Why Attempt to Assess Health Services?

Why Attempt to Assess Health Services?Author(s): STANLEY GREENHILLSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 59, No.9 (SEPTEMBER 1968), pp. 353-356Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41984243 .

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Why Attempt to Assess Health Services?1

STANLEY GREENHILL,2 M.D.

THE annual meeting of the Canadian A Public Health Association is an appropriate occasion to discuss a question that is of universal interest and concern - the provision of adequate and acces- sible health services to individuals irres- pective of their class, colour, creed or cash.

In order to provide background information for the remarks that follow, some of the more significant socio-economic changes that have occurred since the turn of the century will be mentioned. • Even if the advent of "the pill" proves to produce a slowing in the growth of the Canadian population its effect will not, to judge by recent trends, significant- ly decrease utilization rates of health services. • In the coming decades there will be an absolute increase in the number of the over 65 year olds. This age group already constitutes those who make greatest use of our available health facilities and services. • The increasing differential between the longevity of male and female will become progressively more apparent. By 1970, the ratio of females to males will be 132 to 100. The elderly females, the lonely widows in our population, make a dispro- portionate use of doctor time and hospital beds already. • The past fifty years have also been notable for the increased educational levels of most of our population. Perhaps an unfortunate by-product of an educated populace is its increased expectations from the health professions and the assumption that as educated consumers of health services they will have some say in deter- mining the ways and means whereby such services will be delivered.

1. Presented at the 59th annual meeting of the Cana- dian Public Health Association held in Vancouver, B.C., May 7-9, 1968.

2. Professor and Head, Department of Community Medicine, University of Alberta, Edmonton, Al- berta.

• The affluence of our wage earners, and their employers, during the past half century has been used mainly for the osten- tatious acquisition and consumption of some needed and many unneeded material goods. One effect of living in a wage- earning acquisitive society is the increased importance that health maintenance and so economic self-sufficiency plays in the lives of all. "Health" is an essential compon- ent of an acquisitive materialistic society. Such a society, to remain healthy econom- ically, is dependent upon the continued ability of its work force to maintain its dollar earning capabilities. Poor reasons perhaps for physical and mental well-being having such importance to the average citizen, but nevertheless potent ones, both for the individual citizen and society at large.

Socio-economic Change and Health Services

Within the medical and health professions themselves, the most significant trend, and a trend that continues to occur at an ever-increasing pace, is that of specialization. This trend is a perfectly nat- ural one - a human response to the spate of new information that threatens to inundate our intellectual capabilities. Better to be a master of one trade than a nincompoop in all - and when this pre- cept is applied to health services it can be argued it is to the benefit of the sick and ailing that they be tended by many, each "healer" with special skills and competencies. Others may interpret this trend to specialization as an acceptable means of sloughing off the broader aspects of professional responsibility through the acquisition of special competencies and skills and applying them to a narrower field.

No matter how this trend is interpret- ed, it is now a fact of life. In the United States in 1950, 36% of medical graduates were specialists, by 1960 this figure had grown to 56% and by 1965 specialists

353



354 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 59

made up 65% of all doctors. In other words in the United States, at the present time, specialists outnumber general prac- titioners by two to one. This ratio be- comes three to one within the confines of teaching hospitals and the cloisters of clinical research units.

Another response to the information/ knowledge explosion is the ever-increasing number of physicians working in groups. Though the numbers of full-time salaried physicians are still small their rate of growth is rapid. This applies not only to those physicians in private group practice but also to those in teaching, research and administrative positions.

If the increase in the number of salaried physicians shows rapid growth, it is small compared with the growth of those employed by the health industry.

The health industry is the third largest industry on the North American conti- nent. Its rate of growth is so rapid that by 1970 it may well become the biggest industry. In the United States in 1960, it employed 2,600,000. In Canada in 1965, 260,000 individuals received their pay cheques from the hospital sector alone. These individuals constituted 3.6% of Can- ada's total labour force. About two-thirds of the running costs of the average Cana- dian hospital go in wages. These costs will rise sharply as those who have found un- skilled jobs in hospitals, usually after living in rural areas, become organized and initiate action leading to an upward spiralling of wages.

