CHAPTER 16:
NATIONAL MENTAL HEALTH INITIATIVES

16.1      TOWARD A NATIONAL MENTAL HEALTH STRATEGY

From the very beginning of its study of mental health, mental illness and addiction, the Committee has heard the call for a national mental health strategy.[356] Many witnesses have stressed the tremendous significance of and need for such a strategy, noting that Canada is alone among the G8 countries not to have one. In fact, it has been five years since the Canadian Alliance on Mental Illness and Mental Health issued A Call for Action: Building Consensus for a National Action Plan on Mental Illness and Mental Health.

While it is important to point out that there is no evidence to suggest that Canada treats people living with mental illness significantly differently than other highly industrialized nations, nevertheless the absence of a national approach to mental health issues represents an important national deficiency. Not having a national strategy symbolizes neglect of mental health issues by government; it also forecloses on a number of very concrete initiatives that would benefit people living with mental illness throughout the country.

 

16.1.1    What Kind of National Mental Health Strategy Is Needed?

Although many witnesses expressed support for the concept of a national strategy or plan, their views varied on its exact purpose and what it should contain. There were many suggestions relating to the role of the federal government in creating such a strategy.

Phil Upshall, National Executive Director of the Canadian Alliance on Mental Illness and Mental Health, testified that:

The Canadian Alliance on Mental Illness and Mental Health advocates for an overarching national action plan. … Our preferred option is a national action plan that is developed by a distinguished blue-ribbon panel including consumers, patients and families, which will advise the policy work of the federal, provincial, and territorial governments. We think that this is an essential element of a national strategy.[357]

For its part, the British Columbia Schizophrenia Society suggested that:

A national mental health plan should be developed to (i) focus on standardized care for the seriously mentally ill; and (ii) monitor outcomes across the country. A Canadian national mental health plan should also establish national standards for education, early intervention and family support that will lead to improvements in treatment and care for Canadians with serious mental illness.[358]

Some believed the federal government should take the lead in developing a national plan that would, in the words of Tina Pranger, Mental Health Consultant to Health and Social Services in Prince Edward Island, “provide direction to the provinces and territories in developing, refining and supporting their own mental health plans” and “include national standards for service delivery.”[359] Others, such as Jocelyne Green, Executive Director, Stella Burry Community Services in St. John’s, insisted on the need for the federal government to provide “targeted and significant levels of funding for mental health services” that the provinces could access only “if they deliver programs in line with national standards, with no ‘ifs’, ‘ands’ or ‘buts.’”[360]

From the beginning, the Committee has recognized that mental health, mental illness and addiction issues resonate with every level of government; they affect, to all intents and purposes, the entire population of Canada. Strategies are required at every level — locally, regionally, provincially, federally, and nationally.

The Committee believes it important to make the significant distinction between “national” and “federal,” and to be clear on what a feasible national mental health strategy could look like in Canada. Many tend to look on the federal government as the repository of all national efforts and, therefore, call on it to initiate the development of national strategies, independent of the particular sphere of activity.

With mental health reform, however, this approach cannot work. While there is a leadership role for the federal government in the development of a national approach to mental health, this level of government is not responsible for its development and enforcement. The Committee believes that, in Canada, any attempt to establish a national approach in health care related areas, including mental health,[361] must take into account, among other factors, the reality of which organizations actually deliver health-related services and supports and the fiscal capacities of each level of government.

It bears repeating that the provinces and territories are responsible for delivering health services, including mental health services, to the general population. The federal government carries this responsibility only for recognized or registered First Nations and Inuit, Canadian Forces personnel, federal offenders, and a few others that fall under the federal jurisdiction.[362]

The federal government’s influence on the way health care is delivered is largely exercised through its fiscal capacity, i.e., its spending power. The provinces and territories receive federal grants in exchange for agreeing to respect certain conditions on how they use these transfers. This is how federal legislation such as the Canada Health Act works. This basic fact sets limits to the role that the federal government can play in developing a national strategy or a national action plan relating to responsibilities that fall primarily within the jurisdictions of the provinces and territories.

 

16.1.2   Elements of a “National Strategy”

Does this report contain the elements of a “national strategy”? The answer depends on what one expects a national strategy to contain. Some of the ground-breaking recommendations put forward here by the Committee are, indeed, national in scope. But this report also contains recommendations directed at all levels of government (federal, provincial/territorial, regional and local) as well as at the providers of mental health services and supports. To some extent, at least, the report can serve as the basis upon which a national mental health strategy could be developed.

As in its previous reports on the acute care system, the Committee has made recommendations in this report on issues that fall outside the jurisdiction of the federal government. No effective, systematic approach to the delivery of mental health and addiction services could have been made otherwise.

The Committee recognizes that neither the provider groups nor the provincial or territorial governments to which many of the recommendations in this report are addressed are under any obligation to respond to our recommendations. Nevertheless, in our experience with previous health reports, we have found that if recommendations are based on careful consideration of the evidence, they are often received favourably by those to whom they are addressed, jurisdictional boundaries notwithstanding. The Committee is hopeful, therefore, that its recommendations on mental health, mental illness and addiction will be considered on the basis of their merit by all those to whom they are directed.

An overarching question the Committee believes of particular importance, given the extent to which the mental health sector has been neglected over the decades, is how to maximize the chances of this report’s recommendations being acted upon. It has become clear that a mechanism of some sort is needed both to undertake certain critical tasks at a national level and also to maintain a needed national focus on mental health issues.

 

16.1.3   The Creation of the Canadian Mental Health Commission

The Committee’s key recommendation to achieve this objective, a proposal to create a Canadian Mental Health Commission, was made public by the then Minister of Health, the Honourable Ujjal Dosanjh, on 24 November 2005, tabled in the Senate of Canada and released on the Committee’s website. Minister Dosanjh announced that the Government of Canada, along with all provincial and territorial Ministers of Health, with the exception of Quebec, had already agreed to the creation of the Commission; their agreement was based on the proposal that the Committee submitted to a meeting of the federal/provincial/territorial Ministers of Health on 23 October 2005. Steven Fletcher, health critic for the Conservative Party in the 38^th Parliament, also expressed his support for the establishment of a national Mental Health Commission.

Before presenting an expanded version of this proposal, the Committee would like to comment on the significance of its having already been endorsed and on the role the new Commission will play in the development of a “national” approach to mental health in Canada.

The announcement that a Canadian Mental Health Commission would be created was the culmination of several months of consultations between the Committee and many mental health stakeholders across the country. It was greeted with universal enthusiasm by those concerned with mental health issues in Canada. For example, Dr. John Service, Executive Director of the Canadian Psychological Association, wrote:

It is our belief that the announcement of the Commission was an historic event in Canada. It has the potential to significantly change the way we deal with mental health issues in this country. For the first time, we will have a pan-Canadian forum to examine and draw attention to successes and gaps and to work with governments and stakeholders to improve the lives of Canadians.

