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Centre for Health Services and Policy Research --=----- Centre for Health Services and Policy Research Proceedings of the Second Trilateral Physician Workforce Conference November 14-16, 1997 Vancouver HHRU98:4 December 1998 Health Human Resources Unit Research Reports THE UNIVERSITY OF BRITISH COLUMBIA Proceedings of the Second Trilateral Physician Workforce Conference November 14-16, 1997 Vancouver, B.C. Editors: Morris L. Barer, MBA, PhD Director Centre for Health Services & Policy Research Laura Wood, MA, MHSc Research Manager Centre for Health Services & Policy Research Centre for Health Services & Policy Research 429 - 2194 Health Sciences Mall Vancouver, B.C. V6T 1Z3 Health Human Resources Unit The Health Human Resources Unit (HHRU) was established as a demonstration project by the British Columbia Ministry of Health in 1973. Since that time, the Unit has continued to be funded on an ongoing basis (subject to annual review) as part of the Centre for Health Services and Policy Research. The Unit undertakes a series of research studies that are relevant to health human resources management and to public policy decisions. The HHRU's research agenda is determined through extensive discussions of key current issues and available resources with the senior staff of the Ministry of Health. Various health care provider groups participate indirectly, through on-going formal and informal communications with Ministry of Health officials and with HHRU researchers. Three types of research are included in the Unit's research agenda. In conjunction with professional licensing bodies or associations, the HHRU maintains the Co-operative Health Human Resources Database. The Unit uses these data to produce regular status reports that provide a basis for in-depth studies and for health human resources planning. The Unit undertakes more detailed analyses bearing on particular health human resources policy issues and assesses the impact of specific policy measures, using secondary analyses ofdata from the Co-operative Database, data from the administrative databases maintained under the HIDU, or primary data collected through surveys. The HHRU also conducts specific projects pertaining to the management of health human resources at local, regional and provincial levels. Copies of studies and reports produced by the HHRU are available at no charge. (See final pages of this document for a listing of HHRU studies and reports.) Health Human Resources Unit Centre for Health Services & Policy Research #429 - 2194 Health Sciences Mall Vancouver, B.C. V6T lZ3 Tel: (604) 822 - 4810 Fax: (604) 822 - 5690 e-mail: [email protected] web: www.chspr.ubc.ca ACKNOWLEDGEMENTS Special appreciation is extended to those who were involved in the planning and organisation of the Second Invitational Trilateral Physician Workforce Conference, especially the Planning Committee, Karen Cardiff, Mary Brunold, and Juliet Ho. Elements of these Proceedings are derived from notes taken by Jennifer Gait and Dr. William Webber. Kathy Campbell worked from less-than-adequate tapes to produce transcripts of the presentations by Bob Evans, Noralou Roos, Tony Mathie and Phil Lee. Juliet Ho and Doug Jameson patiently edited documents and retrieved tables and figures. Karen Cardiff co-ordinated the process of document preparation. Thanks are also extended to those who supported the Conference and the production of these Proceedings: B.C. Ministry of Health and Ministry Responsible for Seniors Canadian Medical Association College of Family Physicians of Canada William A. Webber Health Canada Josiah Macy, Jr. Foundation Royal College of Physicians and Surgeons of Canada U.S. Bureau of Health Professions U.K. Department of Health Table of Contents Introduction M. L. Barer, L. Wood i Day One Opening Plenary - Physician Resources Policy Challenges: Deja Vu All Over Again. R.G. Evans................................................................................................................... 1 General Discussion 13 Morning Panel - Overservicing US IfDoctors were Free, Would We Always Want More? David Goodman............................................................................................ 