Saskatchewan adventure : A personal record.

THE POLITICAL PROCESS

Saskatchewan adventure: a personal record.

Part I, background to the story

By Lord Taylor, B. Sc, M.D., Hon. LL.D.,F.R.C.P., F.R.C.G.P. I have been asked to write an account of my part in the remarkable series of events which took place in Saskatchewan in 1962, and to comment on the effectiveness of the solution.

My story is part history, part sociology and part autobiography. It records what was in effect the final stages of an unusual industrial dispute. Professional people do not as a rule resort to the ultimate weapon of withdrawal of services, if only because they are as a rule "self-employed". But once a profession is converted, or in danger of being converted, into a public service, the situation is different. Earnings cease to be determined by professionally-devised scales of fees and the haggle of the market. Instead, the profession has to struggle for its share of the available public revenue. It also has to struggle to retain its professional

autonomy in the performance of its work.

The so-called "strike" or "withdrawal of service" by the Saskatchewan doctors in July 1962 was, in fact, never complete. The doctors organized their own free emergency medical service, so that urgent public needs were still met. And the government recruited a small number of doctors from Britain.

The term "strike" was most carefully avoided by the doctors and their representatives, and, indeed, by all who were working towards the ending of the dispute, including myself. In fact, it was a strike.

A substantial part of the public supported the doctors, if only because they disliked the government. In retrospect, it would appear that the government acted with the best of motives, but with a lack of understanding of the feelings of the ordinary medical practitioner. On the other hand, the doctors could not believe that the government was composed of honest and responsible people, at least as concerned with the needs of the public as the medical profession.

The most important single part of the story is the Saskatoon Agreement.

This brought the dispute to a conclusion, which has, in the long run,

Lord

Taylor

proved satisfactory. It has provided a model for the other provinces of Canada. It is far from being a piece of doctrinaire socialism. It is, rather, a pragmatic exercise in methods of paying for medical care, so as to ensure that both public and professional needs are fairly and properly met. Strangely enough, very few people seem to have read the original document.

Medicine is a tough and difficult profession, which demands toughness in those who practise it. In consequence, doctors tend to perform on their own terms or not at all. The most important of these terms is that they should not be "pushed around" by other doctors, or by laymen whether patients or politicians, civil servants or administrators. In the last analysis, it was because the doctors believed that the Saskatchewan Government was trying to tell them how and where they should do their job that they struck.

In most industrial disputes, rates of pay bulk large. On this occasion, they were hardly mentioned. The scale of fees recommended by the College of

720 CMA JOURNAL/MARCH 16, 1974/VOL. 110

Physicians and Surgeons of Saskatchewan was accepted as fair by both the doctors and the government. The proposed method of raising the money to pay for medicare was of greater importance to the medical profession, because it made insurance for medical care a government monopoly.

It follows that part of the dispute eentred on the dangers inherent in having a single paymaster. These dangers are real. Planners, whether socialist or capitalist, seem to delight in unnecessary consistency. To achieve this, they do not hesitate to narrow down other people's freedom of choice.

In so far as I was able to play a part in solving the problems underlying the dispute, it was largely because I was experienced in both politics and medicine. I am by nature a planner.

But I know, from experience, that planning will only work if it is flexible and non-confining. To do his best, man must be as free as possible, and he must feel free as well. The plan must also be just. But justice without freedom is not acceptable. Finally, the plan must be effective, that is to say, it must achieve what it sets out to do.

Otherwise, it is best filed away and

forgotten.

Effectiveness demands a measure of discipline on the part of those who carry out the plan. For the most part, this must be self-discipline. So the plan must be acceptable, and must continue to be acceptable, to those who have to operate within its framework. But some will deliberately exploit either the situation or their colleagues, by cheating or taking more than they give.

For these few, there must be some sanction. But it is better to condone abuse by a few than to damage or destroy the legitimate freedom of the

great majority.

view, the Saskatoon Agreerequisites.

A few days after the job was done, I was asked to dictate my account of what happened for the Archives of In my

ment fulfils all the above

Saskatchewan. My verbatim record has already been drawn on briefly by Drs. Robin Badgley and Samuel Wolfe for

their book, "Doctors' Strike" (Macmillan of Canada, 1967).

Their book contains a mass of useful material. But it seems to me to have a strong left-wing viewpoint. I find myself in considerable doubt about the blacks and whites, as painted in by Drs. Badgley and Wolfe. I see honest men on both sides, well motivated but mystified by the actions of their opponents. I therefore welcome the present opportunity to correct the picture while it is still fresh in our minds.

Many people in many countries played a part in the creation of national health services and medicare. There were also many bitter opponents.

Among the opponents, none were more vociferous than the more conservative elements of the medical profession.

Often devoted servants of the community, they feared that the practice of good medicine would be destroyed by bureaucracy, that a medical hierarchy would wipe out initiative in the name of administrative tidiness, and that the freedom of the medical profession to advance the science and art of medicine and to speak out on all public matters would become a thing of the past.

These were real and reasonable fears, far more important than emotional allegations of "creeping socialism".

I am fortunate to have played a part in the design and the launching of the British national health service, and in the start of medicare in Canada.

I have long held that the modern world can only be made to work by a judicious mixture of socialism and private enterprise. Too much socialism saps initiative, while too much private enterprise tears itself to death. This doctrine of balance has proved easy to accept in Britain, though its application has presented great difficulties. In the United States, however, private enterprise has been seen as the only road

Harlow New Town took so much of Lord Taylor's time in 1962 he didn't get around reading Saskatchewan Premier Woodrow Lloyd's challenging speech on medicare until he was flying the Atlantic.

to

without parallel in the civilized world.

Indeed a part of this excellence springs from the almost pathological modesty of the average Canadian. The impact of Canada on the States is without noise, and almost without external evidence that it is happening.

It will I think be surprising if medicare, Canadian style, is not universal in English-speaking North America within the next 10 years. When this happens, it will be because the Canadian demonstration has succeeded on its merits.

Thanks to the demands of Frenchspeaking Quebec for freedom within the confederation, the provinces have substantial autonomy in relation to the central government. I believe the re¬

sulting diversity is, on balance, healthy.

It so happened that there were in to Utopia, a messy Utopia perhaps, Saskatchewan a number of men of but one full of vigour and life, en¬ English, Scottish and Welsh origin, who thusiasm and hope. had been active in the British labour In emergency, the Americans are movement in their youth. Cooperation, quick learners. But they prefer prag- trade unions and political action were matic demonstration to theoretical for them the normal pattern of life, teaching. Canada, so like America in and a democratic socialist Utopia many ways, is nevertheless very dif¬ seemed to them a practical possibility. ferent in national temperament. It is So out of farmers, trade unionists and quieter, less ebullient, and less certain working-class socialists, the first maof the way ahead. The typical Cana¬ jority socialist government of democradian is careful and cautious, a saver tic North America was born. And for and an insurer, by no means totally decade after decade, with a short committed to private enterprise, and Liberal interregnum, it has ruled Sasnot averse to experiment in state enter¬ katchewan with considerable success.

In 1946, I paid my first visit to prise, state marketing and comprehensive state welfare.

Saskatchewan. Tommy Douglas's CCF But for all this, there is great com¬ government had already inaugurated a munity of interest throughout English- free cancer treatment service, a free mental health service and a flying speaking North America.

Despite its quiet and hesitant tempo, ambulance service. The term "free" it is my view that Canada offers a must at once be qualified. These servpattern of life

to its citizens which is

ices

were

free at the time of use, but

paid for eral taxation.

were

by

everyone out of gen¬

The government

was

at that time

just about to start a comprehensive hospital insurance scheme, covering all costs except doctors' bills. Legislation to deal with doctors' bills was postponed until 16 years later. But even then, the doctors were making it clear that they were not interested in a salaried service, which they equated with slacking and a poor cash return

for hard work. Interest was eentred, in so far as there was any, on fee-forservice payment, that is, piece-work.

Having seen both systems in action, I am inclined to prefer the Saskatchewan system of fee-for-service. This has now become general all over Canada. It encourages self-reliance and it rewards industry and energy. These are priceless assets in the practice of medicine. Moreover, excessive earnings can be reduced, by the simple process of limiting items of service to a number within the capacity of the honest and efficient doctor.

In some circumstances and in some places, for example sparsely populated areas, an element of salary is essential, if only to attract and hold the necessary practitioners. But, on balance, experience has shown that fee-for-service payment makes for a happy and united medical profession whose value to the public is correspondingly increased.

Salaried service results in artificial discrimination and a medical hierarchy based on salary, in which quality of work at all levels tends to decline.

Fee-for-service has one serious disadvantage. As people get older, their total work capacity declines. A wise doctor in his fifties will see fewer pa-

CMA JOURNAL/MARCH 16, 1974/VOL. 110 723

tients and perform fewer acts of service than in his thirties and forties.

Yet the quality of his work may, as a result of experience, be higher than ever. There is no good reason why his total earnings should decline. It is not, therefore, surprising that some older doctors speak out for a salaried service.

Perhaps the option of a salary might be offered to doctors over 50.

In the 16 years after my first visit to Saskatchewan, I left the House of Commons, and became a new-town builder and visiting research fellow in social medicine for the Nuffield Trust.

