1. Louis Demers École nationale dadministration publique, Québec, Canada The 13 th International Conference on Integrated Care Berlin, Germany April 11, 2013 ENHANCING INTEGRATED: THE CASE FOR SUBSIDIARITY

2. 2 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

3. 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 Three principles: results primacy, subsidiarity and accountability

4. 4 RESULTS PRIMACY Diagnosis: heavy bureaucratic burden on operatives Underlying logic: mistrust and search for uniformity Solution: reduce rules and set clear objectives for operatives

5. 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. 6 ACCOUNTABILITY Results primacy + subsidiarity = clear mandates and autonomy Hence: possibility of making operatives responsible for their decisions The three principles go hand in hand

7. 7 IMPLEMENTATION OF THE PRINCIPLES The public administration reform The Couillard Reform

8. 8 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 »

9. 9 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

10. 10 RESULTS PRIMACY IN PRACTICE Widely applied but… Increased paperwork (data collection, reports) Increased size of regional agencies Imperfect indicators

11. 11 SUBSIDIARITY IN PRACTICE HSSC: Real latitude to realize health services integration projects but… Ministerial and regional commands Tagged budgets All in all: increased centralisation

12. 12 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

13. 13 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?

14. 14 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

15. 15 REFERENCES D EMERS, L., Y. P ELCHAT (forthcoming in 2013) « Le réseau intégré des services aux aînés en perte dautonomie des Bois-Francs : une innovation mise à lépreuve » [Integrated network services for frail elderly in Bois-Francs sub-region. An innovation under pressure], Recherches sociographiques. D ESCHÊNES, J.-C., J. B RUNET, T. J. B OUDREAU, G. M ARCOUX (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].