(Quebec) Medical specialists will soon have to follow new rules to ensure better access to their services. Quebec intends to force them to take more care of patients throughout the territory, including in regions and hospitals that are neglected at the moment, learned La Presse. They will have to offer better availability in emergencies and accept unfavorable schedules.
Minister Christian Dubé’s bill creating Santé Québec and dealing more broadly with the “efficiency” of the network will also review governance in depth.
These changes come at a time when a hard-hitting report from the College of Physicians, which La Presse obtained, concludes that the population does not have the same access to care within an acceptable geographical radius. It is difficult to offer hospitals in the same territory uniform access to services.
“Waiting lists for surgeries or specialized care are asymmetrical from one region to another and illustrate the lack of adequate interregional management”, can we read in this document from the professional order. The College even breaks a taboo by concluding that “the question of the maintenance of certain establishments becomes problematic and takes on a political character”.
In an interview with La Presse earlier this month, Prime Minister François Legault issued a warning: “the organization of the work of specialists must be more efficient”. The specialists decide “quite a bit” themselves how their work is organized, while the general management “doesn’t have much say, sometimes”. This situation will have to change, he explained in substance.
Quebec will move from words to deeds. He intends to require medical specialists to assume “population responsibility” in order to better care for patients. By responsibility, we mean new obligations of three kinds: responding more effectively to requests for consultation made by family doctors, providing on-call duty in the hospital and accepting the sharing of unfavorable hours (after 4 p.m., for example).
The Legault government is thus seeking to reduce the wait for patients, increase the availability of specialists to treat emergency cases and avoid service disruptions.
Quebec regrets that specialists practice a lot externally and offer little availability at the hospital. However, the situation varies from one medical specialty to another. It is considered that the majority of specialists do what is expected of them, but that about 20% of them create 80% of the problems in the network.
The government says it wants to work in collaboration with specialists, but it seems obvious that the new rules will make people unhappy. François Legault also acknowledged in an interview with La Presse that “it’s tricky to negotiate with the FMSQ”, the Federation of Medical Specialists of Quebec. “You have to take some and leave some, be able to find a balance. That’s what Christian [Dubé] is trying to do with the FMSQ,” he added, giving the impression of walking on eggshells.
Governance will be reviewed to ensure the implementation of the new obligations. In each CISSS and CIUSSS, Quebec will appoint a medical director – instead of the director of professional services who, according to Quebec, does not have enough decision-making power. He will report to the CEO who, himself, will be under the orders of Santé Québec – the new agency responsible for coordinating the operations of the network while the Ministry will now focus on orientations. This medical director will be supported by an assistant director for family medicine and by a director for specialized medicine.
The medical director will be responsible for distributing the specialists on the territory according to the needs. He could decide, for example, that the absence of doctors of a certain specialty in a hospital is unacceptable because too many patients are being redirected to an outpatient clinic and are experiencing a long wait time. It would then require that the practice of these doctors be done more in the hospital.
In addition, a new “interdisciplinary trajectory council” will bring together representatives of all professionals, including nurses. The government wants to put everyone on an equal footing to better organize services in hospitals. The role of the Councils of doctors, dentists and pharmacists will be limited to the evaluation of the quality of care.
Quebec believes that at present, management is done too much in a vacuum and that the roles of the various actors are unclear. This situation hinders decision-making. A culture change is needed, he says.
Quebec is making these changes at a time when the College of Physicians has just produced a powerful report on access to care. This report bears witness to the observations made by its president, Dr. Mauril Gaudreault, during an extensive tour of hospitals in recent months – a first for the professional order.
Not only is access to services difficult in Quebec, but it is “more dramatic in certain regions where health care is simply not available”, concludes the College.
“Managers are faced with tense situations related to the scarcity of resources, which sometimes leads to competition between regions or establishments. We have noted that the distribution of Physician Resource Plans (PEM) or Regional Physician Resource Plans (PREM), a unique model in Canada, results in flagrant inequities between regions. The objective of the PEMs is, however, in principle, to distribute specialist physicians equitably between establishments according to priority needs and to promote the population’s access to specialized medical services.