Then 1958, I was made a Life Peer, and it soon became my duty to look after health service affairs and higher education for the Opposition from the front bench in the House of Lords. I must confess I gave little thought to the great nation of Canada across the water, and less still to Saskatchewan.

The first time I knew there was trouble brewing in Saskatchewan was in June 1962, when I heard from an old friend of war-time days, Graham Spry. Mr. Spry was by this time Saskatchewan Agent-General in London.

His letter enclosed a copy of a speech which had just been delivered by Premier Lloyd to the College of Physicians and Surgeons of Saskatchewan.

I was, at this time, extremely busy in Harlow New Town and in parliament and, I must confess, I did not read Mr. Lloyd's speech.

A few days later Mr. Spry brought a Dr. Wolfe to see me at the House of Lords. This, incidentally, was the same Dr. Wolfe who later wrote "Doctors' Strike". They told me that a

Medical Care Insurance Act had been passed by the Saskatchewan Legislature, against the wishes of the medical profession. If it was implemented, the doctors proposed to withdraw their services, setting up an emergency free service at the major centres in the

province.

working. Accordingly, I advised Mr. Spry to advertise in the non-medical journals, particularly the so-called The Times, "quality" newspapers Manchester Guardian and Daily Telegraph and to circularize the whole medical profession directly through the .

.

post. I believe both these steps

were

taken.

Workable, reasonable

Looking back on it, I was perhaps glanced through the act and unduly naive. The doctors could have thought that, on the whole, it seemed answered my argument by saying that workable and reasonable. But one the government had only to withdraw clause clause 49(1) g could be the medicare act to have their services interpreted as giving the Medical Care back at once. The government could Insurance Commission the power to have replied to do so would have condirect doctors in the way they should stituted an abrogation of sovereignty, do their work. All my libertarian in- a hand-over of power from the elecstincts were aroused and I suggested torate to a small professional group to my two colleagues that this section intent on getting its own way. Since of clause 49 ought to be withdrawn. each side considered its case to be They then suggested that I should write overwhelming, and neither would budge to Premier Lloyd and give him my an inch, battle was inevitable until one views. At the same time, I wrote on side won or a peace could be agreed. the same lines to The Lancet.

On July 4, the House of Lords was A few days later, Mr. Spry again debating the working of the new Mental got in touch. This time, he wanted Health Act, and I was leading from to tell me he was about to attempt to the front opposition bench for the recruit British doctors for Saskatche¬ Labour Party. My speech had involved wan, to man the services in the event a great deal of research and things of a strike. Medical journals in Britain went well. Nevertheless, I was quite were refusing to carry his advertisetired at the end of the debate, and got home late. There I found waiting for ments, and he sought my advice.

I had now to think matters over very me a letter from Graham Spry, telling carefully. We had then no experience me that Premier Lloyd wanted me to of doctors' strikes. So I had to make come out to Saskatchewan to help. up my mind on inadequate evidence. I Needless to say, the letter was marked concluded that it was fair for the "Urgent".

Government of Saskatchewan to offer It so happened that I was very fully employment to British doctors, pro¬ engaged at the time. However, I disvided they understood precisely the cussed the matter with my wife, and, conditions under which they would be in view of my special experience, she felt strongly that I ought to go.

I

.

.

Conditions

The House of Lords, where Taylor was speaking the day he received an urgent "help-us" message from embattled Saskatchewan government.

I laid down certain conditions. First, the Government of Saskatchewan must pay all my expenses. Second, I must receive no fee, for, if I did so, the doctors would not be prepared to trust me. Third, I would wish to have a week's fishing holiday at the government's expense at the end of my visit.

I felt there was no likelihood of the doctors' misunderstanding suoh a request; here I was quite right, for most of them were, in fact, spending their own free time in precisely this way.

The London representatives of the Canadian press and television descended on me, and I made full use of this to try to build up a picture of myself which would prove acceptable to the doctors of Saskatchewan. I had to play down my Labour Party associations and emphasize my interest in the life and work of the ordinary medical practitioner. I had to show that a member of the House of Lords was not necessarily a stuffed shirt. I had to

show, also, that, although I

was

being

CMA JOURNAL/ MARCH 16, 1974/VOL. 110 72$

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DOSAGE Essential Hypertension: 2 to 4 tablets per day.

Treatment should be continued at least two weeks.

Edema: 2 to 4 tablets per day. Occasionally the dosage requirement may range from one to eight tablets per day.

For children the daily dosage is 1.5 mg of Aldactone per pound of body weight.

PRECAUTIONS Caution is to be exercised in treating patients with severe hepatic disease, hepatic coma, gastrointestinal intolerance and known hypersensi-

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invited by the government, my interest was in fair play all round. Thus, I was doing my best to set the stage, as it were, to facilitate the task of peacemaking when I arrived.

I also made it clear that I was not a mediator. A mediator is appointed by both sides, while I was appointed by one side only. I hoped that, in due course, I might be able to help the doctors as well as the government, but I knew at the start that my only chance was to make the true position abundantly clear.

I am fairly well known among British doctors for the part I played during the introduction of the National Health Service, and also for the studies I have made of good general practice.

I also count myself fortunate to have a very large number of medical friends in Britain. In consequence, I was able to talk with the editorial staff of The Lancet and the secretary of the British Medical Association about what I was being requested to do. I asked both if they felt they could properly say anything to make me acceptable to the Canadian doctors. They were very good about this and wrote extremely helpful leading articles and gave me good wishes, which I am sure meant a great deal on the other side of the ocean.

I also sent a cable to Dr. A. D. Kelly, the General Secretary of the Canadian Medical Association. I got back a message that he hoped to see me in Saskatoon.

Atlantic crossing On Monday, July 16, I flew to Canada. When I arrived at Toronto I was met by a prominent member of the New Democratic Party, George Cad-

bury.

We had a long talk and it was much like talking to one of our own intellectual Labour theorists in Britain.

We faced just the same situation in Britain when Labour came to power in 1945. Our keenest people were often those who had undergone a powerful intellectual conversion to socialism.

But having experience of government in a modern industrial community helps to teach one the need for compromise, and I think most people in the British Labour Party have learned this. They know from experience that politics is the art of the possible, and they want to improve the life of the people, rather than attempt to usher in the new millennium. Strangely enough, some of our theorists seem to have a political death-wish. They would rather stick to the pure milk of the doctrine and fail gloriously or ingloriously than compromise and succeed.

When I started work in Saskat-

chewan, I discovered that there were a number of people whose views coincided closely with our British theoreticians. They wanted to achieve a pattern of health services dominated by local citizen groups on which they had set their hearts. Two or three such groups had been established, but they were far from popular with the majority of doctors.

I suspected that cooperative consumer-controlled medical clinics were not generally compatible with the highest standards of medical practice. To this generalization I am sure there are exceptions, so I would not prevent such clinics by law. Experience is in this matter, both for the public and the doctors, the best teacher. But equally to attempt to impose such clinics by law is both foolish and self-defeating. Clearly, I was going to have to explain these views to the Government of Saskatchewan; and also, at the same time, convince the doctors that it was safe to permit such clinics to exist; they would provide a service in no way superior to that given in conventional practice, and would therefore present no challenge in the long run.

Moreover, there might be areas, especially in the poorer parts of larger towns, where the standards of general medical practice were lower than they should be. In such areas, cooperative or municipal clinics might well offer the best hope of upgrading general

practice.

This digression serves to show how important was my talk with Mr. Cadbury. Although he did not know it, he was in fact warning me of the true nature of the doctors' fears and the government's misapprehensions.

At each place where the plane stopped, I was met by the local press and radio and television. On each occasion, I said the same thing: "I am not a mediator; I am coming out at the request of the Government of Saskatchewan; I am only too willing to help both sides; but I will only help the doctors if they want me to do so."

At Regina I was met by members of the government and a great concourse of pressmen together with people carrying banners. These latter were representatives of the "Keep our Doctors" organization - KODS for short.

Once again I gave my little talk to the press. On this occasion I added that, even though I was appointed by the government, I was not receiving any pay other than my promised fishing trip.

Only then did I get to bed.

In the second part of his story, Lord Taylor describes how he analyzed the dispute, and the personalities involved, and worked out ways in which the conflict could be resolved.

CMA JOURNAL/MARCH 16, 1974/VOL. 110 727

THE POLITICAL PROCESS

Saskatchewan adventure: a personal record.

Part II, making contact

By Lord Taylor, B.Sc, M.D., Hon. LL.D., F.R.C.P., F.R.C.G.P. Lord Taylor continues his series of personal reminiscences, written specially for CMAJ, of the part he played in the settlement of the great medicare dispute in Saskatchewan in 1962. The first installment described how he received an urgent message from Premier Woodrow Lloyd asking him to fly to Regina and help.

Regina on the night of Monday, July 16. The next day was extremely busy. First I went to the parliament buildings to meet provincial Premier Woodrow Lloyd and one or two of his ministers. The setting is magnificent, with a fine artificial lake reflecting the great building and the beautiful gardens which surround it.

