THE STANDING SENATE COMMITTEE ON Social Affairs,
Science and Technology
EVIDENCE
OTTAWA, Wednesday, April 20, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 3:45 p.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
The Chairman: Honourable senators, we are here to continue with our series of witnesses on the mental health and addiction study we are doing. We have witnesses here to take us into the evening.
We are delighted to have witnesses from across the country tonight. Our first witness is Mr. Terry Bogyo, the Director of Corporate Planning for the Workers' Compensation Board of British Columbia. Some of you will recall that we have had evidence in the past about the role that workers' compensation boards across the country play with respect to treating workers who are not "injured" in the usual physical sense, but suffer from some sort of mental illness such as stress and burnout. We thought it was important to understand how workers' compensation boards approach those problems and, in particular, to be able to contrast the role of workers' compensation boards with that of private insurance companies that provide employee benefits and employee health care services in a number of white-collar industries.
I know you have a short opening statement, from which you have given us some overheads. You will make your opening statement and we will be delighted to ask you questions.
Mr. Terry Bogyo, Director of Corporate Planning, Workers' Compensation Board of British Columbia: Senators and staff, I appreciate the opportunity to speak with you today about workers' compensation.
Workers’ compensation is nothing new. It has been around in Canada for about 90 years. It is based on a report done for the Ontario government by Sir William Meredith. That report resulted in the first Worker's Compensation Act in Ontario in 1914. Every province copied the basic principles that Meredith put forward in his legislative proposal. Today, every province and territory has a workers’ compensation act. The federal government has one too; it is called the Government Employees Compensation Act.
Now, Meredith included some principles in his legislative proposal, and one of them was the "historic compromise." This is what differentiates workers’ compensation from the private insurance or the insurance liability model that you were looking into. Essentially, workers’ compensation is a social contract. It is a form of insurance, yes, but what it really does is protect the employer from being sued by his workers for work-related injuries.
That protection comes at a cost. The employer has to fund a no-fault insurance program in order to pay the benefits to the workers. The worker draws his benefits for medical aid and wage loss from that no-fault insurance program, but we have taken away that worker's right to sue. That is part of the social agreement that is worker's compensation. The worker and the employer, the state and the community, are better off as a result of the reduced friction, lower court costs, and more rapid justice, if you will, for the worker involved.
Each jurisdiction has its constitutional responsibility for health and labour and has to set its own scope for its own legislation. They have to decide who is covered. They have to decide what is covered by the workers' compensation legislation and what authority the agency should have.
In British Columbia, we cover between 93 and 94 per cent of the employed labour force, but we are also the health and safety agency. We are the inspectorate. We set the worker's compensation regulations, the occupational safety and health regulations. We are the promoter of health and safety in our jurisdiction. That is not true of every workers' compensation board, so there are differences across Canada.
However, people still get hurt. We have 2 million workers in British Columbia. Every year, about 150,000 of them have a workplace injury; 60,000 of them have a serious enough injury to miss time from work; and sadly, we have to accept 150 claims for fatal workplace injuries.
Some people with mental illness and addiction problems do work, and some of them do get hurt. When they are hurt, we have the same issues as anyone else in trying to address their needs. Sometimes, their mental health or addiction problem is superimposed on an injury, and it can affect their recovery. At other times, a physical injury can cause a mental health problem. Think of a worker with a brain injury. Think of a worker who develops an addiction problem as a result of medication for back or neck pain. These are all real issues that can occur in a claim.
Some individuals have an underlying condition, and the occasion of the injury triggers a psychosis or development of a disability as a result. In all these cases, we have laws and policies that allow the workers’ compensation board to act. Last year in British Columbia, we conducted 960 psychological assessments on individuals in our system to assist them in recovery and treatment and also in the adjudication of claims.
We do have the policies, and we do deal with the cases where there is a need and a clear connection between work and the injury of mental illness or the addiction. Where we do have difficulty is in the area of stress. For a specifically triggered stress, a traumatic incident — a hostage-taking, a bank robbery, a firefighter taking a child out of a burning building and seeing other children perish in the blast — these are concerns. These are real incidents and they cause psychological stress. We can deal with those under our legislation, and we do.
Some provinces have put a limitation on gradual onset stress, that is, stress that starts out as not perhaps connected to a specific incident, and over time becomes more significant. The trend in North America is to exclude those conditions from coverage under workers’ compensation. This goes back to the historic compromise. How do you connect the workplace to the condition? Where is the nexus there? If you intend to force employers to fund the system, this is one aspect that has to be examined.
This is not universal. In Australia, the workers’ compensation system for federal government employees is ComCare. It does include compensation for stress, including gradual onset stress. You should be aware that stress now accounts for 7 per cent of all claims received by the federal workers’ compensation system in Australia and accounts for 27 per cent of all costs in that system.
You have similar legislation, as I said, the Government Employees Compensation Act, which protects the employer, the federal government, from being sued by its employees for work-related accidents and injuries. The federal government asks each province to administer that act. I have distributed through the clerk a copy of a very recent decision, Royal Canadian Mounted Police v. Bruce Rees and Vina Rees, in the Newfoundland and Labrador Court of Appeal, Chief Justice Clyde Wells, which perhaps gives you a better idea of the complexities in gradual onset stress and the fact that there are different definitions at the federal level from those at the provincial level. This is perhaps one of the first cases of gradual onset stress that, at least according to the courts, should be covered under the Government Employees Compensation Act, and it may have some implications with regard to policy.
The Chairman: Quickly, you can tell us the essence of the decision?
Mr. Bogyo: The worker was an RCMP officer who suffered a series of harassment events, as it was characterized, on the job that eventually led to a mental breakdown, to the point where he could not work. The case was taken to the Human Rights Tribunal and ultimately an award of damages was made to the worker and to his spouse. It went in that direction because the worker was told he could not appeal or make an application to the Newfoundland workers’ compensation system because that system excludes gradual onset stress. The court ruled that there should have been an application to the workers' compensation system in Newfoundland, but that really it is an application against the Government Employees Compensation Act, the federal legislation. The definition in the federal legislation of an "accident" is different from that in the legislation in the provincial sphere.
The Chairman: Different as in broader?
Mr. Bogyo: That is correct. It is broader. It contains no exclusion for gradual onset stress, whereas the provincial legislation specifically excluded it.
The situation, therefore, according to the judgment, and again I have only had a chance to read it through a few times since it was posted yesterday, indicates that the Government Employees Compensation Act is responsible for this. It should not have gone through any other jurisdiction. The proper jurisdiction was workers’ compensation. The Newfoundland workers’ compensation system would then have to adjudicate the claim, but using the definitions in the Government Employees Compensation Act, and award compensation, even though under its own compensation legislation, it would be barred.
The Chairman: Presumably now the plight of this particular RCMP officer goes back to the Newfoundland workers' compensation board?
Mr. Bogyo: That was my understanding.
The Chairman: Thank you. I had not read it, and I thought, since this is being shown on CPAC, why not tell people what the answer was rather than just what the question was.
Mr. Bogyo: It is a complex situation, and it creates a differential in the way in which cases will be handled. The case also illustrates some of the pain that individuals go through, including, in this case, the worker's spouse.
The Chairman: Thank you.
Mr. Bogyo: That is the essence of my presentation today. I do want to emphasize that workers’ compensation legislation is decided by the legislatures across Canada. We do act on stress and mental illness, whether it is pre-existing or is triggered by the injury. If it is a barrier to recovery, we clearly are involved.
I actually got a phone call this morning indicating that last year we treated 780 individuals — this was beyond assessment — for $1.4 million.
Today, at any given time, we have 370 individuals who would be classified as having mental illness or addiction problems and who are in active treatment within our system. Most commonly, these are mood disorders, post-traumatic stress disorders or depression. We deal with learning disabilities, which cause problems for individuals.
We have a network of 300 psychologists who can provide assistance, particularly for brain-injured individuals and those with psychosis. Internally, we have 14.5 full-time equivalents that monitor and manage the cases that need to go in this direction.
Are we seeing more cases now than we did in the past? According to our psychologists, more workers with pre-existing psychosis, mental illness and addiction are being injured. They have this overlay that they bring with their physical injury to their recovery. We are not seeing more stress claims because according to our legislation gradual onset stress is barred from the system.
The Chairman: You point out that the federal legislation does not exclude stress that increases over time, gradual onset stress. You might have some information on this in B.C. because you would adjudicate any federal claims based on that. Have you had a number of federal claims come through based on gradual onset stress?
Mr. Bogyo: To my knowledge, not many. Part of the reason is that until this decision, I think most people assumed that the legislative definition of the provincial statute would prevail. Indeed, as we now know, it is the federal jurisdiction definition that prevails. Will we see more? I think that is possible, given this ruling, should it stand.
The Chairman: I am struck by your statistics from Australia, which pertain, as I understood it, to federal workers, not to the entire workforce.
Mr. Bogyo: That is correct.
The Chairman: You said 7 per cent of their claims are for mental illness-related issues. I look at that 7 per cent and compare it with the roughly 1,000 out of 150,000, using the numbers you gave. More staggering to me is the statement that in Australia it is not just 7 per cent of the claims, it is 27 per cent of the costs.
Mr. Bogyo: That is correct.
The Chairman: I cannot quite get my mind around why that would be the case. We will have to attempt to answer that. It just seems completely out of proportion to me.
Mr. Bogyo: It does seem out of proportion. That is one of the concerns.
Australia is not the first jurisdiction to run into this issue. Similar statistics came out of California and Oregon, which both changed their definitions and the test for access for any sort of stress. In that legislation, I believe it is called "mental mental claims." These are where there is mental stress as opposed to a physical injury. In both cases, that meant a more restricted access to benefits.
The other thing you have to realize is that most physical injuries, even broken bones, generally heal within six weeks. Damage to the psychological makeup may be far more pervasive and much harder to treat and rehabilitate. That 27 per cent of the cost in Australia is related primarily to the wage-loss equivalent and the treatment that goes on for many of these individuals for a lifetime.
The Chairman: In fact, it becomes an ongoing, much lengthier time cost than the cost of simply fixing a broken leg or a shoulder or whatever.
When people come to you with a complaint that is, if not stress related, is mentally related, you take the position that is not covered under your legislation. Therefore, they need to go to the health care system in B.C. or somewhere else, if that is the only problem they have. Is that correct?
Mr. Bogyo: Yes, with one qualification. If there is a doubt, we are an inquiry-based system. We have the ability to pay for a psychological assessment so we can make that determination. In some cases, we determine, having done the assessment, that this is not work related. The worker is free then to take that relatively costly psychological assessment and use it to access care, either in the community or through some other agency, including perhaps an employer's assistance program.
The Chairman: On the other hand, what if people come to you who have suffered a physical injury on the job, perhaps caused because they were depressed, got careless and were not functioning as well as they could? I am not talking about schizophrenia or something like that; I am talking about a stress-related issue that caused them to get careless. Did you say that under those circumstances, in addition to treating the physical injury, you would also try to treat the underlying illness?
Mr. Bogyo: I said that where it is a barrier to the recovery or the treatment, we have a policy in place whereby we can address the addiction or the mental illness. There is a case right now of a homeless individual with a shoulder injury whom we have put up in a hotel. That homeless individual has a pre-existing mental health issue and a drug addiction. These are preventing him from becoming stabilized to the point that he can have the shoulder surgery.
The Chairman: Presumably he hurt the shoulder when he was working and not homeless.
Mr. Bogyo: That is correct. There is a connection to the work. He was hired, if I remember correctly, under a day-labour situation. Regardless, as long as he has the shoulder injury and it is related to work, we must deal with that. The way we are doing this is to offer, and the worker has accepted, assistance in controlling his addiction and stabilizing his mental health condition so he can have the surgery.
After the surgery, we will put him back in the hotel and have visiting nurses and counsellors change his bandages and ensure he is stabilized before we discharge him from our jurisdiction. As soon as we have done that, then we will try to connect him — and we are trying — with the appropriate community-based services, since we have no further jurisdiction after we have overcome that barrier.
The Chairman: However, the practical reality is that once his shoulder is fixed, he is no longer your problem.
Mr. Bogyo: The historic compromise that was based on this work-relatedness will no longer justify the expenditure from the employers’ funds that have been given to us.
The Chairman: You may not know this for sure, but does every province's workers' compensation board legislation treat mental illness and stress-related problems the same way? You indicated the federal legislation does not, but is all the provincial legislation basically the same?
Mr. Bogyo: It is going in that direction. I cannot speak to every piece of legislation. There is some variability. In your first report, you have a table that indicates the variances in each province. There are continual changes to that. In practice, the situation that I outlined was based more on the policy than on the legislation. You do have some variability in policy across the country as well.
Senator Cordy: I would like to go back to what happens when a physical injury is superimposed on a mental condition or an addiction. The example you gave us involved somebody who had a pre-existing addiction. What about the situation where an injury could in fact cause an addiction or depression? Somebody is housebound with a back injury for months and becomes depressed.
What happens in those situations? Do you just deal with the injury that was directly related to work, the back injury? If a mental condition or an addiction is as a result of the physical injury, are you responsible for that in addition?
Mr. Bogyo: The short answer is absolutely, yes. If there is a clear nexus between the work-related injury and the depression or the drug addiction, we act. This is a very common situation causing depression, drug addiction, particularly to pain medication, even suicidal thoughts. We intervene and provide counselling.
I started my career 25 years ago as a vocational rehabilitation consultant. One of my first cases was an individual who had been working in a print system where sometimes the paper gets jammed and catches fire. He was clearing a jam when a breeze picked up the paper and wrapped it around his legs, and it caught fire. It melted the polyester in his pants to his body and he was seriously injured. I got the case about three months after the injury, and I noticed that we had not had contact with the individual for about three or four weeks. I went to his apartment. He did not answer the phone. I asked the manager to see if he could get the individual to come to the door. We knocked on the door and the individual let us in. He was in bed. Having talked to the individual, I determined he was suffering from what I thought might be suicidal thoughts and what the psychologist told me later was post-traumatic stress. The worker took a long time to recover, and I do not think he ever went back to work in that particular place. All the treatment, the psychological treatment, the drugs that we used, the time that it took and the wage loss were all covered as a sequel to the injury, and therefore within the purview and jurisdiction of workers' compensation.
Senator Cordy: Would the person have to prove that it was not a pre-existing condition? For example, if he had suffered a bout of depression five years earlier, would that be considered?
Mr. Bogyo: That sort of information is important. As I said before, if it was a condition and not a disability in the sense that the person was working, they were able to cope with whatever it was prior to the injury, we must take the person as we find them. The principle of a thin-skulled individual being injured is one that we have to accept in workers' compensation. The fact they have a more serious injury or impact as a result of the work-related injury does not preclude us from making the appropriate expenditures to ameliorate the effects. We must do what we can to restore that individual to the situation that they were in.
Senator Cordy: If you are dealing strictly with a mental health issue or an addiction, you would have to prove a clear connection between work and the mental health issue. How difficult is it for the person who is suffering from stress to prove a clear connection with work? Is it laborious, or is it fairly routine?
Mr. Bogyo: We are an inquiry-based system, and our legislation says that if the balance of probabilities is equal, we rule in favour of the worker. Most of these cases come to our attention from adjudicators or physicians and physiotherapists who are treating the individual for a physical problem and note that there is a change in behaviour. The person is making depressive comments, or they recognize one of the other symptoms of addiction or mental illness. They inform the adjudicator and it is in those cases — at least 960 times last year — we end up doing a psychological assessment. We begin to investigate what the problem might be, and if treatment is necessary, we initiate that treatment.
Senator Cordy: How long is the waiting time for somebody to appeal a case, whether it is a physical or mental problem?
Mr. Bogyo: Under the most recent legislative changes in British Columbia, we have strict timelines for both our internal review, which is a form of internal appeal — I believe it is in the order of 90 days — and the secondary level, the workers' compensation appeal tribunal, in the order of 150 days. These are legislative deadlines that must be adhered to should there be a dispute.
We attempt right from the beginning to deal with as many claims as we can. You have to remember in most of those cases, where we are talking about a psychological overlay or development of psychosis or mental illness or addiction following injury, chances are we have already accepted the claim. We have been treating the injury. The question may now be, is the problem still compensable? That is a very rare appeal and I do not have any statistics on it. I am sure if the committee wished, we could perhaps run some specific tests to find out what that number would be.
Senator Cordy: Is there legislation in other provinces in terms of timelines?
Mr. Bogyo: That is a trend in legislation to ensure that there is a timely decision on claims.
Senator Cordy: You hear stories about physical injuries in my province of Nova Scotia. You always read in the paper about the worst-case scenarios, but certainly about backlogs of workers' compensation cases, which is difficult enough if it is a physical injury, but is compounded if it is stress related because that would just increase the stress level.
Mr. Bogyo: We agree, and the legislature agreed and imposed time limits within the legislation that we now must meet.
Senator Cook: I understand that the Province of B.C. is on the cutting edge of workers' compensation across this nation. I gather from what I read here that you have a comprehensive program. We are looking at the possibility of developing a national mental health strategy. I would like you to hypothesize, if you would, about the gaps across this nation that we would need to look at and solve to bring that about. For instance, would workers' compensation mental health claims policies be reviewed, and by whom? How can uniformity be achieved among the various workers' compensation boards with respect to mental illness and addiction? That is the lens I am looking through. If, at the end of the day, we are looking at a national mental health strategy, is there a common denominator across the spectrum, or are there any gaps in the system?
Mr. Bogyo: I remember these were the kinds of questions that were raised in your Options paper. There are some complexities here. Workers' compensation legislation is a provincial matter. Each jurisdiction's legislation is designed not in a vacuum, but within the context of other pieces of legislation within that jurisdiction. British Columbia may well have legislation that already supports a certain aspect of mental health within the community. The limitations and scope of the workers' compensation legislation is developed within that context.
In looking at the national scene, we do have an association of workers' compensation boards in Canada. We use that association to exchange ideas and to bring forward information that may be of use to legislators and policy-makers. However, we are talking about an association that has three full-time equivalents and a half-time person to help us prepare some statistics. This is an association of administrators, not of legislators. Such a strategy would be, at the legislative level, very much analogous to health care.
That is a provincial concern. It takes a national consensus among legislators to reach a standard on that level. We can also make comparisons, which tend to bring some consistency. The work of this committee and that of the Association of Workers' Compensation Boards in identifying the differences helps legislators and the public to decide what areas need to be adjusted. The federal government, as a player in workers' compensation through the Government Employees Compensation Act, can perhaps use that in a leadership position in trying to move other organizations toward consistency through its contracts with the provincial governments to administer those claims. The federal government could put specific wording in its own legislation. That could have the effect of bringing some consistency to treatment across the country, at least for federal employees, and ultimately, for others.
Senator Cook: Within the current system there are silos from province to province. Is there a benchmark of best practices to help us pull it together to develop a national mental health strategy under the existing framework, or should we look at an alternative?
Mr. Bogyo: Generally speaking, that would be a little too ambitious, in our view, because of the nature of workers' compensation. As well, there is a competitive aspect to what we do. The cost of premiums for workers' compensation is between 2 and 3 per cent of the cost of labour in Canada. We are competing in a world market. The cost structure and limitations for workers' compensation boards in the U.S. are similar to ours. Given what we know about more inclusive coverage for gradual onset stress, in particular, that would tend to drive up costs, as it did in California and Oregon. This is a concern for business because that cost would affect their competitiveness. In some respects, I want to switch that around and say that workers' compensation boards benefit, but more generally, it is society and the Canadian economy that benefit from having mentally healthy individuals in our population. We benefit in Canada from the access that workers have to a good health care system, something that they do not experience in the United States and which is a big concern for workers' compensation in that jurisdiction. We benefit from this and would be supportive of wellness. We are advocates for wellness, and prevention particularly, because our organization in British Columbia has a prevention mandate. Although I do not know whether you could create consistency within the workers' compensation framework specifically, there is an argument that we would benefit from having a united strategy with respect to it.
