Restore “accountability”. This is one of the great promises of the CAQ reform of the health system.
Minister Christian Dubé wants to bring the decisions back to the floor. In return, leaders should be accountable. The seat would become ejectable. At least, that’s the theory.
I’ve spent the last week talking with health administration experts, and they’re still asking for some convincing. The idea does not seem bad to them, but they doubt its impact.
The source of their skepticism, in condensed form: You can’t be held accountable for what you don’t control, and even if you fire a leader, that won’t necessarily make the problems go away.
Now here is the long version.
When a scandal occurs in a hospital, it rebounds in question period, and the minister is blamed for an event of which he has only just learned.
He then seeks to make a quick move that will calm his critics. This phenomenon worsens the centralization of the health system, with decisions that are first evaluated according to their political utility.
It frustrates health ministers and it doesn’t help patients much either.
To remedy this, Mr. Dubé promises two changes.
The first: separate politics from operations by creating Santé Québec, a new Crown corporation. The minister would dictate the broad objectives, and this agency would implement them.
This is what exists in Alberta, Ontario and Nova Scotia, in particular.
A local leader in each “facility”, such as a hospital. This shift had already begun during the pandemic, with the return of a manager in each CHSLD.
Mr. Dubé’s other promise is to make these leaders “accountable”. According to him, this will decentralize the network. However, the decision to dismiss a leader would still come from the minister himself or from the agency. It’s vertical accountability, coming down from the top.
Several questions remain.
First, will a hospital or CHSLD manager have the means to obtain the desired results? Currently, the CISSSs or CIUSSSs have divisions responsible for different sectors, such as emergency and home care. With the Dubé reform, the CISSSs or CIUSSs would become territorial agencies of the state corporation. But even if a CIUSSS becomes Santé-Estrie, most of the network’s current structure will remain. For example, the director of a Sherbrooke hospital will not have full control of emergencies at home.
Above his head, the wires will still cross in the spider’s web of the flowchart.
Before the Couillard and Barrette reforms, each hospital had its board of directors and its budget. He was solely responsible for it. This is no longer the case. In the bill, the power of the local leader is not clearly defined.
Another question: data. The health system is notorious for its poor data. Mr. Dubé tries his best to make them more precise and transparent – in particular, he publishes a dashboard on the Ministry’s website. But for the moment, it is still difficult to measure how a hospital or a CHSLD treats patients. And without reliable data, you can’t assess a leader’s performance to hold them accountable.
Even if a minister gets the head of a leader, will the patients be better off? Hard to say. For the minister, however, it is an undeniable gain.
Take the example of the Société de l’assurance automobile du Québec. After the chaotic management of the SAAQclic system, its CEO Denis Marsolais was dismissed. Surely he deserves most of the blame. The fact remains that he had nevertheless warned the government in November that the offices would close for three weeks during the transfer of the platform. At the time, the caquistes saw nothing wrong with it. In this case, the “imputability” of the leader also rhymed with “political immunity”.
Another form of accountability exists, more communal than vertical. It consists in letting the local administrators decide on the future of the leaders. This was what prevailed in the 1990s.
That said, these boards often drew criticism. And when a crisis arises, politicians prefer to have their finger on the button that ejects the seat.
For the “accountability” of doctors, the Dubé reform is more promising.
In 1970, doctors opposed the creation of a public plan. To rally them, they were offered the status of self-employed workers. They manage their schedule as they wish, choosing their patient profile. Even if the vast majority works with devotion, a small minority remains rebellious.
Mr. Dubé wants to establish a “population responsibility” so that doctors share the task more equitably and that their organization of work is done according to the needs of patients.
It’s a good idea, supported by the College of Physicians. And if there were more doctors, that would of course help, especially since a wave of retirements is approaching.
How can we strengthen equity while encouraging older physicians to stay at work? That is what the upcoming consultations will be for.
Certainly, pumping more money into the system will not be enough. The organization of work must change.
Experts I spoke to agree that “accountability” is not just about structures and organizational charts. First of all, it is part of a culture. To change it, everyone will have to row in the same direction. This is also what the upcoming consultation on Mr. Dubé’s bill should serve.
Its colossal reform requires patient and meticulous study. Because even bona fide experts still ask to be convinced.