Speech at the parliamentary committee concerning Bill 10
Distinguished Committee Members,
Thank you for asking the Québec Ombudsman for its viewpoint.
In accordance with our mission, our first analytical focus is the real impact of any government undertaking on public service quality and citizens’ rights.
The Québec Ombudsman has no particular attachment to a specific structure format. What it cares about is citizens’ access to quality health services and social services in a timely and equitable fashion and in keeping with the imperatives of universality. What it considers important is that citizens’ economic conditions not hamper their access to services and that it is their health condition—and not their ability to pay—that determines access within a reasonable time frame to the services they require.
Our examination of this Bill was solely on the basis of these interests and imperatives.
Why is the Québec Ombudsman interested in questions having to do with governance of the health and social services network? Because in many of the problematic situations we see during the investigations we conduct, the dysfunction observed is connected—directly or indirectly—with governance. The frequent lack of coordination as soon as two or more institutions have to work together and service accessibility problems—incidentally, our complainants’ number one cause of dissatisfaction—can be linked to factors such as work organization, lack of accountability or the inefficiency of certain procedures. These are important facets of governance.
If I had to summarize what we have found in the course of the interventions we carry out, I would have to say that access to quality, clearly defined, properly integrated services delivered equitably and at reasonable cost hinges on streamlining of structures, greater accountability and clarification of the basket of services. Bill 10 zeros in on the first two issues. It will address the third later.
With regard to streamlined structure and greater accountability, we consider that the goals of the Bill are fitting responses to the Québec Ombudsman’s concerns, subject to certain conditions. But from the outset I must caution against the sizable risks posed by the projected reorganization of the health and social services network and draw your attention to the need for a rigorously orchestrated and orderly transition, with reasonable timelines, and a realistic and credible assessment of transition costs. In short, if the Québec Ombudsman agrees with the broad strokes of the Bill and, ultimately, the proposed endpoint, it nonetheless underscores the importance of taking the time to do things properly and of having strict markers along the way.
One thing is certain—and I am fully aware that it is a major challenge—alongside this governance reform (and not after), accessibility, equity and efficiency of service delivery must be improved everywhere in Québec.
I believe that the removal of one decisional level—health and social services agencies—will terminate the current overlap of responsibilities between the Minister, the agencies, and the institutions. Clearer assignment of responsibilities between the Minister and the new CISSSs will also serve to reinforce network coordination and accountability. Similarly, one of the strong points of this Bill is the improved integration of services that it promises. The amalgamation of institutions at the regional level has the potential to improve service continuity, seamlessness and, by extension, in the long run, accessibility to services.
That is why the Québec Ombudsman subscribes to the rationale of establishing one institution per region, except for more populous territories. We see this as a relevant response to problems with lack of coordination when several institutions are involved in a user’s care pathway, problems that surface all too often in the course of our investigations. For example, for people requiring surgery, inter-institutional transfers and the patient’s return home afterwards are not always synchronized due to poor coordination. For people with rehabilitation needs, we witness shuttling between the CSSS and the rehabilitation centres for physical and intellectual disabilities alike. Too often, service plans are not executed, updated, followed up on or integrated for each institution involved in the care pathway. This is one of the reasons why the Québec Ombudsman supports the idea of regional integration of services.
That said, I caution prudence. The experts concur that around 500,000 inhabitants is the cut-off point beyond which service planning and coordination becomes less efficient. This raises the question of the value of the proposed model in more populous regions such as Montérégie (1.5 million inhabitants), Capitale-Nationale (725,000 inhabitants) and Laurentides (600,000 inhabitants). Furthermore, the special treatment accorded to the supraregional institutions in the Montréal region, which remain independent, raises the question of the status of comparable university institutions in the Capitale-Nationale and the Estrie regions. Why does the same reasoning not apply to them?
Above these questions related to the proposed new structure, my main concern—and I cannot overstate it—has to do with planning the transition. The various health and social services players cannot be blamed for being very worried about such a sweeping reorganization. The transition must occur transparently by taking the time to gauge the negative and positive impacts of the proposed measures and to assess the direct and indirect costs using recognized economic and accounting standards. One of the things I am thinking of is the short- and medium-term cost of the integrated management of various information assets the Department intends to retrieve.