Senator Cook: I compliment you for saying that the injury may begin as a physical one but you take a holistic approach to healing. That is comforting to hear from a workers' compensation official.
The Chairman: I want to welcome Senator Dyck, from Saskatchewan, who was appointed to the Senate last week. We are delighted that she is a member of this committee.
Senator Cochrane: Mr. Bogyo, your brief mentions section 6.4.2 in volume 1 of a study that suggests some workers' compensation boards are more reluctant than others to provide mental health disability benefits. Would you explain that to me?
Mr. Bogyo: That was from volume 1 of this committee's report, which quoted a report done for the Yukon, if I remember correctly. It simply laid out the legislative provisions. It is not that the boards are reluctant to provide that benefit but that the legislators have made rulings appropriate for their jurisdictions in respect of the extent to which stress or certain kinds of mental illness will be covered under their legislation.
That is a choice of the legislators, and the workers' compensation boards are the administrators of the legislation. My comment was that the table in the report shows the range of legislative differences. It is not reluctance on the part of the boards to provide the benefit, because the boards do what the legislation tells us to do. We are the body that gives life to the legislation. The legislation drives us in the same way that the Government Employees Compensation Act, which was missing from that list, also has some influence over what is covered for federal government employees. That variability goes back to the responsibility of legislators to design legislation that is responsive to the social, political, economic, cultural and historical values that are inherent to that jurisdiction. Whether it is right is not for the boards to say. It is our job to administer that legislation. It is not a matter of reluctance. If the legislation says that we cover it, then indeed it would be covered by us.
Senator Cochrane: I do not know if this is a fair question: Frequently, we hear on the news about people losing more time at work because of stress. Stress is having an effect on the work per se. Do you see that?
Mr. Bogyo: We have approximately 2,200 employees. Certainly we have a concern about "presenteeism." We believe that the wellness of our workforce is so important that we have initiated an employee assistance program. We call it an "employee and family assistance program" because we believe that the family should have access to the services without having to worry about going through the employee directly. We send messages home via fridge magnets. We believe so strongly in this that we have introduced a new program for our employees to model what we think is an appropriate employee safety, health and wellness program to encourage that. Certainly we see reports of stress-related effects. Nationally and internationally, we see more of it in the workers' compensation field. The report of the National Institutes for Occupational Safety and Health is a wonderful, free publication on work-related stress. In the U.S. not many cases of work-related stress are covered, but clearly, it is an issue that even the NIOSH are trying their best to ameliorate.
Senator Cochrane: Do you know of any companies that place an emphasis on the kinds of programs that your organization has put in place for employees and their families?
Mr. Bogyo: Yes. I would hate to single them out, but I will say that this is a growing trend. You will find it in the human resource literature at the American Association of State Compensation Insurance Funds conference last summer in Minneapolis. One of the keynote addresses was about wellness, particularly within the organizations. We saw similar reports at the Workers' Compensation Summit in Sydney, Australia, last year. The International Association of Industrial Accidents Boards and Commissions had a special leadership seminar this year in Omaha on exactly this topic.
There is a growing recognition among employers that mental health and wellness, the balance in people's lives, is something that we need to value and encourage. We at the WCB in British Columbia believe that we should model that for the employer community as well as doing it for our own employees.
Senator Cochrane: We have also heard from witnesses in Toronto about how organizations, employers and so on, should be more cognizant of the fact that for some of these people who are undergoing a lot of stress and mental disorders, schedules should be allocated differently. For instance, rather than a nine-to-five job they can probably work from nine to three or nine to twelve and they accommodate them, knowing full well that they have a few difficulties that others do not. Do you see anything like that happening?
Mr. Bogyo: My first career and part of my credentials was as a vocational rehabilitation consultant, someone who works with individuals. Within our own program at workers’ compensation in British Columbia, we have a strong return-to-work program. If people are suffering from a mental illness or a physical one, regardless of whether it occurred at work or because they have some other problem, we will do what we can to make an adjustment, an accommodation for them in our workplace.
Recently, I had a person working with me for about a year who was dying of cancer. She did not want to be at home with her teenage son. She would rather be with people. We made an accommodation and she worked with me up to the week before she died. My assistants and I developed quite a friendship with her. It was hard, but it was also very valuable for her, and, I think, for the people in my group. It was very gratifying.
The Chairman: Just one quick question on your responses to Senator Cochrane. I assume that the kind of program for your employees that you talked about, whether dealing with stress on the job or helping to avoid it, was not in terms of them as WCB claimants, but under the capacity of the WCB’s employer-sponsored health plan. Is that right?
Mr. Bogyo: That is correct. We believe we must walk the walk and we do believe in disability management. We believe in return-to-work. We believe that work is a valuable part of everyone's life, and if we believe in wellness, whether it is work related or non-work related, we want to model that. We are doing it as a good employer, but also because it reflects our values at workers' compensation.
The Chairman: I assume you have a private insurer of some kind from whom you buy a policy.
Mr. Bogyo: We do for the long-term disability payments, but we have our own return-to-work staff who work with our employees regardless of whether it is work-related or non-work-related injuries; and we do get both. We have our own wellness program, which is run by our human resources department. We have our own fitness program, which is run by volunteers from our own staff.
The Chairman: You self-fund your own short-term disability program? It is not insured?
Mr. Bogyo: It is all self-funded. Our insured program is a third-party administered flow-through cost.
Senator Pépin: I see you have a prevention program, you have different programs like — I will read it in English — mental wellness, intellectual wellness, spiritual wellness. I also see that you have a program in the schools in collaboration with the Ministry of Education. I would really like you to elaborate on it a little because it seems quite interesting.
Mr. Bogyo: This is a very interesting area, and one that we are very proud to be involved in. We believe that the next generation of workers needs to be safe, to have the right attitudes, the right beliefs regarding safety and prevention. With the Ministry of Education, from kindergarten right through to graduation, we have integrated into the curriculum programs about workplace safety and safety generally.
I would be very happy to send the committee one of our resource books, particularly for the high school group, but this is not unique in Canada. In Prince Edward Island they use a mascot called Stella the Safety Skunk, because "Getting Hurt Really Stinks!" The idea is to focus children from the earliest stage on the idea of safety and prevention. In British Columbia we have introduced a character called Work Safe Sam, who is a cuddly individual, wears a hard hat and looks a bit like a smurf. He now comes to parades and events to try to make the idea of safety more attractive and accessible to children and families. We believe it is society that has to change attitudes, in the same way that your report speaks about society changing attitudes towards mental illness and addiction.
Senator Pépin: They start in kindergarten, which I think is great, because they become aware of what they should do and things like that at an early age. I would like to see a copy of it.
Mr. Bogyo: I would be happy to send the committee some of our resources for the kindergarten through high school program.
The Chairman: That will be very helpful.
Senator Gill: I just want to know if this program applies to First Nations people.
Mr. Bogyo: Does the program apply to them? The education program?
Senator Gill: Education and the others, the compensation?
Mr. Bogyo: The education and the compensation programs apply to First Nations people as well. They are covered by workers' compensation. We get claims from that sector. We work with local bands. Some of our offices are located in areas where there is a high concentration of First Nations individuals, and our prevention officers, adjudicators and rehabilitation officers develop a relationship with the band to help workers get back to work and to prevent injuries.
Senator Gill: That means you are on reserve and off reserve?
Mr. Bogyo: Yes, some on-reserve employment is covered. It is not excluded.
The Chairman: In winding up, I will make three or four points on the basis of what you said and ask you if I am right or wrong. Number one is that, by and large, the increasing rate of mental illness among Canadians is not covered by WCB, simply because WCB was never meant to cover anything except on-the-job injuries. As you pointed out from the Oregon and California data, expanding WCB coverage to include all forms of mental illness, particularly stress-related illness, would have a significant economic impact. That would indicate that if this committee is to look at changing the system for helping people with these kinds of problems, we have to look elsewhere than the WCB, because of the economic implications and because it is a much broader employer question than simply an on-the-job issue.
That then indicates that we need to look in some detail at what various employers are doing to help their employees deal with occupational stress. Is that a reasonable conclusion?
Mr. Bogyo: I think that is a very reasonable conclusion. I might add that I have heard others propose that programs and services be available from collectives of employers, because we are dealing with a lot of small employers who do not have access to these services. If there was infrastructure in place, clearly that would have the benefit of creating a healthier workforce.
The Chairman: Right. That would not be a classic group plan, which is for a group of employees of a single employer; you would have a group plan where the group was a collection of employers.
Mr. Bogyo: That is a proposal I have heard. Again, it is beyond our scope.
The Chairman: I am still struck by the Australian data. If you could let us know where you got that number, I would love to get as much detail behind it as possible.
Mr. Bogyo: It comes from two sources. One is a press report from Australia; I would be happy to send the actual clipping to the committee. I believe there was also a presentation in Australia that my colleague, the vice-president of review and investigations, Roberta Ellis, attended about a month ago. I will see if I can get any additional data on that.
The Chairman: That would be great. My last question is, since the Canadian act covers many of the things that the provincial acts do not, have you seen any data on the cost of the Canadian plan? There would not be any data on Canada, I would guess, because everyone assumed that the provincial statute set the terms, so there would be very few claims under the Canadian act. Is that correct?
Mr. Bogyo: I think that would be true. It would be very difficult to isolate the actual costs of the claims from Canadian data. If you did, perhaps it would be shaded because of the perception that the Government Employees Compensation Act was no broader than the workers' compensation act of a given province.
The Chairman: In our other study, on the physical care, hospital-doctor system, we found that the Australian data are pretty comparable to Canada’s, not in absolute dollars, but in terms of percentages of various claims and the federal-provincial split, or the federal-state split in their case.
Thank you very much for coming. I appreciate you coming all the way from the West Coast; you were very helpful.
Mr. Bogyo: Thank you very much.
The Chairman: The next panel of witnesses is from the Canadian Medical Association, the Canadian Psychiatric Association and the Canadian Paediatric Society.
We have Dr. Albert Schumacher, President of the Canadian Medical Association; Dr. Blake Woodside, President of the Canadian Psychiatric Association; and Dr. Diane Sacks, past president of the Canadian Paediatric Society, who appeared before us in the early stages of this study. We will ask the witnesses to make their opening statement and then we will turn to questions to the panel as a whole.
Dr. Diane Sacks, Past President, Canadian Paediatric Society: Thank you, it is good to be back.
I would like to say that there are a tremendous number of positives about the work that this committee has done, and I have been following it closely. However, I would waste my time here if all I did was pat you on the back and say "Bravo." Indeed, you did not ask for that.
I address you as immediate past president of the Canadian Paediatric Society. Our society represents about 2,000 people, almost all of the country's pediatricians and many of our country's hospital-based pediatricians.
Pediatrics is a developmental and preventive health specialty whose practitioners spend four years after medical school focusing on infant, child and adolescent conditions. Many spend a large part of their consultant and primary care time addressing mental health issues. We are perfectly situated to rule out physical conditions that mimic psychiatric disorders and to follow medical treatments instituted by our colleagues in child and adolescent psychiatry. Our expertise in developmental and behavioural norms is a bonus, yet pediatricians are often ignored in provincial plans organized to address the mental health problems of children and adolescents.
The greatest omission in the work that I see is that it fails to stress the reality that most of the mental health disorders affecting Canadians today begin in childhood and adolescence. Failure to recognize this fact leads us to dealing with a stage-four cancer, often with major secondary effects, instead of a stage-one or stage-two disease. Like obesity, mental health issues, if not addressed early in life, threaten to bankrupt our health care system.
It also neglects the success of current approaches that are already in place in communities being practiced by child developmental, behavioural and health experts. Pediatricians, psychologists, social workers and pediatric nurse practitioners, with collaboration from schools, family doctors and our colleagues in child and adolescent psychiatry, screen, identify and can successfully treat these conditions and some of the disorders that we worry about up to 70 per cent of the time. Lack of support for these approaches is dooming them to failure.
The society has submitted a response to the committee's report, some of which I would wish to elaborate on. It is positive to recognize that children and adolescents with mental health disorders are in fact "the orphan's orphan." Recognizing that the majority of adolescent mental health disorders — depression, anxiety, ADD, LD — being scientifically genetic in origin, begin in our young and do not go away, it is vital to take the next step. We should target youth identification and treatment. Child and adolescent disease should be understood as the precursor of adult disorders, and not stand alone as an orphan. It should in fact be a priority.
It is positive to recognize that services need to be involved in the school system. The next step is to recognize that we are now able to offer available, inexpensive, easy-to-apply and validated tools for identifying many of these disorders in children. These tools need to be utilized in a high risk, definable population identified within the school system.
What is this population? These are the children who are frequently absent, failing or dropping out. They need to be tagged and automatically screened for mental health disorders. We do not need to wait until they are in prisons to test them and find out, as they did in the U.S., that up to 80 per cent of prison residents have diagnosable conditions.
It is imperative that family doctors be taught to identify and tag for screening all children of parents with these disorders. Ministries of education need to be included in provincial mental health strategies. We need to recognize that services need to be community based; and in doing so, we need to recognize that treatments are done in communities, many by experts, many of whom are already in place and can, with educational support and appropriate remuneration, address these problems.
The current situation does not recognize the available professionals who are already working effectively on these disorders. It leads us to the problem of inequitable access in the community.
We have to recognize that many of the experts and known successful treatments are currently available only to those who can pay. Those experts based in hospitals or clinics often have waiting lists over a year long. That, in fact, is the current wait list for OHIP-covered anxiety treatment at the Hospital for Sick Children.
New funding for regulated health professionals willing to work with these children and their families needs to be made available. The shortage of pediatricians initiating and following medical treatment, as well as other treatments of mild to moderate cases, and the extreme shortage of child and adolescent psychiatrists to help with the most difficult cases, especially in rural areas, also makes accessibility anything but equitable.
We need to recognize, as you did in your report, that an adolescent suicide crisis exists today in Canada. As well, we have to recognize that diagnosing adolescent depression, which is the foremost precursor of adolescent suicide, is possible today, and medical and psychotherapeutic treatments are known to be effective in up to 60 per cent of cases. A study produced in the United States was concurrent with their statistics showing suicide rates in the United States have dramatically dropped with some of these therapies.
Therefore, as noted in the reports, Canada needs a national strategy to address mental health issues. We must recognize how much public support there is for national action in this area, especially if it aims at helping our young. Huge numbers of families affected by mental health issues feel isolated and desperate, and with lack of screening and diagnosis, parents often think they are failing. Most families with adults with these disorders realize that their loved ones have been ill since childhood and wish they had known what was going on.
We recommend a national institute of mental health. We need that institute to conduct a high-profile public education campaign. We need to coordinate and support initiatives that are currently under way, eliminating duplication or, worse, the neglect of successful programs. We need to oversee funding into research on new therapies and innovative ways to collaborate with our child and adolescent psychiatric colleagues and institute special educational grants to increase the number of professionals doing this work.
This institute needs to support pharmacological research in children and youth in this area. Lack of drug testing in pediatrics makes these patients the orphan's orphan, so federal drug regulators must be included. We need the institute to coordinate the organized sharing of programs that are working across the country through regular meetings and to disseminate this information and new research through supported publications. Such a plan could facilitate the sharing of information on these conditions in a timely way to help to avoid the recent fiascos of recalling or black-boxing medications without warning to front-line workers, so patients simply stop their medications without notice.
The committee needs to understand that failure to address problems of mental health disorders at the beginning, before years of isolation, failure and social dysfunction, leads to self-medication with drugs and alcohol, bullying behaviours, low self-esteem, other antisocial behaviour and, all too often, unfortunately, suicide. As well, we need to educate and remunerate professionals so that they can work effectively in this area and to ensure that they are accessible to all. We need to remember that there are many people working in this area who are experts in the field, but because of lack of organization and communication, they are not working to their fullest potential.
Dr. Albert Schumacher, President, Canadian Medical Association: Honourable senators, the Canadian Medical Association is pleased to appear before this committee once again and highlight the critical need to address mental health issues, mental illness and addiction in this country. As you are aware from our previous appearance, we made a series of recommendations to the federal government and we stand by those today. Since then, your committee has released its report on mental health, mental illness and addiction programs and policies in the country and the associated issues in the Options paper, which is comprehensive and a thorough study of both the programs and the services. Your report contains the scope and breadth of all the concerns related to mental health and mental illness.
In that context, the CMA is focusing on the role of the federal government in the areas of leadership, accessibility, accountability and availability. As we move forward, we believe that an unprecedented level of federal leadership and intergovernmental collaboration is necessary to address the epidemic of mental health problems and addictions in this country. A first step to achieving this would be to create an adequate resource, a centre for mental health within Health Canada led by an associate deputy minister. This ADM would initiate and coordinate activity across all federal departments to address federal government responsibilities to specific populations under its direct jurisdiction. That would include federal employees, Aboriginals and veterans.
The ADM would also oversee pan-Canadian policies and programs that impact on mental health, mental illness and addiction and that support the intergovernmental collaboration. This would accomplish two objectives: It would send the message that the federal government seriously intends to address the historical imbalance in the treatment of mental health and illness care and would ensure that mental health, mental illness and addiction are not seen as separate from the health care system but as a component of acute care, chronic care and public health services. In terms of equitable availability, the federal, provincial and territorial governments must take a holistic approach, recognizing the interplay of health services, education, housing, income, community and the justice system in mental health and mental health care. The recent $3.2-million major health research initiative aimed at improving mental health in the workplace announced recently by the Minister of Health, and the appointment of the Hon. Michael Wilson as special adviser, is a demonstration of the leadership required.
Let us talk about accessibility, which is the number one concern of patients and their families about the health care system. This is particularly true for access to mental health and addiction services and programs. The CMA has long identified accessibility as an essential issue that must be addressed in order to improve the health care system. In the National Physician Survey released in 2004, we found that 65 per cent of physicians rated access to psychiatrists as fair or poor on a national basis. However, it must be recognized that it is not only an issue of accessibility but also one of availability. Many important mental health and addiction services cannot be accessed by patients because the services are simply not available. In my hometown of Windsor, Ontario, the reorganization of health care services has resulted in a decrease in the number of acute and long-term psychiatric beds. While the population base in Essex County requires 35 psychiatrists, we have only 12. We borrow two pediatric psychiatrists for a few days each month because we do not have our own in town, let alone the five that we actually need. Our children wait up to one year for care from the local youth services program. I know that you will agree with me that this is not acceptable.
In September 2004, the CMA released a national plan of action to address the issues of accessibility, availability and sustainability across the entire health care system. This plan for better access and better health includes recommendations such as establishing pan-Canadian wait-time benchmarks, a health human resource reinvestment fund, expansion of the continuum of care and an increase in the federal core funding commitments, all of which would have a positive impact on the access to mental health and addiction services. As noted in this report, availability is first and foremost about the people who provide quality care and the tools and the infrastructure that they need to do so.
Mental health and illness depend upon integrated and interdisciplinary care from a variety of health care providers. The shortage of family physicians, specialists, nurses, psychologists and other professionals in the public health system impacts our ability to deliver the care and the services. Therefore, in terms of addressing accessibility and availability, the CMA believes priority has to be given to the establishment of a national health human resource strategy to find a solution to the chronic shortage of health professionals.
I will touch on accountability. Since 2000, the first ministers and their governments have committed to reporting on numerous comparable indicators on health status, health outcomes and quality of services. Unfortunately, mental illness, despite a critical need, has received little attention in all of these reports. Of the 70 indicators that have been developed, only two directly address mental illness.
Those are potential years of life lost due to suicide and the prevalence of depression.
Also, no performance indicators related to mental health outcomes or wait times for mental health services have been included. This is yet another example of how mental illnesses and related issues are overlooked and a vicious cycle is created, since the lack of indicators makes it harder to present the case for greater attention.
