A prescription for Quebec’s health system

Strong primary care services are essential, Matthew Hacker Teper and Claire Godard-Sebillotte say.

On Oct. 22, 2018, a panel of experts convened at McGill University’s Department of Family Medicine for a roundtable discussion on the state of primary care in Quebec. Three former Quebec cabinet ministers — Claude Castonguay, Jean Rochon and Michel Clair — as well as professor of political science and health policy scholar Antonia Maioni offered their views on the actions required to improve the Quebec health-care system. Despite marked differences in their professional backgrounds and political affiliations, the panellists agreed on the current needs of our primary care system: a decentralization of decision-making, an increase of transparency concerning healthcare costs and outcomes, an expansion of the role of multidisciplinary primary care and a shift in tone (increased collaboration) among stakeholders. The “one size fits all” model is no longer appropriate. The power of decision making should be incrementally decentralized to local health-care authorities. These local authorities — Centres intégrés (universitaires) de santé et de services sociaux (CISSS and CIUSSS) and départements régionaux de médecine générale (DRMG) — should be given the autonomy to design, simplify and deliver health care in a way that works for the populations they serve. The needs of Montreal are different than those of Îles de la Madeleine. Organizing health-care services around geographic territories, and adapting health-care services to the specific needs of a population, will ensure that the right services reach the right patients. The costs of primary care must be clarified, and rendered transparent. Funding should reflect the real costs of services. In primary care, dollars directed toward administration and infrastructure should be differentiated from those allocated to pay physicians. Alternative systems of physician payment (e.g. mixed remuneration) must be introduced. This new transparency of costs needs to be supported by transparency of outcomes. Performance indicators, developed and monitored by an independent health commissioner, are needed to hold the system accountable for achieving population- and patient-centred objectives that have long been ignored. The health-care system should be centred around strong primary care services, like Family Medicine Groups and centres locaux de services communautaires (CLSCs). This is especially important in an era of aging and chronic disease, since these patients require a more continuous and comprehensive network of support. A multidisciplinary approach to primary care is essential. Health care is a team sport. In a world of refined technology and complex knowledge, siloed practices need to expand, intermix and collaborate. We need to reconfigure the scope of practices for different health-care professionals. For example, nurse practitioners should be permitted to take on greater responsibility in patient care. These changes must be accompanied by a shift in tone. Instead of settling into divided camps, policy-makers, practitioners and the public should work toward the common goal of improving the system for all. This might be achieved through a conference that includes health-care authorities and stakeholders from all relevant groups — not just physician federations, but also clinician groups and the public. The conference panel was united in its belief that the Quebec health-care system can and must be repaired. Together, we envision a health-care system that is accessible, efficient and performs to the standards of citizens and professionals. It is our hope that, in sharing these reflections, we may stimulate thoughtful action in the continued pursuit of a better health-care system for Quebec.

Matthew Hacker Teper is an MSc candidate, and Claire Godard-Sebillotte MD, is a PhD candidate, at the McGill University Department of Family Medicine. Also signing this article are: Claude Castonguay, former Quebec Minister of Health; Jean Rochon, MD, former Quebec Minister of Health; Michel Clair, former Quebec cabinet minister; Antonia Maioni, professor, McGill Department of Political Science; Isabelle Vedel, MD, assistant professor, McGill Department of Family Medicine, Co-Director of the McGill Observatory for Health and Social Services Reforms (MOHSSR); Howard Bergman, MD, chair, McGill Department of Family Medicine; Amélie Quesnel-Vallée, director of MOHSSR.