Quebec's pioneering network of community health and social care centres provide easily accessible integrated services on a neighbourhood basis. Helen Busby and colleagues explain how they work

Quebec's vision of a network of centres providing unified and accessible health and social services is rooted in a history of deprivation. Until well into the 1970s, mortality and morbidity were markedly worse for the people of Quebec than for other Canadians, despite political reforms which gradually established equal economic and employment rights for its disadvantaged Francophone citizens.

The Castonguay reforms of the 1970s sought to establish unified provision of healthcare within a public health framework. Centres locaux de services communitaires were to be a linchpin in this new framework, replacing the existing patchwork of church and philanthropic institutions.1

CLSCs were established in over 160 communities throughout Quebec over a 15-year period. The history of their development provides a picture of the prizes and pitfalls of developing a primary care network integrated into a public health agenda.

CLSCs are mandated in law to provide first-line health, social and community services to the whole population in their geographical area. Prevention, health promotion and primary medical care all fall within their sphere of responsibility.

A regie - similar to an English health authority - frames priorities and decides division of services between organisations. This gives the network of local centres a common framework but allows diverse service responses. The CLSCs, which vary in size, are based on neighbourhoods rather than statutory or geographical boundaries.

Though diverse, they are required by the province to provide specified core services, including general health and social services, during opening hours, currently from 8am to 8pm each weekday. Each centre runs an information line, staffed by nurses, with a centralised duty service in the evenings.

Alongside nursing staff - who are prominent in the management of the centres - and physicians, CLSC staff usually include social and community workers, nutritionists and home care workers. 'Homemaker services' covering domestic help and support can be provided for medical or social reasons.

CLSCs take initiatives in collaboration with community groups and have community representation at board level.

But CLSCs have been in the headlines in recent months. In some areas they have announced that due to a shortage of physicians they could no longer provide out-of-hours medical cover. This crisis is a symptom of the longstanding tension between the provincial government's vision of a network of public health services and the opposition of the physicians' unions to the implementation of this policy. Opposition by the majority of physicians in Quebec to the development of the CLSCS and, more particularly, to the terms and conditions offered by them, significantly undermined the initial vision behind their development.

Although originally intended to provide both primary medical care and preventative and social care, CLSCs have come to focus on the latter. Currently most have well below their full complement of medical staff: practitioners working outside the CLSCs have continued to be the major providers of medical care. In rural areas, however, CLSCs provide a larger proportion of medical care, with some in remote areas having inpatient beds.

Recently, the centres have provided new services, and the integration of domiciliary care within the primary care service allows them to offer patients post-operative care and support at home. As Francois Beland of the University of Montreal notes, the network of community level organisations is invaluable when efforts are being made to find ways to devolve care from hospitals to communities.

Historical patterns of spending remain influential, and CLSCs still account for a small proportion of overall health expenditure. Nonetheless, expenditure on CLSCs has increased at a greater rate than any other element of the healthcare budget. The centres are extremely popular and have emerged largely unscathed from many inquiries and reorganisations. In Quebec, the backing given to the CLSCs by nationalist politicians is seen as a tangible symbol of commitment to the common good.