It is remarkable that the federal, provincial and territorial governments came together in such a short period of time to agree on a Commission. It is a testament to the fact that governments recognize the extent of the need and the necessity to address the need as quickly as possible. The governments are to be congratulated for their willingness to collaborate and to come to an agreement.[363]

The Canadian Collaborative Mental Health Initiative (CCMHI) also applauded the announcement and pointed to the potential advantages of the Commission’s structure:

A real strength of the Commission will be the partnerships it will develop with governments, employers, mental health stakeholder organizations and, in particular, Canadians living with mental illness and their families and caregivers. Advisory committees to the Commission will also play a big role in ensuring the breadth of mental health issues in Canada are well understood and adequately represented.[364]

For its part, the Canadian Mental Health Association (CMHA) saw the establishment of a Commission on Mental Health and Mental Illness “as a momentous step towards the development and implementation of a strategy to address the mental health needs of all the people of Canada.”[365]

Dr. Paul Garfinkel, President and CEO of the Centre for Addiction and Mental Health, stressed the importance of the proposal’s emphasis on reducing stigma and ending discrimination:

Every day we hear from patients and their families who delayed seeking treatment because they feared the social stigma that a diagnosis of mental illness or addiction would bring. In fact, research shows that two-thirds of affected people never seek treatment. The power of stigma cannot be underestimated, and this commitment by the Federal Government to create a national commission to help educate Canadians about the reality of mental illness — with the ultimate goal of eliminating all forms of discrimination against people and families living with mental illness — will be welcomed from coast to coast.[366]

It is no exaggeration to say that the creation of the Canadian Mental Health Commission heralds a new era in mental health in Canada. For the first time, there will be a body that can help to channel institutional and financial resources at a national level into a sector that has been systematically neglected. The Committee wholeheartedly commends all the Ministers of Health who have signed on to this proposal, as well as the Government of Canada for agreeing to fund the Mental Health Commission.

While the financial resources that are required for the Commission will come from the federal government, its institutional structure also encompasses the other levels of government in addition to non-governmental stakeholders. The Commission will operate at arm’s length from government; a majority of its board of directors will come from outside government, as will its Chair (the Mental Health Commissioner of Canada). Thus, no single group, including government, will be able to dominate the Commission’s Board of Directors. In this sense, it is very much a “national,” as opposed to a “federal,” undertaking.

 

16.1.4   The National Dimension in This Report

The creation of the Mental Health Commission is, in the Committee’s view, one of the two key components of what could be called a “national strategy” contained in this report. The second involves the creation of a Mental Health Transition Fund. If agreed to by the federal government, this Fund will permit the transfer of federal funds to the provinces and territories for their use in accelerating the transition to a mental health system  predominantly based in the communities in which people with mental illness and addiction live. The rationale for this fund is set out in detail in Chapter 5; later in this chapter (see section 16.5) we discuss how large this fund should be and how the money should be raised.

The Committee recognizes that many other recommendations in this report also have a national dimension, despite being directed only at one or another level of government. For example, the investment of an additional $25 million annually in mental health services research, as recommended in Chapter 11, will have a national impact, although the recommendation is directed solely to the federal government.

The recommendations involving the Mental Health Commission and the Mental Health Transition Fund, however, entail the creation of a new institution that brings together not only the different levels of government with responsibility for providing mental health services and supports, but also the people who actually deliver those services as well as the people who benefit from them.

The potential impact of creating of a Mental Health Commission is substantial. Should the Transition Fund also be created, these two entities will represent a truly momentous injection of institutional and financial resources into a sector that has been neglected for decades. The lives of many thousands of Canadians can be improved.

Nevertheless, the Committee hesitates to call this report a national strategy or plan. In other countries, such plans typically specify details about how various services should be provided and who will be responsible, and to whom, for the plan’s implementation.[367] Important specifics of this kind are not contained in this report; nor would it have been appropriate for the Committee to have included them.

Nonetheless, the national measures that the Committee has recommended in this report lay a firm foundation for an exploration of how a mental health plan could be developed, negotiated, and endorsed by all stakeholders. The Committee’s recommendations, implemented in full, would also move the reform agenda forward in immediate and concrete ways, including by providing funding for transformative change by the provinces and territories. In addition, the activities that the Mental Health Commission will undertake on its own (anti-stigma work and establishing a knowledge exchange centre) will significantly alter the landscape for people living with mental illness.

Thus, there is a plan of action in this report with a “national” dimension to the recommendations it contains. The plan is a feasible one tailored to the realities of health care delivery in Canada. The Committee fervently hopes that all stakeholders will agree that its implementation promises a huge advance for people living with mental illness and addiction.

16.2      A PROPOSAL TO ESTABLISH A CANADIAN MENTAL HEALTH COMMISSION

In this section, the Committee’s proposal to create a Mental Health Commission is reproduced as tabled in the Senate of Canada on 24 November 2005.[368] Section 16.4 contains additional comments on the proposal that the Committee feels it is important to make, including a more detailed discussion of the tasks the Commission will undertake “in-house” (a ten-year anti-stigma campaign and the establishment of a Knowledge Exchange Centre).

16.2.1   Rationale: Why a Commission?

Several factors led the Committee to recommend the creation of a Canadian Mental Health Commission:

a)      Although the Committee’s work and, importantly, recent actions by several provincial governments have begun to focus a long-overdue spotlight on mental health, it remains that the whole complex, pervasive problem of mental illness and addiction in Canadian society continues to be neglected. The Canadian Mental Health Commission will provide a much needed national (not federal) focal point that will keep mental health issues in the mainstream of public policy debates in Canada and accelerate the development and implementation of effective solutions to the long-standing problems of this sector.

b)      Those most directly affected are people living with mental illness, their families, friends and employers. But, given that, each year, one in five Canadians will experience a mental illness, virtually all Canadians will be affected, directly or indirectly, by mental illness and/or addiction. Mental illness is truly of national concern.

c)      No single level of government has the resources needed to deal with the full range of mental health issues on its own. Creating a national focus will add substantial value, especially with respect to exchanging information and facilitating collaboration among governments and between governments and stakeholders.

d)      In both public and private sector businesses and workplaces, mental health problems and substance abuse disorders are responsible for a large proportion of all disability, absenteeism and diminished workplace productivity. The proportion of workplace disability associated with mental illness and substance abuse is rising more rapidly than those associated with other illnesses and has been estimated to cost Canadian companies about $18 billion a year in recent years.[369] The economic as well as the social implications are both obvious and of universal concern.

e)      In every government, whether federal, provincial, territorial or municipal, responsibility for mental health issues is dispersed among several departments and agencies — health, social services, housing, etc.  Managing issues that span ministerial/departmental boundaries is notoriously hard; truly effective ways of doing so are few and far between.  The Canadian Mental Health Commission will benefit all governments by facilitating the exchange of information on best practices on how to deal with this classic interdepartmental issue.

f)       There is, as well, no easy mechanism now available for stakeholders in the mental health sector to exchange knowledge and distribute information about best practices coast to coast to coast. A national Knowledge Exchange Centre will be an integral part of the Canadian Mental Health Commission.

g)      Canadians must become better educated about the reality of mental illness. They must be encouraged to understand and be more tolerant of people living with mental illness and addiction. To those ends, a national campaign is needed to combat the stigma and discrimination associated with mental illness. Such a campaign will be most effectively managed nationally by the Canadian Mental Health Commission.

The Committee considered alternatives to the creation of a national commission. It concluded, however, that no existing organization has a mandate that encompasses, or could be modified to encompass, a majority of the factors set out above. For example, the mandate of the Canadian Centre for Substance Abuse is too narrow to encompass the range of mental health issues of concern to this Committee. Moreover, it has no role in changing public attitudes.

While mental health falls naturally under the purview of the Health Council of Canada, its chair, Michael Decter, has told the Committee that it will be some years before the Council’s extremely full agenda will be cleared sufficiently to address mental health adequately. The Health Council’s mandate also includes monitoring the performance of all government health care systems. The Canadian Mental Health Commission proposed by the Committee explicitly will not have any role in monitoring any government’s performance in dealing with mental health and addiction.

