What Does the Public Want of Health Services? The Need for Some Health Indices

What Does the Public Want of Health Services? The Need for Some Health IndicesAuthor(s): Stanley GreenhillSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 63, No.2 (March / April 1972), pp. 108-112Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41985577 .

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What Does the Public Want of Health Services?

The Need for Some Health Indices1 Stanley Greenhill, m.d., d.p.h., c.r.c.p.

The concern over health services being expressed by governments , media , and the health professions seems to be at variance with the overall satisfaction expressed by the users of such services. It is suggested that such satisfaction is not a cause for complacency but an opportunity to rationalize existing health services in a manner appropriate for current and future health needs.

OST OF THE people, most of the time are well. This simple dictum tends to

be forgotten by those whose work brings them into contact with the sick, the ailing, and the well - but - worried. It is only natural that the busy health professional gains the erroneous impression that most of the people, most of the time are sick. Sick- ness to most people is but an unwelcome and disruptive episode in their assumed lifespan of three score years and ten. It becomes, therefore, a matter of public and professional interest and concern to consider if existing health services are (1) acceptable to their users, (2) appropriate for their ills, and (3) justifiable to governments and their agencies who have the responsibility of raising, allo- cating, and expending public funds on such services.

Acceptability - Some Studies A study of health care utilization patterns

by Albertans pre-and post-Medicare provided some insight into the perceived wants of the public by reflecting some attitudes towards both physicians and the health care system. 1. Based cm a paper presented to the Annual Meeting of the College of Family Physicians of Canada, Banff, Alberta, September 1971. 2. Chairman, Department of Community Medicine, Uni-

versity of Alberta, Edmonton, Alberta.

The responses were those of a sample of adults insured and uninsured drawn from metropolitan Edmonton, the City of Red Deer, and a defined rural area around Red Deer. (1)

The responses reflected remarkably little dissatisfaction with existing health services.

Table I: Alberta Health Care Study 1968 and 1970, Phase I - Pre-Medicare.

Question: "Is the location of your doctor's office convenient?"

Response No. Per cent Convenient 1,497 93.2 Inconvenient 93 5.8 No opinion 16 1.0

Total No. 1,606 100.0

Table II: Alberta Health Care Study 1968 and 1970, Phase I - Pre-Medicare.

Question: "Are your doctor's office hours convenient?"

Response No. Per cent Convenient 1,540 95.7 Inconvenient 58 3.6 No opinion 11 0.7

Total No. 1,609 100.0

Table III: Alberta Health Care Study 1968 and 1970, Phase I - Pre-Medicare

Question: "Did your doctor spend enough office time discussing your problem?"

Response No. Per cent Not enough 23 8.6 Enough 243 91.4

Total No. 266 100.0

108



Table IV: Alberta Health Care Study 1968 and 1970, Phase I - Pre-Medicare

Question: "Were you satisfied or dissatisfied with your visit to your doctor?"

Response No. Per cent Dissatisfied 23 8.6 Satisfied 243 91.4

Total No. 266 100.0

Table V: Alberta Health Care Study 1968 and 1970, Phase I - Pre-Medicare

Question: "Would you like to have known more about what was going to happen to you during hospital stay?"

Response No. Per cent No 219 83.9 Yes 42 16.1

Total No. 261 100.0

Some dissatisfaction appeared to exist with respect to the ease of obtaining house calls. All respondents indicated a high degree of satisfaction with their own individual physicians, physicians in general, methods of practice, accessibility of physicians ... as well as a belief in the omniscience and omnipotence of the medical profession.

The World Health Organization Inter- national Collaborative Study on Medical Care Utilization (2) provided a unique opportunity to obtain similar data from the

Table VI: World Health Organization/Inter- national Collaborative Study of Medical Care

Utilization First Quarter Data, June 1 - August 31, 1968,

Grande Prairie (Canada) Study Area (Total Respondents - Adults - 813)

Question: "After deciding to see a doctor, was the wait for an appointment longer than you wanted?

Response No. Per cent No 96 85.7 Yes 16 14.3 Don't know 0 0.0

112 100.0

March/ April 1972

Grande Prairie region of Northern Alberta. Again the users of physician services and health care facilities appeared contented and satisfied with the health care provided them.

Table VII: World Health Organization/ Inter- national Collaborative Study of Medical Care

Utilization First Quarter Data, June 1 - August 31, 1968

Grande Prairie (Canada) Study Area (Total respondents - Adults - 813)

Question: "At that visit with the doctor, did you have to wait too long in the waiting room?"

Response No. Per cent No 85 80.2 Yes 21 19.8 Don't know 0 0.0

Total No. 106 100.0

Table VIII: World Health Organization/Inter- national Collaborative Study of Medical Care

Utilization First Quarter Data, June 1- August 31, 1968

Grande Prairie (Canada) Study Area (Total respondents - Adult - 813)

Question: "In your opinion, did the doctor spend enough time, or not enough time with you?"

