Reforming healthcare: social mission or accounting logic?  

This article was published in the first edition of La Résonance magazine.

Since the RSSS was set up at the turn of the 1970s, reforms and policies have systematically been presented from the angle of improving access to care. However, the same issues are still criticized: labour shortages, long waiting times in emergency departments and difficulties in accessing front-line care. What explains this stagnation?  

To answer this question, we must ask another: what do the outpatient shift under Minister Rochon and the Couillard, Barrette and Dubé reforms have in common? Economic objectives dressed up as promises to improve public services. All recent reforms in the RSSS were deployed in parallel to waves of major budget cuts, which make it difficult to achieve the objectives of improving the network. 

By encouraging a smaller role for the government and greater role for the private sector, in addition to seeking profitability, governments barely uphold their promises of care accessibility and universality. Focusing on the performance of the private sector in health care means agreeing to have profitability drive decisions and priorities, which, in addition to excluding people, means increasing the workload, which has been growing for decades. 

RSSS reforms will be ineffective as long as economic objectives are behind the decisions being made. For a reform to be beneficial, the sole objective needs to be care accessibility.  

Centralization 

The Dubé reform is the biggest centralization operation in the history of the RSSS. The government claims it is prioritizing proximity management by hiring hundreds of proximity managers and making them more accountable and accessible. 

The Santé Québec superstructure and the revision of the roles and powers of the institutional boards of directors (IBD) have the opposite effect. We observe a distancing of care from management, which is very concerning. It is essential that the needs and issues in the field are heard and that local authorities have real decision-making power. It is key for local specificities to be taken into account, but also to ensure care quality and safety for the population. 

Privatization  

The Dubé reform stipulates that services be provided to the population from now on by public and private institutions, without distinction. The government refused to prioritize the public network and to stipulate that Santé Québec would be a not-for-profit organization.  

One thing is clear: the profitability of the private sector depends on the public health and social services network being in poor condition. The more the public network falls apart due to reforms and budget cuts, the more the population and the government turn to the private sector, which then appears as a necessary evil. However, interweaving the private sector into the public network is extremely costly for the government and the population who finance public services through taxes. Private companies charge more for the same services, in addition to seizing the public network’s limited resources. As such, the solution to the problem worsens the initial situation. It’s a vicious circle. 

Deprofessionalization  

The Coalition Avenir Québec (CAQ) is banking on what is known as “deprofessionalization” to expand the pool of people available to provide certain care or services. By relaxing professional regulations, the government is relegating certain reserved activities to less trained staff or even patients’ loved ones. 

The deprofessionalization of care is first and foremost a devaluation of female-dominated professions. It leads to a loss of meaning in professional practice, less autonomy and a heavier workload, since it is often healthcare professionals who have to take responsibility for the activities carried out by the staff. 

By focusing on deprofessionalization, the government is placing the burden of care accessibility on the shoulders of healthcare professionals and families. As such, it is removing its own accountability for its obligations, which of course has impacts on the care and services provided to patients. 

Efficiency 

The government wants to make the public network more “efficient.” This managerial vision of care relies on performance indicators set by the MSSS and Santé Québec, which are far from the concerns of healthcare professionals and patients. Achieving these targets is difficult without affecting the quality and safety of care.  

This type of management generates an additional workload for healthcare professionals who from now on must complete even more administrative tasks to satisfy senior management’s Excel tables. If they are busy demonstrating their performance, they are less available to offer care. 

What indicators can be used to measure the comfort, attentiveness and empathy needed to provide comprehensive, humane care? By focusing on performance, governments make a major piece of the work invisible even though it is essential to patients’ recovery.