Quebec healthcare system reform: origin, objectives, and impact – Bill 15

More than 300 pages long and amending 35 laws, the bill aims to reform the governance of the healthcare system by creating the Santé Québec agency (Health Quebec), which will become the sole employer of the healthcare network.

Minister Dubé wants to completely overhaul the Loi sur les services de santé et les services sociaux (Act respecting health services and social services). The biggest reform of the Legault government’s second term aims at improving access to care.

This text outlines the origin of the bill, its objectives, and its impact.

Origin of Bill 15

Health care is a provincial competence in Canada. The provinces opt for different solutions to the same problems. They are national health systems.

In Quebec, the current healthcare system came into being in 1971, with the adoption of the first Act respecting health services and social services. Healthcare is the largest budget item for the Quebec government, as it is the system’s main insurer and administrator. It accounts for more than 40% of government spending and has been rising steadily for almost 20 years.

Waiting times are constantly increasing, and access to care has been deteriorating for decades. An aging population is no stranger to this trend. Added to this is a labor shortage and an overwhelming bureaucratic apparatus.

Countless reforms have attempted to curb the problem, none of them successful. The idea of introducing a co-payment system or leaving more room for the private sector is gaining ground as a solution to these problems. Federal government funding is another solution.

Although healthcare is an exclusive provincial jurisdiction, the Government of Canada has a role to play. It has the federal spending power. In 1984, it also adopted the Canada Health Act, which ensures that Canada’s various healthcare systems are coherent, public, and universal.

In this way, the federal government can both offer health funding to the provinces and financially penalize provinces that do not respect the principles of the Canada Health Act.

In the spring of 2023, provincial governments accepted the federal government’s offer to increase health transfers by $46.2 billion over 10 years, for a total of $196.1 billion. However, the provinces consider the offer insufficient. For two years, they had been demanding that the federal government fund 35% of healthcare costs. With this agreement, the federal government will contribute 24% of provincial health spending.

In the wake of the pandemic, Health Minister Christian Dubé took up the issue. The pandemic highlighted several shortcomings in the healthcare system, inspiring him to draw up his Health Plan.

Presented in the spring of 2022, this Plan initiated a shift in the healthcare network to better care for patients. The Plan echoed many of the promises made by the CAQ during the fall 2022 election campaign.

For example, it proposed a review of the organization of healthcare personnel, better access to and use of healthcare system data to catch up technologically, and a review of accessibility to services.

Mr. Dubé’s Health Plan was the genesis of Bill 15, which was tabled a year later. With this bill, the Minister of Health intends to undertake a vast reform of the organization of the healthcare network.

The governance of the healthcare system has undergone several reforms. Various reports have highlighted the need for a change in governance and culture within the network. The latest report, dated 2022, noted that several problems had been exacerbated by the pandemic.

Essentially, these were access to services, shortage of manpower, aging population and increasing needs, lack of diligence and resource capacity to respond to problems on the ground, outdated information systems and difficult access to data.

Bill 15 addresses these issues through four objectives: separating policy from operations, returning to local management, improving access to services, and enhancing the patient experience.


Separation of policy from operations – Creation of Santé Québec Agency

The highlight of Bill 15’s four objectives is the separation of policy from operations at the Ministry of Health, through the creation of the Santé Québec (Health Quebec) agency. New rules for the governance and organization of establishments would enable local management and greater service fluidity.

Specifically, Santé Québec would become a government corporation with its own board of directors. It would be responsible for the operationalization of services by public facilities, and for overseeing and coordinating the activities of private facilities. Santé Québec would serve the facilities by carrying out day-to-day and operational activities.

The Health Minister would henceforth exercise responsibilities focused on strategic planning, such as developing programs and policies, setting broad orientations and assessing performance. In this way, the Ministry would be more responsive to the needs of the population, by resuming its planning role.


Back to local management

Bill 15 would allow for the hiring of a person responsible for each facility, to initiate a cultural shift towards proximity management. The Liberals’ last major healthcare reform in 2015 abolished more than a thousand managerial positions.

