Reading some more of Paradigm Freeze, it became clear that its authors consider that the Canadian health care system primarily includes hospitals, doctors and the services they provide, and that policy changes are meant to reform that landscape. In the book, they are worried about how slowly this system changes. Let’s take a look at how the system came to be in the first place – here are some significant events in Canadian health system development:
• 1947 Saskatchewan Hospital Insurance Program
• 1949 British Columbia Hospital Insurance Service
• 1962 Saskatchewan Hospital & Doctor care
• 1957 A National Hospital Insurance Program across Canada
• 1966 Medicare Hospital & Doctor care across Canada
• 1984 Canada Health Act:
– Covered hospital care and Doctors’ fees for medically necessary services
– Did not cover drugs outside hospitals
– Did not cover much non-medical treatment outside hospitals and doctor’s offices
The “centre local de services communautaires,” or CLSCs as they are known, are an example of a service that is hardly considered in the book. These local community services organizations came into existence in Quebec as a result of major reforms and since then have virtually disappeared in the process of regionalization.
CLSCs were put in place in the 1970s during the quiet revolution in Quebec. These organizations, along with others like the CEGEPs (Collège d’enseignement général et professionnel or in English, General and Vocational College), were part of a larger vision to create a comprehensive social umbrella that would be responsible for the overall wellbeing of its citizens. At the time, participative democracy determined the expressed values of the CLSCs. They were governed by citizens of the local area and staff members who together set the policies, planned the services and managed them.
The CLSCs became significant members of the health and social services system. Doctors, nurses and social workers were their major employees, and the hope and expectation was that these local organizations would develop and thrive while providing a broad range of locally needed services – everything from preventive services to primary care, to financial and marital advice. Overall the CLSCs would increase the capacity of the population to live well through education and service.
Because they were indeed local, there was a wide variety of CLSCs that provided different services in their different locations. There was also quite a variation in their uptake and effectiveness. In some better off communities, the vast majority of people had family doctors and little need for social services; in others, the CLSC was a vital part of the community with ever evolving services and support. The result was that there was little standardization of their services, which had been the original idea. By the time of regionalization, some CLSCs, such as CLSC Notre Dame de Grace in a working class neighbourhood of Montreal, were very effective in their localities – providing a wide range of services including education and prevention programs, social and other supports for people at risk living in the community. Others were very small and provided a minimal range of services, mostly community nursing and home support.
Regionalization resulted in disbanding the large, more effective CLSCs like the one in Notre Dame de Grace. The smaller ones lost their local governance and were merged into home care agencies, and continued to exist in that form. Regionalization in Quebec quickly and effectively ended the CLSC experiment at exactly the time when it would have been a good idea to see how to expand services in the community even more. Interestingly, only a small mention is made of this rather devastating change in Paradigm Freeze. That is, I think, largely because the loss of these services is not seen as having a connection to the health care system as they understand it. It’s important that we expand the notion of health care to include precisely the range of services that are largely ignored in the book – positive change comes even more slowly when impactful community-based solutions are overlooked.