ARCH Senior Psychologist testifies before Canadian Senate Committee examing
Mental Health and Mental Illness
Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 21 - Evidence - June 9, 2005 - Afternoon Meeting
EDMONTON, Thursday, June 9, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met
this day at 1:16 p.m. to examine issues concerning mental health and mental
illness.
Senator Joan Cook (Acting Chairman) in the chair.
The Acting Chairman: Thank you all very much for such a compelling
presentation.
Senators, we now welcome Dr. Alan Gordon, Mr. Peter Portlock and Mr. George
Lucki. We will begin with Dr. Gordon.
....
The Acting Chairman: Thank you very much.
Mr. Lucki please proceed.
Mr. George Lucki, Chair, Alberta Alliance on Mental Illness and Mental
Health: Madam Chairman, senators, thank you very much for the invitation to
present to the committee this afternoon.
I will speak from rather than read the notes that I have provided. We have
also provided some additional reading material relating to work that we have
done on issues that we believe in Alberta have paralleled some of the interests
of the Senate Committee in your fine reports.
I will just take a moment to describe the organization and to introduce
myself. I am George Lucki, a psychologist by trade. I work in private practice,
but in a volunteer capacity I chair the Alberta Alliance on Mental Illness and
Mental Health, a coalition established in 1999 that included at that time, and
has continued to include, the major stakeholders in mental health in the
province.
The Alberta Alliance on Mental Illness and Mental Health is a unique
provincial coalition of all of the major mental health professions, the
not-for-profit agencies dedicated to mental health advocacy and community
support, associations representing mental health consumers and family members.
We comprise all of the large stakeholders in the mental health field outside
those charged with financing and delivering mental health services. We came
together with some concern about the state of mental health in the province of
Alberta and about some significant deficiencies both in funding and the way in
which systems were organized.
Our first paper, of which I provided a copy to you, was titled very aptly,
and I think from our perspective addressed the crux of the problem, "Good
People... Good Practices... No System.'' We lacked in this province a system of
mental health care, a condition that we believe exists in other provinces across
the country.
Our attention as a coalition was first of all addressed to the matters that
we held universally. The strong consensus that developed among these divergent
interests was amazing regarding what the problems were and what needed to be
done.
The solution started not with examining the funding or the services, it
started with an examination of what was happening at the top of the system. We
recognized that we needed a system of governance of care that would address the
problem. Services were fragmented and insufficient. There were significant gaps
in services, in equities. Some people could get services that other people could
not.
Wherever we looked, we found ourselves targeting only a portion of the real
mental health problems, because outside of even developing the best possible
services for people in sufficient quantity, unless we also address the social
determinants of health, of mental health — poverty, homelessness, income
support, family problems of various sorts — we will be unable to tackle the
problem effectively.
We were also concerned in this province that mental health had found itself
in a bit of a dead end — a cul-de-sac of sorts. We can use the analogies of
stove pipes or silos, but mental health was separated from the rest of the
health system, and mental health problems do not exist separate from problems of
the body or problems of the soul or problems of interactions with people.
We need to work to integrate services, not only across the social
determinants of health but effectively integrate health and mental health
services. There is not a health service that does not have a mental health
component, and we need to be able to effectively organize services so that they
address the whole person and the real needs that contribute to dysfunction or
disease or less than optimum performance.
We are pleased that we have had a couple of excellent health ministers in
Alberta and real support through the Mazankowski report, through the initiatives
of the Mental Health Board and the provincial health department, to move the
agenda forward in mental health in line with the recommendations that the
alliance and alliance member organizations have been making.
It is time for us to take this even further. It is time for us to move from
passion to action.
I provided you with a copy of a document that looks at how we rationally
separate issues of the governance and the operation of the mental health system,
and how we evaluate, after a period of time, the outcomes of our efforts.
We also developed a blueprint for reform which is a checklist or report card
to help us determine whether we have, in fact, had a positive impact on the
system of care, not just on the funding and the services that are delivered.
Today, I come to speak to you about your Issues and Options paper and
to make some, hopefully, welcome recommendations. Our interest has been largely
as a provincial alliance, but some of what needs to be done in mental health
requires the efforts of the federal government. It requires a pan-Canadian, an
interprovincial, a national approach.
