RES E A R C H A R T I C L E Open Access
Implementation of the Quebec mental
health reform (2005–2015)
Marie-Josée Fleury
1,2*
, Guy Grenier
2
, Catherine Vallée
3
, Denise Aubé
4
, Lambert Farand
5
, Jean-Marie Bamvita
2
and Geneviève Cyr
2
Abstract
Background: This study evaluates implementation of the Quebec Mental Health (MH) Reform (2005–2015) which
aimed to improve accessibility, quality and continuity of care by developing primary care and optimizing integrated
service networks. Implementation of MH primary care teams, clinical strategies for consolidating primary care,
integration strategies to improve collaboration between primary care and specialized services, and facilitators and
barriers related to these measures were examined.
Methods: Eleven Quebec MH service networks provided the study setting. Networks were identified in consultation
with 20 key MH decision makers and selected based on variation in services offered, integration strategies, best
practices, and geographic criteria. Data collection included: primary documents, structured questionn aires complete d by
25 managers from MH primary care teams and 16 respondent-psychiatrists working in shared-care, and semi-structured
interviews with 102 network stakeholders involved in the reform. The study employed a mixed method approach,
triangulating the three data sources across networks.
Results: While implementation was not fully achieved in most networks, the Quebec reform succeeded in improving
primary care services with the creation of adult primary care teams, and one-stop services which increased access to care,
mainly for clients with common MH disorders. In terms of clinical strategies implemented, the functions provided by
respondent-psychiatrists had a greater impact on the MH primary care teams than on general practitioners (GPs) in
medical clinics; whereas the implementation of best practices were indirect outcomes of another reform developed
simultaneously by the Quebec substance use disorders program. The main integration strategies used for increasing
continuity of care and collaboration between primary care and specialized services were those involving fewer formal
procedures such as referrals between teams and organizations. The lack of operational mechanisms and protocols
governing new services and structures were important barriers to primary care consolidation and service integration, as
was the lack of interest and involvement of most GPs in MH.
Conclusions: Successful and sustained healthcare reform requires attention to process and outcomes as well as structural
change or service reorganization. Six recommendations for more successful implementation of the Quebec MH Reform
are provided, with implications for healthcare reform internationally.
Keywords: Mental health r eforms, Implementation, Primary care , Networks, Integration, Strategies, Determinants,
Shared-care, Collaborative care
* Correspondence: flemar@douglas.mcgill.ca
1
Department of Psychiatry, McGill University, 845 Sherbrooke Street, Montreal
H3A 0G4, Quebec, Canada
2
Douglas Mental Health University Institute Research Centre, 6875 LaSalle
Blvd., Montreal, Quebec H4H 1R3, Canada
Full list of author informa tion is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Fleury et al. BMC Health Services Research (2016) 16:586
DOI 10.1186/s12913-016-1832-5
Background
Mental health disorders (MHD) are a leading cause of
worldwide health-related disability [1]. Depression is
predicted to become the greatest contributor to global
disease burden by 2030 [2]. MHD co-occur with medical
disorders such as diabetes, cardio-vascular disease and
substance use disorders (SUD), and with social problems
such as poverty and victimization [2]. Yet relatively few
affected individuals use mental health (MH) services [3, 4].
With fragmented services identified as a critical barrier to
care [5], the MH needs of individuals can best be met
through a range of continuous, diversified and integrated
bio-psycho-social services [5].
Most industrial countries includin g the US, UK and
Australia have reformed their MH systems over the past
two decades, generally aiming to improve access, quality
and continuity of care [6–8]. Treatment has shifted from
hospital to community [9, 10], reinforcing primary MH
care, and integrating primary care with specialized MH
services, including SUD treatment [11, 12]. Interest in
providing evidence-based practices such as assertive com-
munity treatment (ACT) or cognitive behavioral therapy is
strong [13]. Integration strategies at administrative and
clinical levels have also been found to facilitate both re-
form implementation and organizational integration [14].
Although MH reforms encompass similar objectives, they
differ in terms of timing, problems addressed, and the
structures or clinical interventions implemented [15]. For
example, reform in Finland included SUD as a MH
disorder [16]. MH reform in England clearly specified the
desired functions, operations and outcomes [7]; whereas re-
form in Belgium focused more on structures targeted for
implementation [10].