It is clear to the Committee that a new national organization is required. It must be emphasized, however, that the success of the proposed Commission in contributing to improvement of the mental health of Canadians depends critically upon there being in place strong structures and committed people at the provincial and territorial level to translate policy, knowledge and ideas into action on the ground. This is true also with respect to the mental health services provided by the federal government through its various entities such as the First Nations and Inuit Health Branch of Health Canada and Correctional Service Canada.[370]

The Committee’s intention is that the work of the Canadian Mental Health Commission will complement, and not replace, that being done by existing structures and people at the federal, provincial and territorial levels.

Finally, consistent with its view that structural solutions to any problem should not be permanent, the Committee recommends that the Commission “sunset” in ten years.

 

16.2.2   Guiding Principles of the Canadian Mental Health Commission

The key principles are that the Commission:

 

 

§         Be an independent, not-for-profit organization at arm’s length both from governments and from all existing mental health “stakeholder organizations”;

§         Make those living with mental illness, and their families, the central focus of its activities;

§         Build on and complement initiatives already under way throughout Canada, and avoid duplicating the roles and activities of those currently working in mental health;

§         Establish partnerships with governments, employers, mental health research organizations and service providers, other health care organizations, and the spectrum of existing national and international mental health stakeholders;

§         Put its emphasis on evidence-based mental health policies and methods of service delivery;

§         Rigorously evaluate, assess and report on its own activities, in order to ensure their appropriateness and efficacy and to maintain the Commission’s credibility with governments, its collaborating stakeholders and the Canadian public.

 

16.2.3   Mission/Mandate of the Commission

The mission of the Commission is:

§         To act as a facilitator, enabler and supporter of a national approach to mental health issues;

§         To be a catalyst for reform of mental health policies and improvements in service delivery;

§         To provide a national focal point for objective, evidence-based information on all aspects of mental health and mental illness;

§         To be a source of information to governments, stakeholders and the public on mental health and mental illness;

§         To educate all Canadians about mental health and increase mental health literacy in Canada, particularly among those who are in leadership roles such as employers, members of the health professions, teachers, etc.;

§         To diminish the stigma and discrimination faced by Canadians living with a mental illness, and their families.

 

16.2.4   The Commission’s Method of Operation

To discharge its mission, the Commission will form collaborative relationships that amount to partnerships with governments, employers, mental health stake­holder organizations, professional associations, research organizations and, in particular, those Canadians living with mental illness and their families. Such relationships will be developed with existing organizations and committees such as the Canadian Institute for Health Information, the Canadian Institutes of Health Research, the Canadian Alliance for Mental Health and Mental Illness and its constituent organizations, the Global Economic Roundtable on Mental Health and Addiction, the Canadian Centre for Substance Abuse, the Public Health Agency of Canada,  federal/provincial/territorial Committees on Mental Health and Substance Use, and other relevant organizations and committees concerned with mental health and addiction.

The coordinating functions and collaborative role of the Commission will help to reduce duplication of effort and to facilitate cooperation among all stakeholders, particularly governments and service providers.

In order to discharge its collaborative mandate, the Commission will establish, in addition to partnerships, a number of advisory committees.  While it will be up to the Commission to decide on their number and composition, two advisory committees are obligatory — one composed of representatives of all federal/provincial/territorial governments and another of representatives from Canada’s Aboriginal communities.[371]

The Commission will assist governments, employers, and service providers in a non-confrontational way, recognizing that the circumstances in which mental health policies and services are provided in every community are distinct. Yet every community can benefit from lessons learned elsewhere, especially given the linkage between the most effective mental health services and primary and community-based care — areas in which best-practice information would be particularly helpful both to communities seeking to improve the effectiveness of their own services and to provincial and territorial governments.

 

16.2.5   Activities of the Commission

The Commission’s activities can be divided into six broad categories:

a)       Development of a National Mental Health Strategy

§         Proposing goals relating to mental health, mental illness and addiction and a framework for a national strategic plan to achieve them, recognizing that such a plan must:

o        take into account existing federal, provincial and territorial mental health plans;

o        reflect the fact that governmental responsibility for mental health  is very much inter-ministerial in nature (i.e., not confined to ministries of health);

§         Providing information to governments, stakeholders and the public on mental health issues (section 16.2.9 expands on the benefits of the Commission’s being a source of information to governments on such issues);

§         Reporting annually to the Federal/Provincial/Territorial Conference of Deputy Ministers of Health and the Deputy Ministers responsible for Social Services (and of other ministries/departments as required);

§         Ensuring that the specific issues on which the Commission will focus at any given time are in accordance with the interests of its Board and its committees as they evolve over time.

b)       Synthesizing Relevant Knowledge for Application to the Canadian Context

§         Developing reliable and valid measures, indicators and tools to facilitate monitoring by governments and health authorities of the performance of their mental health systems over time;

§         Developing benchmark capacity requirements for different types of service along the entire spectrum of mental health services.

c)        Encouraging Research

§         Through the Canadian Institute for Health Information and Statistics Canada, collecting on a regular basis data on the mental health status of Canadians and providing, on the Commission’s website, a comprehensive database for use by researchers and governments;

§         Encouraging the Canadian Institutes of Health Research (CIHR) to support research into the best structures and/or mechanisms to supply, most efficiently, the wide range of services required by people living with mental illness and addiction;

§         Encouraging CIHR to support research on how to measure the outcomes of mental health services so that governments can assess the success and effectiveness of their mental health programs.

d)       Collaborative, Integrative and Networking Activities

§         Supporting consensus-building activities relating to adoption of the best evidence-based clinical and service-delivery practices and system-level approaches;

§         Facilitating the sharing of knowledge across jurisdictions and stakeholder groups regarding effective approaches, developments and innovations;

§         Promoting the integration of primary care services with other forms of service delivery, such as secondary and tertiary treatment services, health promotion and disease prevention programs;

§         Fostering greater collaboration between addiction and mental health stakeholders with a view to improving services and supports for the many individuals coping with addictions who are also living with mental illness;

§         Providing information on how services for people with concurrent disorders can be most effectively and efficiently integrated;

§         Working with employers and organizations, such as the Business Roundtable on Mental Health, Mental Illness and Addiction, to develop programs to reduce the burden of mental illness and addiction on those affected and on the economy.

e)        Public Education and Public Awareness

§         Implementing a national anti-stigma program to educate Canadians about the reality of mental illness, with the ultimate goal of eliminating stigma and all forms of discrimination against people and families living with mental illness;

§         Mounting targeted communications campaigns on specific aspects of mental illness (e.g., the signs of serious depression) aimed at specific target audiences (e.g., school-aged children);

§         Educating Canadians on ways and means of optimizing their own and their loved ones’ mental health;

§         Promoting population mental health and the prevention of mental illness and addiction;

§         Sponsoring activities such as conferences, seminars, and an annual awards program to celebrate people who provide exceptional leadership in mental health.

f)        Knowledge Exchange

§         Creating an Internet-based national Knowledge Exchange Centre for the distribution of information about mental health;

§         Publishing studies, reports and other documentation on mental health;

§         Monitoring national and international developments in mental health policies and services and, where relevant, incorporating this information into the website of the Knowledge Exchange Centre;

§         Making the Knowledge Exchange Centre accessible to people living with mental illness, their families and caregivers, employers, researchers, governments and other stakeholders;

 

 

§         Linking the Knowledge Exchange Centre website with relevant sites operated by provincial governments and stakeholder groups.

The Commission will both contract out projects and undertake work itself on behalf of various Canadian and international institutions, including both governments and non-governmental organizations in the private sector.

It is important to emphasize that the Commission is to be advisory and facilitative, not operational in nature, apart from its commitment to undertake some project and research work that is consistent with its mission.

