Dr. Gaétan Barrette, Minister of Health and Social Services for Quebec, recaps the ambitious healthcare reforms pertaining to system integration and primary care access he has implemented since assuming position in April 2014, the philosophy driving his reform style, and the advantages that Quebec boasts as a life sciences hub.

Having been in position since April 2014, healthcare reform has been the defining mandate of your term as Minister of Health and Social Services in Quebec, starting from April 2014. What has been driving these changes?

The Canadian Constitution states that healthcare and social services provision falls entirely under the jurisdiction of the 13 provinces and territories, not the federal government. What I would like to highlight is that while all provinces and territories face similar healthcare challenges, we do not address them in necessarily the same ways. Since 2014, Quebec has been trying to transform the system significantly – in a way that communicates quite clearly that it is no longer acceptable in a society like ours today to invest so much money in a system without seeing proper results.

Firstly, we have decided to transition to a comprehensive two-tier organizational structure by merging a number of health institutions into 28 regional boards. This territorial administration will manage the overall budget and maintain overall responsibility to organize all services from home care to rehabilitation to cancer care to high-end surgery and so on. Where it is not possible to provide them all in one given territory – e.g. if they do not have universities – there are collaborations in place, both clinical and administrative, to provide them. The idea is to provide an integrated healthcare provision system that allows the patient to move more fluidly from home to hospital and back. The goal is simplicity for the patient.

Another significant area we have tackled is primary care access, which as you are aware remains a problem across the country. Here, we have been much more aggressive in doing things that nobody has done before – by tabling bills and laws to push through legislative reforms, most notably Bill 20, which forces doctors to modify their practices and to be available to patients on a same-day or next-day basis. This has been very much criticized – but by doctors, not the public – but the result is that doctors are actively changing the way they practice medicine.

Two years ago, I said that these changes cannot happen overnight, but it can happen over three years. My objective at the beginning of my term was to fix the most important aspects – service integration and primary care access – before advancing to the next steps regarding quality of care, appropriateness, efficiency and so on.

These have been significant healthcare reforms and accordingly, have met with some controversy. How much room is there for more change to be driven through the system?

As I always say, healthcare is not about hospitals or medical equipment or tables; it is about the people in the system, and people have a tendency to resist change. Sometimes, positive change needs to be pushed.

For instance, this ‘same-day access’ strategy was not successful in Ontario because they decided to pursue this goal through negotiation. I took a different route: I imposed it legislatively, and it worked. Today, a third of family physicians – much more than a few years ago – are conducting their practice based on the advanced access patient model instead of the traditional patient booking model. 80 percent of the time, patients are now seen within three days in their own doctor’s office. Advanced access is adapting your practice to the needs of the public instead of the traditional way of filling your schedule for the year ahead. This is a significant revolution. Patients are seen by their own doctors in a shorter amount of time, emergency departments are not overcrowded and continuity of care is maintained. It does take time for physicians to change their practice but we are seeing this change.

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The next twelve months will be very significant as well as there are new measures being negotiated with family physicians that will be a game-changer for the next decade. We are really that close to resolving the primary care access in our province. I know for a fact that other provinces are looking at us in terms of best practices.

The means do not matter, what matters are the results – and we have achieved very tangible results. We need a system where productivity is built into the system, seen positively and with rules that allow us to reduce over-usage and excess.

These reforms have focused on the provision of health services. Another aspect of your mandate pertains to pharmaceutical and medical products. What reforms have you introduced here?  

Since 2001, I have been involved in the issue of group purchasing, with the fundamental aim of getting the bigger bang for our public buck.

To put a complex issue simply, when it comes to access to drugs, we have to consider both innovative and generic drugs. For the latter, Quebec has the most aggressive approach of any province in this country. In July, we reached an agreement with the Canadian Generic Pharmaceutical Association (CGPA) to reduce our generics spending by about 40 percent – meaning an annual cost reduction of over CAD 1.5 billion over the next five years. This was achieved because we had pushed through legislation in 2016 that allowed us to move to a tendering process for generics procurement, and we communicated with the industry that we were ready to implement that unless they could come to a suitable alternative agreement with us.