Therefore, the CMA strongly supports setting national standards and targets on both resourcing and availability of mental health services and addiction treatments. The objective of these targets is to reduce the burden of mental illness, but it has to be understood that the standards and targets cannot be established until we have a clear and accurate picture of the current situation in the country. Pan-Canadian research is needed to determine the gaps in the availability of services and the wait time for accessing services across the country.
In conclusion, the Canadian Medical Association believes that in terms of the federal role in enhancing the delivery of mental health services in Canada, priority should be given to, first, establishing a strong federal office for mental health, mental illness and addiction to coordinate and collaborate on issues of accessibility and availability; second, the federal government, working with the provinces and territories, needs to develop a health human resource strategy for the field of mental health, mental illness and addiction; and third, create standards and targets to enhance the mental health system and make it more accountable to patients and the public.
In short, we need to do for mental health what we have done for public health. While SARS was the wake-up call that precipitated action in public health, the need for urgent action in mental health is no less. As a final point, I want to again stress the need for an effective, national public awareness strategy to reduce the stigma associated with mental illness and addictions in Canadian society. Until we address that stigma, too many Canadians will not seek the care they need. Those who do will continue to experience societal ignorance and prejudice.
Dr. Blake Woodside, President, Canadian Psychiatric Association: Mr. Chair and senators, I am a psychiatrist. I am chairman of the board of the Canadian Psychiatric Association. The CPA represents the approximately 4,000 psychiatrists who practice in Canada. Psychiatrists are medical doctors who then receive additional training in the field of psychiatry and whose practice involves caring for those with mental illness.
It is a pleasure to have another opportunity to address the committee as it continues its important work in the area of mental health in Canada. The Canadian Psychiatric Association has valued and continues to value the opportunity to participate in this process. The association, as do the others, wishes to commend the committee for the leadership role it has taken. The preliminary report is a comprehensive document and clearly sets us on a specific road for a specific journey. I will come back to that. From our perspective, we are already seeing signs that the work of the committee is starting to have an effect. There appears to be an enhanced awareness of the importance of mental health as a national policy issue, an awareness that has spread all the way to the federal minister, who has been very open recently to identifying the mental health of Canadians as an important national priority.
I am also pleased to see that the medical community is coming together in a more focused manner in our various roles in improving the quality of mental health care for Canadians. If the committee achieved nothing else, that would be significant. Trying to get physicians organized is like herding cats. You have done a good job in that regard.
I have with me copies of a more detailed list of our recommendations for the committee. For the purposes of this short presentation, I would like to focus on a subset of these recommendations. I do not want to repeat what the other speakers have said. I will group these recommendations along a theme. The recommendations all focus on the role of the federal government in the ongoing development of the mental health systems.
In your preliminary report, it struck all of us at the CPA that you were calling for Canadians to embark on a journey to create a new system of care for those with mental illness in this country. I thought that, in commenting on our recommendations, I would create that metaphor, if you like, and frame them in terms of how you actually get from A to B.
The first thing that occurs to us is that if you are planning to take a journey, it is probably helpful to know where you want to get to. In terms of where you want to get to, the federal government has an important role in policy development. The federal government’s role in policy development needs to be strengthened. This would involve the government taking a much larger role in helping to focus national policy development in mental health and to facilitate the development of national standards for the reduction of mortality and morbidity caused by mental health problems.
Dr. Schumacher has commented on issues like setting standards for wait times. In my own practice, I run a treatment program for the most severely ill people with anorexia nervosa. When I left the office this morning at about 10:30, there were 25 people on that waiting list. I will admit the twenty-fifth person in about September. That person weighs 72 pounds. When I presented to this committee last March, I had 30 people on my waiting list. In April, we closed my waiting list. That meant that we refused to see new patients. We are the sole service provider for all of Ontario except for Ottawa. When we got a referral for somebody who weighed 60 pounds, we told them we could not even see them in consultation. We cleared the waiting list. It took till the end of August. We opened it up again, and here we were six months later with almost the same waiting list as we had this time last year, and I anticipate closing the waiting list again by the end of April or the middle of May.
Over the last 12 months, the Government of Ontario has spent $4.5 million to send 33 people to the United States to receive treatment for anorexia nervosa. I am very glad those people got treatment. Many of them were on my waiting list. Over the last year, I treated 45 people with anorexia nervosa for $900,000. The government paid five times the cost for 33 patients. That is the chaos that exists in this country in the mental health system. You have documented that beautifully. I do not have to tell you that. I know that is preaching to the converted.
We recommend the creation of a mental health and services division as a policy arm within Health Canada to focus on these policy issues. The role of this division would be to try to achieve the goals that I set out above on helping to focus a national policy discussion around mental health. That is separate from the mental health agency that the CMA is recommending, which we support as well.
If I continue on the journey theme, even if you decide where you want to go, if you do not know where you are starting from, it is hard to get there. There is an acute need for increased surveillance in the area of mental health. The most pressing needs, in our opinion, fall into three areas. The first is prevalence. We need to know more about who is ill and with what. The Canadian Community Health Study was a wonderful start, but it is only a start. The second is access to services. Who is getting what? What are the patterns of access? We still do not know enough about that. The third is the status of the human capital in mental health. In mental health, our most treasured resources are human resources, the people who provide care one on one to those with mental illness. We do not have big machines or fancy diagnostic tests. We have people talking to people. We need to be able to identify the human health resources required to meet the needs of the population. There has to be a population-needs-based assessment, and then we need to figure out how we will train those people to do the job they need to do.
We agree with the Canadian Medical Association that we should create a mental health centre. Where it is located exactly is a matter for discussion. The purpose of the mental health centre or the mental health agency is to coordinate these surveillance activities. We would suggest it be affiliated with a public health agency because the activities of such a centre would overlap with the activities of the public health agency.
The third point is that, when you are on a journey, sometimes you get lost, and you have to come up with some new ideas about how to get to where you want to be. We think innovation will be required as the country grapples with how to reorganize the mental health system. We will need constant innovation. We would most certainly recommend that targeted funding for the neurosciences and addiction institute be provided for research in the models of service delivery and knowledge transfer. It is not so much the generation of new scientific knowledge. That is important, and that is already funded. This is new funding to focus on research into how you deliver care to people who are mentally ill and how you translate new scientific knowledge into clinical advances.
The last comment about our journey is we would like to take the entire Canadian public with us. That speaks to the issues of stigma and discrimination and the need for increased public awareness. Frankly, we think the federal government's responsibility, or the way in which the federal government can provide leadership in that area, is to figure out how to coordinate and provide funding primarily for non-governmental organizations that represent families, affected individuals and so on, to increase public awareness around mental illness.
We think there should be some coordination, possibly through the mental health centre, of funding approaches among Health Canada, the public health agency and Social Development Canada.
Members of the committee, we have other recommendations that I will not take a lot of time to talk about now. I will be happy to take questions later. We are often asked, "Where would you start?" We would agree with our colleagues at the Canadian Paediatric Society that children are a good place to start. We have a long series of recommendations about health human resources in mental health, particularly as it relates to psychiatrists. At this point, I will stop and be happy to take questions from members of the committee.
Audience Member: I am disabled and crippled. I cannot come next time because I am in too much pain when I sit here. Dr. Woodside, I will email you. I am a non-violent activist, and electroshock therapy is going to go in Canada because we have a steering committee and my freedoms are what are at stake. We will send emails to all the senators in the U.S. and also in Canada to stop this barbaric treatment called electroshock therapy. I am not a violent person, but as you know, I am an activist, I have integrity and I will always speak out for my peers who have been brain damaged by electroshock therapy. The truth does not come out from the APA or CPA.
I gave a presentation in 1993. The Canadian Psychological Association invited me with Dr. Brendan, an expert on electroshock and a psychiatrist in the States. He said electroshock always causes brain damage, and it does. You still continue to give electroshock therapy, and I have permanent memory loss, diagnosed in 1995. I had no memory loss before 1972. Electroshock is a crime against humanity.
I shall leave. I am sorry, all senators and people present, but I must speak the truth. Whether you put me on camera or not, I had to say this in front you. In the next few years, electroshock therapy is going to go. Go to B-R-E-G-G-I-N dot com, he has been speaking out for 30 years, a psychiatrist, and he is being listened to. That is all I will say. That is my integrity speaking to you, and I will not shut up for the truth.
The Chairman: Thank you.
Audience Member: Whether you shut me off CPAC, I do not care. You will hear my name, Sue Clark, psychiatric survivor and advocate who will stop electroshock therapy, because it is going to go. It brain damages people. Look on the Internet at B-R-E-G-G-I-N dot com. He has been speaking out for 30 years and psychiatrists like you do not tell the truth. It will be done. I am angry because it still continues. One in 200 people die from electroshock. You can go into a coma, and 14,000 electroshocks are done in Ontario, 100,000 in the U.S. yearly and 1 to 2 million worldwide.
The Chairman: Thank you, ma'am.
Audience Member: Dr. Woodside, shame on you for not stopping electroshock, shame on you.
The Chairman: Thank you, ma'am.
I wonder if I could ask each of the witnesses about a couple of items where I would like some more information.
Dr. Sacks, you suggested a national institute of mental health. I am not looking for an answer now; this is something you can send to us. Similar recommendations have come from many people. It is something that we obviously would like to think about. To the extent that you can flesh it out and tells us specifically what you would see as its mandate, it would be very helpful.
Secondly, these ideas have been floated elsewhere, and we need all the additional details you can give us. On the issue of national screening programs or developing screening tools for children, particularly for use in schools, we would love to know if anything like that exists. I happen to know of one pilot project in one school in Kingston. If there have been any pilot projects on which we could get the information, it would be helpful.
The third issue that other witnesses have raised with us deals with the way schools are handling children with ADD or ADHD where you have a child in a class of, say, 35, particularly in elementary school, who is disruptive. The evidence is anecdotal, but it seems to suggest that the standard response to that problem is to give the child Ritalin. It does not necessarily treat the child, it treats the symptoms, and that in turn solves the teacher's problem and the other students' problem, but does not deal with the issue.
Again, you may want to comment on that after the question period, but I would love to know the extent to which that anecdotal evidence that several people have commented on is real, or is it just that we happened to run into some people where that was the case in classes that their students are in?
Dr. Schumacher, on your proposal for a national centre for mental health, to the extent that you can flesh out the details, not necessarily today, it would be helpful to us. You might comment on the issue because we have heard some people say it should be in Health Canada and other people say it should be in the public health agency. Dr. Woodside suggested a public health agency. The CMA may very well say that is an organizational issue for the federal government. I would love to know on which side of that you would come down.
Dr. Woodside, the statistics that you gave us about your own practice are just staggering. We know this intellectually, but it is quite different when an individual tells us that he has had to close his practice. It is one thing to be told that the HR situation is desperate, but when it is put to you in terms of the kind of numbers you gave, it is just staggering. I thank you for that example. You pointed out in your written document that the society is preparing a much more detailed response. We look forward to that. I thank all of you for your presentations.
Senator Keon: We thank all three of you for coming here. There is no debate about the magnitude of the problem, and there certainly is no debate about the need for a solution. It seems to be some way off. Certainly we need a mental health strategy like other developed countries have. Perhaps rolling out of that are some of the ideas that you have come with today, whether it be a national mental health centre or an institute. Where that will fit with the CIHR and the combined neurological mental health institute has to be defined also and sifted through.
I will ask all three of you a question in the context of medical manpower. We need much more than medical manpower to solve this situation, but in the context of medical manpower, medical services and the mosaic of our federal/provincial health arrangements, where do you see the mix? Where do you see the interface between the psychiatrists, the specialists, the specialty institutions, the in-between people, the specialties such as the pediatricians, the internists and so forth, and the people on the ground in primary care? My perception is that if we are to reach the 70 per cent of people who are not being serviced in mental health now, we will need a huge development in primary care to provide the access. Let me try to focus for you, because this is a unique opportunity.
Dr. Woodside, please answer first, followed in order by Dr. Sacks and Dr. Schumacher.
Dr. Woodside: Thank you, Senator Keon. Increased cooperation between psychiatrists and primary care practitioners is critical. We have been engaged in a shared care project with that focus for 10 years. Recently, the Primary Health Care Transition Fund provided funding to the CPA and the College of Family Physicians for a collaborative care project to assist in the development of shared care projects. We are hoping that the federal government will provide funding for a second phase of that project. That is critical work. Having said that, there is a major shortage of family doctors in this country; and there is a major shortage of psychiatrists in this country. Trying to restructure the mental health system by offloading mental health care from psychiatrists to family doctors is like rearranging the deckchairs on the Titanic. Obviously there have to be cooperative mechanisms whereby psychiatrists perform functions that only they can, and other kinds of health care practitioners, family doctors, nurse practitioners, psychologists, social workers, and so on, provide additional services that do not require the expense of a psychiatrist. Currently, we work in such teams. As a professional, I do not think we have much turf to protect. I work on a 20-person multidisciplinary team with eight disciplines. We are not trying to chase other people out of the business of mental health. Most of the disciplines in the community are not funded. They are private services, so you have to pay out of pocket and access becomes a huge issue. Yes, we very much look forward to continuing to develop collaborative relationships with primary care and other health disciplines. There are not enough practitioners in any of those disciplines to simply transfer or offload the existing work at this time. There are shortages in all of those disciplines right across the board.
Dr. Sacks: I was pleasantly surprised, although I know about the shortage of psychiatrists in the country, to hear that there are 4,000 of them. There are 365 child and adolescent psychiatrists in the country. Pediatricians have been trained to do developmental and behavioural screening. Currently, the vast majority of community pediatricians, and many who are based in hospitals, are doing a great deal of screening and diagnosing and are initiating treatment of these conditions for the mild and moderate cases in children.
Fortunately, we have collaborative programs in many of our major cities and some of the small towns. I travel with a child psychiatrist up to Orillia, Ontario, with a population of 25,000. We collaborate with them and they help us with the difficult cases. There are so few that sometimes they cannot see those cases. We are working on that. I would like to say that pediatricians are trained to deal with mild and moderate cases of mental illness in children and adolescents and to help their families. Most of our referrals from family doctors are related to behavioural and mental health issues. Most of them suffer from attention deficit disorder, ADD. They have been tossed out of school and end up in my office. Certainly, depression and anxiety are the major problems being treated now.
I have been on two North American-based task forces with family practice colleagues and psychiatrists and have screening tools available for adolescent depression and ADD, as well as attention deficit and hyperactivity disorder, ADHD. These are to be taught to primary care physicians who are willing to learn and to take up the charge.
Thanks to an Ontario health study and the late Dr. Dan Orford, we have the numbers on children with the major psychiatric diseases. Although it was done in the late 1990s, it is likely still valid. We have a great deal of information and I become a little frustrated when we regress to square one. We know the numbers, and in many cases we have reasonable treatments for these conditions, some of which are medical, some psychotherapeutic and some a combination of the two. I think pediatricians are ready to move forward on this; we have only to be brought onto the team. That happens in many cases, but not often enough.
Dr. Schumacher: Senator, you talked about a mix. That would occur in an ideal world where the professional might not be certain of the exact problem, so would send the patient to the pediatrician to look at the developmental side and to the psychiatrist to look at the mental illness side. In the ideal world that would happen. However, the problem is that we often do not have one or the other. Pediatricians are burdened with providing a disproportionate amount of psychiatric services, especially in my community. Second opinions do not occur much these days. That choice does not exist in most areas. Rather, a patient or a family is content to have someone with more letters after their name see the patient within a reasonable time. As a professional, I am happy to do the hard work, but I need to try various options for treatment for the next six months and then send them back if certain things result. However, if I have to wait for four or five months, in some cases involving an emergency admission due to arrest, it is likely that the situation has spiralled out of control and I do not have that opportunity. We were trained that way in the hospitals, where we once had all the mixes. Out in the community, that no longer exists. You get one and you have to be happy with that; and hopefully, it is the right one from the beginning.
Senator Keon: They are no longer in the hospitals either, so it is a question of how one begins to develop this mix. Some kind of plan must evolve, even if it is not perfect from the outset. There will have to be a kind of structural framework to develop a system and provide the appropriate personnel for the interface.
Dr. Schumacher: We have been missing a re-entry point in the system for physicians to receive additional training. I am not talking about returning to school for an additional four- or five-year fellowship. There are probably enough people with an interest in this area of work such that they could take additional training for one year while supported as a resident and be integrated into the system. I think that many people would be interested in doing that. However, we have not had a structure for postgraduate training in the country, and it should be available.
Senator Pépin: I will ask about working on a new structure and having a coordinator who might be a doctor, a social worker or other expert in the field of mental health. Do you envision the new structure in that way?
Dr. Woodside: There is a myth that most psychiatrists work alone in an office, but that is not true. Most psychiatrists work in hospitals or clinics. We have been developing multidisciplinary teams such as you describe for about 40 years. Our present ability to develop multidisciplinary teams is totally maxed out. We have done as much of it as possible. To do more, you would have to provide funding to pay the psychologist or the social worker, et cetera, because there is no money to pay for them. You would have to train those people. In family medicine, we have existing structures via our shared care initiative. We have 250 sites across the country that are part of a national registry of arrangements between family doctors and psychiatrists for collaborative care. We would love to do more of that, but we need funding to support the psychiatrists. Most of it involves the psychiatrists going to the family practice clinic to help the family doctors in their offices. We need funding to pay the psychiatrists to do that because it is not a billable service.
We need more family doctors so that there are more places for us to go. We need more psychiatrists so that we can send them to more family doctors’ offices. There are structures and models in place for collaborative teamwork. It is what we do, it is how we have spread ourselves so thinly thus far, but we are like too little butter on too much bread. There are five people in Ontario who treat patients with anorexia nervosa. How thinly can you spread me?
Senator Keon: It is a rather unique opportunity.
I will propose something to you that I talked about yesterday in Toronto. There are at the community level multidisciplinary care clinics where the mentally ill can gain access without any stigma by virtue of going to the same clinic that someone with a broken leg goes to. These clinics are properly placed geographically, properly resourced, linked with the secondary and tertiary care institutions and appropriately linked with psychiatric facilities and so forth; and of course there will have to be money to pay the psychologists who are not paid now. I have lived with that in my own institution, where people had to pay for their psychological counselling because the in-house psychologist was overwhelmed. Therefore, the only thing a person could do was go downtown and pay out of his own pocket.
If we are planning to expand these services by this enormous 70 per cent, which seems to be needed, we have to start at the community level. It will require pediatricians and internists. Also, it will require the assistance of psychiatrists, but the community level comes first. I want you to tell me if I am wrong.
Dr. Schumacher: One of the good signs, if you look at the agreement just reached between the doctors in Ontario and the government, is the government will now reward comprehensive care physicians, whether they are solo practitioners or in a family health group or network. They will give bonuses for taking care of seriously mentally ill patients, people with schizophrenia or bipolar illness. They do not have to be offering all the mental illness services, people can be taken care of by a psychiatrist as well, but if they are seeing a patient like that on a regular basis, some of whom frequently miss appointments, have a lot of admissions and other things going on, they receive a bonus. If they are taking care of five, they get a $1,000 bonus. If they are taking care of 10 or more, they get a $2,000 bonus. It is actually the first time an incentive has been put in place so these seriously challenged individuals can have the stability of having a family doctor at the centre of their care. It has been a very positive sign to many of us who offer that kind of comprehensive care. I have 11 patients who qualify. I was excited about that, because this is difficult work. However, I was very pleased. It is a step in the right direction. Would I like to see other services made available? I would love to see, on a shared, rotational basis, the use of social workers, psychologists, whoever else we can get. Unfortunately, the only place in the community where there are services is in hospitals, where they have global funding or some other alternate payment system. It does not exist outside the walls of the hospital or the virtual hospital.
The Chairman: This says a lot about the need to change the funding mechanism, but that is a different issue.