Specifically, the Commission will not:

§         Provide any services itself, except for its management of the Knowledge Exchange Centre and the national anti-stigma campaign, or in association with its doing work under contract for other institutions;

§         Monitor the performance of any government with respect to mental health services. The Commission will recognize explicitly that each government’s approach to providing mental health services will reflect the particular characteristics of that jurisdiction.

 

16.2.6   Composition of the Board of the Commission

The Commission will be established under federal legislation or other appropriate authority (e.g., through incorporation as a not-for-profit corporation).

In structuring the Commission’s Board, two principles must be kept in mind:

§         First, as set out in the guiding principles outlined above, the Commission will operate “at arms-length both from governments and all existing mental health stakeholder organizations.” Therefore no single stakeholder group, including government, may have a majority of seats on the Board;

§         Second, to facilitate its effectiveness, the Board should not be too large. Adequate input from all stakeholder groups can be ensured through the judicious use of advisory committees (including the federal/provincial/territorial governmental advisory committee and the Aboriginal advisory committee specified above).

These two constraints, together with the precedents established by the composition of the Boards of the Canadian Institute for Health Information and the Canadian Patient Safety Institute, lead the Committee to recommend that the Board of the Canadian Mental Health Commission have nineteen members, approximately one-third from governments and approximately two-thirds without any government affiliation or connection.

 

Therefore, the Board of the Commission will consist of:

a)      Five provincial governmental nominees chosen as follows: one from the Atlantic provinces, one from Quebec, one from Ontario, and two from the Western provinces.

b)      One member nominated jointly by the three territorial governments.

c)      One member nominated by the federal government.

d)      Eleven nominees at large, chosen by the seven government nominees to represent a wide range of stakeholders involved in mental health issues, including those living with mental illness, their families, caregivers, service providers, the professions, employers, etc. No nominee can represent a specific organization; each must be widely recognized as reflective of the mental health community at large.

e)      A non-governmental chair (the Canadian Mental Health Commissioner) chosen by the seven government nominees.

Board members will serve three-year terms and be eligible for renewal once. All, including the Commissioner, will be part-time.

 

16.2.7   Staff of the Commission

The full-time staff of the Commission, initially consisting of 25 to 30 people, will be under the direction of an Executive Director.

 

16.2.8   Funding for the Commission

All funding (the amount of which is currently under study by the Senate Committee) will be provided by the federal government. The budget will consist of:

§         Core funding for the Commission’s  Board, staff, and operations;

§         Funding “earmarked” for establishment and management of the Knowledge Exchange Centre;

§         Funding “earmarked” for public education and anti-stigma and other communications campaigns.

 

16.2.9   Appendix

Every government faces a myriad of issues as it attempts to improve services to people living with mental illness.  While some of these issues are specific to a jurisdiction, many others are broadly applicable across jurisdictions.  It is with respect to the latter that the Commission can play a valuable role for all governments by providing information on what has proven to be most effective in other provinces and other countries (i.e., best practices), sparing each government from having to gather and assess the information on its own.

Four such issues illustrate the point:

a)       Strategic Investment Decisions

To plan effectively for the transformation of the mental health service delivery system across the continuum of provincial, regional and community-based services, it is critical that governments have available, evidence-based information with respect to the most effective practices elsewhere in Canada and in other industrialized countries.  In the absence of such information, governments have little defence against pressures to adopt particular policies and practices based only on anecdotal evidence or representing “flavour-of-the-month” fads.

Having collected information on and evaluated practices used elsewhere, the Commission will provide leadership in building a natural consensus around best practices.

b)       Primary Care and Community-Based Service Delivery

Experiments in new ways of integrating mental health services into multidisciplinary primary care clinics and of delivering community based services are taking place across the country. Evaluation of the effectiveness of these experiments and developing a comparison of evidence-based best practices will be very useful to governments and service providers alike.

c)         Chronic Mental Illness

People living with a chronic mental illness need a range of services, many of which (social housing, for example, and various types of income support and training programs) are not provided by health departments. Given that they are usually the responsibility of different government departments, often there is no mechanism, or at least no easy mechanism, to coordinate the range of services needed by a single consumer. Because no single department “owns” or has sole responsibility for a person living with a mental illness, even an aggressive case manager — clearly part of the solution to the problem — will have difficulty crossing departmental lines.  That some of these services, social housing for example, have fallen out of political favour in recent years makes solving the problem even more difficult.

The Commission will help governments in two ways: 

§         First, by evaluating mechanisms that have been used elsewhere to coordinate effectively multi-department services for a single consumer, and proposing options for governments to consider.

§         Second, by identifying gaps in the services required and encouraging governments to fill them.

d)       Mental Health Human Resources

It is widely acknowledged that a severe shortage of mental health human resources exists across the whole spectrum of mental health service providers.  It is also acknowledged that existing training programs (and programs designed to update the skills of people currently working in the field) need modification.

For example:

§         Few people are trained in how to help those who suffer from concurrent disorders.  Often someone with both a mental illness and an addiction is treated sequentially; the treatment is frequently ineffective because the problems are linked.  The solution to this problem requires significant change in the training of mental health workers.

§         Nurse practitioners and nurses need more training in how to help people living with a mental illness and how to identify the presence of concurrent disorders.  This requires changes in academic curricula, always a very slow and difficult thing to achieve. Family members also need training of the same kind but in community settings.

§         Scope of practice rules must be modified if multi-disciplinary primary care clinics are to become the predominant point of entry into a transformed mental health system.  There is bound to be resistance to such changes.

§         Assessment of the skill set required to provide various mental health services will enable accurate forecasts to be made of the numbers of mental health workers of different categories required in Canada in the future.

By providing an informed, authoritative source of national pressure, equally independent of government, advocacy groups, service providers, and those responsible for providing training and education programs for mental health workers, the Commission will reinforce governments as they seek changes of the kind listed above.

16.3      GETTING THE COMMISSION UP AND RUNNING

As noted earlier, on 24 November 2005, Minister Dosanjh announced that the Government of Canada, along with all provincial and territorial Ministers of Health, with the exception of Quebec, had agreed to the creation of the Canadian Mental Health Commission and the Government of Canada agreed to fund the Commission. The Committee believes that it is essential to move forward quickly, and recommends:

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That a Canadian Mental Health Commission be established and that it become operational by 1 September 2006. That the guiding principles, mandate, method of operation and activities of the Canadian Mental Health Commission be as specified in sections 16.2.2 to 16.2.5 of this report. That the composition of the Board of the Commission and its staff be established as set out in sections 16.2.6 and 16.2.7 of this report.

That the Government of Canada provide $17 million per annum to fund the operation and activities of the Commission; of this amount, $5 million per annum should be dedicated to a national anti-stigma campaign, $6 million per annum devoted to the creation of the Knowledge Exchange Centre and $6 million per annum used to cover the operating costs of the Commission.

16.4      FURTHER COMMENTS ON THE PROPOSAL TO CREATE A CANADIAN MENTAL HEALTH COMMISSION

16.4.1   The Nature of “Representation” on the Commission

It is important to make a few additional remarks on the how the Committee envisages choosing the members of the Board of Directors of the Canadian Mental Health Commission and on the nature of their role.

 

 

The composition of the Board of the Commission was crafted so that it will be able to propose and advocate for innovative policy and educational initiatives that will significantly improve the lives of people living with mental illness across the country. In determining the number of governmental representatives on the Board, both the Committee and the provincial governments with which it has consulted believe it important to include a representative from the three territorial governments, in great measure because of their significant Aboriginal populations. The Committee believes this is one way to ensure that the concerns of Canada’s Aboriginal peoples are at the forefront of the Commission’s activities.

