clearly, concern about the doctor-patient relationship was directed more toward protection of the doctor's side of the interaction than the patient's. The threat to quality of care is conveniently used by the medical profession as a means of devaluing many non-traditional elements of practice or enhancing opinion on current modes: 'Quality is also affected by factors such as supply, availability, knowledge and skill of physicians. Since all these factors affect quality, the claim by the Canadian Medical Association that the fee-for-service system of remuneration promotes quality of medical care is obviously too selective, if not distorted. On the other hand, knowing the concern of medical care insurance officials ... and the general public with the quality of care provided by physicians, the Association by relating quality to the fee-for-service system of payment seeks government and community support for that system.' 1 Finally, the more recent tack taken by physicians has been criticism of alternatives for the absence of evaluations assessing quality of care or the level of consumer satisfaction. They oppose the introduction of alternatives without guarantees on such matters for the patient. In other words, at the same time as they argue for the patient's right to free choice, they are claiming that in some instances patients must not be presented with the choice until it meets the standards defined by the physicians. More time will be spent exploring the issue of evaluation in a later chapter of this section, but suffice it to say here that the measurement of 'quality of care' or 'patient satisfaction' has proved as elusive in the fee-for-service sector as in appraisals of alternatives. The criticisms directed to the alternatives may just as well, therefore, be turned back on the traditional modes of practice. THE MEDICAL IDEOLOGY

What, then, are the real reasons for opposition if the overt declarations of traditional medicine appear, upon investigation, to be unsubstantiated? When juxtaposed statements are incompatible, one is led to believe that the opposition is not based on progressive steps through a logically patterned framework, but on something more fundamental but less marketable in the eyes of rational society. The professional ideology of medicine is what really generates the opposition, but society demands that they should fashion seemingly logical premises from this inherently emotional framework of ideology. A professional ideology is a set of commonly held beliefs and values which borrows partly from the mores of society but largely from the historical experiences and self-perceptions of the members of that profession. It acts as a bonding device amongst colleagues, a guiding light through the waters of constant decision-making; and it is always there ready to be presented to the world when

130 First and Foremost a consensus response is required of the profession. The ideology derives its power from the need for this consensus, which represents the trademark of an identifiable profession clearly distinguishable from other areas of human endeavour. It is the 'why we are special' declaration of a privileged group, members of which are peceived as accomplished individuals in society. The frequency with which medical students' parents are also doctors, the gruelling rituals of medical school training, the tendency to socialize largely with medical confreres, and the influential nature of local medical societies (particularly noticeable in the Sault), all serve to strengthen and perpetuate the ideology. To define fully the ideology of the medical profession is a task far beyond the space available here, but it is not difficult to isolate a number of its values which can clearly be held responsible for the ongoing reticence about alternative delivery. In general terms there is reticence about change of any kind. In a profession which has seen massive change over the last twenty years in the form of increased specialization, new technologies, and government insurance, there is even more of a tendency to want to put the brakes on and assimilate the new order before planning a future order. 'Under the present system, many physicians have achieved success or recognition, change may require new professional roles or changes in existing roles ... The physician is emotionally committed to a career under the existing system, and from it derives many of life's satisfactions ... There is thus a built-in resistance to change within the profession particularly when the impetus for change comes from outside with the possibility of outside control of professional activities.' 2 Many physicians feel almost cheated by the very suggestion that alternatives in delivery should be supported by government: they agreed to participation in a medicare system which had particular rules and constraints that they fought hard to obtain; if the rules of the game are changed, then the government's obligations to the physicians' hard-fought gains are treated with contempt. That, to them, is cheating. A first element of the ideology is, therefore, resistance to change per se, i.e., preservation of the status quo. Preservation of one central concept-the independent and autonomous physician -subsumes almost all other aspects of the guiding framework. The freedoms to fix your own prices, to set your own hours of work, to practise in your own style, and to choose to whom you will provide service are the hallmark of the professional. Professional status represents the zenith of achievement in today's specialized society, and maintenance of personal and professional autonomy ensures recognition as one of these privileged achievers. Not only is this attitude taught in medical schools, but the very concept of independence and freedom is one of the major attractions for many medical school applicants.

131 Medical Attitudes A 1970 study of the personality characteristics of all new first-year students in the professional schools of the University of British Columbia concluded that 'the men in the health sample had higher income expectations, attached more importance to working independently ... had less community volunteer experience and were more likely to be reserved and introverted than men in other fields.' 3 Prospective doctors enter training with independence of operation very much in mind, and such beliefs are strongly reinforced throughout medical school. It is not surprising, therefore, that this becomes a central tenet of the medical ideology. The fear of encroachment upon this autonomy could be seen in the Sault Ste Marie medical society's protestations about 'union domination' at the health centre. The profession's Canada-wide fight against government health insurance was waged along the battle lines of the physician's right to 'deal directly with the patient', thereby maintaining professional autonomy. The strength with which this conviction is held can best be seen when it is realized that dealing directly with the government provides guaranteed bill payment, but despite this economic advantage physicians continue to fight for the right to opt out of medicare and bill patients directly. 4 The entrance on this scene of alternative delivery concepts which go almost hand in hand with the idea of lay boards and community control, is bound to arouse medical opposition and distrust. The development of group practice has been slowed by this identification with 'outside control.' In 1967 the Canadian Medical Association made its concerns in this direction clear: 'everything else being equal, there appears to be no advantage to the public or the profession in outside sponsorship of groups. The profession, by accepting positions in such groups, are tending to put their destinies into the hands of others ... the Committee would most strongly recommend against this type of arrangement.' 5 Fierce opposition of the sort encountered in the Sault had been well-known in the United States for many years prior to 1960. There, just as in Canada, vehement opposition to group practice was directed very much against the prepaid plans where boards of directors collected premiums and organized care, rather than against the physician-sponsored groups. The political power of u.s. medical societies obviously exceeded that of the Canadian equivalents for 'by 1971, 22 states had enacted laws, usually at the behest of their state or county medical societies, prohibiting the establishment of organizations to engage in "corporate medical practice, conjointly with non-physicians".' 6 Much of the early behaviour of the medical group at the Sault health centre was directed towards establishing an 'arm's length' relationship with the steelworkers and board, and asserting their professional autonomy. Much of their later behaviour was an attempt to increase this autonomy by placing more

132 First and Foremost and more aspects of the health centre's operation under their direct control. Even as doctors practising within an alternative, they felt the necessity to respond to their ideology. Besides the consumer-control aspect of alternatives, another major factor which has become synonymous with the concept is the departure from fee-forservice remuneration of the doctors. Even though a number of Hsos in Ontario have developed under the sole auspices of physicians and are devoid of lay boards, they too have suffered from the opposition of their colleagues. This has come about because the method of remuneration has also become closely identified with the potential for outside control and increasing threats to autonomy. In addition to the generally held concept that professionals must receive compensation by charging a fee for each of their services, there are clear reasons for favouring fee-for-service on personal autonomy grounds. 'Different systems of remuneration provide for more or less interference in the relationship between physicians and patients. Salaried positions are an integral element in a bureaucratic structure in which the employer has the power to interfere in this relationship; the fee-for-service is associated with independent practice in which there is less opportunity for outside interferences.'' The opposition even to physician-sponsored Hsos comes about, therefore, because of a fear that government now has more direct access to (and therefore control over) the physician's behaviour. The payment mechanism decreases the discretionary power of the doctor to determine the size of his own income. In the Sault the increasing role for the fee-for-service income components (including the large contribution of 'productivity points' to income) of the health centre doctors' remuneration, was a re-assertion of their right to have at least some discretionary control over the size of their incomes. Thus, the importance of professional autonomy within the ideology of the medical profession can be seen as a potent force in generating opposition to alternative delivery concepts. The belief that the physician should be the 'gatekeeper' of the health system has a similar effect. It is the physician who should make the decisions on patient care, regardless of the reason for seeking care, the nature of the problem, the place of entry into the system, or the relative expertise of non-physician health personnel. Nurses, psychologists, social workers, physiotherapists, and countless other health workers rely heavily on physicians to direct patients to them for care. This conviction brings with it an onerous responsibility to sign forms, follow up on care, be available around the clock, attend every conceivable case conference, and file the billing statement on many more aspects of care than they actually deliver. For the traditional physician, however, this must be done if the valued role of gatekeeper is to be maintained. The policy of alternatives to make greater use of non-physician personnel in

133 Medical Attitudes the care of patients, and the advocacy of a team approach to health care, brings these alternatives into direct conflict with this 'gatekeeper' concept. The capitation system is specifically designed to allow greater use of non-physicians in an attempt both to reduce costs and to address more appropriately the specific needs of some patients whose problems are not pri'marily medical. This is not an approach likely to endear alternatives to holders of the medical ideology. Related to the whole concept of the physicians' value system is their supposition that they will always be paid in line with their broad responsibility, i.e., they have claim to an appreciable percentage of the health care dollar. If alternative delivery facilities became more widespread, then more of the health dollar would become disseminated to non-physicians through the alternative payment channels. Thus both the professional and fiscal recognition of doctors as primary deliverers of health care would become undermined. Alternative delivery concepts, as vehicles for this incursion on physician primacy, present a threat to the physicians share of the health budget. THE FORM OF OPPOSITION

Clearly then, the medical profession's ideology produces powerful reasons for their opposition to alternatives in health delivery. While individual physicians at the local level try to defend themselves against threats to the medical ideology, the real protectors are the voices of organized medicine-the medical associations and colleges of the provinces and the country. They are more able than the individual physician to remove themselves from the specifics of a local situation and take a more tactical and political approach at governmental level. State medical societies in the United States represent one extreme-they make little attempt to hide their displeasure; in Canada, more subtle but equally devastating measures have been taken. The very structure of medicare itself, including all its barriers to the full implementation of alternative delivery concepts, owes much to the lobbying of traditional medicine. The insistence on free choice is a good example. Only in Quebec, where language barriers severely weaken the physician's threat to 'vote with his feet,' has there been any degree of significant resistance to the dictates of the medical ideology. In Saskatchewan the development of community health centres in the 1960s was not only forced to take place with fee-for-service remuneration, but progress was severely hampered by the College of Physicians and Surgeons which used its power to prevent their advertising and to constrain them in the granting of hospital privileges. In Ontario, the development of alternatives under the PDIG was effectively halted by the provincial medical associations' (and individual physicians') protestations to the minister.

134 First and Foremost The power of self-regulation of the professions, granted by governments, is not always exercised in the interests of consumers. The regulations can be, and are, all too easily used as impediments to the development of alternative delivery. For physicians in community health centres, advertising restrictions place serious obstacles in the path of health promotion and education efforts. Recent regulations in Alberta have made attendance at home births illegal for physicians in that province, serving to undermine further the introduction of alternatives and to increase dependence on physician-controlled hospital delivery rooms. The experience of the Sault when transformations of dental regulations prevented direct hiring of dentists, can be interpreted only as an example of specific opposition, from above, to the health centre concept. At the local level, however, the opposition takes a more direct form. Furthermore, the reasons for opposition extend beyond protection of the general medical ideology. While provincial medical associations do not express serious opposition to group practice run by physicians, local solo doctors are not so approving. For them, there are two additional factors at work: the emergence of a significant competing power base, and the threat of economic competition. As the Canadian Medical Association's Special Report noted, 'the very existence of groups of doctors working together in "Group Practice" has always seemed to create abnormal feelings amongst non-group doctors in the community ... If the group seems to garner in a larger share of the medical work in the community than its component doctors would individually, this also cannot help but raise the eyebrows of its economic competitors ... Other aspects ... relate to the influence which a large group may exert over the use of available hospital beds as well as the medical staff of hospitals- re seniority and appointments.' 8 Opposition generated by these concerns can take the form of day-to-day harassment, social sanctions, exclusion, and unco-operativeness -as the Sault's health centre doctors discovered. The attempts by organized medicine to portray a picture of responsible opposition to alternatives can easily be frustrated by this over-zealous behaviour of their local counterparts. Furthermore, as the provincial or national medical associations are aware, the natural response to direct attack is vociferous defence and a strengthening of the resolve to survive. This was highly evident in the Sault. The more subtle legalistic and governmental interventions initiated by the OMA proved, in the long term, to be far greater obstacles to the Group Health Centre's development than the annoying, but surmountable, onslaughts from local solo practitioners. The competitive aspect of the alternative does engender changes for the better in all aspects of local delivery. Despite their clandestine activities, the solo doctors in the Sault held down their fees, increased their numbers, built their own Medical Arts building, provided a local on-call service, and reduced their

135 Medical Attitudes dependence on hospital admissions. Such a positive response from the doctors is not uncommon. A striking example of this was the reaction of solo doctors in California's San Joaquin Valley to proposals by local labour groups to introduce a prepaid group practice to the area. They recognized the inevitability of change but wanted to ensure that it occurred under their auspices. They therefore developed the concept of Individual Practice Associations (IPAS) similar to the plan instituted in the Swift Current health region of Saskatchewan in the early 1940s. 'At the core of the San Joaquin experiment was the desire to preserve the professional autonomy of fee-for-service medicine while providing an organizational framework to limit costs and improve the quality of care. In one sense, the challenge facing ... planners was even greater than that facing their group practice counterparts: to harmonize the cost-efficient features of prepayment with the professional autonomy associated with fee-for-service medical practice.'9 They successfully met the challenge, rebuffed the prepaid group practice proposals, improved local health care, and translated the more common blind defence of the status quo into a constructive alternative. Their idea has flourished, and IPAS are now dotted across the U.S. There are few examples of such organized response to the threat of alternatives in Canada: the provincial and national medical associations have had enough success in retarding the development of alternatives that doctors at the local level have felt less compulsion to respond so constructively. Government health policy-makers have always accorded the greatest respect to the values of medical ideology. This presents the doctor working within an alternative with a three-pronged oppositional force- the local doctors, the provinicial associations, and the government itself. The task is therefore an uphill one for the physician working in an alternative structure. With both local and provincial colleagues expressing disapproval in their own particular ways, it is to government that the physician turns for support and protection. However, the government is responding positively to those same oppositional forces, with measures that actually institutionalize many of the impediments to successful medical practice in the alternatives. When dental regulations contrary to the interests of the Sault were being promulgated in 1975, for example, it was the minister of health who approved them, despite the pleas of those working in the alternative health structures. If governments are to encourage alternatives, they must not only remove the impediments but they must also provide support to the alternative health provider. Such widespread medical opposition to alternatives has given rise to a particular irony: physicians who choose to work in such settings, and therefore to buck the traditional trend, display high levels of independent thought, an independence which probably exceeds even that found in the 'traditional' physi-

136 First and Foremost cian. Thus, the very characteristic required for survival in an alternative delivery setting would seem to come into direct conflict with the capacity to co-operate and compromise required to work with consumer-sponsored and community boards.

10

The Role of the Community

Consumer input, through 'community boards,' is not an unusual component of the health care system. Not only hospitals but also social service agencies and charitable organizations have, historically, been overseen, by worthy citizens of the community. Community presence, however, in primary care facilities which provide physician services has not been so common. In 1963 the Sault was one of the first examples of such a facility in Canada; there, as we have seen, and as has happened elsewhere since, difficulties arose shortly after the initial honeymoon, and board enthusiasm waned as the doctors pressed increasingly for greater autonomy. Generally, the significant community input which marks the start-up phase quickly becomes exchanged for either timorous board disentanglement or conflict with providers. A number of community health centres, most notably the Regina Clinic in Saskatchewan, have actually come to grief over this aspect of alternative delivery. Some investigation of what these difficulties are and how they might be minimized seems warranted. THE BARRIERS TO CONSUMER-PROVIDER COEXISTENCE

The decision by a community to establish a health centre normally signals the beginning of intense activity which lasts for a period of years. Keenly interested members of the community take it upon themselves to sample the opinions, desires, and needs of a significant portion of potential users before integrating them into the community's common concept of 'health centre.' In Saskatchewan, the process was precipitated by sheer necessity when the strike of 1962 forced communities to seek alternative ways of ensuring medical care for their citizens. In Quebec, the catalyst was government initiative following the Castonguay report. In Sault Ste Marie the excessive cost and poor accessibility of care prompted the steelworkers. It is at the initial stage, when staffing levels and roles

138 First and Foremost are still undecided, when hostile forces are not yet organized, and when the energies of initial commitment are overflowing, that the lion's share of consumer input tends to occur. Glenn Wilson's description of the early days of planning at the Sault gives an excellent view of the breadth of the process: 'The opposition made it necessary to conduct an extensive public education campaign. A door-to-door questionnaire, carried out by volunteers, made it possible to evaluate the health care needs of the community. We learned from all these experiences the kinds of medical services the community expected, the hours they expected services, and how much they were willing to pay for the service, well in advance of the time we began to design a building. Nearly a hundred members of the local union met regularly and discussed the Health Centre, and they in turn talked to nearly all of the 6,000 employees of Algoma Steel. The campaign that started in 1957 and intensified in 1959-60 made it possible for several thousand people to help shape the health centre program. The health centre was the major topic of conversation for nearly four years, and in that four years it was difficult not to know something about what was going on.' 1 However, this all-encompassing consultation rarely occurs again during the life of a centre. There are several reasons for this. Ambiguity of role division between board and providers is a primary culprit. While neither board nor providers would deny that the 'practice of medicine' is clearly the responsibility of providers, the issue of where the dividing line lies is not so clear-cut. Some providers consider that the determination of something like hours of opening should be a medical matter; conversely, the more interventionist consumers would claim that policies regarding periodic health exams or regular immunization are decisions for the board. The potential for conflict is very real. Hasting's federal Community Health Centre report warned of this danger in 1972 when it noted that 'the role and authority of any board must be defined very clearly and very precisely. Without this process, a board's enthusiasm and its impact on service provision that frequently occurs in the initial stages of its existence can be dissipated.' The reality of a primary care facility is that physicians (and other health care workers) do sit on the front lines: day by day they handle the health problems of the centre's population, and day by day not only do they practice but they have the legislated monopoly on medicine. Their legislated rights are vast: they stretch from the direct-a planned birth in the absence of a physician is illegal- to the indirect-access to insured care by non-physicians is generally possible only through physician referral. Legislation specifically prohibits the 'corporate practice of medicine,' whether it be by a non-profit corporation like the Sault's Group Health Association or a multi-national like INCO. These are powerful reasons,

