Honourable Members of the Commission,
The management of the health and social services network encompasses many important issues. The changes proposed by Bill 127 deal essentially with the structures in place and, as such, their practical and immediate impact on the improvement of services to the public – which is always the Québec Ombudsman’s primary angle of analysis – is insubstantial.
First of all, I would like to express my approval of several provisions in the bill that will lead to increased transparency and that should ensure that the public is better informed and consulted. I am thinking, for example, of the proposal to oblige institutions to use different methods to inform and consult the public on the organization of services and to determine public satisfaction with the results achieved. Likewise, the bill clearly expresses a desire to enforce government orientations and establish much-needed consistency of action.
I do have some hesitations, however, concerning the approach adopted with regard to the structures, which I fear may be a source of confusion. This bill is based on the Act respecting the governance of state-owned enterprises, an act that is very suitable for state-owned enterprises, which are actually self-financing businesses: Hydro Québec, the Société des alcools, and Loto Québec, for example, produce goods and services that they can sell – under a monopoly – to a captive clientele. A lucrative market for these goods and services exists, and self-financing is possible, as is the generation of profit.
The production and management of public, universal health and social services, however – beyond the fact that it is a driver of economic activity – leads to government expenditures and generates little income and no profit, even under a monopoly. Even comparison to other public insurance plans is of extremely limited value. The public health care insurance plan differs significantly from other public insurance plans that strive for and may achieve self-financing, such as the automobile insurance and occupational health and safety plans (the latter being jointly financed and managed).
Applying the Act respecting the governance of state-owned enterprises to the management of health and social services without major adjustments could generate inconsistencies, particularly with regard to accountability. It seems to me that it would be preferable to adapt the modifications of the Act to the reality of the public health and social services plan and the demands of medical, professional and administrative practice in all regions. I have a few recommendations in this regard.
In my opinion, with regard to management, the fundamental question is whether we need to invest in the development of structures and the expertise of boards of directors or strengthen the management capacity of the stakeholders who are truly accountable, from the Ministry to the institutions? I opt for the second choice, which assumes that we can clarify the roles and division of responsibility, establish clear and realistic expectations, and grant the degree of independence required to implement these expectations and manage the risks, all with a minimum of technocracy. I will come back to this point.
I would like to explain the connection between the conclusions of our investigations and the management of the health and social services network. (To respect the time allotted to me, I will raise just a few highlights from the text that we submitted to the Commission).
In terms of health and social services, the substantiated complaints – complaints we receive as second recourse – deal mainly, and in descending order, with accessibility and wait times (43%), failure to respect rights (18%), lack of coordination between programs and services (11%), environment and living situation (11%) and financial issues (8%) (The other reasons for substantiated complaints represent a total of 9%). It should come as no surprise that we receive no complaints about management itself, since this is not the angle that is of concern to the public.
That said, we can relate certain findings to the management of the health and social services network by drawing on an analysis of substantiated complaints and the conclusions of our investigations. Based on these, three management concerns emerge:
- Coordination and accountability
- The service offer
I am fully aware that these concerns reflect only a portion of the issues related to the management of the health and social services system. We focused our examination in particular on ways to improve management so as to influence the quality of services.
First concern: coordination and accountability
In this regard, it seems to me appropriate, first of all, to point out that the last overhaul of the Act – with the creation of local service networks and health and social services centres (CSSS) – generated a notable improvement by combining certain authorities. Real progress was made.
The lack of coordination continues, however. For people with rehabilitation needs, for example, we see people shunted back and forth from the CSSS to the rehabilitation centre – and these are not isolated cases. Likewise, inter-institutional transfers and services when an individual returns to their home region after treatment elsewhere are not always systematically synchronized.
In October 2009, I had the opportunity to present to this Commission our report on pervasive developmental disorder (PDD), which illustrated that the problem of sectoral and intersectoral silos persists, with major consequences for the people affected and those responsible for them. Another example, this time in mental health, is related to access to services for people with multiple problems: sometimes people are asked to resolve their drug addiction problems before they can access mental health services, and at the same time they are asked to stabilize their mental health issues before they can access drug addiction services.
Bill 127 perpetuates some areas of confusion. In practical terms, it is hard to determine whom the executive director of an institution reports to. To the chair of the board of directors or to the president and executive director of the agency? The same question arises for the president and executive director of the agency: Does he or she report to the agency’s board of directors or to the deputy minister? The chain of command is unclear.
