PRIMARY HEALTH CARE SERVICES AND COMMUNITY HEALTH CARE SERVICES

PRIMARY HEALTH CARE SERVICES AND COMMUNITY HEALTH CARE SERVICESAuthor(s): J.E.F. Hastings and J.W. BrowneSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 69, No.2 (MARCH/APRIL 1978), pp. 95-97Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41986379 .

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Editorial

PRIMARY HEALTH CARE SERVICES AND COMMUNITY HEALTH CARE SERVICES

J.E.F. Hastings We are currently carrying out a major

study, funded by Health and Welfare Canada and supported by the provincial and territorial governments, the Canadian College of Health Service Executives and the Canadian Public Health Association, on Health Admini- strators in Canada. We have already visited several provinces to discuss preliminary findings based on a questionnaire used in the study. During these discussions, we have sensed a re- awakening interest in organized community health programs as a means of meeting needs in a time of restraint. The Canadian Public Health Associa- tion Annual Conference will also touch this theme but from the viewpoint of the delivery of primary health care services to the community.

What is the relationship between primary health care and community health care? How can we ensure that both sectors work together to ensure the health of individuals and families?

Unfortunately, there is little common agreement about how either sector

should be defined and, hence, little agreement about the services appropriate to each. There are many reasons for this lack of agreement: both primary care and community care are really a collection of spectrum of services and some services might improperly be excluded by too precise a definition; the two sectors are not mutually exclusive; both terms may refer to a type of service, the milieu in which a service is delivered, or be used as a generic name for a service; finally, many practitioners and clients feel they move freely between the two sectors.

We do not intend to propose a new basis for separating or thinking about the two sectors. Rather, we would like to propose general, descriptive defini- tions and then ask some questions about the issues we feel arise from a consideration of how the two areas might be related.

We would describe primary health care services as those personal health and treatment services which are delivered to an individual who is ambulant, who is not an in-patient in a hospital or chronic-care institution. Such services are given by professionals such as family physicians, "basic" specialists, primary care nurses, dentists and dental auxiliaries. The services are provided in settings which include physicians' offices, out-patient depart- ments, clinics, family practice units and the like.

Community Health Care Services are more difficult to describe but include

those organized public health services or community based services that provide care for people. Examples of this kind of service include visiting nurse programs, well-baby clinics, meals-on-wheels, or immunization clinics. We would exclude from the current discussion such services as environmental sanitation programs which, although part of organized community health services, do not impinge directly on individuals and hence, do not overlap or potentially conflict with Primary Care Services.

Three questions arise on the relationship between primary care and community care:

What kinds of services belong in each sector?

What kind of professional should deliver the services?

What type of setting should be used to deliver the services?

The particular kinds of services that are appropriate to either sector depend upon advances in medicine and technology, changes in social values, the resources available to the health system, or, in Canada, simply upon geography.

The care of cardiac patients offers a case-in-point: pacemakers that can be monitored by telephone, new drug therapies, and changed social percep- tions about heart attacks now mean that cases that would formerly require the resources of the secondary care sector can now be treated through the primary care sector.

Community Health Care Programs

Canadian Journal of Public Health Vol. 69, March/ April 95



are also sensitive to the changing environment. The new emphasis on developing programs of health promo- tion shows how quickly changing social values can affect community care. New programs will probably be stimulated by the new fiscal arrangements between the federal and provincial governments. Already, for example, we have seen several provinces attempt to close hospitals and shift resources to community care services.

The geographic factor must always be considered in Canada. In the north, in the sparsely populated areas, little distinction exists between primary and community care. All services, under whatever auspices, are required and welcomed.

As a result of these kinds of factors, particularly because of the unstable financial climate, we feel that the distinction between Primary Health Care Services and Community Health Care Services cannot be based on a theoretical distinction between the sectors. Any planning that is done on the basis of such a distinction will be quickly overtaken by events.

Thus, for example, a question about the most suitable location for immunization services should not be decided on the basis of tradition or professional prestige but on questions of cost- effectiveness, convenience to client and professional, ease of record-keeping, and availability of resources.

If we turn to the question of who should deliver services, we touch upon a most controversial area and raise issues relating to professional education, prestige, status and salary. Each professional and technological group seems bent on preserving certain functions and roles as its exclusive prerogative. There is little opposition to introducing personnel of less training and lower cost into either sector provided they carry out less desirable tasks, they are under the control of the senior professionals, and their use does not lead to any reduction in either the numbers or income levels of senior professionals.

We note, for example, the resistance encountered in Ontario in trying to sort

out the tasks appropriate to dentists, denturists and dental hygienists. Yet, experience in other countries, even in other provinces within Canada, demon- strates that some functions usually performed by a dentist can be safely and adequately carried out by auxiliaries.

It is not only the senior health professions who are jealous of their prerogatives. Some professions, such as nursing, social work, and psychology, while pushing for greater independence and status and demanding access to the primary care functions usually carried out by physicians, are most unwilling to yield their cherished functions to new professional and allied personnel.

Professionals in Community Care Programs are not much different from their Primary Care counterparts. Many Medical Officers of Health, for example, are extremely unwilling to consider devolving their role as Chief Executive Officer to non-physician administrators. We could also mention the traditional tensions between Medical Officers of Health and Directors of Public Health Nursing or between Public Health Nurses and Psychiatric Social Workers attached to Public Health Units.