17 UK Overservicing. Klim McPherson 38 Canada What can administrative databases tell us about overservicing in Canada? Ben Chan 57 Discussant Noralou Roos 84 General Discussion 95 Afternoon Panel - Primary Care Reform US Primary Care Reform in the US: The Best ofTimes and the Worst of Times Kevin Grumbacli 101 UK Primary Care Reform in the UK Angela Coulter 121 Canada Primary Health Care and Canadian Physicians c. 1997 Michael Rachlis 143 Discussant Tony Mathie 163 General Discussion 172 Evening Plenary - Medical Workforce Policy and Planning in Australia John Horvath 175 General Discussion 193 Day Two Morning Panel - Substitution US An Analysis of the Non-Physician Clinicians Who Provide "Physician Services". Richard Cooper, Craig L. Dietrich 197 UK Labour Substitution in the UK Sue Jenkins-Clarke and Roy Carr-Hill.: 221 Canada "Substitution" For and Among Physicians: a Canadian View Peter Newbery 247 General Discussion 258 Closing Plenary - Perspectives on Overservicing, Substitution, and Primary Care Reform in Canada, the United Kingdom, and the United States Dr. Phil Lee 265 Conference Program 273 List of Participants 277 Introduction The First Trilateral Physician Workforce Conference involving the United States (US), United Kingdom (UK) and Canada was held in Washington DC in November 1996. The Conference objective was to share experiences of the three countries with respect to physician workforce planning and management, to identify degrees of commonality and differences in issues, solutions, and policies adopted by the three countries. The conference focused on physician supply and requirements determination, physician immigration and emigration, geographic and social distribution, postgraduate medical education and residency training issues. Finally a panel of experts discussed drawing the link from data analysis to policy change. The Conference was funded by the Macy Foundation, US Bureau of Health Professions, Health Affairs and AMA. Canada hosted the Second Trilateral Physician Workforce Conference in Vancouver in November 1997. The themes for the conference included issues related to 'overservicing', 'primary care reform' and 'substitution'. The themes were considered to reflect the common priority issues and concerns confronting the three countries in the area of physician workforce planning. Physician workforce planning had again become a major issue, as some countries had begun to forecast physician shortages in the next few decades. Canada is at the centre of this debate, as its physician supply-per-capita figures have begun to decline recently after over 40 continuous years of (at times rapid) increase. Physician workforce planning and management requires the co-ordinated involvement of a number of stakeholders, and the participants were chosen to represent those organizations and interests that have to be part of the discussion to ensure continued dialogue and concerted action in Canada. As with the previous meeting, the overarching objectives of this symposium were to: a) enhance understanding of the political and social forces bearing on physician resource policy in the participating countries; b) compare current policy approaches (and research methods and findings on which they may draw, or which are indicative of their relative effectiveness), that show promise in each country in addressing selected thematic issues; c) consider the potential for (and barriers to) international policy learning and cross-fertilisation in the physician resource policy area; d) continue the development of a network of academic and policy leaders in the three countries who can maintain channels of communication and policy learning, and promote same in their respective jurisdictions; e) produce a series of papers and discussions that could be disseminated through a number of avenues, post-conference. This document has been put together in recognition of the last objective. In it, we present edited transcriptions of the plenary speakers, the discussants, and summaries of the discussions, as well as edited versions of the papers presented at the conference. The conference opened with a plenary on the relationship between cost constraints and workforce planning which invited participants to ground their speculations in a consideration of the accounting identity by which the inputs and outputs of the system were necessarily in balance, so ii that to change one aspect of the system was to have an impact throughout the system. The discussion which followed looked at the available strategies for workforce and budget management, the role of technology in affecting system costs and the relationship between political will and the implementation ofchange based on research. The first session examined claims of, and evidence on, the provision by physicians of inappropriate or unnecessary care. The papers produced for this session explored the evidence on over-servicing, and the policy implications and approaches, in each of the three countries. The discussant then demonstrated another approach to the problem of identifying overservicing, while the discussion which followed ranged around issues having to do with over- and under-servicing, the difficulty of changing physicians' patterns of practice, and the relationship between specialisation and over­ servicmg. The second session explored developments in primary care organisation and financing
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