To someone coming fresh from England, it was a surprise to find the legislature in a Canadian province housed in the same building as the civil service. In Britain we keep them apart quite deliberately; yet in communities with small populations, the Canadian arrangement makes good # # t sense. Members of the legislature, including the cabinet, use the same cafeteria as the civil service, and relationships are far less formal than in Britain. of them departed and are now occupyMr. Lloyd had been a schoolteacher. ing key positions in other provinces He had taken over from Tommy or in the federal civil service or in Douglas a few months previously and universities.

I do not think I would be unfair to From the parliament building I him if I said that the duties of leader¬ went to the offices of the Medical Care ship sat heavily on his shoulders. He Insurance Commission, the body which was a man of great charm and kindhad been set up to administer medicare. ness, but he preferred to act as an The president of the commission was impartial chairman to his cabinet, a Don Tansley, who had previously been gentle seeker of consensus, rather than in charge of finances in the Saskatas a dynamic leader. chewan civil service. The chief medical Over the years the Saskatchewan CCF officer of the commission was Dr. government had collected a remarkable Graham Clarkson, originally from group of civil servants. Attracted by Glasgow, who trained for the RAF in the idealism of the party, they had western Canada during the war. Dr. come from all parts of Canada and Clarkson, in due course, became deputy combined efficiency with dedication in minister of health of Saskatchewan, remarkable measure. When the Thatch- and he was, in effect, the principal er Liberal I arrived in

%w%%*:w

*^W?*; ^^^f^i

government took over, many

v-Vjf 4

Saskatchewan during these critical months.

The executive and clerical staff at the medical care commission were in a low state of morale. They had been all set to administer the payments of medicare to the doctors, and then had come the strike. They had nothing to do but imaginary dummy runs and exercises, at which they were becoming pretty perfect. I was asked to give them a few talks to try to cheer them up, and this I did in each of the offices.

Good luck Next came a piece of gratuitous good fortune. I was asked to go and see Mr. Justice Emmett Hall, Chief Justice of Saskatchewan, who was chairmedical officer to the government of man of the federal Royal Commission CMA JOURNAL/APRIL 6, 1974/VOL. 110 829

but sometimes may persist after discontinuation of the phenothiazine. Parasthesias, slowing of the EEG, disturbed body temperature, muscle weakness and convulsions also reported.

Autonomic: Dry mouth, constipation, urinary frequency, blurred vision, and nasal congestion may occur. Cardiovascular: Severe, acute hypotension, of particular concern in patients with mitral insufficiency or pheochromocytoma; ECG abnormalities (quinidine-like effect), changes in Nourolept c-Antidepressant pulse rate and cutaneous vasodilatation also reported. Toxic and Allergic: The phenothiazine compounds have produced blood dyscrasias INDICATIONS: 'ELAVIL PLUS'* (amitriptyline (pancytopenia, thrombocytopenic purpura, hydrochloride and perphenazine) is indicated in leukopenia, agranulocytosis, eosinophilia); and patients with anxious or agitated depression. It is liver damage (jaundice, biliary stasis). These have particularly indicated in patients with depression not been observed with perphenazine. Skin disassociated with marked psychomotor unrest and orders (photosensitivity, itching, contact anxiety. It has also been found useful in some dermatitis, erythema, urticaria, eczema, up to schizophrenic patients who have associated symptoms of depression. 'ELAVIL PLUS'* has been exfoliative dermatitis), as well as other allergic reactions (asthma, laryngeal edema, angioneurotic used in depressed patients, suffering from marked agitation, anxiety and tension, who may respond to edema, anaphylactoid reactions) have occurred.

Endocrine and Metabolic: Disturbances in the the combination of a phenothiazine with menstrual cycle, lactation, swollen breasts, failure amitriptyline. of ejaculation, reduced sexual urge in the male, DOSAGE SUMMARY: Keep in mind indications, increased sexual urge in the female, pseudomanagement considerations, dosage schedules pregnancy, infertility, and glycosuria. Increased and attention to tolerance and response of appetite, weight gain, hyperglycemia, altered patients to either perphenazine or amitriptyline. fluid proteins, peripheral edema. cerebrospinal The usual initial dose of 'ELAVIL PLUS'* is one Ophthalmological: Centrally located stellate tablet three or four times a day, individualized cataracts, corneal opacities, pigmentation of the according to the need and response of the patient, conjunctiva, cornea or lens, lacrimation and not exceeding 9 tablets per day. Dosage for kerato-conjunctivitis reported following use of children not established. Sedative effect is rapidly phenothiazines; pigmentary retinopathy occurred apparent, the antidepressant effect is delayed. with some phenothiazines with a piperidyl-ethyl After a satisfactory response is noted, dosage side chain. Miscellaneous: Other adverse reactions should be reduced to the smallest amount reported with various phenothiazine compounds necessary to obtain relief from the symptoms. include gastrointestinal effects such as nausea, vomiting and heartburn; potentiation of CNS CONTRAINDICATIONS: Central nervous system depressants; headache; and cerebral edema. depression from drugs (barbiturates, alcohol, hydrochloride: Behavioural: Amitriptyllne narcotics, analgesics, antihistarrines); bone marActivation of latent schizophrenia; high doses may row depression; known hypersensitivity to cause temporary confusion or disturbed phenothiazines or amitriptyline; during the acute concentration, or rarely, transient visual recovery phase following myocardial infarction, hallucinations; hypomanic reactions; drowsiness and in the presence of acute congestive heart failure; patients receiving guanethidine or similarly which usually disappears with continuance of therapy; insomnia, giddiness, restlessness, acting compounds. Do not give concomitantly with agitation, fatigue, nightmares, disorientation, MAOI drugs. Allow minimum of 14 days between therapies, then initiate therapy with 'ELAVIL PLUS" delusions, excitement, anxiety and jitteriness.

Neurological: Epileptiform seizures; numbness, cautiously, with gradual increase in tingling, paresthesias of the limbs including dosage until optimum response is achieved. peripheral neuropathy; dizziness, fine tremor, WARNINGS: Tricyclic antidepressant drugs headache, ataxia, seizures, alteration in EEG including amitriptyline particularly when given in patterns, extrapyramidal symptoms, tinnitus and high doses have been reported to produce incoordination; severe tremor only observed in arrhythmias, sinus tachycardia, and prolongation high doses. Autonomic: Evidence of of the conduction time. A few instances of anticholinergic activity, such as urinary retention, unexpected death have been reported in patients reversible dilatation of the urinary tract, with cardiovascular disorders. Myocardial constipation, and more rarely, paralytic ileus of infarction and stroke have also been reported with particular concern in the elderly; dry mouth, drugs of this class. Therefore, these drugs should blurred vision and disturbance of accommodation. be used with caution in patients with a history of Cardiovascular: A quinidine-like effect and other cardiovascular diseases such as myocardial reversible ECG changes such as flattening or infarction and congestive heart failure. inversion of T waves, and bundle branch block; Patients on 'ELAVIL PLUS'* should be cautioned orthostatic hypotension, and with toxic doses, against driving a car or operating machinery or ventricular tachycardia and fibrillation have apparatus requiring alert attention. Use cautiously occurred. A few instances of unexpected death in patients with history of urinary retention, have been reported in patients with cardiovascular glaucoma, or convulsive disorders. 'ELAVIL PLUS'* disorders. Myocardial infarction and stroke have is not recommended for use in children or also been reported with drugs of this class. Toxic pregnant patients. and Allergic Effects: Bone marrow depression PRECAUTIONS: Suicide is a possibility in seriously including agranulocytosis, eosinophilia, purpura and thrombocytopenia; jaundice rarely. Allergic depressed patients and may remain until type reactions manifested by skin rash, urticaria, significant remission occurs; this type of patient should be closely supervised, especially during the photosensitization or swelling of the face and tongue and itching occurred rarely. early phase of therapy. Patients should be cautioned against errors of judgement attributable Gastrointestinal: Nausea, epigastric distress, heartburn, vomiting, anorexia, stomatitis, peculiar to change in mood, and also of possible increased taste, diarrhea, parotid swelling, black tongue. response to alcohol. Observe caution when Endocrine: Testicular swelling and gynecomastia administering to patients who have previously in the male, breast enlargement and galactorrhea exhibited severe adverse reactions to other in the female, increased or decreased libido, phenothiazines. The antiemetic effect of perphenazine may obscure signs of toxicity due to elevation and lowering of blood sugar levels.

Metabolic: Increased appetite, weight gain or overdosage of other drugs or render more difficult weight loss in some patients. Ophthalmologic: the diagnosis of disorders such as brain tumors or Precipitation of latent glaucoma or aggravation of intestinal obstruction. Discontinue the drug in the existing glaucoma; blurred vision and mydriasis. event of signs of individual intolerance to Miscellaneous: Other side effects that may occur perphenazine. If hypotension develops, epinephrine should not be used. To avoid possible include fainting, weakness, urinary frequency, potentiation of action of any of the central nervous increased perspiration, and alopecia. Withdrawal Symptoms: Abrupt cessation of treatment after system depressants or atropine in concurrent prolonged administration may produce nausea, therapy, reduce dosage of 'ELAVIL PLUS'*. headache, and malaise; these are not indicative of Antidepressant medication may provoke mania or addiction. hypomania in manic-depressive patients; the PRODUCT CIRCULAR AVAILABLE ON REQUEST likelihood of this seems to be reduced by the HOW SUPPLIED: Ca 3311 - Tablets tranquilizing component of 'ELAVIL PLUS'*.