Dr. Woodside: I was intending to provide Dr. Keon with a metaphor that he can explain to the rest of the committee later. Dr. Keon is a cardiac surgeon. You could probably reduce a bypass operation to one or two actions that you had to perform, like sewing the grafts, and have other people do the other things. You can envisage a system where you went from operating room to operating room and all you did was sew the grafts. Maybe if there were a dozen dedicated operating rooms, you could do a lot of cardiac bypass surgery. However, what you start with is one day a week to do operations, instead of 12 running flat out to make maximum use of your time as a cardiac surgeon. That is where we are at with mental health right now. We are like you the cardiac surgeon with one day a week of operating time, and to maximize that, we would need 12 operating rooms running around the clock. That is the magnitude of the resource shortfall right across the system.
Dr. Sacks: I wanted to add something to Dr. Keon's comments about community-based systems. One of the additional reasons those are essential in Canada is our multiculturalism. Certainly in pediatrics, I see kids brought in whose families describe behaviour that I would not recognize necessarily as mental illness, but it is, just from a different culture. If we do not go out into the communities with community and cultural specialists, we will miss this entire group, and then we will be back where I am afraid we are now, with a group of new immigrant kids and adolescents who have been missed because we did not recognize their disorders. Therefore, we have to go to the community for a number of reasons, as my colleagues have stated, but also for kids that we will miss for cultural reasons.
Dr. Isra Levy, Chief Medical Officer and Director, Office for Public Health, Canadian Medical Association: Thank you. There was a space problem at the start, so I did not join you until later.
I did want to pick up on your last question, Senator Keon. The issue of community, the local level, links right back to your original question, Senator Kirby, about this mental health centre that we are thinking and talking about.
The enormity of the challenge and the multi-dimensional complexity will make it difficult to bring a federal solution to bear on a local issue, perhaps here more than anywhere else. What is underpinning all of the presentations, and I know has underpinned your interim report, is an awareness that at the clinical interface for this particular set of medical and health problems, these are issues that require enormous sensitivity. We see people in tremendous pain, and that pain manifests in a number of ways, anger being one of them, and we have all just witnessed that.
You ask how, at the clinical interface, you can help at the local level with pain that manifests in unusual ways in a structural system. It might seem odd that we bring that solution around and say, "Well, open a centre in the federal government." However, there is logic to that, which is found in our call for strong leadership, notwithstanding the well-articulated needs for increased human resources and, obviously, for ongoing and increased training at the front lines for existing personnel. The other role that the federal government can play so clearly here is the leadership role. It is a leadership role that can be played within the federal government, a cleaning-up your own backyard situation, which calls for both inspirational political leadership and an administrative gravitas, adequately resourced wherever you put it, whether in Health Canada, an independent entity or the agency. Our thinking has evolved into a belief that you probably need to put that in Health Canada, because at its core, these are health issues. However, one needs to think about mechanisms whereby that can be resourced and structured in a way that will allow cross-department and sector coordination at the federal level as well as effective leadership through the provincial and territorial level to the local level.
I think that comes back then not only to recognizing the appropriateness of positioning it at the local level, but also to the rationale for a federal centre, probably located within an entity like Health Canada right at a senior management level, twinned with strong political leadership.
The Chairman: Thank you, Dr. Levy.
Senator Cordy: It is obvious that you have all done so much work before you came here. Your recommendations are very helpful to us.
My question is for Dr. Sacks. When you were speaking about children and mental health issues, you said if we do not address the situation early, it can lead to things like anxiety, depression, suicide, bullying and low self-esteem.
In society today, there is a lot of pressure on the school system to deal with bullying because of the increase in violence in society. Many schools systems have developed a policy of zero tolerance for bullying. While that may, in the short term, appease the parents because the bully is punished and, in many cases, removed from the school situation, it really does nothing for the child who has the problem.
I am wondering, first, how you feel about zero tolerance for bullying. Second, you cannot talk about the child in isolation. You have to talk about the family, and you mentioned that the family, the parents, need help. I used to be an elementary schoolteacher. Certainly, many parents and many families are in crisis.
As a teacher within the school system, very often you felt that you were outside the loop. How do we engage the school system to help these children? When I talk about engaging the school system, I am not talking about the school psychologist, who may have responsibility for 10 or 15 schools, or sometimes more, within the system. I am talking about engaging the teachers who are dealing with the children on a day-to-day basis.
Dr. Sacks: Those are big problems and issues but they are all very addressable. For one, in any new institute, the boards of education need to be included. I note B.C. has a wonderful new system for dealing with the mental health problems of children, and they have included physicians, nurses and psychologists. They have not included education.
Any of the screening tools that I am aware of — and I helped develop some of them — have been addressed to kids who are identified at school. These are kids who, for some reason, are not doing well. Certainly, you can have a school psychologist look for a learning disorder, but we need as a society to look for other reasons these kids are failing in school.
It is interesting to see whether they are absent all the time or they are not doing what they should be doing. You can identify and pick up early anxiety, certainly by the age of six, seven or eight, and a little later on, in young adolescents, depression. The teacher needs only to identify that this kid is not learning and I have tried my best.
In terms of the bullies, it is interesting that the bully has some issues, but not the ones that we necessarily think of. However, the person being bullied almost always has anxiety or depression or some other issues. Bullies pick on the vulnerable. Both of those need to be addressed.
The school does not have the resources to do anything now but send them home; and no one is home, often, so that is a disaster. That does not help anyone, not even the school, because it has not taught anyone a lesson about how to deal with it. Schools need to be taught; and part of the job of this institute would be education of the people involved with children and adolescents. They need to be taught that certain things are not allowed in this school society. Everyone at that school, whether they have been bullied or not, needs to be identified and the school has to change its society.
What we need is coordination. We need to include teachers because, as far as I am concerned, they are the vital ones, not parents. First of all, they spend more time with the child than the parents, and interaction is when kids' illnesses often are displayed. Therefore, it is more likely that illness in children and adolescents will be picked up in the school society. We need to teach the teachers how to identify that this child needs some screening. It could be put on a report card.
Having worked in pediatrics for 30 years, I spent the first 20 trying to tell people who insisted on getting the next kind of X-ray that the tummy ache was not due to a stomach tumour. Whether it is because of the media or whatever, that has changed in many cases. Now I have to fight to try to get a physical test because the mother is so sure it is anxiety. They come in ready to accept some of these diagnoses. We have made some steps forward.
That is the public support we would have for these conditions, which I think is already there. I do not know who did the work, maybe the psychiatrists and other people, but I think it is available. However, the school must be included in early identification of these kids who are going on to become adults with mental disorders.
The Chairman: Can I ask a follow-up question to that? How do you get around the problem? First of all, you mentioned school psychologists; in a great many school boards across this country they have vanished as a part of budget cuts. The speech therapists who used to exist have been reduced dramatically, also the school psychologists and so on.
How do you get around the following problem? In effect, what you have is diagnosis of a medical condition by a teacher, at least a diagnosis in the sense that there is a problem. Let us suppose you go to the next step whereby, in some sense, the student will receive some help. At that point, am I not correct that you almost have to cut the teacher out again because the privacy laws make it almost impossible for the person who is treating the patient — whether it is a GP, paediatrician, psychiatrist or whatever — to talk to the teacher or the family about what really needs to happen? Am I correct that the collegial, multidisciplinary treatment that would be required is difficult to offer because of privacy laws?
Dr. Sacks: Not really, with the cooperation of the family. Pediatricians spend a lot of time at schools talking to teachers about what is going on with patients who come to them. As you mentioned, I get scribbled letters from teachers saying this child is out of control, give him something.
The Chairman: Just get rid of the problem.
Dr. Sacks: That is right. In fact, if we do diagnose a problem that needs to be addressed with the cooperation of the school, we need the teachers on board. By the way, Ritalin is prescribed in this country in about the same percentage number as the kids that we would estimate have ADD or ADHD. It looks as if it is being poured out like water. It is not.
The Chairman: My comment was a different one. To what extent does simply giving Ritalin and doing nothing else merely quiet the disruptive student down and solve the teacher's problem, but not the student's problem?
Dr. Sacks: I hate to tell you the answer to that because you will not like it. Attention deficit disorder is a chemical disorder, genetic in origin, which responds in about 70-plus per cent of cases to pharmacological therapy. The truth is that I never treat a child unless I have cooperation on behavioural changes at home and at school — that the teacher will place this kid in a certain place, that she will cue him to pay attention, that she will help me with the use of the medication.
It is like diet medication. No matter how many diet pills you take, if you want that chocolate cake, it is going in. As much Ritalin or stimulant medication as I give, unless it is supported by behavioural treatments at home and structure at school, it will not work as effectively as it can.
The Chairman: You are able to talk to the teachers and the privacy law is not an issue.
Dr. Sacks: With permission from the parent, and most of the time, in the school situation, on that particular issue, ADD, it is okay. They sometimes have more difficulty talking about some of the other psychiatric diagnoses.
Dr. Woodside: Just to follow up on privacy, the PIPEDA legislation, which for everyone else is a huge shock, is similar to the law about mental health information that has been in place for 20 or 30 years. We have worked under a PIPEDA-like system for decades.
The Chairman: Would you clarify what PIPEDA is for the television audience, please?
Dr. Woodside: PIPEDA is the privacy legislation. The restrictions have been in place for mental health information for ages. We have already established our multidisciplinary and collaborative teamwork arrangements under strictures that are about as extreme as the new privacy legislation. We get along with that fine.
Establishing provincial, regional or district networks where mental health information is part of a comprehensive medical record probably will be impossible under the new privacy legislation, but inside a clinic or a family practice, a single group, we get on fine with very tight constraints on mental health information.
Dr. Levy: You have correctly identified a problem, particularly for the non-institutional setting. The barriers to multidisciplinary work in the community context are indeed significant. The best way to deal with that, given the realities of and the good reasons for the constraints, is to bring it back to de-stigmatization efforts. The nub of the solution is in consent. In my experience, the reason for consent being denied is invariably fear of discrimination at some other level. Again, it does not seem like a direct answer to the question, but in a strange way, the privacy issues go away when the stigma issues go away.
The Chairman: In essence, Dr. Woodside's comment, that psychiatrists dealing with mental illness have been under stricter privacy rules for a longer time than the rest of the medical profession, is a clear indication of the stigma. The reality is that people who had a physical illness felt less need to hide it. It is not that they did not want privacy, but clearly if someone found out about it, they could live with it. If someone found out they had a mental problem, that was quite a different order of magnitude, and I suspect that is the origin of the fact that your rules were different.
Senator Cook: To help you understand the context of my questions, I should tell you I come from the province of Newfoundland and Labrador. The problems there are the same as in other parts of Canada, but the resources, people like you, are very thin. The province has one tertiary care hospital. When I hear about clusters and primary care and all of those things, how I wish we had those resources. Given where we are, the impossible will take a little longer to achieve.
I want to look at structure, because if we intend to begin on a journey, we need to do that. Dr. Woodside recommended that a mental health centre be housed within the public health agency, and Dr. Schumacher mentioned a centre for mental health within Health Canada. I want you to think of that in the context of where I live, with 500,000 people, which is equivalent to just a small corner of the Greater Toronto area. I can see that as a positive for my province.
I want to go a step further. Last year, the people who govern this land signed a 10-year health accord, so we have to work within the parameters of that. We will be moving forward in what I would call trying to put a quart into a pint bottle. Addressing the needs we are hearing about here will challenge the best of us. I am interested in hearing if you would support dedicated funding for this centre so that within public health or Health Canada, you do not have to fight for the money that you need to do the jobs that need to be done.
I will leave the structure for a moment and go on to the human resources that are necessary to deal with the issue. We are looking at a long time, probably 10 years. Is there an opportunity here for federal bursary programs? Should we be looking at not only a curriculum for medical schools but also extra training for nurse practitioners? Do we do it through telemedicine? Are we looking at a curriculum for teachers so they can recognize issues before it is too late? Where are we with all those bits and pieces?
Ideally, a cluster means a group of learned people who can take care of the total person. For my province, that is a dream that will take a long time to become reality. Nevertheless, I think we should strive to do it. We talk about sociologists. We talk about psychologists. We know what the funding is under the Canada Health Act and medicare. Some of those people are outside of that jurisdiction. We need to offer a seamless delivery that treats the total person.
Those are the challenges that we have to look at here first, and if we are to start, Dr. Sacks, yes, let us start at the beginning. Let us start with our children. Let us get this right. In the meantime, we have to maintain the status quo.
I heard you talk about your anorexia nervosa wait list. I experienced a young person's life being turned around with the aid of a dietician and a psychologist who was writing her master’s on eating disorders. Because of dedicated people like you, that life was turned around.
While we aim for the ideal, I would like to hear you say what is possible now, and how we can work together in the present environment. I hear that 70 per cent of family physicians have not had a lot of training, if any, in mental health issues. I do not know if that is so or not. As we move forward, I think we have to do so from a human resource perspective. What can we offer in the current system, whether teleconferencing, telemedicine, consulting, to enable my province to have a mobile cluster of learned people so all the pieces might work? I would like to hear your opinions.
The Chairman: That is a good range of questions.
Dr. Woodside: The answer to the question, Senator Cook, is yes. You are right. It will take a long time. If we never start, we will never get there. One of the disadvantages for a province the size of Newfoundland and Labrador is that there is a lot of space and not many people. There is no fish, and maybe there is oil and maybe there is not. There is a resource problem. The advantage is that you can think about it. It is a size that you can actually comprehend in your head. If you ask me to solve the problem in Toronto, my head will explode trying to think about it. It is too big and complicated a problem. If you asked me to consult with people in Newfoundland and Labrador for a year to develop a mental health system that will suit that province, I could probably do that because it is small enough.
Some of the things you propose as a committee may, initially, in fact be more suited to most of the space in this country, the relatively sparsely populated rural areas and smaller communities, because people can think about that.
All of the things that you describe will be part of the solution, and that will be different for Labrador than for Prince Edward Island, Nova Scotia or Newfoundland. As Dr. Keon indicated, you will start at the community level and state that this is the goal. This is what we want to provide for the population, what we want people to have access to. Here is a basket of things that might help. They may be useful strategies.
Let us have you help us design a strategy that will work for your community. It will work best where people can think about it rather than being overwhelmed by the magnitude of the problem.
Dr. Schumacher: First, let me reassure you about medical education. The curriculum is already pretty chock full. While you are right that formal training in geriatrics might be only 1 per cent, and formal training in pediatrics might be 1 per cent, the reality is from the first day in medical school, 30 per cent of our contacts are with seniors and 30 per cent of our contacts are with paediatric patients because they see physicians disproportionately more than others. Therefore, while the absolute training and textbook time might be less, the reality of the experience is that we have daily contact with those kinds of people.
The same is true for mental illness, where 30 per cent of the encounters I have as a family doctor have some emotional component to them. That is just the way it is. If you are not good at it from day one, you will be pretty good at it by day five.
I wish to touch again on screening. It is one of the most important things we can do better right away. One of the most useful acts in my office is to remove the stigmatism attached to this. I have this nice little coloured card in every examining room that just sits there. I try to keep the examining room fairly uncluttered. It displays the different types of symptoms of depression. It makes up two words. It has "sad" and "faces" with an "I" in between. Each letter stand for one of the symptoms, whether it is a problem with sleep, increased or decreased appetite. The last one is "thinking about suicide." It will sit there and people will look at it while they are waiting. They will indicate that they are scoring about 6 out of 9 on that one. It removes the stigmatism attached to the idea of mental health because it is there for them to look at. It is the same as if I have another poster there. You would be offended if I started to ask you about your risk for AIDS. However, if I have a poster in the waiting room that asks questions about HIV, you are likely to walk in and ask questions, such as what is the big deal with HIV, and we can start the conversation. That is one of the easiest ways we can do that. Every physician's office is a safe place to talk about mental illness.
Where should this centre be located? I think it has to be in Health Canada. I do not think we can have one building for somatic and physical illness and a separate building for mental illness. The two have to go hand in hand. The person in charge has to be in the middle of everything. We have to adequately treat and assess mental illness within the federal government first. If we cannot bring the resources into Ottawa or other big centres that need psychologists, social workers, and integrate everything in a place where people have reasonable benefit plans, then where in the country can we? Therefore, as much as we need to start at the beginning, we also need to pick the low-hanging fruit. The federal civil service is the low-hanging fruit. If we want to get to a group in a really good way, let us go there first and use that as a shining example.
The Chairman: Dr. Sacks, do you have any comments?
Dr. Sacks: I appreciate that Newfoundland is different from Ontario, but I envision a national institute as being a place where we can collaborate and inform. At the annual meeting of the Canadian Paediatric Association, it is wonderful to hear what other people are doing. I wish I had known. I am one of the reviewers of the institute of child centres of excellence. I get many proposals for research. I am amazed how people 200 kilometres away do not know that someone else is trying to research something very similar to what they are doing. We certainly need a place where we can increase collaboration. They are both good projects, why cannot they work on it together?
Dr. Woodside: Just a brief supplementary comment. There is no solution where one size fits all, and that is where the federal government comes in. It sets a standard, such as nobody should wait more than 30 days after their depression is diagnosed to receive treatment. Those from Newfoundland and Labrador will say, "How will we do that?" People from Health Canada will say, "Here are 200 great ideas. Which ones do you think will be helpful for you?"
Senator Dyck: I am from Saskatchewan. As you may know, in Saskatchewan we have what I call a brown baby boom. We have a very large and growing population and we are predicting than in about 25 years, 50 per cent of the children within the public system will be Aboriginal. Therefore, in terms of pediatrics and the incidence of any medical illness, it would represent a significant challenge.
My question relates to screening. You were saying you have screening tools available. I am wondering if they would be as reliable in an Aboriginal population as they would in a Caucasian population. As an Aboriginal person, I get a little nervous about tagging. When you were talking about different cultural populations, you mentioned that you were worried that you might be missing certain mental illnesses in the new immigrant population. My fear is the exact opposite. You might be picking up things that really are not mental illness.
Dr. Sacks: Those are very important issues. The Canadian Paediatric Association has a First Nations and Inuit committee, and in May we will be having a First Nations and Inuit summit on the major issues of this group. It will include a strong bias toward mental health issues. As you know, the degree of adolescent alcoholism and suicide in this population is absolutely untenable. It is just a national disgrace. The present screening tools will have to be modified with the help of our First Nations and Inuit colleagues.
In fact, that is one of the major goals of the summit, to pick out these circumstances.
I used the word "tag" and I knew that it would get people's back up. However, if we can help people, then we should tag them, because we know it will not go away and we know what happens if they are not treated. If we cannot help because we do not have the tools, and that may be true of the cultural population that we see, then there is no reason to tag. In fact, it can be dangerous. However, I think, certainly with the help of colleagues and working together, we will develop those tools quite easily. The tools that have been developed are certainly multicultural from the standpoint of many of the cultures that we are seeing in Canada now, but not the Aboriginal culture, you are right.
Dr. Woodside: The purpose of screening is to identify individuals who require further assessment. The purpose of screening is not diagnosis. I will just translate your comments to another field. If we accept your reasoning, we should not do screening Pap smears on women because some women will be falsely identified as possibly having cervical cancer, and we could not have that, could we? The purpose of screening is to pick up the kids who are at risk and do a thorough assessment on them to decide whether they have a depression or not. In mental health, under-diagnosis is the problem, not over-diagnosis. The screening should not stigmatize anybody. Neither should the diagnosis. The screening is to figure out who needs more attention.
We screen across the entire practice of medicine, and I think this is a table where people are pro-mental health; we think about our own attitudes. Maybe we should not screen because people might be defined as at risk when they do not have the illness. We would not think like that in any other area of health care, not a single one, because it is so important to identify the people who are suffering and offer them treatment.
The Chairman: The stigma makes people very reluctant at times.
Dr. Schumacher: If we look at the Aboriginal community as a whole and not specifically the pediatric community, that community carries a greater burden of chronic illnesses, diabetes being one of them. One of the things we have learned in general medicine is that when men have heart attacks, within a year 50 per cent of them will suffer from clinical depression. That is so high that you should think about intervening with everybody who has had a heart attack or bypass surgery. Retrospectively, we should probably have been putting all of Dr. Keon's patients on anti-depressants right in the hospital. The same applies to rheumatoid arthritis, the same applies to diabetes.