The organization of superspecialized or ultraspecialized services (3rd and 4th line) raises another grey zone between the integrated university health networks (RUIS) and the agencies. We have four RUISs – each one connected to a university health centre (UHC): Québec, McGill, Montréal and Sherbrooke – which cover the whole of Québec, fifteen agencies and three separate authorities for the northern regions, which do likewise. Obviously, this is a complex matter, but it is certainly relevant to ask whether we need four RUISs as well as eighteen regional authorities. Couldn’t we simplify things? Avoid overlaps? Integrate?
Furthermore, section 51 of Bill 127 suggests adding subsection 346.3 to the Act respecting health services and social services to create a regional management committee consisting of the president and executive director of the agency and the executive directors of the institutions. At first glance, it seems to be a good idea to bring these people together to provide better coordination. But does that mean, given the coordinating roles of the agencies, that this is not already being done? Do we need a law to ensure this is happening? I believe that the problem lies elsewhere, specifically in the confusion over the division and exercise of responsibilities at various levels.
Once again, as in the creation of the RUISs, we are adding without really eliminating. If we want to strengthen the chains of command and coordination – and maintain the boards of directors – shouldn’t we do more to clarify and outline their responsibilities? Why are we not questioning the need for certain boards of directors, those of the agencies, for example?
To all this we can add ambiguity concerning the leadership that the Minister and the Ministère de la Santé et des Services sociaux (MSSS) should be exercising to define the best management and implementation tools for its policies or to evaluate the efficacy of the methods of service organization. Even though the Ministry has internal expertise and expert agencies (Institut national de santé publique du Québec (INSPQ), Institut national d'excellence en santé et services sociaux (INESSS)) to rely on, its guiding presence is not always sufficiently assertive.
The result is a gap that is naturally filled in by other stakeholders: the various institutional associations and private businesses – such as the pharmaceutical industry and the technology production industry – which write best practice guides on the matter and make decisions about the value of different methods of organization and intervention.
Second concern: fairness
In our investigations, we frequently see significant variations in the service offer from region to region and within regions, in a variety of services. I will use home care as my example. Of course, there are government orientations, and we cannot overemphasize the need to develop home care, since the mission of the health and social services network is to provide services, not to provide accommodations. We have noticed, however, that for people in very similar circumstances, the home care service offer varies widely, not only from region to region, but from one CSSS to another. There are no clear guidelines, no minimum levels required by the Ministry, and everything is left to the discretion of the agencies and institutions. The lack of clear guidelines also makes home care very vulnerable in the face of financial constraints.
It is not fair that, based solely on where they live, people in similar conditions do not have access to the same services. In the United Kingdom, they call this phenomenon “postcode prescribing”: tell me your postal code and I will tell you what kind of services you can receive. This situation cannot be considered acceptable.
Third concern: the service offer
We are witnessing the gradual erosion of the basket of services. At its origin, in a universal medical care program, the official service offer is as complete and as generous as possible. The historical core – the hospital insurance plan and the health insurance plan that covers medically necessary services – is solid: major emergencies are generally treated quickly and effectively. The inner perimeter is relatively well defined.
The surrounding area, however, especially the whole social services aspect, is very vague, and this is where the problem lies for the public. In reality, the service offer announced is more generous than the available resources, and for a long time now we have let this slide. We expect agencies and institutions to manage with an imbalance between the theoretical (and disjointed) basket of services and the actual resources at their disposal. Faced with the difficulty of dealing with rising costs, peripheral services are being reduced, leading to de facto deinsurance.
Another approach is to take the service out of the hospital setting – consider, for example, the treatment of macular degeneration – to offer it in clinics. The medical service is covered by the Régie de l’assurance maladie du Québec, but the technical component is not, and the patient end up with drops that cost $230 to absorb an administrative cost that is real but not covered by the public plan. For lack of making choices, the basket of services gradually erodes. Because the composition of the basket of services has become a taboo subject, we allow it to slide.
People with private insurance and those with high incomes can pay for access without being influenced by the cost. Others hesitate or simply deprive themselves of these services, to the detriment of their health. The deleterious impact of health care fees charged at the point of service has been clearly demonstrated in Quebec and elsewhere in the world.
Besides resulting in a suboptimal use of resources, this failure to act boosts the inequities that are increasing over time. Inequities in access to service are frequently the subject of complaints, and this is a crucial governance issue, even though it is not included in the bill under examination here today.