We feel that the sorting out of professional roles in specific programs cannot be based upon a priori judge- ments about the role of that professional group. Rather, one must focus on the particular problem to be solved or the particular program to be imple- mented and ask who can deliver the service most effectively and efficiently.

This approach may mean devolving tasks and responsibilities and, in the current fiscal climate, implies the replacement of one type of professional by another rather than the addition of more professionals.

We feel that a partial solution to inflexibility and service pattern and to controversy between the professions can be found by stressing the organizational setting in which both types of service are delivered.

For many years, no effective focus existed for primary care services. The secondary and tertiary care systems had, at their heart, the community

hospital and the teaching hospital with their attendant groups of specialists, technologists and administrators. No such setting exists in many communities for primary care services. Several years ago, at the request of the Conference of Health Ministers, a select committee suggested that a network of Community or Primary Care Centres be established.

The Report of this Committee indicated that Community Health Centres offered a point of contact between community and public health services on the one hand and primary care services on the other. Health Centres might also provide a milieu in which different professionals professionals could work together and might provide a counterweight to the secondary and tertiary care sectors.

We were both intimately involved with the Community Health Centre Project and have recently gone through the rather sobering experience of trying to assess its impact.

We believe that the federal and provincial governments intended, in 1972, to take the steps aimed at implementing a network of Community Health Centres. However, the failure to renegotiate the federal/ provincial cost sharing agreements, the elimination of the federally proferred T rust Fund and the policy, then being enunciated, of shifting leadership and responsibility for health services from Ottawa to the provinces made it unlikely that any province could or would institute such an organized system. Except for Quebec, where extensive legislative change occurred as a result of the Castonguay Report, only modest and piecemeal steps have been taken.

Without overall guidance from the federal or provincial levels, it was impossible to establish a coherent concept and/ or clear objectives which are basic to effective planning for the organization, structure and operation of such Centres.

Most governments today seem to have reverted to the policy of short-term response to individual emergent problems. Any thought of looking at the organizational and planning aspects of the relationship between the sectors

96 Canadian Journal of Public Health Vol. 69



or of thinking through the system-wide impact of specific steps appears to be a low priority.

If primary care and community care were brought into a closer relationship, what are some of the issues to be faced?

First, as we stated earlier, the division of services between the sectors must be decided after considering technology, resources, community values and geography. No single service pattern can be applied across the country or even in a single province. In large metropolitan areas, for example, paediatric services will probably continue to be delivered by specialists; in the North, public health nurses will fill the same role.

The principal question to be raised in this area is that of poorly distributed resources. We speak not only of maldistribution between parts of a province but also between sectors of the system. Should incentives (or quotas) be established to limit the number or type of professional that can practise in a given area? Should hospitals be closed and community care programs established? Paradoxically, fiscal restraint, the major factor working against cooperation in the health care system, may eventually force coordination of planning and service delivery.

Secondly, we must openly discuss manpower issues. If we believe that primary care and community care can be delivered in a more economical and efficient manner by auxiliary personnel we imply a larger role for the "paraprofessionals". Any reallocation of tasks to auxiliaries, unless approved by the dominant professions, is difficult to achieve. Thus, we may have to look at cutting back enrolment in some

professional schools and channelling the resources freed thereby into produc- ing paraprofessionals and health auxiliaries.

We must also look very hard at our current educational programs. Too often, the training of health professionals is carried out in such a way as to sow the seeds of future rivalry; only a few universities have, for example, really tried to develop unified health science faculties in which shared teaching and practice support the notion of teamwork.

In a modest way, we have recently tried to implement these ideas in our new community health graduate program in Toronto. By replacing the categorical Diploma programs with a single Master's program, we hope to remove some of the barriers that can easily arise between public health professionals. We also hope that our field training programs can be established in a variety of settings across the country both to demonstrate to students the need for inter-provincial cooperation and to make them more aware of the problems faced by their own province.

Thirdly, we must repeat our convic- tion that organized primary and community care settings are only possible when clear policies and detailed objectives are enunciated by government. In Ontario, for example, the Ministry of Health encouraged citizen groups to develop proposals for small programs, called Health Service Organizations, and for medical group practices willing to shift from fee-for-service to other forms of payment. The absence, however, of support, clear policy and expert planning help has meant that

each HSO is unique and that evalua- tions and comparisons are of doubtful worth. Citizen groups, on the other hand, while noteworthy for their enthu- siasm and commitment in the fact of obstacles, have been marked by a general naïveté and lack of planning skills; some even appear to resist seeking experienced advice, fearful that their "grass-roots" quality would be affected by expert involvement.

In conclusion, we feel that it is now time to stop wallowing in confusion and negativity. A time of cost restraint and change within the system is also a time of great opportunity, a time when it is even more imperative to look at health services and to put into place those concepts, objectives and guidelines we feel are required for the next 10 years. It is the job of the professional associa- tions to focus ideas and debate and it is the job of government to give leadership and govern. The Annual Conference of the Canadian Public Health Associa- tion provides an opportunity for the membership to make clear their view on these matters. Then it will be up to the governments to develop the incentives and the plans to achieve those clearly stated goals.

J.E.F. Hastings , M.D., D.P.H., F.R.C. P.(C),

Professor and Associate Dean,

J.W. Browne, B.A., M.A., Assistant Professor,

Division of Community Health Faculty of Medicine University of Toronto Toronto, Ont. M5S 1A1

March/ April 1978 97



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PRIMARY HEALTH CARE SERVICES AND COMMUNITY HEALTH CARE SERVICES