With the tabling of the bill creating the Santé Québec agency on March 29, Minister Christian Dubé is undertaking the ninth reform of health services since the Castonguay-Neveu report, which dates from 1972. We have been at the search for the structure and mode of operation that will make it possible to meet the needs of the population as effectively as possible with regard to both health and social services.
Currently, the two networks include 137 regional establishments (including 22 CISSS and CIUSSS) and 1,450 service facilities employing approximately 300,000 people. The Ministry of Health is responsible for managing all services and the government is of the view that this approach does not allow for “optimal coherence”. There is a need, experts say, to review the governance of the system, as the ministry is too removed from operations and “its decisions do not always reflect the reality experienced by managers and employees on the ground.” It is a management record that is deemed unacceptable.
The overall objective of the reform that the government is undertaking is to increase efficiency in order to improve care and reduce waiting times in the emergency room and for surgical procedures. Day-to-day management will be entrusted to the agency, which will be a state-owned company. “Like a dynamic, streamlined organization,” the agency will be led by a President and CEO and an accountable Board of Directors. The Ministry will no longer have any direct responsibility for network management. From now on, it will deal only with policy planning and evaluation.
The law will make it possible to put in place “the tools that promote greater local management”. A manager will be appointed in each of the hospitals. But instead of having 34 employers as there are now, the agency will be the single employer for all health and social services, reducing bureaucracy in managing staff. The goal is to have less disparity and inequity in the network.
Ultimately, the government wants to enhance the satisfaction of users who receive services by giving “managers the necessary levers to develop a results-oriented culture”. In particular, we want to set up an interdisciplinary Council for the evaluation of trajectories and clinical evaluation within a hospital or establishment. The agency’s board of directors will also have a National Vigilance and Quality Committee whose mandate will be to analyze and manage complaints and recommendations that come from other bodies in the system or from the government.
The government is thus preparing to upset the organization and functioning of one of the most important sectors of society on the basis of an idealistic management discourse that will be impossible to achieve. But where are the documents that give a minimum justification for the choices that are made? Can we get expert testimonials on governance? When we try to analyze and understand the entire reform project, we no longer know in the end what is a priority for the functioning of the health and social services system for the next 10 years.
Has there been an assessment of the common management of health and social services within the CISSSs and CIUSSSs? If so, would it not be more appropriate to have a separate agency whose organization and operation would be better suited to these types of services? Otherwise, the name should be changed to the Quebec Health and Social Services Agency.
Beyond a redefinition of structures, what the government is proposing “is a long-term culture change” so that “managers have free rein to make the right decisions based on what their patients and their employees.
The government’s priority is to improve local management, but it can already do so immediately by requiring that all service points be under the responsibility of a general manager assisted by an adequate team. When we count down the establishment of the new corporation, there will be a probable hierarchical structure from the minister to the local manager of at least six levels, ranging from the CEO of the Health Quebec agency, to the vice-presidents of the agency, to the CEO of establishments which are subsidiaries of the agency and to their sector directors and then to the hierarchical levels of the care units. How can we be sure that there will be real proximity management?
There remains one last point to emphasize, namely how the Ministry will be able to fulfill its planning role when the law gives the agency the power to determine the interregional allocation of resources (article 93 of the bill) and when it will have the obligation (article 99) to prepare itself a strategic plan explaining the stakes, the objectives, the results targeted in the medium term and the indicators which will make it possible to judge its performance? One might as well say that the Ministry will be abolished, even with regard to policy planning and evaluation.
Faced with economic, financial and social conditions that will be problematic in the medium term, the chances of success of a reform that seeks to establish a new management culture by creating a government corporation are low. The government must find another more pragmatic approach to improve the functioning of the system. The current bill is excessive and unrealistic.
