Impact of Québec’s healthcare reforms on the organization of primary healthcare (PHC): a 2003-2010 follow-up

Abstract

BackgroundHealthcare reforms initiated in the early 2000s in Québec involved the implementation of new modes of primary healthcare (PHC) delivery and the creation of Health and Social Services Centers (HSSCs) to support it. The objective of this article is to assess and explain the degree of PHC organizational change achieved following these reforms.MethodsWe conducted two surveys of PHC organizations, in 2005 and 2010, in two regions of the province of Québec, Canada. From the responses to these surveys, we derived a measure of organizational change based on an index of conformity to an ideal type (ICIT). One set of explanatory variables was contextual, related to coercive, normative and mimetic influences; the other consisted of organizational variables that measured receptivity towards new PHC models. Multilevel analyses were performed to examine the relationships between ICIT change in the post-reform period and the explanatory variables.ResultsPositive results were attained, as expressed by increase in the ICIT score in the post-reform period, mainly due to implementation of new types of PHC organizations (Family Medicine Groups and Network Clinics). Organizational receptivity was the main explanatory variable mediating the effect of coercive and mimetic influences. Normative influence was not a significant factor in explaining changes.ConclusionChanges were modest at the system level but important with regard to new forms of PHC organizations. The top-down decreed reform was a determining factor in initiating change whereas local coercive and normative influences did not play a major role. The exemplar role played by certain PHC organizations through mimetic influence was more important. Receptivity of individual organizations was both a necessary condition and a mediating factor in influencing change. This supports the view that a combination of top-down and bottom-up strategy is best suited for achieving substantial changes in PHC local organization.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…131 To these outcomes must be added the perennial uncertainties of implementation, especially when changes (such as revising occupational roles) are contentious and may be resisted or renegotiated. 95 As Pineault et al 60 observed in Québec, modifications of structures and resources come first, with new working practices always lagging behind.…”

“…Change in ICIT score was associated with both this evolutionary trend and central reform policies. 60 Decisions from higher authority were the third mechanism for the formation of MCP-like entities. Decreed 'top-down' reform was instrumental and an obvious prerequisite for initiating change in the Québec health-care system.…”

“…These primary care organisations did not regard health and social care centres' support in creating PCMH-like organisations as very substantial. 60 The Ontario Health Ministry's use of 'simple rules' encouraged change in the desired direction without stifling creativity and innovation. 61 In Australia (a similar primary care system to the UK in many respects), HealthOne Mount Druitt needed sustained support at higher governmental levels (New South Wales Health and the regional Local Health District management), but in a form enabling policy change without attempting to micromanage local developments, which would have ended all chance of GP participation.…”

“…61 Implementing 'top-down' decisions to create PCMH-like organisations in Québec also required their internal 'receptivity' to joining a network, including a 'mimetic' context of other exemplar PHC organisations also participating [but the admired prototypes were family medicine groups (FMGs) and/or network clinics rather than the new health and social services centres], and the presence of 'local champions' advocating the new models and demonstrating their feasibility and desirability. 60 A realistic time scale was also required. PCMH programmes typically took a few years to reach maturity and produce measurable effects.…”

“…l Primary medical care (excluding CHS) with mental health services -international equivalents include the Norrtälje project (Sweden 24 ), Inter-Mountain Health, Utah 66 and (more narrowly because essentially contract driven) the Integriete Versorgung mental health schemes in Germany. [150][151][152] DISCUSSION AND CONCLUSIONS NIHR Journals Library www.journalslibrary.nihr.ac.uk l Primary medical care with social care -for this interface, international equivalents include Local Community Services Centers (Québec), public clinics providing health with social services 60 and the Mount Sinai organisation in New York. 78 Italian USLs organisationally integrate primary medical care and social care, but (as noted) in a structure of separate subhierarchies ('silos') with a common manager only at the most senior level.…”