In addition, there will have to be a detailed breakdown of the phases involved and a realistic timetable for completing them. These are absolute prerequisites—and several of my recommendations are related to these aspects—for our mind to be set at ease about implementation of such a reform. If not, and this would be truly regrettable, users will pay the price.
Another risk that other presenters have also pinpointed is that the medical-hospital mission takes up a large share of resources at the cost of prevention, psychosocial care or rehabilitation within future CISSSs. Our brief notes the danger of the medical-hospital mission of the amalgamated institutions being favoured at the expense of the efforts put forward to re-channel budgets towards front-line services. At least that is what happened when local service networks were created in 2005 as demonstrated in an evaluation by the Ministère de la Santé et des Services sociaux.
The saying goes that the past is an indication of what the future holds, so I am calling on the Minister and the Department to exercise all due vigilance so that this overhaul does not occur to the detriment of proper handling of the problems that need crucial attention. Important service programs seem to be more at risk, namely, troubled youth, support for elderly autonomy, mental health, addiction, physical disabilities and intellectual disabilities and pervasive developmental disorders. Apart from section 55 of the Bill, which prohibits transfer of sums allocated to a service program, there have to be other firewalls and clear guidelines for preventing budget slippage that adversely affects prevention, rehabilitation and psychosocial intervention. We must never lose sight of this concern if the most vulnerable members of society are to be protected.
Another concern: preserving user participation. Abolition of the current electoral procedure for choosing user representatives, as provided for in the Bill, is justified. The poor rate of participation in these elections, the large number of seats left vacant for lack of candidates or representatives elected by acclamation as well as the costliness of the exercise are compelling reasons for questioning the very validity of this process.
Similarly, the Québec Ombudsman feels that user participation and upholding users’ rights do not preclude choosing representatives for boards of directors based on their expertise, as proposed by Bill 10. However, it seems to me that forums for democratic participation must be maintained. Here I am referring to users’ committees and other local, regional and Québec-wide spaces for cooperation. It is imperative that users and the committees that represent them be able to voice their opinions on service quality and respect for their rights to the authorities. A careful reading of the Bill indicates that there is something missing in this respect. Our brief provides a few suggestions for ensuring the genuine participation of those who are the health and social services network’s reason for being.
In the same vein and for the same reasons, we recommend that the number of user representatives on boards of directors be kept at two. In order to properly reflect the required balance between institutions’ medical-hospital and social services missions, a user representative must have experience in both areas. This is yet another measure likely to help prevent the risks I brought up concerning the imbalance between future CSSSs’ psychosocial and rehabilitation interests.
To come back to the clarification of the basket of services, year after year, we have witnessed the gradual erosion of the range of public health services offered, and even more so in social services. More and more, services that were once included in universal coverage are in fact being cut without official notice. The truth is that the service offering presented is more generous than what available resources can afford to provide, a lingering and long-neglected problem. Given the difficulty of dealing with growing costs, peripheral services are reduced or measures that amount to implicit deinsurance are taken.
Another approach that we see consists of transferring various medical procedures from hospitals to clinics. Medical activities are covered by the Régie de l’assurance maladie du Québec, but the technical component is not. This means that users must assume these fees. How do you explain to users that they have to pay $40 for a 4 cm2 adhesive bandage after minor surgery in a clinic when the same bandage is provided free of charge at a hospital?
Privately insured citizens and those with high incomes can get care without worrying about cost. Others hesitate or simply do without, and their condition suffers.
When clear and transparent choices are not made, inequality takes root. This is a governance issue. Which guidelines should managers use to integrate regional policy when the Bill becomes law? There must not be a race to the bottom in the service offering because of budgetary pressure. In our opinion, it is up to the Minister to define the guidelines for an equitable service offering.
In closing, I insist on the overriding need—indeed, duty in the public interest—for the implementation of these proposed changes to be harmonized with the efforts required so that service provision is not only maintained, but improved in terms of accessibility, fairness and efficiency everywhere in Québec.