We believe that the federal government has important jobs to do. The first is
that the federal government must lead by example as a quality and a policy
leader. The federal government does have responsibilities in mental health care
that do extend into our province as well, and they need to do as good a job in
that area as we hope to do in terms of our own provincial responsibilities.
You have heard about the care for individuals in the Armed Forces, and those
who are police officers. Very passionately you heard of some of the difficulties
with Aboriginal care. These are all areas of direct federal mental health
involvement.
We are concerned about a two-tiered health care system, but we have tolerated
two-tiered health care in mental health. Those issues need to be articulated and
there needs to be a debate across the country about that deficiency.
The Canada Health Act excludes mental health care. There is no federal
legislative protection for public mental health care. We need a federal mental
health act that addresses these considerations; an act that supports provinces
in delivering comprehensive mental health services.
I do not believe any dedicated transfer payments have been made to the
provinces to help fund or encourage the funding of needed mental health care.
Mental health funding needs to increase so that the services provided better
reflect the burden of suffering and disability related to mental health. That
has not yet occurred in our province or in many parts of the country.
A pan-Canadian mental health strategy also needs to consider a mechanism to
provide equitable funding to help address the needs of those affected by mental
illness.
The federal government is also a leading purchaser ofnon-insured benefits
that provide those who work for the federal government or those whose health
care is a federal responsibility with mental health care that is not available
to the people of Canada at large. These services themselves are often not
particularly well coordinated with other health services that are delivered by
provincial authorities. We believe that these programs should be comprehensibly
reviewed to ensure that they reflect best practices, address the mental health
needs of those they serve, Aboriginal people being probably a priority.
Mental health services need to be provided to the same degree to those who
have the private insurance that the federal government affords its own employees
or provides in non-insured benefits. Those benefits are available to all
Canadians.
Through income support, employment, housing and many other federal programs,
the government plays an important role in supporting mental health care
outcomes, but these programs need to work well together and work well with
provincial programs operating in areas that relate to mental health. There is a
lot of work to be done in that regard.
The federal government can be a champion for mental health reform and a
strong supporter of all of the community initiatives in that regard.
Mental health needs to stay on the policy agenda. It has at times briefly
been on the national policy agenda, but not on a consistent basis. Federally, as
provincially, there are good people and good programs, but there is no system of
care. Services are fragmented and insufficient.
We need a mental health system and we need a plan. The plan needs to be
developed with the active participation of everybody who is involved. A first
ministers' conference dedicated to mental health is needed to set the policy
agenda, but then everybody needs to be involved, because mental health requires
the involvement of coalitions such as our own and the diverse groups across
Canada whose needs are unique and particularly relevant.
We cannot develop a mental health system with a one-size-fits-all model. We
must take into account individual needs and the preferences and requirements of
the people that we serve.
How we build the system has to mirror the sort of system that we want. The
plan has to be integrative and transcend traditional boundaries. Mental health
crosses so many jurisdictions, so many departments, so many mandates, that we do
need to find some way of pulling those all together.
Even within health care, mental health and addictions are tied together. A
significant proportion of all primary care visits have a mental health
component. Hospitalizations are not without their mental health component.
Addictions and mental health together account for a significant proportion of
morbidity, absence from work and social problems in this country.
Excluding mental health care from health care may lead to the stigmatization
of the mental health components. We need to develop new ways of delivering
mental health care in our communities.
The services need to be coordinated. They need to be consumer centred. One
consumer said quite eloquently that the system is so complex that you have to be
a healthy person to be able to navigate through it. There is truth to that.
Mental health issues are complex, but we need to create a system that, from the
consumer's perspective, is easy to access and easy to navigate. Services need to
be equitable. I believe I have addressed that.
Mental health care is not a supplementary health benefit. Credit does need to
go to employers that have provided plans to address the large gap in services in
the public health care system.
How would Canadians react if we were comparing notes and speaking of
employer-funded cardiac care? What would the reaction be if employees had to pay
50 per cent of the cost of bypass surgery? Yet, we do this with our mental
health care by providing it as a supplemental health benefit.
Finally, I will deal with the question of stigma. Stigma is built into the
system. Addressing stigma is more than just funding a public education campaign
or a media campaign with posters and television commercials. The existence of a
separate mental health care system with poor legislative protection, with poor
funding, emphasizes the stigma.
