Case 4: Québec health and welfare commissioner's consultation forum

The Health and Welfare Commissioner for the Province of Quebec
François-Pierre Gauvin, PhD, Centre de collaboration nationale sur les politiques publiques et la santé, Institut national de santé publique du Québec
Élisabeth Martin, candidate au doctorat, département de médecine sociale et préventive, Université Laval
Julia Abelson, PhD, Centre for health economics and policy analysis, McMaster University

Introduction

In 2005, the Government of Québec created the Health and Welfare Commissioner, whose mission is to shed light on public discussion and government decision making, thereby contributing to the improvement of the health and welfare of the people of Quebec.¹ To fulfil this mission, the Commissioner must assess the results achieved by Québec's health and social services system, examining the various factors that influence health and welfare.

Why citizen engagement?

In 2008, in accordance with section 24 of the Act Respecting the Health and Welfare Commissioner (R.S.Q., chapter C-32.1.1), the Commissioner established a Consultation Forum composed of 18 citizens and nine experts. The mandate of this forum is to provide the Commissioner with its perspective on health care performance and to discuss select social and ethical dilemmas related to the health care system that have been submitted to it by the Commissioner. Since 2008, topics discussed by the Consultation forum have included prenatal screening for Down's syndrome, chronic diseases, perinatal health, mental health, and the rights and responsibilities relating to health and social services.

Methods

When making its plans for this Consultation Forum, the Government of Québec examined the experience of the Citizens Council of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom at some length.² Ultimately, however, Québec decided to create a hybrid forum whose members would include not only ordinary citizens, but also persons with special expertise. The underlying objective was to develop a new perspective on the issues based on the combined knowledge of citizens and experts. The Forum met 13 times between March 2008 and March 2011.

Recruitment and selection of members

The Forum consists of 27 members who were appointed by the Commissioner for a period of three years. Of these 27 members, 18 are citizens drawn from all of Québec's administrative regions, while the nine others have special expertise in the field of health and social services.

Two different processes were used to recruit the members of the forum — one for the citizens, the other for the experts — but both processes were governed by the Regulation Respecting the Procedure for Choosing Persons Qualified for Appointment to the Consultation Forum.³ During the process of recruiting citizens, an invitation was issued through all the major media for interested persons to submit their applications. In the process for recruiting experts, the Commissioner invited various bodies to submit a list of no more than three potential candidates each; nine expert members were then selected from these lists.⁴ By the end of the recruitment campaign, the Commissioner had received 266 applications for the 18 seats that were reserved for citizens, while some 30 different bodies, including university departments, had suggested 51 different persons to hold the seats reserved for experts.

How the forum operates

The legislation appointing the Commissioner gives him a great deal of freedom to determine how the Forum operates. About four times per year, the Commissioner brings the members of the forum together for a two-day meeting where they discuss various topics in plenary sessions and smaller groups. These discussions are guided by specifically developed questions and the help of a professional moderator. In general, the members of the Forum are consulted two or three times on the same topic.

For each meeting, the members receive a set of briefing documents. These documents include a consultation guide that reviews literature on the topic to be discussed and provides information gathered through a targeted call for submissions, hearings, and the results of other consultations (as appropriate). Experts sometimes make presentations to the Forum's members in order to stimulate the discussions at their meetings. It should be noted that the Forum does not explicitly seek a consensus; instead, it simply tries to highlight issues that will be useful for the Commissioner to know.

The Forum's discussions are recorded in a set of minutes prepared after each meeting by a member of the Commissioner's office. These minutes are then validated by the Forum's members in discussions held via its extranet site before they are adopted in their final form at the following meeting. Only after the final version of the minutes has been adopted is their content used in the Commissioner's work. Thus the consultation process is iterative, allowing every topic to be discussed more than once, both in face-to-face meetings and in discussions via extranet. The Commissioner hopes that this process will enable the Forum to come to a position to which all of its members have contributed.

Outcomes and impact

In the members' opinion, it is difficult to know whether the Forum has had a real influence on government decisions or public debates. The Forum has three major characteristics that may have reduced its ability to exert an influence.

First, the Forum's meetings are not public and neither are their minutes. This may minimize the Forum's influence. The legislation does, however, require the Commissioner to provide an account of the Forum's deliberations, its conclusions and recommendations. These are therefore included in the reports published by the Commissioner, which are submitted to the Minister of Health and Social Services and then to the National Assembly. The Commissioner's reports are then made available on his web site.

Second, the Forum serves in a consultative capacity to the Commissioner, who himself serves in a consultative capacity to the government. For this reason, it is not possible for the Forum to influence the government directly.

Third, the Commissioner can use a variety of mechanisms to broaden the debate and examine topics in greater depth. He can conduct targeted consultations with experts, decision makers and groups that have an interest in a given topic. He can also conduct public consultations online. Thus, although the Forum is a highly valued source of information, its consultations are only one among a range of consultation options.

That said, the Forum has encouraged institutional learning within the Office of the Commissioner.⁵ The Forum has unquestionably made a key contribution to the Commissioner's methods of assessing the performance of the health and social services system — so much so that it would now be hard to imagine any rigorous assessment process that does not systematically apply citizens' knowledge.

Lessons learned

On the whole, the members of the Forum and the Office of the Commissioner have found the experience with the Forum to be a positive one. This experience has also brought to light three main challenges associated with deliberative forums:

1. The Government of Québec and the Office of the Commissioner wanted to institutionalize and structure the Forum in order to ensure the integrity and smooth operation of its deliberations. It is important, however, that this structure is flexible enough to meet any needs and expectations of both the participants and the host organization that may emerge over time.
2. Summarizing hours of discussions in a document that is perceived as valid and legitimate by the participants — and useful by the host organization — is a complex, delicate task. Great care must be taken that the discussions are not framed too vaguely, that the members are not asked to consider too many questions, and that members are encouraged to develop collective statements at their meetings that can be reproduced in the minutes.
3. Hybrid forums such as this one may generate some confusion as to the respective roles of the citizen members and the expert members. The citizen members of this forum had some trouble determining what "voice" they represented and what original contribution they were making in discussions that were sometimes highly technical. At the same time, given their role as "citizens with special expertise," the expert members had trouble defining the kind of special knowledge that they were supposed to bring to the discussions.

Date modified:

2013-11-18