Eugene Vayda

Private Practice in the United Kingdom: A Growing Concern

During the past decade private medical insurance in the United Kingdom grew first rapidly and then steadily. Once almost entirely non-profit, half the private beds and 10% of the private insurance market are now in the for-profit sector. Apart from abortions, cold or elective surgery is the chief private sector service. Average annual consultant income from private practice is now approximately 19,000 pounds sterling. Recent growth of the private sector has been fanned by the present Conservative governments support of privatization generally, by limited levels of National Health Service (NHS) funding, and by vigorous advertising by private insurance companies which plays on the concerns of British consumers.The private medical sector is largely unregulated. Present government policies make its reduction or elimination unlikely. To make it possible for the public sector to compete more equally, a strategy which requires the same levels of regulations, quality assurance, accountability and public scrutiny for the private sector and the NHS is proposed.

Universal Hospital and Medical Care Insurance in Canada: Utilization and Cost Performance

jra *n5LTHOUGH the Canadian provinces have constitu{ tional responsibility for hospital and medical care, a universal program was established in Canada when the federal government offered 5o/5o sharing of hospital and, later, medical care costs (1). The terms of reference 3*4t2X c!.A required to qualify for federal cost-sharing are broad, and there is variation among the ten provinces, particularly in the case of supplemental benefits. Under the new 1977 funding arrangements, even greater variation can be expected. The 50 /5o cost sharing was calculated to pay the poorer provinces more than half their costs and the wealthier provinces slightly less than half. Revenue sharing has been retained in the new 1977 fiscal arrangements. How has the system performed since 1958 when universal hospital insurance began, and since 1968 which marked the beginning of universal medical insurance? Despite initial concerns, the universal plans themselves did not result in persistent runaway utilization, although there were sharp increases in hospital spending between 1958 and 1961 and in medical care spending between 1968 and 1971. The universal plans in Canada were built on existing provincial insurance programs. In the case of hospital insurance, five provinces already had universal insurance when the Hospital and Diagnostic Services Act was adopted and implemented, and there were varying degrees of insurance in the other provinces. No persistent utilization effect can be demonstrated after the universal hospital insurance was adopted, but it may well be that any utilization effect had already been absorbed by the public and private health insurance which predated the universal plan. Per-capita admissions and patient days in general and allied special hospitals (acute-care hospitals) increased between 1% and 2% per year in the 1950S and 196os. Since 1970, patient days per 1,ooo population have fallen slightly. The decrease has

Looking North for Health: What We Can Learn From Canada's Health Care System

Foreword 1. Health Care in the Canadian Community(Robert G. Evans) 2. A Comparison of Our Two Systems(The Honorable Perrin Beatty) 3. From Inside the System: A Physician, Hospital Administrator, and Business Executive Talk About Their Work in Canada(Jerry Estill) 4. Voices from the Polls: Consensus and Satisfaction from Canadian Patients and Taxpayers(Ian McKinnon) 5. The Political Perspective: Planning and Implementing the Canadian System(The Honorable Allan Blakeney) 6. Delivering and Financing Long-Term Care in Canadas Ten Provinces(Rosalie Kane) 7. Serving Elderly Patients: The Benefits of Integrated Long-Term Care in British Columbia(Paul Pallan) 8. Understanding the Health Care System That Works(Orvill Adams) 9. Eleven Lessons from Canadas Health Care System(Ron Pollack).

Education and Research in Community Health in Canada

OMMUNITY health is concerned with health and illness in populations, with health behavior and promotion, and with health services utilization. Data obtained from the community are used to inform and influence e ~ qhealth policy, implement community-based programs, and assist in patient management. Where can the diverse knowledge and skills which community health practitioners and researchers require be obtained in Canada? Current university programs, regardless of their quality, are not coordinated and do not systematically address Canadian community health personnel and research needs. Individual community health programs presently located in Faculties of Medicine, Nursing, Dentistry and Management serve and should continue to serve an essential but complementary role. They capture individual and institutional expertise, train specialized professionals and researchers, and provide community health input into undergraduate medical, nursing and dental curricula. However, these programs are not substitutes for a comprehensive school of community or public health. Such schools in the United States and Europe fulfill broad mandates. Most have full or substantial national and/or state support and subsidy and serve as national teaching, research, and service resources in community health. The Schools of Hygiene in Toronto and Montreal were absorbed into their respective Faculties of Medicine in the 1970S. While this change addressed the issue of isolation, it placed a field which is made up of many different health professions under medical sponsorship. To return to isolated unsupported Schools of Hygiene would be to turn back the clock, but to fail to provide an environment for coordinated population-

Aspects of Medical Manpower under National Health Insurance in Canada

caGaGm ANAD A has had universal hospital insurance since 1961 S and universal medical care insurance since 1971. Medical care insurance was enacted: 1) as an inevitable consequence of universal hospital insurance, 2) because of its successfiul adoption in Saskatchewan, and 3) because the federal government accepted the recommendations of the 1964-1965 Royal Commission on Health Services (the Hall Commission) that it enact federal-provincial cost sharing for medical care insurance. In this paper we will examine the effect of universal medical care insurance on medical (and to a small extent nursing) manpower in Canada. We also will look at some of the current issues at the interface between governments and physicians. Although the analysis is national, health care in Canada is primarily a provincial responsibility and manpower policies are made at the provincial level. However, in the early days of universal medical insurance, federal contributions to the funding of medical education gave rise to a strong federal presence in medical manpower policy. Since the late 1970S, federal support of medical education and health care has decreased. With or without financial support of medical education at the federal level, medical manpower is a national resource in all of Canada except Quebec; licensure is donejointly by the nine anglophone provinces and movement of physicians among them is essentially unrestricted. In recommending universal medical care insurance in 1964-1965, the Hall Commission report made a number of assumptions (1): 1. The existing physician to population ratio of 1:857 was a minimum optimal ratio. This ratio had to be maintained or improved because of anticipated increased use due to unmet need and increased demand for services. 2. Population growth at existing rates would continue.