In many ways, government policy has underscored that mental health problems
are different from other problems and less worthy of our support and attention.
Addressing stigma can occur by bringing mental health considerations into the
main stream of health care and by effectively funding and integrating mental
health and other health care delivery.
Stigma is also heightened by the experience of other social problems. When
you are poor, homeless, unemployed, when you have involvement with the justice
system, these conditions all add to the stigma, and these are all correlated
with poor quality, less coordinated mental health services. We need to be able
to see that connection, that is, addressing those problems will help reduce
stigma.
Empowering consumers to help lead mental health initiatives will reduce
stigma as well. Mental health consumers have been the passive recipients of
services and we need to provide an opportunity for them to have their own voice,
choice, and the greatest possible opportunity to direct their own care as they
do in other areas of the health system. The development of apan-Canadian
strategy with new services and national discussion will help reduce stigma.
Education and the dissemination of research will obviously increase not only
self-awareness of the problems that people face, because there is a large gap in
self-awareness sometimes, but also the awareness of the problems that others
face.
Finally, perhaps, in response to a very timely question, I spent much of the
morning reading Chaoulli v. Quebec (Attorney General), and many Canadians
are probably asking themselves, not quite knowing, today: What does this
decision mean for me? What does it mean in terms of the health care that I
receive?
The experience of Canadians seeking mental health assistance may be
informative here, because the question that concerns Canadians today is the one
that we have been living with for quite a while. Mental health has forever been
outside of the Canada Health Act, and though that legislation is set up as an
expression of our health care values, it does exclude mental health. The issues
that were determined by the Supreme Court give people access, perhaps, in some
cases to private insurance. Private insurance is the only way that Canadians
have been able to purchase needed psychological and other services in the past.
That has been the only way to avoid waiting lists and program limitations.
Employer-funded mental health programs make up a significant portion of all
mental health expenditures. By some estimates, the employer-funded mental health
programs approximate half of all of the publicly funded mental health
expenditures.
There has been little incentive for or little demand for governments to
provide these same sorts of benefits to all Canadians. Canadians with means have
purchased these additional mental health benefits. Vulnerable Canadians have
not, and they have often not had a voice in this matter. Even those who
purchased such benefits may not have received optimum care because these
supplemental benefits have not been well integrated with other health and social
programs. They are better suited to those whose needs are moderate rather than
to those whose needs are significant or severe. They fall through the cracks.
Again, how would Canadians feel about cardiac programs available only to
those with private coverage in addition to public coverage? Mental health
consumers have had to face thattwo-tiered mental health system all the way
along.
If the federal government is serious about a universal, publicly funded
health care system, it might start by trying to provide additional funding
through transfers and payments for the full range of mental health services the
provinces need to offer.
A Canada mental health act should be enacted that places mental health on as
strong a footing as the Canada Health Act places the health system on. We need
that pan-Canadian mental health plan. It is sad that we are one of the few
developed countries that does not have such a strategy, that does not have such
a plan.
Finally, we cannot ignore the two-tiered health care that is there for people
with mental health problems while purporting to care about two-tiered health
care altogether. We are pleased that the opposition has taken the initiative,
brought forward a motion, had a day's debate on mental health and other serious
health concerns and has called for a national strategy on mental health care.
The federal Liberals, the government party, has also adopted that motion.
Now we must take immediate action to address the problem. It is time to move
from passion to action. We would be happy to be a part of helping you in the
next steps along that road.
The Acting Chairman: I would thank all of you most sincerely,
particularly Mr. Lucki. I want to personally thank you for helping me to roll
away that stone called stigma. I appreciate the insight that you have shown
regarding stigma.
Mr. Portlock, I would like to know more about yourombuds-type service.
Dr. Gordon, you used words of our esteemed chair who said that money is not
necessarily the answer and maybe we need to look at reallocation of the funding
that is in the system. However, as we did in our study on health, where we saw
the need for change, we did not hesitate to cost it out. You will see that if
you refer back to our reports. We hear you loud and clear on that one.
Senator Trenholme Counsell: I have not had a chance to read the debate
in the House of Commons yesterday, but I will do that tomorrow. It should be
interesting to see how the other House is dealing with this matter. It is good
news to know the matter is before the House.
