Louis Demers

École nationale d’administration publique, Québec, Canada

The 13th International Conference on Integrated CareBerlin, Germany

April 11, 2013

ENHANCING INTEGRATED: THE CASE FOR SUBSIDIARITY

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AIMS OF THE PRESENTATION

Discuss the health reform being implemented in Quebec in the light of three principles (Deschênes Report, 1996): • results primacy• subsidiarity • accountability

Show how the implementation of these principles has impinged on health services integration

Present some lessons learned

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THE DESCHÊNES REPORT (1996)

Senior public administrators

Mandated by the Minister of Health and Social Services

Make recommandations about the roles and responsabilities of central, regional and local authorities

Three principles: results primacy, subsidiarity and accountability

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RESULTS PRIMACY

Diagnosis: heavy bureaucratic burden on operatives

Underlying logic: mistrust and search for uniformity

Solution: reduce rules and set clear objectives for operatives

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SUBSIDIARITY

A central authority should perform only those tasks which cannot be performed effectively at a more immediate or local level

Primacy of the local level for the service users and the population

Regional and central levels in support of local actors

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ACCOUNTABILITY

Results primacy + subsidiarity = clear mandates and autonomy

Hence: possibility of making operatives responsible for their decisions

The three principles go hand in hand

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IMPLEMENTATION OF THE PRINCIPLES

The public administration reform

The Couillard Reform

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THE PUBLIC ADMINISTRATION REFORM

Law on Public Administration (2000)

The « governance bill » (2001)

Health and social services sector:

• Implentation starting in 2004

• Multi-year strategic plans

• Annual « management agreements »

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THE COUILLARD REFORM

Laws enacted from 2003 through 2005

Province divided in 95 sub-regions

Hospital, nursing homes and local community services center mergers (HSSC)

HSSC animating and coordinating local services networks

Goal: accessibility and continuity through integration

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RESULTS PRIMACY IN PRACTICE

Widely applied but…

Increased paperwork (data collection, reports)

Increased size of regional agencies

Imperfect indicators

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SUBSIDIARITY IN PRACTICE

HSSC: Real latitude to realize health services integration projects but…

Ministerial and regional commands

Tagged budgets

All in all: increased centralisation

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ACCOUNTABILITY IN PRACTICE

Regulation through partial, imperfect « volumetric » indicators

Unintended effects • risk of working to reach targets instead of intended

goals• risk of gaming and cheating (Freeman, 2002)

Accountabilty more rhetoric than real

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THE IMPACT ON INTEGRATED CARE

Conflicting messages:

• Responsability towards population or ministry?

• Integrated care or more outputs?

• More coordination makes HSSC look less effective

Integration in spite of the reform?

• Early innovators (Demers and Pelchat, forthcoming)

• Laggards?

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LESSONS LEARNED: COMPLEXITY, SUBSIDIARITY AND INTEGRATED CARE

IC: complex endeavour (Glouberman and Zimmerman, 2002)

Regulating trough central indicators is inappropriate

Integration must be encouraged by policies in a way that

• send clear and strong signals in favor of integrated care

• preserves and strengthens local actors’ capacity and willingness to

− innovate − adapt the prescriptions to their context

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REFERENCES

DEMERS, L., Y. PELCHAT (forthcoming in 2013) « Le réseau intégré des services aux aînés en perte d’autonomie des Bois-Francs : une innovation mise à l’épreuve » [Integrated network services for frail elderly in Bois-Francs sub-region. An innovation under pressure], Recherches sociographiques.

DESCHÊNES, J.-C., J. BRUNET , T. J. BOUDREAU, G. MARCOUX (1996). Examen des responsabilités respectives du Ministère de la santé et des services sociaux, des régies régionales et des établissements. Réflexions et propositions. [Examination of the respective responsabilities of the ministry of health and social services, regional boards and institutions. Reflexions and propositions].