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Mr. Justice Hall helped make Taylor acceptable to the medical profession. on Health Services. Judge Hall was an old friend of John Diefenbaker, though I did not know it, and I think the fact that he asked to see me helped to make me acceptable to the medical profession.

Actually, our discussion had nothing to do with the medicare dispute. Mr. Justice Hall wanted to talk to me about the future of mental health services and, in particular, what sort of bed provision was likely to be needed in the years ahead.

My next move was to telephone Dr. C. H. Crosby, the coordinator of the doctors' emergency services in Regina.

It will be recalled that the doctors had decided to set up a free emergency medical service in the major centres before they withdrew their other serv ices. I asked Dr. Crosby if I might come and talk with him and he readily agreed.

I met him and three of his colleagues at Regina General Hospital and we sat around the table and simply chatted. As I had expected, they differed in no respect from good doctors anywhere else in the English-speaking world. They were obviously fine men, but they were puzzled and worried about what had hit them. They knew little of politics and had no love of politicians. They knew that professional freedom was essential, if they were to do their work properly. They believed it was in danger, but they could not say precisely where the danger lay. I imagine that, at the same time, they were trying to sum me up and decide what kind of person I was.

I have no doubt they let their colleagues in Saskatoon know their feel-

CMA JOURNAL/APRIL 6, 1974/VOL. 110 831

Donald Tansley, president of the newly formed MdCI.

ings, just as I told the government of my feelings about them.

When one is faced with a difficult piece of negotiation, it is useful to come to it with a mind which is fairly clear and not cluttered up with a lot of detail. I knew a great deal about the general conditions necessary for good medical practice; but at this stage I knew none of the history of the medicare dispute in Saskatchewan. This early history is well given in MacTaggart's "The First Decade", and in "Doctors' Strike" by Badgley and Wolfe.

The actual plan for the medicare scheme had been worked out by a commission headed by Dr. W. P. Thompson, a former president of the University of Saskatchewan and a nonmedical scientist. The plan itself was a good one. It was based on the principle of universal prepayment for medical care; universal coverage for medical service; fee-for-service payment to the doctors and a single Medical Care Insurance Commission to administer the scheme.

Unfortunately, the bill introducing the scheme was not properly discussed with the profession and was thrust through the Legislature in a hurry because of the impending move of Mr. Douglas from provincial to federal politics.

Reluctant In the 15 years preceding the passage of the new act, the Government of

Saskatchewan had built up a remarkably fine hospital service on an insurance basis. At first the doctors had been reluctant participants; but soon they were cooperating to the full and they themselves had created two voluntary insurance schemes to enable those patients who could afford it to insure against doctors' bills.

The doctors were quite willing to see these medically administered schemes extended. What they objected to was a universal state scheme which would abolish their independent schemes and provide them with only a single paymaster. It was this belief - that they were to be forcibly enrolled as civil servants - rather than any overt anxiety about finance which caused them to refuse to cooperate with the government of the province and ultimately led to their withdrawal of services.

The government, on the other hand, was sincere and dedicated in its determination to ensure that the people of the province should all receive the best possible medical care, without financial burden at the time of illness and without any taint of charity. Mr. Douglas graphically described his own experiences as a child in a Winnipeg charity hospital, and one had only to talk to the cabinet to realize that here was a group of men whose motives were of the highest.

Nevertheless, there were intense political overtones. Over 20 years the CCF government had inevitably built up its enemies. The press was, in the main, hostile although outside Saskatchewan a high level of objective reporting obtained, particularly in Winnipeg and Toronto. Moreover, industry and business and the professions looked to the political parties which they supported, rather than to the government, for any help they felt they needed.

The American Medical Association was at this time hysterically opposed to medicare; and it endeavoured, not without some success, to communicate its hysteria to the doctors and the public in Saskatchewan. It was in this mood that the "Keep Our Doctors" association was able to develop. Many of those who opposed medicare saw in this struggle an opportunity to bring down the CCF government, at a time when the dynamic leadership of Tommy Douglas had just been removed.

I think it would be fair to say that, despite its goodwill, the government was quite ignorant of the pattern of thought of the ordinary medical practitioner. Its members could not conceive of people who did not believe in collective action) who were resolutely opposed to public control, and who believed that even the most benign of civil services would all too soon

832 CMA JOURNAL/APRIL 6, 1974/VOL. 110

XStemetil prochlorperazine

Indications: nausea and vomiting of various etiologies: gastrointestinal disorders, drug intolerance, motion and radiation sickness, post-operative conditions, pregnancy, vertigp and migraines.

Dosage: Oral route - Usual effective dosage is 5 to 10 mg, 3 or 4 times daily; in very mild cases, a single dose of 5 to 10 mg is often adequate. Parenteral route (not to exceed 40 mg per day) In general practice: 5 to 10 mg I.M., 2 or 3 times a day. In surgery: 5 to 10 mg l.M., 1 to 2 hours before anesthesia.

Repeat once during surgery if necessary. Post-operatively, same dose of 5 to 10 mg l.M., repeated every 3 to 4 hours. May be given l.V. during and after surgery in the infusion solution at a concentration of 20 mg per litre. In obstetrics: 10 mg l.M. during first stage of labor, subsequent 10 mg doses as needed. Post partum: the usual total daily dose is 15 to 30 mg orally or l.M. Contraindications: comatose or deeply depressed states of the CNS due to hypnotics, analgesics, narcotics, alcohol, etc.

Precautions: etiology of vomiting should be established before using the drug as its antiemetic action may mask symptoms of intracranial pressure or intestinal obstruction. If used with CNS depressants, the possibility of an additive effect should be considered. Patients with a history of convulsive disorders should be given an appropriate anticonvulsant while on prolonged therapy. Use with great caution in patients with glaucoma or prostatic hypertrophy. No teratogenic effects have ever been reported; however, the drug should be used cautiously in pregnant patients.

Overdosage: no specific antidote; symptomatic treatment. In case of hypotension, standard treatment for shock; if necessary, norepinephrine should be used.

Dosage forms: tablets 5, 10 and 25 mg; ampoules 2 ml/10 mg; multidose vials 10 ml/50 mg; liquid 5 mg and 15 mg per teaspoonful (5 ml); suppositories 5, 10 and 25 mg.

References 1. Peterfy, G. and Pinter, J.: Current Therap.

Res. 14(9):590-598, September 1972.

2. Goodman, L. and Gilman, A.: The Pharmacological Basis of Therapeutics, 4th ed., 1970, p. 160.

3. Today's Drugs. Brit. Med. J. 1:481, February 21, 1970.

4. Wood and Graybiel: Clin. Pharmacol. Therap.

11(5):621-629, September-October 1970.

5. Courvoisler et al: C.R. Soc. Biol., 151, (6), 1144-48, 1957.

Complete information upon request MEMBER

* l~EE

have no doubt it will continue. The doctor at the operating table or the bedside must inspire confidence. When he presents his bill, he is far less popular. The revelation of the range of doctors' earnings in the public press is an inevitable concomitant of any publicly financed service.

All in all, it was not surprising that the Saskatchewan government and the doctors had clashed. It speaks well for the wisdom of both sides that we were able to resolve the dispute in eight #I

Premier Woodrow Lloyd, kind and charming, a gentle seeker of consensus.

dangerous tyranny. the doctor's individual good. But the collective image image of the profession was, and is, far less flattering. One of the difficulties of medical politics is that the practice of medicine and surgery is so absorbing that relatively few of the top men are prepared to devote their time to the political side. By contrast with the practice of medicine, committees and speech-making are boring and seemingly nonproductive. So the

turn into

a as now, was

Then,

doctors' case is, as a rule, not as well as it should be. In fairness to those who make medical politics a major job, it must be said that the quality of their work is far above the quality of their speeches.

In my experience, doctors in active practice work hours which would be considered foolish by any administrator. They continuously take responsibility which would horrify a cautious civil servant. In both matters, the doctor has no choice. These are conditions of the job, willingly accepted.

In return, the doctor expects to be free from financial anxiety. Viewed objectively, this is not an unreasonable expectation. But when the public see the doctor's gross earnings, they forget both the overhead expenses and the conditions of the work. Jealousy and other emotions are given free play, often most strongly by other professional people.

This ambivalence about doctors has existed for hundreds of years, and I

put

days.

Opportunity

The CCF had their annual convention scheduled for Wednesday, July 18, in Saskatoon, and the doctors' representatives were already meeting there in a sort of vertical Harley Street called the Medical Arts Building. This presented us with a splendid opportunity to get discussions going, with both sides in close proximity but not actually meeting. In Regina I had met only one or two of the cabinet because the rest were out in their ridings politicking (this was a new verb to me but it is an extremely descriptive one). There is nothing wrong in politicking, but, in my experience, as a means of finding out facts about anything it is an extremely one-sided operation.

So on Tuesday evening, we finished the day by driving to Saskatoon on my first journey across the Prairies. I must say I never saw anything like it in my life. It seemed to go on and on. I saw a prairie dog or gopher for the first time. We stopped at a little town called Davidson; we found it had nine churches and a total population of about 500; a most religious lot, or at least a most heterodox lot when it came to religions. Then we drove on to Saskatoon, and in the garden next to the Bessborough Hotel I saw my first North American robin.

