For health as for education, Prime Minister François Legault and the ministers concerned are asking for more flexibility and more flexibility in the organization of work so that managers can provide services to the population more effectively and obtain better results. .
However, this approach is far from innovative. It is in fact inspired by New Public Management (NPM) for which the private sector represents the reference model.
It is mainly based on three structuring characteristics. Firstly, the separation of the political function, for the definition of orientations by elected officials (“ steering “), the function of organizing services entrusted to managers (” rowing “) as part of an agency separate from the ministry. Second, a customer orientation focused primarily on results, but with little regard for processes. Third, great flexibility and moderation in employee demands, to reduce costs while ensuring greater productivity.
What should we think of these requests, which are at the heart of the reform which has just been adopted?
Not very original when we know that NPM appeared more than four decades ago. It gave rise to significant adaptations in the countries which initiated it, namely the United Kingdom, Australia and New Zealand. However, over time, the separation of the political function from the management function appeared artificial. These two functions feed each other. It goes without saying that ministries should not manage waiting lists in hospitals.
However, by entrusting the organization and management of services to an agency separate from the ministry, the latter loses, over time, the knowledge and skills essential to decide on directions. As a result, the political side gradually becomes dependent on managers to define directions. We thus achieve what we could call internal privatization and depoliticization. But there is still more.
By taking inspiration from private enterprise for the production of services and the organization of work, a relatively autonomous agency tends to evaluate its performance on results alone, without taking into account the process, thus forgetting the specificity of services to people, particularly the uncertainties that exist between health services and outcomes and, for this reason, the importance of professionalism.
Unlike industrial production and commercial services, personal services, such as health, social services and education, are a co-production which is firstly achieved through relationships and interactions between professionals. and users over time which is based on trust. In other words, both must be active in the production process. It is difficult to care for someone who does not want to be cared for or to teach a student who does not participate or who does not have the support of those close to them.
Hence the concerns raised by the declaration of Minister Dubé, who said he wanted to entrust the management of this agency to “ top guns » from the private sector, to whom we intend to pay salaries adapted to the business environment.
Greater rigidity
In personal services, the work relationship is combined with a “consumption” relationship. Flexibility and flexibility in the working relationship of professionals are therefore essential due to this co-production and the nature of the services produced.
By restricting the flexibility and flexibility of these links for the exclusive benefit of the relationship with managers, the CAQ’s proposals promote greater rigidity in the relationship with users and a sharp reduction in the production of public value precisely because the lack of attention given to the process. In doing so, job satisfaction and commitment of professionals decline greatly, while the quality of services and user satisfaction decrease.
Furthermore, unlike the government proposal, personal services, as is the case with health, cannot be defined simply as a government system. These services are part of an ecosystem that includes various sectoral and territorial systems. This is what the Commissioner of Health and Well-being, Johanne Castonguay, recently demonstrated for home care and support services. From this point of view, health mobilizes a wide diversity of organizations and actors.
Some can be easily identified, such as unions, community groups, research centers and foundations; others are more difficult to identify, such as those active in living environments, quality of life and the environment, social justice and the fight against inequalities. Both provide tangible and intangible resources which are even more important for an approach focusing on prevention. From this perspective, it is undoubtedly necessary to mobilize increasingly significant financial resources, but also non-market resources (e.g. State subsidies) and non-financial resources (e.g. local caregivers).
Wrong direction
From this perspective, the governance that is required must be able to link the vertical dimensions (State and civil society) and the horizontal dimensions (between stakeholders). Appropriate governance in personal services cannot simply be hierarchical and centralized; it must rather be network governance or distributed governance.
We will understand that the health reform which has just been adopted is going in the wrong direction. In fact, she is doing what Philippe Couillard and Gaétan Barrette had not dared to do, namely taking health services out of the ministry and giving them management to a third party. One thing is certain, the CAQ was not elected to crown the reforms initiated by the PLQ. In the absence of a vision and in the absence of a real public debate, the reform proposed by Minister Christian Dubé is causing a lot of concern and disappointment. The proposed direction does not seem up to the challenges of health and social services in our time.
From now on, real health reform will have to be on the agenda, but it will be more costly and even more difficult. We will undoubtedly have to wait for another government which will have the courage to engage in more in-depth debate and reflection to outline a reform which arouses the enthusiasm and mobilization of all stakeholders. Nothing prevents us, however, from starting to prepare for this reform now.