However, according to the report, “recent examples of the distribution of the workforce on the territory demonstrate that it is not only mathematical logic that prevails. In addition, territorial criteria do not always take into account changing demographics, so in some regions there is clearly an imbalance in the ratio of doctors per 100,000 inhabitants”.
The College of Physicians adds that “in covert words or sometimes very openly, the inertia and lack of coherence of the health and social services network were addressed [during the tour]. The immobility and the lack of listening of decision-makers in the public service remind us daily of the subordinate role of the managers of establishments, who are nevertheless asked to perform miracles with means that shrink like a trickle. Figuratively, the admin leash is too often a strangler.”
The professional order says that administrators “openly want the closure of certain places of care on their territory because it is impossible to maintain the necessary staff there to avoid a break in care. Expensive, inefficient, underutilized are terms that come up about the network. We thus wish, despite the challenges of distance, to maintain, for example, four establishments out of six open, in which all the required staff is maintained with a complete offer. […] The managers believe that the network and the political decision-makers lack the courage to close establishments in favor of the concentration of an adequate supply of services in each region. This politicization of regional facilities is ultimately an impediment to public access to care.”
According to the College, “this inertia for an issue that has been known and analyzed for decades leads to unnecessary expenditure and an inefficient use of human capital. As we see the network cracking on all sides, now would be a good time to take courageous action and put forward measures that would ensure real public access to health care in their immediate region.”
He adds that ER doctors are in “distress”. He notes staffing problems to provide care, but also shortcomings in patient care. “The medical staff illustrated to us the constraints of examining people on a stretcher, in the middle of the corridor, or were able to observe the visible deterioration of patients with loss of autonomy who find themselves there while waiting for a appropriate support. »
“Regions cannot count on staff in basic specialties and referral corridors must be negotiated to maintain essential services. Unfortunately, it is the citizens of these regions who bear the brunt of this, as they are forced to travel significant distances to benefit from services that are more widely offered elsewhere. […] A member of the regional CPDP [Council of Physicians, Dentists and Pharmacists] told us that a patient, who was faced with traveling for more than 8 hours by bus to undergo a delicate procedure in a large centre, far from his family, had preferred to lose the sight of one eye rather than go through such an ordeal again. »
“In all the establishments visited, emergency physicians express their constant fear of error in what has become a battlefield for them. Weakened by exhaustion, they see no light at the end of the tunnel. Their colleagues fall in battle while it is difficult to attract others to replace them. […] Several doctors have told us that they are haunted by the fear of discovering a deceased patient in the emergency room during their shift. […] The shortages come to increase the responsibilities in terms of guards: the monthly ratios are distorted if we compare them with those of a large center in which the distribution is made among dozens of colleagues. In the regions, the number of colleagues can sometimes be counted on the fingers of one hand. Guard towers are bound to return faster. Exhaustion sets in. »
“In most regions, the doctors we met during the tour told us that rapid elective surgeries, which mobilize few personnel, are of short duration and do not require a stay in the intensive care unit, are favored. This is done to the detriment of heavier and sometimes more urgent ones, which monopolize more staff and require more time. […] The scarcity of technical platforms in certain regions with a shortage of personnel encourages surgeons to look for establishments that allow them to carry out surgical interventions. In one specialty in particular, doctors resolve not to see patients in consultation when they know that they will not be able to operate on them afterwards. Ultimately, the patient is penalized. »
“If the government’s intention is to make the private sector complementary to the public network, in terms of perception at the very least, this is far from being the case. Often perceived as an enemy, the private sector is minimally a spoilsport that siphons off the best resources from the public network and skims it. Specialized medical centers (CMS), for example, relieve the private network of one type of case and allow rapid and measured treatment, but the personnel required come from the public network, which in turn is deprived of it to proceed with the treatment of heavier cases within a reasonable timeframe, which swells the waiting lists. The fact that CMS can develop new technical platforms while those of hospitals are closed, for lack of staff, remains an aberration in the sense of the managers and doctors met. »