First and Foremost in Community Health Centres: The Centre in Sault Ste. Marie and the CHC Alternative

Jonathan Lomas provides an in-depth historical analysis of Canada’s first community health centre (CHC), which opened in 1958. In the first part of the book, the reader is introduced to the political, economic, and social issues inherent in both alternative and traditional health care delivery systems via a chronological history of the Sault Ste. Marie CHC. The effects of complex interactions among government, the medical profession, and the community are outlined in the second section.

Over a dozen community health centres currently exist in Ontario and are collectively part of the Association of Ontario Health Centres. Alternative health delivery services such as CHCs provide more opportunity for cost efficiency as the economic incentives are different from those evidenced in traditional modes of delivery. The physician is no longer the major decision maker in allocating health resources, and the implementation of prepaid group practice eliminates the problem of overbooking patients. There is no extra billing or extended waiting times, and on-call schedules are more convenient to the patient. The base of health services available is broadened with employment of a multidisciplinary approach. Most importantly, community input is, theoretically at least, a factor in the allocation of resources. In many ways, CHCs appear to be an ideal alternative to traditional delivery systems as they are more cost-effective, convenient to patients, and community responsive. However, resistance from the medical profession and a lack of support from government has hindered full development of the CHC alternative. Government, until recently, seemed to favor the physician-sponsored health service organization (HSO) model, in which community input and the team approach most often do not exist. There have also been problems with community representation on CHC boards, with the actuality of this concept varying widely from theory. This difficulty is especially troubling since CHCs are traditionally defined as “health system structures where the community humanely and unselfishly optimizes health resources” (p.180). All too often community representation is not representative of the community.

Government, even ready to reduce health care costs, has recently made a greater commitment to CHCs. The problem of community participation and the tendency to regress to physician-dominant operations still remain. Lomas fails to propose solutions to these areas of concern. If lack of community participation and resistant medical attitudes are not addressed, CHCs will evolve as delivery systems that are not really alternative in the true sense of the word. Like physician-sponsored HSOs, they will possibly provide for a more cost effective delivery system but will fail to meet diverse community needs.

While this book will appeal to a limited audience, it does provide an excellent historical analysis of alternative health care delivery systems and the political forces that shape health services in Canada. Unfortunately, Lomas does not provide much information on the experiences of other CHCs. This would have provided his discussion of CHCs with a wider perspective.