The first thing I did on Wednesday morning was to ring up Dr. A. D. Kelly, general secretary of the Canadian Medical Association. He had said in his cablegram that he would see me, and he was as good as his word.

He came around to my room at the hotel with Dr. William Wigle, CMA president-elect, and one of the members of the council of the College of Physicians and Surgeons of Saskatchewan. We had a most friendly and helpful talk, and I must pay tribute to the conciliatory role that both Dr. Kelly and Dr. Wigle played. They were, to some extent, outside the fray, though not as far from it as I was.

In consequence, they were able to help our Saskatchewan colleagues, especially when feelings were running high and common sense was disappear-

834 CMA JOURNAL/APRIL 6, 1974/VOL. 110

Tommy Douglas, ex-premier, leader

moving

to federal

dynamic

a scene.

ing out the window.

At the end of our meeting, they suggested I might like to come around and meet with the representatives of the college in the afternoon. So here I was, after only 36 hours, about to meet a fully representative group of Saskatchewan doctors.

Meanwhile, they suggested that, for the rest of the morning, I might like to see how the emergency medical services were working. This I was very pleased to do.

I was taken around the hospitals by

Dr. Sam Landa, the coordinator of the doctors' emergency service. I was much impressed with the splendid buildings.

Indeed, I was commenting on one of these, when I was told it was, in fact, obsolete and was slated for the wrecker's ball. The university hospital, built of a fine local stone, was reminiscent of the Aberdeen Royal Infirmary. Here my host was Dr. Hansen, the professor of surgery. It was fairly clear to me that the university hospital would have liked to have steered clear of the medicare dispute; to what extent this had been achieved I did not find out.

Once more, my impression of the doctors who were staffing the emergency service was favourable. Perhaps inevitably, the emotions seemed to be stronger in Saskatoon than in Regina, if only because this was where the action was. But these doctors differed in no obvious way from my colleagues back in Britain. By and large, they did not understand politics or politicians

and disliked the subject and its practitioners. On the other hand, they were devoted to their profession, and their ultimate concern was with how best to serve their patients.

Met

college council

In the afternoon of Wednesday, July 18, I had my first meeting with the council of the College of Physicians and Surgeons. We always met in the same room, a solarium at the top of the Medical Arts Building, with a magnificent view of Saskatoon and the country around.

The council was a big group with between 30 and 40 members. Things were so arranged that Dr. H. D. Dalgleish, the president of the college, sat with me facing the group. Dr. Dalgleish was an extremely fair man.

He disliked socialism intensely. But he was determined that I should be given a fair hearing. And, as time went on, we became firm friends.

Another of the outstanding personalities was Dr. George Peacock, registrar of the college, whose duty it was to keep the special list of doctors licensed to practise in Saskatchewan. This, in itself, indicated one of the problems facing the government. Not only was the college a negotiating body for the

doctors; it also provided statutory pro¬ I asked each of them in

turn to be tection for the public against improperly kind enough to give me his name, qualified doctors. It was easy to see place of work and specialty. I wrote how an overanxious government could this all down in a notebook, so that, believe the worst of the college, when thereafter, I was able always to address it came to registering newly imported, a person by his name. Strangely strike-breaking doctors. enough, this helped break the ice; to To me, Dr. Peacock was kindness anyone setting out on a similar task I itself. He kept me supplied with to¬ can recommend it. bacco from his own pouch, and when Apart from this, I took very few I got tired of negotiating, he and Dr. notes. Every now and then, I would Dalgleish would take me out to an¬ write down a few words as a kind of other room where there was liquor and headline reminder to myself, for action Coca-Cola available. The only thing later in the same session or when I met the other side. But, for the most lacking was a cup of tea.

Another unusual character was Dr. part, as far as possible, I tried to carry E. W. Barootes, a urological specialist points in my head, so as to avoid forfrom Regina. Dr. Barootes was quite mality. the most talkative member of the assembly. Finally, one day when he had NHS experience tried the patience of all of us, I told him that if he did not keep quiet, I To open things up, I described to would have to ask him to leave the them some of the difficulties we had room! I had no authority for this, but had in England, when we started our the pressure of public opinion was such National Health Service. I told them that it worked! Now, Dr. Barootes is about how frightened the doctors were one of my best friends in Saskatchewan; of a salaried medical service and how, he recently told me how well the medi¬ in the end, we had been able to persuade care scheme had turned out, despite the then minister of health, Aneurin his forebodings.

Bevan, to write a new clause into the My first step was to give my col¬ act, making it clear that the governleagues, as they had now become, a ment had no intention of introducing short biography of myself, with special such a service. The response to this reference to my medical work. Then among my audience was unmistakable,

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CMA JOURNAL/APRIL 6, 1974/VOL. 110 835

and, in due course, a similar amending clause was agreed to by the Government of Saskatchewan.

It was clear, however, that the doctors had other serious concerns. They were desperately afraid that the existence of a single paymaster for the medical profession would inevitably lead to control from outside. As a means of escaping from this, they wanted the government to accept the existing voluntary insurance plans which they themselves had established, so that the medicare scheme would cover only the residue of the population.

I had to explain to them the difficulty of having any scheme which gave a special position to those who were good health risks, leaving the bad health risks to be carried by the state. I also pointed out that I could not imagine the government accepting voluntary agencies as collectors of what was, in effect, taxation revenue.

At the same time, I saw the point of their proposal that the existing prepaid insurance plans should be retained, as a means of paying those doctors who wished to be paid through them. The object of doing this would simply be to provide a barrier between the state and the profession. To jump ahead for a moment. The following morning the government agreed to this proposal, and from then on a very different atmosphere began to prevail.

To say that the doctors were in a touchy state would be an understatement. They were ready, at the drop of a hat, to put the worst possible interpretation on anything which the government might say. It was all understandable enough, but at the same time, it had to be dealt with. I quickly decided that, since the doctors and the government were, in effect, speaking different languages, it was vital for them not to meet. If they did, there were bound to be misunderstandings and, at once, the fighting would start all over again. So I had to keep them apart at all costs, until final agreement had been reached.

The corollary was that my reporting back to each side had to be absolutely accurate and truthful. It was essential that they should be able to trust, completely, anything I said, and to know that I would never in the slightest degree misrepresent either side to the other. It so happens that this is the way my mind normally operates. Sometimes I wish it were more tortuous, more capable of knight's moves at chess, and poker and bridge playing.

But I cannot think deviously, however hard I try. My concern is with finding the truth, and telling it when I have found it, in such a way that it is absolutely clear, Of course, one

knows all the time that truth is provisional only, waiting to be confirmed or controverted, when new evidence comes along. All this is simply another way of saying that by inclination and training I am a scientist and a teacher.

As a spy or a confidence trickster, I would be hopeless.

@LOmoti I速 slows the gut fast COMPOSITION: Each tablet and each 5 ml liquid contain 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate.

of

Too much At the end of this first fairly long session with the doctors, I reported back to the government in the hotel.

First I spoke with Premier Lloyd. Then I met with Don Tansley and Dr. Graham Clarkson, of the commission.

Then, finally, I met with the whole cabinet. This meant that, in effect, I had repeated myself four times in the course of an afternoon and evening.

I decided this was too much. Three talks to three sets of government spokesmen was roughly equivalent to six lecture-tutorials; to cram these into a four-hour period at the end of a busy day was positively absurd. So I managed to get Mr. Lloyd and his cabinet colleagues to agree to meet with the representatives of the commission as well as the civil servants concerned, as a single group. The result was that, from then on, I only had to make one report to each side.

That evening, Dr. Dalgleish addressed a large meeting of CCF delegates and visitors in the Bessborough Hotel ballroom. For the first time, an official spokesman of the doctors spoke with something approaching conciliation in his accents. The doctors must be able to work outside the act if they want to, he said; and the health insurance agencies must be built into the scheme. Once these were ensured by legislation, a return to work by the doctors could take place. For the first time, the doctors had dropped their demands for the repeal or suspension of the Medical Care Insurance Act. This first day was a very important one. Not only had both sides come to accept the idea that I might act as an intermediary and interpreter, as it were; but both were, for the first time, ready to make concessions. So it became vitally important to make sure that the reasonable demands and criticisms of both sides were fully understood and appreciated.

I had also discovered that both sides were prepared to listen to my suggestions, knowing that I had been over similar ground before. As far as I was concerned, from then on, analysis and synthesis could march hand-in-hand.

In the series' third part Lord Taylor describes how the Saskatoon Agreement was drafted and agreed.

836 CMA JOURNAL/APRIL 6, 1974/VOL. 110

INDICATIONS: Acute and chronic diarrhea; whether functional, or associated wlth conditions such as gastroenteritis, irritable bowel syndrome, regional enteritis, ulcerative colitis, infectious diarrhea and diarrhea following drug therapy. Also may provide effective intestinal control in patients following gastric surgery, ileostomy or colostomy.

CONTRAINDICATIONS: Jaundiced patients or patients hypersensitive to the components of Lomotil.

PRECAUTIONS: Lomotil should be used with extreme caution in patients with severe cirrhosis or advanced liver disease and In those patients receiving barbiturates or addictive narcotics. Administer with extreme caution to known atropine and diphenoxylate sensitive individuals. Do not exceed the recommended dosage.

