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Special consultations and public hearing on Bill 33,
An Act to amend the Act respecting health services and social services and other legislative provisions
Comments by the Québec Ombudsman presented to the Social Affairs Committee
Québec City
October 2006
Mr. Chairman,
Mr. Minister,
Members of the Social Affairs Committee,
I would like to thank you once again for giving me the opportunity to discuss with you one of the main challenges facing our health and social services system—ensuring timely user access to specialized medical services.
I speak to you today on behalf of the users of these services rather than as an expert in the field. The general public is largely unfamiliar with the increasingly technical nature of the law, the complex standards it creates, and the structures that are put in place to better serve its needs. Their worries and fears are expressed in the complaints that Le Protecteur du citoyen receives on a daily basis. If there is one thing users demand, it is to receive prescribed medical treatments within a time frame that, at very least, does not cause harm by aggravating their condition or putting their health at greater risk.
This issue cuts to the heart of a person’s right to life and security and, consequently, the right to receive “with continuity and in a personalized and safe manner, health services and social services which are scientifically, humanly and socially appropriate." 1
The Supreme Court of Canada ruling in the Chaoulli-Zeliotis case brings us back to the fundamental role of a public health and social services system: ensuring that individuals have access, within a medically reasonably time, to the services vital to their health and well-being; and, also, using the ever-increasing public resources allocated for this purpose in an appropriate and responsible manner.
This ruling poses the challenge of upholding two predominant social values that underpin the health and social services system—universality and accessibility. In assuming his responsibilities, the minister must also make choices that take into account a variety of factors, notably the legal framework and structures in place, recent reforms and their impact on employees and users, and the history of the health system, including the role of private insurers. In addition, the private sector’s already active involvement in providing services must be taken into consideration.
I have thought about the effect of the proposed amendments on the public, the hands-on implementation of the law, and how it can help further improve quality of services. I share the minister’s desire to protect the public interest, which is at the heart of government concerns with respect to health and social services.
My comments do not deal with the proposed structure, or the advisability of private sector involvement. What is important to me is that users receive the same quality of services and have access to the same mechanisms for asserting their rights, no matter what resource they are referred to. The government’s proposal stresses the importance of preserving the system’s values of equality, freedom, dignity, and solidarity for all citizens. I see this bill as an invitation to both the public and the private sector to respect and give life to these fundamental values.
That said, in a brief I presented to this committee last May, I commented on the government proposal set forth in the discussion paper entitled Guaranteeing Access: Meeting the challenges of equity, efficiency and quality. I made recommendations intended to guarantee referred users access to quality services and the same complaint mechanisms, continuity of rehabilitation services, and timely access to homecare. I stressed the importance of providing personalized information to users and expressed my concern that they not be subject to additional fees they would not pay in the public system. Lastly, I urged the minister to correct discrepancies in user travel assistance programs, particularly for those living in outlying regions.
The draft bill contains provisions that take these recommendations into account. I will refer to them in the remarks that follow while at the same time highlighting certain aspects of the bill I think can still be improved.
Controlling the quality of specialized medical services delivered in a non-hospital setting
Various provisions of Bill 33 set forth obligations regulating clinical activities conducted outside of the hospital setting, whether in specialized medical centers or clinics associated with a hospital. Various control measures are identified.
Sections 333.1, 333.2, and 333.3 deal with the legal status, ownership, and management of specialized medical centers run by participating or non-participating physicians, as well as with the type of medical services they provide. These centers must hold a ministerial permit (s. 437), undergo certification (s. 333.4), and designate a medical director (333.5). The minister has the right to inspect the centers (s. 489) and seek the opinion of the Bureau of Collège des médecins as to the quality and safety of the specialized medical treatments they offer and the qualifications of the physicians who practice there (s.333.7).
These measures are consistent with our desire to maintain service quality and safety. They should also reassure citizens who are referred to these services about receiving the same quality of service that they would be entitled to in a public hospital. However, these controls will not have the sought-after impact if they are not fully and effectively implemented.
In the course of my duties, I plan to keep a close watch on user satisfaction levels and remain vigilant about the creation of these new medical organizations.
Access to remedies: a double standard?