139 The Role of the Community therefore, why a board which desires a meaningful say over the running of its centre might shy away from clear and precise definitions of respective roles; ambiguity may allow more extensive influence than does the law. On the other side of the coin, a community board is invested with a moral obligation to further the interests of the users when, sometimes, they may conflict with those of the providers. Moreover, not only do they formally represent the patient in the doctor-patient relationship, but they are frequently the financiers and controllers of the facilities and plant used by the doctor. Therefore, with formal and precise definitions, the physician may find himself unable to control the working hours of a nurse or the placement of his office; with ambiguity of role definition, however, his office hours and location may be more flexible. At the health centre in the Sault the respective roles of board and physician group were contained within their Medical Services Agreement. However, the infrequency with which this document was updated and the acrimony which tended to accompany its renegotiation suggest that both parties tended to view its contents as being detrimental to, rather than supportive of, the desired roles of each. In other words, there are good reasons why both sides might perpetuate ambiguity and avoid the protracted negotiations necessary to delineate clearly their respective areas of responsibility. Defining respective roles is not a finite process which occurs only once for the life of a centre. Changing motivations and personalities on both sides, reforms of existing or the introduction of new legislation (medicare for instance), expansion, financial deficits or surpluses, can all necessitate renegotiation at any time. The consequence of side-stepping such negotiations is crisis management. This could be seen at the Sault when medicare was introduced, and in 1980 when the changed aspirations of the board and physicians had not been reflected in changed agreements. Walking this kind of tightrope carries the ever-present danger of falling off-without a safety net. Unfortunately, even when the parties overcome any natural reluctance to sit across the table to weave the net together, other inherent pitfalls emerge from their respective positions. On the providers' side is the nagging pressure, from their own ideology and their colleagues' badgering, to reject the community control and assert their autonomy. In addition, as we have seen, the most independent among them may have difficulty accepting the compromise of negotiation. The personality profiles of professionals in British Columbia (quoted earlier) revealed a further problem. Few physicians have any community volunteer experience before they enter medical school. After entrance they are allowed little time to engage in the kinds of extra-curricular activity enjoyed by most other students, which frequently

140 First and Foremost involve some kind of community participation. As a professional group, physicians often find it easier to deal with fellow professionals, rather than with community representatives, who may have little in common with them beyond their mutual interest in health delivery. This goes part way to explaining why most hospital boards, as opposed to health centre boards, experience few of the difficulties outlined above: the hospital board is frequently replete with professionals; not so the community health centre board. For those physicians who wish to thwart community input, the science of medicine offers a ready barrier to hide behind. A major consequence of increasing specialization has been the burgeoning of technology and the progressive professionalization of ever-widening areas of health care. It is not difficult for the trained physician to hide within a technological cocoon when dealing with the non-physician on a board. The purchase of new X-ray equipment, for example, may become justified on grounds of medical necessity 'beyond the understanding' of non-physicians. The technological cocoon can afford easy protection from the cautious but genuinely curious board member. Finally, physicians seem naturally distrustful of bureaucracy. Given bureaucracy's close identification with loss of autonomy, such distrust is hardly surprising, but this attitude presents a number of problems if areas of responsibility have to be negotiated. Fearing to become sucked into the whirlpool of endless administrative committees, memos, and draft agreements, many physicians simply balk at starting the process at all. The remainder find themselves delegated to speak on behalf of the entire group. Frequently, those willing to become administratively involved are also the most progressive of the group and hence are not necessarily representative of the group. In consequence, signed agreements may come to be opposed by the group as a whole when a particular crisis reveals the details and extent of their commitment, and the community representatives find it hard to understand how the physician negotiator's position comes to be so different from that of the people he purports to represent. The dependence of the Sault board and administration on Ferrier -who was more progressive than most of his physicians-as the main negotiator was partly responsible for the gradual divergence of the goals of the physician group and the board through the 1970s. The professional attitude, the paucity of experience in community participation, the ready-made technological cocoon, the natural dislike of administration - these are some of the retarding factors on the providers' side in the search for a successfully negotiated agreement for harmonious consumer input. The community boards also act in ways which discourage agreement. One of the greatest dangers is the desire of the board to operate as the 'ideal,' as if in a vacuum, protected from the market realities that surround it. Running a

141 The Role of the Community health centre is not an academic exercise in basic structural reform; it is a pragmatic exercise in extracting the best possible approximation to the ideal from what is frequently an incompatibly structured over all health system. For instance, the broad legislative protection of physician supremacy in the health delivery is a fact that must be recognized and worked with. If it is not, then illegality is a probable consequence, along with time-consuming battles with external elements-with the government for instance. These serve only to distract energies from the primary task of providing good health care. The desire for a truly team approach, where the worth of all health professionals is valued equally, is an admirable goal. However, if this means that physician remuneration will be held at the same level as that of nurses and counsellors, or even above that level but well below the market price for a physician, there will be a rapid turnover of physicians and a consequent lack of continuity of care. If an attempt is made to match other provider incomes with those of the physician, bankruptcy must surely be inevitable! It is to the credit of the board in Sault Ste Marie that they always recognized that social change cannot be achieved at the economic cost of the person capable of creating and sustaining that change-in this case, the physician. It was always the board's policy that their physicians should 'receive as much or more than they could receive in solo practice.' Finally, pure ideologues on a board can easily become embroiled in the political struggle for basic structural reform. If more of the board's energies are spent in this direction than in providing for its community's health, then it should be no surprise if the physicians and other staff feel a need to take greater control of the centre itself. The experiences at the Sault demonstrated clearly the demands of pragmatism placed on the shoulders of the board members. Despite his ideological commitment, John Barker still saw the necessity for pragmatic compromise, where the goal of continued good health care for citizens of the community took precedence over the demands of principle. The demise of the Regina Clinic and many of the smaller centres in Saskatchewan is often blamed on the highly political nature of their boards, which were said to be more interested in furthering radical health policy than running efficient facilities. One of the physicians at the Regina Clinic, recalled events: 'A "progressive" group took over the board and wished to dictate programs largely aimed at a special section of the population. It derided so-called "sickness oriented" programs, wished aggressively to overthrow the current programs and turn out the good with the bad. The physician group took fright at the heavily biased propaganda that accompanied this group's activities ... the majority of patients left the community clinic and went with the physicians and staff when they finally departed. A hot political

142 First and Foremost climate surrounding a clinic is not contributory to the kind of atmosphere that is comfortable for a patient.' 2 The paradox, however, is that it is often hard for board members to maintain their enthusiasm for handling the centre's affairs without such an ideological commitment. Naturally, those development years offer exciting, immediate rewards for effort, but later the rewards may not be so apparent. The British sociologist, Rudolf Klein, described this difficulty: 'The greater the resources which will be obtained as a result of involvement, the higher an investment of involvement costs is justified. Thus clear consumer involvement will yield greater benefits if (for example) a new hospital is the end-product rather than a new chair in the doctor's waiting room.' 3 The temptation, therefore, is gradually to grant more decision-making power to the administrators by default. The difficulty is that the power does arrive by default and is not accompanied by changes in the administration's mandate, allowing it to make such decisions. The entire organization can quickly grind to a halt in this situation - the board uninterested in making decisions, the administration officially unable to decide, and the providers totally unclear about who is deciding and how reliable the decision is. The decision-making process is time-consuming, especially when technical matters are being considered by lay persons. Some boards are guilty of desiring the power without taking on the responsibility of educating themselves sufficiently to make the decisions. Poor decisions and inefficient operation quickly result, and before long providers will demand control to ensure that fiscal solvency and responsible management are maintained. Expansion presents particular problems in this regard. Whereas it may be quite feasible for a board to decide many matters of day-to-day concern for a small clinic of one or two doctors, these same matters become inordinately time-consuming as more doctors and other medical and administrative staff become added to the structure. Original board members may tend to cling to their former breadth of power while slowly drowning under the weight of voluminous new information, often dragging the whole structure down with them. 'Letting go' can be one of the hardest things for board members who have nurtured a centre from seed to flower. The community activist's tendency to ideological intransigence, the difficulties of maintaining enthusiasm and committing time to self-education, and the temptation to cling to power after outgrowing feasible exercise of it, are all common obstacles to healthy community-provider relations. Added to the barriers inherent in provider behaviour, they produce formidable handicaps to the successful synthesis of provider and community interests in the delivery of health care.

143 The Role of the Community STRUCTURAL CONSIDERATIONS

An understanding of how to circumvent some of these possible pitfalls can be obtained by first exploring some of the structural alternatives available for the organization of community health services. Klein's thoughtful paper takes the whole process back to fundamentals when he emphasizes the need to 'challenge the assumption that the case for greater patient involvement can be taken for granted.' Increased patient involvement in the form of community boards can be justified as a counterweight to the physician's tendency to approach each case individually: 'Physicians see their responsibilities in terms of an individual patient who needs medical care ... this can best be supplied in a situation in which they have personal and professional autonomy.'4 The task of the community board is not to judge individual cases, but to establish an operational framework based on the social, economic, and health needs of the entire community. They must decide on the appropriate overall allocation of resources, the nature of the provider and user incentives, and the organization of the physical facilities. Within this framework the provider is left to deal with the individual case. An example may help clarify the distinction. A local factory is emitting high levels of lead into the surrounding community; some local children develop symptomatic lead poisoning while many others are asymptomatic. With solo-practitioner physicians in the area, each doctor may see one or two of the cases each year, administer an antidote and bring the child back for checks possibly twice a year; the individual case is treated, and repeated visits for checks are encouraged by payments for each service. In contrast, a community board establishes a different set of incentives. Their physician group may wonder at the high incidence of lead poisoning; in the absence of fees for service they have no financial incentive to have repeated visits for such a condition and will wish to have its cause eradicated. The community board is able to use its power to isolate the cause of the problem (the factory) and organize demands for improvement in the situation. Meanwhile funds may be allocated for a community worker to increase local awareness of the problem, encourage care of asymptomatic individuals, and achieve reductions in lead levels at the source. The money for such work can come from the funds that will be saved by not having to deal with increasing instances of lead poisoning in the future. The board has transcended the individual case and ensured a more rational use of resources that ultimately improves the health (and awareness) of the entire community. s It would appear desirable, then, that the final structure, whatever its form, should provide the board with enough power to be able to appraise and act on

144 First and Foremost the over-all picture and thereby counter the provider's natural tendency to focus on the individual case. 6 The board must be able to see the forest for the trees. What structure can best assure that this is possible? Should it be an elected board? How representative should it be of the users rather than of the business skills required? Should the ideological zealot be avoided or encouraged? Are there optimum sizes for a centre beyond which a community board loses control? The nature of board composition is a central question. In general, the boards of hospitals or charitable institutions are staffed largely by upper-middle-class community stalwarts-often elected representatives to councils, business leaders, or lawyers; ethnic minorities, women, and lower socio-economic groups are generally severely under-represented. These boards emerged from the 'corporate' model of governance, an attitude which has been defined well by J.G. Cibulka in his consideration of community mental health centres: 'Finding the public interest is really an administrative or technical problem rather than a political one. Hence, institutions should be governed by the best qualified persons selected from the public, particularly businessmen possessing "useful" knowledge, while administration should be left to a corps of professional experts. This ideology emphasizes recruitment of civic elites to serve on boards, insulation of these elites from electoral or other political pressures, and strong authority for professional administration.' 7 This view stresses efficiency rather than representation and has strong elements of paternalism. The prevalence of business and professional individuals tends to support the status quo, retard major innovation, and keep the board well away from encroachment on even the broadest definition of medical practice. While the business expertise it possesses is often useful, the corporate model nevertheless represents a fairly unsatisfactory solution to the difficulties of achieving community involvement in health care. 'It is often difficult to organize around health care when most people use health facilities intermittently or as individuals, or do not accept health care planning as a community problem, or are unaware of the discrepancies and inequalities in delivery of services. Providers traditionally have monopolized patient care and sustained the notion that health care planning and administration require similar levels of expertise. Patients are socialized into a subservient orientation in which an acceptance of the medical monopoly in treatment is transferred to planning and administration.' 8 At the other extreme are the aggressively ideological boards, like those in parts of Saskatchewan. These, too, rarely represent the community; they tend to be staffed by middle-class reformers who desire basic structural reform of the political-economic system - health delivery is only the vehicle for their more

145 The Role of the Community grandiose scheme. Their aims of social and economic equality or justice are noteworthy, but their involvement is not generated by the perception of specific health needs for a specific community. The danger here is that they become quickly disenchanted with slow progress towards the greater goal and may attempt to make their organization run before it can walk. One such organizing zealot, Don Keating, actually recognized this danger, and argued against involvement of the 'structural reformer' in health delivery: 'Good organization can have a higher priority than good health. While training in Chicago, I learned there was little point in worrying about how healthy people are in a ghetto. Establishing a community-controlled health centre in the ghetto would be ... focusing on making themselves comfortable in the ghetto. At some point, a generation has to come along and focus on getting rid of the ghetto ... [But] Establishing community-controlled health centres in ghettoes is a necessity and must be the responsibility of somebody, anybody, everybody, but not the organizer.' 9 Somewhere between the ideologue and the civic elitist lies the pragmatist whose interest stems from a perception of unmet health needs in his community. The original composition of the board at the Sault was shrewdly reflective of the need for an ideological balance. Local clergymen and a prominent tory businessman were specifically included on the board to temper any real tendency, or accusations of a tendency, to become 'ideological.' The composition of the health centre board was achieved by a complex mixture of indirectly elected positions (from the steelworkers) and appointed positions (from the community at large) which has continued to the present day. The question of elections for, or appointments to, boards raises two main points. First, when all board members are elected there is a danger of take-over by special interest groups or over-zealous ideologues. In recent years, hospital boards have come to experience some of these problems when anti-abortion groups have successfully engineered majority positions with the sole aim of controlling the hospital's therapeutic abortion policy. 10 On the other hand, without some degree of accountability there is no assurance that the board is really operating in a manner that reflects the community interest. The second point is that a fully elected board provides no guarantee that specific areas of expertise like accounting, law, organizational ability, and so on will be represented on the board. As responsible managers and analysts of the facility, the board will have an easier task if at least some of the required skills can be found amongst its members. If such specialists are simply involved as advisers, they will feel less allegiance to the organization then if they are present as full board members. The question of optimum size can best be examined by reference to the Sault.