We are more cognizant of the fact that those people have a much higher risk of depression than others. You have to be much more proactive. You cannot passively let the sign that says "ask me about depression" sit there. You have to get in there and ask those questions. If we are identifying the populations at risk, yes, we will ask those questions more often, for good reason, as part of the screen and because we have paid attention. We have ignored cardiac illness in women for too long. We have underplayed their symptoms. We have underplayed them in other situations. This extra attention on the part of health care providers is not a bad thing; it is probably a good thing.
Senator Dyck: The difference in screening adult women is that they are adults, and it is done in private. A screening that is done in a school system is on children, and if it is done in a more private way so they are not stigmatized, and if the tagging does not then become a label, that is a better situation. Going back to your example of education, if there is a system in place whereby it is seen as a normal practice and not as segregation or labelling or tagging, it would make a difference.
Senator Fairbairn: Dr. Woodside spoke of the importance of public awareness. I noticed that there is reference to that in the documents. From the perspective of this committee, the issue of federal funding, how and where, would be a very important one.
It seems to me that this is crucial in getting to where you want to go. In a sense, it is also one of the most difficult things to do. It is fair to say that some of the media now spend a lot more time writing about mental illness and the various incidents that happen in communities. Very often, it is after the fact, and it is a tragedy. I am thinking of how much public awareness has been generated, for instance, through television, the Internet and everything else. I am thinking particularly of some of the ads that are put out. I believe there is federal funding for some of them. I think of smoking. A woman who was a waitress here in Ottawa has gone onto the airwaves and personally across this country to say she is dying of lung cancer because of second-hand smoke, never having smoked a day in her life. It is a powerful personal message. There are others that have to do with alcohol and, of course, driving, and what alcohol does to families.
It would seem to me that this is such a huge issue, such a personal issue. All of our systems always need pressure in order to produce, and pressure ultimately has to come from the public. This is something that should be high on your list, and I suppose you would want to know more, and this committee certainly would, about how you can present that to the people whom you want to fund it. Mental Health Awareness Week is great, but it is a week. This is something on which you want to be consistent. Could you give us some suggestions, because this is certainly within the realm of a federal responsibility? Also, perhaps tell us, in your discussions with, be it Health Canada or some other part of government, what kind of reaction you have had from people in public life, whether it is federal, provincial or whatever, to taking this on as a cause. You mentioned children, start with children, because by the time people get into adulthood, the situation is not just worse for the individual, it is also worse for the public purse because it goes on and on. To me, it is a very critical part of the equation in moving this issue toward greater understanding and greater action. I am wondering if you see a spark of success anywhere along the line, or even promise in some of the discussions that you may have had with people in government.
Dr. Woodside: Someone has to take the lead. We are willing to help. We think there is a role for the federal government as well. You commented on the woman who is going across the country dying from cancer very publicly. Forty years ago she probably would not have admitted that she had cancer. She would have felt too badly about that. Attitudes do change over time.
The federal government can say, "It is okay to have a mental illness, it is okay to come forward, you deserve treatment; we are making this a priority and we will tell everyone that the needs of this segment of the population have been neglected and now have to be addressed." That is an important step in allowing people to feel more comfortable abut saying, "I guess I do need some help." Most people with mental illness know they are ill. They are not in denial about that. There are exceptions, but most people know they are sick. There are advocacy groups, but their funding is a patchwork. We are suggesting that the mental health agency, however it might be constituted, perhaps have a coordinating role to help fund or organize financial support for non-governmental advocacy groups, family groups, consumer groups and so on. It is possible to generate consensus among these groups.
CPA is part of a group called CAMIMH. We held a summit two or three years ago with 27 national mental health advocacy groups. We were able to agree on a five-point plan to make a start on reforming the mental health system. There are things that people agree on. The federal government needs to help. It needs to make public statements about how important this is, so that the other people who are attempting to advocate about increased awareness, about the importance of treating those with mental illnesses, do not feel they are just left hanging. That is why we advocate strongly for the federal government to take a leading role in assisting in both funding public awareness directly and coordinating funding efforts for other non-governmental advocacy groups in the mental health area.
If there is a consolidated effort over a long time, it will be like cancer. Thirty or forty years from now there will be someone going across the country talking about their bipolar disease, or whatever. It will take time. It is worth the effort. We know how to do it. We have done it with other illnesses.
Senator Fairbairn: In your discussions with government, what has the response been?
Dr. Schumacher: The response, unfortunately, has not been the $800 million that was invested in Aboriginal health and not the $800 million that was invested in public health. You need a big number like that to make an impact on a national issue that is as prevalent as this one.
It has been tackled with some very small budget diversions, not any kind of substantial investment that the federal government has recently made in other areas. It is very important. When the five priority areas for wait-list times, on reducing wait times for heart, hip, knee and cataract surgeries, were announced, one of the first things that Dr. Woodside and I said was, "Where was mental health?" As far as we were concerned, although it might not be number one on the list, it is at least number six. This should be recognized. We have to do everything we can to ensure that psychiatric mental health and other services receive the same level of respect that cardiac surgery receives. Unfortunately, being a cardiac surgeon is on a par with being an astronaut; it is very cool. There are no fancy shows about psychiatrists. There was Frazier, but few others where the psychiatrist was the coolest person. We need to change that societal perception.
Dr. Sacks: I think most of the psychiatrists I know are very cool. Senator Fairbairn, you quoted me, although I am not sure that you were here for my presentation. Much of what you said I agree with. In respect of advertisements, we supply medical information education to give people the knowledge. That is the first step. That will eventually help them change their attitude toward the subject and then they will change their behaviour. I feel the same way about the governments we are talking to about this issue. We need to teach them that we can identify these people and provide some positive treatments. We have to teach governments. Your reports are doing that in a way that we professionals could never do. Governments must know that we are able to not only screen and diagnose, but also to provide positive treatments. That will change governments’ attitude toward mental health and, hopefully, open their pocketbooks. We are willing to wait, although I am afraid our patients are not willing to wait, and may not be able to wait.
Dr. Levy: Social marketing and attitudinal changes are a big part of the difference that you can make. It takes big-ticket dollars to do this. There is also the structural issue. When you ask about the response we receive from government on this issue, it is difficult to identify which bureaucrat is at what level in the government. Occasionally, individuals show up who are dedicated people working in very diluted structures. If the federal-provincial-territorial network was not literally disbanded back in 1990, it was effectively disbanded. At every level, you cannot identify people within government with whom to speak. When you do, they are dedicated, committed and extraordinarily frustrated because they are working within systems that create roadblocks to policy relevance.
Senator Fairbairn: When it comes to the issue of public awareness and using all of the opportunities to communicate the messages, you will probably have to address this at the political level because the direction to get something done will come from there. The message has to be communicated so people can learn, understand, feel better and be encouraged to come forward to seek help.
I will not beat the drum any further, but in this age, visual messages that can be sent to millions of people stand a fairly good chance of connecting on this difficult issue in a way that we have not known before. Perhaps it would be a good idea to address the issue using someone in the communications business. We are conscious of the issue and we will do the best we can.
The Chairman: I want to thank our panel of witnesses and give them a homework assignment. As we look at this problem, there are a couple of things that strike us in comparison to the physical health system: The mental health system is in much greater disarray than the physical health system, and with much less momentum behind it. I have two requests. First, the committee does not like to produce reports that have no impact. Our previous report is beginning to have an impact across the system, as you know. Your three organizations could help substantially by giving us a list of between five and ten specific, concrete things that could be done within 18 months of the release of the report. That could create the momentum. Many of our recommendations will take time to implement, and clearly we do not have the necessary $800 million. I will not argue that the money is not needed, obviously. My concern is that it is so easy, because of the stigma and other issues, for government to wait us out, that the more concrete and specific you can be with your recommendations, the more we could get moving on this. We would have specifics to speak to rather than the non-specific, less tangible wish-list.
Second, assuming that we use those lists to generate initial momentum, what do we put in place to ensure that this issue does not vanish for another 20 years in the way that it has in the past? There is a real risk of that. The committee genuinely appreciates the positive comments made by all of you about our work to date. However, there is the risk that we could finish this and after three months, it could disappear. Some of us are bound and determined to do our damnedest to ensure that that does not happen. You could help the committee greatly by telling us what the baby steps are to start us down that road and how we can maintain the momentum. If you can give us that by September, or any time before, that would be helpful to the committee. For all of the reasons you have talked about, the collective resistance within the system is enormous.
I have a final comment to Dr. Levy. Do not feel badly about not being able to find the people in the federal government responsible for mental health. We did a search and our best result was one and one-half person years in an 8,000-person department, so the odds were against it.
The Chairman: The first of our three witnesses on the next panel, continuing our hearings on mental illness and addiction, is Ms. Christine Davis, President of the Canadian Federation of Mental Health Nurses. We have heard from the Canadian Nurses Association repeatedly over the years, so we are delighted that the Canadian Federation of Mental Health Nurses is here tonight. With her is Penelope Marrett, who is the Chief Executive Officer of the Canadian Mental Health Association, and Mr. John Arnett, the new President of the Canadian Psychological Association. We had your predecessor with us a number of times in the past.
Ms. Christine Davis, President, Canadian Federation of Mental Health Nurses, Canadian Nurses Association: My name is Christine Davis and, as Senator Kirby mentioned, I am the President of the Canadian Federation of Mental Health Nurses, which is the national voice of registered nurses working in the area of mental health, mental illness and addictions. I want to note that as of 2003, there were 12,016 registered nurses working in the area of mental health, mental illness and addictions across the country.
I would like to take this opportunity to congratulate the committee for its forward thinking in addressing such a critical issue for my fellow nurses and for Canada as a whole. Mental health, mental illness and addictions are specialty areas of health care, employing a significant proportion of the total pool of registered nurses in various settings in communities, hospitals, prisons, homeless shelters and on the street. To leave more time for dialogue, I will take this opportunity to highlight a few key points rather go through our entire written brief.
For the most part, patients cannot access one program without having first dealt with issues related to another. For too many, treatment is limited to one ailment at a time. Just as patients are asked to address one issue per visit in walk-in clinics, so is the care of mental health issues approached in a segregated manner. Unfortunately, it would seem that holistic approaches are few and far between.
There are, however, pockets of service integration across the country. For example, in British Columbia, the Ministry of Health Services has brought the mental health and addictions programs together at the ministerial level, and this is actually being implemented across the province in the health authorities. As we know, primary health team approaches also bring together teams of professionals who are able to deal with the whole person and all their needs.
The issue of waiting lists became politically hot during the last election. This led to federal, provincial and territorial agreement to reduce waiting lists in five priority areas. We are concerned that mental illness and addiction was not viewed as one of those priorities.
The Canadian Mental Health Association stated that as of July 2003, 1,500 mentally ill and addicted people remain on the streets in Ottawa because there are no services for them. Once on a wait list for community mental health services, the waiting period is from three to five years. Of the 175 people waiting for community mental health services in Ottawa, 50 per cent have attempted suicide.
The lack of service is a huge issue across the country. That some patients/clients and their families have to wait for services imposes costs on employers, communities, patients/clients and their families. There is a need for a tertiary service to support the patients/clients and their families while they are waiting to receive ongoing service.
Nurses can provide solutions to the lack of services for those affected by mental illness and addictions. For example, expanding the role of public health nurses in schools would facilitate early detection and intervention. I would add that this would be a return to a role that public health nurses used to play.
Too often, we approach illnesses through acute care. Nurses believe that more emphasis on prevention would benefit society not only from a perspective of overall good mental health, but would relieve pressures related to lack of acute care services. School nurses would identify the problems early on, directing the child concerned to the appropriate services.
By increasing telehealth services, nurses can respond to the needs of those in rural and remote areas of Canada. Tele-mental health can provide initial relief to a crisis situation before it leads to negative consequences such as we have seen in rural communities.
With proper training, nurses within the prison environment could play a more active role in the area of mental health assessments, evidence-based practice and long-term care of the inmate with mental health issues. Too often, people are incarcerated because of the lack of forensic beds. If nurses providing physical care were supported to perform mental health assessments and treatments, there would be less pressure on forensic institutions and more chance that persons within the justice system affected by mental illness could be directed toward care sooner.
Occupational health nurses manage programs to create healthier workplaces, employee health and firm-level productivity. We know that a high level of absenteeism in the workplace relates to mental health issues. Occupational health nurses managing wellness programs may be able to address issues before they result in costly absenteeism.
Innovative models that include nurse practitioners as part of community mental health services need implementation and/or replication. Nurse practitioners with particular expertise in the area of mental health and addictions are an integral resource for a multidisciplinary mental health system, a resource currently not used to its full potential.
As part of the solution, the federation strongly supports a pan-Canadian mental illness/mental health strategy. As part of this strategy, the federation believes there is also a need for an education campaign among health professionals. There is a generalized discomfort and lack of knowledge about mental health, mental illness and addictions throughout the system of providers. This has a direct impact on our patients.
To wrap up my presentation, I would like to address the key areas in which the federal government can demonstrate leadership. The federal government must play a role in making the connections between the social determinants of health and the promotion of mental health for children, youth, their families and adults.
The federal government must play a key role in ensuring services and education in the area of mental health, mental illness and addictions are available, and that it is a priority across this country. Merely turning funds over to provinces will not ensure that patients/clients and their families will see any improvement in service.
The federal government must ensure that every Canadian has shelter or a roof over their head. Housing is protection from illness. Housing is protection from the vagaries of mental illness, from the voices, from the fears. The federal government must address the lack of affordable housing. I have only touched on the tip of the iceberg here, and I would be pleased to answer your questions when my colleagues are finished.
Ms. Penelope Marrett, Chief Executive Officer, Canadian Mental Health Association: Good evening. My name is Penny Marrett and I am the CEO of the Canadian Mental Health Association, Canada's only voluntary charitable organization that deals with both mental health and mental illness. Our mandate is to promote the mental health of the people of Canada and to support the recovery and resilience of people with mental illness. The work being done by the committee is extremely important, and the association wishes to congratulate the committee on the work done thus far. The three reports provide an excellent base from which to continue this critical effort.
Supporting and ensuring the good mental health of the people of Canada has never been as high a priority for the Government of Canada as ensuring accurate diagnosis and availability of treatments and services for other medical conditions such as cancer, cardiovascular disease, diabetes or HIV/AIDS. Too often referred to as the health system's poor cousin, mental health and mental illness concerns are often sidelined. Mental health and mental illness have been neglected in Canada for far too long. At least one in five people is directly affected by mental illness during their lifetime. Indirectly, it affects millions of Canadians who are involved with loved ones, friends, colleagues and neighbours who have a mental illness. At the same time, good mental health is critical to everyone's well-being.
[Translation]
For two years now, the Canadian Mental Health Association has been managing a project that has involved its participants in the process of developing a framework for a mental health policy. The document entitled "Citizens for Mental Health" offers a mechanism for discussing the impact of the social factors of health on mental health policy. Two decisive factors, identified as a priority by Canadians across the country, are housing and income support.
Today, we would like to focus on those two issues. Research on housing has shown that 30 percent of homeless persons suffer from mental illness. Approximately 75,000 homeless single women suffer from mental illness. Mentally ill persons who are housed by others often have an unsanitary living environment. Between 1980 and 2000, the number of affordable housing units created by the federal government declined from 24,000 to 940.
[English]
As David Hulchanski has rightly stated, the lack of affordable housing for the people of Canada cuts off significant numbers of Canadians from supportive communities, from access to employment and, indeed, from the exercise of their citizenship rights. Try to get a job when you do not have an address.
Quite apart from the morality of the situation, this represents an enormous waste of human potential in this country, with serious consequences for the community at large. Therefore, the Canadian Mental Health Association strongly urges this committee to recommend, as part of the federal government's commitment to affordable housing, that funds be allocated for the following: 20,000 new housing units, 10,000 units of rehabilitated housing, $300 million to ramp up the Affordable Housing Framework Agreement, $150 million for homeless initiatives, and $500 million over the next five years for a new housing rehabilitation fund.
[Translation]
Our second major concern is income security. Health is dependent on income security. As our colleagues have already said, income security is really a key factor in the mental health of our communities. Low-income Canadians are more vulnerable in health terms. Over the years, research has shown that chronic conditions are more widespread in the poorer regions of Canada. Approximately 15 percent of children and young persons — that is one in seven — experience mental health problems serious enough to have an impact on their development and functioning. The children of poor families are more prone than the children of high-income families to suffer from low self-esteem, related mental problems and disorders and exclusion from cultural and athletic activities.
[English]
Issues related to the working poor are also of concern. The National Council of Welfare's 1993 report underlined a sharp decline in the value of minimum wages since 1976 and the trend towards part-time, precarious and temporary work instead of well-paid, secure jobs. The result of the diminishing minimum wage is that minimum wage workers could not reach the 1998 poverty line by working 40 hours a week, even if they were without dependents. We could go on and list many other examples.
The Canadian Mental Health Association strongly urges this committee to recommend the federal government address limitations of income security programs as they impact the people of Canada and their mental health and mental illness. More detailed information about this is contained in our formal submission to the committee.
In conclusion, despite a healthy, highly competitive Canadian economy, we still face high levels of homelessness, household debt, child poverty, diminishing health care services and the exclusion of many segments of Canadian society from a quality of life that should be expected in a country as rich as ours.
[Translation]
So as to better distribute the impact of this economic growth, the Government of Canada must show leadership and make a major investment in affordable housing and improve income security for all Canadians. The government must also ensure that the social fabric of the country continues to develop and respond to citizens through various initiatives, including strengthening the voluntary and community sector.
[English]
Mr. John Arnett, President, Canadian Psychological Association: I am very pleased to be here to represent the association. In my day job, I am also a professor and head of the Department of Clinical Health Psychology, University of Manitoba. This is my evening job, obviously.
CPA agrees with the committee's basic vision that mental health and addiction services should be of high quality, individualized, and well integrated with other health services. We also agree that the care delivery system should be focused on the specific needs of the individual, with the goal being recovery to the fullest extent possible. In addition to being patient centred and focused on recovery, we would suggest that the vision should also strongly emphasize illness prevention as an integral component of the program. We appreciate the committee's recognition of the strong influence that a wide range of factors plays in mental health, mental illness and addiction as outlined in report 1, and that many of these factors extend well beyond the traditional realm of the health care system per se. This very fact leads to the conclusion that mental health, mental illness and addiction are best approached from a broadly based population health perspective.
It is also true that mental health issues are important not only in relation to mental health conditions, but also in relation to physical illnesses, as we are continuing to learn. Thus, we need to build on the prevailing biomedical model in order to provide the best possible and most comprehensive care to Canadians.
Dr. George Engel, an internist by training, recognized that the traditional distinction between mental health and physical health was, at best, arbitrary, as each strongly affects the other. In 1977, he proposed the need for a new model, the bio-psycho-social model, to more comprehensively integrate the biological, psychological and social factors that are so important not only in mental health but in all illness.
Given that a model tends to shape our perception of circumstances, it substantially influences how and what services we seek to construct, be they in mental health or in physical health. Dr. Engel’s biopsychosocial model fits nicely with the population health approach advanced by this committee. It also provides a conceptual framework that diminishes the factors that support and maintain separate physical and mental health silos, about which this committee has also spoken, and that tend to divide rather than integrate health care. The biopsychosocial model brings mental health into the mainstream of health and thereby provides an important tool to diminish the stigma about which I spoke to this committee some time ago. This is a significant impediment to securing better care for all Canadians with mental health problems.
We also need to ensure that the research agenda is broadly based, not only in concept, but also in the actual disbursement of grant funding. A brief review of the CIHR grants disbursed in January 2005 suggests there is still a need for improvement in this regard.
