Russ Ford's Blog

The Quebec Experience with Health Care Restructuring

Last week we did an analysis of the government’s new health care reform package called Patients First. The reforms suggested are administrative and follow a similar process that was employed by the Government of Quebec.
In health care we often talk about “best practices” which essentially are actions that we know from experience or research to be the most beneficial intervention available. While best practices are often reserved for clinical interventions, they can also be applied to organizational development.
So let’s take a ride down the Trans Canada to see what "best practices" can be derived from the Quebec experience with health care reform. 
Quebec has been in the business of health care reform much longer than Ontario. Almost a decade ago Dr. Couillard who is now the Premier but at the time was the  Minister of Health,  merged all health and social agencies except regional services into 95 provincial agencies.  Their equivalent of the LHIN was responsible for the coordination of services but decision making rested with the Quebec Ministry of Health.
(Any similarity this reform has to Patients First is entirely deliberate.)
CLSCs which are or were the Quebec equivalent of Community Health Centres were part of the merger.  Local boards of citizens were abolished, CLSCs were no longer allowed to do health promotion or social development work as we would define it and some of their nurses were moved into private health clinics operated by doctors. Services that were operating in hospitals were out sourced to private clinics which in the next reform package were allowed to extra bill if they were providing a service that was not being provided by a hospital.
Recently the passage of Bill 10 has created more mergers and given even more authority to the Ministry.  For the few organizations that still remain, the Minister  now appoints the CEO and all board members.  Public Health, the only remaining community service still standing has had its budget cut by 30%. By contrast, physician salaries in Quebec have risen 89% in the last ten years.
Unlike Ontario, Quebec’s reforms did get people into the streets.  Quebec’s health care workers marched as did the Anglophone community which saw centralization as an attack on minority rights.  Bill 10 passed in the National Assembly only after the government stopped the debate.  All opposition parties voted against Bill 10,  but Dr. Couillard has a majority government.
Like Ontario, Quebec   used accountability as its stick. We need these reforms to ensure greater accountability for public money.   Who can argue against the proper  spending of public money?  Yet even on that score Quebec’s provincial auditor has blasted the government for the financial waste that was created by these reforms.
No doubt some of you are saying just because centralization was a bust in Quebec does not mean that Patients First will yield similar results.
The Quebec experience did result in the University of Montréal’s Department of HealthAdministration doing a study on the organization of health services.  Their study concluded that there is no evidence to support the notion that the merger of health care organizations generates any economies of scale or reduces bureaucracy and has no positive impact on the integration of services.
There was even a conference in the United States titled “Why Health Care Mergers Fail.”  Yet we in Ontario seem poised to start merging and centralizing.
The Montréal study found that integration of services, which apparently is one of the things our government wants to achieve, is best done thorough the coordination of autonomous organizations.  Let me quote the Montréal study directly because I simply can not express it better.
Scientific data clearly shows that a decentralized system is closer to the centres of decision making and allow for health and social services to be better adapted to population needs especially those of the underprivileged or those living in rural or outlying communities.  Contrary to Industry which seeks the production of uniform and standardized services at the best price, health systems need to be able to adjust services to the populations being serviced.
Patients First is a document that is devoid of any rational arguments.  There is no evidence or “best practices” to support its central assertion that centralized control will lead to positive health outcomes.  It is just not true. In fact the evidence is quite the opposite especially for those citizens and groups who face barriers to access.
That is not to say there won’t be winners with Patients First.  The MBAs at Queens Park will have their “system” and all the power that goes along with it.


End Notes: Dr. David McEwan the head of Toronto Public Health and Dr. Duncan Sinclair the former head of the government’s task force on hospital restructuring have both come out against Patients First.  To paraphrase, Dr. McEwan believes it will be the end of health promotion funding and Dr. Sinclair sees it as a power grab by the Ministry.  Could not agree more with both of them.
There is a proposal which seems to have legs that will merge Ignace Community Health Centre with the hospital in Dryden. It has begun…
A rally is being organized by CHC nurses and Dieticians for March 3 at noon at Queen’s Park.  They are protesting a six year long salary freeze which shows no sign of thawing and in general the under funding of community based health services. 


health care

The systems and technical people always forget that humans are not robots who can be treated on the assembly line. Every person is unique even if their ailment is a standard condition (hip replacement; diabetes; heart attack; broken wrist). No matter the condition each person needs to be treated as a separate person because of their various backgrounds, social situations, educational experience, family settings, etc. etc.
Focussing on real human beings and not just the system or techniques is the challenge for us all in this technology gone crazy society.

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