146 First and Foremost The centre there was originally built to accommodate a maximum of 25,000 patients; it now handles over 50,000. Much of the spirit of community participation which marked the first years has dwindled with the expansion, and the task of adequately representing the various user groups on the board has become nearly impossible. Even the health needs and interests of a small population of consumers would be varied enough to present a major challenge to those seeking a common approach. With the probable exception of the 15,0000 original steelworker subscribers, the vast number of other users at the Sault have long ago lost the feeling that they as individuals can significantly influence that common approach. Additionally, such a large facility needs a great many medical providers, and the difficulty of achieving board-doctor consensus became exacerbated by the inevitably increased variance of opinion. It seems clear, then, that a centre cannot play a true community role once its size passes a certain limit. The Sault experience suggests that 50,000 patients is over that limit, but the lack of comparable schemes means that the optimum size cannot yet be assessed. CONCLUSIONS

Having explored some of the barriers to consumer participation and taken account of some structural considerations, it is possible to draw a few tentative conclusions. They relate first to the community board's role in relation to the provider, and second to its relationship with the consumers themselves. In their relations with community boards, providers, especially physicians, frequently fail to appreciate that the usual business concepts of efficiency are no longer applicable. The benefits of consumer input have to be valued enough to justify the costs of negotiation and discussion necessary between the parties. The high proportion of businessmen on hospital boards indicates that these boards have exchanged real community input for a version of 'civic corporatism.' An important asset of a community health centre board is its knowledge about its neighbours. If this 'grassroots' knowledge is to be translated into complex health policy, it is obviously going to take more time and effort than it would if professional health planners and administrators alone were making the decisions. This does not justify inefficient operation; rather the providers must be prepared for the frustration of prolonged committee decisions, and the boards must face the heavy responsibility of self-education. Unless the providers are willing to sit down and interact with the community board, and the consumers are prepared to expand their knowledge of health care (and therefore their credibility with the providers), the costs of decreased efficiency soon outweigh the benefits of community participation. Crisis and ad hoc management take

147 The Role of the Community over, and the multi-input structure of community health centres is ill-suited to effective crisis management. Some of the board-physician difficulties encountered at the Sault's health centre can be attributed to the unwillingness of some board members to go through the necessary self-education in health care matters. Probably equally responsible for the difficulties has been the unwillingness of the physicians to recognize the need for administrative help and to set aside a certain amount of time in order to ach.ieve effective interaction. If providers are expected to consult with, as well as help care for, the community, then they must have the resources (both time and funds) to do this effectively. Similarly, if consumers are going to educate themselves, the least that should be provided is travel and attendance at conferences or workshops, and it is certainly not unreasonable to expect to have staff available who can help in the education process. Funding of alternative delivery should, but does not, take these organizational costs into account. What, though, is the purpose of all this interaction time? First, it is necessary to ensure that decisions are reached only once all those who should have input have made their opinions known. A consensus does not happen overnight, and if the procedure is by-passed too often, significant resentment and bitterness will soon start to emerge. This is clearly what happened in Sault Ste Marie at the end of the 1970s. Second, time must periodically be set aside fof consideration and subsequent reconsideration of whether final decision-making powers are appropriately allocated between board and providers. This, in essence, is the question of where to draw the line between the inviolable practice of medicine and community participation. In deciding where to draw this line, the prevalent circumstances of the time- including the motivation levels of board members or administrative interests of providers-are the key considerations. However, it is tempting for community boards to ignore the fact that today's circumstances in health care are heavily in favour of provider autonomy and against community 'interference.' Despite the government's current focus on community services, the legal rights of providers are far better protected than are the nebulous rights of community to selfdetermination in its health. This makes it advisable to deal with the provider physicians as an independent medical group or partnership, rather than co-opting or integrating them into the board's structure. To do otherwise would not only blur the line and induce ambiguity, but would be to fly in the face of entrenched legal precedent, to say nothing of medical ideology and training. Ironically, the professional's inherent dislike of administrative burdens will often counteract the community's apparent divestment of power. The board's relationship to the consumers is important in this regard. If it is seen to be enthusiastic and truly representative of those that use the services,

148 First and Foremost rather than a group of fringe radicals or slothful citizens in sincecures, then providers are more willing to allow intrusion on medical soil. If an electoral process is feasible, it is desirable that a part of the board be elected. To avoid the 'fringe group take-over' phenomenon, to which small community facilities are so susceptible, the elected members should probably not outnumber appointed or nominated members. The electoral process also helps to keep board members active and motivated, as re-election is unlikely to occur for the 'passenger' participants. Providers, however, are also placated (and sometimes intimidated) by the sight of a few experts on the board. In operations like the Sault's, where budgets are in millions of dollars and financial responsibilities sometimes complex, the presence of community members who can readily handle aspects of the operation, without time-consuming self-education, can be invaluable. These members are also useful in helping educate other participants about their areas of expertise and can sometimes unravel the technological cocoon behind which the provider hides. Their professional standing not only adds credibility to a board in the eyes of the provider but it also offers traditional physicians an opportunity to approach the board through a 'fellow professional,' if they do not feel comfortable dealing with the other members. With this mixture of elected and appointed members, the board is able to assess its needs and plug gaps not filled by the election process. Appointees by such bodies as municipal or social planning councils, church groups, unions, or universities could include ethnic minority representation, women, or any number of other possibilities, beyond the 'business' needs of accountants, lawyers, and so on. However, all board members should be primarily committed to delivering the best health care they can to their particular community. The prevalence of any larger objective-be it marxist revolution in our lifetime or election to the local council -can only lead to dissension and deflected energies. More than one community health centre has fallen into the clutches of groups more interested in it as a vehicle for ends other than health delivery, only to find itself in the gutter when its usefulness towards that goal was outlived. There is increasing hope that in the future more meaningful roles will start to emerge for consumers in the actual delivery of health care. While it is unlikely that many boards will make significant inroads to jealously guarded medical practice, it is becoming apparent that the really significant gains in individual health are to be found not there anyway, but rather in consumer education. As Mark Lalonde, then the Federal Minister of Health and Welfare, pointed out in 1974: 'When the full impact of environment and lifestyle has been assessed ... there can be no doubt that the traditional view of equating the level of health in Canada with the availability of physicians and hospitals is inadequate.

149 The Role of the Community Marvellous though health care services are in Canada ... there is little doubt that future improvement in the level of health of Canadians lies mainly in improving the environment, moderating self-imposed risks and adding to our knowledge of human biology.' 11 Thus a significant role has been defined for community health centre boards willing to take up the challenge of health promotion and education. Who better to understand the optimum orientation to such 'community' issues than the community members themselves? Furthermore, this approach offers the dual reward of improving community health and establishing communication channels between the board and those whom it represents. Instead of hankering after influence over the medical practice of yesterday, community boards may be better served by creating the health practices of tomorrow and by leaving tradition to the professionals.

11

The Role of Government

'Government is not in the business of providing services; it's in the business of paying for services.' This simple comment by a health official in the Ontario government goes a long way in explaining how government has perceived its role in the health care field. The introduction in Canada of hospital insurance in 1958 and medical insurance in 1968 were not, for all their political significance, events of importance for the organization of most health care in Canada. Certainly the schemes had a dramatic impact on the quantity of services delivered, the availability of the services, and the incomes of providers, but they really made very little difference to the nature of the services, who delivered them, or how and in what setting they were delivered. The absence of a defined role for the government in these organizational aspects of health delivery ensured that the costs of care were largely out of their control. Yet the government, as the representative of the taxpayer, has a responsibility to oversee the expenditure of funds in a way which gives the maximum return (good health) for the minimum outlay (efficiently organized care). Current cost pressures may finally be pushing government into a more aggressive, catalytic role in the organization of care. But so far they have failed to remove even the more elementary impediments to fair and equitable competition between traditional and alternative approaches. FINANCING WITHOUT ORGANIZING

Ironically, it was only for plans like those of the Sault, where the organization of services fell outside the traditional mould, that government insurance created problems. Throughout the 1960s hospital insurance prevented the health centre from including in-patient care in its plan, and hence from enjoying any financial rewards for its decreased use of hospitals. Medical insurance, in 1969,

151 The Role of Government legislated moment-to-moment free choice, thereby removing the sense of responsibility felt by the patient to the plan and vice versa. These issues were clearly organizational in nature; they fell outside the area of simple payment for services, hence escaping the attention of the government. Always wary of being drowned in a political maelstrom, the government avoided the choppy course of government financed and organized services, preferring to sweep up all of the contemporary system with its traditional values and aberrant incentives, and fund it, no questions asked. They effectively removed the vestiges of an economic 'marketplace' for the delivery of health services, and they failed to replace it with any controls on the supplier or the consumer. In pre-medicare days it was possible for fair competition, like the Sault's plan, to spring up in markets where prices and/or accessibility were not at accepted standards for the consumer. With medicare's introduction and the consequent uniformity of the fee-for-service, physician-run system, such competition was made illegal or well-nigh impossible in most circumstances. In effect, to gain the co-operation of the majority of physicians in the country, the government had to agree to the funding of a system in which organization was determined by traditional medical ideology. This excluded alternative approaches, including consumer organization and non-fee-for-service payment. The government did not appreciate that, having removed any market forces, it had a responsibility to induce competition in the form of encouragement of and protection for alternative plans. By protecting the status quo it ensured that there were no incentives for efficiency or economy in the legislated system; feefor-service, physician-run care had an unconditional mandate. It was hardly surprising, therefore, that costs started to increase faster than the government had originally envisaged. 1 Somewhat bewildered by the situation they had created, and still steering clear of direct intervention in organization, the government started to tinker with peripheral aspects of financing in an attempt to control costs. In Ontario the first policy initiatives were directed to the hospital sector: ceilings were placed on hospital budgets in an attempt to redress the undue slanting of care to these institutions which had occurred as a consequence of introducing hospital insurance before covering other aspects of the system. 2 By the mid-1970s it was obvious that, while these initiatives were resulting in some cost control, this was far from the desired level of containment. The realization that the physician was the central determinant in health care spending then led the government into attempts at cost controls in this area. With the help of the federal government, the provinces blocked the further migration of foreign physicians to Canada; controlling the number of physicians would result in at least some measure of control over the volume of services. Under a fee-for-

152 First and Foremost service system this would mean less cost. Attempts were made to monitor physicians whose billings were disproportionately large, by establishing medical review committees. This proved to be too much of an encroachment on the physicians' autonomy; it was challenged in the courts and successfully rebuffed by organized medicine. Finally, an attempt was made to control costs by holding down the price per unit of service, i.e., the level of the fees payable to doctors as negotiated by the government. This initiative was aided by the introduction of anti-inflation wage and price controls; these gave legislative muscle to proposals for only small increases in fee schedule reimbursements. Modest success was achieved through this, although physicians were later to take their revenge by opting out of provincial medicare schemes in large numbers, taking direct job action and negotiating large fee increases in the late 1970s when controls were removed. All these measures, with the possible exception of the ill-fated monitoring attempt, were part of the policy to restrict payments. None of the initiatives addressed the central issue of how the service delivery was organized. None the less, some minor experiments were undertaken. There was the incentive payment to the Sault for decreased hospitalization, but, as previously noted, the restrictive aspects of medicare legislation ensured its failure. A handful of community health centres was funded (the PDIG initiative), but their development was abruptly terminated once medical opposition took hold. Nurse practitioner training programs were started but, with the exception of one, quickly terminated when political exigencies prevented the introduction of legislation which would enable them to perform a meaningful role in the health system. Perhaps that kind of legislation was considered too close to organizing the system in a way that would break faith with the medical profession. The Sault's roller-coaster relations with the Ontario government illustrate the difficulty the provinces had in finding a role for themselves in the organization of care. The Sault was seeking policy initiatives and payment mechanisms which required direct government control over the nature of health delivery. It wanted to use OHIP computers not just as passive billing and payment tools, but as active data-gathering and organizational elements in a planned health delivery exercise. The power of 'government as paymaster' was being proposed as a lever to encourage efficiency-an approach which could replace the prevailing 'softly softly' attitude towards physician payment autonomy. The aims of the two parties were contradictory in so many ways that it was inevitable that difficulties would arise and surprising that any concessions or changes were actually made. The small changes which were made were insignificant compared to the proposals which the government was receiving from task forces and in reports that it had commissioned.· The experts to whom the government turned for advice

153 The Role of Government on cost containment saw clearly the need for basic organizational change. In 1972 the Hastings report on community health centres concluded that 'community health centres are increasingly seen as an important means for slowing the rate of increase in the cost of health services.' The 1974 report of the Health Planning Task Force in Ontario even chastised the government: 'Perhaps most significantly, despite its assumed role as the chief financier of health care, the provincial government has failed to develop a systematic, coordinated plan for the organization of the health sector ... greater experimentation should be undertaken with such alternative methods as salary, salary plus expenses, global budgetting for ambulatory and hospital care, and combination schemes such as capitation plus fee-for-service, to facilitate the development of new arrangements.'3 Yet the government appeared unwilling to listen. To be fair to the provincial governments, there were a number of external factors, in addition to the fear of upsetting the medical apple-cart, which retarded innovations in organization. The federal government had not provided their funding in a fashion designed to encourage the required organizational explorations: until 1976 costs would be shared only for the provision of expensive inpatient hospital care and the remuneration of physicians. These strict limits on cost-sharing discouraged greater use of allied health professionals, while the federal criterion of service delivery under 'uniform terms and conditions' further inhibited the development of differently organized alternatives. After the Hastings report, the federal government proposed a multi-million dollar 'thrust' fund to encourage the development of community health centres, but allowed this to flounder on the rocks of federal-provincial jurisdictional jealousies. By 1976-77, however, the national government had changed cost-sharing to a system of block-funding which gave provinces the flexibility to introduce alternatives and fund them without losing federal dollars. This more enlightened federal approach recognized that traditional practice modes were emphasizing cure to the detriment of prevention; henceforth the provinces were to expand their horizons beyond simple reimbursement for curative care. A further complication was the association of alternative delivery with political opposition parties. The New Democratic party, having led the way in Saskatchewan and Ottawa on medicare, was constantly pushing for greater support of community health centres and non- fee-for-service remuneration. Political animosities therefore further discouraged the rational introduction of such measures and, to borrow a favourite phrase from the medical associations, turned health delivery into a 'political football.' This was most clearly in evidence in Saskatchewan, where the Liberal government (1964-71) cut off most support for the NDP-endorsed community health centres and introduced user fees in direct contrast to its predecessor's policies. On their return in 1971, the NDP

154 First and Foremost removed user fees and started line-by-line budgetting rather than fee-for-service funding of the community health centres. It is interesting that the health centre at the Sault steered well clear of direct political allegiance of any kind. It saw clearly the dangers of becoming allied to or identified with any specific political interest and tried to play a role justifiable to all parties. Throughout its existence it has studiously avoided becoming embroiled in political rhetoric, astutely maintaining that the delivery of good health care was its only goal. This goes a long way in explaining the centre's enduring success in the face of changing political climates. Finally, the fact that 'community-controlled' health centres had become the focus of alternative delivery proposals worked against provincial government interests. The federal government, through its provincial funding, was threatening to encroach on the territory of provincial health care; provincial governments feared that community control would reduce their status to mere stop-over points for health funds, with no effective control over, or kudos from, the expenditure of these funds. It was not surprising then, that by the late 1970s, as the temporary respite from cost escalation provided by provincial tinkering was coming to an end, new measures yet again avoided significant changes in the organization of care. As if it had come full circle, Ontario once more focussed on hospital costcontainment, again avoiding the organizational issues surrounding the physician's delivery of care. In 1979 funding for hospitals became tied to specific bed numbers adjudged to be the required need for a particular community, and a battle of bed ratios ensued between the ministry and hospitals. 4 When antiinflation controls ended in 1978, hospital workers and physicians claimed the right to catch up on lost ground. Wage settlements for hospitals were moderated by compulsory arbitration legislation, but annual fee schedule increases for physicians were well in excess of 10 per cent for the end of the 1970s and the beginning of the 1980s. Not only fees but also the number of services being provided were increasing, s due probably to a combination of increased patient demand and, perhaps more significantly, the desire of physicians to increase their service levels in order to maintain incomes under the fee-for-service system. Between 1975 and 1979 the volume of billable physician services increased by 20 per cent while the population increased by only 5 per cent. These were all ominous signs for a government restricted by philosophy to tinkering with payments. Unwilling to play a leading role in the organization of service delivery, the government was reduced to statements like 'the alternatives are: raising more revenues or cutting services ... we may have to contemplate raising additional funds from within the system itself, including employing modest user charges.' 6 Therefore, alternative delivery is unlikely to receive government

155 The Role of Government support on the grounds of its community input; its only hope is to be recognized as a tool for cost-containment. For many years prepaid alternative health plans in the United States suffered from the same lack of support from successive administrations. The U.S. government 'ignored the potentialities of prepayment as a tool both for developing leverage over a health care system badly in need of reorganization and for maximizing federal investments in health within a coherent health fiscal policy.'7 However, at the start of the 1970s, that country's own cost-containment problems led to the passing of the Health Maintenance Organization Act of 1973. Not only did this provide start-up funds and initial loans for the alternative approach, but it required employers of more than twenty-five people to offer them a choice between conventional coverage or an HMO, if the choice was available in the area. Regarding this latter provision, American HMO advocates have pointed out that 'although this stipulation has been criticized in some quarters as heavy-handed Government interference, it was an essential step toward breaking the grip held by traditional carriers on health care coverage.' 8 These bold U.S. initiatives suffered the ravages of 'pressure from elements in organized medicine and the medical insurance industry,' but nevertheless by 1980 they had increased enrolment in such plans to 4 per cent of the U.S. population. Significant cost savings, especially on hospital care, were being realized for this 4 per cent compared with those with conventional insurance coverage. By contrast, in Canada alternative plans like those in the Sault cover barely 1 per cent of the population. The existence of universal health insurance in this country undoubtedly alters the policy imperatives of, and some would say negates the motivation for, alternative health delivery. However, one positive aspect of the Canadian system is its greater facility for centralized planning, compared with the fragmented state- or region-oriented planning in the United States. As costs continue to increase sharply, a role for the government in health care organization may become inevitable, and it may yet break out of their 'we only pay for services' mentality. If this occurs, a minimal step would be the removal of many of the impediments to the development of alternatives. REMOVING THE IMPEDIMENTS TO THE LOST MARKETPLACE

The previous section has shown that the political imperatives of costcontainment in the field of health care may soon come to outweigh the Ontario government's historical tendency to protect the traditional system. The dilemma facing the government will be how to introduce alternative delivery yet maintain at least some faith with the traditional professional lobby. The answer is that they probably cannot. There is one strategy, however, which the govern-

156 First and Foremost ment could adopt, which might at least appease some of organized medicine's opposition. Taking a lesson from HMO developments in the United States, the government could stress the 'free enterprise' aspects of a new approach. A new incentive structure could be made available to the entire health care sector, but the details of how these incentives would be organized into care delivery would be left to the marketplace itself. This aspect of HMO initiatives in the States has already been raised: 'By leaving the specifications of organizational structures to the delivery system itself, but defining incentives designed to accomplish particular objectives, it could be argued that the federal government was removing itself from interference in the direct delivery of health care and confining itself to the role of catalyst and purchaser. The idea could be sold, from this frame of reference, as a market reform strategy rather than yet another federal program requiring a large bureaucracy of civil servants to manage it.' 9 Quite simply, by removing certain impediments and introducing a handful of catalytic new measures, the government could put prepaid capitation alternative delivery in fair competition with traditional practice. The consumer of health care would then be able to choose between the options, and the natural remedy of market forces might facilitate solutions to local problems, as they did in Sault Ste Marie in the early 1960s. The government role would then become that of the facilitator who tries to establish circumstances in which both traditional practice and alternatives could have an equal chance of success. It is beyond the scope of this text to develop a detailed blueprint for such an approach, 10 but it is not difficult to identify some of the impediments which must be removed. The primary barrier to the development of alternatives has been the insistence of the government on maintaining that free choice means the choice of individual physician rather than of method of medical organization. This insistence perpetuates the notion of the solo-practice doctor as the unit of health delivery. Experiences at the Sault since medicare's inception have shown clearly the difficulties caused by the free-choice provision as it is currently defined: the centre has to fight against reduced feelings of accountability for its patients; it must carry the costs of services used outside the centre but has no control over them; it is difficult to establish patient loyalty to the centre. These problems all work directly against the success of alternative prepaid health delivery. 'In order to plan and budget for medical services a prepaid health plan must be able to enroll members and limit their out-of-plan use by not paying for it. Provincial governments have not been willing to adopt enrollment or to deny insurance coverage for out-of-plan utilization. Denial of payment for any health care services is seen as incompatible with universal insurance. Absolute free choice of

