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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 19 - Evidence (11:00 a.m. session)

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OTTAWA, Thursday, June 7, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:04 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Honourable senators, as part of our larger study on the state of the health care system in Canada and what the federal role in that is now and should be in the future, we are focusing today on the issue of mental health. We will begin with some officials from Health Canada and then hear some non-governmental witnesses.

Our first witness this morning is Ms Nancy Garrard.

Please proceed with your opening statement, Ms Garrard, and we will then turn to questions.

Ms Nancy Garrard, Acting Director General, Centre for Healthy Human Development, Population and Public Health Branch, Health Canada: Honourable senators, with me today are Tom Lips, Senior Policy Advisor for Mental Health, and Carl Lakaski, Senior Analyst on Mental Health Issues in our Centre for Healthy Human Development.

We have for you a presentation outlining some of the issues around mental health promotion and some of the federal responses to it. Mr. Lips will walk you through the presentation and we will be happy to answer any questions.

Mr. Tom Lips, Senior Policy Advisor for Mental Health, Population and Public Health Branch, Health Canada: Honourable senators, mental health was identified as a government priority in the Speech from the Throne and the relevant passage from the speech is included in the material that we have provided to you.

Why has mental health emerged as a priority? The four essential reasons that we see for this are: the centrality of mental health, the burden of mental health problems and disorders, the gaps in the current response, and the opportunities to act. I will speak to each of those points briefly.

Centrality of mental health refers to the fact that, as the WHO definition conveys, mental health is not separate from health but a critical dimension of it. We know from survey research and other research that factors related to psychological well being are critical in people's assessment of their own health. When you ask people to rate their own health and you study the factors associated with that, mental health is a critical dimension.

We know from research that mental health directly affects physical health, the risk of illness, the severity of illness and the recovery from illness. There is extensive co-morbidity between mental health problems and physical problems and there are many common risk and protective factors for mental health problems and physical health problems.

Much can be said about the burden of mental health problems. We have provided two small examples. One is the high rates of distress reported by the population through the national population health survey. We also have figures from that survey on depression and various other mental health measures. The other example is the high rates of suicide, particularly in the Aboriginal population.

Other examples include the burden on business because of psychological distress, which has been estimated at as high as $22 billion, and the fact that 25 per cent of Canadians report that their workplaces are major sources of stress in their lives. Suicide is the leading cause of death among Canadian males age 10 to 49, and the suicide rate for Aboriginal male youths is five to eight times that of their counterparts in the general population. Those are just a few examples of the burden of mental health problems.

Burdens of mental disorders are second only to cardiovascular in direct health care system costs and they are seventh in overall costs, including both direct and indirect costs. They account for the highest number of days of hospitalization of any category of health problem if one factors in the number days in psychiatric hospital. Hospitalization data that may have been presented to you in the past would typically not have included psychiatric hospitals. Mental diagnoses account for up to 35 per cent of federal and provincial disability payments. This is obviously a major burden.

The next slide uses a measure called "disability adjusted life years," which is an aggregate measure including impact of premature mortality and morbidity. Of the 10 leading causes of mortality and morbidity in the developing nations, several have dimensions of mental disorder.

The Chairman: The only technical word I have seen you use so far is "unipolar." What does that mean?

Mr. Lips: Unipolar is contrasted with bipolar. Bipolar is what is known as "manic depressive disorder." There is an element of mania - heightened mood, excitement - and there is an element of depression, which alternate. Unipolar depression simply has a depressive component.

Senator Morin: You also mentioned self-inflicted injuries, maybe you explained that. I missed that.

Mr. Lips: Self-inflicted injuries, in this table, are a reflection of suicide attempts and self-injury.

The Chairman: That would include successful suicides, too, I presume.

Mr. Lips: It would include both.

The Chairman: The phrase "successful suicide" may be an oxymoron.

Mr. Lips: We use the term "completed suicides." It does include both, and both should be taken into account.