Canadians with mental health and addiction problems should have greater access to a wider range of clinical services and service providers than is now available with existing funding under current legislation. At present, for example, most psychological services that people require are provided in the private rather than the public sector, and are therefore primarily available to Canadians of some financial means. Unemployed and underinsured or uninsured Canadians have little or no access to needed psychological services. Furthermore, we believe that access to these services will likely worsen in the future without an appropriate legislative remedy. This is particularly troubling with regard to services for Aboriginal populations, children and adolescents, elderly Canadians and individuals who live in rural areas, as well as services in the schools and criminal justice systems, where there is an exceptionally high demand.
This committee, as well as the Health Council of Canada, has expressed concern about the shortages of human resources in health care. We believe that this is indeed a serious problem. With psychology now having the dubious distinction of being one of the health professions with an ageing practitioner base, excluding present company, we are particularly concerned about human resource and training issues. Institutional cutbacks in recent years due to budgetary restraints, particularly in Ontario, have resulted in the elimination of a significant number of psychology training positions. These decisions and actions that are quick to implement may take years to reverse when there is a recognition that this cutting has gone too far. Although understandable in terms of the economics of the moment, they will almost certainly lead to serious supply and access problems in the long run. In Ontario the present number of training positions has fallen below a level sufficient to fully train the required number of doctoral-level psychologists needed to meet present demand and replace those psychologists retiring and leaving practice. This situation can only exacerbate the current problems with access to psychological services for Canadians who need them.
We understand the intent underlying the committee's considerations relative to separate funding envelopes for mental health and addiction and a special charter attempting to guarantee improved access and financial parity with physical health care. However, we would ask the committee to further consider whether such a well-intentioned policy change could unintentionally lead to further entrenchment of the very silos that this committee has appropriately criticized and the continued separation of mental health and addiction services from primary health services.
The Chairman: I will ask you to think about something, and then we can come back to it. This is directed to you, Ms. Marrett. I do not disagree with you at all on the critical importance of the determinants of health, and you have talked specifically about various forms of affordable housing programs and income support programs. This is not disagreeing with that. We will not get $1 billion or more in the next 18 months to two years to throw at this issue. Recognizing the long-term goal is exactly what you have outlined it to be, how do we get manageable bite-sized items that we can begin to make some progress on? I will ask you to think about that. Mr. Arnett, just a clarification on your material. We absolutely understand the importance of the primary health services as the way 85 or 90 per cent of people will get into the system. We would never suggest creating a silo in that sense.
Here is the issue with which we wrestle: Every other country that has tried to do this has found that if you do not ring-fence new money, then the acute care system immediately swallows up most of it. It is a practical problem, and not a philosophical problem, of wanting to break down the silos, although frankly, even within the mental health area there are all kinds of silos. Secondly, how do you nevertheless ensure that if you do obtain new money and make changes, that it is not overwhelmed by the rest of the system? Any thoughts you have on that would be helpful.
Also, you commented on doctoral-level psychologists. I have always been under the impression — maybe they are the only ones I know — that a substantial amount of clinical work is done by master’s-level psychologists, or sometimes those with a master’s degree in social work, and not those with doctoral-level degrees. Is the supply of master’s-level psychologists dropping below the replacement rate, as you indicate the doctoral level is?
Thirdly, for Ms. Davis, you commented, and I took it as a favourable comment, on the creation in British Columbia of the Minister of State, or whatever the official title is, for Mental Health and Addictions, and in fact they have combined various things into a cross-sectoral program. I would love to know, either today or subsequently from you or your members who are involved with that program, what has made that work. It would be helpful for is to understand that. I say that because frequently in organizational changes, it turns out that the successful ingredient is the people rather than the organizational change per se. Therefore, if any of you want to comment on any of those three points, you can do it now or later.
Mr. Arnett: Just a comment on doctoral versus master’s degrees. Partly, it depends on where you are in the country. For example, in Quebec, the vast majority of psychologists are now master’s-level psychologists. However, if you look at the actual level of training, it is almost the equivalent of the doctoral level in terms of the requirements that have been added over the years.
The Chairman: Without the thesis.
Mr. Arnett: That is correct. They are now moving to eliminate the master’s program in Quebec because they recognize that the difference between that and the doctoral program is very small and the demands and requirements in terms of skill sets are increasing.
The Chairman: Except, just to argue the other side of that, it would be okay if you had a degree that did not involve spending the year and a half or two years doing the dissertation.
Mr. Arnett: You can move toward a professional degree, which is what they are doing.
The Chairman: It is a professional degree minus the dissertation.
Mr. Arnett: It is an important, interesting point, because it is not always minus the dissertation. The CPA board recently took a look at the requirements for the proposed Pys.D and one particular program in Quebec versus the Ph.D. It is hard to drive a wedge between the two programs.
The Chairman: Ms. Marrett, would you like to make a comment?
Ms. Marrett: I would like to answer it subsequent to the testimony because I would like to go back and speak to a couple of colleagues. I think there are some steps.
The Chairman: There have to be some steps. I am not being critical of you. Understand our dilemma here: If we do not give government something that allows them to start showing progress, it will be easy for them to say "It is another pie-in-the-sky social services study, so we are not doing it."
Ms. Marrett: One of the challenges is in the Affordable Housing Framework Agreement. If I recall, Mr. Ralph Goodale, during discussions on the budget, indicated there was approximately $500 million left in that agreement. It was not being used by the provinces. We consider that a serious issue and we need to find ways in which the federal government, the provinces and territories can work to ensure that blockage is removed. Ontario has not picked much of the monies. Therefore, in a sense, he has made a commitment that once that money is used up, more will be available. One of our challenges is we all need to work out how best to do that. That is a general comment, but I will come back to it.
Ms. Christine Davis: I would like to comment on what is happening in British Columbia. I have just come from Victoria. Mental health and addictions were put together at the ministerial level. I can tell you it was difficult. I worked in the Vancouver Island Health Authority at the time and people were presenting for service who had addiction problems, and they could not be treated in the mental health system until their addiction problems were treated. It created all kinds of chaos. People were being shuffled back and forth. The Vancouver Island Health Authority did all kinds of innovative things. They have, for instance, developed and built a sobering centre where people can come in off the street for up to 23 hours. They can be drunk, they can be stoned, they can be however they come, and they can stay there for 23 hours. If they need mental health services, then mental health personnel can go there to see them, or vice versa.
They have created a new psychiatric emergency service, which is right next to emergency. They are triaged from emergency into the psychiatric emergency. We had people there who worked in addictions who would do assessments, and we would do assessments together to see what people needed first and foremost; was it addictions counselling, or was it mental health services. There are all sorts of innovative things happening on the ground.
The Chairman: Is that a one-off? There are interesting, innovative things going on across the country. By the way, one of the things this business clearly lacks is one place in this country where you can go to find out what is working well on the ground. People come here and they tell us. We probably know more than many others because people from all over the country have given us great examples.
Senator Cochrane: I have a supplementary question on what Dr. Arnett was talking about. I am talking about Quebec now and the master’s program. If this program will be eliminated, will there not therefore be a void in Quebec while these people pursue higher education?
Mr. Arnett: No, because we are talking about the future production, not necessarily changing the requirements for people who are currently in the system. It is in the future. They will be moving to a Psy.D approach that will just add a little to the training that subsequent students will get. There will be no change in the levels.
Senator Cochrane: What happens to the ones who are already in the system?
Mr. Arnett: They will continue in the system. Some of them will choose to upgrade, although they do not need to do that. The key point here is that the master’s degree in Quebec means something different, and it is in many ways a higher standard to begin with. The difference between them and doctoral-level people in other places is not very great. It has grown that way over the years because they have added more and more requirements as they recognized that people needed more and more training. They have added so many requirements that they have virtually created a doctoral program.
Senator Cochrane: Is there a change in salary?
Mr. Arnett: I cannot answer that question. I am not positive.
Senator Keon: I find I am sticking with a theme with everyone who comes before us because I agree with the chairman that the expenditure we would be looking at to move services from covering 30 per cent of the population to 100 per cent would be enormous. We have to try to think about how we can do that gradually. Consequently, at one level we have to develop a structural framework or a national strategy for mental health. Then we have to move to the ground and look at the community, what resources have to go into the community to allow entry into the system and appropriate triage up the line, with, of course, continuity of care when people come back into the system. I was very pleased to hear what you had to say, Ms. Davis, about some of the innovative things that can be done when you get down to a reasonable level where you can make something work, change something.
The medical people were here before you, the specialists and the family physicians and the in-betweens, interns, pediatricians and so forth. I would like to glean from you what kind of unit you see in the community that could deal with mental health and the associated social problems as part of family medicine. In other words, help people find a job or an income or housing or whatever and deal with the emergencies that they encounter that are now being handled by police and other people who are doing the best they can; deal with the counselling services and psychological services, Dr. Arnett, that your folks have to offer.
Are you aware of any model that is working anywhere at this time? What kind of model do you see in the community that could integrate the specialized mental health system, the social system, so to speak, or the other components into the larger medical system? I would like all three of you to comment on that. I appreciate that I am putting you on the spot, and I do not at all suggest what you say has to be definitive. We are just groping around here.
Mr. Arnett: As you know, most of the resources are allocated to institutions, hospitals, at the present. On the other hand, the vast majority of mental health problems do not require the resources of the hospital. What you need in the community, and what does not now exist, is a multidisciplinary team who can work with family doctors, with psychiatrists, with psychologists, with the social workers, with the nurses and with others. That system is underdeveloped. The vast majority of resources are in the institutions. I do not think developing that kind of multidisciplinary approach is rocket science, but it does require a change in emphasis away from the traditional places of practice, which are institutions.
Senator Keon: Are you aware of any? I have looked at some examples of primary health care delivery systems that work fairly well, but I do not know of any that have the broad dimension that I just described and that I think is necessary to give a mentally ill person a job, an income, a place to live and so forth.
Ms. Marrett: That is an excellent question. The Canadian Mental Health Association works under the rubric of a framework for support where the individual is at the centre and then the resources that are required are available and surround the individual. We have a number of branches at the community level that are involved in some very innovative work and are trying to implement more. Part of it is that they have health care professionals who work for them. That includes psychiatrists and general practitioners, as well as, in one or two branches, nurse practitioners. The programs that they offer include housing or employment, but also some health care issues.
One branch in particular is trying to find sufficient funding whereby they would also be able to have a program for primary health care for individuals who are seriously mentally ill that would look after not only that portion of their life, but also their whole being. Oftentimes, people who are seriously mentally ill do not have a family physician if they are not connected in some way either to their family or to someone else, and they have other health issues as well. This is our Windsor-Essex branch, based out of Windsor. They have moved to that approach because of the realization that, as they provide support and services and treatment through their professional welcome teams, a piece is missing that no one else in the community is offering. They are trying to be the conduit to offer that.
In several of our branches — we have 125 across the country — some of the services are provided through the health care professionals. For example, people will leave their medication with those professionals and then come in to get it because they have decided that is the only way they can be sure to stay on track with their medication. Also, it enables the health care professional to help them if they need to see a social worker because they are having trouble with housing, for example, or if they need to see someone else. It helps those people access the rest of the team. We have several branches like that. I can provide a list of the branches that offer services of that nature.
The Chairman: That would be helpful. Clearly, it is one thing for us to describe what ought to happen. It is another for us to be able to say, "Here are two or three or four illustrative examples that are actually working."
Ms. Christine Davis: That is an excellent question, but there are pockets of programs that are working quite effectively across the country. We need to broaden our thinking so that it is not, "How can these programs fit into the larger system?" which are the institutions, or which includes institutions. People do not stay in institutions for any length of time, and they come back to institutions when they are not being maintained in the community. We need to look at innovative ways to keep people in the community.
I know about what is happening on Vancouver Island. At the Comox Valley Nursing Centre they have multidisciplinary teams who are offering all kinds of services to keep people in that community and out of the hospital down the island in Victoria. There are all kinds of innovative programs in the Downtown Eastside in Vancouver that are trying to support people in finding housing and doing what they need to do to be healthy, however they define that.
I get concerned about our focus on the people who are living with mental illness and addictions. We need to think about prevention too. There needs to be a continuum of services. There are programs at the Hospital for Sick Children for infant mental health. That means looking at the family and what supports are in place to the family to encourage parenting methods that will promote the child's mental health. That includes housing. That includes food. It includes access to support, community programs and those kinds of things. The whole early development initiative that the government has undertaken is one step in the right direction, but how that is implemented in each area is a dog's breakfast. I do not have an answer, but there are pockets of innovative programs, and certainly I could provide you with information on those.
Senator Keon: Thank you very much.
Mr. Arnett: I agree with Ms. Davis wholeheartedly about the need for health promotion and prevention. It is not on the radar screen as much as it should be. The Winnipeg Regional Health Authority has developed what are called health access centres. These are, in concept, exactly what you have described. They not only bring together multidisciplinary groups, but also social services if you are trying to find a job — employment counselling and so on. The reality, however, is that while they are terrific in concept and some bricks and mortar have gone up, in fact the professional staff and other staff have never been funded. While we have a great concept, we cannot actualize it because of a lack of funding. That funding exists in the institutions, but it is very difficult to move it to the community.
Senator Keon: One of the problems there is that the institutions have been around for a long time. They have their organization and their agenda. When a little funding becomes available, they are positioned to go after it. For the kind of thing you are talking about, we somehow have to get ahead of the situation we are in now, develop a plan, and at least open the door to the growth of the concept. At the present time, the people who develop these concepts have nowhere to go.
Mr. Arnett: You are absolutely correct.
Ms. Christine Davis: You are right about organizations. They have been in place for so long and are very powerful. When money is given to ministries of health and then to health authorities, health authorities do what is most pressing, and that is to reduce wait lists for hip surgery, knee replacement, cardiac surgery and that kind of thing. If it is not earmarked for mental health, it is not put into mental illness and addictions. Mental illness and addictions are at the bottom of the hierarchy of health care, and people with those problems are seen as less deserving than others. It almost needs to be earmarked for mental health from the get-go.
Again, I will talk about British Columbia because that is where I am from. The Ministry for Children and Family Development there instituted a mental health plan. They put dollars behind that. It is a community-based mental health plan with lots of dollars for early detection, prevention, intervention, all of those aspects. They have to do certain specific things with that money. It can be done.
Senator Fairbairn: I have tried to go through your presentations, all of which were great, and find a question for each of you.
I will rattle off the questions and then one can start and you can think about it as you go along.
Mr. Arnett, you mentioned in your remarks that underinsured Canadians have little or no access to needed psychological services. You say that this will likely worsen in the future without an appropriate legislative remedy. Could you explain what you are looking at as far as a legislative remedy is concerned, whether it is just dollars and cents or a significant change in policy?
Mr. Arnett: What I mean by that is that the vast majority of psychological services, probably three-quarters, are paid for privately. There are a small number of services that are paid for within the health care system. However, the vast majority of psychological services that people receive are paid for out of their own pockets or through some kind of an insurance scheme.
If we look at the various acts, they refer to funding for medically necessary procedures, and I use the words "medically necessary" because that is the term in the legislation. That means it excludes a large number of services that are provided by non-medical disciplines. This creates a serious problem of access to these services, which are very effective; in fact, if you ask people about their preferences, they will choose them. They will choose them over a lot of pharmaceutical products, but they do not have access to them because the legislation does not create the conditions where these are funded to any significant level.
Unless there is some legislative change, and you would know better about that than I, we will have a continuing situation where people who are uninsured, or do not have supplementary plans, simply cannot afford them because most of them are in the private domain; they are not in the public domain.
Senator Fairbairn: Thank you very much. It might be one issue we can follow up. Ms. Davis, you have talked about seniors, and I think this is one of the saddest end-result pieces of this puzzle. You talk about the need to explore the use of non-traditional approaches to maintain people in the community as much as possible. Yet you often find that seniors are almost encouraged, if they are in hospital, to go into a home that is not their own. Could you talk a little about the non-traditional approaches that you were referring to?
Ms. Christine Davis: Some of those non-traditional approaches include daycare for seniors. For instance, people who have a longstanding mental illness or late-onset mental illness with aging are taken to places for the day so that family members who provide care to them in their own homes can still continue to work and have a life outside of taking care of their parent or whatever.
There are arrangements like having people who are not nurses do home visits and spell people off for a couple of hours to go out and buy groceries, go to doctors' appointments, et cetera. Those are some of the more innovative, non-traditional kinds of programs that I am aware of.
I think if we ask families and people who work with the elderly what kind of non-traditional, innovative programs they would like to see, they have ideas; they have that knowledge. I cannot speak to those off the top of my head, but I can certainly find out and forward that to the committee. All I am aware of is the daycare kind of model.
Senator Fairbairn: Ms. Marrett, you have talked about progressive subsidies supporting, for example, training and child care. You focus on a strong link between education level and income.
One issue I have spent a lot of time on over the years is literacy. One of the saddest aspects is the adults who have not learned to read or write for whatever reason, whether they have problems physically or mentally or have just fallen through the cracks. Whether their child is in daycare or not, they still have to come home at night and face the lack of that support, because it is not there.
The strain on individuals and families due to this situation is huge. I am wondering whether, when you are speaking of education, you are thinking of them as well, and not just institutional education.
Ms. Marrett: We are looking at it in a broader sense. Recently, we produced a booklet with the Hincks-Dellcrest Centre, for example, on mental health and early childhood care. It was specifically designed for early childhood educators: What are some of the things that they could do working in a child care setting to improve and maintain a young child's mental health? It is specifically designed to assist people working with very young children — in a daycare setting, for example — and it is not just the child, it is the family.
I have a young child myself and I can recall going to an evening session held by the daycare centre about "literacy and my child." I was quite stunned by the number of parents who did not recognize the importance of reading to children, and then I realized that many of those individuals had not been read to themselves. Because of that, they were not aware of the importance of it; but the daycare was taking on that responsibility to help parents understand the importance and the importance of continuing with it over a long period.
In that sense, from our perspective, it is not just individuals in a formal institution or setting, it is everyone.
We produced a booklet recently, a resource for individuals who are in higher education. It is called Your Education - Your Future, and it is to assist the mentally ill in community college or university, if they need accommodations, for example, with how to go about finding those accommodations to enable them to complete their program.
We also have produced a new resource for high school students called Mental Health in High School, and it talks about mental health on the broadest continuum, which would include mental illness. It is designed to help them as individuals who may or may not wish to speak to their parents about some of their anxieties or issues or how they are feeling with what steps they can take to help themselves, and also what steps they can take if a friend is feeling anxious.
I think the education system is trying to address some of those issues through education of parents; but in the end, the resources are so limited that only a certain number can do it. One of our biggest challenges is where the resources are being spent.
Senator Cook: On the question of continuing education, I would like your opinion on a possible federal bursary program for people within the system, such as a nurse wanting to become a nurse practitioner. Any number of disciplines could be provided for and the programs delivered in myriad ways, such as teleconferencing, telemedicine and correspondence courses. The nurse may be married with a family and not have the resources or time to pursue those goals.
Ms. Marrett, I would like to speak to the issue of affordable housing. We have not talked much about the role of the NGOs in this mental health system. Am I to understand that there is money sitting in the federal treasury because of the lack of matching funds from the provincial treasuries or NGOs? Is that correct? In my province, the United Church of Canada is in partnership with the federal government to provide affordable housing for consumers of mental health services. Currently we have up to 79 units. The good news is that the clients run the facilities. It is a good news story. I think there is a role for us in reaching out to the volunteer sector. With the proper underpinnings to help them, they can provide a wonderful service. I think that across this country many NGOs and volunteer agencies are doing that kind of work. Have you ever looked at the value of that to see if we could enhance it?
Also in my province, seniors' resource centres play a valuable role in the enhancement of their lives. Loneliness is common among seniors and get-togethers for activities and meals at a resource centre can provide wonderful relief. Many good things are happening across this country but we do not know about them all. Is there some way that they could be coordinated? We are looking for ways to care for people in a heart-warming, dignified manner.
