Care in the Doctor's Office
When national health insurance legislation was enacted by the federal government in 1957 and 1966 there was already a medical care delivery system in place. The purpose of the health insurance legislation was to provide more adequate and better distributed funding to support this system of care. It was not until the whole new funding system was in place that questions began to be raised about the health outcomes of this subsidized traditional structure of organization (Le Clair 1975), for until then, the main thrust of government policies had been towards improving universal access of individuals to hospitals and physicians' services.
The medical model of health care was firmly established in Canada in the nineteenth century. Desrosiers (1979) associated its rise with industrialization in Quebec, but elsewhere demand for medical services was not confined to the cities. When the prairies were settled early in the twentieth century, one of the principal objectives of the farmers' cooperatives' policies was to encourage well qualified physicians to serve rural communities (Badgley and Wolfe 1967).
In 1910 Flexner reviewed the work of medical schools in North America and made it clear that they should provide teaching based on scientific research in laboratories and teaching hospitals. The effect of this study was to put medical schools at the top of a pyramid — a "regional hierarchy" (Fox 1987) — with quaternary care specialists working in university health science centres at the peak, tertiary specialists providing service in metropolitan areas, secondary specialists working in hospitals in the larger population centres in the middle (although often these secondary centres in the provinces are known as regional centres) and primary care giving general practi