It will be crucial to establish a balance in selecting the 12 non-governmental directors. The Committee believes very strongly that these directors should neither be, nor be seen as, “representatives” of any particular stakeholder group or organization.

It will, of course, be essential that the full range of views and expertise from all stakeholder groups be heard, not only via the various advisory committees to be created by the Commission but also at the Board of the Commission itself. However, it is critical that Board members not see themselves, or be seen, as representing any of the narrowly focused interest groups that now constitute integral parts of the current mental health system. There can be no room on the Board for the kind of “silo” approach that is still all too common in the organization and delivery of mental health services and supports. The Board members must be capable of looking at the broad system as a whole and making this the centre of the Board’s concerns.

The key to the success of the Commission will be its ability to take into account a wide cross-section of views and to distill these into a coherent overall program that will improve the lives of people living with mental illness and addiction from coast to coast to coast. The non-governmental members of the Board must be carefully selected to ensure that they bring a diversity of experience to the table but are nonetheless able to look at what needs to be done primarily from the broad perspective of the country as a whole.

There is no doubt that the Board will need in its membership people with knowledge of a variety of mental health constituencies. They must include, first and foremost, people living with mental illness themselves as well as their families. In addition, there must be individuals who understand and have experience of issues confronting people of Aboriginal origin, and the special needs of children and youth, as well as service providers inside and outside the medical professions, and experts in as many areas of mental health as possible.

Additional input from all of these constituencies will also be channelled into the Commission through advisory committees that will be created. In this way, the Committee believes it will be possible for the Commission to have access to the full range of views that will be needed to make sure that its initiatives respond to the needs of Canadians living with mental illness without developing a structure for the Commission that would be so unwieldy as to prevent it from completing its mandate.

 

16.4.2   Anti-Stigma Campaign

In its first report on mental health, the Committee devoted an entire chapter to the issue of stigma and discrimination.[372] Witnesses have consistently told the Committee that a systematic effort to reduce stigma and combat discrimination is essential to improving the situation for people living with mental illness.

During its cross-country hearings, this point was reiterated by Jean-Pierre Galipeault of The Empowerment Connection:

[A]ll of the efforts in terms of mental health policy development, system reform, consumer and family member involvement will be unattainable without making some efforts to address the issues of stigma and discrimination.[373] 

The Committee has included development of a sustained anti-stigma campaign as a key element of the mandate of the Canadian Mental Health Commission. While it will be up to the Commission to work out the details of how this campaign should be undertaken, the Committee believes it is important to summarize the results of its own findings on this issue.

In its first report, the Committee quoted Professor Heather Stuart from Queen’s University, who emphasized the importance of carefully targeting anti-stigma interventions. She told the Committee:

With respect to anti-stigma interventions, how do we stop stigma and discrimination? We are learning from the World Psychiatric Association work that one size does not fit all. It is a waste of time and energy to embark on a large, public education campaign that is designed to improve literacy as an anti-stigma intervention because segments of the population have different views.[374]

Professor Stuart also noted the connections amongst a number of dimensions to anti-stigma work. She told the Committee that the need to carefully target anti-stigma interventions also pointed to the importance of reaching people at an emotional as well as an intellectual level; it was also important to involve people living with mental illness themselves in these campaigns:

When we talked about targeting things, we were trying to target experiences. We figured out we had to get them at an emotional level. We had to make them aware that their whole system of beliefs was somehow ill-founded. One of the best ways to do that was to construct situations in which people who have a mental illness could meet people who have perhaps never met someone with a mental illness, under controlled and constructive kinds of situations. They would talk about their mental illness. They would convey factual information, but more important, they would convey information at a human level. That is what made the difference.[375]

This point was reinforced by Tara Marttinen, who told the Committee of her experience of speaking about her own illness:

I have spoken to a diverse range of individuals and groups regarding my illness. Because I am healthy, fairly articulate and approachable, people are generally more receptive to learning about the disease, and I try to shatter those barriers of stigma that people often have. Hence, I strongly recommend implementing a mental health ambassadors program that is not volunteer-based. I believe this should be a paid position and this program would eliminate some of the stigma I think that a lot of people with mental illness have to endure.[376] 

Jean-Pierre Galipeault told the Committee that this kind of effort has to be undertaken at the local level, and sustained over time.

One approach is the old grinding approach, what I am starting to call the “one-block-at-a-time” approach.  A couple of years ago a manager of a mental health program in downtown Dartmouth asked me how can we make sure that consumers are viewed as full citizens. I think part of the answer is those of us who are involved in this [have] a responsibility to assist in this regard.  I told her to take a one-block or a two-block radius of  you’re the program location and hold a town hall meeting and have consumers present and talk to the citizens in that area. I told her to start knocking on doors, dropping off flyers, inviting people out and letting them know how consumers contribute to the economic well-being of that two-block community and how they contribute to the cultural mosaic of that community.  You work those two blocks for a period of months or a year and then you spread out to two more blocks.  I think it is a long, slow approach, but I think it is part of the solution.[377]

Several witnesses also highlighted the importance of making resources available across the country to support this kind of campaign. The Honourable Elvy Robichaud, Minister of Health and Wellness in New Brunswick, told the Committee:

Stigma is more difficult to address, and is not open to legislative protection as is discrimination under the human rights legislation. In this area, the federal government could play a major leadership role. Anti-stigma and social marketing campaigns are costly and often beyond the fiscal resources available in our province, or if we did it on our own. It might be a whole lot better if all jurisdictions would get into the act and have something that is at least essentially the same. Usually we can adapt to most any Canadian jurisdiction. Further, this is an area in which the federal government has demonstrated competence and leadership — for instance, on the tobacco campaign — and one in which federal initiatives would be beneficial to all provinces and territories.[378]

Reid Burke, Executive Director, Canadian Mental Health Association of Prince Edward Island, emphasized both the need to sustain anti-stigma campaigns over time and the need to focus on the potential for recovery:

Social marketing and changing attitudes is the way to go.   It is not going to happen with one campaign.  ParticipAction took 10 or 15 years and now everybody well understands how important that is.  If we want to call it “mental fitness” or “mental wellness,” there needs to be a concerted effort in this country to put money into social marketing that normalizes mental health.  I do not think that will take away from the devastating effects of the illness, but we need to promote hope, as well as recovery and resilience.[379]

The Committee was very impressed by initiatives undertaken by the Australian government to educate people about the realities of mental illness and to combat stigma. In particular, the Committee believes that there is much to learn from the separate, not-for-profit, private company that was funded by the Australian government called “beyondblue.” The company was established in October 2000 with the objective of promoting a better understanding of depression. It works in partnership with health services, schools, workplaces, universities, media and community organizations, as well as with people living with depression, and thus brings together both expertise in depression and personal experience of the problem.[380]

In its plan for the years 2005-2010, beyondblue notes that:

§         As an independent national body, beyondblue can reach beyond government politics and policies into states, territories and local communities and across regional and rural Australia. beyondblue will establish new and expand existing programs to meet emerging national priorities for prevention, treatment and awareness of depression, anxiety and related substance use disorders.

 

§         beyondblue’s collective national strengths are greater than an individual state-based focus on depression. It is cost-effective for all state and territory governments to conduct their promotion, prevention and early intervention strategies for depression and related disorders in partnership with beyondblue. The return on investment through delivery of national programs and website provides outcomes that are greater in value than the individual contributions made by state and territory governments.