The services offered by the various sites would be tailored more closely to local needs and realities. This local management would be personalized to the context of each site. Nevertheless, it remains to be seen to what extent local managers will enjoy real autonomy. Otherwise, decentralization will not be as effective as announced.

Each Santé Québec facility would be headed by a CEO. The Santé Québec Board of Directors would oversee their appointment, which would no longer be subject to the usual public service appointment rules. In this way, the Minister aims to bring in “top guns” to run healthcare facilities.


Improved access to services

To improve access to health and social services, the Minister of Health would review the responsibilities of doctors, strengthen coordination between establishments and consolidate territorial governance of the health network.

Specialist doctors would be subject to the same licensing requirements for specific medical activities as general physicians. This would include, among other things, care, and availability requirements.

Santé Québec would be responsible for coordinating the operations of the healthcare network. It would focus on the user and employee experience to achieve its mission and functions.

Under the bill, the governance of a facility would involve the appointment of a facility medical director and two territorial medical directors.

Appointed by the CEO of a facility and reporting directly to him or her, the medical director is a physician who oversees the supply and availability of medical services.

Under the authority of the facility’s medical director, territorial medical directors for family medicine and specialized medicine would ensure better continuity of health and social services between facilities in a given territory.


Enhanced patient experience

Also in the governance realm, Bill 15 calls for the creation of at least five councils per facility, a facility board, and several committees. Firstly, the interdisciplinary council for the evaluation of clinical trajectories and organization would “evaluate the quality and relevance of clinical care and services”.

It would be made up of various professionals working within the facility. Its central role would be to advise the CEO and make recommendations on the organization of the facility and the distribution of care and services.

Four councils would exercise responsibilities towards the interdisciplinary council: members of the council of physicians, dentists, pharmacists, and midwives would act as advisors to the interdisciplinary council to foster interprofessional collaboration.

Members of the multidisciplinary health services council and members of the council of nurses would also act as advisors to the interdisciplinary committee.

The social services council, comprising professionals from psychosocial disciplines, would act as advisor to the interdisciplinary committee for the evaluation of trajectories and clinical organization.

Secondly, each Santé Québec facility would have a governing board. Appointed by Santé Québec‘s Board of Directors, its membership would be representative of a variety of backgrounds and would include users and the facility’s CEO.

The functions of each governing board would be to evaluate, on an annual basis, users’ experience of the health and social services offered by the facility, and the social and health needs of the communities it serves. It would advise the facility’s CEO on matters relating to service delivery and prepare and adopt an annual report of its activities, with a copy to Santé Québec.

Finally, the Vigilance and Quality Committee would act as a watchdog to ensure the quality and accessibility of services, and that the Governing Board fulfills its responsibilities in this regard.

Users’ committees and residents’ committees would be elected by users to represent them. They would be involved in assessing user satisfaction with the services provided and would submit an annual report to the national users’ committee.

Risk management committees would be tasked with analyzing accident risks and preventing their occurrence, ensuring that support is provided to the victim and his or her loved ones, ensuring that an accident monitoring system is put in place, and recommending measures to the governing board if necessary.


Santé Québec to become the network’s sole employer

Union certifications will be merged, which will have two major benefits. The government will have four union bargaining tables instead of 136, since there will be one for each job category. Health network employees will be able to change regions without losing their seniority, since it will no longer be based on locations.


Local managers in each facility

Each Santé Québec site will have an accountable manager. This will give users and employees a greater sense of proximity to their environment. Services will be more accessible and adapted to local realities. The new proximity management will free up staff time to focus on user care rather than paperwork.


Greater obligations for healthcare professionals

Specialist doctors will be required to work on less popular shifts and in underserved regions. Responsible doctors will ensure the quality and availability of medical services in each facility. Resources should be better distributed to reduce waiting lists and waiting times for services.


A better patient experience

The organization of the healthcare network is being redesigned with user satisfaction in mind, as with the transformation of boards of directors into facility boards and the creation of the position of national service quality and complaints commissioner. These reforms are aimed at adapting the system to user feedback and improving accountability to users.

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