Bill 10 retrospective: A look back at vanquished hospital boards and sweeping measures

This weekend marks the first anniversary of the passage of Quebec's Bill 10, which saw the abolition of some 200 hospital boards and other healthcare institutions across the province. It will be an occasion for some to celebrate, others to lament.A cornerstone of what Quebec's French-language press dubbed "La révolution Barrette," Bill 10 passed the provincial legislature by a 62-50 vote shortly after midnight on Feb. 7, after Premier Philippe Couillard's majority Liberal government invoked closure.The vote ended months of heated public debate, warnings and dire predictions about the sweeping measures contained in the bill, which spared only a few specialized centres and university hospitals.The bill also transferred and concentrated historic powers and responsibilities into the hands of Quebec Health Minister Dr. Gaétan Barrette.The minister argued that the mergers and other structural changes contained in the 70-page bill, which came into effect on April 1, would lead to the elimination of 1,300 full-time administrative jobs, and save the Quebec healthcare system $220 million a year without having to close a single point of service.Physicians across Quebec, notably specialists, railed against the bill."Here we are, powerless, facing another reshuffling of structures, essentially for budgetary reasons," Dr. Diane Francoeur, president of the Fédération des médecins spécialistes du Québec, was quoted as saying in a press release a day before the vote in February 2015.She compared Bill 10 to the last major reorganization of structures in 2003 by Couillard, who was then provincial health minister."We were promised the sun and the moon," wrote Dr. Francoeur. "There would be no more waiting in the ER, the patient would be at the heart of decision-making, things would be closer, more efficient; there would be better services, less bureaucracy; and, of course, the savings would be important."So what happened? The savings disappeared and, most of all, the patient never benefited from the big upheaval."The public was also worried, judging by a Léger-Journal de Montréal poll a few days before the vote that found 60% of Quebecers thought the reforms would be a failure.During the raucous debate on the evening of Feb. 6, police removed 25 protesters who shouted "Refuse this law!" from the National Assembly's public gallery. Several hundred union members held a late-night rally outside in -24 C weather.In late 2015, in a year-in-review interview with the Medical Post, Dr. Barrette said the results of Bill 10 have surpassed even his lofty expectations."The number of healthcare management positions have decreased 41% in a few health boards, like Quebec City and Chaudière-Appalaches, and they are down significantly in all boards," said Dr. Barrette. "We thought it would take three years to achieve those numbers. And there's been no apocalyptic downfall as many predicted."He said he expects more good things from Bill 10, especially in what he calls "dysfunctional" areas of healthcare and social services, including re-adaptation, mental health, and youth protection."We've only seen 25% of the benefits in terms of structure, fluidity, efficiency and integration from the standpoint of patients," Dr. Barrette said.Potential problemsBut recent incidents involving Montreal hospitals have some pundits wondering whether chinks are appearing in Bill 10's armour.One is the death on Nov. 2, 2015, of an elderly man who was denied potentially life-saving surgery for a ruptured aortic aneurysm at St. Mary's Hospital. According to news reports, Dr. Carl Emond, a veteran vascular surgeon who was on duty that day, informed the ER doctors that the hospital's new administration had revoked his privileges to perform this type of operation in July as part of a reform of services. The patient was transferred by ambulance to the Glen site hospital of the McGill University Health Centre (MUHC), but died before he could receive surgery.This week, the MUHC's surgeon in chief, Dr. Gerald Fried, wrote a letter to hospital staff, saying a performance-related funding shortfall will likely lead to cancellation of between 1,000 and 1,500 scheduled surgeries."(We) made a strong argument to the ministry to reconsider our funding, based on the impact on patient care, access to timely surgery and the complexity of the work we do," Dr. Fried wrote."This was essentially refused."See related articles:Quebec’s health minister vows to continue pace of reformSpectre of early MD retirement: Battle lines being drawn over Bill 20According to Dr. Fried, the province uses an 85% occupancy rate to determine funding for MUHC. But he said the facility's true rate is around 91%.In an interview with the CBC, Dr. Fried said the hospital would be forced to close its elective operating rooms for up to 30 days a year to make up for the cuts."Sometimes we get to the point where we feel that this has pushed us to the limit of what we feel comfortable with professionally," Dr. Fried said. "There are compromises that need to be made that are sometimes quite difficult for us and difficult for the patient."According to Steven Appelbaum, a professor and former dean of the management faculty at Concordia University, Bill 10's concentration of power in the health minister's hands is resulting in micro-managing to a detrimental level."I had a student who recently applied for an associate director's job at MUHC, and the appointment had to be approved by the minister," Appelbaum told The Medical Post today. "He got the job, but he was shocked, and so was I."According to Appelbaum, modern management systems rely on delegation to managers at different levels, which enables system leaders to focus on big-picture issues."Imagine the president of IBM okaying decisions six or seven levels down," he said. "If our health minister spends 20 minutes looking over a resume for a job in a hospital, that's 20 minutes he won't be thinking about why the MUHC has waiting lists, or other important issues."Critics say more organizational and funding challenges lie ahead for Quebec due to Bill 10, as well as Bill 20 (which threatens doctors with fee cuts if they don't reach patient quotas), and funding cuts (including a 30% cut in 2015 to public health spending, which represents 2% of Quebec's health budget)."It's clear that Quebec healthcare is underperforming," said Dr. Astrid Brousselle (PhD), a Université de Sherbrooke professor and Canada research chair in evaluation and healthcare system improvement. "But a major restructuring wasn't the answer."An expert in how healthcare services are organized, Dr. Brousselle was part of a group of four Quebec academics who appeared at public hearings on Bill 10 in the fall of 2014. In their brief, they questioned the need to restructure."We didn't consider it to be a high priority as a way to improve access, which was the stated goal," said Dr. Brousselle. "It would have been better to rethink the way primary care is organized, and encourage work between multidisciplinary teams."Implementing Bill 10, she added, "carried a huge cost" in terms of human resources and money."That has weakened efforts to do other important things," said Dr. Brousselle. "And it's a prejudice to think we don't need system administrators."She added that the doubling of doctors' fees over the past decade has increased tensions between physicians and hospital administrators who are now forced to rationalize and cut costs."We are doing things that are not evidence-based," said Dr. Brousselle. "There is no global vision of where we want to go."

Bill 10 retrospective: A look back at vanquished hospital boards and sweeping measures

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