WARNING: Keep out of reach of children; accidental overdose may cause severe respiratory depression.

ADVERSE REACTIONS: Are relatively uncommon; most frequently, nausea; less frequently, drowsiness, dizziness, vomiting, pruritus, skin eruption, restlessness, insomnia, bloating and cramps have been reported; and rare incidences of numbness of the extremities, headache, blurring of vision, swelling of gums, euphoria, depression and general malaise have occurred. Many of these might be symptoms of disease being treated; accurate differentiation Is often impossible.

DOSAGE AND ADMINISTRATION: ADULTS: 5 mg (2 tablets or 2 x 5 ml liquid) 3 or 4 times daily. Usual initial adult dose Is 2 tablets.

CHILDREN: 3- 6 months 5.0 ml 6- 12 months 7.5 ml 1 - 2 years 10.0 ml

2 - 5 years 5 - 8 years 8 - 12 years (5 ml equals 1 teaspoonful.)

12.5 ml 15.0 ml 20.0 ml

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SealePhrmcetial Oavl

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THE POLITICAL PROCESS

Saskatchewan adventure : a personal record.

Part III: drafting the Saskatoon Agreement

By Lord Taylor, B.Sc, M.D., Hon.LL.D., F.R.C.P., F.R.C.G.P. arriving July 16, 1962 in Regina, Taylor went the following day to Saskatoon, where the CCF had scheduled its annual convention and doctors' representatives were already meeting. Taylor believed a written agreement could be negotiated while the two sides were in the same city.

Within the first 48 hours, I wrote After Lord

essential that everybody should know what had been agreed. Every doctor and every citizen would have a practical interest in the outcome; this was all the more important because, as far as I could see, every citizen in Saskatchewan was also a

was

politician.

Not only had the practising politicians

draft document setting out the basis to be clear about the nature of the of an agreement which I thought both agreement, but their civil servants had sides could properly accept. I suspected to be clear in their own minds as well, that we were now witnessing a test- for much of the detailed implementacase, as it were, in North America, of tion would be in their hands. All this the conversion of a powerful and re- meant that the document must be luctant profession into a social service. written, not in legalistic language, but If the necessary agreement could .be in good plain Queen's English. drawn up, so as to make clear not only I remember that, when I had finished the reasonable requirements of the my first draft, I showed it to Tim Lee, government, but the essential rights secretary of the cabinet. He read it and freedoms of the medical profes¬ over carefully, but did not register any sion, we would have here a basis on change of expression. I thought to mywhich a wide range of future action self, "My goodness, it can't be very could be taken. good; and here was I thinking I had If the two sides could bring them¬ turned out a masterpiece." This just selves to sign a written agreement, goes to show how important it is to there would be no danger of a war of have a Mr. Lee always at hand, to attrition, which would leave behind pour cold water on one's first efforts. dissatisfaction, distrust and hatred.

But any such agreement must be The right basis so clear and so devoid of ambiguity I was working on the theory of that neither side would be able later to claim misunderstanding. Only if multiple alternatives. Just as the patients both sides knew exactly what they were should be free to choose their own doing, and were satisfied that this was doctor, having regard, among other right, could the danger of subsequent things, to how he was going to be paid, so the doctors should be free to choose flare-ups be avoided.

This, in turn, meant that the agree¬ their way of practice. They should come ment had to be fair and just all round. into medicare because they were One might say that not only had the satisfied this was the right thing to do, law itself to be right, but the common and for no other reason.

I was gambling and, as it turned sense underlying the law had to be right as well. If we got common sense out, rightly, on the terms of employwrong, then the agreement would not ment under medicare being so good that almost every doctor and almost stand up to the test of time.

There was another reason why the every patient would choose to come agreement had to be crystal clear. It in of his own free will in the end.

978 CMA JOURNAL/APRIL 20, 1974/VOL. 110 a

That, of course, was on the user side. As taxpayers, all citizens had to pay their fair share, even if they decided not to avail themselves of medicare's benefits. At first sight, this sounds unfair, but, in practice, it is the only way. Unless everyone makes a contribution, an impossible situation arises whenever those who have stayed out are overtaken by the combination of illness and poverty; they then need the service, but have not paid their admission fees.

Once I started serious negotiating in Saskatoon, I never seemed to stop. The three days, Thursday, Friday and Saturday (July 19, 20 and 21) were for me a sort of space-time continuum. I cannot, in retrospect, clearly distinguish one day from the next.

Suddenly, in the middle, I was called upon to make a major public speech to the Farmers' Union. Here was I in a country that was politically new to me, in the midst of a piece of negotiation in which I had to be completely neutral, faced with the job of addressing a huge political meeting. All the members of the CCF Convention were certain to attend and probably a lot of the KODs and other supporters of the doctors.

I suppose I could have refused; but on balance, I decided I must accept the challenge. Here was an opportunity to do something to win over the grassroots CCF supporters to the compromise which would be necessary, if the goodwill of the medical profession were to be carried out into the medicare

plan.

I came out of a meeting of the council of the college at seven o'clock one evening quite bushed, and I had not a single moment to prepare my speech.

I did not even know when or where the meeting was to be held. First I had

been told it was 8:30, then eight o'clock. In fact, the time was 8:30, but it had been announced at the CCF Convention that it was at eight so as to get in as many CCF supporters as possible, and thus keep out the KOD people. I was taken in along with the others.

I just managed to snatch something to eat in the hotel dining room and I remember the Maitre D' saying to me, "Just take it calmly and quietly; it will be all the same in a hundred years from now! So why worry?" Then a kind old farming journalist, a Mr. Von Pilis, an Austrian Catholic in origin, picked me up. He saw I was in none too good shape, so he popped into the rest centre attached to a Catholic church. Here I got 20 minutes quiet rest on a sofa, and rose like a giant refreshed.

The meeting was packed. There were about 800 people there, and one of the worst public-address systems I have ever encountered. The chairman had no luck with the thing, but by standing well back I managed to get it to work.

I made it clear from the start that I was not going to talk about local problems. Instead, I spoke about the British National Health Service, and told of the practical difficulties we had had, and, wherever possible, I threw in a joke. It all went extremely well, and when I had finished something happened I had never seen before. They gave me a standing ovation. This is extremely rare in England, but, I gather, it is fairly common in Canada. Naturally I felt very pleased; it was a case of ignorance being bliss.

Political

answer

Then we had a question time. They tried to trick me into making political answers, and I had to hit the balls back as hard as I could. One person asked me if the British doctors who were coming over to strike-break were properly trained for working in Canada.

I remember replying, "Well now, that is a smart political question, and I

politician, political

going give They

am a so I am to a smart answer. are as well trained as the hundreds of other British doctors who have come

you

just

out to Saskatchewan ten years". Without

during the past exception, the questions were pointed and sensible, but fairly easy cut and thrust if one knew the subject. Whenever I could, I threw in a joke and we had plenty of laughter. Then I got another standing ovation at the end of the questions.

When it was all over, I went thankfully back to bed, hoping that I now

had the support of the party rank and so that there would be no accusations later on of the government having

file,

result of the machinations British doctor.

The gentle art of preparing a document which is not only clear but satisfying to a diversity of parties, is an essential part of the process of democracy. Committees of all kinds come together to prepare reports or draft legislation. Inevitably, there is some diversity of opinion. When it is a matter of preparing a report, views must be fairly stated, but it is very important not to over-emphasize the extreme opinions expressed by small minorities. When legislation is to be prepared, then decisions cannot be obscure and there must be firm rulings.

The same process applies to the drafting of committee minutes. A good cabinet secretariat will sort out and make sense of a discursive discussion, and will, if necessary, make good any defects in chairmanship. Indeed, a good committee secretary is often the most important single person in the process of making decisions.

I have spent much time drafting policy documents for doctors' organizations in Britain, for the British Labour Party, and for such voluntary organizations as Political and Economic Planning (PEP). There was a time when I used to write leaders for the Lancet and feature articles for at least two British daily newspapers. In consequence, I have acquired a certain skill in the gentle art of drafting.

The essence of the process is making sure that the document is both clear and internally consistent. One has to be ready to modify any point to meet legitimate criticisms. But at the same time, one has to hold hard to the essentials of any argument which has achieved majority support. Decision by noise is a fairly certain recipe for long-term failure.

When I am drafting, I know from the beginning that I am going to have to alter and rewrite my draft time and again. It is even worthwhile sometimes to put in special pieces in the first draft, so as to give critics the opportunity to cut them out, and thus feel that they have made a satisfactory contribution to the final version.

In this particular situation, I had to carry with me three key people. First, Tommy Shoyama, chief government planner, had to play his part and be satisfied that he was, in fact, doing so.

Fortunately, he was, and still is, an outstanding planner; we worked together well and there were no difficulties here. On the details of medicare administration, Don Tansley, the chairman of the Medical Care Insurance Commission, and Dr. Graham Clarkson, the chief medical officer, were no less important; both were first class, not only as critics but as constructive

ratted, of

a

as a

smart

workers, especially in certain areas problems of which I knew nothing. Thus, there was a part of

with local

Saskatchewan which had had its

own

system of medicare and in which little

change

proposed; this was the region. Its existence necessitated exceptions all along the line.

Al Johnson, the deputy provincial treasurer, had a specially difficult job.