157 The Role of Government physician is required. Individuals cannot choose a health plan instead of an individual physician for a defined period of time ... Unless enrollment issues are resolved, the future of capitation-prepaid group practice in Canada is uncertain.'• 1 What makes the persistence of the free-choice provision all the more frustrating is that it is a logical impossibility. It provides freedom of choice to both patient and doctor. Hence, if the doctor chooses to exercise his freedom to reject a patient's choice of him, then the patient's freedom of choice is automatically denied! If legislation were changed to allow a patient to choose either a health plan or an individual doctor, and to restrict him to that choice for a specified time, a number of positive effects would follow. The physician or physicians would have to be responsible for that patient, so whether he called at midnight or at noon it would clearly be necessary for someone to be available. The patient's care would all be co-ordinated in one place, ensuring integration of all aspects of care for each patient, and his entire medical chart would be available in a known place in case of emergency. The medical 'shopper,' who can cost the system the price of any number of doctor visists for the same episode, would be virtually eliminated. Finally, the costly and complex administrative and data systems required to calculate how much, when, and whose captitation payments should be withheld for using out-of-plan services would be made redundant. When the Sault was able to operate with this type of 'closure' in their system (i.e., prior to medicare) there was rarely, if ever, any concern expressed by patients about the supposed restriction on their 'free choice.' A natural corollary to the removal of total free choice is the need to remove advertising restrictions. If patients are to be enrolled in a plan or with a doctor for a specified time period, then they must have the information to decide which one they would like to choose. The government must resist the self-protecting arguments of the College of Physicians and Surgeons and open the health field to tasteful but informative advertising. The removal of these restrictions would also allow for more extensive health education and promotion undertakings by the providers of care. Advertising would therefore be necessary to obtain informed enrollment and encourage health maintenance. Besides these two major impediments, a host of smaller issues abound, preventing the expansion of alternative facilities. The unwillingness of government to block hostile college regulations-like the obstruction of the Sault's attempt to employ dentists directly, or the way hospital privileges were withheld from health centre physicians in Saskatchewan-only serves to increase the resigned cynicism of the alternative provider. Nevertheless, it cannot but be annoying when donations to hospitals are made tax-deductible, but the same pro-

158 First and Foremost vision is not extended to health centres. Government sales- or land-tax exemptions have also in large part been denied to health centres; similarly with capital support for building and expansion. Furthermore, while no proof of efficacy is required of the fee-for-service system, alternatives are constantly challenged to justify their performance compared with that system. The development of the concept of a team approach to patient care is seriously undermined by professional regulations and statutes which allow physicians effectively to control the practice of nurses, social workers, and most other allied health professionals. If at least some of these barriers were swept aside by government (and they do have the power, if not the political will, to carry out such a job), then alternatives and traditional practice could be placed on an equal footing. However, as the advocates of HMos in the United States have pointed out, this is probably still not enough. The forces of the status quo require to be counterbalanced by active encouragement for the alternatives. A measure similar to the 1973 American HMO Act requiring inclusion of alternatives among options available during collective bargaining would be just such a counterbalance. It would still avoid direct government involvement in the organization of care, but would open the way for interested groups to organize their plans with government approval, rather than with its begrudging tolerance. 1\vo further incentives could move the government beyond merely paving the way for alternatives into actually encouraging them. First, captitation payments could be made available which were calculated for hospital as well as medical care of patients. This would then allow known savings in hospital costs through prepaid alternatives to be used for additional services for the patients of a centre. Furthermore, providers would be less inclined to refer patients to hospital for treatment, the need for which was doubtful, if they knew that such referrals would cut into the general funds available for their income; thus the overservicing aspect of the fee-for-service system would be removed. In parts of the United States where this system is in operation, the fear that it would encourage under-servicing or the withholding of hospitalization when it really is necessary has proved to be unfounded. Second, legislative recognition of non-profit community organizations as legitimate organizers of health care would provide the impetus for alternative delivery to become based upon community interest. The provision of developmental and planning seed funds for community groups interested in health care delivery would encourage a broader view of patient needs, instead of the physician's concentration on individual cases. Also, as a consequence of providing health care funds to a non-profit community group rather than directly to the physician, health dollars could be spent on a range of appropriate ser-

159 The Role of Government vices matched to that particular community's needs, which might or might not include care provided predominantly by physicians. The physician as gatekeeper of the system would be exchanged for a representative community gatekeeper. The government could go even further by playing an educational role, both within the professions and outside. Community health centres affiliated to teaching hospitals could expose medical students to the alternative approach during training, when their medical values are developing. This would encourage a more positive orientation towards alternative delivery, as well as decreasing the possibilities of later friction between boards and physicians. The Sault has developed wide-ranging ties with teaching institutions both within and outside Canada, and has consistently found that the response to its program, when presented in this practical fashion, has been positive. Public awareness could be increased by sponsoring seminars, workshops, and conferences appealing to community groups and interests. Staff could be available within a health ministry to help interested groups to plan and operate facilities. Finally, if the concept were to be embraced totally, then community animateurs could be provided, as they were in Quebec. Quebec provides an example of a province where the government embraced the role of catalyst. It demonstrated that if barriers are removed, incentives instituted, and education embarked upon, then alternative, community-based health care can become a reality. It stands alone among Canada's ten provinces as a demonstration of what can be done when the government takes an active role in the organization of health care. The greater mobility of the English-speaking physicians in the rest of Canada does, however, reduce the expectations of other provinces, which are ever-fearful that their physicians might express their disapproval of radical changes by a mass exodus. Such an aggressive government role as in Quebec is not, therefore, likely to be politically acceptable in the rest of Canada. It is for that reason that I have divided possible government action into three progressively more active stages-the removal of impediments, the introduction of incentives, and finally active prosyletizing through education. For most of English-speaking Canada, the best that can probably be hoped for by the advocates of alternative delivery is the removal of enough barriers and the introduction of some incentives to place traditional practice and alternative delivery in fair competition. Then the forces of the marketplace, i.e., the exercise of consumer preference, would be returned to health care delivery, greater efficiency would result in both the availability of more appropriate services and the moderation of cost. As G.L. Stoddart, a particular advocate of the 'competition' approach in Ontario, has said: 'Providers will have an increased incentive to behave efficiently because

160 First and Foremost otherwise they will lose patients who have the option to enrol elsewhere at lower cost. Patients will have the incentive to choose an efficient provider because now they can benefit financially from doing so.' 12 The approach would be very different from that of Quebec's in that a specific delivery mode would not be earmarked as predominant. Rather, the consumers' choice would determine predominance. From many viewpoints the latter is a preferable situation, given the lack of sufficient extensive experience with alternatives in Canada to enable identification of the method of organization. If increasing cost concerns do finally force government to make the leap from their current paymaster role to a limited role in encouraging differently organized health delivery, then the potential impact of alternatives may finally be realized.

12

Evaluation

It is imperative to attempt any evaluation of alternative delivery from a neutral standpoint. Yet this area of health care research has so much political, social, and professional vested interest that it is difficult to produce a truly 'objective' assessment of its efficacy. The ideological viewpoint of the evaluators or their sponsors can and does dictate the choice of the dimensions of evaluation if not the measurement of these dimensions. Governments are most interested in evaluating immediate cost factors, physicians focus on quality and job satisfaction, while consumers are more concerned about the relevance of services to their needs. In health delivery research certain variables and issues may also be omitted from evaluations because of poorly formulated or non-existent measuring tools. Tenuous concepts like 'quality of care' or 'health status' have so far largely eluded the approaches of the biostatistician. However, despite these many shortcomings, some conclusions do emerge on the basis of the limited evaluations available. Unfortunately, the general applicability of these conclusions is still somewhat in question. THE IDEOLOGY OF EVALUATION

'Traditionally social evaluation has been viewed as a tool to assist decision-makers to make better decisions about the modification, continuation or termination of programs designed for those effectively precluded from the decision-making process.' However, 'the political stance of the evaluator has consequences for his (or her) choice of techniques of information-gathering and analysis.'• The story of the Sault health centre contains many illustrations of the latter point. Political considerations played a large role in evaluations of the health care provided at the centre, and in many instances the results were put to political

162 First and Foremost use: for example, the Ontario government helped fund the World Health Organization's study of the Sault as a result of pressure from political opposition parties; and conclusions of the 1975 comparison with the fee-for-service Glazier clinic were partly responsible for the freeze on further HSO developments in the province. Not only political but also personal interests were frequently vested in the evaluations of alternative health care, and a biased approach often led to a biased interpretation of the findings. An official from the Ministry of Health was struck by the subjective approach of the medical profession: 'It's the first time I got exposed to the sort of entrenched caricaturized image of the medical fraternity ... As I listened to their arguments, they were arguing as well from a philosophical bias ... There was always that phenomenon, you know, where expert A comes in and says, "black is white," and then expert B comes in and says, "No it isn't, white is black".' 2 As a consequence of the prevailing political climate, alternative delivery in Canada is on the defensive. Tolerated in a health scene dominated by traditional practice, it is up to the supporters of alternative health delivery to prove its worth. This means that evaluation is a matter of measuring the alternative's performance against the prevailing fee-for-service system. It also means that the focus is on the immediate costs of care, rather than on appropriateness, quality, accessibility, or any of the other less measurable variables. In fact, the official Ontario policy towards the development of alternatives stated explicitly that financing will not exceed 'the OHIP cost of providing medical care to a corresponding population under the traditional fee-for-service system.'3 Evaluation therefore inevitably centres on which system costs the government more, regardless of the breadth of service, the possible future savings from the alternative's focus on prevention, the decreased cost to the patient who can receive all services under one roof at one time, and a host of other crucial considerations. Fred Griffith understood this: 'One method [of evaluation] is even more odious than averages and that's the so-called fee-for-service profile. Under this system you are told that you provided x services and according to the fee schedule that accounts for xy dollars, therefore you are more expensive than fee-for-service. The believers in this system neglect the fact that method of payment reflects method of practice. Measurements of activity derived under one system of payment cannot be used to measure activity under another system of payment-as a matter of fact, the generation of dollars is probably a poor proxy for measuring activity in any circumstances.' 4 One of the best examples of the inappropriateness of this type of comparison occurred in the early insurance role years of the Sault: the provincial superintendent of insurance insisted that their premiums be raised because they were pro-

163 Evaluation vi ding ten times as many services to pregnant women as the rest of the system. In fact the rest of the system's fee schedule paid one lump sum for all pre-natal care, which, although it might involve ten or more office visits, showed up on fee-for-service data as a single claim. With no fee-for-service component in the data-reporting for the Sault, each visit was counted as a service and compared to the single claim of the fee system. Clearly, contrasting alternative 'service' data with traditional 'claims' data is an apples-and-oranges comparison. Nevertheless, in Ontario this method of evaluation was decided upon in the mid 1970s when the progressive mandate of the PDIG was unceremoniously withdrawn. This group had recognized that focusing on the short-term costs and 'claims' aspect of care ignored many other important considerations in evaluation. With the demise of PDIG, however, their 'bottom-up process' of evaluation was displaced by the fee-for-service cost comparison. The gold standard for comparison became the fee-for-service system. Thus, although they may provide a broader range of services and devote more time to patients in the office in order to prevent hospitalization, alternatives must match the costs of fee-forservice care, which is delivered largely by single doctors who utilize hospital services more regularly but, on paper, are not responsible for the cost of hospitalization. This approach is like rejecting the car which does seventy miles per gallon in favour of the gas-guzzling standard model just because the initial purchase price is greater for the former. The focus on cost evaluation has been further encouraged by the lines of accountability for government-funded alternative delivery. The ultimate monitoring agency, outside the Ministry of Health, is the Public Accounts Committee. While this committee may have some interest in consumer satisfaction or quality of care, its primary concerns are political gain and the cost of care. s Costs are also the easiest measurement to take when evaluating a system-they are tangible and traceable. To measure other factors, sophisticated research tools have to be developed. Unfortunately, the distribution of research funds continues to reflect the bias away from developing these organizational aspects of the system. In 1981-82 the Canadian federal government provided only $11.1 million, under the National Health Research Development Program, for such organizational research. This can be compared with the $100.2 million for research into treatment and cures of diseases granted through the Medical Research Council. In other words, decisions about how, whether, or when to use the results of medical research have to be made with a research commitment which is only 11 per cent of the monies spent on the research. 6 As a consequence of this focus on cost factors in evaluation, many variables are omitted which could reveal the real worth of alternative compared with traditional practices.

164 First and Foremost OMISSIONS IN EVALUATION

Even if the focus is to be on cost it should look beyond the immediate costs to government. For example, evaluations have not considered the cost incurred by consumers in their use of different delivery mechanisms. The extra-billing of some fee-for-service physicians, especially in urban areas, can be a significant additional expense. By contrast, the convenient presence of X-ray, laboratory, and specialist services all under one roof, as is the case for many group practices operating as alternatives, can ensure that patients do not have to take excessive time off work (and therefore lose wages) to attend to their health problems. In the 1973 study of consumer attitudes in the Sault, the 'convenience' of the Group Health Centre was probably the most praised aspect of their service. Alternatives also frequently provide physiotherapy, nutritional, or counselling services as an integral part of care, while patients outside such a system may have to pay additional sums for that kind of service. Furthermore, the costs to government are only calculated on a short time scale. It might well be that the additional preventive and educational programs of alternative delivery facilities increase the over all general health of their population and decrease their future use of, and therefore their costs to, the health system. If lead pollution is reduced in a community, then there are obviously going to be cost savings, a few years down the line, from the reduction of lead-poisoning cases requiring health services. By focusing on the short term, government may well be guilty of being penny-wise and pound-foolish. The utilization of services by individuals under different practice modes have to be traced over years- not months- to answer this kind of question. The costs of community participation are a further omission. These are automatically considered 'extras' when the alternative facilities are constrained to provide service with the same level of funding as fee-for-service practice which has no such participation. Community involvement, which encourages personal responsibility for health care, is not seen as being worthy of additional funding consideration. The sense of loyalty, pride, and achievement a community may feel because of its role in the delivery of its own health services is not considered a public democratic value when comparisons are made with other practice patterns. Furthermore, community involvement may often lead to the provision of services more appropriate to the health needs of the population than services provided without such input. A community health centre located in an area with a high proportion of elderly individuals, for example, can easily adjust its staffing to include more geriatricians, home support services, or social services. Individual practitioners scattered in the same area cannot adjust as easily. The

165 Evaluation general appropriateness of the care being delivered is not a factor which receives much attention in the current cost-oriented evaluation process. Consideration of the over-all quality of care is also neglected. Beyond ascertaining that the providers are qualified and not practising unethically, there is minimal investigation. Issues like continuity of care, availability of emergency services, frequency of tranquillizer prescribing, accessibility for minority or ethnic groups, adequacy of complaint procedures, office-waiting times and so on, are not quantified or compared. Finally, no consideration is made of the effect an alternative's presence has on other providers. In the Sault, as a consequence of the competition from the health centre, the other physicians reduced their hospitalization rates below the provincial average (although still above health centre figures) and aggressively sought to increase the range of specialist services available for the community. Such benefits are not credited to the alternative when the cost-saving and qualityimproving potential is calculated in the evaluation process. 7 Many of these omissions can be traced to structural and political elements of government health care organization. Some can be attributed to the lack of adequate measuring techniques-this category includes most of the 'quality of care' variables and the issues which require demonstrations of changes in health status. However, these problems of measurement are not insurmountable and would likely be solved through careful and extensive research. Unfortunately, the avoidance of organizational involvement by governments has led to the inadequate provisions of research funds. The Sault and other alternatives in Ontario are expected to fulfil their extensive research and evaluation obligation from within their normal budget-a budget which must not exceed the equivalent cost of the fee-for-service sector which has no similar evaluation obligation. Other omissions may simply be attributed to the absence of adequate information within ministry and health centre data systems. The attempts to show the long-term cost savings of the alternative's more preventative and co-ordinated approach are of this type. Ministry data is based on information gathered from claims and does not allow easy tracing of the care received by individuals over a period of time. The 1972 decision to discontinue individual identifiers in favour of single contract numbers for entire families meant that the government was no longer able to isolate an individual's health care utilization. It also demonstrated the government's lack of understanding and commitment to the use of the OHIP data bank as a health planning and evaluation tool, and confirmed it as simply a centralized billing system. The PDIG had made attempts to modify the OHIP system to meet some of the data needs of alternatives: 'The system was designed for use x; we were trying to use it for y, and so it was problematic ... they [OHIP administrators] thought we were criticizing them for being

166 First and Foremost stupid and designing a system that was bad. What we were saying was, "This system doesn't meet our needs. If you would adjust it this way, we could use it." And they were saying, "That would be a stupid expenditure of funds because we don't need it".' 8 Recently, however, the consolidation of the HSO program in the province and the need to justify the role of community health centres have led to the development of a separate data system for alternative delivery systems. This may be the first faltering step towards providing an appropriate data bank for the needs of alternative delivery. The system, however, still suffers chiefly from the insistence upon direct comparison with fee-for-service modes of delivery. This requirement can be blamed for the absence of valid cost comparisons. The alternatives have an identified or registered population to whom they provide services; this enables direct tracing of cost for those patients. Fee-for-service practitioners under free-choice circumstances, on the other hand, have no identified population - they serve anyone who comes through the door for any number of encounters; therefore tracing the costs for these patients is a far more difficult exercise which tends to underestimate costs compared with an alternative's identified patients. Thus a 1977 report which proposed the fee-for-service(called the Normative Practice Unit) comparison 'contained many worthwhile innovations [but] had the serious defect that it did not adequately identify populations served by the Normative Practice Units.'9 Despite this instance of government's demonstrated capacity for valid insight into the problem, the pressure to make exactly this kind of comparison has continued. Finally, the progression towards any form of representative and valid evaluation has been severely hampered by the small number of alternative facilities. Any comprehensive evaluation of alternatives must have a large enough pool or sample of centres to allow generalization. In Ontario not only are there very few centres, but they are far from homogeneous in terms of structure, goals, services provided, populations served and size. Their insignificant share of the health budget provides little impetus for the funding of adequate evaluations. It will require a great deal of patience and commitment to isolate each centre's unique goals and evaluate their performance in relation to such goals, rather than in relation to more traditionally imposed criteria. WHAT HAS EVALUATION REVEALED?

