Bill 10 was introduced to the National Assembly on September 25, 2014. It seeks a major consolidation of health and social service facilities across the province. The Bill would treat as one “establishment” (called a Centre intégré de santé et services sociaux – CISSS) all facilities or service points in a given region. In essence, this changes the very definition of an “establishment” through forced fusions. If it passes, the total number of public health and social service establishments would drop to 28 (later revised to 33) from the current 182 (already consolidated through earlier reforms: there were 683 public establishments in 1982). The Agences de la santé et des services sociaux would be abolished. The stated aim of the reform is a simplified patient trajectory and better circulation of information, as well as savings from the reduction of management positions. The 33 CISSS would be accountable directly to the Ministry and be responsible for planning and delivering services, including negotiating agreements with providers, community organisations and private sector resources. In October and November 2014, public hearings were held and submissions invited. In December, a parliamentary commission began examining the Bill. Here’s a look at some of the concerns that have been raised around Bill 10’s impact on patient and community engagement.
Concentration of power in the Ministry
Bill 10 gives the Ministry unprecedented and direct control over the governance and delivery of health services, eliminating not just layers of bureaucracy, but also citizen and user oversight over health and social services. As Amélie Daoust-Boisvert points out in an October 4 article in le Devoir: “The word “Minister” appears 107 times in this 165-article Bill. The word “user” appears just 12 times.”
Many question whether the provisions included in Bill 10 will actually contribute to its stated goals. Health researchers at the Université de Sherbrooke submitted an evidence-based analysis of the Bill, and conclude that: “No credible evidence would allow one to believe that administrative fusions on the scale proposed in Bill 10 could improve accessibility, quality or efficiency.” The Protecteur des citoyens warns against mega establishments with heavy management. “Management in these mega establishments will be even further away from the realities of service delivery and, as a result, less able to assess quality.”
Community representation in governance
Changing the definition of a healthcare “establishment” to include only the 33 regional entities would eliminate existing Boards of directors. As well, the composition and selection of the 33 CISSS boards would be quite different, relying heavily on Ministry appointments. Boards currently include elected public representatives, appointed members from the establishment’s user committee and foundation representatives, all of which assure a link between the governing board and the community. On November 5, Alex Patterson warned in the Montreal Gazette, of the danger Bill 10 presents to community support for and involvement in healthcare institutions: “The strength of our institutions lies in part in the fact that the communities in which they provide services take a great interest in them,” he wrote.
The McGill University Health Centre (MUHC) submission to the Bill 10 public hearings emphasizes the effectiveness of current board structures and the importance of credibility with the community served by the institution. “The vibrancy of our institution is due in large part to the knowledge and experience of the members of our Board of Directors. These individuals are fully committed to solving the specific problems of the communities that they represent,(…).” The MUHC expressed concern over the impacts of the Bill’s provisions on the composition of the Board of Directors and the role it plays in the life of the institution and stated that it deplores “that the provisions of the draft of Bill 10 weakens the public’s voice in how their healthcare institution is managed and disenfranchises citizens when it comes to the choices that must inevitably be made within a healthcare system that has growing needs and limited resources.”
The submission from the Association des fondations d’établissements de santé du Québec (AFESAQ) emphasizes the importance of foundation funding to the proper functioning of health facilities and the need to recognize them as a crucial partner in governance. On the 33 proposed CISSS boards, foundations would have only observer status, and the question of how these would be identified from among individual institutions’ foundations remains ambiguous. The Fédération des centres d’action bénévole du Québec warns of the loss of community expertise and citizen representation that would come with the abolition of existing boards. It also questions what would happen to the channels through which volunteer groups and healthcare establishments currently work together.
The Protecteur du citoyen believes the reduction in the number of establishments will be accompanied by a commensurate reduction in the number of user committees. He states it is “imperative that the users and committees that represent them have a means of expressing their views on the quality of services and the respect of their rights.” He sees this as a major gap in the structure proposed by Bill 10. The Regroupement provincial des comités des usagers (RCPU), which represents 86% of the province’s user committees, insists that the Bill must not compromise the relevance of user committees and user committee representation of its board of directors that, under current Quebec legislation, every establishment is required to have. There are currently some 600 user committees in the province. The RCPU recommends (and claims the Ministry has agreed) that existing user committees continue to function under the same terms as before, even with the change in designation of an “establishment.” However, without a board on their home facility, the opportunity for user committees to gain attention to and prompt action on their concerns would be sharply circumscribed. While the Bill proposes having the Minister select user representatives for the 33 CISSS boards, the RPCU recommends that they be nominated directly by the user committees of facilities within the CISSS territory.
Association québécoise des établissements de santé et de services sociaux (AQESSS) president Diane Lavallée concludes that “If adopted as is, the law would bring a major loss of power and influence of local actors in decision-making in health and social services and could mark the end of citizen participation in this vital sphere of society.” Under the Bill, the AQESSS, which has provided a unified voice for health and social services establishments in the province and has contributed to quality initiatives, would be closed down on March 31, 2015.
English language groups and establishments see the Bill as a major threat to the continued accessibility of health and social services in English. The Centre de réadaptation de l’ouest de Montreal maintains that regional structures would dilute English-language representation within the CISSS. The Quebec Community Groups Network considers Bill 10 a “catastrophe” for the 22 establishments designated by the Office québécoise de la langue française to provide English-language services to their communities. “What assurance is there that any members of the new Boards will represent the English-speaking community?” the QCGN asks in its submission.
A high cost to pay in community and user engagement
Paul Lamarche, Réjean Hébert and François Béland in the Department of Health Administration in the School of Public Health at the University of Montreal wrote a critique of Bill 10 that circulated in late 2014. The following is an excerpt from the letter:
” Scientific data show clearly that a decentralized system is closer to the centers of decision- making and allows for health and social services to be better adapted to populations needs (…) The creation of regional mega structures will result in an important loss of linguistic, cultural and community identity. Those institutions serving their community for many years and are essential for their role in maintaining community ties and supporting community development will be lost.”
The letter was signed by 16 other professors at the Université de Montréal.