§         States and territories already benefit from the greater understanding of depression generated by beyondblue’s national awareness programs, positive media and community profile, and the beyondblue website with its series of clinical fact sheets; interactive on-line depression self-assessment; media centre and supporting links.[381]

Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, for the Department of Health and Ageing, Government of Australia, told the Committee that the various initiatives undertaken in Australia had helped improve “mental health literacy in the Australian population by about 10 percentage points since 1996.” He also told the Committee that:

our hospital contact data and our health service contact data show that there is a greater proportion of the population seeking care than was the case when we did our epidemiology study. We would conclude from that that they are now at least more prepared to seek treatment…[382]

A recent study of the impact of beyondblue confirmed Mr. Casey’s assessment, and noted that:

The data are consistent with beyondblue having had a positive effect on some beliefs about depression treatment, most notably counselling and medication, and about the value of help-seeking in general. These findings suggest that national awareness campaigns may be effective in improving community mental health knowledge. The data also demonstrate the potential value of population monitoring of mental health literacy.[383]

There are thus six points that stand out in with regard to building an anti-stigma campaign in Canada. The evidence strongly suggests that, to be successful, an anti-stigma campaign must:

1.       Be carefully targeted to specific audiences;

2.       Be sustained over a substantial period of time;

3.       Both educate people about the reality of mental illness and engage them at an emotional level;

4.       Involve people living with mental illness as spokespeople;

5.       Focus on the potential for recovery and highlight the positive contributions made to local communities by people living with mental illness;

6.       Deploy national resources that can be adapted to regional and local circumstances.

 

 

 

The Committee believes that these lessons should guide the Mental Health Commission in the design and implementation of the anti-stigma campaign with which it has been charged.

 

16.4.3   Knowledge Exchange Centre

As outlined above, the second major task that the Canadian Mental Health Commission will undertake is the creation of a Knowledge Exchange Centre. Many witnesses pointed to the need for such a centre.

Moreover, in October 2005, the Committee received a detailed proposal from three distinguished academics that contains recommendations that align very closely with the Committee’s intentions. The following observations draw on this submission by Goering, Goldner and Lesage[384] and expand on the description contained in the Committee’s proposal to create the Commission reproduced above (see section 16.2.1).

The authors call for the creation of a “Canadian Mental Health Services Knowledge Translation Network” that is very similar to the Knowledge Exchange Centre and related functions of the Commission in the Committee’s proposal. The network would be 

a dedicated national, expert resource to facilitate mental health services knowledge translation, including the use of research syntheses and best practices across the country regarding the organization and delivery of mental health prevention, treatment, rehabilitation and support services. …The Network would facilitate the exchange of the best available knowledge between mental health services knowledge producers and users across Canada. It would facilitate the translation of mental health services research into “on the ground” policies and practices.[385]

Based on a scan of several organizations in Canada (including the Canadian Centre on Substance Abuse, the Canadian Institute for Health Information, and the Canadian Institutes of Health Research) the authors found that “while several individuals and organizations across Canada are engaged in mental health services knowledge translation activities in a variety of capacities, this function is typically not their primary focus,” and that “a national, dedicated focus for carrying out the mental health services knowledge translation function, currently does not exist.”[386]

The Committee agrees that these functions can best be carried out by a “neutral source, one that is not affiliated or driven by any current mandate or particular stakeholder interests, other than knowledge translation.”[387] Such an organization would produce “research syntheses, national and best practice reports regarding the organization and delivery of mental health prevention, treatment, and rehabilitation and support services”[388]  targeted at governments, providers, and people living with mental illness and their families.

The authors point out that:

Effective knowledge translation also requires expertise in determining what constitutes quality knowledge and the ability to develop and apply optimal methodologies for effective knowledge transfer and utilization. Expertise on mental health service and system issues is vital given the particularly difficult and complex issues with which this sector must grapple — stigma and discrimination, and a low public policy profile.[389]

This would entail both “pushing” research results out to users and facilitating the ability of people to “pull” material from the organization’s database, as well as allowing exchanges between both “pushers” and “pullers.” Thus it would be possible to do the following:

“Push” research findings out to users:

§         Translation of available high-quality, relevant mental health prevention and services research;

§         New mental health services research syntheses/summaries;

§         New national reports on the state of the mental health system;

§         New national reports on the status of mental health of Canadians;

§         New best-practice reports on mental health services; and

§         Toolkits that provide means of evaluating the fidelity and outcomes of programs.

Facilitate user “pull”:

§         Database of existing knowledge syntheses, national and best-practice reports;

§         Mental health services knowledge needs assessments; and

§         Capacity development through the training and education of knowledge users —  i.e., federal, provincial and territorial planners, decision-makers and leaders of service providers and community organizations, as well as advocates for people living with mental illness.

Facilitate exchange between “pushers” and “pullers”:

§         Provide a rapid response consultation service on priority areas, based on the best available knowledge;

§         Educational symposia, seminars, and workshops that facilitate knowledge exchange; and

§         A comprehensive Internet-based knowledge exchange portal.^[390]

The Committee also agrees with the authors that the Knowledge Exchange Centre should “collaborate with existing organizations within and outside of the federal and provincial/territorial governments to avoid duplication and ensure that its efforts add value.”[391]

The authors also rightly point out that there are many tasks that the Centre should not undertake, including: 

§         Funding and undertaking specific research projects;

§         Recreating existing knowledge, data, or information;

§         Recreating existing knowledge transfer tools and resources (e.g., Canadian Health Services Research Foundation);

§         Maintaining research databases;

§         Providing 1-800 service for consumers seeking to access mental health services;

§         Directing consumer/provider/system advocacy; and

§         Implementing knowledge (i.e., policy or service implementation at the provincial, regional, local and individual levels).^[392]

The Committee believes that the Canadian Mental Health Commission should draw on these observations as it establishes the Knowledge Exchange Centre.

 

16.5      THE NEED FOR FEDERAL INVESTMENT IN MENTAL HEALTH

As discussed in Chapter 5, a number of significant benefits would be realized by accelerating the transition to a community-based system of mental health care. Research reviewed in that chapter shows that community care leads to better mental health outcomes,[393] and that treatment within the community environment can improve access to care while making the mental health care system more sustainable. It also enables greater participation in the organization and running of the system by people living with mental illness and their families, community organizations, and voluntary health organizations.

Most importantly, the provision of mental health services and supports in the community fosters recovery by giving people living with mental illness more autonomy and independence. They gain the ability to live in their communities with minimal intervention by formal services; to the greatest extent possible, they make their own decisions.

Despite these benefits, we saw in Chapter 5 that the movement toward a community-based system has not fully taken root. In many cases, deinstitutionalization has been undertaken without the necessary community supports being in place. The result has been that far too many people living with mental illness have ended up in prisons and homeless shelters — indeed, prisons and shelters have become the asylums of the 21^st century. Alternatively, families have been burdened with responsibility for care.

Part of the problem has been that it has proven difficult to fund the costs of transition from institutional to community care. During the transition period the old system must be sustained until the new one can take its place. As explained in Chapter 5, the Committee believes that in order to complete this transformation of the mental health care system from an institutionally based system to one that is predominantly based in the community, a targeted investment by the federal government is needed in the form of a Mental Health Transition Fund.

In the Committee’s view, this Mental Health Transition Fund (MHTF) should have two main components: a Basket of Community Services (BCS) to assist provinces to provide services and supports in communities to people living with mental illness, and a Mental Health Housing Initiative (MHHI) to provide federal funds for the construction of new affordable housing units, as well as for rent supplements so that people living with a mental illness, who could not otherwise afford to do so, can rent suitable accommodation at market rates.

