In 1966, the Government of Quebec mandated Mr. Castonguay and Mr. Nepveu to prepare a report for the implementation of a universal healthcare system. In 1969, the Castonguay-Nepveu Commission¹ recommended the creation of the Quebec Health Insurance Plan (Régie de l’assurance-maladie du Québec) and submitted, in 1970, a report that underlies the existing healthcare system in Quebec. The key recommendations of this report were the creation of three university networks (three faculties of medicine in Quebec at the time) with distinct levels of health care services: primary (community), secondary (hospital) and tertiary (specialized services). They recommended development of primary care services within a number of Local Community Services Centres (Centres locaux de services communautaires or CLSC’s)². It was expected that the medical services in CLSC’s would be offered by family physicians in collaboration with a group of healthcare professionals. The CLSC’s mandate included: managing the health care of the population living on their territory; the development of front line social and medical programs to address the population’s needs (family planning, mental health, etc.), the development of social services and a homecare program. The report recommended the creation of 256 CLSC’s across the province of Quebec, each of which were to take responsibility for a population of 30,000 persons. All the personnel working in the CLSC’s would be employees of the Quebec Health and Social Services Ministry (Ministère de la Santé et des Services sociaux) and the physicians would be paid by fee-for service or by salary.

This vision of our system faced a lot of opposition from the physicians and, initially, even from the community sector. The physicians reacted negatively to state intervention in the medical profession by government regulation of their remuneration. From their perspective, it was a threat to their professional autonomy. This reaction took form with an almost unanimous decision among the general practitioners to boycott³ the new CLSC structure. After almost 40 years, the CLSC’s never achieved their objectives, and only 10% of primary care is located in the CLSC’s.

Furthermore, the planned number of 256 CLSC’s has never been achieved, due to numerous successive reorganizations by the Quebec governments. At the end, only 156 CLSC’s were created.

The state paid physicians on a fee-for service basis and in the first years of the system, the physicians used their nurses to help them care for their patients especially for patient follow-up. If a nurse gave an immunisation inoculation to a baby, the doctor would bill the act and, out of the proceeds, pay his nurse. The government fearing out of control costs required that every patient be seen and treated by the physician directly and payment for the acts done by a nurse and billed by the doctor were refused. This led to MD’s no longer using nurses or other professionals in their offices. This was probably the most important cause for the development of a very weak primary care sector, the non-development of multidisciplinary teams and no chronic care management.

In 2004, the Quebec government put in place a major healthcare reform⁴ and created 95 Health and Social Services Centres (Centres de santé et services sociaux orCSSS), each one integrating a hospital, multiple CLSC’s, long-term care centres and rehabilitation centres into one organization, with the following mandate:

1. To improve the health status for the Centre’s population;

2. To manage their population’s utilization of healthcare and social services;

3. To manage the provision of services to their population.

4. To ensure the management of their population’s health, especially the more vulnerable clients, by the development of local networks covering the continuum of care.

The CSSS’s⁵ were created to address a number of health care issues: accessibility, continuity of care, chronic care management, the difficulty of transferring a person from one level of care to another, and the difficulty to manage services in an integrated manner. This reform and the creation of 95 CSSS’s in a regional-based structure, under the responsibility of the Health and Social Services Agencies (Agences de la santé et des services sociaux or ASSS)⁶, allowed a better integration of the services offered to the population as well as a better follow-up of the population’s health status. Meanwhile, four university networks (four faculties of medicine in Quebec), today known as the Integrated University Health Networks (Réseauxuniversitairesintégrés de santé or RUIS)⁷, were created with the mandate to ensure medical coverage for third- and fourth-line services in all Quebec regions, and especially to ensure that there are no lack of specialized services, in remote regions.

This structural reform did bring a new vision of the health care system based on populational responsibility and the development of a strong primary care system. To achieve the objectives of this reform, it is now necessary to make important cultural changes in our health system, and to go back to the original vision of Mr. Castonguay and Mr. Nepveu with a different approach to achieve the same objectives.