Mr. Lucki, could you expand on your statement that the Canada Health Act
excludes mental health care. I practised medicine for 27 years, and during those
years, I am sure I admitted hundreds of patients with a mental health diagnosis,
and I saw thousands of patients in my office with a mental health diagnosis, and
I was paid an extra 30- minute fee for counselling or psychotherapy.
I agree with you totally that there have been parallel systems where many
people benefited from services outside the system. However, how can you say that
the Canada Health Act excludes mental health care?
Mr. Lucki: Senator, provincial health plans have provided for
physician reimbursement, for hospital care and for hospital programs, As a
psychologist, I worked for about 20 years in the publicly funded system and was
paid to see individuals and help them with their difficulties.
The Canada Health Act, as far as I understand, specifically excludes
psychiatric institutions from that system. It makes no specific provision for
that. The legislative side in the federal legislation is separate from what
provincial plans pay for.
This was first brought to my attention in the mid-1990s working as a
psychologist in Red Deer, when the hospital was able to successfully introduce
significant user fees for psychiatric patients. Psychiatric patients were
required to pay up to $100 a month to access various aspects of the program.
Senator Trenholme Counsell: An inpatient program?
Mr. Lucki: An outpatient program.
The outpatient-inpatient program is in modern institutions as an integrated
approach to treatment. It had turned out that this was in accordance with the
requirements, because those services were not mandated through the Canada Health
Act.
Physician services are only a small component of what we need to be able to
protect legislatively if we are to have legislative protection of standards of
mental health care.
That is the position that I would take on that.
Senator Trenholme Counsell: Through the Canada Health and Social
Transfer many services in mental health clinics are covered.
Mr. Lucki: As far as I understand, none of the transfer payments are
specifically directed to or targeted to mental health. They say that provinces
must offer mental health services in order to be able to obtain those services.
By targeting programs towards other health fees such as Pharmacare or home
care, it has fostered the development of those programs. Transfers that are
targeted towards mental health care could close a part of the gap in services
and funding.
In particular, one of the difficulties we face is that mental health does not
typically have strong advocates, people with a strong voice to say that certain
services are necessary. For a variety of reasons, other health care services
often are able to muster more public and media attention.
The burden of disability associated with mental health problems receives, in
many provinces, considerably less than what would be a proportionate amount of
care.
Senator Trenholme Counsell: Do you think there is any risk in having a
Canada Health Act and a mental health act? My preference is to have a mental
health strategy which I think we desperately need. Do you see any risk in
separating the two?
Mr. Lucki: Yes, I do.
Senator Trenholme Counsell: You are recommending it.
Mr. Lucki: There is risk. Some of the things we recommend have an
upside and a downside to them.
The risk is the one of creating something that is not well coordinated with
health overall, which is something that we would not be supportive of. The
upside is that it does allow for the opportunity to look at the uniqueness of
mental health in a more modern way than the legislation that we have in place at
present. Those would be the advantages and disadvantages.
If someone were to recommend reopening the Canada Health Act so that it would
include a comprehensive coverage of mental health care, we would also support
that.
Senator Trenholme Counsell: Personally, I would see that as much more
positive, because if you think of the mind, body and spirit as being one, there
is a real risk in separating the two. I mean, risk and funding, risk and
perception, risk in everything.
I read in a few places that there is no system. I do not think that there is
no system, but it is a weak system. It is fragmented and needs so much
improvement. I think my province would say that we have a system, whether we
have a pan-Canadian system is another question. Many of the provincial ministers
of health and wellness would say they have a strategy, but I also think we
should strengthen the system.
Mr. Lucki: We are in agreement we can do a lot better in creating a
system of care.
Senator Trenholme Counsell: These are excellent papers. Thank you.
Senator Cordy: Mr. Portlock, you talked about creating a ministry of
state for mental health, and I fully understand why you would want to do that.
We also heard evidence the day before yesterday in Vancouver that a ministry of
state would not be a good thing. We heard, in fact, that it would marginalize
mental health. Since it would be considered a lower level ministry, the main
goal of the person who would be in that ministry would be to become, perhaps,
the Minister of Health or the Minister of Transportation or the Minister of
Finance. That person may not have the ear of the premier, or if it is federal,
the Prime Minister.