Response No. Per cent

Enough time 108 95.6 Not enough time 4 3.5 Don't know 1 0.9

113 100.0

Table IX: World Health Organization/Inter- national Collaborative Study of Medical Care

Utilization First Quarter Data, June 1 - August 31, 1968.

Grande Prairie (Canada) Study Area (Total respondents - Adult - 813)

Question: "Were you satisfied or dissatisfied with what happened at that visit?"

Response No. Per cent Satisfied 104 92.0 Dissatisfied 7 6.2 Don't know 2 1.8

Total No. 113 100.0

Need for Health Indices 109



Table X: World Health Organization/International Collaborative Study of Medical Care Utilization. First Quarter Data, June 1 - August 31, 1968.

Grande Prairie (Canada) Study Area (Total Respondents - Adult - 813). Dis- Per Per Don't Per agree cent Agree cent know cent

Statements If you need medical help at night, do you think it is

easy to get a doctor to come to your home? 325 45.4 291 40.6 100 14.0 Would you say the drugs prescribed by doctors are

better than home remedies? 21 2.9 655 91.5 40 5.6 When you go to a doctorado you believe you should

be given the details of what he is doing to you? 64 8.9 638 89.1 14 2.0 Would you say you have to go through too much

trouble in order to see a doctor? 540 75.4 161 22.5 15 2.1 (Actual respondents N = 716)

Lest it be thought only Alberta doctors and the Alberta health care system were held in high esteem by those in need of medical care the findings from a health attitude survey in a suburb of Toronto (3) reflected similar attitudes.

These "high satisfaction" responses are to be found not only in Canada, but also in the eleven study areas of the seven countries (Canada, U.S.A, U.K., Finland, Poland, Ju- goslavia, and Argentina) collaborating in the World Health Organization International Collaborative Study on Medical Care Utili- zation (2).

A health care utilization study in Sydney, Australia (4), though not concerned primarily with "user attitudes" nevertheless noted that 94 per cent of the 5,343 respondents in the survey expressed satisfaction with the health services available.

It is difficult not to be impressed with the similarity of responses obtained in these sev- eral studies carried out in such widely sepa- rated and diverse areas of the world. The responses strongly suggest - "The health wants of the public are satisfied by the health services available to it." The degree and extent of this satisfaction is apparently not re- lated to such variables as geography, de- mography, economy or political ideology of the areas and populations studied.

The apparent universality of these responses should not produce feelings of satis-

110 Canadian Journal of Public Health

faction, gratification, or complacency among the medical profession. It may well be that current methods of studying "the users of health services" have serious defects. Perhaps the wrong questions are being asked, or the right questions asked the wrong way. But as- suming the responses have some validity, they suggest that the extent of our present con- cerns and anxieties with respect to our health care delivery systems is unjustified. Why then the number and variety of commissions, submissions, briefs and reports dealing with health care recently published in Canada? Why the widespread concern and interest in health care in the face of what would seem to be public satisfaction with such care?

It is axiomatic that political interest in any matter increases in direct proportion to governmental financial involvement. Health care expenditures are increasing at a dis- proportionate rate to all other sectors of the nation's economy (5, 6). These increasing expenditures are not reflected by increased "profits" or by measurable increases in "productivity." Health care systems operate in atypical marketplaces. The usual economic indices with respect to costs, profits, and benefits of an industrial enterprise do not ap- ply to the health care industry. Hence the preference in this paper for "health expenditures" rather than "health costs."

The "costs" of health services are no longer "real costs" to the public. Health serv-

Vol. 63



ices are but one item in the cornucopia of social goods and services that comprise a ma- jor portion of any governmental budget The present "nil-price-infinite demand" (7) po- tential of health services funded from general revenues obtained through general taxation is a matter of concern and priority for govern- ment, and must be for the medical profession.

Health Indices as a Measure of "Appropriateness"

The generally accepted criteria of a nation's health are its mortality statistics. Health statistics such as infant mortality, ma- ternal mortality and leading causes of death are available from the health departments of most countries. Data on prevailing morbidity, on the other hand, are exceedingly rare.

Physicians' submissions to our Canadian health care commissions admittedly only reflect the causes why individuals actively seek medical care. They do not provide a picture of the extent and types of perceived and actual morbidity in that larger population not in the process of seeking medical care. Yet these data have the advantage of being available now, and within the limitations stated, provide current morbidity data. The importance of morbidity data as the bases for ra- tional health service planning cannot be over- emphasized.

Reliable and constantly updated morbidity data enable both the medical profession and governments to assess and evaluate the effec- tiveness of the roles played by the health care system in the maintenance of health and the prevention of disease. These data help delin- eate those conditions, situations, and disease states that demand high priority with respect to deployment of scarce and costly personnel and resources.

