Bringing decision-making power back to local health care: An interview with Dr. Ruth Vander Stelt
Following the announcement of Quebec’s Ministry of Health and Social Services on June 15 to work toward decentralizing health care in the province, the Bulletin contacted Pontiac physician Dr. Ruth Vander Stelt for her comments about some of the issues and challenges caused by over-centralization in the Outaouais in recent years and her thoughts about prospects for the future.
Dr. Vander Stelt lives in Aylmer and has been a practicing physician in the Pontiac since 1995. She is the former president of the Quebec Medical Association and is the current Secretary of the board for the Regroupement Québécois de Médecins pour la Décentralisation du Système de Santé (RMQDSS), a provincial network of 840 doctors who promote health care decentralization in Quebec. Currently practicing at the Quyon CLSC and at the Pontiac Hospital’s emergency room in Shawville, Dr. Vander Stelt has firsthand experience of the effects of over-centralization on medical institutions in the province’s rural areas.
The effects of centralization in Outaouais
Since the introduction of Law 10 in 2015 that amalgamated health care institutions in the province, bringing the number of medical establishments in Quebec down from around 180 to 34, Dr. Vander Stelt said that doctors, nurses, technicians and others involved in the health system have noticed the negative effects of over-centralization.
She explained that, prior to 2015, an individual hospital and region was able to manage its personnel, budget, recruitment and delivery of other services through its own hospital board, director general, and directors for all services in the Pontiac. However, following the shift toward greater centralization seven years ago, all local decision-making powers were transferred to centralized bodies, often located in larger urban areas. This led to various forms of institutional paralysis and mismanagement at the local level outside major city centres.
Closure of health services
According to Dr. Vander Stelt, one impact that this change had on health care in the Outaouais has been the closure of health services previously offered in the Shawville hospital. The hospital’s obstetrics unit closed in 2020 after more than a dozen temporary closures, as did the occupational therapy services following amalgamation. Without an obstetrics unit, women in the Pontiac must drive to Ontario or Gatineau to deliver their babies, and risk being in labour in cars and ambulances. Without an occupational therapy service, stroke patients and others requiring occupational and physiotherapy must travel to the city for care, or wait for a health care provider to visit the hospital. Such visits happen infrequently.
Dr. Vander Stelt described the effect of over-centralization as creating healthcare ‘deserts’ in the province. “Pontiac has become a desert. It’s an occupational therapy desert; it’s a maternity desert; it’s a physiotherapy desert some of the time; it’s a pharmacy desert because we have no regular hospital pharmacist. Many regions in Quebec are just becoming deserts.”
Decrease in quality of care
The 2015 amalgamations also created other difficulties for the Pontiac Hospital, such as the replacement of the director of professional services with a manager based in Gatineau, which has made it difficult to respond quickly to local needs, and the replacement of the hospital’s dedicated pharmacist with a pharmacy service which involves different pharmacists from outside the region visiting the hospital. She explained that this lack of continuity represents a significant problem for the hospital. “We used to have a pharmacist in the hospital and now we have a pharmacy service. There is a lack of continuity, making management on the ground more difficult.”
In rural areas, many patients are now forced to travel long distances in order to receive essential treatment. Dr. Vander Stelt noted that these are often the sickest patients for whom travel is very difficult. Certain cancer patients requiring chemotherapy in the Pontiac as well as other rural areas in the Outaouais such as Wakefield and Maniwaki currently must travel to Gatineau for treatment.
Another challenge faced by health care institutions outside of the city centres in Quebec is the lack of any formal structure for communication and coordination between doctors following centralization. Dr. Vander Stelt noted that, at present, in any of the 34 medical establishments in Quebec, only the individual chiefs of each department can speak to each other on an official basis and these department chiefs are only in the larger centres. In smaller centres, there is no body or formal structure for doctors to communicate with each other and come to decisions on local needs.
“In the smaller centres the doctors cannot sit around the table and speak to each other on an official basis because there is simply no body for that; there is no governance there. Even if they did want to do something different, such as fixing the obstetrics unit or improving quality assurance, they would have to argue their case to the city because they do not have decision-making powers. For all practical purposes, what we have in establishments that are peripheral to the larger centres is a form of hallway management,” said Dr. Vander Stelt.
"Lack of personnel” and local decision-making power
Though there is a recognized need for improved health services in the Pontiac, central health authorities have cited a “lack of personnel” as a reason why services like the obstetrics unit cannot be reopened. When asked about the connection between a lack of personnel and the delivery of services such as obstetrics in local areas, Dr. Vander Stelt explained that while it is true that many nurses and health care practitioners who live in the Pontiac decide to work in Ontario, if local establishments such as the Pontiac hospital had basic decision-making powers, they would be able to develop programs to retain local practitioners:
“In the Pontiac we are very close to the Renfrew and Pembroke hospitals, so we lose our staff to those hospitals, where the salaries are much better. Nurses love to live in the Pontiac but they actually work in Ontario. What we need – and if we had local governance, we could decide this for ourselves – is a retention program where nurses can get paid more to make up for the fact that salaries on the other side are better. We need a program like that but there is nobody who can fight for that because there are no local managers.”
The closure of the obstetrics unit in the Shawville hospital is seen by Dr. Vander Stelt as a typical situation caused by over-centralization. She explained that with even a bit of local management, the Shawville hospital may very well have been able to keep the obstetrics unit open.
Savoie Report announcement
The Ministry of Health and Social Services has acknowledged that over-centralization went too far in 2015. Following the recent publication of a government report known as the Savoie Report that highlights some of the negative effects of over-centralization in the past several years, the Ministry of Health and Social services publicly announced its intention to take steps to address the problems created by over-centralization. According to an announcement by health care minister Christian Dubé following the publication of the report on June 15, the government’s decentralization efforts will include creating several hundred new middle management positions in the field to support health care staff to serve local populations. In addition, the government has pledged a recurring budget of $40 million to the decentralization of healthcare in the region.
While the public announcement of intentions to decentralize may be seen as a welcome development for those who struggle with issues discussed above, Dr. Vander Stelt explained that, from the perspective of RMQDSS, the addition of new middle management positions is not a viable path towards decentralization. This is because the plan does not transfer decision-making powers to local health establishments, but, instead, creates more management positions that report to a centralized health authority. For this reason, Dr. Vander Stelt considers the ministry’s current decision to be a de-concentration of centralized decision making rather than genuine decentralization that would involve transferring some decision-making powers to local health establishments.
Dr. Vander Stelt explained that, while the government has not yet shown specific and concrete response to the RMQDSS’s proposals for decentralization following the organization’s presentation to the Ministry of Health and Social Services earlier this year, they are eager to collaborate with the ministry if they decide to take steps towards greater decentralization, “We are looking forward to collaborating with the ministry on decentralization. We think that decentralization is the future and we are ready to work with the ministry on that.”
When asked about prospects for the future, Vander Stelt noted the emergence of a growing number of grassroots initiatives and citizens groups, such as the provincial Patient Health Alliance, Action Santé Outaouais, the Comité de Vigie des Collines, and Pontiac Voice, to promote health care decentralization and access to local services in the Outaouais region and across the province.
“The bottom line is that there has to be citizen participation. It’s time for citizens to step up and show governments what, where and how they need their health care to be delivered.”