Did you think about the pros and cons when you were advocating that we have a
ministry of mental health? I am not saying it is right or wrong, I am just
saying that we have heard conflicting evidence.
Mr. Portlock: I can understand that there would be conflicting views.
I think it is all in the definition of the mandate and the definition of the
right person and the reporting relationships.
The association's view is that the advantages are likely to outweigh the
disadvantages. There is the notion of creating the optic of separateness, which
is always troublesome, but we believe that it is time, in the evolution of
mental health that it is brought in from the cold, as it were, and that such
separateness could work to the advantage of advancing the kind of reforms we
want to see.
Yes, it is true, the setting up of a ministry for mental health could be
perceived as according some kind of lesser or separateness type status to mental
health, but with care in the way the mandate is defined, we believe it is
possible to meet much of that objection.
I think it is worth the effort. I have talked to some of my colleagues in
B.C. about the experience. It has been variable because there have been some
changes in incumbency, and there has been some confusion about roles and
reporting and to whom that minister is responsible.
I think that it is a concept that probably deserves a much closer look before
it is enacted. We point out in our presentation that, unlike the physical health
system that deals with physical ailments, which does not need leadership at the
federal level — heart disease, diabetes and obesity do not need champions to
tell the provinces what they need to do — we believe that mental health still
does. These kinds of mechanisms serve mostly to sustain the provincial file that
has been so hard to achieve, and I think, on balance, there is much more to be
gained by singling out mental health for that special distinction with its own
ministry.
Senator Cordy: That sounds like a rationale. I think we not only have
to sustain it but also increase because we have a long way to go in the area of
mental health and mental illness.
Mr. Portlock: Indeed we do.
Senator Cordy: Getting back to your comments, Mr. Lucki, about
two-tiered health care in the field of mental health, I certainly think we are
still in the hospital-doctor mode in terms of what is covered by our medicare
system.
If you are outside the medical doctor, hospital situation, then indeed many
services such as consultations with a psychologist are not covered. Those who
have supplementary health benefits, have about 80 per cent of those fees paid. I
am not sure of the percentage.
However, there has not been a big hue and cry about this. There is a tendency
to believe that very few people suffer from mental health conditions, whereas
the reality is that one in five people at some point in their lives will be
affected by a mental illness of some sort, or poor mental health of some sort,
whether it is stress related, whether it is schizophrenia or whatever. Unless
those people have coverage through a workplace private plan, they will be unable
to access certain treatments. That is particularly so if they are dealing with
other social problems such as poverty.
Mr. Lucki: That is correct. We have a serious problem, if only about
half of the folks who experience episodes of depression seek help of any sort,
including help from their family physicians. The first gap is one of stigma; the
second is one of access.
People have a different expectation about being able to access health care
for a broken foot as opposed to accessing health care for a broken mind. We need
to face that particular expectation.
Accessing mental health services is more complex than accessing primary
physician care which primarily takes the form of short visits with physicians
and prescription of medications. Other forms of basic mental health care require
a referral which in our aspects of health care is often reserved to more
specialized services.
When we recognize that primary health care reform will likely evolve into
different sorts of supports for the family physician, whether it is through the
shared care model — specialists working together with family physicians, or
interdisciplinary teams involving nurses and others — that approach holds true
in spades in the mental health field. We need to be able to deliver it
differently.
Even for those folks who can afford supplemental health care and can access
it, the care that they receive may be limited by program funding. The 80 per
cent coverage may only cover, for example, five visits, which may not be
sufficient to address the problem, particularly if the problem is significant.
It may mean changing providers at some point in the care, moving from the
private to the public system, or trying to combine the two. Care is not always
well coordinated across those care systems.
There are excellent publicly funded mental health programs in hospitals and
in regional health authorities and, if an individual can access those and the
program is appropriate, they can get excellent care.
There is another limitation in terms of the appropriateness of care. For
example, when I worked with individuals suffering from AIDS and the
psychological problems that involves, many things often interfered with a
person's capacity to keep an appointment at, say, Thursday at 10 a.m. halfway
across the city. The person might not have the bus fare to get there. We need to
be able to address some of those other obstacles. Besides agreeing with you
about private, public, two-tiered care, there are significant other
accessibility issues that we need to tackle.
