louis demers École nationale dadministration publique, québec, canada the 13 th international...
TRANSCRIPT
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].