The devil is in the details, say the Anglos. And details, there are a plethora of them in the 308 pages and 1180 articles contained in the mammoth bill presented on Wednesday by the Minister of Health and Social Services, Christian Dubé. And these details could turn into pitfalls given the opposition that Bill 15 arouses among the unions of network employees, but also among the powerful union that constitutes the Federation of Medical Specialists of Quebec (FMSQ).
Everyone agrees however on the fact that our health system must be reformed in depth and its management, revolutionized. There is bound to be consensus on the four themes that the Minister outlined on Wednesday: improving access to health services, offering what the Minister calls a “patient experience” that is up to scratch and listening to users, so that the health network becomes an employer of choice and, finally, restore local management by appointing responsible executives in each of the hospitals and other “facilities”, to use the somewhat simplistic term used by senior civil servants.
However, it is obvious that the reform put in place by Bill 15 centralizes the management of the network, even if Christian Dubé claims that this is not the case. The fact of separating the full responsibility for the activities, entrusted to an agency, from the orientations, which remain with the ministry, is in itself a decentralization, maintains the minister. It is a bit short since Santé Québec will become the sole employer for the 350,000 employees of the network, replacing in this role the 34 establishments that are the university hospital centers as well as the CIUSSS and the CISSS.
This autonomous agency is a common structure for public health networks around the world, although it is not the only model, as shown in a review prepared by the commissioner of health and well-being, Joanne Castonguay . This structure has certain advantages and was the subject of recommendations in various reports, including that of the Clair commission and the Castonguay commission.
With the creation of Santé Québec, the government will appoint establishment medical directors and territorial medical directors responsible for ensuring a better distribution of physicians, whether specialists or general practitioners.
For the medical people, the big change is aimed at medical specialists, on whom the government will impose a population responsibility. Their right to practice will be subject to the coverage of “specific medical activities”, specified the Minister. In particular, they will have to provide call duty at the hospital and share unfavorable hours in the emergency department. It is the medical director who will be responsible for assigning specialists and who will grant each medical specialist his “privileges”, this right to practice.
Medical specialists are self-employed, even entrepreneurs, free spirits, say some management experts, who do not necessarily mix well with the complex and technocratic organizations of the health network. We understand that at the FMSQ, the changes that affect them do not pass like a letter in the mail. The Third World War, of which Gaétan Barrette speaks, is here.
Paradoxically, beyond this centralization, there is a desire at Christian Dubé to decentralize the network by appointing directors in each of the hospitals, CHSLDs and other entities. It is worth remembering that it is not the large structures, but these very concrete establishments that are the point of contact with the population, and it is with them that the nursing staff can develop a feeling of belonging. We will have to see what powers and what initiative will be reserved for these executives within the megastructure of Health Quebec so that they can have a real effect on the ground, where it ultimately counts.