In an interview that aired on Radio-Canada, Health Minister Gaétan Barrette invoked the "failure" of the "initial concept of CLSCs" to justify significant activities and resources being transferred from local community service centres (CLSCs) to family medicine groups (FMGs). The Minister's statement suggests that CLSCs are primarily responsible for this "failure," that they did not deliver, hence the need to re-focus the front line towards the FMGs.
Going back through the history of CLSCs, it's clear as day that the Health Department forsook them: they did not fail on their own. This historical reminder is especially relevant now that we are witnessing the definitive end (though we've already heard that more than once) of this unique and innovative model.
CLSCs, a hard-fought victory for unions and the people
First of all, let's be clear: CLSCs were created thanks to the labour and popular movement. As early as 1966, the main central union organizations in Quebec demanded in a joint memorandum, submitted to the Castonguay-Nepveu Commission, the creation of a network of front-line polyclinics integrating healthcare and social services that would be organized according to the principle of multispecialty group medical practice. In the years that followed emerged many people's clinics set up by citizen committees. They pioneered innovative practices focused on community action in relation to democratic governance and disease prevention.
The original CLSC model incorporated many of these requests and innovations. The initial plan was to open up a full network of public front-line institutions integrating community action with common medical and social services (both curative and preventative). As mentioned in a recent blog post, it's worth pointing out that one of the main objectives of the reform was to end hospital-centrism in the healthcare system, a goal that the Health Department is now invoking to justify its most recent reform.
CLSCs were meant to become the main gateway into the healthcare system; they were meant to be vectors of transformation in the healthcare and social service system. It was hoped that the new teamwork practices combined with participatory and local governance would allow these institutions to be firmly rooted in their communities. It was hoped that they would foster a change in culture within a healthcare system dominated by hospital administrations and the interests of professionals (most notably doctors).
Why was "the primary mandate of CLSCs not achieved", to borrow the Minister's own phrase?
The causes behind the "failure": the role of the Health Department
It is widely recognized that doctors played an important role in the transformation of CLSCs. However, doctors are not the only ones responsible for this "failure". The Health Department's lack of political will —and that of the Health Ministers that succeeded one another— must also be called into question. Though the Department might have wanted to avoid a new confrontation with doctors (it had just come out of the crisis generated by the introduction of health insurance), it is also clear that CLSCs quickly fell into disfavour with the Health Department and a good number of politicians: as early as 1974, a moratorium was decreed on creating new CLSCs, and a "checkup operation" was launched to assess their relevance.
The CLSC model was routinely questioned in the years that followed, and it is only through sacrificing important chunks of their original mandate that CLSCs were allowed to carry on. The Health Department very early on dropped its plan to turn CLSCs into the main gateway to the healthcare system. In the mid-1970s, they started to be thought of as "complementary" to the private medical clinics set up by doctors, now recognized as an integral part of the healthcare front-line. The Health Department also quickly limited CLSCs' autonomy, thereby restricting the ability of local populations to democratically define the direction and priorities of "their" CLSC.
We can wonder about the motives behind these repeated disavowals considering the international recognition won by this innovative model. In addition to a favourable bias toward the private sector, the main reason behind the model's forsaking is that CLSCs have, ever since they were founded, been "disruptive" organizations.
Indeed, democratic structures and an emphasis on community action allowed multiple CLSCs, within a few years of their creation, to become central to community organization and popular mobilization in Quebec. People hailing from labour, activist and people's movements flocked into CLSCs and put forth a conception of health inspired by the one developed in people's clinics.
In many CLSCs, "prevention" equals mobilizing the local population to address and to act on the social causes of illness (poverty, social inequality, access to housing, the environment, work conditions, etc.). Multiple left-leaning advocacy and interest groups were born under the impulsion or with the help of CLSCs. Of course, such a conception of health is hardly compatible with the relentless calling into question of established social gains by every provincial government since the mid-1970s.
Minister Barrette's statements and the reforms he is currently steering clearly follow along the same lines as those of his predecessors. The only question left to ask is whether there are enough active political forces left in CLSCs to pick themselves back up after this new onslaught.
Anne Plourde is a collaborator with IRIS, a Montreal-based progressive think tank.