In this context, the Quebec (Canada) Ministry of Health
and Social Services (henceforth Quebec Ministry) devel-
oped a mental health action plan (henceforth MH Reform)
in 2005 that mandated a major reorganization of services
and strengthening of primary MH care [17]. The MH Re-
form resulted from broad consultation with 500 Quebec
MH stakeholders [17]. Key issues that sparked the reform
included long wait times for psychiatric care, insufficient
services for common MHD (anxiety and depression) due
in part to the reluctance of general practitioners (GPs) to
accept MH cases, and an underperforming system insuffi-
ciently attuned to client recovery and quality care.
Within the Quebec public healthcare system, prescription
drugs are provided free of charge, as are MH services ex-
cluding those provided by psychologists in private practice.
MH specialized services are offered in psychiatric or
general hospitals, according to regional variation in
conditions and ser vice availability; and primary care
services in public local health service centers or medical
clinics. Community organizations (crisis centers, peer and
family self-help groups, etc.), residential resources, and
inter-sectorial resources including SUD rehabilitation cen-
ters complete the Quebec MH system. Physicians (GPs or
specialists) are generally paid on a fee-for-service basis,
with the exception of a minority of GPs working in local
health service centers, who are salaried professionals. The
ratio of GPs per inhabitants in Quebec (1,03 per 1000)
and in Canada (1,12 per 1000) is above average for in-
dustrial countries [18]. Moreover, 21 % of the Quebec
population does not have a GP or family physician to
assume continuity of care [19]. Although GPs are the
first point of contact in the Quebec healthcare system
for clients with MHD, this does not necessarily translate
into adequate quality of services or continuity of care for
this population [20, 21].
Quebec healthcare services are integrated with social
services and managed at the provincial, regional, and
local levels. The Quebec Ministry is responsible for over-
all governance and control of healthcare. Within each of
15 provincial regions, a regional agency establishes bud-
gets and coordinates the local Health and Social Service
Networks. In the context of a more global reform of the
Quebec healthcare system that occurred simultaneously
in 2005, 95 local service networks were created, ea ch
with a Health and social service center (HSSC ) emanat-
ing from the merger of acute care hospitals, nursing
homes and local community service centers. HSSCs are
responsible for ser vice integration and quality care in
MH, and other healthcare programs within their respect-
ive networks (before April 2015). The SUD program for
example had initiated training in HSSCs, using standard-
ized tools for SUD identification, screening and early
intervention, as well as motivational interviewing. SUD
specialists offered expertise and advice to HSSC clini-
cians , while emergency-liaison teams worked to reduce
the overflow of individuals with SUD or co-occurring
MHD-SUD in eme rgency rooms [22].
In order to increase access to MH services, the MH
Reform proposed measures to enhance primary care.
Each HSSC was mandated to create one or more MH
primary care teams for treating common MHD among
adults. Regarding staff requirements for the new HSSC-
MH adu lt primary care teams, the MH Reform projected
20 full time psy chosocial clinicians and two GPs per 100
000 inhabitants. Moreover, for networks with 50 000 or
more inhabitants, a one-stop service was set up a s the
point of entry for accessing MH services, whether sup-
plementary MH services for individuals under the care
of GPs, or patient referrals from hospitals to specialized
outpatient services [17]. Clients refer red by GPs , com-
munity organizations, inter-sectorial resources, as well
as stabilized patients in specialized MH services ready
for transfer to primary care, obtained clinical MH assess-
ments at the one-stop ser vices. A maximum 7 day wait
time for MH assessment, and 30-day wait time from MH
Fleury et al. BMC Health Services Research (2016) 16:586 Page 2 of 15
assessment to treatment were projected [17]. Most HSSC-
MH adult primary care teams became operational by
2008, and MH one-stop services by 2009 [23].
In order to improve quality of care, the MH Reform
promoted recovery best-practices (e.g. care pathways,
cognitive behavioral therapy) [17]. For clients with se-
vere MHD in particular, community support programs
such as intensive case management were established
under the direction of HSSC-MH primary care teams or
community organizations. Research has demonstrated the
effectiveness of best-practices for improving outcomes
among clients with MHD [24–31]. Shared-care was also
promoted by hiring respondent-psychiatrists (3 h per
months per 50 000 inhabitants) to provide consultation
and support to HSSC-MH primary care teams and GPs
[17]. According to a meta-analysis, shared-care improves
the capacity of GPs to prescribe pharmacological therapy
and to provide adequate treatment [32]. Individuals
with common MHD, particularly depression, experienced
greater satisfaction and adherence to treatment [32, 33];
whereas the effectiveness of shared-care has yet to be
demonstrated for severe and co-occurring MHD-SUD.