Senator Cordy: Medications is one of them. Across Canada, 98 per cent
of people have a medical pharmaceutical plan of some sort, but in Atlantic
Canada, over 20 per cent of the people have either little or no pharmaceutical
coverage. People who are suffering from a mental illness have to be on
medication.
Mr. Lucki: The same thing occurs in Alberta. For supplemental health
care you have to have a good job or no job. The folks who are struggling in
low-income jobs orlow-benefit jobs are the ones who have limited access to a
variety of programs, including drug benefits.
Senator Cordy: You said that there are good services and programs out
there, and I agree. Travelling across the country we have heard of some
wonderful programs in the different provinces. We heard about the wonderful,
dedicated people, many of whom are working at low salaries, who are working in
the field of mental health.
I remember hearing a departmental witness in Ottawa showing us a list of all
the programs that were available provincially and federally, and my comment to
the person was, "If somebody suffering from a mental illness came to me and
asked, `Where do I start?' I would not be able to tell them.'' Is that what you
mean when you say the system is fragmented and difficult to access?
Mr. Lucki: A road map through the system is a complex series of boxes
connected by lines, but you have to put your glasses on to be able to decipher
which one is what. That already shows that we have a fragmentation problem.
How do people move through the system? There are some significantly difficult
spots. Access presents a difficulty. Admission to hospital is difficult. Getting
the right bed at the right time for an individual presents a difficulty.
Discharge from hospital causes a real crisis for certain individuals, and
community services are often not available to step up in a timely way to provide
the supports needed by people when they are discharged from hospital.
We are making good strides, provincially, here in trying to integrate these
services on a regional basis. We have moved away from the system where we had
two separate mental health systems, one that was run through the Mental Health
Board and the other through regions. We have a more integrated system now, and
we are starting to address some of the issues of integrating with health care.
There has been some progress, but the problems are still there. There still
is an imbalance, at least in our province, between institutional services — the
reliance on hospitals — and the services that would help prevent
hospitalization, would help keep people in their homes and connected with
whatever supports they have in the community.
Hospitalization in the mental health field is often a crisis not of a
person's symptoms but a crisis of our ability to serve them in such a way that
will help them manage their difficulties without having to resort to
hospitalization.
Senator Cordy: You said that Alberta is making strides in the
integration of services. Does the integration depend on the personalities
involved in the various systems or is it built into the system?
Mr. Lucki: It is both. One challenge along the way will be the
training of individuals to work within the integrated system that we hope to
have. In particular, how do we support through training this broader and more
complex job that people will have to do? Family physicians will be in particular
need of good access to those supports so that they can discharge their
responsibilities in an integrated system.
It applies across the board. The panelists before us spoke about the lack of
front-line Aboriginal mental health workers and the need to train people to
deliver culturally appropriate services in ways that make sense to the
individuals who will be receiving those services and in ways that will be
accepted by the communities that they are intended to reach. There is a huge gap
between the way we train individuals and who we train and who receives the
services.
A considerable amount of work has to be done in each of those areas, and we
can point to steps we are taking in this province and likely in many others, but
there is still a great deal more to be done. If we had an overall action plan
that would target some of the things that are lagging in particular ways, we
might be further ahead.
Senator Callbeck: I want to go back to the question of a minister of
state for mental health. Is this the position of the Canadian Mental Health
Association or is it Alberta's position?
Mr. Portlock: This is an Alberta suggestion.
Senator Callbeck: Has any other province had this?
Mr. Portlock: Apart from British Columbia, I am not aware of any
others.
Senator Callbeck: When was it put into effect in British Columbia?
Mr. Portlock: From what I understand it was to address precisely the
sort of situation that we are encountering elsewhere, the sort of second class,
second rate, out-of-the-shadows,second-solitude nature of the mental health
system. From the few conversations I have had with people in BC, I understand
that this was seen as a strategy to try to elevate the profile of mental health
and get it some attention on centre stage.
Senator Callbeck: I understand that. The question was when was it put
into effect.
Mr. Portlock: It was two years ago, I believe.
Senator Callbeck: Was it endorsed by the people working in mental
health in British Columbia?
Mr. Portlock: That is my understanding, yes.
Senator Callbeck: Mr. Lucki talked about getting rid of stigma. Dr.