The Montreal Health and Social Services Agency (which is responsible for regional management), in collaboration with the CEO’s of the CSSS’s on its territory, have developed a vision to achieve the objectives of the reform and to identify the necessary means for its success. The elements of this vision are:

1. To develop a strong and completely reorganized primary care model (a community based and not a hospital based health care system);

2. To ensure a managed care model based on chronic disease management;

3. To engage the population in self management of their own health status, providing them with the necessary tools to do so;

4. To ensure the development of performance measurements based on the development of an Electronic Health record (EHR) as well as the interconnectivity of all medical data for the entire population of Quebec.

Primary care development is the key element to successfully implement the reform’s objectives (2004) for the health and social service system. This development will allow the CSSS to achieve a population-based approach and ensure the management of care and follow-up for the most vulnerable patients or those with a chronic disease.

The development of a strong front-line will allow:

1. Clearly defined levels of care with greater access, for the population, to the necessary services in a timely manner (The right patient in the right place at the right time).

2. The cultural change in services utilization for the people who use, for accessibility reasons, the emergency room twice as much as the normal emergency utilisation rates observed in systems with well developed primary care.

3. A better access to tools, for the clients, to improve the self management of their health status and, above all, their chronic disease.

4. A better utilization of general practitioners (GP) and an important potential to reduce accessibility problems to family physicians.

5. A major reduction in cost (of the health care system) due to better patient management, better utilization of medication, better utilization of diagnostic testing.

The most crucial component of this front-line vision concerns the development of GP’s offices capable of responding to the reform’s objectives. Instead of trying to integrate the medical body into the public sector, we must support medical leadership by promoting the development of their medical offices by adding health and social services professionals to the physician’s team. Quebec’s general practitioners must be encouraged to reorganize their offer of services, to work in a multidisciplinary team, to reorganize their links with the second- and third-line care and to assume the management of patients’ careand the follow-up for vulnerable clients, with chronic illness and multiple pathologies.

In Quebec, this initiative began with the development of the Family Medicine Groups (Groupes de médecine familiale or GMF)⁸, followed by the creation of the Network Clinics (Cliniques-réseau or CR)⁹ to answer the specific needs for Montreal. Then, the model evolved towards the Integrate Network Clinics (Cliniques-réseau intégrées or CRI)¹⁰, which has been fully accepted by the medical body and the CSSS’s Executive Directors as the model to be implemented.

This model contemplates the creation of about 60 CRI’s, each of which could register 30,000 persons, covering the 1.8M inhabitants of the Island of Montreal. These clinics would be open 12 hours a day, seven days a week, with an on-call capacity —organized in collaboration with other CRI’s — to cover the remaining 12 hours. They would have an average of 15 full-time equivalents (FTE) physicians and 15 FTE professionals from different health-related professions (depending on their specific client population’s needs) and a support team, including a radiology infrastructure.

One of the major obstacles is to group physicians in an environment that can support this new front-line reorganization. To date, the development of the GMF’s and the CR’s did not require major changes in the already available working environments (the buildings used by physicians). It is necessary to find a way using incentives to stimulate the development of integrated network clinics (CRI). It is also planned that at least 12 of the 60 CRIs (one in each of the 12 CSSS’s) would have the basic medical specialties with diagnostic tools available, to ensure easier access for the clients on their territory. Medical leadership, initiative and creativity are essential to the success of a strong primary care system. This interest must be supported financially (incentives) by the state. The type and nature of these incentives should be part of an additional discussion.

For the CRI’s development and to make progress with front-line services, it is necessary to gather a number of conditions that will allow for the cultural and environmental changes required. The required conditions to develop a primary care system are:

1. An Electronic Health Record (EHR) which gives access to all GP’s in GMF’s, CR’s, CRI’s or their solo and small practices, the capacity to follow their patients and the evolution of their patient chronic disease and medical history. The Montreal Agency has developed a vision where all GP offices in the city will be integrated into the same platform¹¹. Software will be installed in GP’s offices to access their patients’ medical records. The implementation has already begun and the deadline for completion is scheduled for the beginning of 2013. The interconnection between the EHR (in CSSS’s, hospitals and physicians’ offices) and the Quebec Electronic Health Record (Dossier de santé du Québec or DSQ)¹² will allow patients data to be accessible, no matter where they receive healthcare in Quebec.