In 2015, we had also joined the pan-Canadian Pharmaceutical Alliance (pCPA), which has the opportunity to negotiate prices for any given single drug or class of drugs. This gives us more leverage when it comes to negotiation for innovative drugs, because that is an entirely different ball game; ultimately, innovative companies have a monopoly on some molecules. We have our own processes in this province to manage that, such as the Institut National d’Excellence en Santé et en Services Sociaux (INESSS). I think we are doing as much as we can on this aspect.

At the same time, we are committed to the flip side, which is collaborating with industry to facilitate their R&D investment to this country and province. There is a strong life sciences R&D presence in this province, which we want to maintain and grow. My Ministry works extremely closely with the Ministry of Economic Development, Innovation and Export Trade, as well as industry, to this end.

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There are very complex dynamics at work here; healthcare is both economic and political. Sometimes the two complement and at other times they conflict. As Minister of Health and Social Services, I am a spender within the government. I have a limited pool of resources to dedicate to an increasingly expanding and expensive portfolio of products and technologies. At the same time, our healthcare system is funded by public taxpayers, both individuals and industry, which means that the sustainability of the healthcare system is indirectly linked to the sustainability of industry. What this boils down to is that I do not have a choice when it comes to collaborating with industry – politically, economically or philosophically.

With all these different elements at play, what role do you think Quebec – and Canada – can play within the global healthcare and life sciences ecosystem?

All stakeholders within the system do need to find common ground on which they can base negotiations. It is quite possible for all groups to thrive – and I think this is something Canada can demonstrate. We – and Quebec in particular – can act as a showcase example for productive collaboration between industry and government. We have already demonstrated a model through which healthcare reform can be carried out more efficiently and quickly.

I am also a strong proponent of the use of Big Data. We are in the process of implementing a wall-to-wall unified clinical database in Quebec and expect to complete this in two years. What is particularly interesting about Quebec vis-à-vis Big Data is that roughly 80 percent of Quebecois do not leave the province; this figure used to be 90 percent. This means there is a stable genetic and clinical population pool that could generate extremely valuable data – and the industry understands this value. We want to build the digital and legal infrastructure that will capture this data for use in real-world evaluations, including Freedom of Access to Information regulations.

Factoring this in with the healthcare reforms already discussed, I think Quebec’s ecosystem should be quite attractive for the life sciences industry. We will have this pool of data across all dimensions and categories. Even politically, decision-making will be increasingly more evidence-based. This is where we are heading. I do not know of any other province that will reach this stage in two years.

It is critically important for me to send the message that we are not against industry in any way. We want to build an easy and fluid relationship with industry. The message is, we are not only open for business but we want to welcome that business and actively foster the conditions to attract industry to invest and stay. We have been very successful in building Montreal as one of Canada’s top life sciences hubs but we always seek to do even more.

With Quebec leading the way in implementing bold healthcare reforms, what advice would you give to your counterparts around the world?

Change needs to come from the person sitting in a position of power at the top. Some people question this by saying that in today’s society, only bottom-up change is sustainable. But any changes to be implemented at the ground level needs to be triggered from the top. The transformation does need to occur at the bottom but it cannot happen without being triggered from the top – or to be more nuanced, bottom-up changes work but never fully or quickly. Today’s governments – and the public – demand quick results – and in the healthcare space, time is an even more pressing factor.

This is my philosophy behind driving these healthcare reforms. I have triggered the change on an administrative or institutional level, and subsequently involved the stakeholders on the ground. I changed the administration of healthcare provision but the first area I targeted was primary care provision, which is the frontline. I passed the bill allowing us to introduce a tendering process within the generics industry but it was the generics industry that ultimately reacted by getting together to negotiate a discussion.

I also believe that you cannot transform a system by addressing it from only one angle. Significant transformation requires action to be taken from all angles. What has happened in the past is that improvements in one aspect is somehow offset by deteriorations in other areas down the line, so the efficiency gain becomes ‘stuck’ and the end result is no change. This is why we have decided to reform the existing system from all angles to really drive a complete transformation.