The respondent-psychiatrist position was only ratified in
2009 after protracted negotiation between the Quebec
Psychiatric Association and the Quebec Ministry; the first
respondent-psychiatrists were appointed the following
year. Furthermore, the MH Reform promoted better col-
laboration between primary and specialized MH services.
Integration strategies , such a s service agreements and
use of liaison officers, providers w ho relay information
between ser vices or organizations ser ving the same
clientele, were advanced and proved effe ctive for MH
providers [34].
The reform implementation process marks a critical
phase generally, and entails a high risk of failure [35].
Barriers to implementation reported in the literature
include lack of financial or h uman resources [36, 37],
staff turnover [ 38], absence of leadership [39], obstacles
to information exchange among professionals [40], poor
inter-organizational collaboration [41], professional resist-
ance to new working cultures [11], and lack of role clarity
[42]. With these issues in mind, the present study evalu-
ates: 1) implementation of the HSSC-MH adult primary
care teams in terms of their impact on access to care for
different client populations; 2) implementation of key clin-
ical strategies, including shared-care, clinical approaches
(e.g. cognitive behavioral therapy) and clinical evaluation
tools (e.g. screening tools for MHD, Table 1), for their po-
tential to consolidate primary care and improve service
quality; 3) implementation of integration strategies aimed
at improving collaboration, continuity and integration be-
tween primary care and specialized services; and 4) facili-
tators and barriers to primary care consolidation and
network integration. This study is original in evaluating a
comprehensive, system-wide reform that undertook a
major shift toward primary care and strengthening of inte-
grated service networks, while introducing shared care
and other recognized best practices. These targets are cen-
tral to most international MH reforms in advanced health-
care systems.
Methods
Study design and data collection
The study employed a mixed method approach, triangu-
lating data sources across 11 of the 95 Quebec MH service
networks. Networks were identified for the study in
consultation with a research advisory committee composed
of 20 Quebec MH decision makers (e.g. the MH director in
the Quebec Ministry, MH regional coordinators , a rep-
resentative of the Quebec Psychiatric Association) who
completed a survey. The 11 network s we re sele cted for
maximum variation and representativeness in terms of
geographic area (urban, semi-urban, and rural), the
organization of primary and specialized care, presence
or absence of a psychiatric hospital; and perceived levels
of implementation of the MH plan (from high to low).
The evaluation by the research advisory committee also
took into account a number of other factors including the
range of services offered, integration strategies developed
(e.g. services agreements, liaison officers), uptake of best-
practices (e.g. cognitive behavioral therapy, motivational
interviewing), and barriers and facilitators associated with
the implementation process.
Data were collected from three sources: 1) structured
questionnaires completed by managers from HSSC-MH
primary care teams , including one-stop ser vic es and in-
tensive case management services, and by respondent-
psychiatrist s; 2) semi-structured interviews with key
network stakeholders involved in t he reform; a nd 3)
primary documents written by managers on issues related
to MH teams, organizations and networks. For each net-
work, all managers of HSSC-MH primary care teams and
respondent-psychiatrists were invited to complete ques-
tionnaires. The great majority of managers did so after
consulting with their teams, and with available data banks.
Key stakeholders from the 11 networks were invited to
participate in the individual qualitative interviews or focus
groups (Table 2). The number of interview participants
was based on network size. The research advisory com-
mittee helped with data collection. Questions for both the
structured questionnaires and qualitative interview guides
were developed and customized for this study as is usual
for all descriptive and exploratory research on organiza-
tions. The questionnaires and interview guides were pre-
tested with three participants respectively, and validated
by the research advisory committee.
Primary documents obtained between November 2012
and March 2013 provided data on population and MH
Fleury et al. BMC Health Services Research (2016) 16:586 Page 3 of 15
Table 1 Analytical framework and synthesis of the MH Reform implementation targets
Objective 1: Consolidation of the Health and Social Services Centers (HSSC) and Mental health (MH) primary care teams
(HSSC-MH primary care teams) for the 11 local service networks under study
Quebec MH Reform targets Not achieved Partially achieved Achieved N/A
HSSC-MH adult primary care teams
20 multidisciplinary MH clinicians/100 000 inhabitants 6 5
2 general practitioners (GPs)/100 000 inhabitants
* For a given network, achieved in some, but not all
teams
91* 1
Access to treatment: 30 days 7 3 1
MH one-stop services
A MH one-stop service in all networks with a population
of 50 000 + inhabitants
* In one network, staffing incomplete
1* 9 1
Access to evaluation: 7 days 5 5 1
Objective 2: Strategies used to consolidate primary care and improve quality of care
a) Consolidation of the respondent-psychiatrist function in the 11 networks under study
Quebec MH Reform targets Not achieved Partially achieved Achieved N/A
1 respondent-psychiatrist/50 000 (3 h/service per months: to
HSSC-MH teams and GPs)
38
b) Intensive case management
Intensive case management in HSSC
* Required number of teams not achieved in 4 networks
4* 7
Intensive case management offered by MH community
organizations (but under the responsibility of the HSSC)
65
c) Clinical approaches & clinical evaluation tools based on the literature [67]
Clinical approaches (Best practices) 7 approaches Stepped-care: Care delivery model in which
interventions are performed hierarchically
based on the intensity of client problems.