Both of these initiatives would be subject to the same ten-year sunset provision as the Canadian Mental Health Commission; neither would entail new open-ended funding obligations on the part of the federal government.

With regard to the BCS, research shows that the costs of supporting and treating people in the community are roughly equivalent to the costs of the old institution-heavy system.[394] This means that once a new “steady state” has been achieved, it will be sustainable with the same level of provincial government spending as was devoted to the institutional system it will have replaced. This will allow withdrawal of support by the federal government after a transition period. With regard to the MHHI, it has a specific target — the elimination of discrimination in the provision of affordable housing to people living with mental illness; it too will end after ten years.

As noted in Chapter 5, the Committee has been very careful in crafting its recommendations to ensure that the Mental Health Transition Fund is a genuine transition fund. It is designed solely to cover the costs associated with the shift from one way of organizing mental health services to another that will cost the same once the transition is complete. In this, it is unlike many other federal initiatives that have also been called “transition funds,” such as the Primary Care Transition Fund. Too often, such federal initiatives have entailed the creation of new programs that must either be supported by new provincial money or disbanded once the federal funding that sparked their creation has come to an end. Such initiatives place subsequent ongoing obligations on provincial and territorial governments to fund them.

The Committee believes strongly that the federal government must provide the funds needed to accelerate the transformation of the mental health care system. Therefore, the Committee recommended in Chapter 5:

108

That the Government of Canada create a Mental Health Transition Fund in order to help accelerate the transition to a system in which the delivery of mental health services and supports is based predominantly in the community. That this Fund be made available to the provinces and territories on a per capita basis, and that the Fund be administered by the Canadian Mental Health Commission that has been agreed to by all Ministers of Health (with the exception of Quebec). That the provinces and territories be eligible to receive funding from the Mental Health Transition Fund for a Basket of Community Services, as long as these projects:

·         Would not otherwise have been funded; that is, these projects would represent an increase in provincial or territorial spending on mental health services that is over and above existing spending on services and supports plus an increment equal to the annual percentage increase in overall spending on health; ·         Contribute to the transition towards a system in which the delivery of mental health services and supports is based predominantly in the community. That, as part of the Mental Health Transition Fund, the Government of Canada create a Mental Health Housing Initiative that will provide funds both for the development of new affordable housing units and for rent supplement programs that subsidize people living with mental illness who would otherwise not be able to rent vacant accommodation at current market rates. That, in managing the housing portion of the Mental Health Transition Fund, the Canadian Mental Health Commission should work closely with the Canada Mortgage and Housing Corporation.

 

The requirement that Transition Fund monies be incremental to current provincial/territorial spending on mental health should not act as a disincentive to improved productivity in delivering mental health supports and services. The availability of new funds should not deter anyone in the mental health system from actively working to use all public funds as efficiently as possible. The Committee believes it important that savings derived from productivity increases be available to health departments to invest throughout the health care system and not exclusively on mental health and addictions.

 

16.5.1   Managing the Transition Fund

The Committee believes strongly that the Canadian Mental Health Commission should manage the Mental Health Transition Fund. The Commission will be a truly national body with expertise like none other in mental health care. It will be able to consult all stakeholders on how best to ensure that the fund is used effectively, and it will be able to collaborate with the provinces and territories on the design, administration and implementation of the fund.

As discussed in Chapter 5, the Commission would not direct how the monies from the Basket of Community Services portion of the fund should be utilized, other than to ensure that they are used to support the transition to community-based services (such as Assertive Community Treatment Teams, Home Withdrawal Management Programs, Intensive Case Management and Crisis Intervention Services) and to verify that federal money is used to increase the amount that provinces and territories would otherwise have spent on mental health services and supports. The Committee has deliberately left open which specific programs would be covered under the Basket of Community Services. In other words, it has not attempted to define a comprehensive list of services and supports that would be eligible to receive money from the Mental Health Transition Fund.

In Chapter 5, the Committee explained the many reasons for adopting such a non-prescriptive approach. In part, it is based on the recognition that the Committee does not have the necessary expertise to undertake such a task. There is also the reality of regional and local diversity of circumstance — needs are so varied, resources so differently distributed that it would not be appropriate for any national body to attempt to specify in detail which services and supports deserve to be funded. Any examples that are given in this report are just that — examples of the kinds of services and supports the Committee believes should qualify for Transition Fund support.

The Committee also believes that the fund should be distributed to the provinces and territories on the basis of population. However, access to family and community-based health care services is a particular challenge in the territories, where the distribution of small populations across vast and remote regions poses huge obstacles to community-based delivery of mental health services.

 The federal government recognized these difficulties at the September 2004 First Ministers meeting on health care by creating a Territorial Health Access Fund ($150 million over five years). The Committee also acknowledges the particular circumstances and needs of the territories. It believes that they should receive additional funding to assist the provision of community-based mental health care services to remote populations.  The Committee therefore recommends:

109	That the territories receive additional funding from the federal government, over and above their per capita allocation from the Mental Health Transition Fund, in order to assist them in addressing the needs of remote, isolated and non-urban communities.

 

The Committee also recognizes that similar concerns have been raised concerning per capita funding by some of the smaller provinces. The Committee believes that in the case of Prince Edward Island, careful consideration should be given to the possibility of adjusting the per capita funding level in order to ensure that sufficient funds are transferred to that province to enable it to complete the transition to a community-based mental health delivery system.

As noted in Chapter 5, the federal government, stakeholders, and Canadians in general are entitled to know that money from the Mental Health Transition Fund is: (a) spent on community-based mental health projects; and (b) used to increase the total amount each jurisdiction is spending on enhancing mental health and treating mental illness. The goal is that the Transition Fund be used to support transformation of the mental health care system, not as a substitute for existing provincial or territorial spending.

The Committee realizes that provinces and territories are not in favour of having to report to the federal government or a national organization on how they manage their health care spending. Nonetheless, the Committee strongly believes that there should be some form of accountability for the use of money from the Fund. Therefore the Committee recommends:

110

That the use of the monies from the Mental Health Transition Fund should be subjected to an external audit, to be performed by provincial auditors general in order to ensure that the monies are spent in a manner consistent with the two objectives of the Transition Fund, namely: (a)        to fund community based mental health services and supports; and (b)        to increase the total amount each jurisdiction spends on enhancing mental health and treating mental illness.

 

Subjecting the use of money from the Transition Fund to an external audit will also help to ensure that these funds are effectively segregated from the rest of the health care system. By making it easier for provincial and territorial health ministers and deputy ministers to resist internal pressure from other spending demands of their government, that segregation would help to prevent money from the Mental Health Transition Fund from simply disappearing into the acute care system.

 

16.5.2   Estimating the Overall Cost of the Basket of Community Services

There are currently no reliable data on what it would cost to complete the transformation of the mental health care system from an institutional base to one that is predominantly based in the community. An accurate assessment would require a needs-based analysis not just in each province and territory but within the regions of each jurisdiction, given that the services available and the unmet needs vary greatly across the country and from community to community.

The mental health care “system” is diverse and fragmented; most services and supports operate independently of one other. It is thus very difficult to assess even approximately the needs and the capacity shortfalls in the current system. Consequently, the Committee has relied upon the work of others to establish a reasonable estimate of the size of an effective transition fund.

