If there is a positive effect that the pandemic has brought us, it is to have opened the eyes of the entire population to the fragility of the health network. In a colorful way, it lowered to a critical threshold a river already dried up by a significant gap between the supply of care and the growing needs caused mainly by the aging of the population.
On March 29, Minister Dubé tabled a new Health Plan. The latter must restore vigor to the system, which really needs it. In addition to the issue of general practitioners, the proposals revolve around four central themes: human resources, information systems, data availability and infrastructure.
Before it was tabled, I wondered if the leaders in place were going to look for the root causes of our network problems. Unfortunately, this plan will not go deep enough. Among other things, it lacks essential prerequisites for efficient and safe operation of the front-line access counter (GAP) and, by extension, for increasing the overall number of consultations for users.
Already overwhelmed professionals
No one is against giving responsibilities to pharmacists, physiotherapists and nurses in specialized practice. Especially since they will, in some cases, be better placed than doctors to meet the needs of patients. However, it must be understood that these professionals are already overwhelmed. Doctors’ waiting lists therefore risk becoming waiting lists for other professionals. Nothing is lost, nothing is created, everything is transferred. We therefore remain in cosmetics and haste, in a reform that should have been the lifeline of our system and, by extension, of our public finances. In short, the plan presented, like other previous health promises, lacks audacity and vision.
Among other ideas proposed, we want to seek out different professionals abroad and make the network more attractive. We all want it to work. However, omitting the lack of flexibility of collective agreements from the equation is a fundamental error. If we want to make a real difference in the recruitment and retention of new recruits nurses, orderlies and other professionals from here and elsewhere, it will be necessary to review some of the clauses that are too focused on seniority. We must not forget that beyond the fact that wage gaps persist in certain sectors, today’s workers are first and foremost looking for a better balance between work and personal life.
A new balance
The objective is to find a new balance in favorable conditions between individuals of different generations (distribution of shifts, sharing of holidays, etc.). A better distribution of experience, combined with other optimizations, could even make the current care ratios adequate for the benefits of all employees. This is equivalent to sharing well-being, but also uninteresting conditions, because the labor market paradigms are no longer the same as they were 25 or even 15 years ago. It should be an awareness on the government side as well as on the union side.
Without such changes, it is hard to believe that we will be able to effectively eliminate compulsory (and non-compulsory) overtime and the use of private agencies.
The fact remains that, even if the government and the unions confuse us and decide to work on collective agreements, we will still have to find other solutions to fill all the gaps. In summary, it would be essential to look for innovative ideas that would allow the staff already in place, including the doctors, to do more, under better conditions, without the addition of several additional resources.
To do this, it would be essential to first target efficiency, which will then give us safety, a concept that the professional orders, the MSSS and Accreditation Canada should promote more regularly in their recommendations. Computing and artificial intelligence will obviously and quickly be targeted in this respect. However, it is crucial to take a step back and think about what we want. Do we want to continue to make short-term and local decisions or aim, once and for all, for something more global?
Since 2015, the various facilities (CH, CHSLD, CLSC) of the 34 health establishments in Quebec have been desperately trying to harmonize with each other. Despite this internal standardization which is being done at reduced speed, we will eventually have 34 procedures, 34 policies, 34 protocols, 34 computer systems management and, consequently, 34 more or less similar ways of providing care.
A staggering amount of documents, databases and forms that will be just unique enough to be incompatible from one institution to another. When you add to that the hundreds of different operations of FMGs, community pharmacies and other health care clinics, including those that are private, you will have a fairly accurate picture of the disorganization of the system.
The negative impacts on the exchange of information are enormous, knowing that the patients move a lot between the static structures. We may even wonder why, in 2022, we call our system a “network”, since it cannot even meet its own definition.
As a demonstration of the consequences of this construction in a vacuum, we have only to reflect, as users, on the number of times we have to repeat our allergies or health history to our family doctor, our pharmacist, our physiotherapist , to the various stakeholders in the same hospital or from one hospital to another.
Imagine then, as professionals, how much time is wasted asking questions, searching, transcribing or re-entering data that already exists elsewhere electronically or more often handwritten in the file of the hospital, the clinic, another hospital or other clinic.
Then imagine the enormous possibilities of errors and consequences that can result from this anarchic and outdated operation. All of this will only be amplified in a GAP model. Briefly, we can say that the historical decentralization of decisions on clinical and IT pillars has prevented the simple and effective sharing of information. It has allowed certain content, which is substantially the same, to be found in different containers. In this sense, the lack of efficiency of the Québec Health Record (DSQ) should always remind us of what we must not reproduce in the design of the future digital Health Record (DSN).
One of the essential elements and an absolute priority of the desired reframing should therefore be the harmonization of the major clinical backbones of our network. This would make it possible to build a robust foundation on which IT, technological tools and artificial intelligence could finally come to rely to get all the performance and the not insignificant security that we have been promised for years.
We could then reach the famous continuum of care from birth to death of the user, regardless of the service or the region in which the care was given. In addition, we must not forget that harmonization allows other gains in management, education and labor mobility while facilitating and securing data analysis. Standardization is without a doubt one of the major elements forgotten in the Dubé plan, which was also annoyingly omitted in the Barrette reform.
Potentially, the latter could have limited certain administrative groupings by working instead on a common provincial language. Those who would see it as a form of centralization, we must answer them that it is rather sound and logical optimization that represents the most powerful remedy for the current disorganization. An evidence that the big companies, the financed system and the insurers have understood for a long time. Regardless of what we may think of the place that private healthcare should take, we can at least take inspiration from some of its practices.
Harmonization also includes cleaning up our computer systems, as Mr. Dubé suggested. To achieve this, you must definitely take the time to do a thorough needs assessment. Using shortcuts to catch up too quickly on 25 years of sometimes dysfunctional application decisions would be a basic and potentially very costly mistake. Consequently, it is essential that the choice to keep some of the current software and to evaluate new ones be made first by all the clinical actors, all professions combined. Highly efficient, user-friendly and intuitive computer applications, such as social networks and collaborative telework platforms, would encourage staff support and make their work more pleasant, as the minister wishes.
Finally, if we want modern systems that will propel us towards 2040, it is essential to change the criteria for calls for tenders in order to favor clinical applications or the most efficient application scenarios rather than price. The decompartmentalization of budgetary silos could, among other things, make it possible to take into consideration, in the equation, the various long-term benefits of the software evaluated. The costs of purchasing and maintaining all the technological and IT aids in health could therefore be amortized by saving time on piloting and especially in the daily work of users.
In conclusion, we cannot deny that there are some fine proposals in Minister Dubé’s plan. Obviously, and once again, the most important of them will not be supported by strong and harmonized structures. Unfortunately, this demonstrates the lack of proactivity and long-term vision of governments and certain managers who are sometimes influenced by pressure groups, personal interests or electoral cycles rather than by the common sense of clinicians and pragmatism. This then results in half-decisions that all too regularly lead to delayed problems on the ground and, ultimately, impacts on public services and taxpayers’ taxes. The finding of semi-success of the Dubé plan is therefore sadly already predictable, as have been many other health promises over the past 25 years… When will the real overhaul take place now?
Louis Dumont, system user, taxpayer and institutional pharmacist, Lévis
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Health plan 2022: where has the refoundation gone?
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