Mainly effective for depression [25].
From high to moderate use
(See Table 4)
Cognitive behavioral therapy: Psychotherapy
aiming to change thinking and behavior.
Effective for most mental health disorders,
including SUD [26].
Motivational interviewing: Brief intervention
aiming to engage motivation to change
behavior. Mainly effective for substance use
disorders [27].
Strengths model: Intervention focusing on the
strength and interests of the user rather than
pathology, and oriented toward achieving
goals set by the user him/herself. Mainly
effective for severe mental health disorders
[28, 68].
Care pathways: Systematic interventions
planned for integrating care between
different organizational units or between
providers for a well-defined group of clients
and treatment periods. Originally established
for acute medical care, for which it has been
proven effective. This care process aims at
enhancing continuity of care and system
efficiency, and is also applied currently in
MH [29].
Self-management: Systematic provision of
education and supportive interventions in
order to increase skills and confidence of
clients in managing their health problems.
Mainly effective for depression [30].
Fleury et al. BMC Health Services Research (2016) 16:586 Page 4 of 15
ser vice characteristics , and on integration strategies,
dynamics, and related c hallenges for each ne twork.
Questionnaires completed between October 2013 and
June 2014 were self-administered, and included categorical
and continuous items with five- or six-point Likert scale
responses. The questionnaire for HSSC-MH primary care
teams covered several dimensions: 1) client characteristics
(e.g. age, gender, diagnosis), 2) team profiles (e.g. number
and type of professionals), 3) c linical activities (e.g.
time allocat ed to evaluation, treatment or intervention),
Table 1 Analytical framework and synthesis of the MH Reform implementation targets (Continued)
Recovery approach: Personal journey that
involves developing a secure sense of self,
supportive relationships, empowerment, social
inclusion, coping skills, and new meaning in
life. In most longitudinal studies, recovery
rates were 80 % for bipolar disorders, 65 to
80 % for major depression, 70 % for substance
disorders and 60 % for schizophrenia [31, 69].
Clinical evaluation tools: establish clinical standardization
and rationalization to promote best practices [14].
• Screening tools for MHD From high to low use (See Table 4)
• Screening tools for SUDs
• Assessment tools for MHD
• Assessment tools for SUDs
• Assessment tools for client satisfaction
• Clinical protocols and best practice
guidelines
Objective 3- Strategies used to increase network integration (coordination between primary care and MH specialized services in each network)
Integration strategies
10 key strategies
Liaison officer: Professional designated by an
organization to relay information between
departments of the same organization, or
between organizations serving the same
clientele [14].
From many to few implemented
(See Table 4)
Shared training: A strategy to enhance
collaborative environments by simultaneously
training clinicians with different areas of
expertise, and/or from different services or
organizations in a network [70].
Shared staff: Professionals offering services
across more than one organization to insure
coverage of the required range of services
and to intensify inter-organizational
collaborations [14].
Service agreement: Administrative strategy
used in formalizing mechanisms that facilitate
access and continuity of services between at
least two organizations, or between programs
in the same organization [14].
Referral mechanisms:
• Shared clinical records
• Network resources directory
• Referral procedures within organizations
• Referral procedures between organizations
SUD specialist respondent: Specialist in SUD
who holds case discussions with MH and
other teams concerning SUD, aiming to
reinforce SUD expertise and interventions
for both SUD and co-occurring MHD-SUD.
Individualized service plans: Mutual
agreements among service providers, the
client or his/her representative (or family)
defining which care or service objectives
to pursue. Plans usually target clients with
multiple and often severe needs, who
require case coordination involving several
providers [71].
Not included in Table 4
Fleury et al. BMC Health Services Research (2016) 16:586 Page 5 of 15