I am a member of a drop-in centre for consumers of mental health care. We are celebrating 25 years this year. Senator Fairbairn has heard about my literacy program. About 75 to 80 people dropping in there each day could not focus on their medicines. They did not know how to read the prescription information and would forget to take them. These social centres become their second home, because their first home might be a boarding house. At the social centre they become part of an extended family. I hope that when you go to Newfoundland you will visit us. Now, because of its evolution, we are able to bring in nursing students and social worker students on their rotation systems. This all happens thanks to the generosity of a volunteer sector of this country. I would like your opinions on some of those activities.
Ms. Marrett: I will talk a little about the housing issue. Many local affiliates of the Canadian Mental Health Association are actively involved in housing within their communities for people who are seriously and persistently mentally ill. There are some wonderful examples across the country of how the organization has been able to raise the necessary funds to build apartment dwellings or other appropriate housing for individuals so that they can live as independently as possible. There are different models available, such that some may have more supportive housing arrangements than others.
The challenge for NGOs in this area is the continuing, regular, day-to-day costs of maintenance, particularly when governments change and then spending priorities change. What do we do? Do we abandon the individuals? There needs to be the ability to plan on a multi-year basis, so that if capital costs are involved, the NGO is able to plan for those, knowing that the funding will be available.
Many seriously mentally ill people in this country do not live in housing that any of us have ever seen or would want to live in. We need to provide those things that give people dignity and make them proud of where they live.
Unfortunately, because of the stigma, it is much more difficult for people who are mentally ill to find the right housing to meet their needs in many communities. Yet we are stretched to the absolute limit in our ability to provide appropriate housing or programs. In one community that I am aware of, we do not provide the housing but we do provide all the independent living services. In Calgary, the organization that provides the housing used to be attached to our organization, but it became a separate, incorporated, charitable organization and now raises all the money. It is a fabulous program because these two organizations are working closely together. One provides the housing, the bricks and mortar, and the other provides the independent living services to enable people to live as independently as possible.
Senator Cook: There are a couple of similar places in Ottawa that the committee might want to explore. They are provided through a partnership between a church and the Mennonites. The Mennonites provide the housing and its maintenance, and the church provides other services.
The Chairman: That would be worth doing.
Mr. Arnett: We believe in the importance of social support such as you described at the seniors' resource centres. Social support is important in mental health problems, addictions, and in physical health problems. The seniors' resource centres and the kind of support they provide serve as a good example for health care in general. I was intrigued by your concept of a bursary. This would allow people who could not train otherwise to upgrade their skills. That is a most interesting idea.
Senator Cook: The federal government could take ownership of such a program and there would be a single source of funding and resources. The diversity of the country causes fragmentation, and this is an opportunity to put the idea forward, if you think there is merit in it.
Ms. Christine Davis: I understand that the Canadian Nurses Association asked for such bursaries in its last presentation before the Finance Committee. I think it is a great idea. Many nurses would like to work as nurse practitioners but may have young families and not be able to afford to go back to school full time. It is difficult to work, raise a family and study. People do it, but a bursary would make it much easier and would speak to the value that we put on people's education and the skills that they would bring to their work.
I would like to support the idea of the drop-in centres and resource centres. I have worked in mental health for many years.
I am contradicting myself here, but I do not agree with keeping people in institutions. I worked in institutions, and when they were closed in this province it was a very sad thing to go and visit people in one-room back garages. I remember visiting a man who sat in an armchair in a shed all day, and the highlight of his day was me coming to give him two cigarettes, a loonie and his medications. That, to me, is the saddest part, when people who have been raised and spent all of their lives in these institutions are now put out into communities where they are isolated and have no family. The nurses, the hospital staff and the other patients were their family.
Recently in British Columbia they closed Riverview, which is a provincial hospital. They are sending some of the seniors back to Vancouver Island because that is where they came from many years ago. They put those people on an airplane. They had never been out of the institution, and they put them on an airplane. They were terrified. There are all sorts of stories about people being moved out of what was their home and put in isolated places. They need places to go where they can connect socially.
Senator Cook: Going back to my idea of a bursary program, I understand that the nurse practitioners across this nation are developing national standards?
Ms. Christine Davis: Yes.
Senator Cook: There is an opportunity here for a nurse practitioners’ discipline. I think they have a role to play here. If we could dream a little and put a bursary program in place — and there is an underpinning now that you are talking about accessing, Mr. Chair — we could access that program and show where the system has been proactive.
Senator Cochrane: My question is to Mr. Arnett in regards to his presentation. You were saying that most psychological services that people require are provided in the private sector rather than the public sector. I would like to ask you about the private sector, because generally, patients who cannot get, say, operations or whatever, do go to the private sector. That private sector is generally outside Canada.
What private sector are you talking about here in regard to mental illness?
Mr. Arnett: In this country, there is a tremendous shortage of services that are funded with public dollars. When I talk about public sector funding, I am talking about money for psychological services within communities or within institutions. There is very little of that. The vast majority of psychologists in this country work outside of institutions, outside of community centres, and in fact support themselves through the income that they generate by providing their services.
That is in significant contrast to physicians, who get 98 per cent of their income from the public sector. Very little money comes from the public sector to support the overall psychological activities in the country. That means that those people who require those services more often than not have to access them and pay for them themselves.
Senator Cochrane: Would it be fair to say that people with mental illness do not get the holistic program that they should be getting, services from psychologists, psychiatrists, doctors and nurses and so on? Do they get this holistic program if they access private care, or is it just a stopgap? They will get a certain part of the treatment and then possibly go back to the public sector?
Mr. Arnett: By and large, people do not get comprehensive care within the context of our public system. On any given day, in any given institution or any community facility, they may, but there is a greater chance that they will not. There is a much greater chance that they will pretty well exclusively receive medications for their problems, whether they like it or not.
If you ask people, for example, whether they want any treatment or no treatment, they will take any treatment. If you ask them whether they want a more comprehensive approach or a medication approach, they will choose the more comprehensive approach. However, they do not have access to that.
Senator Cochrane: You say in Ontario the present number of training positions has fallen below a level sufficient to fully train the required number of doctoral-level psychologists. What has happened? Have we closed down some of the universities? Have we closed some of the training positions in hospitals? What has happened in Ontario?
Mr. Arnett: What has happened in Ontario is exactly that. They have closed training positions in hospitals. Hospital budgets have been squeezed to the extent that staff psychologists are given a choice. They either maintain themselves or cut their training positions. It is a Sophie's Choice in many instances that is unpalatable. With the squeezing of hospital budgets here, they have cut these training positions and they are no longer adequate to replace the current practitioners.
Senator Cochrane: Could you give us some positive stories in which people with mental illness have experienced great improvements? Have funds been used to build on great solutions that we can pass on to our own provinces?
Mr. Arnett: Are you directing that to me?
Senator Cochrane: To anyone, I am looking for positive stories.
The Chairman: It is called "looking for a ray of sunshine after five hours of gloom."
Mr. Arnett: Let’s face it, the vast majority of the conditions that people suffer from are treatable and they do well with treatment. There are a small percentage of people who do not. There are a small percentage of people who do not recover. If you look at mood disorders and anxiety disorders, which are the most prevalent disorders, people can be treated for those successfully, either pharmacologically or psychologically, socially, and they do very well. The good news is that most people do very well with appropriate treatment. That is the reality.
There are a small percentage of people who, no matter what you do, need and will continue to need a great deal of support over the long haul. It is not a negative picture overall.
Ms. Marrett: There are lots of positive stories. One of the positive stories is what is happening right now. The treatments and services that were available 10, 12, 15, 20 years ago were vastly different from those that are available now.
That does not mean that it is perfect, by any means. At the same time, individuals who are able to work, if they have found an employer who is open to accommodation and to respecting the fact that the individual may need some flexibility — it may be flex hours or any number of different things — have a much greater chance of having a successful life and contributing to society.
Many more individuals are able to do many more things because of the treatments and services that they have been able to access. However, I say this with a little caution, because there are pockets where this happens.
It is not right across the board.
Certainly, when you are talking about the public versus the private sector, even those individuals who are working and have an extended health benefits program are limited in how much money can be spent on accessing psychological services, for example. For individuals who need psychological services on a regular basis, that is used up within a few months. Where does the money come from after that? Many psychiatrists will tell you that the treatment for many people living with mental illness of any kind must involve psychological counselling. However, if they cannot access it because they do not have the funds, or can only access it for a short time, we have a problem. It is a huge challenge in this country.
Ms. Christine Davis: There are tons of good stories about how well people do. There are also many about people who do not do so well. For me, it is about people doing well according to how they describe that. It is about how people would describe their lives. I hear stories from many people about how their lives are much better outside of institutions and organizations where they have been housed for long periods of time.
I teach nursing, and I can tell you that I take students into mental health facilities. At the end of their 12 weeks on a floor working with patients who have mental illness, all 10 of them want to go back to work on that floor. When they first went there, they were terrified because they had not had any experience. For me, that is heart-warming.
The Chairman: Thank you for that ray of sunshine. I thank all of you for coming. We really appreciate it.
Senators, our last witness tonight is Ian Potter, the assistant deputy minister, First Nations and Inuit Health Branch, Health Canada. Kathryn Langlois is the director general in the same program. In light of the time, I have asked Mr. Potter to be brief in his opening comments. He has given us his opening statement. I have asked him to shorten a bit in the hope that we can ask him some questions. Mr. Potter, I appreciate your tolerance. I know you have been here for a while, listening to the discussion. In many ways, it was probably a good thing you were not here at the time we originally wanted to have you, because the session went overtime, even with one less witness. As you can appreciate, this is a subject that tends to emotionally engage the committee. Thank you for coming. Please hit the highlights of your opening statement.
Mr. Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada: Thank you, Mr. Chairman and senators, for your invitation. I will try to cut my opening statement short and just deal with some of the more important issues. As Senator Kirby said, I am joined by Ms. Langlois, who is the Director General of Community Programs in First Nations Inuit Health Branch and responsible for mental health and addictions programming in our services.
First, I will try to set out what we do versus what provinces and territories do. It is often confusing, even for those of us who are in this on a day-to-day basis.
Basic mental health services and addiction services are provided primarily by provincial governments to all residents of the province, which includes First Nation, Inuit and other Aboriginal people. They provide hospital care, psychiatric and general physician services. Provinces also provide community-based prevention, outpatient treatments, aftercare, detoxification services and residential addiction treatment services.
Health Canada, through First Nations and Inuit Health Branch, works with the provinces and adds to those services by providing specific services for First Nations and Inuit for some elements of the overall mental health and addiction system. In particular, we provide mental health counselling through a program called Non-insured Health Benefits, which provides supplementary health services to First Nations and Inuit regardless of residency.
In 2003-04, we spent approximately $11.6 million under that program on mental health counselling. This is usually provided by psychologists, and it is usually in cases where there is urgency and, frequently, some crisis. We also provide community-based prevention and promotion programs focused on mental health and addiction on reserves and in Inuit communities and residential addiction treatment services for First Nations individuals.
We provide $40 million a year in ongoing funding to community-based mental health programs through a program called Building Healthy Communities, and an additional $51 million per year for mental health and child development activities through Brighter Futures.
[Translation]
To assist communities to address addiction issues, FNIHB provides funding to First Nations and Inuit organizations through the National Native Alcohol and Drug Abuse Program ($59 million per year), the Youth Solvent Abuse Program ($11 million per year), the First Nations and Inuit Tobacco Control Strategy ($12 million per year), and the Canadian Drug Strategy ($1 million per year).
[English]
Most of these programs are managed and delivered by First Nations and Inuit people. We have given the committee two summaries of community programs that are offered under the funding that we provide. I believe we have left those with the clerk of the committee for your information, and I will not get into them today in the interests of time.
I will just talk a little about our agenda. I would like to identify four main issues that we are working on to strengthen our service. The first is related to a significant commitment from first ministers and Aboriginal leaders in September of 2004 in which the Prime Minister, the premiers and all the national leaders agreed to work together on a blueprint for Aboriginal health. The goal is to improve Aboriginal people's health outcomes and to ensure they have access to quality health care.
There is a process currently in which provinces, territories, Aboriginal leaders and the federal government are meeting to consider what should be in that long-term plan. This is an area in which mental health services could be highlighted. The intent is to develop a plan in consultation and to table it at the scheduled first ministers’ meeting on Aboriginal issues, which is likely to take place before the end of the calendar year.
As part of that September initiative, the federal government announced new funding, and in particular, an Aboriginal youth suicide prevention strategy, with $65 million allocated over five years. We are working on the program jointly with the Assembly of First Nations, the Inuit Tapiriit Kanatami and with input from other national Aboriginal organizations, provinces and territories and federal departments. This strategy will support communities in stopping youth from becoming suicidal, reaching youth who are at risk of committing suicide and preventing suicide clusters in the aftermath of a completed suicide.
[Translation]
Second, Health Canada has engaged the AFN, ITK, federal/provincial/territorial networks, and national and aboriginal expert organizations to work together to strengthen mental health and addictions services for First Nations and Inuit. One key objective of this work is to improve coordination of services, so that people who are coping with both mental health and addictions issues, and who are moving between federal, provincial and community-based programs do not experience gaps in service or duplication of processes.
[English]
Third, Health Canada will be engaging experts in a review this year to strengthen the evidence base for mental health and addictions programs for First Nations and Inuit.
Fourth, Health Canada is making progress on increasing the number of front-line addictions and mental health workers who have received accredited training. We are seeking accreditation for all our facilities, particularly our alcohol and solvent treatment facilities. We are taking steps to increase the number of Aboriginal mental health and addiction professionals, who have a critical role to play in supporting front-line workers and providing direct services.
I have also provided the committee with information on First Nations and Inuit, "A Statistical Profile on the Health of First Nations in Canada." This could provide more detailed information, should the committee wish to have it.
I thank the committee for this opportunity to be here. I hope that I can be helpful in its deliberations.
The Chairman: Mr. Potter, I would like to ask you a question or two. You began by describing what you provide and what the provinces provide. Do you reimburse the provinces for services that they provide to Aboriginal and First Nations people?
Mr. Potter: No. When hospitalization and physician services under the Medical Care Act and Hospital Act were introduced, it was the intention of the Government of Canada that those services would be available to all residents of the province, except for RCMP and a few other federal employees. That would include all First Nations and Inuit.
The Chairman: It would include those on or off reserve?
Mr. Potter: Yes. There was some controversy during the 1960s and 1970s as to the application of that, which led to an agreement in 1979 that defined the roles of the federal and provincial governments. It meant that on isolated reserves and areas where provinces were not providing primary care, the federal government would continue to finance and provide that. It meant that the federal government would provide public health services on all reserves, including prevention services. As well, it meant that the federal government would provide non-insured drugs, dental work and transportation for all First Nations and Inuit on and off reserve. For physician services, the federal government bills the province at the rate that they are provided, which is usually a part of it. For example, where the federal government may arrange for physician services on a northern reserve in Manitoba, we would enter into contracts, for example with the university, to provide that service, which includes transportation, et cetera. We would then charge the province for the billing days of those physicians who are covered under the provincial legislation.
The Chairman: You pay the balance.
Mr. Potter: Yes, we pay the rest. Usually, we bill the province about one quarter to one third of the cost of providing those services.
The Chairman: Your budget is about $1.4 billion. Is that right?
Mr. Potter: It is close to $2 billion this year.
The Chairman: That lowers my number even more. If I add up your expenditures on mental health and addiction, out of a budget of $2 billion, it comes to about 5 per cent. Given the magnitude of the problem, that strikes me as incredibly low. I will say that you might have noticed that we were not terribly complimentary about your branch in our Issues and Options paper. Please do not take it personally. We understand that this systemic problem has existed forever within the federal government. The problem is not unique to you. It is equally interesting to me that when I look at the index to your "Statistical Report on the Health of First Nations in Canada," with the exception of a quarter-page on suicide, there is no mention of mental health — it is not covered.
Part of me is wondering why we are doing any of this. Why do you not simply contract with the provinces to do everything? When I look at the relative amount of money that is being spent, and knowing that we are sitting here in Ottawa trying to deliver services at either end of our country, I wonder why we are doing it. Why do we not simply contract it out to the provinces or to someone else?
Mr. Potter: If I may, there were a few questions embedded in your remarks.
The Chairman: I have a tendency to become agitated on this subject.
Mr. Potter: I could try to figure out the overall proportion. We have some difficulties in getting all the data with respect to mental health services; and we are not alone as a health service delivery agent in that. That is reflected in our data reports. In terms of the expenditures, the pharmaceuticals that we pay for are not included. I know that the most prevalent pharmaceuticals, although maybe not the most expensive, are for the treatment of mental illnesses.
The Chairman: Those would be mainly antidepressants.
Mr. Potter: Yes, absolutely. That is our largest number of prescriptions, which amount to$10 million per year that we pay for.
We have an interest in integration and ensuring that there is a clear program available. Part of the blueprint process that I mentioned the first ministers agreed to with Aboriginal leaders was a focus on integration and adaptation of the health system. The integration of the federal services with provincial services would reduce duplicative services or incidence of services that do not fit together. Service would then be truly focused on the needs of the patient so that the system is clear and not broken up by jurisdictional differences. That is our major emphasis. Most of the services we fund are delivered by First Nations and Inuit. Part of that process is to support them so that they can play an active and essential role in the fundamental health care system in Canada, which is provincial or territorial.
We are not trying to withdraw funding. Rather, we are trying to support those health clinics that are run by First Nations, which Senator Fairbairn knows well in her own area. I have been with Senator Fairbairn on some of those visits.
Senator Fairbairn: On the Blood Reserve.
Mr. Potter: The Blood Reserve has an excellent clinic with excellent services. We are trying to help First Nations to work with provincial governments, through federal government financial support, so that there is a good service. We are not just buying it from the provinces, but ensuring that the service delivered is largely led, managed and delivered through First Nations and Inuit. It is an integral part of the provincial medical care system.
The Chairman: I understand what you do. However, when I look at the outcome, my instinct makes me wonder why we do not contract it out to the provinces. I cannot believe it would be substantially worse, and perhaps it would be better.
[Translation]
Senator Gill: First, I should tell you I’m from an aboriginal reserve in Lac-Saint-Jean, that I still live there, and that I’m occasionally one of the patients of the national health system and of the local hospital services. I thank you and congratulate you on the efforts that have been made for a number of years now by the national health system.
It was only very recently that services were transferred to aboriginal people so that they would be managed by them. The areas I am familiar with are relatively good, but obviously nothing is perfect. As Senator Kirby just said, the results may not be proportionate to the efforts and investments made.
Here I have a table that comes from the research service, but I don’t know how accurate it is. I’m looking at federal government expenditures on the Canadian Forces, federal offenders and the Royal Canadian Mounted Police. I see there is approximately $2,000 for First Nations, per capita, and for the others, it is $4,000 and $5,000 per capita. I don’t think this information is scientific, but it’s nevertheless a reference that must be considered.
You said earlier that the provinces offered a lot of services. The hospitals offer health services to aboriginal people, that is correct, but they’re billed to the federal government. You lose me when you say it is not billed.
To my knowledge, there’s an agreement under which most services are provided by the province, as a general rule. Apart from the local reception centres, the Department of Health pays the costs directly. However, I always thought that care provided off the reserves in hospitals or clinics was always billed to the federal government and paid for by the provincial Ministry of Health.
It’s like for education offered in provincial schools. Unless the facts show otherwise, I’d say it’s often the federal government that pays the bills. Since intake is also done by the communities, I am not saying the bills are paid twice, but that they’re paid by the communities themselves. I would like you to tell me whether I am wrong or not.
[English]
Mr. Potter: For the services that are provided to First Nations and Inuit; it is different from the RCMP or the DND. In the case of the RCMP and DND, as I understand it, the federal government pays the province for the services.