Morbidity and mortality statistics should be used as "production targets." The medical profession working with all levels of govern- ment set "production targets" and make pol- icy decisions designed to reduce those causes of morbidity considered too high for a nation

March/ April 1972

with the fourth highest living standard in the world today.

It is realized the practising physician is not primarily interested in statistics of health, sickness and mortality. Nevertheless the medical profession must look beyond its patients in its consulting rooms to the community outside. Recent social change and legislation make the profession an integral part of the society it serves.

The work of the doctor has to be viewed both in its social context and in its relation to the health needs of the population. Methods must be evolved to evaluate the efficacy and appropriateness of his professional activities. The importance of evaluating the doctor's work in and for the community becomes, therefore, a matter not only for academic research, but also for professional concern.

The information now being fed daily into the memory banks of provincial health care commissions' computers by practising physicians is a regular and constantly updated source of morbidity data, giving in ICD diag- nostic categories, the reasons for the public seeking health care.

These morbidity data over a period of time would act as a built-in-health-care-evaluation- system. The changes observed in incidence of morbidity would reflect both the appropriateness of health care policies reached by the decision makers, and the efficacy of the care provided by health professionals.

Discussion The public appears satisfied with the health

services available to it. The two other queries previously raised remain unanswered - (1) whether existing health services are appropriate for the public's present and future health needs cannot be answered because of lack of appropriate data, and (2) whether present and projected expenditures on health services can be justified on economic and/ or medical grounds cannot be answered through lack of pertinent facts and figures.

Governments, as representatives of the public and keepers of the public purse, wish

Need for Health Indices 111



answers to these questions. Governments asked to allocate an increasing proportion of their total tax dollars to health care are going to be increasingly reluctant to do so in the absence of any significant cost-accounting and/ or cost-benefit analyses to justify such expenditures.

The medical profession must not abrogate or abdicate its social and professional respon- sibilities. The public regards the medical profession as the key component of any health care delivery system. This happy state of af- fairs will be maintained if the profession con- tinues to demonstrate interest and leadership in studies and evaluations of itself and the health care delivery system.

The prime responsibility of the medical profession is in the maintenance and improvement of the public health. The chang- ing patterns of morbidity since the turn of the century can be attributed as much to social legislation and rising standards of living as to improved medication and health care facilities. Hence the necessity of the medical profession broadening its interests from the minutiae of single disease processes to the more complicated study of the causes and significance of disease states in the social milieu of today and tomorrow.

Conclusion The maintenance and improvement of the

public health will require certain changes in existing patterns of practice and design of facilities, and a willingness to take the lead in developing, inaugurating and evaluating new methods of health surveillance and tech- niques in health care delivery. Sir George Godber, Chief Medical Officer of the De- partment of Health and Social Security in England succinctly expressed the challenge and the problem now facing the medical profession in his Ciba Foundation Anniversary Lecture of 1970 -

"The greatest problem of the next ten years will be to determine how best we can deploy our total resources of trained manpower and rapidly evolving technology so as to produce the best re- sults for the most people. It is certain that this cannot be done unless outdated methods which waste skill, time and money are revised. There is not going to be either an unlimited outpouring of national resources diverted from other national needs or some new technical magic to make it possible both to have the new and keep all the old ways." (9)

REFERENCES

1. Alberta Health Care Utilization Study (1968 and 1970). Public Health Research Grant (608-7-106) Department of National Health and Welfare, Ottawa.

2. World Health Organization International Col- laborative Study on Medical Care Utilization (Alberta, Canada) Public Health Grant (608- 7-106) Department of National Health and Welfare, Ottawa.

3. LeRiche, H., et al: People Look at Doctors : Sunnybrook Health Attitude Survey . Sunny- brook Hospital, Toronto. Ontario 1971.

4. Adams, H., et al: "Medical care in Western Sydney. A report on the utilization of health services by a defined population." Med. J. Aust., 1971, March 6, p. 507.

5. Gellman, D. D. : "The price of progress. Tech- nology and the cost of medical care." Canad. Med. Ass. J., 1971, 104 : 402.

6. "How Your Dollar is Spent." Information Canada. Ottawa, 1971, pp. 17, 19 and 20.

7. Powell, J. Enoch: "Nil price: Infinite demand." An address to the Proceedings of the Anglo-American Conference on Medical Care, Royal Society of Medicine, 1971, London.

8. Thorner, R. M.: "Health programme evaluation in relation to health programming," Health Services and Mental Health Adminis- tration Reports. 1971, 86: 525. U.S. Dept Health, Education and Welfare, HSMHA, Rockville, Maryland 20852.

9. 'The Liverpool Study - An inquiry into the dynamics of medical care and use of hospital resources in a region" Medical Care Unit, Dept. of Public Health, London School of Hygiene and Tropical Medicine, London, 1971, Chapter 1, p. 7.

112 Canadian Journal of Public Health Vol. 63



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What Does the Public Want of Health Services? The Need for Some Health Indices