A. Paul Williams

Policy, Payment, and Participation: Long-Term Care Reform in Ontario

Although Canadian Medicare gives the population “reasonable” access” to all “medically necessary” physician and hospital services, long-term care is not formally subject to those conditions. In Ontario, long-term care involves a “patchwork quilt” of government, charitable, for-profit, and personally-provided services; an ongoing consultation has been under way in an attempt to rationalize service financing and provision. This paper reviews the series of policy proposals and the accompanying public consultation processes. It concludes that the emphasis on “community involvement” without a clear definition of “community” or the goals of participation has paradoxically increased the “scope of conflict,” increased frustration among stakeholders, and made policy action more difficult.

Promoting Arab and Israeli cooperation: peacebuilding through health initiatives

This article describes a positive experience in building Arab and Israeli cooperation through health initiatives. Over the past 10 years Israeli, Jordanian, and Palestinian health professionals have worked together through the Canada International Scientific Exchange Program (CISEPO). In the initial project, nearly 17,000 Arab and Israeli newborn babies were tested for early detection of hearing loss, an important health issue for the region. The network has grown to address additional needs, including mother-child health, nutrition, infectious diseases, and youth health. Our guiding model emphasises two goals: project-specific outcomes in health improvement, and broader effects on cross-border cooperation. Lessons learned from this experience and the model provide direction for ways that health professionals can contribute to peacebuilding.

Balancing Formal and Informal Care for Older Persons: How Case Managers Respond

Cette étude a examiné la façon dont les gestionnaires de cas de soins à domicile et en milieu communautaire dans la première ligne de la profession voir le rôle des aidants naturels et les facteurs qui contribuent aux décisions de ces gestionnaires en ce qui concerne l’allocation des ressources. La recherche pour l’étude a utilisé deux méthodes de collecte de données: (a) l’analyse secondaire des résultats de simulations de la balance de soins, réalisées dans neuf régions de l’Ontario, et (b) des entretiens en profondeur de suivi avec les différents gestionnaires de la B de S. Les résultats indiquent que les gestionnaires de cas sont d’accord à l’unanimité que l’unité des soins dans le secteur SDMC ne se limite pas à l’individu, tel qu’en soins aigus, mais englobe à la fois l’individu et le soignant. Nous avons constaté, cependant, des variations considérables dans l’assortiment et le volume des services SDMC recommandés par les gestionnaires de cas. Nous concluons que la variabilité de la prise de décision peut refléter la manque de réglementation, de meilleures pratiques, et de lignes directrices pour la responsabilité dans le secteur SDMC.This study examined how front-line home and community-care (H&CC) case managers view the role of informal caregivers, and the factors that contribute to H&CC managers’ resource allocation decisions. The study research used two methods of data collection: (a) secondary analysis of the results from balance of care (BoC) simulations conducted in nine regions of Ontario, and (b) in-depth follow-up interviews with participating BoC case managers. Results suggest that case managers unanimously agree that the unit of care in the H&CC sector is not confined to the individual, as in acute care, but encompasses both the individual and the caregiver. We found, however, considerable variation in the mix and volume of H&CC services recommended by case managers. We conclude that variability in decision making may reflect the lack of regulations, best practices, and accountability guidelines in the H&CC sector.

FLIGHT PATHS AND REVOLVING DOORS: A CASE STUDY OF GENDER DESEGREGATION IN PHARMACY

This paper examines practitioner reactions to occupational desegregation in pharmacy-the effects, for women and men, of a rapid female entry into the profession. The topic is documented in terms of processes of integration, ghettoisation, and re-segregation. With data collected from licensed pharmacists in Ontario, Canada, we find little evidence of either genuine gender integration in the profession or gender re-segregation precipitated by collective male discontent. While female practitioners are more positive in their evaluation of their jobs and their profession, there is no indication that current satisfaction and dissatisfaction is a harbinger of male-or female-flight from pharmacy. We discuss these findings in the light of arguments about a job and gender queue in the labour market.

A typology of medical practice organization in Canada. Data from a national survey of physicians.

Different modes of practice organization may result in advantages for physicians and their patients. Compared with solo practice, group practice may produce economies of scale, efficiencies in health care delivery, and improvements in the quality of care. However, in Canada assessment of the implications of differences in practice organization have been impeded by a lack of relevant data and a tendency to treat practice type as a dichotomous variable. Conventional solo/group distinctions fail to address the significance of the growing number of medical practices that are neither solo nor group, but combinations of both, and they obscure the policy implications of the growing number of physicians in institutional as opposed to private practice. This paper develops and applies a theoretically based typology of practice organization to data collected as part of a national survey of 2,398 Canadian physicians conducted in late 1986 and early 1987. The analysis identifies six practice types, describes their distribution and operating characteristics, and identifies the characteristics of physicians working in them.

Shifting sands: assessing the balance between public, private not-for-profit and private for-profit physical therapy delivery in Ontario, Canada.

BACKGROUND AND PURPOSE The vast majority of health services within Canadas single payer universal health care system are publicly funded. Despite the highly political and controversial emphasis placed on public funding, the structure of delivery within this health care system does not require public ownership. In this research, we developed a conceptual framework for analysing the public and private mix of physical therapy (PT) delivery in the province of Ontario. We then applied this framework to examine the shifts in employment structure of physical therapists (PTs) in Ontario. METHODS A two-phased health policy case study methodology was used. In the first phase, we reviewed publicly available documents and conducted a series of 30 key informant interviews in order to develop our framework. In the second phase, we applied the framework and performed secondary analysis of the provincial PT registration database to assess change in practice setting between 1996 and 2002. RESULTS We identified nine models of delivery that fall into three categories of ownership structure: (a) public; (b) private not-for-profit; and (c) private for-profit. During the six-year period between 1996 and 2002, the relative proportion of PTs employed in the not-for-profit sector decreased (from 59.6% to 54.8%) whereas the share in the for-profit sector grew (from 40.4% to 45.2%). CONCLUSIONS The shifting balance in the structure of delivery may be transforming how PT services are provided in the province. Private for-profit providers appear to be increasing their market share; however, the outcomes relative to this shift has yet to be fully explored. Further policy and health services research is warranted to more fully understand the consequences of this shift on variables such as professional autonomy, access, cost and quality of services across Canada, but also within similar and dissimilar international jurisdictions.

How do Policy and Institutional Settings Shape Opportunities for Community-Based Primary Health Care? A Comparison of Ontario, Québec and New Zealand

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the ‘space available’ for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the ‘barbed-wire fence’ that separates funding of medical and ‘non-medical’ primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence.

Characteristics of Established Group Practices in Ontario

Established group practices in Ontario were surveyed to determine their structure, characteristics and attitudes toward government assistance in the development of group practice. The degree of organization of the groups surveyed was related to size and less than that reported in surveys of United States group practices. Group size and years of operation were strongly associated. Night, weekend and vacation coverage, the use of a unit patient record and the employment of non-physician administrators were reported frequently, and were more common in older and larger groups. As well, fringe benefits, except for professional organization dues, were not commonly provided.

The reproduction of physician autonomy in Ontario medical group practice.

A belief exists about the advantages of group medical practice over solo practitioners. The paper through a survey of 105 group practices examines a number of organisational and operational factors. The results suggest that practices are not always organised in a way to maximise the benefits of group operation but are still characterised by an individualistic approach.