Despite all the ideological and structural straitjackets which have confined the evaluation process, it is possible to come to some conclusions based on the limited attempts to date. The major published evaluations of alternative health delivery schemes in

167 Evaluation Canada have involved the centre at Sault Ste Marie. In 1968 the World Health Organization's study compared it with the solo-practice care of steelworkers who had not chosen the health centre in dual choice. Then, in the mid 1970s, it was compared with the Glazier Clinic's fee-for-service group practice in Oshawa, as well as with some solo-practice fee-for-service doctors. Of these two studies, the former had the major advantage of an undeniably matched population for comparison-steelworkers compared with steelworkers in the same city. The Glazier study suffered from the problem of identifying and defining for comparison a fee-for-service population in a different city. The WHO study revealed that subscribers to the G.H.A. of Sault Ste Marie were found a/ to spend 24 per cent less time in hospital, mainly because of a lower admission rate; b / to have fewer surgical operations; c I on discharge from hospital, to have a lower rate of early readmission; d I more likely to have seen a doctor at least once during a twelve-month period; e/more likely to receive immunizations and check-ups; f I more likely to be attended by an 'appropriate' specialist; g / to undergo more radiologic and laboratory investigations on an out-patient basis. •0 Thus the study showed that the alternative delivery facility cost less as a result of more out-patient work and fewer hospitalizations; the appropriateness of services was better; and there was more emphasis on preventive care. On the negative side, the WHO study indicated that the degree of personalized care was better from the solo fee-for-service physicians. The relevance of these findings to the current situation, however, has been affected by the introduction of government health insurance, with the restrictions and barriers it brought to the operation of the Sault scheme. Therefore it is important also to look at the Glazier study. Despite serious shortcomings in this study's design, 11 the results confirmed that the alternative plan of the Sault was less costly and more appropriate than the service provided by the solo-practice doctors in the comparison; however, the levels of hospitalization and cost in the Sault and the Glazier Clinic's group practice were not shown to be very different. Although this could be accounted for by the methodological problems, the results did raise the question of whether it was merely the group practice aspect of delivery which was effective, rather than the alternative payment mechanism and broader range of services available at the Sault. Reference to the more extensive studies of Health Maintenance Organizations (HMos) in the United States helps to answer this question. They indicate that the key to cost savings and reduced hospitalization is, in fact, the combination

168 First and Foremost of alternative prepayment and group practice. The existence of Independent Practice Associations (IPAs) in the States facilitates the evaluation of the different organizational components of alternative facilities. HMos utilize patient prepayment, non-fee-for-service physician remuneration, and group practice, while IPAs use patient prepayment to the association, but fee-for-service payment of physicians and solo practice. A third option, indemnity insurance, has fee-forservice payment of solo physicians with patients prepaying only to a third-party ('arms length') insurance company. It turns out that the HMO combination of alternative payment and group practice produces the greatest cost savings and the greatest decrease in hospitalization. IPAS do decrease hospitalization and cost somewhat compared with indemnity insurance, but they do not achieve the same level of success as HMos in cost efficiency. 12 Not surprisingly, therefore, it is in the area of cost savings that evaluators have been able to demonstrate the alternative's worth. The inhibiting effect of national health insurance in Canada may well temper the degree of even this cost-effectiveness, but it has not totally negated the potential savings. It seems that the cost-savings are achieved through the efficiency of group practice, the greater propensity for doing out-patient diagnostic testing, the decrease in overservicing of patients, and the lower hospital admission rates. Furthermore, the capitation or prepayment method of funding automatically encourages the availability of more varied health personnel and inevitably increases the likelihood that services appropriate to the varied needs of the population will be available through alternative delivery facilities. However, two major questions still remain unanswered by existing evaluation attempts. First, it is not clear whether cost savings can be realized when the alternative is a small centre serving a few thousand patients with only a handful of providers. The major studies have involved large facilities with responsibility for appreciable numbers in a community-2O,000 or more in the Sault and upwards of 1,000,000 for some U.S. HMos. The smaller centres, which have much less potential for economies in providing services, are less able to influence the health practices of their whole community, and which often serve highly atypical and transient populations, may not appear so attractive in the immediate cost comparison. This raises the second question: whether they may actually prove to be cost-reductive when their longer-term preventive and promotional approach is evaluated. Similarly, the cost-savings already demonstrated for the larger centres may be gross underestimates of a total picture which includes such possible long-term savings. Until such time as long-term evaluations are done, the impact of many of the alternative programs will remain in doubt. Such programs will continue to be operated and justified on faith alone. The effect that nutritional counselling of

169 Evaluation mothers will have on the health status of their children at adulthood; the future reduction in health service utilization as a result of smoking withdrawal clinics; the decreased pressure on psychiatric services because of early out-patient counselling, and better health thanks to environmental pollutant control: these and similar examples will all remain matters for conjecture as long as they are ignored by evaluations. The faith that currently supports and motivates these programs may prove to be misguided in some instances and confirmed in others, but it must surely be in the interests not only of the supporters of alternatives but also of those responsible for health policy to have such questions answered. What is required is an evaluative comparison with the fee-for-service traditional mode of practice, under terms and conditions which allow alternatives to demonstrate what they believe is their true value. Unfortunately, it seems that political realities and ideologies will continue to press for evaluations comparing only immediate costs within the confines of the restricted mandate of fee-for-service practice. Many alternatives fear that, under conditions which are less than favourable to their full development, and with evaluations which fail to measure what they think are their positive effects, they will be discarded as unworkable and inefficacious. It is to their credit that those who have been willing to participate in such evaluations, not least of whom are the people in the Sault, have generally proved their worth despite these biases. The potency and supremacy of the status quo is unlikely to vanish overnight; therefore the further advancement of alternative health delivery is dependent on the willingness of centres to prove their efficacy under the adverse requirements of current ideology. Some may not succeed, but those which remain could form the basis of an alternative delivery system confident of its value to society.

13

Is There a Best Alternative?

Throughout the previous chapters, a view of what constitutes an alternative health delivery facility has emerged. In general terms, it seeks to alter the economic incentives to ensure cost efficiency and to broaden the base of health services readily available to its patrons. It may have consumer input through a community board; even if it doesn't, it will have to develop strategies to counter opposition from traditional modes of delivery. In translating these general aims into organizational structures, alternatives have chosen many different paths and are operating under vastly different approaches. No clear 'best option' seems to have emerged. This may be a consequence of their still being in an early stage of development, their small numbers, the encumbrance of unfavourable government legislation, or the opposition from the status quo. If so, then perhaps a best alternative does exist, but its discovery is being frustrated by an adverse climate. Alternatively, the diversity of forms which alternatives have taken may reflect the uniqueness of each community's needs and circumstances; what is best for one community will be inappropriate for another. Although a few sine qua nons may be isolated, their elaboration will depend on local conditions and attitudes, and the search for a best option will be fruitless. If there is no best option, then health care should be organized in such a way that the flexibility required for responsiveness to local needs is a built-in consideration. THE HETEROGENEITY FACTOR

The idea that a single preferable organizational form exists for health care delivery can most easily be traced to the philosophy behind centralized government funding. When the government enters the field of social programs, the administrative demands are invariably for a single manageable concept which is

171 Is There a Best Alternative? applicable, and acceptable, across the entire system. Heterogeneity is considered both administratively costly and politically unacceptable to those who believe in uniformity and universality of programs. Consequently, a search takes place for the best option through which the entire population can be served. When Canada's medicare system was being drawn up in the 1960s, the group at the Sault did not ask the government to produce a system which would consist solely of reproductions of the Sault Ste Marie and District Group Health Association. The association had, after extensive questioning, established an organization which closely matched the needs and desires of the city. It was that city's 'best option,' and none of its participants would have claimed that it was necessarily the best option elsewhere. All the association lobbied for in medicare was a system flexible enough in its design to allow its own plan and others like it to flourish alongside other options. The variety of health delivery formats in existence prior to Canada's introduction of medicare suggest that uniformity of program is not a natural state of affairs. Admittedly, not all the variations were desirable: some were the product of short supply; some reflected the slowness of health providers to respond to innovation and specialization; and some were simply representative of the inherent self-interest of selected providers. However, others were very positive, and had come about in direct response to unique local needs and circumstances: the shortage of doctors in the Swift Current region of Saskatchewan had, for instance, produced an innovative prepayment approach: the events at the Sault had been a direct response to the inadequacy of local conditions. Therefore, if local circumstances are to be taken into account, a certain degree of organizational heterogeneity would appear to be necessary. The organization of services should take into account both geographic and socio-economic factors. It makes no sense to expect the same structures to be appropriate for health delivery in rural and in urban settings: in rural areas, for instance, the widely dispersed population and decreased concentration of services may require a satellite clinic structure, rather than a single large centrally located facility; heavily industrialized areas will have different needs from agricultural regions. Health delivery in an area with a strong community identity should reflect this identity in its organizational structure: where there are high proportions of poor, unemployed, or disadvantaged people, the organizational structures should facilitate outreach; areas populated by well-informed, affluent upper-middle-class citizens should capitalize on the potential for greater self-care; high proportions of debilitated, but not disabled, elderly people should trigger structures providing more home-support services and less office-centred care. This far from complete list of potential local variations shows how unlikely,

172 First and Foremost if not downright undesirable, it would be to find a single organizational form applicable to the needs of all communities. In the Sault, for example, the consequences of imposing (through medicare) a province-wide structure on the health centre were ten years of painful readjustment, much unrealized potential, and immeasurable 'disgruntlement' on the part of the community. The issue of required pluralism was succinctly described, although not heeded by the government, by Ontario's Health Planning Task Force of 1974: 'Within guidelines established by the Ministry of Health, the health services system should be sufficiently flexible that the provision of services in a given community can be readily adapted to the community's particular needs, taking into account specific social, economic, geographic, cultural and other factors.' THE GENETIC CODE

Having stressed the need to allow for significant local variations in the organization of health delivery, the question arises whether there are any organizational elements which transcend the inevitably diverse conditions. In other words, is there a set of minimally necessary elements which has emerged as best options in forming the basic structure of alternative health delivery? Surprisingly little attention has been paid to this question. In Canada the introduction of national health insurance relegated consideration of the question to the purely academic domain. However, a few explorations of the area have been made and have consistently concluded that at least group practice should be part of the structure. 1 Even the medical associations have come to this conclusion: The 1967 Canadian Medical Association report on group practices, for example, stated that 'doctor sponsorship of medical care organizational units or groups is the most desirable pattern of modern medical organizations.' Therefore, putting aside the sponsorship issue, the consensus is that group practice should be an element in health care delivery. Impressive support has also been given to non-fee-for-service payment methods. Except among members of the medical profession, fee-for-service payment has generally been recognized as undesirable, although there has been no clear consensus on which of the other possibilities should replace it. A representative view was expressed by the Ontario Economic Council in 1976 when it concluded: 'The traditional fee-for-service system, in the context of a largely publicly financed health care system, is undesirable in many respects as a procedure for remunerating physicians. General revenue financing does not provide any incentive for physicians and hospital administrators to hold down costs or to seek efficient methods of producing health care services. Salary, capitation and fixed

173 Is There a Best Alternative? budget systems could be considered; they are preferred alternatives, especially in the context of group practice.'2 Some degree of community participation has also been an expressed preference except, again, in the corridors of the medical associations. It was expressed at the federal level in 1972 by the Community Health Centre Project, and then again in the 1974 New Perspectives on the Health of Canadians. Quebec has committed itself to community-based organization, and the commissioned reports of numerous other provinces have endorsed this as an essential element in the delivery of primary care. Finally, Canadians have long believed in prepayment for health services, in order to spread the cost of sickness across all citizens, not just those who are sick. In Canada, then, prepaid group practice, community participation, and non- fee-for-service payment have been identified as necessary (although possibly not sufficient) conditions for the organization of alternative delivery. It is interesting that these are precisely the organizational elements which formed the cornerstones of the development in Sault Ste Marie of the early 1960s, long before learned studies and analyses of the subject in Canada were available. Because much of the Sault's basic structure was borrowed from the prepaid group practice plans in the United States, it might be profitable also to search among the U.S. analyses of required components for alternative delivery. One of the most thoughtful of these analyses was carried out by Ernest Saward, a long-time participant in and leader of the HMO movement in the United States, and medical director of the Kaiser Permanente Plan in Portland. In an address which was actually given at the health centre in Sault Ste Marie in 1969, he spoke about the 'genetic code' for successful alternative delivery: 'While the genetic code allows for great individual variation, just as the human genetic code allows for individual variation, nevertheless one cannot violate this code without the result being either a stillborn plan or a plan that will be defective in its growth and maturity.' 3 He then outlined six essential components: prepayment, group practice, an integrated facility, capitation payment, comprehensive coverage, and voluntary enrolment. Prepayment 'removes the barrier of a fee at the time of service'; group practice means 'the medical group pools all income ... all members of the medical group are full-time [and] continuing education is integral to the group'; an integrated facility where 'laboratory services, purchasing department, accounting department and administration are unified ... produces substantial economies'; capitation payment 'creates a predictable, budgetary operation'; comprehensive coverage 'directs an appropriate use of the budgetted dollars; the least expensive, effective modality will be the one used'; finally, voluntary enrolment ensures that 'no member of the program

174 First and Foremost belongs to it unless he has chosen it and to be given a choice, he must have an alternative.' These conclusions, based on twenty-six years of experience with alternative delivery in the form of HMos, had been the broad basis for the Sault's program, although voluntary enrolment became impossible with medicare. As broad structural parameters they proved successful for the Sault and millions of patients in HMO programs in the United States. This genetic code probably represents the necessary and sufficient conditions for successful alternative health delivery; they are the closest one can get to a 'best alternative.' BEYOND THE GENETIC CODE

Such a genetic code falls far short, however, of defining fully the complete organization of an alternative delivery facility. Descriptions of sterile structural elements do not capture the excitement and innovation set in motion when real people from actual communities with unique needs set about translating a genetic code into a living organism. In Sault Ste Marie scores of volunteers canvassed the community to ascertain the needs and desires of participants; steelworkers became engaged in animated exchanges at the union hall, in the steel mill and in the local bar; people who had previously not known the difference between a stethoscope and a hypodermic needle discussed the relative merits of fee-for-service and capitation payment, preventive and curative health care; housewives for the first time explored the implications and nature of the doctor-patient relationship; coke-oven workers became confident that they now had trusted spokesmen in front of Workmen's Compensation boards. An entire community vibrant with the dialectic of matching their health services to their health needs was the result. The inflexible provisions of medicare snuffed out opportunities for similar exciting exercises in alternative delivery in the rest of Canada. The provision of health services which are significantly shaped by consumers became a thing of the past under machinery which established organizational clones in one community after another. The central concept of government-controlled funding of health care has never been questioned by health schemes like the one at Sault Ste Marie; indeed medicare's basic policy of spreading the financial burden of health care across society is shared by all industrialized countries (one notable exception being the United States). The manner of its introduction, however, destroyed certain essential components of health delivery, namely cost efficiency, team approaches to care, and consumer involvement. Health care reform, through the establishment of alternative delivery centres and other measures, will have to undo these harm-

175 ls There a Best Alternative? ful side-effects of our system as it is currently conceived. A way must be found to allow communities once again to experience social awareness of the type which permeated Sault Ste Marie, and to encourage delivery of high-quality care in the cost-effective manner characteristic of the Group Health Centre. Unfortunately, more than ten years of legislated support of traditional modes of fee-for-service practice have served to carve in stone the current organization of health delivery. The centre in Sault Ste Marie now stands almost alone as an example of an alternative approach in Ontario. But it is only an example: the heterogeneity factor should mean that, given a mandate to do so, communities could respond in their own way to the task of establishing alternative health care by shaping the genetic code to meet their needs. However, the entrenched nature of the current system means that any further development of alternative health delivery will depend on government taking responsibility for reorganizing the system at least enough to allow alternative plans to flourish. The genetic code could be used to define the minimum criteria and standards which must be part of the structure of alternatives; beyond this they should be free to respond to local needs and the requirements of cost efficiency. Communities could then set about establishing their own 'best alternative' under the government's broadly defined organizational criteria. As Enthoven, a U.S. health economist, has said: 'The government cannot reorganize the health care economy by direct action. People would resist such changes involuntarily imposed. And nobody can bring about such a change quickly. But the government can change the underlying economic incentives so that consumers and providers of care can benefit from forming and joining organized systems that use resources wisely. The delivery system would then be forced to reorganize itself in response to consumers who are seeking out and choosing what is in their own best interest.' 4 Once again the nation could be awakened to the possibility of shaping its own health care delivery in a manner akin to that adopted by the Canadian pioneers in Sault Ste Marie. The opportunity to restore community participation and appropriate cost incentives to the delivery of our health services seems too attractive to be missed.