At the present time, one tenth of the total manpower force in Canada is made up of members of the "approved" healing professions such as registered nurses, physicians, dentists, and the several other thou- sands "less approved" who are categor- ized as belonging to "other healing professions". These "other healing professions", it might be added, are used by an estimated one-third of Albertans at one time or another.

During the past five to ten years hospital employees have shown a 6-7% increase per year, compared with a 3% increase in the number of medical doctors and a 2% increase in the number of dentists. The number of doctors and dentists is increasing at a slower rate than the population.

Obviously, if medical and health services were one of the more efficient seg- ments of our industrialized society the comparatively small changes in the ratio of qualified health personnel to the population at large would be of little signifi- cance.

Efficiency and adequacy of medical and health services cannot be determined solely on the basis of the ratio of the numbers in the health professions to the population at large.

As yet, no indices of health "needs", as opposed to "wants" have been accepted or devised, against which the health professions can plot their effectiveness, or help them determine where their professional endeavours should be concentrated. Unex- pected or unacceptable high morbidity or mortality figures could perhaps be used as pointers to indicate by objective measure- ment where and how the health professions could deploy their limited resources of man and woman power.

The institutionalization of health facilities in the organization of medical care is a significant social fact. This is best represented by the modern hospital, usually of gargantuan proportions, containing within it an infinite variety of specialized facilities and resources and performing diverse functions in the community or region outside.

The increasingly important role played by the hospital in the everyday treatment of patients by the medically qualified is an interesting phenomenon to social scientists and an economic headache to health administrators.

In the United States between 1931 and 1962, the annual rate of hospital admis- sions rose from 56 to 140 per 1,000 population per year. This is an increase of 150% in a 30 year period. Though the average length of stay in hospital short- ened from 15.5 patient days per year to 9.3 patient days per year per 1,000 of population, the number of patient days per year per 1,000 population increased from 860 to 1,295. This represents an increase of 51%. These figures become more impressive if stated in terms of dollars. The per diem hospital cost has risen dramatically. In 1946 in the U.S. the per diem cost in hospital was $10. This figure by 1965 had risen to $48. The average



September 1968 HEALTH SERVICES 355

cost of patient stay in 1946 was $86. By 1966 this figure had risen to $381.(1)

Similar changes have taken place in Canada. Between 1926 and 1961 Cana- dians increased their spending on personal health services tenfold. In 1926 they spent 166 million dollars. In 1961 they spent 1,612 million dollars. Today 4.31% of our gross national product is spent in one way or another on the provision of personal health services.

Our knowledge of the way in which existing health personnel, services and facilities are utilized is really abysmal. Still less is known about the attitudes, fears, and prejudices of those who make use of such facilities.

The time, money, and man-hours now being spent on new and enlarged health resources - both physical and human - may in fact turn out to be inappropriate and unsuitable for the demands and use to be made on and of them. In these days of "human engineering", "ergonomics", and other related bio-social sciences, it seems inappropriate that millions if not billions are being spent on the erection of costly edifices, and the organization of costly personnel for purposes not yet clearly defined, and functions not yet fully known. The need is urgent for the development of techniques and methods to acquire some basic data on some of the factors that determine demands for health care, and utilization of health facilities.

How to devise studies that will result in such basic data has taxed and frustrated many researchers in this field. In fact there would appear to be a definite occu- pational hazard to those brave - or foolish - enough to embark upon research proj- ects designed to study and assess health care services utilization. The following quotation described what I hope is an atypical response to involvement with health service care research -

"Geoffrey Pyke (1894-1948), the orig- inator of operations research in World War II, was responsible for daring inno- vations believed to have furthered the allied cause. Creation of a National Health Service in Britain afforded Pyke an opportunity for peaceful pursuits. As a recognized genius with a reputation for tackling problems from first principles,

given full Cabinet backing, Pyke was as- signed the task of proposing solutions for the current shortage of nurses. He was later to tackle the problems of doctors and hospitals. The assignment was, Pyke said, "the sort of thing too often ap- proached by people who rely on intelli- gent guessing to lead to a solution when a scientific approach is in fact called for".

