The transformation of the Health and Social Services Network : a Few Pieces of Information
All reforms come with fears, worries, rumours, and statements intended to reassure, but instead instil insecurity. The current transformation of the health and social services network is no exception to this rule. It worries all in our field because it will affect the services for the most vulnerable people in our society: people living with intellectual disabilities or PDD. It also affects the families and the people close to them, who already assume more responsibilities than other families, since they will likely be asked to provide even more for their disabled family member.
Are our fears and worries founded? We unfortunately don’t have the answer to that question. Yet we have are a few pieces of information that will help you understand and make up your own mind on this matter, and hopefully find optimism in this transformation that is generally viewed with great skepticism.
During a Montreal meeting of the Association du Québec pour l’intégration sociale (AQIS), Ms. Diane Bégin and Jocelyne Bélanger, of the Service des personnes handicapées du ministère de la Santé et des Services sociaux (MSSS), came to talk about the main points concerning this transformation in a presentation entitled : la transformation du réseau et offre de services. Programme-services Déficience intellectuelle et troubles envahissants du développement. *
First, they reminded us of the need for this transformation (it is not the first one, and will neither be the last one). We could of course say that the goal is to save money and move on to something else. We could however take the time to think about the official answer: to resolve the problem of accessing services, maintaining services and coordinating services to respond to the following challenges: long waiting periods to access services, fragmented services, partial response to needs and a uni-directional way of functioning.
The MSSS has clear objective for this reform:
- Promote health and well-being
- Bring services closer to the population
- Offer more accessible, better coordinated and continuous services
- Ease the person’s way in to the health and social service network
- Insure better care for everyone, especially the most vulnerable clienteles.
Two principles guide the Ministry: populational responsibility (professionals giving services to the population of a given local territory (CSSS : centre de santé et de services sociaux)will collectively share the responsibility toward this population by providing access to the most complete set of services possible, by ensuring their intake and by accompanying them in the health and social service network, while pooling their efforts to maintain and improve the health and well-being of their population) and the hierarchy of services (implies the improvement of complementarity to ease the person’s way between levels of services within a bi-directional reference mechanism).
The tools to transform the network are the following:
- The new definition of programs: program services ( there are nine, including the DI-TED program service), including first line services and second line specialised services.
- A budget allocation in accordance with the population to be serviced and its needs.
- Identification of national and regional objectives that accompany the annual budget distribution and performance reporting.
Let’s go back to the budget. The population-based budget allowance wants to take into account the new situation of certain areas, such as a population increase or decrease (other factors such as distance will also be taken into account eventhough the population in a given region is low). The Ministry will “rebalance” the budget between regions over seven years through its development budget. Regions deemed to have received too much will see their development budget halted, while regions deemed not receiving enough will see their budget increase, or at least not decrease. This approach is denounced by many in Montreal because they argue that there isn’t too much money in the health and social services network and that the needs of Montreal, as a metropolis, have to be taken into account.
This dossier should be followed closely because the transformation will not be effectively realized if no more money is given. Even if no question has been asked up to now as to whether or not the CSSS will get more money to face their increasing populational responsibility, comments have been made to the effect that greater efficiency is expected. Once again, we will have to do more and better with the same money. At some point, the Ministry will have to realise that the elastic doctrine will reach its limit.
Another element pointing towards the absence of budget increase is the claim that the transformation will be gradual. In the short term, the Ministry expects the CSSS to be the entrance gate to the network, assess needs and then refer to appropriate resources, offer support at the time of diagnosis and offer psychosocial support and home support. Furthermore, they will have to have a face-off with the CRDI for the specialised services the intellectually disabled and PDD clientele of its territory will need. In other words, they are reaffirming the CLSC’s role, adding an obligation to service a clientele they did not always provide services for. How can you service a bigger clientele without adding resources?
The presenters then summarised the responsibility of each level involved in the transformation:
The Ministry: Multiyear strategic planning (the 2005-2010 plan is available online),elaborate and broadcast policies on access, continuity, quality, efficiency, and efficacy of services offered and evaluate outcomes.
The Agences: Facilitate the development and the management of local networks, and support its establishments to accomplish it, elaborate strategic planning, coordinate interregional services, support institutions in service organisation, and intervene to foster agreements.
