Thu. Feb 29th, 2024

The implementation of Santé Québec will be long and risks encountering resistance on the ground.

Analysis | Dubé reform: Quebecers will still have to be patient

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The Minister of Health and Social Services, Christian Dubé, during the CAQ assessment.

  • Hugo Lavallée (View profile)Hugo Lavallée

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We probably don't suspect yet all the ramifications that the creation of Santé Québec will have. The bill, adopted at dawn on Saturday morning, has hit the headlines on a few occasions, but many Quebecers continue to wonder about what it really is, because the text is so wide-ranging.

It is true that the administrative reforms intended to restore the health network are arousing increasing skepticism, with many patients doubting that they can really improve their lot. A career manager who has contributed to major reorganizations within the private company, the Minister of Health continues to believe that an overhaul of management methods and better accountability will change the situation.

Christian Dubé chose to bet big on his bill, devoting more than 200 hours of parliamentary work to it in recent months. The text has now been adopted, but its implementation has only just begun – and we will have to be patient before seeing the results.

Minister Dubé has often explained that his intention was to separate the major health orientations, for which his ministry will continue to be responsible, from the daily operations, which will fall under the new entity. However, this is only one aspect of the bill, which will also lead to significant changes in the way hospitals are managed and administered.

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The creation of the CSSS (in 2004) then the CISSS and CIUSSS (in 2015) has certainly led to mergers of establishments and the creation of ever more complex organizational charts, but the governance structures themselves have remained more or less the same.

Until now, each professional group has always exercised its power through its own bodies. Physicians have their Council of Physicians, Dentists and Pharmacists and their director of professional services; nurses have their Nursing Council and Director of Nursing; and so on for other types of professionals. Each of these groups sees itself in some way as a counter-power to the ministry and local management. Most also have, as a general rule, a reserved seat on the boards of directors of the establishments.

From now on, the management of Santé Québec will rely mainly on an interdisciplinary Council for evaluating trajectories and clinical organization, supposed to reconcile the divergent interests of everyone. We also reviewed the allocation of seats on the board of directors and the process of appointing several managers.

Such transformations already arouse enormous mistrust. In the briefs they submitted after the bill was tabled last spring, most professional groups pleaded for a special status allowing them to continue to have direct access to senior management. Several also called for a seat reserved for their members on the future board of directors of Santé Québec.

If the minister made compromises on certain aspects of his bill, he remained firm on the major management principles that he had put forward. The objective is to put an end to preserves and silo work in order to give management levers to those who will manage Santé Québec and the establishments that will be part of it.

On the last day of the parliamentary session, last Friday, Christian Dubé well summed up the spirit that drives the government: Give managers the necessary levers to develop a culture focused on results.

To paraphrase an old statement by the minister, we will now recruit top guns and we will link their destiny to their ability to move the needle of performance indicators in the desired direction.

< p class="StyledBodyHtmlParagraph-sc-48221190-4 hnvfyV">Such a management philosophy obviously arouses strong criticism. Within hospitals, professionals are concerned about seeing their influence and expertise being short-circuited, to the detriment of the well-being of their patients. Many organizations, associations and unions also criticize the minister for having a centralizing and productivist vision of the health network. If the idea of ​​making the State more efficient is nothing new, the current reform intends to push the logic even further.

Implementing such changes will take time and will inevitably generate a lot of resistance. This is because no professional body likes to see its influence diluted for the benefit of career managers. The current leaders are themselves worried, the Association of Managers of Health and Social Services Establishments regretting that the bill has not been amended in order to outline the minister's powers of direct intervention in the daily management of network establishments.

Added to the delicate transition that is beginning is the difficult renegotiation of collective agreements, still in progress with public sector employees, and the renewal of remuneration agreements with doctors, which expired almost a year ago. Just yesterday, the president of the Interprofessional Health Federation of Quebec (FIQ), Julie Bouchard, deplored that we are still far from an agreement in principle unfortunately.

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Julie Bouchard, president of the FIQ

Important debates which were to be resolved as part of the study of the bill were also postponed. The Federation of Specialist Physicians has, for example, accepted that specific medical activities be imposed on certain of its members, but all the terms must still be negotiated. The minister is also giving himself additional time to rule on the merger of the 136 existing union accreditations and the repercussions that this will have on staff mobility and the balance of power between union centers.

Everything will of course depend on how the changes are implemented. While he was Minister of Health, Gaétan Barrette assured that his reforms would lead to notable improvements in the provision of care. However, important aspects of the bills he pushed through were never implemented – or, by his own admission, not in the way he would have liked.

The minister at the time wanted, for example, to impose new obligations on doctors, particularly in terms of care and when renewing their practice privileges in hospitals, but we never knew if this way of doing things had translated into tangible results.

The problem is that it is difficult to concretely measure the benefits (and perverse effects) of the various reforms which have continued to add up over time. The General Auditor has carried out performance audits on specific issues, such as surgical waiting times, telehealth or the quality of access to care indicators, but there is still a lot of work to be done on effectiveness. governance mechanisms, respect for the rules adopted and the rigor of the accountability offered to citizens.

Asked to know when Quebecers would be able to to evaluate the success of the new reform, François Legault responded that we could judge the results in 2026, during the next elections. Those waiting for care may find it long, but the next three years are likely to pass quickly for a minister who wants to implement big changes in a network as vast and complex as that of health.

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