November 12, 2013

Speech at the parliamentary committee concerning the Autonomy Insurance


Mr. Chair,
Mr. Minister,
Members of the National Assembly,

Thank you for your invitation to comment on the document entitled Autonomy for All — White Paper on the Creation of Autonomy Insurance. Everyone agrees that the ageing of the Québec population and the resulting increase in the needs for care and services have put unbearable pressure on the existing system. Investment in home care is a sound way to help people living with a loss of autonomy and their caregivers. It also contributes to better utilization of public residential care resources (such as CHSLDs and intermediate resources) and helps avoid hospitalizations.

The Québec Ombudsman is fully aware of the budgetary and organizational challenges related to this reform. The White Paper suggests new approaches, sometimes breaking with a certain concept of public delivery of long-term care and services. Increased reliance on contracts with recognized private or community resources to deliver home support services, the openness to charging for services now covered by the public system, and the proposal to constitute a fund dedicated to autonomy insurance are all orientations that change the profile of the public system of healthcare and social services. The Québec Ombudsman considers that these are important political choices.

I do not oppose these orientations in themselves. However, I have concerns about their probable consequences, which I would like to share with you today.

We have based our thinking on certain recognized principles: universal public coverage, equitable access to services, the real accessibility and quality of these services, solidarity in funding, the transparency of the system, and the accountability of its players. Our thinking obviously is fuelled by the findings of our investigations and our interventions in the field. I will also refer to a systematic intervention we conducted in 2012 on the specific question of home support services. In some sidebars of our brief, I considered it useful to present real-life cases to illustrate, as concretely as possible, the human impact of organizational and budgetary decisions that were made. These examples lead me to the finding I shared with you last September, when I presented my annual report: in several sectors, including home support services, there is a widening gap between the supply of services announced on paper and the supply actually available in the field. For example, I am thinking of the practice of capping hours of service, regardless of the person's assessed needs. Such practices generate great dissatisfaction among citizens, which is generally well founded. The present reform should be the opportunity to reverse the trend.

My primary concern regarding the proposed reform concerns the quality of services that will be provided. The public network is already having difficulty ensuring adequate control of the quality of its own services. In a context of the intention to rely more on private and community resources to offer home support services, special attention must be paid to quality control. I mean processes that are rigorous, but not excessively bureaucratic, to ensure efficient accreditation or certification of the different types of resources that will be asked to deliver these home support services.

The Ministère de la Santé et des Services sociaux must complete its draft quality assurance policy for care and services. This is a prerequisite to the adequate implementation of the future autonomy insurance plan. To protect and respect the rights of all users, the complaint examination procedure of the health and social services network must also be extended to all services given at home, regardless of their provider. These various means are conditions for respecting a fundamental principle: regardless of the mode of delivery of the services it chooses to deploy, the State must remain accountable and responsible for their implementation and their quality.

I am going to share another concern with you. According to our analysis, the White Paper is primarily designed to meet the needs of seniors who are losing their autonomy. We would like to see its application broadened to other groups, including younger people with disabilities. Their needs must be considered, especially in matters of social and occupational integration. In our brief, we draw your attention to certain undesirable effects of the use of the needs evaluation tools known as OEMC (the Multiclientele Assessment Tool). It does not explicitly account for the fundamental concept of social and occupational integration of persons with disabilities.

Compensating for the functional limitations of persons with disabilities raises clinical and ethical issues, as well as legal issues: respect for their right to equality must be at the core of any discussion of this subject.

Finally, I have a more general comment on needs assessment. Even though the use of a standardized tool is relevant, it must never be applied automatically without accounting for the practitioners' professional and clinical judgment.

I would now like to make a few observations about the implementation of the projected reform. This process must be orderly and equitable, which means that a sufficient transition period is necessary. I have concerns in this regard. The projected schedule appears unrealistic, given the imbalance already recognized between supply and demand in home support services in every region of Québec. Before the CSSS begin to withdraw from direct delivery of certain services, it is essential to ensure that the private and community partners are qualified and ready to take over. Is it really possible that all this will be accomplished concretely by April 2014?

Hasty disengagement by the CSSS would risk causing breaches in the continuity of home support services. I am especially sensitive to this situation, since we have recognized, in several of our investigations, that some CSSS administrations have already started to modify the services they offer in the sense presented in the White Paper. This appears premature, in my opinion. A reminder must be issued throughout the network: before the adoption of legislation and the dissemination of the new framework policy that will accompany it, the 2003 Home Support Policy continues to apply. Citizens have a right to know the standards in force and see them applied, in all fairness.

I will conclude my observations by addressing the delicate and complex question of the plan's funding. I insist on the importance of knowing the financial framework, which must be submitted for public discussion. The terms of funding of the autonomy fund must respect the principles of intergenerational fairness and distributive justice. Entrusting the management of the autonomy fund to a credible public body, in the form of a trust fund, in addition to ensuring its transparent management, should favour public confidence in a fundamental element: the conviction that the money raised for this purpose will not be used for purposes other than the delivery of home support services, to all the people who require them.

The question of fees still remains. The Québec Ombudsman's support for the autonomy insurance plan that will be proposed will depend on an indispensable principle: the users' financial inability to contribute must never be an obstacle to obtaining services. To respect this principle, it is essential to consider not only the fee structure, but also, especially for the lowest wage earners, the additional fiscal effort that will be required to constitute the autonomy fund. The addition of this tax burden to an eventual fee structure is likely to weigh very heavily on these people. The parameters of the fee structure therefore must be explicit, detailed and fair for citizens of every region of Québec. In this sense, I believe that the hourly rate of social economy enterprises that provide home support services (EÉSAD) should be the same throughout Québec and that the rate increases should be governed by standards and offset by an adjustment of the exemption for less affluent individuals.

As you will have recognized, I am open in contemplating the next steps of this important reform, but also cautious, due to the major challenges involved. I assure you of the Québec Ombudsman's full cooperation for the continuation of your work.

Thank you.