The CSSS: Define clinical and organisational projects and ensure the participation of institutions and all sectors, groups or professionals involved in the project definition, ensure the coordination of services of the territory’s population, implement reference and follow-up mechanisms, establish agreements with service providers, foster intersector collaboration to improve the offer of services.
The readaptation centres will have the following responsibilities: participate in the clinical and organisational project definition, define the services they will offer, participate to implement the reference mechanism and make agreements with the CSSS.
The clinical project involves : establish health and social needs of the population, taking into account the social, cultural, ethnic, and linguistic characteristics, the particular living conditions of men and women, inventory resources and services, analyse the gaps, adjust the service offer, identify clinical models, define roles and responsibilities, identify pertinent elements of service agreements, analyse impact follow-up.
For the DI-TED service program, the clinical project is based on the Intellectual disability Policy and Action Plan, the PDD Policy and Action Plan, the Home Support Policy and a document currently being written at the Ministry on defining offers of services.
The Ministry will require better intake for the first line and specialised services from the second line. Ms. Bélanger said that Quebec Readaptation Centres (CRDI) only service 24 000 people out of a possible 220 000 – 240 000 people with intellectual disabilities. She hopes that the 200 000 people who are not serviced by the CRDI will see at least some of their needs met by the first line. Indeed, each CSSS will offer a DI-TED service program, which was not the case in each CLSC. The DI-TED population will be estimated for each territory and services will be provided to meet some of their needs. It should improve the living conditions of some people.
The presenters insisted on the fact that the transformation was partly based on the intellectual disability policy of 2001 entitled: De l’intégration sociale à la participation sociale. Politique de soutien aux personnes ayant une déficience intellectuelle, à leurs familles et aux autres proches. The policy reaffirmed the necessity for integrated services that would allow the person and his family to feel respected, every aspect of the person considered and as such have the right to services that are not separated by areas of concern. Services should be integrated on a local level (the CLSC was then named), and then on a regional level (CRDI specialised services, hospitals, medical services, etc.), and finally on a national level (super specialised services).
They mentioned that the policy included an action plan that stated as a priority that the services for the whole population had to be adapted to the needs of the people, their families and other loved ones. Of course, we want to see the people getting services in the community, like all citizens. But this should not translate into a reduction or a transfer of specialised services. The element of concern right now is that we do not have a list of first and second line (specialised) services.
Discussions are taking place between the Ministry and the Fédération québécoise des centres de réadaptation pour les personnes ayant une déficience intellectuelle (FQCRPDI). The Ministry is setting up an offer of services that should be the same for all nine service programs (the one for troubled youth should be available online soon). The question is what would be the services required to cover all specialised services? It seems the document produced by the Federation is not exactly what the Ministry was expecting but is instead the position statement of a network (CRDI) facing another (CSSS).
The Ministry’s DI-TED offer of services will be discussed with the Agences in November. In the winter and spring of 2006, the discussion will include partners: establishments, families (through national associations), etc., in order to improve content and policies. We should know then what services will be offered and who will be giving them.
The presenters, answering the audience’s questions, reaffirmed that the CRDI mandate had not been changed and that their budget would not be transferred to the CSSS
Throughout this transformation, our best tool as persons or families will be the individualised service plan. After assessing the person and his family’s needs, the required services could be provided on different levels: the CSSS for home support, the CRDI for an educator to help with autonomy skills training, etc. Let me quote one of the presenters when she said that “the goal is to give the right service at the right time and the right place”. Let’s add that the services should be sufficient in quality and quantity to meet the needs and have an impact.
You don’t have to watch the health and social services network closely to realise that intellectual disabilities are not a priority and that PDD have only recently become one and have a long way to go. We will have to make sure once again that we are not forgotten and be heard loud and clear. The individuals and their families will have to make their needs known to each CSSS and the Agences, to be heard all the way to the Ministry level.
For more information, please visit the Ministère de la Santé et des Services sociaux du Québec website at www.msss.gouv.qc.ca
* Excerpts in italics are taken from the presentation document.
A first version of this text was published in the November 2005 edition of the Infocradi.