Minister Christian Dubé has launched the 2022 version of the health system, which he hopes will be fashionable, at least until the election. Prime Minister François Legault designates him as the man for the job. On the other hand, there is reason to wonder whether the direction of such a ministry should be dependent on a single person to ensure its “future”. In fact, health management should be based on founding principles.
Posted yesterday at 2:00 p.m.
Allow me to come back to the word refoundation. For me, this calls for a definition of objectives, of mission, on the installation of the foundations on which we erect the rest. At its origin, the Act respecting health services and social services had listed as its mission: “Adding life, adding health to life, adding well-being to health. » Is it still topical, fashionable?
Add life
The quantity of life is measurable. In life expectancy, in survival associated with the treatment of pathologies such as cancer and heart disease, etc. Life expectancy in Quebec is 83 years, in line with the Organization for Economic Co-operation and Development (OECD) average of 82 years, but slightly lower than that of several countries in Western Europe and Asia. Do we know the reasons for this discrepancy? And do we have programs in place to see to the reduction of it?
For my part, I consider that the proposals of the Dubé refoundation do not make it possible to identify the ways that would make it possible to achieve this objective.
Of course, it is clearly a question of obtaining more data, but their use must aim to identify gaps and adapt the network to fill them. Aim to measure the performance of the public health and care network. And above all apply measures that have been scientifically proven or that will have to be proven by rigorous monitoring.
Add health
Is being healthy measurable? There are scales to measure the amount of symptoms and their intensity for multiple pathologies or treatments. In medical jargon, we also speak more and more of PROs, patient reported outcomes. It is therefore possible to estimate whether diagnostic and treatment interventions have a positive or negative effect on each patient and on the collective and population levels. Once again, scientific rigor ensures that programs to measure and positively modulate patients’ experience with disease are properly administered and accordingly justified. But this requires significant resources that are not announced in the government proposals.
Add well-being
Well-being is a feeling, an impression that can also be measured in medicine with quality of life scales. To economically and socially justify measures and treatments, we can estimate the QALYs (quality adjusted life-years). In succinct terms, one estimates the amount of good quality life provided by the extension of life attributed to a treatment, for example, and the cost associated with it. Science therefore makes it possible to propose measures to improve the well-being of the population.
I allow myself this long preamble to return to the refoundation which does not return much on these objectives, on the mission of health. Do we increase life, health and well-being by being followed by a family doctor or by allowing local care? Nothing is less sure. Major studies have shown that centralized screening programs, like the one that was established for breast cancer in Quebec 20 years ago, have more impact than the individual action of the doctor who offers longitudinal follow-up to patients. Similarly, the centralization of many medical activities is associated with greater productivity and better outcomes.
The decentralization advocated in the refoundation does not seem to prioritize these scientific facts. Admittedly, strong and efficient regional care centers must be created, with the latitude to adjust the supply of services, but the definition of the supply of care should be centralized in provincial organizations independent of any political influence.
For example, patients with cancer of the bladder, testicular, sarcoma, throat or other relatively infrequent cancers have every advantage in being assessed and treated by stable teams with demonstration of expertise and results. , and following evidence-based practice guidelines. In each case, there is evidence that the chances of survival are reduced when treatment decisions are made and implemented by teams that do not have enough references to ensure the competence of the doctor and his team.
In addition, initiatives ensuring well-being at home, whether for long-term care or palliation, benefit from scientific demonstrations which deserve a turn. I refer in particular to the initiatives of the DD Geneviève Dechêne, in Verdun, who, through sweat and blood, established local services for end-of-life patients, freeing up hospital beds and ensuring uncompromising quality of life at home.
There is therefore a lot to be said about the refoundation and these few lines only raise scientific questions in connection with the validity of some of the proposed measures. On the other hand, it is up to the leaders to indicate how the 50 proposals fit into the mission of the Ministry of Health or in what way they modify it. And maybe it’s time to revisit this mission. Approval of medical assistance in dying (MAD) falls on the fringes, while it aims for well-being without the aim of increasing life or health. The WMA has shaken up the medical world and continues to do so with broader inclusions of eligible individuals. It may also be time to shake up the Ministry of Health and Social Services by daring to ask if we are focusing activity to first target health and well-being at the expense of life…
“Health is the next essential thing after morality,” said Thomas Jefferson. In our time, as a society, our moral should be to provide health to as many people as possible. As such, it is necessary to discuss the proposals for refoundation, apart from an unproductive political argument, to define together what the health system should achieve for Quebecers.