Posted at 11:00 a.m.
Following Francis Vailles’ column on the “revolution” that the imposition of activity-based funding for surgeries performed in health establishments would represent, some readers became concerned. They raised their concerns about the risks of impoverishing the quality of care and increasing bureaucracy. To answer them, Mr. Vailles limited himself to relaying the ministerial answers which were intended to be reassuring.1
However, a detour through the vast literature on New Public Management (NPM) leads anyone interested in health administration to take citizens’ reactions more seriously and to doubt the authorities’ responses. These analyzes belonging to the field of the social study of statistics teach us that these methods, which aim to simulate the logic of the market, were invented and used for health services as early as the 1960s. Since then, their participation in the improvement public services has not been demonstrated. On the contrary, the many studies on the subject tend to prove that they are ineffective, because they are done at the cost of creating a new layer of technocrats in an already bureaucratized system.
As early as 2007, an English study on the introduction of activity-based funding in the British public system showed that in less than 10 years, the nursing staff has increased on average by 20%, while the pool of managers has increased by 77.7% and that of administrative staff by 45.3%. In Quebec, health professionals are already experiencing the consequences of this type of approach. Statistical systems force them to mark their activity several times per hour (a task long enough for a category to be used to calculate the time dedicated to it) or to fill out administrative forms such as the computerized clinical pathway tool (OCCI) . These tools specific to NPM have been denounced many times for years by workers who sacrifice care time every day and by researchers specializing in the subject (see the work of Mélanie Bourque of the University of Quebec in Outaouais, between others).
As for studies on surveillance at work, we also learn that the increase in surveillance systems has negative effects on the quality of work. As the statistician Alain Desrosières wrote: “The feedback from indicators induces perverse effects: the actors focus on the indicator, and not on the action itself. This is all the more problematic in the health system where actions are difficult to represent by numbers. When hitting the statistical target becomes more important than a job well done, studies note tendencies to disengage and attempts to circumvent them that lead to ever more coercive cycles of surveillance.
Furthermore, at a time when there is a desire to decentralize the Quebec health and social services system, it is recognized that activity-based funding centralizes decision-making and leaves less room for initiative. Thus, the Ministry of Health and Social Services (MSSS) will set the rates according to the objectives it intends to promote. Health care workers, doctors and managers will lose their autonomy in the process.
Moreover, it is quite surprising to hear the Ministry praise the flexibility of the model since, considering the “colossal work” (10 years!) required to set the rates, it is difficult to see how they could be easily modified. While the approach is supposed to import “soft” methods inspired by private enterprise into the public sector, the reality is that this budget calculation will be extremely rigid and quickly become obsolete.
Finally, these devices, which essentially aim to increase the pace in Quebec’s hospitals and clinics, miss the real problems of the health care system: there is a lack of personnel and the overcrowding of hospitals is primarily explained by the lack access to appropriate services, in particular preventive and first-line services, long-term home care and residential services.
In 2022, after many failed reforms of the health system, the MSSS cannot engage in technocratic reforms that will reproduce the errors of the 1990s, 2000s and 2010s. The implementation of new accounting systems is not not positive simply because it is based on sophisticated calculations. Contrary to management methods that restrict the autonomy of workers and reinforce technocracy, the system must draw inspiration from budgetary currents that favor recognition and trust and stop increasing the administrative and accounting burdens that harm the efficiency and quality of care.
* Myriam Lavoie-Moore is also a postdoctoral researcher at the Australian National University