A good complaints system is one way to help monitor the quality of services. The same holds true for access to specialized medical services. So I am very pleased with the addition of section 349.3. Under this section, services delivered by associated medical clinics under tripartite agreements with referring establishments and regional health and social services agencies are subject to the complaint review process of the referring establishment and, if required, to intervention by Le Protecteur du citoyen.
However, the concerns I expressed in my brief have only been partially addressed. The complaint review process will not apply in full to service agreements concluded between establishments and private clinics under section 108 of the HSSSA. Users unhappy with services provided by a physician at such a clinic will have no alternative but to file a complaint with Collège des médecins, whereas in all other instances involving the health system, they can take their case to a medical examiner. This is a double standard. Citizens dissatisfied with specialized medical services at a hospital or CLSC can seek administrative remedy through the establishment’s medical examiner. If they are unhappy with the result, they can take their complaint to a Centre de santé et services sociaux review committee. But those receiving the same services at a specialized medical center have no such option. Their only recourse is a complaint to Collège des médecins, a complex, quasi-legal process that is much longer and more formal in nature.
This difference in treatment creates two categories of users—those with access medical examiners at referring establishments and those without. If the public system uses private resources to deliver services, this must not come at the expense of user rights, which include access to an administrative complaint system that actively contributes to the continuous improvement of service. The complaint review system should therefore also apply to medical services delivered by virtue of agreements signed under section 108 of the HSSSA. Users and health professionals have nothing to gain from being excluded from a free, readily accessible system that has generally proven effective. The reasons that led lawmakers to introduce access to medical examiners still hold.
It seems fitting that the members of this Committee take the opportunity these consultations provide to correct this unfounded discrepancy in treatment in the interest of genuine equity.
Recommendation 1
That the complaint review system apply in full to service agreements services signed between establishments and private clinics under section 108 of the Act respecting health services and social services.
A centralized access management mechanism linked to the user
The central access management mechanism proposed in the bill is an improvement over the existing situation to help manage hospital waiting lists. However, the challenges of managing operating areas, including lack of availability of operating rooms and health professionals, also have a critical impact on the waiting time. In managing access to services, I believe that those responsible for the mechanism cannot overlook this crucial aspect of the problem.
We have been told that MSSS intends to clarify waiting list rules for specialized and highly specialized services. Criteria for setting and communicating expected treatment dates will also be reviewed. Once again, I stress how important it is to keep citizens informed about the status of their requests. They have a right, and more importantly, a need to receive accurate, personalized information about their anticipated date of treatment, as well as to obtain answers to their concerns and worries during the waiting period.
As for regional waiting list coordination, MSSS has informed us that it is exploring other administrative options, including monitoring by regional agencies. Other possibilities include the appointment of regional waiting list coordinators, identification of inter-hospital service corridors, and negotiation of management agreements. Such measures would answer our concerns about the importance of ensuring that regional agencies are fully aware of the waiting list situation in their area and capable of coordinating services to maintain the waiting time at reasonable levels and quickly make adjustments where required.
Meeting the varied needs for rehabilitation services
Users tell us about the problems they have in obtaining post-operative services. They have to wait to obtain rehabilitation services at their hospital after surgery or after operations at hospitals outside their region. There is also the situation where users consulting for other medical problems are frequently, even systematically, referred to private rehabilitation resources. In all of these cases, waiting times vary depending on the user’s ability to pay or whether they benefit from special insurance coverage (for example, road accident or worker’s compensation, or a group insurance plan).
The purpose of the bill is to noticeably improve access to specialized and highly specialized medical services. To this end, it provides for implementation of a central waiting list management mechanism at hospitals, and for agreements with associated clinics to treat users who have to wait too long. In the case of specialized medical services, these clinics will be an extension of the hospital, and must also deliver rehabilitation services to their clients.
This will probably lead to increased demand for rehabilitation services. Since waits for these services are already long, who will provide them to the larger numbers of people who will now require post-operative or other services in the system?
Neither the draft bill nor the government proposal submitted for public consultation last April contain specific measures to rectify this situation and deal with the increase in demand. Last May, I recommended that an action plan be drafted because intervention by the department had become necessary and urgent. I reiterate my recommendation.
Our complaints indicate that some of the more proactive establishments find solutions to reduce waiting lists for rehabilitation services. However, most still seem unable to resolve the problem.