Gordon mentioned a 10-year national anti- stigma campaign. Do you have any
comments to make about what you think that might entail; and do you know of any
successful programs?
Dr. Gordon: I think you have looked at some in the course of preparing
your reports.
My comment, which ties in with some of the discussion that has been going on,
is that sometimes we miss the goal we are aiming for in all of this. For
instance, the problem of fragmentation of services is a problem of access. The
patient does not care who is providing the funds or who is running the program,
the patient wants to be able to access it. If access is the problem, then let's
identify it as such. The solution to the problem may be to integrate services,
but the problem is access.
The profile of mental health is one of stigma, and one way to solve that
problem may be to put a minister of state in charge. However the problem itself
is that it is stigmatized in relation to or discriminated against in relation to
other branches of medicine.
Let us identify the problem from the patient's point of view and focus on the
problem. The solution may be to appoint a minister of state, although I do have
some concerns about that. I have changed my mind over the past 15 years on this.
Fifteen years ago I was in favour of separating mental health services from
health services in order to protect. Now I believe that we should go for
integration, as full integration as we can. However, we must raise the profile
by dealing with stigma and discrimination.
In terms of the nuts and bolts of how to do that, others are more expert than
I am in that area. People tell me that it needs a long-term strategy; that it
needs support at a high level; that it needs a commitment over a long period of
time, which is why I have suggested 10 years; and that it needs to be
multifaceted, that is to say, looking at education, workplaces, media and
attitudes within the health care system.
One of the core issues is that of stigma, and I think the federal government
can take a significant lead in that.
Mr. Lucki: Addressing stigma is no different from trying to tackle the
problem of racism. It is not easy. It requires a determined effort because it
can present itself in insidious ways.
We will not be able to address the issue of stigma — or shame from the
person's own perspective, the shame that they feel that they have the
difficulties that they do — unless we act in a way that is consistent with the
idea that there is no shame involved in having mental health difficulties.
Sometimes, inadvertently, we convey the message that there is shame.
If, in addressing the issue of racism and said, for example, that people of
colour do not experience the same educational opportunities as other Canadians,
and our approach was simply to give more money to the separate schools for
coloured children, then we would be way off base with that approach. It would
never work.
We need to examine where, systemically, stigma has arisen in the way in which
we approach the problem, how we value it, and if we find that we are not
approaching it in the same way that we approach other social or other health
problems, then we need to address that first.
Stigma will likely be with us for a long time because attitudes are not
easily or quickly changed. There are numerous other sources of stigma besides
those that are structural.
I believe that this is an area in which government can take a lead role in
terms of eliminating some of the attitudes that are within its purview to
address.
The Acting Chairman: Mr. Portlock, when you have an opportunity to get
your proposal on the ombuds service down in black and white, we would like to
have a copy of it.
Mr. Portlock: We would be delighted to give you a copy of it, senator.
It is still in the formative stage. It comes in partial response to a number of
realities.
There are mechanisms in Alberta for people who are in the system to help them
adequately pursue and seek redress respecting complaints or concerns about
access or supply of treatment, or communication, or whatever. The provincial
ombudsman's mandate, which previously excluded hospitals, now includes hospitals
and the people in them.
The mandate of the mental health patient advocate in Alberta, as defined,
includes current formal patients within the system.
The health quality council of Alberta has now completed two annual surveys of
Albertans on their views of the adequacy and the responsiveness of the health
system and, for the most part, the responses were favourable. This past year,
for the first time, the health quality council survey included mental health.
For those who were able to access the system and receive services, there was a
62 per cent level of satisfaction with the mental health aspect of our health
system.
However, across the board, I believe that 83 per cent of all respondents
expressed concern and, in fact, considerable anger with regard to how complaints
and concerns about the system and its responsiveness generally are addressed.
My colleagues in the regions and I pretty much deal every day with people who
have tried to access the system having, as I expressed in my presentation, the
courage to come forward, and for many people it takes courage to finally say, "I
am need help.''
Some of these folks are not often at their best when they try to access the
system looking for help for a mental health issue, and their experience, as I
record in my dealings with them, is such that we believe there is a need. I
believe volume 3 of your last report deals with some form of advocacy to assist
people in accessing the system and to pursue concerns or complaints about the
system when it has not responded in an appropriate way.