Pyke asked questions that had never been asked before, such as: How many nurses is the country going to require? Who should be recruited? What training will be needed? What tasks will they per- form? How can they be employed least wastefully? The replies he got from hospitals and nursing homes often were not helpful and he realized that he was study- ing a subject that had never been studied at a scientific level. Pyke became despon- dent; never had he faced a task or a system in which the objectives of the exer- cise were so obscure, the records so in- adequate, and the problems so poorly defined. Organization of the health services was determined, in his words, "by social- ly inherited patterns of behaviour and the policy of ancestor worship in administra- tion modified a little by fear of the living." Pyke eventually committed suicide; his hopes for a rational approach to the provision of health services seemed im- possible, not for lack of methods, but be- cause the health professions were unac- customed to stating their assumptions, objectives and criteria for decision-making precisely, or even at all."(2)

These are the reasons why it is of paramount importance that studies in utilization of and evaluation of efficacy in the health services be undertaken now, and that such studies be an integral part of any part of any future health service administrative organization.

The increasing interest now being taken in health service delivery systems is due to many inter-related factors - (1) the changing demographic characteristics of our population, (2) the changing socio- economic structure of our society, (3) the changing attitudes of individuals within our society towards health and illness, and (4) the greater expectations of an educated laity with regard to the benefits that they expect from the advances now



356 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 59

taking place in the medical and allied health fields.

These, and many other factors either not listed or perhaps not even yet identi- fied, are putting an increasing strain on existing health facilities and an increased workload on those in the professions providing direct health service. It has been emphasized (1) the number of qualified doctors is not keeping pace with population growth, (2) the growth of specialization has lessened the number of physicians available or willing to provide primary medical care, (3) the increasing utilization of institutionalized health facilities is having an important impact on the type, accessibility, and availability of medical services, and (4) the spiralling costs of medical and hospital care (the health industry) cannot be maintained without serious economic repercussions.

The provision and cost of health services cannot be allowed to mushroom in the present haphazard manner. Methods of evaluation will have to be devised - methods that should be operational in de- sign so that appropriate changes can be made in health care systems without dis- location of services while such changes are being implemented.

But change for change's sake is both purposeless and expensive. Hence it is necessary to devise criteria that may be used as "targets", "objectives" or "bench marks". Only then can the effect of change be evaluated. These criteria may be those health indices that are considered unacceptable for a nation that takes pride in its industrial, technological, and educational development. These criteria should reflect health "needs", not the "wants" of the nation. The efficacy of a health

service could then be measured by the speed with which acceptable health indices were achieved.

However, it will not be possible to insti- tute change in our health care delivery system, until such times as (a) the de- tailed workings of the system are under- stood, (b) the specific types and numbers of health personnel and facilities are known, (c) their duties and workload qualified, and (d) last, but by no means least, the attitudes of the consumers to the health services appreciated.

The importance of "assessing", "evalu- ating", or whatever term has current popularity, the nation's health services cannot be underestimated. To probe the workings of one of our major industries is no light undertaking. Unlike others, the health industry has no concrete tangible product, nor does it have for that matter discrete amounts of basic ingredients. To compound the problem, at every stage of study the role of the individual or individuals has to be taken into ac- count, whether these be health profes- sionals, administrators, wage-earners, edu- cators, etc., all of whom at one time or another will be the consumers of the services with which they are involved. Objec- tive, replicable data will be hard to come by- so measurements will always be crude and impressionistic.

Yet, it is imperative that studies of our health services be initiated and maintained. The problems inherent in such studies have been touched upon - not to dishearten the timid, but rather to demon- strate the challenge, and stress the importance of such work to all those whose concern is with the health of the Canadian public.

REFERENCES

1. Thompson, J.D.: "On Reasonable Costs of Hospital Services". Milbank Mem. Fund. Quart., 1968, 46: Part 2.

2. White, K. L.: "Research in Medical Care and Health Service Systems". Medical Care, 1968, 6: No. 2.



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Why Attempt to Assess Health Services?