With the tabling of the bill creating the Santé Québec agency on March 29, Minister Christian Dubé is undertaking the ninth reform of health services since the Castonguay-Neveu report, which dates back to 1972. We have been at the search for the structure and mode of operation that will make it possible to meet the needs of the population as effectively as possible with regard to both health and social services.
Currently, the two networks include 137 regional establishments (including 22 CISSSs and CIUSSSs) and 1,450 service facilities employing approximately 300,000 people. The Ministry of Health is responsible for the management of all services and the government is of the opinion that this approach does not allow “optimal coherence”. According to the experts, the governance of the system must be reviewed, because the ministry is too far removed from operations and “its decisions do not always reflect the reality experienced by managers and employees in the field”. It is a management record that is considered unacceptable.
The overall objective of the reform that the government is undertaking is to increase efficiency in order to improve care and reduce waiting times in emergency rooms and for surgical procedures. Day-to-day management will be entrusted to the agency, which will be a state corporation. “Like a dynamic and simplified organization,” the agency will be led by a president and chief executive officer as well as an accountable board of directors. The Ministry will no longer have any direct responsibility for network management. From now on, it will deal only with policy planning and evaluation.
The law will make it possible to put in place “tools that promote greater local management”. A manager will be appointed in each of the hospitals. But instead of there being 34 employers as at present, the agency will be the single employer for all health and social services, which will reduce the bureaucracy relating to personnel management. The objective is to have less disparity and inequity in the network.
Ultimately, the government wants to enhance the satisfaction of users who receive services by giving “managers the necessary levers to develop a culture based on results.” In particular, we want to set up an interdisciplinary Council for the evaluation of trajectories and clinical evaluation within a hospital or establishment. The agency’s board of directors will also have a National Vigilance and Quality Committee whose mandate will be to analyze and manage complaints and recommendations that come from other authorities in the system or from the government.
Where are the documents that justify this upheaval?
The government is thus preparing to upset the organization and functioning of one of the most important sectors of society on the basis of an idealistic management discourse that will be impossible to achieve. But where are the documents that give a minimum justification for the choices that are made? Can we know the testimonies of experts on governance? When we try to analyze and understand the entire reform project, we no longer know in the end what has priority for the operation of the health and social services system for the next 10 years.
Has there been an assessment of the joint management of health services and social services within the CISSSs and CIUSSSs? If so, would it not be more appropriate to have a separate agency whose organization and operation would be better suited to this type of service? Otherwise, the name should be changed to the Quebec Health and Social Services Agency.
Beyond a redefinition of structures, what the government is proposing “is a long-term culture change” so that “managers have free rein to make the right decisions based on what their patients and their employees.
But in reality, in the short term, what managers need most are more employees and more hospital beds to meet the growing demand for care. If these two problems were solved, would the problem of governance that is mentioned arise in the same way?
The government’s priority is to improve local management, but it can already do so immediately by requiring that all service points be under the responsibility of a general manager assisted by an adequate team. When we count down the establishment of the new corporation, there will be a probable hierarchical structure from the minister to the local manager of at least six levels, ranging from the CEO of the Health Quebec agency, to the vice-presidents of the agency, to the CEO of establishments which are subsidiaries of the agency and to their sector directors and then to the hierarchical levels of the care units. How can we be sure that there will be genuine local management?
There remains one last point to emphasize, namely how the Department will be able to fulfill its planning role when the law gives the agency the power to determine the interregional allocation of resources (section 93 of the bill) and when it will have the obligation (article 99) to itself prepare a strategic plan explaining the stakes, the objectives, the results targeted in the medium term and the indicators which will make it possible to judge its performance? One might as well say that the Ministry will be abolished, even with regard to policy planning and evaluation.
Faced with economic, financial and social conditions that will be problematic in the medium term, the chances of success of a reform that seeks to establish a new management culture by creating a government corporation are low. The government must find another more pragmatic approach to improve the functioning of the system. The current bill is excessive and unrealistic.