2. A model of care that promotes managed care based on a multi/interdisciplinary team must be implemented in our primary care settings. Only a few experiences in our specialized hospitals, for example in cardiology, are already in place. The training of professional, including physicians, must include courses and traineeships focused on patient-oriented teamwork. In Montreal, the Université de Montréal and McGill University faculties of medicine’s Deans agree with this practice model and are already working to introduce it in their faculties’ curricula. Currently, there are two academic CRI environments¹³ where interdisciplinary practice models are being tested and traineeships are being offered. These two teaching environments also have the mandate to develop teamwork protocols for managing chronic diseases.

3. The implementation of a sufficient number of GMF’s, CR’s and CRI’s to cover for the entire population in Montreal. The GMF’s and CR’s already in place are currently following a progressive plan to add professionals and nurses, with the goal to evolve from current practices to the desired practice models. The GMF’s and CR’s are encouraged to become GMF-CR’s, which allows to group both nurses from each GMF’s and CR’s, thus becoming together the embryo of a CRI. Following this, the number of nurses will be increased to the required number of professionals for a CRI. This component requires the injection of about 1.5M$; one third of this money is expected to come from the Ministry through the GMF-CR funding already in place (and for which the amount of money is already available), one third will come from the Montreal regional budget and one third by reallocating the resources in each CSSS to the physicians office.

4. To complete the service corridors between GMF’s, CR’s, CRI’s and hospitals in order to simplify and accelerate access to the investigations required. Access to specialists for the urgent and semi-urgent clients must be put into place through the use of protocols managed by nurses who can send prepared patients to a specialist for a consultation. For emergency room consultations, the direct access is now well developed on the Island of Montreal. For the semi-urgent clients, we must implement clinical intake programs in each of our hospitals. The goal of this program is to ensure a more direct and faster access to the specialist, once the diagnostic tests are completed. In this program, a nurse coordinator initiates and coordinates the required diagnostic tests through the application of a set of collective prescriptions. The nurse can thus accelerate the procedure and make easier the access to the specialist. For the non-urgent clients, we must reorganize the appointment making procedure for diagnostic exams, to make it more efficient and user-friendly.

5. The development of management programs for chronic diseases¹⁴ will give GP’s and their team an access to more specialized teams for second-line services. These second-line teams are taking care of the patient during a short time period (6 months) to do additional investigation, immediate treatment, and education, and then they return the patient to the care of their family physician and his/her team for the follow-up. These projects are already being implemented in each CSSS on the Island of Montreal.

6. The development of a training plan to support practice change. Currently, the GMF’s and CR’s nurses represent about 100 persons with many years of working experience in Montreal GP’s offices, and they have developed different strategies and protocols to start the multidisciplinary activity. This group of nurses must be supported to ensure the transfer of their knowledge. The objective of the Montreal Agency is to support this approach. The two faculties of medicine have been contacted to solicit their help in the development of curricula on interdisciplinary work in multidisciplinary teams, for pre- and post-graduate formation as well as for continuing education. These new courses and traineeships are currently being implemented.

Primary care development is the most important change in our health system. This new direction requires a change in our health professionals’ habits and working approaches. Although this kind of change is considered by everyone to be the right approach, it is still hard to put it in place. Consequently, we must be even more resolute in our efforts to make it happen. The development of a strong front-line will reduce accessibility problems to healthcare services for the population of Quebec, and will put emphasis on the quality of our health system.

To conclude, there is a consensus about the type of organization of services we must develop. We have a new approach to try to engage physicians and to avoid the implementation obstacles faced by the Castonguay-Nepveu CLSC model. There is also an understanding of the required conditions to achieve success. The only thing now, is to make it happen. This is a big challenge because we are talking about a major cultural change. We must stay alert, while keeping a clear vision and the necessary flexibility to allow us to adjust and adapt to the obstacles on the road ahead. I think we are at the point where all the conditions are present to achieve success. We only have to make sure it really happens.

David Levine

May 26, 2010