Epilogue

Both the Sault Ste Marie health centre and the climate for alternative health plans in Ontario have moved forward since the 1980 conclusion of this account. With the appointment of a new medical director and the death of John Barker, the health centre has continued to grapple with the appropriate balance of powers between board and medical group. In the province, a new and sympathetic minister of health enhanced the standing of alternative health plans and rekindled an interest in community health centres. THE HEALTH CENTRE

The recognition in 1980 of the joint executive of the health centre as the appropriate decision-making body did not immediately alleviate tensions. Through 1981 and most of 1982 the tensions continued to build, the central issue being the degree of community participation. The board considered the prospect of 'starting anew' with only those physicians who felt a commitment to active community involvement; this was rejected. The medical group were adamant in their demand for greater decision-making authority, and Ferrier's position as medical director became progressively less tenable as the medical group's views diverged further from his own. Although he survived a vote of confidence in spring 1982, he resigned his position later in the year to take a sabbatical and return as 'just one of the family doctors.' In September, John Barker, who by this time had given up nearly all involvement with the centre's board, died at the age of 71. The resignation of Ferrier and the death of Barker-the chief supporter of community involvement-were symptom and symbol of change. The community input was steadily being moderated, not just because of the doctors' desires but also because of the community's acquiescence. The new medical director (Guy Barton, a radiologist), Griffith, and other members of the joint executive set about the task of redefining the meaning of community input.

178 First and Foremost That the majority of the community still regard the centre as the primary location for non-hospital care is testimony to its success. Nevertheless, it can be argued that the move to dilute community input was merely the formalization of a situation which had existed and been evolving ever since the centre's opening. The community's role certainly did become less important (or at least less relevant) in the context of medicare and a flourishing group practice of over thirty physicians. Near the end of his tenure as medical director, Ferrier noted that 'the history of the Sault Ste Marie Group Health Centre demonstrates the potential for high quality physicians to learn to work with administration and non-physician members of the community and to evolve a sharing of ... authority ... appropriate and equal to the responsibility of each.' 1 As the medical success of the centre had grown, so too had the physicians' perceptions of their responsibility. With this view of their increased responsibility, and clearly encouraged by the sight of medical colleagues within and outside Sault Ste Marie who were unencumbered by community participation, they wanted to attain an authority equal to that responsibility. For community members there were no extra-bills from physicians, no extended waiting times to see the doctor, no inadequate on-call schedules or unavailable care- i.e., none of the conditions which had prevailed in Sault Ste Marie in the 1950s and early 60s remained. Health care was satisfactory in the city, and they saw no reason to assert themselves as they had done earlier under the leadership of John Barker. The community role had not been discarded, but it was no longer realistic to think that the community could be mobilized to achieve new horizons for the delivery of care in Sault Ste Marie. Now the board finds itself better suited to the role of 'partner' with the physicians, contributing to but not solely determining the nature of already well-organized health care in the centre. Whatever the reason for the attenuation of the community's role, the provision of cost-effective and satisfactory health care for the city continues. THE CLIMATE FOR ALTERNATIVES

By 1980 the future of the largely physician-sponsored health service organizations (Hsos) in Ontario had been assured with guaranteed capitation funding. However, community health centres (cHcs) had been left with a far less certain existence. Despite the fact that few of them would be able to survive on the HSO funding mechanism, it was assumed that they too would soon be required to run on capitation or be closed down entirely. Cognizant of the need for a common voice and the sharing of information, the nineteen Hsos and thirteen CHcs met together in May 1981 at the first sym-

179 Epilogue posium on health service organizations. At the conclusion of this meeting the Association of Ontario Health Centres was formed to maintain communication. In the spring of 1982 a new minister of health, Larry Grossman, came to the portfolio with an interest in cHcs. Initial meetings with representatives of the new association were convened, and a 'Tusk Force to Review Primary Health Care' was appointed. Under the chairmanship of Dr Fraser Mustard, the task force was asked to review cHcs and Hsos and make recommendations on their role, scope, and funding. The task force deliberated through the summer of 1982 and their final report was completed at the end of the year. 2 In the meantime, Grossman committed himself to its initial recommendations. The minister provided CHCS with their long-awaited security: 'Community Health Centres will ... no longer be considered an experiment. We will no longer view them as Hsos that have not fully matured. The CHC is a distinct, different and important element in the health services systems and will receive stable and ongoing funding in the same manner as the other established elements within the system.' 3 He went on to commit the ministry to 'foster their further development ... and-where possibleremove obstacles to the development of these organizations.' Full details of this commitment were not disclosed, but the basic framework recognized the need to 'evolve a broader range of approaches to the delivery of services.' Global budgets for service packages would form the basis of funding for the cHcs, and these 'service globes' would also be available for Hsos or fee-for-service practices which could identify and provide the service with community support. However, the CHC was clearly seen as most appropriate for lower socio-economic groups: 'The Community Health Centre will ... play an increasingly important role ... particularly in relation to identified high-risk populations.' The announcement was greeted with guarded optimism by members of the association; it remains to be seen how this new policy will be effected. Only three months after this new initiative, Ray Berry's Program Development Branch was dissolved, and responsibility for cHcs and Hsos passed to a new Community Health Branch of the Ministry. To some this seemed yet another example of the erratic and tenuous commitment to alternative plans; the ministry heralded the change as part of the new commitment to a now-established program. By mid 1983 the new branch had released guidelines on the global funding of cHcs. 4 It was intended to fund up to six new cHcs and six 'service globes' attached to Hsos or fee-for-service practices, within twelve months. However, implicit in these draft guidelines were indications that cHcs were unlikely to be funded unless they located in areas with high-risk populations; organizations which could provide a currently available service more efficiently would not qualify; and community participation would not be required beyond the cen-

180 First and Foremost tres being 'open to community input.' If these draft guidelines become finalized the focus of CHCS will have been significantly altered to stress the nature of the populations served by CHCS. Current CHcs will obtain security of funding, but any future centres will have to be more concerned about who they serve than about how they provide those services. The declining role of the community in the Sault's health centre appears to have been mirrored in the province's new policies on cHcs. Just as the Group Health Centre had difficulty in defining a function for community participation in the face of a successful medical program, so too did the government in the face of successful medicare. At the Group Health Centre the introduction of medicare made the board's role as health agents for the community redundant, and left it with the task of negotiating funds; similarly, in the absence of a clear definition of the 'community' aspect of CHCS, the government defined the centres as potential recipients of a different method of funding. The introduction in 1980 of a stable funding mechanism for the alternative health plans known as Hsos (of which the Sault was one) left the government with a collection of undefined CHCS and the Sault with a community board which no longer had a defined function. In its continued search for a definition of CHCS, the government turned to the low socio-economic status (and therefore high health risk) of some cHcs' patients, and redefined CHCS by their role in serving high-risk communities. The Group Health Centre at the Sault has not yet redefined their community board's role. If the Sault responds to the government initiative, then the future role of their board would seem to be to identify high-risk groups in their community and develop special services to meet those needs. It seems, however, that the most important aspect of any future community participation in alternative health plans will be the possibility of having an independent arbiter to decide on the manner in which health resources are allocated. Implicit in the government's vacillating attraction to CHCS is the belief that the 'community' will be able to act as the 'agent' and allocate resources in an optimal fashion for the health of their citizens. The definition of CHCS as health system structures where the community humanely and unselfishly optimizes health resources is the basis of many of the expectations but few of the policies for cHcs. The government persists in defining them according to funding or population-base and not appropriate organizational structure. Without the protection of a defined role as the final arbiter, the CHCS which exist are unable to demonstrate whether they are capable of the task or not. They are also left unsure of their precise function and are largely unable to withstand the natural desire of their physicians to retain control over the allocation of the available health resources. Certainly the Sault Ste Marie and District Group

181 Epilogue Health Association is currently unsure of its function. However, it demonstrated in the early years prior to medicare that even under an adverse climate it could, with a clear mandate to be the agent of the community, improve the health resources of their city. Nevertheless, it is not possible to say whether it or other communities could reliably repeat the task; perhaps the Group Health Centre was, after all, a lucky coincidence of people, places, and time ...

Notes

CHAPTER I

2 3 4

5

6

7

According to the Department of National Health and Welfare's 1954 study of group practices there were 359 groups of three or more physicians in Canada. The Royal Commission on Health Services estimated that in 1962 less than 15 per cent of all private doctors were practising in any kind of group setting. Ted Goldberg, 'Breakthrough in Canada,' Address given to the Group Health Association of America, 1962. International Union Digest, winter 1962, 3-11 Memo from Goldberg to John Barker, 'Report on Union Health Centre,' Jan. 14, 1958 According to figures supplied by the company, in 1955 Algoma Steel employed nearly 7,000 people in a city of 48,000. Even in 1980, with an increased diversification of companies in the city, Algoma steelworks employed over 10,000 people out of the population of 80,000. In 1939 the base rate hourly wage was a meagre 41 ½ cents; after the strike, in 1947 it had jumped to 83 cents, and in the late 1950s it was almost $2.00. Between 1956 and 1964, Sault Ste Marie was always one of the top three cities in Canada in average per capita income. In four of these nine years it ranked highest. According to Statistics Canada the average per capita income in 1963 was $5,314 per year-the highest of any community in the country. C.M. 'Don' Ramsey, former president of Local 67 of the International Brotherhood of Pulp, Sulphite, and Paper Mill Workers, quoted in 50 Years of Labour in Algoma: Essays on Aspects of Algoma's Working Class History (Algoma University College, 1978) Anthony T. Barclay, ' The Group Health Centre of Sault Ste Marie,' B.A . thesis, Goddard College, 1968

184 Notes pp. 6-18 8 Including the neighbouring townships of Korab and Turentorus, which were incorporated into the city in 1964, the population was 48,490 in 1955 and 68,880 in 1963. (Data provided by the Central Statistics Services, Ministry of Treasury and Economics, Ontario.) 9 According to information received from uswA, the combined membership of the three major steelmaking locals-2251,.4509, and 5595-grew from 6,497 in 1955 to 7,595 in 1965. 10 J.A. Boan, Group Practice (Royal Commission on Health Services, Queen's Printer, Ottawa, 1966) 11 Unpublished Dominion Bureau of Statistics comparison of retail prices, Nov. 1961, quoted in correspondence from Goldberg to Wilson, 7 Feb. 1962 12 Dr Arthur A. Scott 13 Globe and Mail, 'The Doctors Back on Call,' 20 June 1981 14 Number of physicians obtained from Canadian Medical Directory; year and population figures from the Ministry of Treasury and Economics 15 Les Woodcock 16 Lou Fera 17 Sault Star, 10 July 1959 18 Ibid., 9 April 1960 19 District 6 now represents Ontario only. 20 Paul Krmpotich, A Tribute ... to the Members of Local Union 2251 (uswA, L.U. 2251, 1980) 21 Deric Johnson 22 Fera 23 Algoma Unionist, May 1957, vol. 5, no. 5 24 Letter from George Callahan, Prudential Insurance, to the president of 2251, USWA, 23 April 1957 CHAPTER 2

Memo from Ted Goldberg to Bill Mahoney, 23 Feb. 1960 2 Wright-Hargreaves' Medical Aid Plan, 'Rules and Regulations,' revised as of 1 June 1957 3 Report of C.C. (Doc) Ames, local representative, to uswA, Feb. 1960 4 R.F. Badgley and S. Wolfe, Doctors' Strike: Medical Care and Conflict in Saskatchewan (Toronto: 1967), 19 5 J.A. Allison and A.K. Gillies, 'Closed Panel Clinics,' Ontario Medical Review, Jan. 1961 6 Plan/or Health (the quarterly newsletter of the Kaiser Foundation Health Plan), Summer 1958, vol. m, no. 2

185 Notes pp. 19-27 7 Articles of Incorporation, GHAA, 1959 8 'Report of the Committee Established to Investigate Organizing a Union Health Centre,' 16 Jan. 1958 9 21 Feb. 1958 IO Resolution adopted at Canadian National Policy Conference, uswA, Winnipeg, April 1958 (my italics) 11 Resolution adopted at the 9th Constitutional Convention, uswA, Atlant_ic City, New Jersey, Sept. 1958. In response to the resolution lg Falk produced the 'Special Study on the Medical Care Program for Steelworkers and Their Families,' in Sept. 1960 12 Information about this attempt comes from a summary of the Toronto development prepared by Goldberg for Falk, dated 19 July 1960. The executive was not appointed until September 1959, but during late 1958 and early 1959 Goldberg had started the initial contacts and co-ordination which led to the formal incorporation of the Toronto Labour Health Centre Organizing Committee in September. 13 15 June 1959 14 Falk, 'Exploration of Local Union 2251 Interest in Developing a Group Practice Prepayment Plan at Sault Ste Marie, Ontario' (internal memo), 4 March 1960 15 Amended motion of Local 2251 regular membership meeting, 6 April 1960. The original motion, passed on 20 Jan. 1960, included a check-off for funds for a new union hall made necessary by the proposed demolition of the old hall to make way for an international bridge. The amended motion separated these two building funds. 16 Memo, 4 March 1960 17 Northern Daily News, 'Unethical, Says OMS of Old Medical Plan,' 1 Feb. 1960 18 28 March 1960 19 Letter from Barker to Larry Sefton, 31 March 1960 20 Dr Walter A. Zaharuk 21 Dr Arthur A. Scott 22 OMA, Minutes of Council, May 1960 23 The original proposals by the OMA included an invitation to Algoma Steel Corporation but they, as well as the union, did not feel that company attendance was appropriate. 24 Telegram, 'Ads Add to Labour-MD Tilt,' 9 May 1960 25 'Canadian Labour's Approach to Providing Comprehensive Health Services through Organized Health Centres,' 93rd Annual Meeting of the cMA, 16 June 1960 26 Draft minutes, OMA Board of Executive meeting with uswA representatives, Sault Ste Marie, 8 July 1960. The executive were in the process of formulating their policy with a fact-finding trip.

186 Notes pp. 28-38 27 'Report of the Special Committee on Medical Care and Practice,' OMA, Minutes of Council, May 1961 28 'Report of the Special Committee,' (my italics). This policy is an interesting contrast with the oMA's behaviour at the introduction of government health insurance later in the 1960s. By then their interpretation of freedom of choice had narrowed to mean choice between all individual physicians; the choice of a 'group' of physicians had no standing by then. 29 Globe and Mail, 23 March 1961 30 The OMA no doubt remembered that all of the Sault Ste Marie Medical Society had opted out of the OMA insurance plan in 1958. 31 Sault Star, 'Ontario Doctors Critical of Steel Union Medical Plan,' 10 May 1961 32 Dr Arthur A. Scott 33 Lachlan Hallam 34 The results of the questionnaire were never formally published; the data used here were quoted in various budget planning documents circulated among Falk, Wilson, and Goldberg, especially in a letter from Wilson to Falk on 27 Oct. 1961. 35 Contract negotiations between union and management generally focus on this 'cents per hour' figure; the negotiations produce a certain number of cents per hour increase which the union can distribute any way it likes. In this case the minimum figure of 7 cents reflected coverage just for dependants as defined by PSI, i.e., spouse and unmarried children under 19 years. In fact the health centre was to cover all persons defined as dependants on income tax returns. The difference between these two definitions was the difference between the figures of 2.6 and 3.25 average dependants per employee. 36 20 Oct. 1961 37 Medical care section of USWA Local 225l's brief to conciliation board, 14 Nov. 1961 (my italics) 38 Deric Johnson 39 All details of this agreement are taken from Appendix c of the Algoma Steel Corporation and Local 2251 'Memorandum of Understanding,' 27 Nov. 1961 CHAPTER

2 3 4

5

3

Memo by Ted Goldberg, 'Summary of Meeting Regarding the Establishment of the Sault Ste Marie Health Centre,' 21 Dec. 1961 Letter from Glenn Wilson to I.S. Falk, 1 Dec. 1961 Wilson, 'Progress Report, Sault Program,' Feb. 1962 16 Feb. 1961 'Program for the Group Health Centre, Sault Ste Marie,' Feb. 1962

187 Notes pp. 39-52 6 'Current status of Sault Group Health Centre,' March 1962 7 Letter to Glenn I. Sawyer, general secretary of the OMA, 5 March 1962 8 'Report on the Status of the Group Health Centre for Sault Ste Marie,' 5 April 1962 9 Letter to Cecil G. Shepps, Professor of Medical and Surgical Administration, University of Pittsburgh, 18 Jan. 1962 10 Sault Star, 21 July 1962 11 Letter from Dr Arthur A. Scott, president of Sault Ste Marie Medical Society, to J.S. Arthur, director of Prudential Insurance Company of America, 16 May 1962 12 Decision of Ontario Municipal Board, A.H. Arre!! Vice-Chairman, Toronto, 23 July 1962 13 Sault Star, 25 July 1962 14 Sault Star, letter to the editor, 2 Aug. 1962 15 Memo to J.F. Tomayko, Pittsburgh, 17 Aug. 1962 16 Dr Walter A. Zaharuk 17 Sault Star, 13 Sept. 1962 18 Dr Hastings was also, at that time, the consultant for the Toronto Labour Council's attempt to start a health centre. He was in the process of writing a feasibility report in 1962. 19 Most of these votes, it should be pointed out, had taken place not in isolated communities like Sault Ste Marie, but in larger urban areas. Also they often did not require complete re-selection, i.e., if you didn't bother to vote you stayed with the old plan, which meant that the status quo was heavily favoured. CHAPTER 4