In 2000, the Ontario Minister of Health and Long-Term Care established nine regional task forces to develop recommendations for regional and local improvements to mental health services across Ontario; these included restructuring the psychiatric hospital system, community reinvestments and the implementation of mental health reform.[395] The Toronto-Peel Mental Health Implementation Task Force, like the other regional task forces, made a wide range of recommendations affecting the full spectrum of mental health care services.[396] It also provided an overall costing estimate to transform the mental health care system in that region.[397]

The Committee’s estimate of the overall cost of transforming the mental health system is based on the work of this task force. Rather than attempt to cost out each and every recommendation, the Toronto-Peel Task Force provided an overall, “order-of-magnitude” estimate of the increases required in the base funding for mental health care services in its region. It concluded that, to achieve an adequate transformation, the region’s mental health system required an investment of approximately $245 million over five years.

The report by the Toronto-Peel Task Force is one of the few detailed, systematic attempts to examine the needs of the mental health care system in Canada and provide an estimate of the costs of transforming that system. While the Committee realizes that the area studied is largely urban, it combines a fairly well serviced area, Toronto, with one of the most poorly serviced areas in Ontario from a mental health service and support perspective, Peel.[398]

Furthermore, the Toronto-Peel region incorporates a high degree of socio-economic diversity. The Task Force had to balance the gaps and capacity needs of each part of the region. Similarly, it would be up to each province and territory to determine where services are most needed and where additional resources would be most effectively allocated. The Committee believes that the costing estimate of the Toronto-Peel Task Force is a useful base from which to calculate what the needs of the mental health care system might be in Canada generally.

In order to determine the overall size of the transition fund for all the provinces and territories, the Committe extrapolated on the basis of population from the Toronto-Peel region to the rest of Canada. In 2001, when the last census was conducted, Toronto-Peel constituted 30.42% of the population of Ontario; Ontario constituted 38.02% of the population of Canada. By extrapolation, the total required for Canada would be $2.148 billion.

The Toronto-Peel Task Force requested that the recommended increase in funding be allocated over five years. The Committee believes, for two reasons, that it would be preferable to spread the allocation to the Mental Health Transition Fund over ten years:

§         First, given the human resource and supportive housing shortage facing the mental health sector, the Committee does not believe that the system could effectively absorb the full transition funding in five years.

§         Second, it is unreasonable to expect the federal government to be able to afford to close the service funding gap in a period as short as five years.

The Committee believes that ten years is a realistic time frame for transition, although it recognizes that it may not be possible to put in place at once all the programs that are needed. Instead, it may be necessary to begin slowly and increase the flow of funds over time. Therefore, the Committee recommends:

111	That the Basket of Community Services component of the Mental Health Transition Fund average $215 million per year over a ten year period, for a total of $2.15 billion.

 

This is a lot of money, but the total pales in comparison to the estimated $2.7 billion the province of Ontario alone spends on mental health care each year[399] or to the $14.4 billion that mental illness and substance use problems cost Canada in 1998.[400]

 

16.5.3   Mental Health Housing Initiative

As discussed in greater detail in Chapter 5, one of the biggest problems facing people with mental illness is the lack of affordable housing. Because people with mental illness often have little or no income, they are often forced to live in neighbourhoods characterized by high crime rates, drugs and violence. Among the homeless, it has been estimated that between 30% and 40% have mental health problems.[401]

According to data provided by the Canada Housing and Mortgage Corporation, 15% of the Canadian population as a whole is in need of housing that is adequate, suitable, and affordable.[402] At the same time, the housing situation confronting people living with mental illness is considerably worse; 27% (approximately 140,000) are in need of adequate, suitable, and affordable housing.[403] In other words, the percentage of Canadians who are living with mental illness who need access to such housing is almost double the percentage of people in the general population whose housing needs are not being met. The Committee believes that this constitutes discrimination against people living with mental illness.

According to the Canadian Mental Health Association, between 1980 and 2000, the number of affordable housing units created by the Government of Canada dropped from 24,000 to 940.[404] In many communities, adequate and affordable housing is beyond the means of people who rely on publiclyfunded income support. For example, in British Columbia, people on disability benefits or social assistance receive $325 for shelter costs per month, yet average market rents in Metropolitan Vancouver are over $600 per month; even run-down single-room-occupancy hotel rooms cost $350 a month on average.

The Committee concluded unequivocally in Chapter 5 that: more affordable housing units are required; more assistance is needed so that people can afford to rent existing apartments at market rates; and more supportive services are needed so that people living with a mental illness can live in their communities.

It is critical that a significant increase in community-based supportive services for people living with mental illness be part of any housing initiative targeted at people living with mental illness. Otherwise, such a program cannot achieve its objectives. Therefore, all such services must be eligible for funding under the Basket of Community Services portion of the Mental Health Transition Fund.

The federal government has begun to reinvest in affordable housing, primarily through the Canada Mortgage and Housing Corporation. It recently extended the National Homeless Initiative, which funds community supports such as emergency shelters and drop-in centres. It also established the Residential Rehabilitation Assistance Program, which provides assistance to low-income households, persons with disabilities and Aboriginal people to bring their homes up to minimum health and safety standards, as well as repair shelters for victims of family violence and support home adaptations for low-income seniors.[405]

In addition, through the Affordable Housing Initiative, the federal government has agreements with the provinces and territories to share the cost of the construction of new affordable housing units, as well as to provide rental supplements to low-income households. The federal government does not have any housing programs, however, designed to meet the specific needs of people living with mental illness.

The Committee considers inexcusable the lack of affordable and appropriate housing for people living with mental illness. It is appalling that the proportion of people with mental illness in need of housing (27%) is nearly double that of the population as a whole (15%). According to the Canada Mortgage and Housing Corporation, approximately 56,500 people living with mental illness would need access to some form of affordable housing in order to bring down the proportion of people living with mental illness in need of housing to the national average.[406]

 

Ideally, the Committee would like to see all Canadians have access to affordable housing; but this is not a realistic goal in the short term. The Committee does want, however, an end to the current discrimination against people living with mental illness; this is why it has recommended the establishment of the Mental Health Housing Initiative as part of the Mental Health Transition Fund. This is also why the Committee has recommended that 57,000[407] new affordable housing units be developed.

The needs of people living with mental illness are not all the same — some require supportive services while others who are more independent have trouble finding adequate housing. The Committee believes that a program to meet the core housing need of people living with mental illness should establish a 60/40 mix of rent subsidies relative to the construction of new housing units.

The Committee also believes that when the Mental Health Housing Initiative is launched, its initial focus should be on rent-subsidized units because of the need to act quickly to address the housing shortage.[408] The MHHI should be modelled on existing housing programs and “cost-shared” with the provinces in the same way that current supportive housing projects are — such as those targeted at people who are currently homeless.

The Committee feels so strongly that the housing shortage must be addressed immediately, that it is recommending that the federal government pay the full share of the rent subsidies for the first three years. This will kick-start the program and allow time for agreements to be reached subsequently with the provinces and territories.

More specifically, the Committee is recommending that in years 1 through 3 of the MHHI, 80% of the people provided with housing should receive a rent supplement of $6,020 in the first year and $4,250 annually thereafter. The remaining 20% should move into newly constructed units costing $75,000 per unit.[409] In years 4 through 7, the proportion of rent supplements to newly constructed units should be 60/40, and in years 8 through 10 the proportion should be 40/60.

The table below shows that the total cost would be $2.24 billion over ten years at an average annual cost of $224 million.

The MHHI would draw on evidence-based housing policies and best practices in supported housing. Consideration should also be given to innovative approaches by governments, health authorities and non-profit organizations, such as aggregating their subsidies to allow partnerships with tenants in the purchase of housing properties. Such approaches may help to address the economic realities of escalating rents and capital costs.

 

Table: Costing Analysis of the Mental Health Housing Initiative