The private sector on health care’s front lines: a new deal?

Before 1971: primary care as the preserve of the private sector

It’s a little known fact that prior to the 1970s physicians in private practice were the principal providers of primary health care services. These doctors were essentially small business owners who often operated solo and sold their services directly to patients, like any other commodity. There was no public health insurance back then, and the vast majority of Quebecers only had access to limited care and services provided by religious communities and private charities.

1968-1973:  Castonguay-Nepveu Commission gives private sector failing grade

In November 1966, the government created the Commission of Inquiry on Health and Welfare (the Castonguay-Nepveu Commission) and mandated it to develop a plan for health-care services (and later social services) as part of a comprehensive social security policy. The aim was to improve Quebecers’ physical and mental health by incorporating “not only treatment for physical and psychological conditions, but also prophylaxis and, if necessary, rehabilitation.”¹

The Castonguay-Nepveu report was clear: private medicine delivered by individual practitioners relies on a curative model of health care that neglects prevention and takes a strictly biomedical rather than a more comprehensive approach to care; it thus fails to fulfill its primary-care function. The report also highlighted the existence of medical deserts in unprofitable areas such as disadvantaged neighbourhoods and sparsely populated rural regions.

The Commission called on the government to reform the health-care system and recommended the creation of local health centres (centre local de santé or CLS), community health centres (centre communautaire de santé or CCS) and university hospital centres (centre hospitalier universitaire or CHU), to which existing staff and resources would be allocated. The CLS was seen as the “main provider of general care,”² pointing toward a shift to fully public primary health care.

1971: heading towards fully public front-line health care?

On July 19, 1971, on the recommendation of the Commission and in response to pressure from unions and grassroots movements, the Quebec Liberal Party announced a plan to set up 25 local community service centres (centres locaux de services communautaires or CLSCs) throughout the province. This team-based organizational structure, comprising a number of different health-care workers (doctors, social workers, nurses, dentists, technicians, and so on), was destined to become the main gateway to the network and “the nucleus of the general health-care system.”

The Commission also noted that the fee-for-service model of physician compensation  was not readily applicable to these multidisciplinary teams. It therefore recommended that the model be “phased out in favour of other forms of remuneration, such as salaries and remuneration prorated to the number of cases treated.”³

1974-2000: the counter-offensive by pro-market forces

This sparked fierce resistance, with physicians boycotting CLSCs by refusing to practice there and creating parallel private polyclinics. They were supported in their efforts by Québec’s business community, which, beginning in 1973, repeatedly pressured the government to reduce social spending, particularly in the Social Affairs sector, which included the CLSCs.

According to Anne Plourde, the CLSCs quickly became a bugbear for the business class: “Given their democratic character and their role in community action, many CLSCs helped foster the climate of social protest in the 1970s. […] Many of the socio-political struggles the CLSCs gave rise to – concerning health issues related to industrial pollution, for example, as well as working conditions and real estate development, among others – posed a direct threat to certain business interests.”

In 1974, the erstwhile Ministry of Social Affairs declared a moratorium on the creation of new CLSCs and redefined these institutions as playing a “complementary” role to that of private clinics, with general practitioners establishing themselves as the front line of medical care. Moreover, the CLSCs were increasingly relegated to the role of providing a safety net for vulnerable and marginalized groups, rather than providing a broad range of services to all Quebecers.

2000-2002:  dismantling public provision of primary care

On January 17, 2001, the Clair Commission tabled its recommendations. The Commission had been established in June 2000 to study the delivery of health and social services in the province and propose solutions to the growing problem of access to a family doctor. It recommended that primary care be organized around family medicine groups (GMFs) of six to 10 physicians, who would provide 24/7 care.⁴ After more than a year of hard bargaining, an agreement was reached between the Parti Québécois and the Fédération des médecins omnipraticiens du Québec (FMOQ), providing for an injection of $15 million and the participation of 330 physicians. One third of the amount paid in the first year was devoted to increasing physicians’ pay. It was agreed that they would receive nearly $70 per hour for administrative and multidisciplinary work not covered by fee-for-service compensation, as well as a $50 lump sum for weekend on-call duty. Managers of family medicine groups were to receive an additional $15,000 per year.⁵

2003-2022: the nail in the coffin

In 2003, the Charest government adopted Bill 25 under closure and forced the merger of CLSCs, CHSLDs and non-university hospitals into what would later become health and social service centres (CSSSs). From that point on, CLSCs no longer had any official legal status.

In 2015, it was Gaétan Barrette who set about imposing new mergers on the integrated (university) health and social service centres (CI[U]SSS) with the aim of saving $220 million per year by means of “administrative streamlining.” In an unprecedented centralization drive, the number of institutions in the network was reduced from 182 to 34. In tandem with this reform, the Ministry of Health and Social Services (MSSS) concluded an agreement with the federation of Québec GPs to revise the management framework for family medicine groups, granting them additional funding and professional resources transferred from the CLSCs and paid for by public monies.

Today, the Legault government’s health-care reform plan is enshrining the replacement of CLSCs by GMFs, delivering primary care into the hands of a primary care “Medicine Inc.” that has been able to germinate as successive governments have bowed – willingly or reluctantly – to pro-privatization forces. However, in their 20 years of existence the family medicine groups have never achieved their objectives, despite unwavering financial and organizational support from government.⁶ If the past is any indication of what the future holds, private-sector primary care is unlikely to be the cure-all we’re told it will be.

Source: Plourde, Anne, IRIS, CLSC ou GMF? Comparaison des deux modèles et impact du transfert de ressources, Montréal, May 2017, 16 pp.

¹ Castonguay, Claude; Nepveu, Gérard, Commission d’enquête sur la santé et le bien-être social, Rapport de la Commission d’enquête sur la santé et le bien-être social, v. 4 t. 2 La santé : le régime de la santé, p.14, Québec, Éditeur officiel du Québec, 1967, 7 tomes en 15 vol.
² Castonguay, Claude; Nepveu, Gérard, Commission d’enquête sur la santé et le bien-être social, Rapport de la Commission d’enquête sur la santé et le bien-être social, v. 4. t. 4 La santé : les ressources. L’instauration du régime de la santé, p.253, Québec, Éditeur officiel du Québec, 1967, 335 pp.
³ Idem, p.287
⁴ Clair et al., Commission d’étude sur les services de santé et les services sociaux, Rapport et recommandations : Les solutions émergentes, p.52, Québec,  Éditeur officiel du Québec, 2001, 454 pp.
⁵ Paré, Isabelle, Le Devoir, 15 millions pour lancer les groupes de médecine familiale, Montréal, June 5, 2002.
⁶ Plourde, Anne, IRIS, Bilan des groupes de médecine (GMF) de famille après 20 ans d’existence – Un modèle à revoir en profondeur, Montréal, May 2022, 26 pp.
⁷ Idem