Dube says his health reform won't make a 'big bang,' but critics are worried

Quebec Health Minister Christian Dubé has promised to "shake up the pillars of the temple" with his new health reform -- but "without making a Big Bang."

After crafting his health reform bill over 2023, the minister will lay the foundations for the new Santé Québec Crown corporation in 2024.

But even with "top guns" at the helm, many observers foresee considerable turbulence.

The "Act to make the health and social services system more efficient" was passed under a gag order in the early hours of Dec. 9. The voluminous Bill 15, which contained 1,080 articles at the time of tabling, ended up with over 1,600 articles, the result of unfinished analytical work despite nearly 300 hours spent in parliamentary committee.

Although Dubé has repeatedly stated that his reengineering of the network will improve both access to care and working conditions for professionals, Quebecers shouldn't expect immediate the effects.

In fact, during the vote on the adoption of Bill 15, the minister made a point of reassuring network personnel, saying that he wanted to carry out the transformation "transparently," "cautiously," and at a speed that suited them.

"I think we have to realize how often reforms can be a success, and how often they can be a lesser success," he said.

At the heart of the Dubé reform is the creation of a government corporation to coordinate the operations of the entire Quebec healthcare network.

Alberta and Nova Scotia adopted a similar model. In both cases, the transition did not go smoothly, according to a research report written by Quebec Commissaire à la santé et au bien être (health and wellness commissioner) Joanne Castonguay.

The commissioner warned of "the limits of a strictly structural approach to transforming governance." Opposition parties have done their utmost to portray the Coalition avenir Québec (CAQ) project as "another structural reform."

This criticism was also voiced by key players in the network, such as the the FMOQ, or Fédération des médecins omnipraticiens du Québec (Quebec Federation of general practitioners).

"Will it improve things? I'm skeptical. You'll be reading me again in a few years' time, and I'm not afraid to say what I say, and we'll come to the conclusion that this structural reform [will not have] had any concrete effects on the ground," predicted FMOQ President Dr. Marc-André Amyot.

According to commissioner Castonguay, "culture plays a crucial role." She warns that "a change in structure [...] may be limited in its contribution to achieving results if the mentalities held by the players in this system" are not aligned with the objectives pursued.

This no doubt explains why Christian Dubé places so much emphasis on his desire to instill "a change of culture" in the hope that the network will embrace his "results-based" vision.

This philosophy is well illustrated by the increase of performance indicators implemented by the minister, including his famous dashboard available online.

However, this "adherence" to change, described by the commissioner as a critical element of the transformation strategy, is not a foregone conclusion, according to Lise Goulet, President of the Coalition solidarité santé (health solidarity coalition) and advisor to the CSQ union.

"How do you expect us to join, mobilize and collaborate when, one, we don't agree. Two, we don't understand. And three, there's been a breach of trust," she commented in an interview with The Canadian Press.

She believes that throughout the work, "we never had a global understanding of what was going on" because the minister was constantly making new amendments that modified his initial proposal.

She denounced a lack of preparation that resulted in an accumulation of "errors, oversights and misunderstandings."

Multiple groups representing field staff also criticized the minister for rushing to impose his reform before the holiday break. Citing Alberta as an example, Joanne Castonguay writes that "the early days of Alberta Health Services [were] marked by uncertainty, instability, disengagement and mistrust," particularly outside the major centers where the effects of centralization were feared. It took a full decade to overcome the initial resistance.

The Quebec Liberal Party, Québec solidaire and the Parti québécois interpreted the consolidation of operations within a large agency, as envisioned by Christian Dubé, as a centralizing project.

The minister, on the other hand, defended himself by asserting that he wanted to give more power back to local establishments through Santé Québec, while ensuring that best practices would be standardized across all regions.

ONE STEP AT A TIME

During the hundreds of hours he spent in parliamentary committee, the Dubé was peppered with questions about the process and timetable he intends to follow to complete his overhaul of the healthcare network.

"We're voting on the bill, we have a transition committee, we have a first date, which for me will be the appointment of the President and CEO [of Santé Québec]," he replied to a question from Québec solidaire MNA Guillaume Cliche-Rivard in the final stretch of the detailed study of PL-15.

These first two steps are expected to occur quickly, at the start of 2024. The composition of the transition committee is of particular interest to administrative staff, who want to have their say.

On the side of Médecins québécois pour le régime public (Quebec physicians for the public plan), Dr. Camille Vernooy believes the shift towards privatization of care could lead to a "de-motivation" of the medical profession. She expects these changes to worsen an already fragile situation.

These concerns are shared by the Association des spécialistes en médecine interne du Québec (Quebec association of specialists in internal medicine).

Dr. Pierre McCabe expects stagnation in the short term, as no one will want to make major decisions during the musical chairs game that will bring ministry officials into Santé-Québec's organization chart. "That's what happened when the CISSS and CIUSSS were created," he recalled.

According to the timetable put forward by Minister Dubé, the merger of establishments should occur about six months after the future president of Santé-Québec takes office, followed by the merger of union certifications under this new single employer of over 300,000 workers.

It's estimated that it will take at least the remainder of 2024 to negotiate Santé Québec's very first collective agreement.

In the meantime, the solution proposed by the minister to relieve the pressure on hospitals is to ask for patience from patients, and above all, to avoid going to emergency departments unless unless urgently needed.

This report by The Canadian Press was first published in French on Dec. 25, 2023.