He had to make sure that we picked out the precise points where modifications of the law were needed to give effect to the final draft. Moreover, his legal drafting had to be comprehensible was

Swift Current

to an anxious and angry group

of

doctors.

Political

tendency

As soon as I had completed my initial draft, I took it to the cabinet and went through it with them clause by clause. They listened carefully and were most patient. But when I had finished they started arguing. There was a great tendency for them not to deal with specific points, but to indulge in political speechmaking. On these occasions I used to ask for clear instructions. When they had blown off the necessary steam, I always got a clear answer from the cabinet, and, in the end, I think they always made the right decision.

Once my initial draft was agreed by the government, I took it over to the Medical Arts Building to go through it with the doctors. They wanted me to hand the draft over to them, but I would not let them have it. I knew full well that once any committee started altering it, with no coordination and control, the result was bound to be nonsense. Time and again I have seen this happen, when committee members who have failed to grasp the overall sense of a document try to arrive at agreement by a series of mutually contradictory minor alterations. The result is chaos. With the politicians, this danger was small, as they were not concerned with the minute details. With the doctors, on the other hand, I was certain that they would start picking things over and worrying at them until the document

made nonsense.

So, instead, I read it out to them.

First of all, I read the whole thing fairly quickly, so that they could get the general sense of the document.

Then I took it paragraph by paragraph, and as I went along they made their objections to each paragraph. Sometimes I accepted these objections at once. Sometimes I argued back. And

eventually we always managed to reach a compromise. When I had collected all the amendments they wanted

CMA JOURNAL/APRIL 20, 1974/VOL. 110 981

little nearer final agreement. There those who said, "What's the hurry?" But I knew there was a hurry, because we were in the unique situation of having the doctors and the cabinet together in one place. I could help the doctors far more if we stuck it out in Saskatoon, than I could if the cabinet dispersed and negotiations became bogged down by paperwork over a distance. In a job of this sort, time is crucial. There is a point when both sides are prepared to be reasonable. If you wait a few days, reason will have flown out of the window, and prejudice will have moved in.

By this time I was fairly certain that the government would accept good conditions of service, as well as reasonable amendments to the Medicare Act. If the doctors accepted these in advance, then the service could begin with a high measure of goodwill. If, however, they were seen as a unilateral imposition by the government, then the would continue the war met Arts Medical A recent view of SaSkatoon's college representa¬ over doctors building. Taylor months and years, and the chance tives in the rotunda atop the building, which he terms a "vertical Harley Street". of a plan which was good for doctors and patients alike would have been not by any means the number they person would rise and object to the lost.

I took them back to original proposition and the objection. had proposed On one occasion, I had to say to Near agreement the government and once more went through the document to see if the new them: "Look gentlemen! What would We were now getting close to agreeversion was acceptable to them. you think, if you were doing an operation for appendicitis, and all the rela¬ ment, but still there were a number tives came along and started telling of obstinate points. Moreover, we were Athenian democracy you how to do it? You really must all beginning to get very tired. AcThe college council was not used to leave the law to the lawyers. They are cordingly, to speed things up, I said the conventional working of demo¬ the experts. We are all amateur law¬ that I would stay in Saskatoon until cracy. They did not allow any one yers and would enjoy writing our own Saturday night and no longer.

When Saturday night came, I had person to act as their spokesman; nor law; but we shall inevitably get it did they seek majority decisions, by wrong. Our job and your job is to had enough, I packed my bags and which the minority would abide. For give clear unequivocal instructions to checked out. I told the doctors, "I'm a long time during our discussions, one your lawyer, to make sure that he leaving. I am sick and tired of this, and I can take no more. You're wasting "black ball" was enough to negative a knows what we want him to do." my time and everybody else's time, and proposition on which everyone else the sooner I am out of it the better." seemed to agree. In this sense they Natural self Then a remarkable thing happened: were, I suppose, a truly Athenian deThere were times when my patience they begged me to stay. I think at heart mocracy. But until we were able to overcome this disruptive spirit, progress began to run out. I would listen for they were afraid of being tricked by the hours to some individual who seemed politicians. They saw I was a doctor was impossible.

In fact, there were only two college impervious to the simplest process of first and a politician second, and they members who remained adamant reason though I am sure he was believed I was able to protect the real against any form of medicare. One of an excellent doctor. Every now and interests of the profession. And, in a these was open to conviction. The other then I exploded with violent wrath and sense, they were right.

So I said, "Well, I will stay another the strongest possible language. I think was a sad and lonely figure who had suffered much as a Japanese prisoner- there were a number among the doc¬ day, until four o'clock on Sunday." of-war. I could understand how so tors and among the cabinet who en- By this time I was so tired of reading dreadful an experience could produce joyed these episodes far more than I out drafts to both sides that I decided did. Looking back on it, I must say it I must have help. Accordingly, I got a loathing of all forms of authority.

But I could do nothing to help. So, in probably was very funny. Both sides Dr. Clarkson to come with me and act the end, our solitary objector was left thought I"was hamming it up, and in as my reader. quietly fuming in a corner as the work the end I got a pseudo-Oscar or Calvert I First, we went to the cabinet. Then went on.

Trophy for my acting ability from "my took him to a meeting of the college.

We ran into precisely the same kind chums and mates of the Saskatchewan This had an additional value, inasmuch of difficulty when Mr. Robertson, the Government". This was quite unde- as he had to gain the confidence of solicitor for the college, tried to obtain served! I was just being my natural the doctors, since he would be working with them after I had gone. instructions from the council. Someone self.

When I brought Dr. Clarkson in, Dr. Back and forth I went between the would make a statement, and then someone else would get up and object Bessborough Hotel and the Medical Stewartson, a council member, gave a with the utmost vigour; then a third Arts Building, and each time we got character sketch of him to the asa

were

.

.

982 CMA JOURNAL/APRIL 20, 1974/VOL. 110

sembled college council; this made it quite clear that Dr. Stewartson thought he was a good, trustworthy man. When I saw how well Dr. Clarkson read out the agreement, I decided that he should do the final public reading of the agreement at the end.

Meanwhile, as he read out his draft, I could rest and concentrate on the points which we still had to clear up.

His presence had an additional advantage, in that he could deal better than I with the minor technicalities, which were now beginning to be important.

While all this process was going on, our legal colleagues - those of the government, and Mr. Robertson representing the college - were working out the precise implications of the draft agreement. In particular, they were drafting the necessary amending legislation. Here I was able to help a little, as I have had a good deal of experience of drafting bills and amendments to bills in the House of Lords.

Clock stood still When four o'clock came on Sunday, I said to Dr. Dalgleish: "Look here, we are getting on well; let's make the clock stand still. But if we do that, I really must ask that you sign the document tonight."

At this point, we had a tremendous struggle over certain phrases and words which I had put into the draft. I must confess I had not done it on purpose, but I had allowed my own ideologies and beliefs to creep in. Naturally enough, these were acceptable to the government; but they were anathema to the doctors.

Now the doctors reminded me most forcibly that they were not socialists and, of course, they were right to do so. Accordingly, we had to cut out SERUM HEPATITIS

continued from page 977 and nonspecificity to be overcome. A genuine advance in technology will be made when the virus is cultivated, preferably in cell culture. The clinicians, said Dr. Fisher, are at the moment "in the wings" unable to do much for their patients, but this may change.

One of the highlights was the series of electron micrographs of Dr. Huang portraying the development of the Dane particle in the intranuclear position in hepatocytes.

The papers on epidemiology, full of interest, nevertheless were frustrating.

Thus, while a substantial reduction in incidence of that long-standing problem

66S -A~ ':

w-iElL From the college Taylor shuftled to and fro the Bessborough Hotel where the CCF party was holding its 1962 convention, with all major cabinet members in attendance. the ideology. Nevertheless, there were the Cabinet was most sensible. They certain phrases which I had to stick did not want to run the risk of the by, if the government was to be able whole thing breaking down at the last to carry the agreement with its own moment. But, at the same time, they supporters. On these points I had to thought the risk of delay was somestand firm. Once more I became ex- thing which should be taken. tremely emotional and angry, and then Accordingly, I wrote a letter to Dr. I had to apologize in the end for the Dalgleish. In this I pointed out that scene I had made.

I had twice stayed on, when I had As I left them, I thought to myself: thought that my usefulness was ended, "They will sign tonight; but, oh dear, and I would be willing to stay on once what a spirit to sign in." I came back more. I said that we were all very to the cabinet, and reported I thought tired, and I did not want the doctors the doctors would sign within an hour there to feel they had signed something or so, but it would be bad if they did. that they did not think in their hearts The signing had got to be without any was right. So I said: "Let us leave the pressure or element of intimidation, question of signing until tomorrow". if the agreement were to mean all it Lord Taylor continues his reminiscences should to both sides. in the next issue of CMAJ with an acWe talked it over, and I must say count of the signing of the agreement.

of post-transfusion hepatitis has oc- asked if Australia antigen has been curred it does not appear that even "milked dry"? No, certainly it has not the use of the more sensitive radio- and some of the papers at the conimmune test will reduce the present ference, like Dr. Barker's, pointed out incidence substantially. The question paths of further exciting progress. Some of anti-infectious precautions to be of the excitement is shifting from the adopted in hospitals and laboratories original Australia antigen to the core was well aired by Drs. Reese, Spence of the Dane particle. and Mosley who stressed practical difFinally, Dr. Fisher felt the conficulties in implementing some of the ference had been of considerable improposed codes of practice. Dr. Fein- portance in that it had stimulated inman's studies on carriers and their dustry, voluntary health agencies, contacts were also topical and raised government scientists and universities many ethical and other questions. to work and plan together. Also of Dr. Barker's review on immunization importance was the fact that while was right up-to-date and we may con- we much appreciate the contributions clude that cautious optimism is in of our colleagues in the U.S., this was order. Dr. Pedler's paper emphasized essentially a forum where Canadian the need for education of the dental workers were able to present their profession (no less than in the medical own work for comment and informaand nursing professions!). Dr. Fisher tion.