2 3 4

5 6 7 8 9 10

The association's first employee-Carole Parton-was still employed as assistant to the medical director in 1980. Memo to health centre organizers, 22 Oct. 1962 Dr Walter A. Zaharuk, quoted in Globe and Mail, 23 March 1963 'Unusual Opportunity for Physicians Interested in Group Practice' (brochure prepared for recruitment), Oct. 1962 Memo from Tom Ferrier, 'Conversations with Local Doctors,' Oct. 1962 25 Feb. 1963 28 Feb. 1963 Letter from J.C.C. Dawson, Registrar of the College of Physicians and Surgeons of Ontario, 24 April 1963 22 May 1963 Canadian Medical Association Journal, 'News and Views,' 19 Jan. 1963

188 Notes pp. 52-66 11 30 Jan. 1963 12 Dr A. Sinclair 13 The same argument is made by organized medicine today with regard to the government's role in funding medical services. The maintenance of fee-forservice payment is seen as crucial in ensuring that the government remains only as paymaster and does not encroach on how or when the doctor and patient will interact. 14 Dr Walter A. Zaharuk, quoted in Globe and Mail, 23 March 1963 15 Sault Star, 24 Sept. 1962 16 Deric Johnson 17 Letter from Ferrier to Glenn Wilson, 20 March 1963 18 Memo to 'File of the Sault Ste Marie Medical Society,' 7 March 1963 19 Carruthers Clinic Limited v. Herdman, Ontario Reports, 1956, 52, 770 20 Letter from Jolliffe, Lewis and Osler, lawyers, to Thomas P. Callon, QC, lawyer for medical director applicant Dr George Morrison, 19 July 1962 21 The omission of the office workers of Local 4509 from representation on the board lasted only until 1968. The board minutes of 24 June 1968 recorded a bylaw change that incorporated the president of Local 4509 as a board member. 22 Letter from Jolliffe, Lewis, and Osler to Goldberg, 25 July 1962 23 Letter from Jolliffe, Lewis, and Osler to F.H. Silversides, the health centre administrator, 24 June 1963 24 Globe and Mail, 14 Jan. 1963 25 14 Jan. 1963 26 Submission of the Sault Ste Marie and District Group Health Association to the Ontario Medical Services Insurance Inquiry, Dec. 1963 21 Globe and Mail, 23 March 1963 28 Transcript of CBC program 'Seven-O-One', 27 Aug. 1963 29 Official Address, Opening of Sault Ste Marie and District Group Health Centre, 4 Oct. 1963 30 Sault Star, 1 Oct. 1963 CHAPTER

5

Minutes of medical staff meeting, 8 Oct. 1963 2 Minutes of medical staff executive meeting, 8 July 1966 3 Minutes of medical staff meeting, 19 May 1964 4 Memo by Fred Griffith and Glenn Wilson to board executive committee on 'Meeting with Medical Group,' 5 Oct. 1965 5 Minutes of the Sault Ste Marie and District Group Health Association, board of directors meeting, no. 65-20, 24 Nov. 1965

189 Notes pp. 66-75

6 Dr Simon Marinker 7 Dr A.B. Sinclair, 'Recommendation to the Medical Staff,' 11 Aug. 1966 8 Policy statement of board executive committee of Sault Ste Marie and District Group Health Association, 19 Aug. 1966 9 Griffith, 'Notes on a meeting held at 8:00 p.m., 25 Aug. 1966, in the Board Room, Plummer Memorial Public Hospital.' 10 Minutes of the Sault Ste Marie and District Group Health Association, board of directors meeting, no. 67-24, 27 Jan. 1967 11 This study, 'The Organization of Services for a Better Use of Resources in a Group Practice Setting,' was later presented by Ferrier at the annual meeting of the Canadian Public Health Association, 26 April 1967. 12 Donald C. MacDonald, Legislature of Ontario, Debates, 3 May 1%6, p. 3025 13 J.E.F. Hastings, F.D. Mott, A. Barclay, and D. Hewitt, 'Prepaid Group Practice in Sault Ste Marie, Ontario: Part 1: Analysis of Utilization Records,' Medical Care, vol. 11, no. 2 (March-April 1973) 14 Dr RW. Elgie, secretary of Sault Ste Marie Medical Society, to Dr R.G. Martin, health centre physician, 14 Feb. 1965 15 Letter from A.K. Gillies, executive secretary of the OMA, to Dr R.G. Martin, 26 May 1965 16 G.H. DeFriese, 'Community Health Centres and Private Solo Practice under Universal Health Insurance: The Consumer's View. The Sault Ste Marie Community Health Survey of 1973.' Final Project Report to the Minister of National Health and Welfare, May 1974 17 Draft Jetter, Ferrier to Glenn I. Sawyer, secretary of the OMA, 3 March 1965 18 Dr David Gould 19 26 May 1967 20 Letter from Dr R.A. Mengebier to Ferrier, 2 July 1965 21 Memo from Ferrier to board of directors, Sault Ste Marie and District Group Health Association 'Status of the Program from the Point of View of the Medical Group,' 9 May 1968. The high turnover ensured that the group had to spend a lot of time recruiting new physicians. This was taking place in a market with low supply and high demand. It is hardly surprising, therefore, that niceties such as 'the correct philosophy' or 'group practice experience' went by the board in the face of pressing needs for physicians to meet the commitment to a subscriber population. This, unfortunately, only served to perpetuate the turnover, as incompatible doctors tended to be weeded out on the job rather than pre-screened before arrival. 22 Dr R.A. Mengebier to Ferrier, 2 July 1965 23 Letter to the board of directors, Sault Ste Marie and District Group Health Association, 9 May 1968

190 Notes pp. 75-87 24 Memo of telephone conversation between Ferrier and officers of the Sault Ste Marie Medical Society, 8 Aug. 1968 25 Dr A. Sinclair 26 Submission from Algoma District Medical Group to J.C.C. Dawson, registrar, College of Physicians and Surgeons of Ontario, 16 Oct. 1968 27 Letter from Dawson to Ferrier, IO Dec. 1968 28 Joint declaration by Sault Ste Marie Medical Society and Algoma District Medical Group, 29 Jan. 1970 CHAPTER

6

I 3 Dec. 1969 2 Advertising restrictions had been used by the Saskatchewan College of Physicians and Surgeons against the community health centres in that province. They became quite successful in intimidating physicians to the point where few wanted to brave the hostilities concomitant to working in such health centres. Eventually, representatives of the centres successfully challenged the Saskatchewan College in the courts on this advertising issue. 3 24 June 1969 4 Bessie Weatherhead 5 Letter to John Barker, Gordon Milling, Fred Griffith, and Tom Ferrier, 13 May 1968 6 The main examples of these were the Hagey Committee, 'Ontario Medical Services Insurance Inquiry,' in Dec. 1963, and the Committee on the Healing Arts in 1967. 7 Memo from Ferrier to board of directors, Sault Ste Marie and District Group Health Association, 9 May 1968 8 Ibid. 9 Minutes of the board of directors meeting, Sault Ste Marie and District Group Health Association, IO April 1969 IO Memo, 9 May 1968 ll Dr David Gould 12 F.H. Griffith, 'Problems of a Clinic Manager,' 1971 l3 Sault Star, 'Medicare May Kill Sault Group Health Plan,' 31 Oct. 1967 14 Memo from Ferrier to Griffith, 'Medical Group's Current Position on Capitation from the Provincial Medical Care Scheme,' 27 June 1969 15 Memo, 'Medical Group Position on Capitation plus Payment for Services Otherwise Provided in Hospital,' 17 Oct. 1969 16 Ontario Health Services Insurance Act, 1969, section 20 17 Clare Papineau 18 Minutes of Algoma District Medical Group, partnership meeting, 30 Oct. 1969

191 Notes pp. 88-101 19 Memorandum of understanding between Sault Ste Marie and District Group Health Association and Algoma District Medical Group, Nov. 1969 20 Ontario Health Services Insurance Act, 1969, section 15 21 It was true that the introduction of inter-selection in 1966 had ostensibly granted patients the right to see any doctor and be paid for it without a referral. However, inter-selection was never openly advertised and, furthermore, a condition of exercising such a right was to opt out of the health centre at the next dual choice. 22 Financial plan of the Group Health Centre, 1975-76. 23 Brief to the Ministry of Health from Sault Ste Marie and District Group Health Association, 1972 24 Letter from Barker to retired subscribers, 22 May 1970 25 Indeed the World Health Organization study of Hastings et al did show clearly that hospitalization rates for discretionary operations by the fee-for-service doctors were far higher than those for health centre doctors. In the case of tonsillectomy and adenoidectomy there was a rate of 26.7 / 1,000 children under 14 for solo-practice doctors and only 8.8/ 1,000 for health centre doctors. 26 Brief to Dennis R. Timbrell, minister of health, 21 Sept. 1979 CHAPTER 7

1 Letter from Fred Griffith to subscribers, 29 March 1971 2 G.H. DeFriese, 'Community Health Centres and Private Solo Practice under Universal Health Insurance: The Consumer's View. The Sault Ste Marie Community Health Survey of 1973.' Final Project Report to the Minister of National Health and Welfare, May 1974 3 Minutes of board of directors meeting, Sault Ste Marie and District Group Health Association, 20 Dec. 1973 4 13 Feb. 1973 5 Memo from Glenn Wilson to Griffith, 'A proposal to provide medical services in northern Algoma and remote communities,' 5 March 1979 6 Letter from Griffith to Dennis Timbrell, Minister of Health, 3 Oct. 1977 7 Griffith, 'Entering our Fifteenth Year,' June 1977 8 Draft regulations under Health Disciplines Act, 1975 (Denistry), section 16 (ii) and (iii) 9 More recently the College of Dental Surgeons tried to restrict further the boundaries of 'ethical practice' with a regulation outlawing prepayment for dental services. They used the time-worn argument that such prepayment plans would not allow patients free choice of dentist. See Toronto Star, 'Dentists Fight Prepaid Care,' 27 Jan. 1981. 10 Dr Eleanor Hogg-Kuntz

192 Notes pp. 102-10 11 Minutes of board of directors meeting, Sault Ste Marie and District Group Health Association, 16 Nov. 1977 12 Dr David Walde 13 Executive Committee Minutes, Algoma District Medical Group, 22 May 1973 14 Ibid., 21 Sept. 1971 15 Ibid., 4 Jan. 1972 16 24 Sept. 1980 17 Minutes of board of directors meeting, Sault Ste Marie and District Group Health Association, 23 Dec. 1980 CHAPTER

2

3 4

5

6 7 8

8

The Castonguay-Nepveu Commission was appointed by the Quebec government in 1966 to look into the entire field of health and social welfare. It produced a number of reports between 1967 and 1972 which formed the basis of Quebec's entry to medicare as well as the development of its social health policy in the 1970s. 'The Community Health Centre in Canada,' report of the Community Health Centre Project to the Health Ministers. Ministry of Health and Welfare, Ottawa, July 1972 Globe and Mail, 'Province Won't Aid in Building Ottawa Health Centre: Potter,' 12 Oct. 1972 Potter's attitude increased the fear that a failure at St Catharines could destroy any government commitment to the Sault as well. At this time, St Catharines was having difficulty controlling the cost of their outside services, and consequently funding through capitation was not proving viable. In April the following year, they adopted a cost-reimbursement budget similar to hospital funding, which helped the outside services problem but restricted flexibility and opportunities for innovation. The Sault, by contrast, was entirely viable on capitation but labouring under some of the problems caused by government's inadequate understanding of cttc's needs. Potter, publicly at least, simplistically lumped the two centres together, with both being of 'questionable success' to him. These centres were: Student Health Organization, University of Toronto; Centretown Health Centre, Ottawa; St Anne's Clinic, Ottawa; St George Health Centre, Toronto; Springhurst Community Health Centre; St Mary's Medical Clinic; Regent Park Community Health Centre, Toronto; Charlton Family Health Centre, Hamilton; Flemingdon Health Centre, Toronto. Bessie Weatherhead Tom Greer The term HSO was used interchangeably with CHC until 1979, despite the fact that

193 Notes pp. lll-19 many of the Hsos had no real consumer sponsorship or community board. 9 Bessie Weatherhead 10 'Chronology of Major Events Associated with Health Service Organizations' Developments,' Program Development Branch, Ontario Ministry of Health, April 1981 11 In the early 1970s the Sault had been required to pay the full cost of such outside services, despite the fact that they had no means of controlling such utilization. 12 The twenty-six remaining centres were: Cardiff and Area Health Centre; Centretown Community Health Clinic, Ottawa; Lakeshore Area Multi-Service Project, Toronto; Lawrence Heights Medical Centre, Toronto; Dalhousie Community Services Centre, Ottawa; South Riverdale Community Health Centre, Toronto; York Community Services, Toronto; Clinique Ste Anne, Ottawa; Don District Community Health Centre, Ottawa; Flemingdon Health Centre, Toronto; Regent Park Community Health Centre, Toronto; Sandy Hill Community Health Centre, Ottawa; Sault Ste Marie Group Health Centre; West Central Health Centre, Toronto; Boyden Medical Centre, Toronto; Caroline Medical Group, Burlington; Charlton Family Health Centre, Hamilton; Dundas Family Medical Group; East Hamilton Medical Group; D.W. McLean M.D., Hamilton; Medical Associates, Parry Sound; Mount Forest Medical Clinic; St George Health Centre, Toronto; St Mary's Medical Clinic; Sharbot Lake Family Medical Centre; Wilmot Medical Centre, Hamilton. 13 Minutes of board of directors meeting, Sault Ste Marie and District Group Health Association, 22 June 1978 14 J.E.F. Hastings, 'Community Health Centres-What's Happened since the Hastings Report? Neither Sweet Nor Sour' (paper delivered at 19th Annual Refresher Course; Issues in Community Health, Toronto), 7 March 1978 15 Draft letter to Ray Berry, director, Program Development Branch, Ontario Ministry of Health, 1979 16 25 Jan. 1971 17 Negotiating document for Ministry of Health, Sault Ste Marie and District Group Health Association, Sept. 1972 18 Ministry of Health memo from E.V. Margetts, secretary, Ministry Programmes Committee, to H.I. MacKillop, director, Special Projects, 10 Nov. 1972 19 'Initial Policy Proposals for the Community Health Services Project' (draft discussion paper no. 2), Program Development and Implementation Group, 29 March 1974 20 Griffith, lecture delivered at 19th Annual Refresher Course; Toronto, 6 March 1978 21 The deliberations of the Ontario Council of Health on this issue were eventually

194 Notes pp. 120-43 published, although the recommendations were not adopted by government: W.O. Spitzer, et al., 'Evaluating New Methods for Provision of Primary Care: An Ontario Strategy', Medical Care, vol. 16, (1978), 560. 22 Griffith, lecture, 6 March 1978 23 To Phil Bostelaar, president of the Board of Sault Ste Marie and District Group Health Association, 11 May 1978 CHAPTER 9

1 Bernard R. Blishen, Doctors and Doctrines (Toronto 1969), 159 2 ibid., 174 3 'Study of Career Choices in Professional Schools,' University of British Columbia, unknown source, 1971 4 The right to opt out of provincial health insurance plans has been fiercely defended of late, in the face of growing opposition by the federal government, consumer groups, and various recent commissioned reports. The profession has gone as far as threatening to engage in industrial action to answer attempts to remove this provision from medicare legislation. 5 'Group Practice in Canada,' report of the Special Committee on Group Practice with Additional Guest Articles (cMA 1967), 34 6 Joseph L. Falkson, HMOs and the Politics of Health System Reform (American Hospital Association, Robert J. Brady Co., 1980), 20 7 Blishen, Doctors and Doctrines, 64 8 'Group Practice in Canada,' 34 9 Falkson, HMos, 21 CHAPTER IO

1 Letter to John Barker, 1 Feb. 1972 2 David Road, 'Medical Staff Community Board Relationships' (unpublished manuscript), March 1975. See also T. Kue Young, 'Lay-Professional Conflict in a Canadian Community Health Center,' Medical Care, vol. 13 (Nov. 1975), 897, for further discussion of the Regina Clinic problems. 3 Rudolf Klein, 'Notes toward a Theory of Patient Involvement' (commissioned paper for the Community Health Centre Project), 1972 4 Fred Griffith, 'Problems of a Clinic Manager' (commissioned paper for the Community Health Centre Project), 1972 5 Elements of this example are based on a real situation. The community is Riverdale in Toronto and the factory, the Canada Metals Plant, has recently been forced to improve its pollution controls after years of pressure from the South Riverdale Community Health Centre Lead Committee.

