Decentralization

Premier Legault made a much needed declaration on health care last week in his National Assembly address outlining his government’s priorities for the final year of his mandate before next fall’s Quebec election. Indeed he began his speech with it.

He promised a “vast decentralization” of Quebec’s health system. We hope he follows through. Those words were the first reversal of thinking in sixty years during which centralization of seemingly everything was the watchword for nearly every administration in Quebec since the Quiet Revolution of 1960.

From the beginning, medical voices cautioned against removing decision-making from the local level. Doctors tried to make government after government understand that local hospitals and local doctors knew best what their institutions and populations needed. Sadly they were rarely listened to and the state of medicine — qualitatively and quantitatively — declined over the decades.

Today’s failures and frustrations have reached a zenith due in great part to what are called the Barrette Reforms under the Couillard government. It was not only centralized policy-making based on theories and averaged statistics that have caused this. The building up of a hyper-bureaucracy to oversee the centralized directives and to keep doctors and medicine limited, now sucks up over 40% of our health budgets. Health care no longer “follows the patient.” We are all captive to the political goals of health policy that only rarely — and seemingly randomly — meet the needs of people.

The instinct for decentralization is an important one. But as Premier Legault well knows the devil is always in the details. Mr. Legault spoke of transferring power to regions and sub-regions. That’s fine. But it does not go far enough. And Mr. Legault alluded to that.

He said that, “The people who are best placed to choose the best ways to meet our objectives are those on the ground, those who are close to the action.” Amen. He also admitted the current system was a “dysfunctional” one.

Each region and sub-region have their own supra-bureaucracies. The decentralization must go past the regional administrative bodies and past every CIUSSS. It must go back to the hospitals and doctors. Those are the people “on the ground” as the Premier put it who must have an equal say in decision-making. They are the ones “close to the action” who must save lives while dealing with budget cuts and directives based on faulty numbers.

If the Premier goes that far, then decentralization can work. It can loosen the constraints on where doctors can practice, how many patients they can see and how much money they can earn. Mr. Legault recognized in his speech the rising number of people without a family doctor. This is the prescription for it.

Only a counter balance that strong can prevent errors that occur when bureaucrats give Health Minister Dubé wrong information that lead him to reduce the number of family doctors permitted in Montreal and increase the number in the Monteregie. Bureaucrats told him that Montreal doctors are only seeing some 70% of their allowable patients. In fact they are seeing close to 100% and that is why 600,000 Montrealers have no family doctor. The bureaucrats averaged the numbers for all regions. The able Mr.Dubé didn’t get the right advice. A decentralized system would have given the Association of General Practitioners of Montreal an equal call on his time.

The Premier has taken the first step back to reason in fixing our health care system. We believe that what we have suggested here is an important part of the prescription to make it work.

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