CMA JOURNAL/APRIL 20, 1974/VOL. 110 983

Saskatchewan adventure: a personal record.

Part IV: signed, sealed and delivered

By Lord Taylor, B.Sc, M.D., Hon. LL.D., F.R.C.P., F.R.C.G.P. Taylor concludes his account of the part he personally played in settling the great 1962 medicare dispute in SaskatLord

chewan.

It seemed to me that we should do all we could to build up the signing of

the Saskatoon Agreement in the in¬

terests of everyone concerned. But I failed to get a public signing, for which

I tried.

We made plans for a public signing and sent these over to the doctors. This was more than our medical colleagues could take. They gave as their reason that the medical profession is bound not to seek personal publicity, and that any public signing would be a breach of normal medical etiquette. So it was agreed the signing should be done in private in the premier's room at the Bessborough Hotel.

There arose the question of public statements immediately after the document had been signed. The College of Physicians and Surgeons wished to issue a statement, and Premier Lloyd wanted to make a speech to the people of the province. He had a major public speech scheduled in three days. I begged him to say nothing for a week, and to see that the members of the government did the same. Clearly this was only possible if the doctors would agree to keep quiet for the same time.

I was dreadfully afraid that the quarrelling would break out again, and that each side might want to put in qualifications, and so, in effect, go back on the agreement. After some hectic telephone conversations, both sides agreed to my proposals. Perhaps the hardest part for them was to agree that I should make a few general comments after the signing, to explain why nothing was being said by either side.

Despite all these preliminaries, we still did not know for certain if the doctors would sign. They were still worried over small legal technicalities, which suddenly seemed to assume enormous importance. I understand they sent for Dr. Crosby from Regina, and that his fresh mind helped them to resolve their doubts.

At the same time, Mr. Robertson, the doctors' legal adviser, Al Johnson and Bob Ellis, legal advisers to the 1102 CMA

government and the department of health, did a splendid job in ironing out

remaining legal difficulties.

Monday morning, July 23, and when I was having my bath there was a knock at the door. In came Dr. Clarkson. "It's all right," he said, "It's on. They are going to sign this morning." I have seldom seen anyone grinning more widely, and I have seldom enjoyed a bath more than I enjoyed the rest of that one.

I spoke once more with Dr. Dalgleish on the telephone, reminding him that if he agreed not to speak to the press, the government would also agree to keep silent and that this was really the best thing for everyone. I then went through what I proposed to say, and he agreed that this was fair and just and reasonable. He also agreed that Dr. Clarkson should read out the full text of the Saskatoon Agreement.

As the final fair copy of the document was being typed, ready for the signing, I looked it over. I must confess, I felt a certain amount of pride. It was clear in form and clear in intent.

Above all, it contained proposals which the

I got up that

should work well for the people, the doctors and the government.

The actual signing was beautifully done. Dr. Dalgleish brought over Dr. Peacock, the college registrar, and Mr. Robertson. The agreement was signed between the premier and the president of the college. Then all those who had taken part signed as witnesses.

Then Dr. Clarkson and I went down to the ballroom of the Bessborough Hotel to face the gentlemen of the press and the microphones and television cameras. I was acutely conscious of the fact that a happy solution had to be converted into a dramatic news item. I think we just succeeded.

First, I announced that the Saskatoon Agreement between the government of the province and the doctors had just been signed. Then I called on Dr. Clarkson to read the full agreement, so that all the citizens and all the doctors of the province could have the full picture. I must say, Dr. Clarkson read it beautifully, just like a Royal Proclamation, from start to finish. It is only fair to add that, by this time, he had had a good deal of practice at the job.

However, I had heard it so many times that I just could not take it any more. So I slipped out for a while, relaxed in the corridor, and looked in at intervals to see how things were going.

Then, just before Dr. Clarkson had finished, I was able to nip back into my seat.

Taylor's report Then I made my report: very short, and each part was designed to do a

Dr. Graham Clarkson, MCIC chief medical officer

JOURNAL/MAY 4, 1974/VOL. 110

particular job.

"I have met many of your doctors," I said, "They are good men, rugged men. They are also strong individualists, and they would not be good doctors if they were otherwise. They are a little bit argumentative and very determined. But they have been fighting for principles in which they believe and have been very helpful in reaching a conclusion. I think you should be proud of them."

Here I was trying to heal any personal breaches there might be between

doctors and patients. It was axiomatic that about half the patients were political enemies of their doctors, and vice versa. It is part of the ethics of medicine that the doctor does his best for his patients, regardless of politics or anything else. This is the real basis of the doctor-patient relationship. So it was essential that the patients' confidence in their doctors should be reestablished.

"I have met many of your politicians while I have been in Saskatchewan," I went on. "Politics apart, they too are a fine group of men. They have been conciliatory, helpful, patient and have given me every assistance in the difficult work I had to do. In particular, I must say a word about your premier, Mr. Lloyd. He is one of the finest men I have ever known in my life.

You should be proud to have such a

premier."

The government needed and deserved all the help they could get in implementing the Saskatoon Agreement. They had to carry with them not only their political opponents, but their own supporters, many of whom would have liked them to have taken a tougher line.

Major operation "Now I say a word to you ladies and gentlemen of the press and the other news media. This province has been sick. It has had a major operation.

It is just convalescent. I prescribe for it absolute rest. This is a doctor's order, absolute rest. I would beg of you therefore not to seek interviews with either the politicians or the doctors or with me when I have finished, for at least a week. We are all nearly dead. The doctors of the college and the government have agreed to keep quiet for a week to give everybody a rest, a chance to get over these difficulties and for peaceful good relations to

again."

Looking back on it, I tremble at my audacity. The Saskatchewan doctors' grow

strike was the top news story all over North America. And herei was I arbitrarily imposing a week's moratorium

gathering! difficulty is that the news media like a fight. It would have been the easiest thing in the world to have wrecked the Saskatoon Agreement. The right wing of the doctors and the left wing of the CCF could each claim that their own side had surrendered and would have enjoyed the publicity of doing so.

The truly wonderful thing is that, without exception, the media responded to my appeal. Saskatchewan, and incidentally Lord Taylor, dropped from the news without a ripple. I wonder on news

The

if this would have

happened

in any

One account

published during

the Saskatchewan crisis carried this cartoon

country but Canada. I have noticed

time I regarded it as a piece of antisince that in labour relations and CCF politicking, and a breach of labour disputes Canadians of all parties good faith to the government and the and groups tend to be more mature doctors. So I asked the deputy-premier, than people elsewhere. This generaliza- Mr. Brockelbank, to call the unfortion includes the media. tunate director of the television station.

I had to be very careful in my con- I then spoke to him with a degree of cluding remarks. I believed we had vigour which I have never achieved between us created a blueprint for a before or since.

In retrospect, I regard my behaviour first-class system of medicare. I thought, and still think, it was substan¬ as monstrous. But it was pragmatically tially better than the British Mark I justified. That evening, as we were model, and something of which the motoring across the prairie, I spotted politicians in Saskatchewan had every a cottage with a television antenna bereason to be proud. But I could not side a grain elevator. So I knocked at say this, because it would have upset the door and asked the astonished householder if I could watch the teleand offended the doctors.

"And now a word to the people of vision program. "Name's Taylor, says Saskatchewan," I said. "I believe you he's a Lord, and can he watch the have got a workable health plan. You TV, Ada," he shouted. And there we must make a success of it. You must watched the transmission in full, as work together, doctors, citizens, mem¬ the children ran around and I fed them bers of the commission and government sweets. to make it a success.

Looking back on the job I see now "Finally, I have a word of warning that timing was very important. I was to the pike, pickerel and grayling of lucky in arriving at just the right monorthern Saskatchewan, for that is ment, when enough blood had been where I am going now. Good-bye to let to satisfy honour on both sides. A week or so earlier I would have been you all."

When the agreement had been able to do nothing.

When I left Saskatchewan, I really signed, I was much concerned that its full text should be given to the people supposed that I had said good-bye for of Saskatchewan over television. On good to the people of Canada. But the afternoon of the day of signing, five years later a voice on the telephone July 23, I learned that the local tele¬ opened a new chapter: "The premier vision station was refusing to let it be of Newfoundland speaking," it said broadcast, on the grounds it was too with an accent I was to come to know long. Looking back on it I have much well. "I want you to be president and sympathy with this view, but at the vice-chancellor of our university." ¦ CMA JOURNAL/MAY 4, 1974/VOL. 110 1103