Louis Demers École nationale d’administration publique , Québec, Canada The 13 th International Conference on Integrate

1. Enhancingintegrated: the case for subsidiarity Louis Demers Écolenationaled’administrationpublique, Québec, Canada The 13th International Conference on Integrated Care Berlin, Germany April 11, 2013

2. Aims of the presentation • Discuss the healthreformbeingimplemented in Quebec in the light of threeprinciples (Deschênes Report, 1996): • resultsprimacy • subsidiarity • accountability • Show how the implementation of theseprinciples has impinged on health services integration • Presentsomelessonslearned

3. 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 • Threeprinciples: resultsprimacy, subsidiarity and accountability

4. ResultsPrimacy • Diagnosis: heavybureaucraticburden on operatives • Underlyinglogic: mistrust and search for uniformity • Solution: reducerules and set clear objectives for operatives

5. 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

6. Accountability • Resultsprimacy + subsidiarity = clear mandates and autonomy • Hence: possibility of makingoperativesresponsible for theirdecisions • The threeprinciples go hand in hand

7. Implementation of the principles • The public administration reform • The Couillard Reform

8. The public administration reform • Law on Public Administration (2000) • The « governance bill » (2001) • Health and social services sector: • Implentationstarting in 2004 • Multi-yearstrategic plans • Annual « management agreements »

9. The Couillard Reform • Lawsenactedfrom 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 continuitythroughintegration

10. ResultsPrimacy in Practice • Widelyapplied but… • Increasedpaperwork (data collection, reports) • Increased size of regionalagencies • Imperfectindicators

11. Subsidiarity in Practice • HSSC: Real latitude to realizehealth services integrationprojects but… • Ministerial and regionalcommands • Tagged budgets • All in all: increased centralisation

12. Accountability in Practice • Regulationthrough partial, imperfect « volumetric » indicators • Unintendedeffects • risk of working to reachtargetsinstead of intended goals • risk of gaming and cheating (Freeman, 2002) • Accountabilty more rhetoricthan real

13. The impact on integrated care • Conflicting messages: • Responsabilitytowards population or ministry? • Integrated care or more outputs? • More coordination makes HSSC look less effective • Integration in spite of the reform? • Earlyinnovators (Demers and Pelchat, forthcoming) • Laggards?

14. Lessons learned: complexity, subsidiarity and integrated care • IC: complex endeavour (Glouberman and Zimmerman, 2002) • Regulatingtrough central indicatorsisinappropriate • 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

15. 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 frailelderly 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].