In the same line of thinking, at the Québec Ombudsman we receive more and more complaints related to incidental fees and new formulas of service provision outside of or in association with public institutions: fees charged by cooperatives, administrative or incidental fees charged by private clinics, and fees charged by private subcontractors that offer home care, for example.
In terms of referrals and services offered by private businesses, it is the Ministry’s responsibility to provide clear guidelines and control mechanisms. This is a corollary of the definition of the basket of services: if there are choices to make about the scope of the public health care service based on government revenues, that is a political issue, not administrative. This must be clearly expressed.
I shared these concerns with you to provide the background for the changes I feel are appropriate for this bill.
A few specific comments about Bill 127
What emerges from this bill is the desire to strengthen the lines of accountability. This seems to us to be desirable and also likely to ensure better coordination between institutions and to avoid subjecting users to inequities, a lack of coordination or unequal service coverage based on their geographic location. It seems, however, to lack an important corollary: a simplification of the structures and a clarification of the responsibilities of the various stakeholders, which should complement each other. This is nothing new and has been raised repeatedly by many experts. The overlapping of responsibilities between the Ministry, the agencies and the institutions must be eliminated.
Secondly, this bill provides for a reduction in the size of the institutional boards of directors, which will drop from an average of 19 to a maximum of 15 members. More specifically, it cuts half of the members elected by the public, which will lead to a reduction in public participation. Although this may seem surprising, the Québec Ombudsman would not be opposed to the designation of public representatives by a means other than the current electoral method, due to the very low historic rate of participation (less than 1%) for these elections, which fill fewer than half of the seats not filled by acclamation because of a lack of candidates. The cost of these elections is nearly $2 million, which leads us to question the efficiency of the process.
Bill 127 also expresses the intention to make the boards of directors more expertise-oriented, rather than simply representative. In this case, the role of users and their representatives, who are citizen-experts, should be enhanced. This is why I have concerns about the 50% reduction in user representation and the restriction of their designation to members sitting on user committees. The users are the primary people affected by the decisions of the board of directors, and their enlightening presence, or that of their representatives, should be maintained at its present level. I am also in favour of having a representative of the institution’s foundation sit on the board.
Thirdly, we note that this bill proposes extending the length of accreditation to four years. I support this approach. In this regard, it seems more appropriate and important to ensure proper risk management and continuous quality improvement. In practical terms, this means in particular that after the initial visit and granting of accreditation (or certification, in the case of private seniors’ residences), the inspection interval and the intensity of follow-up could be based on the scope of observed problems.
- To allow for more representative participation and avoid isolating user and public representatives on institutional boards of directors:
- provide for the participation of two user representatives;
- provide for the designation of a substitute member, in the event that one of these representatives is incapacitated.
- To adjust governance methods to the reality of the health and social services network, particularly with regard to accountability:
- clarify the role of the health and social services agencies, units reporting to the Ministère de la Santé et des Services sociaux and their chain of command with regard to the institutions; in particular, specify the extent of their coordinating role;
- by extension, abolish the boards of directors of the health and social services agencies;
- clarify the obligations and accountability of the institutional directors and their immediate and hierarchical chain of administrative command;
- define the responsibilities of the boards of directors more clearly, including their relationship with the executive director of the institution and their accountability, where necessary.
- To ensure the most efficient management, insofar as the institutional directors play a critical role in upholding government orientations and are therefore accountable:
- grant increased room for manoeuvre to institutional directors at the local level to facilitate the implementation of these orientations in keeping with the populational approach, which entails respecting the realities and specific needs of the people in the territory they serve.
- To ensure equitable access to services, including financially, for all people wherever they live, and to clarify what has become an area of confusion for both institutions and the professionals involved:
- establish clear guidelines for all questions related to administrative and incidental fees or other cost components that may affect access to services;
- require all institutions to plan for the technical component when they choose to outsource a service;
- require the Ministre de la Santé et des Services sociaux to report annually on any changes made to the basket of services and the factors behind these decisions.
I acknowledge the complexity and the sensitivity of the issues related to health and social services management. That said, Bill 127 appears to me to provide relatively minimal progress which does not resolve the main problems raised by the public. We need to push further in order to simplify structures to promote improved coordination, reduced costs and strengthened accountability, and in order clarify the basket of services. This is where the primary needs of the public lie: access to clearly defined, well-integrated and well-dispensed quality services at a reasonable cost.