195 Notes pp 144-54 6 Ironically, the contrast between free choice of physician and dual choice of health delivery plan reflects this approach. Moment-to-moment free choice encourages the consumer to join the provider in making decisions on health utilization at the level of each individual encounter. Dual choice recognizes the severe limitations placed on consumers at this 'micro' level which preclude truly informed choice. It proposes, instead, that consumers exercise their option where they are most able to make accurate judgements, i.e., at the level of the type of delivery mechanism. 7 J.G. Cibulka, 'Citizen Participation in the Governance of Community Mental Health Centres,' Community Mental Health Journal, vol. 17, no. 1 (spring 1981), 20

8 B. Checkoway and M. Doyle, 'Community Organizing Lessons for Health Care Consumers,' Journal of Health Politics, Policy and law, vol. 5, no. 2 (summer 1980), 224 9 D.R. Keating, The Power to Make It Happen (Toronto 1976), 136 10 For a description of how providers and administrators can pervert the electoral

process see B. Checkoway, 'The Empire Strikes Back: More Lessons for Health Care Consumers,' Journal of Health Politics, Policy and law, vol. 7, no. 1 (Spring 1982), lll-24. 11 M. Lalonde, A New Perspective on the Health of Canadians (Ottawa, Ministry of Health and Welfare, 1974). In fact this point has been made forcefully by others before Lalonde, most notably by the British academic Thomas McKeown in his book, The Role of Medicine: Dream, Mirage or Nemesis? (Princeton 1979). CHAPTER I I

2

3 4

5

Between 1969 and 1972 the yearly per capita expenditure on health services in nearly all ten provinces more than doubled. In Ontario they moved from just over $100 to nearly $250 per person. By 1975 Canada was using nearly 2,500 bed-days per 1,000 people each year. This compared with just under 2,000 for the United States and fewer than 1,500 for the United Kingdom. 'Report of the Health Planning Task Force,' Ontario Ministry of Health, 1974 Earlier attempts in 1976 to close some hospitals had met with such public outrage in the affected communities that the decisions were rescinded. The new 'bed ratios' approach was a more subtle way of achieving the same ends without such a clear issue for local communities to address. It is difficult to know to what degree services were really increased, as opposed to the same number of services being expressed as a greater number of 'claims.' As the fee schedules which are used to pay physicians have evolved, the sophistica-

196 Notes pp. 154-63

6 7 8 9 10

11 12

tion with which each service has come to be broken down into a number of 'subservices,' each representing a 'claim' to the provincial paymaster, has increased significantly. To date there has been no extensive study of the structure of fee schedules which could give an accurate idea of the real increase in services, as opposed to the artifactual increase in claims. Speech by Dennis Timbrell, Ontario Minister of Health, Ottawa, 11 Sept. 1981 J.L. Falkson, HMOs and the Politics of Health System Reform (American Hospital Association, Robert J. Brady Co., 1980), 27 E. Saward and S. Fleming, 'Health Maintenance Organizations,' Scientific American, vol. 243 (Oct. 1980), 50 Falkson, HMOs, 31-2 But see J. Lomas, and G.L. Stoddart, 'Physician Manpower under Competing Health Plans: Where We Could Be, Where We Are and Issues in Getting From Here to There,' Research paper no. 3 (Council of Ontario Universities Tusk Force on Physician Manpower, May 1982). E. Vayda, 'Prepaid Group Practice under Universal Health Insurance in Canada,' Medical Care, vol. 15, (May 1977), 385 G.L. Stoddart, 'Paying for Health Care: The Canadian Perspective Today,' (address given to symposium on Health Service Organizations: 'Alternatives in Health Care,') Hamilton, Ont., 1 May 1981

CHAPTER 12

B. Hall, A. Etherington, and T. Jackson, 'Evaluation, Participation and Com-

2 3 4

5

6

munity Health Care: Critique and Lessons,' (paper delivered to American Public Health Association, Nov. 1979) Tom Greer 'Health Service Organizations,' Program Development Branch, Ontario Ministry of Health, 25 July 1977 F.H. Griffith at 19th Annual Refresher Course: Continuing Education in Community Health, University of Toronto, 6 March 1978 The entire alternative delivery system in Ontario has only once been brought into full public scrutiny as a consequence of a Public Accounts Committee investigation into the apparently excessive cost of one particular nso. See Toronto Star, 'Doctors Paid Thousands for Patients They Didn't See,' 8 April 1980. Ontario's 1974 report of the Health Planning Tusk Force recommended a ratio of 100:29 for distribution of research funds for medical versus organizational investigation. The 1981/82 ratio shows significant shortfall in this recommended ratio.

197 Notes pp. 165-79 7 For further discussion and evidence of this 'ripple effect' see Group Health News, vol. 20, no. 11 (Nov. 1979): 'HMos May Be Influencing Fee-For-Service Physicians in 1\vin Cities,' Also L. Kane, 'Health Care lrends in Minneapolis-St. Paul: Summary Highlights,' Interstudy Report, Aug. 1979. 8 Tom Greer 9 'Health Service Organizations' 10 J.E.F. Hastings et al, 'Prepaid Group Practice in Sault Ste Marie, Ontario: Part I: Analysis of Utilization Records,' Medical Care, vol. 11, no. 2, (1973), 102 11 Hastings commented that the Glazier investigation was 'an apples, oranges and prunes comparison.' For further discussion of the shortcomings of the study, see chap. 8 above. 12 For further discussion of these comparisons, see Harold S. Luft, Health Maintenance Organizations: Dimensions of Performance (New York 1981). CHAPTER 13 CMA 'Group Practice in Canada' (Toronto 1967); Task Force Report, The Cost of Health Services in Canada, vols. 1-m (Ottawa 1969); Report of the Committee on the Healing Arts (Toronto 1970); Report of the Special Study regarding the Medical Profession in Ontario (Toronto: OMA 1973); Science for Health Services (Ottawa: Science Council 1974); Report of the Health Planning Task Force (Toronto 1974); Issues and Alternatives-Health (Toronto: Ontario Economic Council 1976); Final Report of the Task Force to Review Primary Health Care (Toronto 1982) 2 Issues and Alternatives-Health, 35 3 Ernest W. Saward, 'The Relevance of Prepaid Group Practice to the Effective Delivery of Health Services,' (paper presented to the 18th Annual Group Health Institute, Sault Ste Marie, June 1969) 4 Alain Enthoven, 'Consumer-Choice Health Plan,' New England Journal of Medicine, vol. 298 (1978), 709

EPILOGUE

1 Letter to the author, 5 Nov. 1981 2 Final Report of the Task Force to Review Primary Health Care (Toronto: 1982) 3 'Ontario Health Centres-An Idea Whose Time Has Come,' remarks by Larry Grossman, Minister of Health, to the Annual Symposium of the Association of Ontario Health Centres, 28 Oct. 1982 4 'Development of Policy and Procedural Guidelines for the Community Health Centre Program', May 1983

Interviews

The following interviews were conducted in preparation for Part One of the book: UNITED STEELWORKERS OF AMERICA

John Barker 8 April 1980, 24 March 81 Lauchlan Hallam 14 April 80 John Ferris 7 Nov. 80, 24 March 81 Ted Goldberg 20 and 21 Jan. 81 Paul Krmpotich 17 Oct. 80 Clare Papineau 7 Nov. 80 Les Woodcock 5 Nov. 81 Jack Ostroski 27 Jan. 81 Tony Bradley 17 Feb. 81 Dr. I.S. (lg) Falk 22 Jan. 81 C.C. (Doc) Ames 16 Feb. 81 SAULT STE MARIE AND DISTRICT GROUP HEALTH ASSOCIATION

Fred Griffiths various dates from Oct. 80 to March 81 Glenn Wilson 6 and 7 Jan. 81 Carole Parton various dates from Oct. 80 to March 81 Ruth Therien various dates from Oct. 80 to March 81 Karen Scott 10 Nov. 80 Bishop Frank Nock 7 Nov. 80 Phil Bostelaar 14 Jan. 81 Ian Hollingsworth 11 Feb. 81 John Harwood 7 Nov. 80

200 Interviews ALGOMA DISTRICT MEDICAL GROUP

Dr Tom Ferrier various dates from Oct. 80 to March 81 Dr Simon Marinker 20 March 81 Dr David Walde 21 March 81 Dr Eleanor Hogg-Kuntz 23 March 81 Dr Mike Kuntz 23 March 81 Dr Bob Martin 23 March 81 Dr David Gould 24 March 81 SAULT STE MARIE MEDICAL SOCIETY

Dr Alexander Sinclair 4 Nov. 80 Dr Walter A. Zaharuk 10 Feb. 81 Dr Arthur A. Scott 21 April 81 ALGOMA STEEL

Nigel Kensit 4 Nov. 80 John Mislan 18 Feb. 81 Deric Johnson 18 Feb. 81 Lou Fera 12 Feb. 81 Dr David Cowan 7 Nov. 80 ONTARIO MINISTRY OF HEALTH

Dr Jack Aldis 4 Feb. 81 Glen Simpson 2 June 81 Bessie Weatherhead 10 March 81 Tom Greer 26 Jan. 81 Dr Ray Berry 17 Feb. 81 Dr. H.I. (Mac) MacKillop 17 Feb. 81 PRUDENTIAL INSURANCE COMPANY

John Arthur John Kirk Glenn Sawyer, Ontario Medical Association 13 Nov. 80 Jerome Markson, architect 10 March 81 Dr John Hastings, University of Toronto 16 Feb. 81 Tony Barclay, University of Toronto 5 May 81 Hon. Arthur A. Wishart, Plummer Hospital Board 28 April 81 Dr George Morrison, Thunder Bay 12 Feb. 81 Peter Neelands, Kirkland Lake 15 Feb. 81

Index

Aldis, John 109 Algoma District Medical Group: formation of 64-6; and fee-for-service practice 69, 80-1, 84-7; positions on local committees 72, 96; referrals from local physicians 73, 76, 83, 128; and anaesthesia crisis 75-7; and medicare's introduction 82-6; productivity points system 83-4, 102-3, 132; after medicare 102-5 Algoma Steel Corporation 5, 8, 13, 54, 69, 138; contract negotiations 22, 34-5 Algoma West Academy of Medicine 93, 100; as Algoma District Medical Academy 76 Anaesthesia Crisis 66-7, 70, 75-7, 82-3 Association of Ontario Health Centres 179 Barker, John; personality 12; before the health centre 5, ll, 12; initial organizing for the centre 4, 20-4, 30-1, 33, 37-8, 40, 46, 58; selection of site 32, 38, 41, 44, 45; conference presentations 40, 78; relationship to physicians 56, 64-5, 105; as president of centre's board 64, 68, 70, 78, 101;

introduction of medicare 93; community health centre project committee 107; death of 177 Barton, Guy 177 Berry, Ray ll2-14, ll9, 120, 179 Bostelaar, Phil 101, 121

Canadian Medical Association (CMA) 27, 28, 39, 52, 72, 129, 131, 134, 172 Capitation 81, 85-6, 89-91, ll2, ll3, 153, 156, 172, 173; flexibility of 98, 133; size of payment ll7, 118, 121-2; enrolled population 117, 118, 121-2 Castonguay-Nepveu Commission 107, 137 Clergue, Hector 5, 6 Closed panel clinics 24-5, 27, 28, 74 College of Physicians and Surgeons of Ontario: and physician contracts 44, 51; and advertising restrictions 51, 79, 133, 134, 157; role in anaesthesia crisis, 75-7, 78 Community boards 128, 131, 137-49, 154, 158-9, 165-6, 173, 180-1 Co-operative Commonwealth Federation (CCF) 16, 26, 27

202 Index Dental care 99, 105, 134, 135, 157 Dual choice: negotiation of 34-5; election campaign 37-40, 43, 45 -8, 55; yearly availability 66-7, 69, 70; under medicare 90, 116 Dunn, Sir James 5, 6 Enthoven, Alain 175 Expansion 80, 84, 93, 94-100, 142 Falk, Isadore 19, 21, 23-4, 31; report on the Sault 24; search for medical director 36, 40; resignation of 46 Ferrier, Tom: initial contact 31, 40-1; selection as medical director 45, 46; activities before centre opens 49-52, 54; hiring group physicians 50-1, 79; relationship to board 64, 68, 79, 140; and anaesthesia crisis 67, 75-6; and medicare's introduction 82-7 passim; relationship with Griffith 104-5; resignation of 177 Ferris, John 12, 23, 31 General Hospital 8, 55, 96 Glazier Clinic: comparison with Sault 118-19, 162, 167 Goldberg, Ted: personality and background 19; with United Steelworkers of America 20-3, 27, 36, 39, 46; legal structure of centre 41, 56-9; with United Auto Workers 59, 71, 79, 80 71, 79, 80 Griffith, Fred 69-9; initial encounter 43; and anaesthesia crisis 67; on philosophy of centre 79, 84, 94; relationship to board 79, 80, 92, 101-2, 103; negotiations around medicare's introduction 80-2, 85-8; relationship with Ferrier 104-5; deal-

ings with ministry 115-16, 118, 120 Grossman, Larry 179 Group Health Association of America 19, 31, 41, 59, 71 Group practice: early development 3, 16-19; advantages of 7, 62, 95, 164, 167-8, 172, 173; disadvantages of 63, 74, 95, 134, 167-8; in the United States 18-19, 43, 131; physician employment structure 43, 56, 64; and hospital utilization 70-1, 91-2, 119; under medicare 81, 87, 155 Harwood, John 79, 92, 120 Hastings, John 47; wuo study of centre 71, 77, 119; community health centre project 107-9, 113, 138, 153, 173 Health maintenance organizations 155, 156, 158, 167-8, 173, 174 Health service organizations: replacement term for cues 110, 110n, 120; development of 112-14, 118, 120-2, 162, 166, 178-9 Hollingsworth, Ian 54, 57 Individual practice associations 168; in San Joaquin Valley 135 International Nickel Company (INCO) 16, 27, 29, 138 Joint executive committee: formation of 88; and financial negotiations 100, 102, 104; as physician-board focus 103-5, 177 Kirkland Lake 17, 25 Klein, Rudolf 142, 143 MacKillop, H.I. 112, 117, 119-20

203 Index Mahoney, Bill ll, 20, 22-3, 31, 56, 79 Marinker, Simon 54, 62, 76 Markson, Jerome 38 Medical services agreement 65, 80, 139 Medicare: early announcement of 57, 69-70, 80; introduction of 86-92; free choice provisions of 88-90, 92, ll2, 113, 116, 127-8, 150-1, 156-7 Miller, Frank ll0 Morrison, George 41-2, 43, 44 Mustard, Fraser 179 New Democratic Party NDP 70-1, 153 Nock, Frank 46, 50, 52, 57, 121 Nurse practitioners 96-8, 152 O'Leary, Monsignor J.J. 46, 50, 52, 57, 79 Ontario Council of Health lll, ll9 Ontario Economic Council 172 Ontario Health Insurance Plan (OHIP) 109; and individual identifiers 91 , 117, 165; and ambulatory care incentive payments 91-2, 112, 114, ll6, 118, 121-2, 152 Ontario Health Services Insurance Plan 86, 109 Ontario Hospital Services Commission 71, 86, 88 Ontario Medical Association (OMA): Physicians' Services Incorporated (PSI) 8, 33, 42, 54, 57, 128; attitude to closed panel clinics 18-19, 27, 28, 29, 44; as mediator 27-30, 39, 47, 134; affiliates of 73, 76 Ontario Ministry of Health: program development and implementation group (PDIG) 109-ll, 113, ll7, ll9-20, 133, 152, 163, 165; special projects

branch 109-11, ll7; data development and evaluation branch lll; program development branch ll2, ll9, 179; community health branch 179; dealings with the centre 114-23 Ontario Municipal Board 41, 44, 45 Ostroski, Jack 105 Pharmacy services 57 Physician shortage 8, 9-10, 50, 53 Plummer Memorial Hospital 8, 26, 44, 45-6, 54, 55, 67, 73 Potter, Richard 108 Prudential Insurance Company 13, 24, 35,42,48,54,59 Quebec: and cHcs 107, 133, 137, 159, 160, 173 Ramsay, Russell 120, 122 Robarts, John 57, 70, 88 St Catharines centre 99, 106-20 passim; initial plans for 71; alliance with the Sault 79-81, 85, 91; termination of 113, ll7, 120 St Joseph's Island 96 Saskatchewan: and health insurance 16, 27, 40, 72; Swift Current Region Health Plan 17, 135, 171; and CHCS, 72, 106-7, 133, 137, 144, 153, 157; Regina clinic 137, 141-2 Sault Ste Marie and District Group Health Association: activities of first board 41, 44, 46, 54, 58; relationship with own physicians, 65-6, 67-8, 75, 78, 101-5; after introduction of medicare 78-82, 101-2 Sault Ste Marie Medical Society: organization of 9, 10; initial response

204 Index to centre 25-9, 39, 42, 47, 49-56, 131; opposition after centre opens 72-7; and anaesthesia coverage 66-7, 75-7 Saward, Ernest 173 Scott, Arthur 29, 53 Sefton, Larry 12, 31, 56, 79 Silversides, Frank 60, 68 South Riverdale Community Health Centre 143n Stoddart, G.L. 159 Timbrell, Dennis 121, 122, 154n Toronto Labour Health Centre Organizing Committee 22, 79 Tulchinsky, Ted 79, 80, 107 United Steelworkers of America (uswA) 11-12, 61, 70; early interest in health centres 18-22; representation on centre's board 57, 79 Local 2251 20, 31, 33; development

of 11; early accomplishments of 12; health centre check-off 23, 34, 35, 36-7, 48, 56; household health survey 31-2, 138; representation on centre's board 57, 81, 101; Local 4509 31, 34, 48, 57; Local 5595 31, 34,48, 57 Wawa, 97 Welfare plan: before the health centre 12-15, 24; negotiations for health centre 22, 33-5 Wilson, Glenn 31, 36, 46, 138; construction of building 59-61; as consultant after opening 64, 68, 80, 92, 96-8, 120 Wishart, Arthur 26, 44, 45-6, 54 Woodcock, Les 12, 20,23,43,56, 101 World Health Organization (wHo) 3, 71, 77, 91, 106, 107, 119, 162, 167 Zaharuk, Walter 51, 53, 60