“The columns of the temple will shake. These terms used recently by Christian Dubé clearly reflect the effects that Health Quebec and the new law will have on health efficiency.
The law will hit very hard, according to the information I have obtained from various reliable sources of the Legault government. Quebec will merge the union seniority of employees throughout Quebec, force medical specialists to practice in the regions, end regional boards of directors and appoint general managers in all large establishments, among other things.
The bill creating Santé Québec, in particular, will be tabled on Wednesday or Thursday. This central organization to manage the network will have its president, its human resources, technological and other vice-presidents, as well as a board of directors, like Hydro-Québec.
Once in place, the 34 directors general of the regional centers – the CISSSs and the CIUSSSs – will report directly to Santé Québec and no longer to local boards of directors or to the Deputy Minister in charge of the Ministère de la Santé et des Social services1.
From 136 to 4 trading tables
As a result, the 375,000 network employees will ultimately have a single employer, Santé Québec, rather than the 34 local employers. This centralization will eventually have the effect of merging local collective agreements, which have become a shambles to manage, with their particularities.
Thus, instead of the current 136 negotiation tables with the unions, the law will reduce them to only 4 national tables. This reform will greatly simplify the next negotiations (those that will follow the ongoing negotiations) and the organization of work, it is expected in the government.
By reporting to a single employer, employees will see their seniority recognized throughout the network, rather than in their CISSS or CIUSSS alone. For example, an experienced nurse from Laval or Gaspé could be hired in Montérégie or elsewhere without losing her tenure and seniority, which is not currently the case.
The objective is not to force employees to change regions, but to make the network more efficient, by improving mobility, I am told.
Last October, columnist Patrick Lagacé reported the pathetic case of a young girl with a rare syndrome who was a victim of union rules. By moving from Ahuntsic to Laval, 8 km away, the little girl came within a hair’s breadth of losing her extremely dedicated nurse because the latter lost her union skills while moving from one CISSS to another.23. The law will have the effect of correcting these kinds of problems.
PHOTO ROBERT SKINNER, LA PRESSE ARCHIVES
“Currently, a nurse with a bachelor’s degree gets a starting hourly salary of only $1 more than a nurse with a DEC from CEGEP,” indicates our columnist.
The new law will be complementary to other measures desired by the government, such as salaries that vary significantly for nurses according to their region of work, their training or their schedule.
The implementation of these differentiated wages is one of the government’s demands in the current negotiations, but the unions are opposed to it, for the most part, judging that everyone should be treated equally, in principle.
Currently, a nurse with a bachelor’s degree gets a starting hourly salary of only $1 more than a nurse with a DEC from CEGEP. In addition, current public bonuses do not encourage night or regional work very much, which would explain, in part, why private agencies have been able to recruit so many nurses, relying on this type of bonus.
The new law is also part of Quebec’s desire to give priority to competence over seniority for certain key positions, a very controversial issue. The government would like 10 to 15% of the positions in the network to be filled first according to skills, one of my sources tells me.
This element must be endorsed by the unions in the current negotiations, but the eventual pan-Quebec decompartmentalization of union gains that the law will allow would lead to a better matching of positions.
In April 2021, in one of my four columns entitled “La Maison des fous”, I reported the case of a clinic which had suffered heavily from this strict rule of seniority in the replacement of its day nurse.
Neither merit nor technical skills could be taken into account, only local union seniority took precedence. This requirement forced the appointment of nurses overwhelmed by the function, causing their resignation in turn, which harmed the functioning of the clinic and the patients for several months4.
In another column, a doctor claimed that union rules prevented her from having a competent secretary. “We have the union to confront, and the leaders are afraid to confront the unions. We help the incompetent to stay in place, ”she said.
Requirements for medical specialists
Another thunderclap: the law will oblige medical specialists to have a populational responsibility, which will force them to practice in certain neighborhoods and certain regions, as is the case with family doctors.
PHOTO MARTIN CHAMBERLAND, ARCHIVES LA PRESSE
“The law will oblige medical specialists to have a populational responsibility, which will force them to practice in certain neighborhoods and certain regions, as is the case with family doctors”, reports our columnist.
According to my information, the government wants medical specialists, in parallel with the law, to take on a greater share of responsibility in improving the efficiency of the network. For example, currently, medical specialists are not required to be present in the emergency room after 4 p.m., which contributes to the lengthening of patient waits.
The Ministry considers that the non-compulsory practice in the regions for specialists is one of the reasons that explain the popularity of specialized medicine among young people to the detriment of family medicine, a phenomenon that the law could curb.
Local Boards of Directors
Moreover, the law will put an end to the local boards of directors of the CISSSs and CIUSSSs as we know them. The role of these local councils will be redefined. Prime Minister François Legault referred to it in an interview with The Press three weeks ago, where he spoke of tapping into his “reserve of courage”5.
According to what I have learned, these “establishment boards” will be made up of their respective CIUSSS CEOs, as well as people from the community and patients. It is impossible to know, for the moment, if they will only have an advisory role or some decision-making power. According to a source, they would have to make a form of annual accountability to the population on the functioning of their CIUSSS.
On the other hand, for local management, Quebec will appoint a responsible general manager in each large establishment (hospital and others), among others, as suggested in the Savoie report, in June 2022. This type of appointment occurred in CHSLDs during the spring 2020 pandemic wave.
For example, at the moment, the Maisonneuve-Rosemont hospital and the Santa Cabrini hospital have only one director general. After the changes, everyone will have their own responsible boss, I’m told.
About 80 executives will be appointed to fill these positions. In the end, the Legault government, under Christian Dubé, will have appointed 400 executives, a difference of around 900 with the approximately 1,300 executives removed under Gaétan Barrette.
In another of my columns on “La Maison des fous”, a former president of the board of directors of a CIUSSS had denounced the nests of corporatism of these boards, where everyone defends their territory. According to him, the current boards of directors are a decoration without real powers, since the evaluation of the CEO of the CIUSSS, among others, is the prerogative of the minister. “Quality managers are paralyzed in an indescribable bureaucracy,” he wrote to me.6.
Similar story from another former CISSS president in this column. “Bureaucracy stifles initiative and creativity. If the health network were a private company, it would have been bankrupt a long time ago. »
The full effects of the new law will take a few years to be felt, probably after the next renewal of the collective agreements, in three or four years. This delay should allow the parties to assimilate the changes gradually.
The law will therefore attack the “union straitjacket” in health, I am told, and it will no doubt be strongly criticized. Disputes will probably be initiated by the unions – that of nurses as well as doctors –, in particular concerning the sacred cow of seniority and competence.
One has to wonder whether this centralization of part of the governance of the network will have the effect of reducing bureaucracy or increasing it. Will the grievances of the new local councils be heard?
Be that as it may, the Legault government appears determined to move forward, once the compromises are incorporated into its bill, and to make the network more efficient. He believes he has a golden opportunity to make this important cultural change at the start of his term, given his strong popular support in the last election.
1. Currently, the 34 CEOs report de facto to Deputy Minister Dominique Savoie, who also has 14 deputy ministers in her charge, a level deemed intolerable. The withdrawal of the day-to-day management of the network from the hands of the Ministry of Health had notably been recommended as early as 2001 by the report by Michel Clair, according to which the Ministry should rather deal with strategic orientations and performance evaluation. The Savoie report of June 2022 came to similar conclusions.