“The columns of the temple are going to shake,” vowed Christian Dubé, Quebec’s Minister of Health and Social Services, days before tabling legislation designed to restructure the province’s health system.
Despite the hyperbole of biblical proportions, Bill 15, or “An act to make the health and social services system more effective,” will essentially see Quebec do what a number of other provinces have already done – create an agency that oversees the day-to-day administration of the health system.
Santé Québec will differ very little from Alberta Health Services, Ontario Health, the Saskatchewan Health Authority, Nova Scotia Health Authority and Health PEI.
Alberta started this trend – hiving off the daily operations of the health system from its provincial ministry of health – more than 15 years ago, so Quebec is hardly breaking new ground here.
This is evolution, not revolution. Still, health care reform is never simple, or cheap.
The proposed legislation is a whopping 300 pages-plus in length, with 1,180 clauses, and will require amendments to 30 existing laws – more a testament to the breadth of bureaucracy than the complexity of the task.
Creating the new Santé Québec structure, with a CEO, management chain and board of directors at arm’s length from the government (at least in theory) will cost about $60-million. It will also have a ripple effect on the province’s 35 existing regional health entities, which will essentially be enfeebled as decision-making is centralized.
Gabriel Nadeau-Dubois, leader of the opposition Québec Solidaire party, called the restructuring an exercise in “creating a mega-bureaucracy to manage the current bureaucracy.”
Where Quebec does differ significantly from other provinces, however, and where Bill 15 could actually have an impact, is in labour relations.
The way health care contracts are negotiated and implemented in the province has long been dysfunctional. Health care workers are highly unionized and there are currently 136 bargaining units – under the proposed law, that number will be reduced to four.
Unsurprisingly, unions are fiercely opposed to the streamlining. They don’t seem convinced by Mr. Dubé's promise of “collaboration, not confrontation.”
Physician associations have also spoken out against the reform because, among other things, it will force specialists to work more nights and weekends, and do on-call shifts in the ER. General practitioners are already subject to these rules, and that has made the already-difficult recruitment of family doctors even more so.
As many critics have pointed out, Bill 15 will do nothing to resolve the most pressing issue in health care: labour shortages.
Going forward, a large majority of the province’s $59-billion-a-year health and social services budget will go to Santé Québec, but the provincial Ministry of Health and Social Services will continue to exist, with a pared-down role to provide policy and strategic advice. In other words, it will tell the “independent” agency what politicians want done.
In coming late to the restructuring party, the big advantage Quebec has (or should have) is learning from the mistakes of other provinces – and there have been many.
Health systems are big and complex, and fundamentally changing the governance structure takes time. When you rush change, bad things happen. (Alberta learned that lesson brutally.)
Running a health system is not the same as producing widgets. The notion that contracting out services to private companies will magically fix everything has been disproven time and time again. That’s why Quebec’s vow to find a “top gun” CEO from the private sector to whip the system into shape is laughable.
One of the main reasons structural reforms have produced middling results in most provinces is that politicians can’t keep their sticky little fingers out of operations. There is no point in creating an “independent” agency if its administrators are going to be lackeys and/or constantly second-guessed.
But the most important lesson of all has been this: Culture eats structure for breakfast.
In health care, everyone wants change – as long as it doesn’t affect them. There is a fierce attachment to the status quo.
Until we make fundamental changes – like focusing on results instead of volume, giving patients a real voice and choice in their care and investing as vigorously in prevention and health promotion as in sickness care – no amount of structural fiddling will make an appreciable difference.
And that’s really the key unanswered question in this proposed reform: Will it actually improve access to, and quality of, care?
Sadly, there is very little evidence that it will, nor any indication of how its success will be measured.
That makes Mr. Dubé's prophecy about the law’s impact shaky at best.