We begin this issue of Healthcare Quarterly with an update from the province of Quebec. David Levine, CEO of the Montreal Health Authority, describes his participation in what he considers to be the first real reform in healthcare since the beginning of Medicare in 1970. In his opinion Quebec is undergoing a second "quiet revolution" in healthcare as important as the first one, a revolution not in structure but in the philosophy of how healthcare is provided to its population.

In December 2003, the government of Quebec adopted draft bill 25, which launched a major reorganization of Quebec's health and social services system. Initially, the regional boards were abolished and replaced by new regional bodies called Agencies for the Development of Health and Social Services Networks that were given the mandate to propose a new way of organizing services on their territory, based on the concept of integrated networks, with the goals of bringing services closer to the population, facilitating case management and helping vulnerable patients obtain the care and follow-up they require. In 2004, the Montreal agency held a widespread public consultation involving the population, providers of healthcare services and other partners in healthcare delivery, and a proposal was made based on an organizational model of 12 Health and Social Service Centres (HSSC) on the island of Montreal.

The 12 new HSSCs, on the island of Montreal, were formed from the merger of 54 institutions, the abolition of their boards and the selection of 12 new CEOs. Each HSSC was formed from the merger of local community health centres, local community hospitals, long term care centres and certain rehabilitation centres such that each HSSC would have the resources necessary to carry out their new mandate. With a responsibility for a population ranging from 100,000 to 250,000, the 1.8 million people of the island of Montreal were divided among the 12 new networks.

Focusing on the improvement of the health of the population, giving specific population-based responsibilities to local networks, defining the role of service providers and the corridors of services required, and introducing the principle of the delivery of care as close as possible to one's place of residence has profoundly changed Quebec's healthcare system. Finding ways for primary care physicians to work hand-in-hand with public providers is the key to the success of this reform, and there is a concerted effort by all to achieve this objective.

Gregory Marchildon, Canada Research Chair and Professor at the University of Regina, discusses the Chaoulli case, which he considers to be of potential importance in leading to a two-tiered health system. In his view, those governments and individuals who support the current medicare system need to act quickly to prevent further privatization of the health system.

In our section 'Ideas at Work,' we hear first from Parle, Parker and Steeves who report on experiences in the Calgary Health Region, the Mental Health Centre in Penetanguishene and Capital Health Nova Scotia in declaring their sites 100% smoke-free in 2002/2003. Since then a national trend has evolved in Canada where many healthcare facilities have also become smoke free or have plans in place to do so. Also in this section is an article by Devitt, Klassen and Martalog reporting on the experience at Toronto East General Hospital in adopting a strategic management system.

In the Health Law section, Karen Weisbaum, Sylvia Hyland and Mark Bernstein, who are affiliated with the University of Toronto's Centre for Bioethics, raise the question of whether consent is required to publicize information on medical errors. While the authors recognize the importance of publicizing information on medical errors - that it is critical to error-prevention - they elaborate on the extent of patient's right to privacy, right to be informed and right to "control" release of information publicly.

Also in this issue are new additions to the Case Study Library, including the experience of the Royal Ottawa Hospital in public/private partnerships and the restructuring of supply chain management in the London region.

Our FutureThink article focuses on pay-for-performance in a think piece by Frank Vounasis and Isser Dubinsky who describe the underlying principles of incentive-based compensation models, especially for physicians.

This issue provides an eclectic array of short research reports from CIHI, CIHR and ICES. I also recommend the interview with Hume Martin who offers insights from his long career in health administration in many large organizations across Canada. And, finally, the new "Opinions" section offers perspectives on biotech commercialization as well as the future of the Ontario's new Local Integrated Health Networks.

Enjoy the read.

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