The agreement that was reached in 1979 is one in which the province provides basic hospital care and medical care, the same types of services that are available to the general public, to the First Nations and Inuit. If we are providing a hospital service — and we still have a few hospitals — and if we are providing a physician service, we bill the province for that service.
[Translation]
When you compare the federal government’s expenditures for Aboriginal people and national defence, the difference lies in the degree of responsibility of the provinces relative to that of the federal government.
Senator Gill: Let us consider the example of the health insurance card in Quebec. Everyone has one, including aboriginal people, the members of the RCMP and the members of the Canadian Forces. I imagine that, when that card is used, services are billed to the provinces.
[English]
Mr. Potter: I cannot speak with certainty with respect to the DND or the RCMP. I can tell you with certainty with respect to the First Nations. In those cases, those services that are covered by the Canada Health Act, what we call insured services, are provided by the province. If the federal government is arranging for physician services or hospital services, we charge the province back for those services.
We do not charge them back for the community services. We have a number of nurse practitioners who provide services in isolated communities. That is paid for by the federal government. The basic clinical services — preventive services, well baby clinics, basic community mental health services, those types of things, are all funded by the federal government in the communities.
[Translation]
Senator Gill: Have you taken any steps to promote traditional medicine among aboriginal people? Are the people working locally in the health field making efforts to adopt traditional medicine?
Drugs cost a fortune, and I know there are a lot in the aboriginal world. I also know that the pharmaceutical industry markets some of those drugs. Is the Department of Health striving to develop traditional medicine?
[English]
Mr. Potter: Yes, we certainly have. I will ask Ms. Langlois to reply in general terms. In many of the facilities that Health Canada has funded, you will find places for traditional medicine. Many of the First Nations provide those as part and parcel of their medical clinics.
We have some limitations with respect to funding traditional medicine because there is no system in place that defines who is a traditional medicine specialist. In other countries — and it is something we have tried to encourage First Nations and Inuit people in Canada to look at — the people who practice traditional medicine have organized themselves to certify who is a legitimate provider of these services. So far, we have not been able to achieve that. There is a difficulty, as liability issues arise; if we pay for something, we should know what standard we are paying for. We are trying to get some system of standardization. I will ask Ms. Langlois to respond.
[Translation]
Ms. Kathryn Langlois, Director General, Community Programs Directorate, First Nations and Inuit Health Branch: In response to Mr. Potter’s question, I would like to add this. We are trying to integrate traditional aboriginal medicine through the NNADAP program for substance abuse, and a lot of physicians practise this type of medicine.
Perhaps you are familiar with the Aboriginal Healing Foundation, which has integrated traditional aboriginal practices. On our side, we are trying to see the orientation we will take in the future with regard to these projects. In response to your question on traditional medicine and the use of drugs, we’re not really advanced on that point.
Senator Gill: Do you have a program that might eventually encourage traditional medicine? I understand the practice isn’t recognized by physicians in general, but is it encouraged? This type of medicine is also used by non-aboriginals. Do you at least have something planned to encourage traditional medicine?
Ms. Langlois: Not for the moment, but I must say there are traditional alternative therapies in British Columbia, where there are a lot of aboriginal people. We’ll have to look at the evolution and effectiveness of those therapies in the future.
Senator Gill: We are starting to see physicians, surgeons and psychiatrists who go and study at university. Are there any programs encouraging those people to study medicine?
[English]
Mr. Potter: I do not think that we do that, although I believe in some settings there, in some medical schools, it is taking place.
[Translation]
Ms. Langlois: That will be the responsibility of the universities. We have to work together.
[English]
Senator Fairbairn: I should probably confess to a slight bias here in regard to our witness, with whom I have visited sites many times in my province of Alberta. If the federal government had a sainthood program, Mr. Potter would be in it. It is a very challenging job, and at the same time very invigorating when you visit medical centres on a reserve and see the people being treated by their own doctors and their own practitioners, which is happening more and more. It may have been slow, but nonetheless it is moving forward.
I have one question in looking at the table of contents here, and I should know this, but I do not. One of the big issues, particularly with young people in many parts of the Aboriginal community, is the difficulty that they have with drugs and alcohol, and coming out of that, the FAS children, the fetal alcohol syndrome children. Have you been able to develop programs with Aboriginal people as significant participants, and have them work on them with their own people, in the areas where FAS is so evident, as it is in so many parts of my area?
Mr. Potter: It is an area of great focus and attention in our program at the moment. We are fortunate that the government did increase funding to $15 million a year for FAS-dedicated resources. We have made this an important issue, both in terms of knowing how to tackle it and exchanging best practices. We have entered into collaboration with the U.S. Indian Health Service to work together on programs and interventions to deal with fetal alcohol spectrum disorder. In fact, the Canadian Paediatric Society, American Pediatric Society, Health Canada and the Indian Health Service of the United States are sponsoring a major conference on FASD in Seattle in approximately a week's time.
I will ask Ms. Langlois to talk a little about the specifics of that program.
Ms. Langlois: Based on the work we are doing with Indian Health Services in the United States, we are looking at best practices around preventing FASD births. We have learned that the best predictor of a woman having an FASD birth is that she has already had one. We need to work with women at risk to change the drinking behaviour and their addictions. One of the key best practices coming out of Seattle — and it has been around for a number of years and we are adapting it — is the mentoring program, where you pair an at-risk woman with a woman from the community who has had, perhaps, a similar life experience. That woman works with her to begin to break the cycles and the practices, access services and try to find ways to move away from the behaviour.
We actually have a mentoring project in place in Northern Saskatchewan, in the Northern Inter-Tribal Health Authority. That community is suggesting that it is seeing good results. It is very early days. With the new monies that were injected, we are a year and a half into it. We are hoping that it will build the evidence base for us to be able to expand that kind of program. That is an example of what we are doing.
Senator Fairbairn: This would be a federal program, not a federal-provincial program?
Ms. Langlois: A federal program.
Mr. Potter: It is a federal program, but it has applications for provinces. It is an area where we in Health Canada are also working with the provinces on exchanging best practices and supporting a concerted effort in that regard.
Ms. Langlois was talking about the particular program within our branch, where we have a delivery obligation for First Nations and Inuit on reserve, but the same programming is applicable off reserve.
Senator Fairbairn: This is being accepted by the people in the Aboriginal communities?
Ms. Langlois: In fact, just to link it to the provinces and territories, we actually had people from the STOP FAS program come from Manitoba to talk to us about their experience when we were looking at adapting it for on-reserve purposes. It is a program, I believe mostly in Winnipeg, that works with off-reserve Aboriginal women, and we were adapting it for on reserve. That is why it needs to be adapted, and the community in Northern Saskatchewan is doing that to make sure that it is applicable and can work there.
The Chairman: You do not fund the off-reserve program, do you?
Ms. Langlois: No, we do not. That would be funded by the province.
The Chairman: That brings me back to my previous question. I do not know why, if the province is running a program that is working for some part of the Aboriginal community, we do not let them do it for the entire Aboriginal community and simply reimburse them.
Senator Cordy: I am wondering, for informational purposes, what the First Nations and Inuit Health Branch regional offices do — and there is one in Atlantic Canada. Is it strictly administrative? Do you work in conjunction with the provinces? Do you work in conjunction with the Aboriginal people living within a particular region? What exactly does the regional office do?
Mr. Potter: The regional office in the Atlantic is located in Halifax. It has people who work in different provinces and in different loose arrangements. We have an office in Labrador because of the particular problems there.
A large part of the programs are delivered by First Nations and Inuit themselves, in the Atlantic particularly. Part of the office's responsibility is managing contribution agreements that fund the bands, the First Nations, to deliver the services. There are administrative people managing that. There are program experts in that office. For example, our medical officer of health would be in there. We have what we call senior practice nurses. These are nurses highly specialized in psychiatry, child care, et cetera, who provide expert advisory services to nurses working in the health clinics on the reserves.
We would have program people who are managing and supporting mental health programs or drug addiction programs, children's programs, the diabetes programs. A lot of the other work of the offices is working with the provinces to make sure that we have coordination and integration of the programs.
Senator Kirby asked why the provinces would not just provide the services on reserves. We would not object if they wished to, but generally, most provinces do not provide those services or will not provide them.
The Chairman: So we are clear, I was suggesting you would actually pay for it. You do not pay for the rest of it. I was not suggesting that you manage to offload the cost to the provinces. I began by thinking you actually paid for services to Aboriginals on reserves even if they were normal medical services, and you have enlightened me tonight. I discovered that you do not. Listening to you, you have people who have to coordinate with what is going on in the province, which you could do away with, presumably, if they were running it all. You are running smaller, less-economic-sized programs, taking your example of the one in Winnipeg. It is less economic if you have to train other people to do it. There is clearly an element of administrative costs associated with the bands doing the managing that would be eliminated if the same manager ran it. It just strikes me as a colossally inefficient waste of money and, more importantly, the results are not great. If the results were good, it might be different, but they are awful. I do not have a viewpoint on that subject; I just thought I would express it.
Senator Cordy: The point is that it is a shame when so much money is tied up in bureaucracy.
To change the subject a little, you said you are taking steps to increase the number of First Nations and Inuit health care personnel or front-line workers. What steps are you taking, and are they successful? Senator Fairbairn spoke about the increase in numbers in her province.
Mr. Potter: We are doing a few things. We provide bursaries and scholarships to Aboriginal people to take professional medical programs — nurses, physicians, pharmacists, dentists, et cetera. Most of our effort has been on providing support to nursing students. We have done some recent work with provinces to try to increase the numbers of Aboriginal people in the professions, and they are very limited. There are between 100 and 200 Aboriginal physicians out of a physician population of 50,000.
The Chairman: There are two psychiatrists.
Mr. Potter: Right.
The Chairman: I believe that is the number; that is the number we have been given, and we met 50 per cent of them.
Mr. Potter: There are very few. There are only approximately 1,000 to 2,000 Aboriginal nurses out of a population of 250,000.
You need to work at this throughout the system, starting in grade school, so that Aboriginal people see this as a realistic opportunity. We have recently provided funding to the Aboriginal Achievement Foundation. They have developed a program in schools that was modeled on one called Aboriginal Railways, which was paid for by VIA Rail. It is promotional material for use in First Nations schools about how they could become doctors and nurses and dentists and what kind of work it is. There is a real need to ensure that people learn sciences in high school.
The government has allocated, as part of its new commitments, $100 million for an Aboriginal health human resources initiative. The funding has not been finalized by Treasury Board, but it is likely to go toward helping students in the form of financial support, and also financial institutions. I have been in discussions with most of the medical schools in Canada on how we could support them in providing the ancillary services that are needed to make it a success for Aboriginal students. Often, that means helping them get into the program. It means providing support, social, educational and tutorial, while they are in the program, and an environment in which they feel that they can continue to be supported. Those are the kinds of things we are doing.
Senator Cordy: Are universities with nursing programs and medical schools in the loop? Are they actually trying to be part of the solution?
Mr. Potter: Yes. We have been working with the medical schools and the nursing schools. We are having a major conference at the end of this month, I think it is April 30, at which representatives of all those organizations will come together to help us and the provincial governments — the provincial governments have a huge stake in it, as they are the funders of the colleges and the schools and the licensing authorities — use the $100 million that we have announced as leverage for a better system to produce more Aboriginal health professionals.
Senator Cordy: Part of the Catch-22 is that when you have low numbers, you do not have role models for young people to look up to.
My last question has to do with an issue that you mentioned in your opening remarks, and that is the Aboriginal suicide rate. A few years ago, National Chief Matthew Coon Come and former minister Allan Rock set up a suicide prevention advisory group. I have not seen the recommendations, but I am assuming you have. Are you working on the recommendations, and if so, what stage are they at?
Mr. Potter: I will ask Ms. Langlois to talk to you about that specifically. Yes, we have seen the recommendations and we are acting on them. One of those recommendations, which segues into your earlier question, is support for an Aboriginal role model program. We are funding the National Aboriginal Health Organization to sponsor Aboriginal young people as role models. Their first choice was Jordin Tootoo, who is an incredible hockey player, and the first Inuk player who made it into the national league. His brother, as many of you may know, committed suicide. He is dedicated to working with Aboriginal people, using his personal experience and knowledge, and to setting an example to show what can be done; he is also very conscious of and sympathetic to the issues around suicide.
Ms. Langlois: There were four themes in the recommendations of the suicide prevention advisory group that was set up by National Chief Matthew Coon Come and Minister Rock, who was Minister of Health at the time. The four themes had to do with increasing knowledge about what works in suicide prevention, developing more effective and integrated services, supporting community-driven approaches, and building youth resilience, identity and culture.
Prior to the announcement of the $65 million for the suicide prevention strategy, we had been working with the Assembly of First Nations and the Inuit Tapiirit Kanatami to address those recommendations. I will talk about the things we did prior to getting this new injection of money, which I think positioned us to get the support for this new strategy.
We wanted to document the promising strategies that exist around youth suicide prevention in Aboriginal communities. In fact, we found that the RCMP care very much about this issue. The Centre for Suicide Prevention, which is an arm of the Canadian Mental Health Association, produced a document entitled "Promising Strategies." I highly recommend that document to this committee, and we could make it available to you. It has evaluated 27 examples and shows what the impact can be. We modeled much of our thinking and work on that document.
We have also worked with the Canadian Institutes of Health Research, the Institute of Aboriginal People's Health, to develop some suicide research funding. We funded them to put out a call for suicide research amongst their new emerging teams, and they have done that. We are also working with the Canadian Population Health Initiative to adapt the work of Chandler and Lalonde, some groundbreaking suicide research in British Columbia.
As Mr. Potter mentioned, we have been working with the Indian Health Services in the United States on a common suicide-prevention agenda, because it is a key issue for them as well.
That is what we have been doing to increase knowledge.
In terms of developing more effective and integrated services, we decided the best way to start was to bring all the parties together, the provinces, the territories, ourselves, the AFN, the ITK, and mental health experts. Ms. Marret, who was just here, is part of the group that we are calling our mental wellness advisory committee. That group will take the work that we did collaboratively with the AFN and the ITK, on which we issued a report in 2002, called "The Mental Wellness Framework," as a basis to move forward with a strategic plan for how we will develop more coordinated services with the provinces and territories and work towards that seamless continuum. We are putting that in place now.
We are also doing a scan of federal-provincial-territorial and Aboriginal collaborations on mental health and addictions, including suicide prevention, to find out what is already out there.
In terms of supporting community-driven approaches, we have developed a community-planning suicide prevention toolkit with the National Aboriginal Health Organization, and we have been focus-testing that in communities. With the new money, we expect to do more work with that toolkit and begin to bring it out to communities.
We have supported Aboriginal trainers to deliver the applied suicide-intervention skills training program. We have adapted that curriculum for Aboriginal communities, since that had not been done before our support. We have delivered it in more than 40 communities over the last year.
Building youth identity, resilience and culture is a key part. We have worked with the Assembly of First Nations Youth Council to develop and pilot a youth leadership-development curriculum. We know that the engagement of youth in issues within their communities is a key protective factor in suicide prevention. We also worked with the National Inuit Youth Council to help them develop their national prevention framework, which was recently published. As Mr. Potter mentioned, the other element is our national Aboriginal youth role model program. Those are the things we have been doing prior to the new $65-million injection. It is our response to the suicide prevention advisory group report.
Senator Cordy: It is a worthwhile report.
Senator Keon: Mr. Chairman, my questions have been answered, for the most part. I have had a little experience with the hospital in Iqaluit and with patients travelling from the North for treatment here. Language is a dreadful problem. Senator Cordy asked you the questions that I had in mind, so I will expand on them. Is there a dedicated program for the management of the mentally ill, because the communication problems can be serious enough in somatic or physical illness? However, such communication problems must be overwhelming in mental illness. Within the hospital in Iqaluit and when patients land here from the North, not much conversation transpires. While there are translators, the health professionals usually have no ability to communicate in a native language.
You have answered the question on suicide prevention and I commend you for it. However, on the larger question of psychiatric services, have you looked specifically for a way to deal with communication between psychiatric patients and health professionals?
Mr. Potter: I will try to address that question. Being able to communicate effectively in the Inuit language has long been a tradition in our program. We have what we call "community health workers," who started out as translators, essentially. Their job has developed over the years, but that translation function is still critical. In mental health services, it is a challenge. One promising area where we are doing more work and putting more resources into support is producing helpful results. It is tele-mental health services, whereby we do not take people out of the community where they can actually communicate with others. Rather, we have them stay and talk to their relatives and provide them a link to psychiatric services in facilities elsewhere through a video-conferencing system. I understand that has been a highly effective therapeutic intervention. We have been supporting the expansion and development of that kind of service across the country.
Senator Keon: That is most interesting. I spent one week up North a couple of years ago with our technology team to assist them in setting up telehealth. I am quite familiar with it, and it is a great asset.
Senator Cook: Mr. Potter, how do First Nations and Inuit access long-term mental health counselling?
Ms. Langlois: That is where our services would end. We would provide the short-term crisis mental health counselling and then a referral would be made to the provincial system. It would be accessed in the same way as any individual off reserve, through emergency or a family physician.
Senator Cook: Who would pay for the service in that instance?
Ms. Langlois: The province would pay.
Senator Cook: Would that be at the point of entry?
Ms. Langlois: Provinces are responsible for providing hospital and physician services for all their residents.
Senator Cook: That is under the Canada Health Act.
Ms. Langlois: Yes, for all their residents, no matter where they live.
Senator Cook: Off-reserve First Nations people are covered under the Canada Health Act.
Ms. Langlois: Also, on-reserve people are covered for hospital and physician services.
Senator Cook: I keep forgetting that you have hospitals on reserves.
Senator Gill: I do not think you have done much about the mental health issues of First Nations people. I have one recommendation for you. If you wish to do something, do it within the communities, because most of the local people have the remedies — they know what to do about it — instead of bringing people south to hospitals here. I would recommend that a program be set up with the people in their communities and they will find the solution.
Mr. Potter: If I may, senator, I totally agree. All of the information we have, both scientific and the advice we receive from First Nations and Inuit, indicates that the secret to better health services and outcomes, mental or physical, occurs when working with the communities and supporting them to support their members. That is absolutely critical.
Mr. Chairman, if I may, I would like to address the committee in writing on how to provide the services and whether we should pay the provinces to provide them.
The Chairman: Yes, absolutely.
Mr. Potter: One aspect is that the communities want to be empowered. They need to feel that they have more control of the health system. I am absolutely convinced that better health outcomes will not be achieved unless we can support the communities in taking a more active role. Our strategy is to try to work with the provinces and the communities, using the federal government resources, to see if we can design a health system in which communities can play that role. I do not think that we will get the results, as technically proficient as we may be, unless we can build a health system that is seen to be driven by the community, supported by the community and, often, delivered by community members.
The Chairman: I could not agree with you more. I only make the observation, apropos of Senator Keon's comments earlier, that that exact statement can be made about the delivery of health services to any community. It has nothing to do with the community being Aboriginal. I have no disagreement with you about the need to deliver the services at the community level, for all the reasons you have given. I would make the argument that everything you have said applies to communities collectively across the country, not only to on-reserve communities. I would like a more detailed response, if you would.
You said that you pay for 10 million prescriptions each year for about 750,000 people. Do you pay for prescriptions for off-reserve people as well?
Mr. Potter: There are approximately 750,000 people.
The Chairman: That is 12.5 prescriptions per year for each man, woman and child under your jurisdiction. I want to know if that number is right. I will try to obtain the Canadian average number of prescriptions and compare them. Your figure must be three to four times the Canadian average when you recognize that you are dealing with every man, woman and child. Perhaps I am completely wrong.
Mr. Potter: I have all of those details and I could provide the committee with an exhaustive report on the pharmaceutical expenditures by type.
The Chairman: That would be great. If the number of prescriptions is two to four times the Canadian average, it tells us how bad the health status is. Those numbers tell the story. Thank you.
The committee adjourned