We are developing a proposal that will provide anombuds-service. A classic
ombuds-service must involve a neutral person, that is, a person who is not in
the chain of command and who can investigate a complaint or a concern and can
assist an individual in resolving it and, in certain models, have the power to
make recommendations for changing in the system in order to make it more
responsive.
This will be done on a trial basis. There are other mechanisms that deal with
formal patients, people in the system, and operated under the auspicious of the
CMHA. It is not the responsibility of one particular RHA, which would bring all
sorts of other complications to the table.
What we require, apart from the funding to run the project for the year — and
that is what I am currently engaged in trying to secure — is the buy-in and the
cooperation of the RHAs, because in the furtherance of the investigation of
complaints and concerns by people who would access this service on a 1-800
basis, it would be a central point of response and approach, if you like, for
people who have tried to access the system and have had difficulty or simply do
not know where to access it.
It is more of a patient advocate or patient representative kind of function.
We would require the approval or at least the consent of the RHAs to be active
in their territories, because it would require us or the ombuds people employed
in this trial to deal directly with the RHAs, if there is a concern in a
specific area.
We initially conceived this idea as something people could use to address
concerns they had with services provided by the CMHA at the regional level. In
talking about the idea we soon saw that it, in fact, could be and perhaps it
probably should be larger in scope.
We are to gear up to this. I have experience as an ombudsman in the health
system so, of course, I have a particular interest in this. We are trying to
introduce this in on a trial basis across the province. The fallback position is
to try it within a couple of RHAs. Failing the system-wide approach, we will try
it within a couple of RHAs and see how it works.
We would be glad to provide you with the proposal. It is an idea whose time
has come, given the results of the HQCA survey. We hope that it will find some
responsive and friendly ears.
The Acting Chairman: If any one of you has a closing statement, we
will hear it.
Dr. Gordon: I should like to follow up on what Peter said about access
which I take to mean not just front-end access and access to assessments. Only
38 per cent of people with mental health access their GP. They know that there
is a 6 to 12 month wait to see a psychiatrist and to have access to mental
health clinics. These are front-end access issues. There are also treatment
access issues. You can only get into a hospital now if you are deemed to be
dangerous. It is most unusual to have an elective admission to hospital.
Equally important is access to support services. It may take six months to
access a support service that deals with housing. Why do we have to wait four
months to get AISH? Why are some people waiting for months and even years to get
into vocational rehabilitation programs?
Access issues are not just front-end issues — walking through the door of the
mental health clinic — they include access to the range of treatment services
and also the range of crucial support services.
The Acting Chairman: Mr. Lucki, do you have any closing comments?
Mr. Lucki: I would simply reemphasize the importance of undertaking an
inclusive process to build a system and a plan that will mirror the plan we hope
to create. I believe that each person we listen to, each group we listen to,
informs us of another important aspect of what it is that we need to create.
A system is not simply built around the psychiatrists, the psychologists or
the nurses who provide the treatment, a system of care includes a whole range of
supports, many of which are not even within the health care system. We need to
do this inclusively so that those who are most affected by mental illness have a
strong voice in creating the sort of system that reflects their needs, their
values, and that realistically supports them not just in a way that works for
the providers. I think we have done a better job of creating provider-driven
systems of care than client-centred, consumer- centred systems of care.
Mental health needs a champion. Your committee has been such a champion for a
number of years now by raising the issue of mental health on the national
agenda, and that is very supportive to our efforts on a province-by-province
basis, because it keeps us in touch with some of the issues that resonate across
the country. It points to the fact that solutions may be different in each
province. It gives us an opportunity to explore ideas that we may be able to tap
into or be able to model.
Hopefully this will see light at some point as a comprehensive mental health
strategy for the whole country, one that we will hopefully gladly adopt, because
it is in our interest as a nation, not only from a health and a social
perspective, but also from an economic perspective for those who like to think
in terms of dollars and cents. It is nothing but to our advantage to get this
one right because the costs of not doing it will be far greater than we have
ever been able to calculate, on a social level, a human level, or in financial
terms.
I thank you for the opportunity to present and wish you well in the rest of
your hearings and in developing the important recommendations which, hopefully,
we will see implemented down the road.
The Acting Chairman: Thank you very much to the panel. This has been a
real learning experience.
The committee adjourned.