Let us take the case of a rural resident who complained because she had to wait four weeks after an operation to access rehabilitation services at her regional hospital. The woman underwent a knee operation at a specialized facility in Québec City, then returned home with a prescription for two physiotherapy sessions per week. After a week without news, she contacted the hospital, which confirmed that her request had been received, but that she would have to wait for a physiotherapist to call her to schedule a first appointment at her home. Three days later, she called the hospital back and was told that there was a staff shortage. After three more days, the physiotherapist contacted her and asked her to come to the hospital for an appointment, since time was short for home visits. Another seven days went by before she finally obtained her first appointment, not for treatment, but for an initial needs assessment.
Our investigation confirmed the woman’s account and allowed us to determine the causes of the delay, which were fourfold: difficulties in recruiting rehabilitation specialists in the regions, inadequate waiting list followup, increasing demand for services due to population ageing, and a budget freeze which prevented the hospital from fully filling available positions.
We also observed the various corrective measures taken to decrease the waiting time. The Centre de santé et de services sociaux first carried out a study on reorganizing services and drew up an action plan to better control and curtail waiting lists. It developed a service reorganization plan built around various categories of clientele: children, outpatient clinic users, hospitalized patients, users in adapted housing, the elderly, and users at home. Work schedules were revamped to take the new priorities into account. The center also has made plans to contact heads of surgery at all hospitals within its territory to ensure better coordination of postoperative rehabilitation services. In addition, an agreement has been signed with the regional hospital to handle users with special needs for predetermined periods.
This is a good example of the type of initiatives a healthcare establishment can take on its own to remedy the situation.
However, most of the complaints we handle show that the situation for users consulting hospital outpatient clinics for rehabilitation services—in other words those who are receiving post-hospitalization follow-up—is of greater cause for concern.
For example, in other cases we have investigated, users have been told that rehabilitation services are offered on a priority basis to hospital patients and those requiring immediate post-hospitalization care. With the waiting time of over a year, other users are referred to private clinics where they must assume the cost of services.
Implementation of Bill 33 can be expected to increase demand for rehabilitation services. I suggest that various means can be explored to ensure the timely availability of these services. A ministerial action plan could be drawn up to deal with the shortage of qualified rehabilitation specialists. The plan should set forth special, region-specific conditions for attracting and retaining specialists in the public system, or identify service corridors between hospitals where the waiting time are unreasonable. Another avenue worth exploring is the proposal submitted to this committee by the Fédération des physiothérapeutes du Québec, which calls for framework agreements to ensure complementarity of services between private clinics and the public system.
I therefore recommend:
Recommendation 2
That Ministère de la Santé et des Services sociaux, in conjunction with the parties concerned, develop and adopt an action plant to address the problems of accessing rehabilitation services. This plan should ensure that users receive services commensurate with their actual needs, irrespective of who is responsible for the cost of these services.
Information to better explain a complex system
To conclude, I would like to share the overall impression I had upon reading the bill, which adds new structures and standards to an already complex health and social services system that is growing increasingly. Therefore, I support the proposal to promote public awareness about how to make better use of health and social services. I believe that access to relevant, readily available information is a crucial prerequisite to getting more citizens involved in the collective effort to improve our health and welfare.
However, I would argue that there is still room for creativity and simplification in explaining the workings of the system meant to serve them. Not only should information be accessible, it should also deal with the rights citizens are entitled to, the services available, and the ways to access them. I believe that public information must answer basic concerns. Who should I contact and where? How do I go about it? When should I act? Do I have to assume certain costs? Which ones? Information to the public is one of the cornerstones of a health and social services system mindful of the values on which it was built and the needs of those it is intended to serve.
Recommendations
- That the complaint review system apply in full to service agreements services signed between establishments and private clinics under section 108 of the Act respecting health services and services.
- That Ministère de la Santé et des Services sociaux, in conjunction with the parties concerned, develop and adopt an action plan to address the problems of access to rehabilitation services. This plan should ensure that users receive services commensurate with their actual needs, irrespective of who is responsible for the cost of these services.
Note
1 Act respecting health services and social services, R.S.Q., c. S-4-2, section 5. back to text
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