Getting back to our four major points about why mental health is a priority. The third point deals with gaps in society's current response. I know you will be hearing more about this from the other presenters, however I would like to highlight three points. The first of which is a serious shortfall in surveillance. Although most mental disorders are treated in the community, rather than in hospital, our data on mental illness come primarily from hospital data. We have a growing body of knowledge based on national health surveys. That will be improving in the future.

There is still a serious need for attention to improve mental health surveillance. There is a limited and fragmented community capacity to promote mental health, prevent suicide and support the mentally ill and people in crisis.

Finally, there is a gap or a need in the area of identifying interventions that are evidence-based. Canada has a diverse and changing population: The age and ethnic profiles are changing. Our mental health programs need to reflect this. The impact of social determinants of health has been, to a great extent, neglected in the mental health area. There are gaps in mental health services to First Nations and Inuit people.

Factors affecting mental health and mental disorder are essentially the same factors that affect all health and disorder. We have listed them here. These are drawn from work in the population health model. Some of them are amenable to intervention and others less so.

The provincial and territorial governments have primary responsibility for the planning and delivery of mental health services for the general population. The federal government has a special mandate for health service delivery to First Nations people on reserve and Inuit people. The federal government also undertakes national health promotion efforts.

Both levels of government have been active in mental health promotion, research and surveillance and have collaborated to address some service delivery issues.

Health Canada has had a long tradition of information activities for the public and professionals. We have a tradition of collaboration with provincial and territorial governments as they work to strengthen mental health services. There have been a number of research and project funding and sustaining grants programs, which have contributed in some measure to mental health. While research and project funding programs have not generally been targeted specifically to mental health, there have been one or two.

Health Canada also provides funding for crisis intervention services, and prevention and promotion activities for First Nations and Inuit, and broad-based health promotion programs - for example, parenting programs, some of the programs around substance abuse - and general heart health promotion. These are programs which are not focussed primarily on mental health, but which have significant implications for mental health.

Finally, there is a strong mental health content in the 1994 National Population Health Survey and in the upcoming community health survey, 2002. That will allow us for the first time to establish prevalence rates for some of the main disorders on a province-by-province basis.

As part of the overall thrust of the federal government towards increasing health research through the Canadian Institutes of Health Research, there is an institute on neurosciences, mental health and addictions. In addition to that institute, several other institutes have a broad interest in mental health.

There are several operative factors relating to opportunities and what we perceive as the new emerging climate for action. There is a growing knowledge base from research and practice. We know more than we did 10 or 20 years ago about what can be done and what the needs are.

Various federal working groups have completed a lot of groundwork in the area. While these groups have not necessarily focussed on mental health, the Working Group on Women's Health, for example, brought forth the need for a much stronger need for mental health surveillance. Virtually every provincial and territorial government has recognized the importance of mental health issues and has launched policy initiatives and in some cases legislative reform over the last several years.

There has been extensive groundwork by Canadian NGOs and stakeholders. I know you will be hearing from the Canadian Alliance on Mental Illness and Mental Health today. There have also been extensive consultations with First Nations and Inuit people across the country. Internationally, there have been major initiatives on mental health in other countries notably by Australia, New Zealand, the United Kingdom and the United States.

The Chairman: Has Canada done a similar major initiative?

Mr. Lips: We hope to get to that.

Primarily because of the increasing evidence of the global burden of mental health as part of the global burden of disease, international bodies such as the World Health Organization, the European Union and the OECD, have also focussed an increasing amount of work on mental health.

With regard to developing a national approach to mental health, the possible scope of national action that we are suggesting here - and these should be regarded as examples - includes strengthening surveillance and applied research in mental health. These are areas where the federal government has been active in general health in the past.

Improving mental health literacy across the country is another suggestion. By "mental health literacy," I mean improving the general knowledge of mental health and mental illness, reducing stigma associated with both mental disorder and help seeking, and increasing people's familiarity with what is available in terms of mental health programs and services.

Another area of focus could be outreach to groups at risk to increase social support and resiliency. It is clear from a large body of evidence the importance of social and interpersonal support in maintaining and improving mental health and resiliency.

Another dimension would be to develop the mental health aspects of all major health-related initiatives. There is virtually no major health-related initiative that does not have a potential mental health dimension. Often that dimension is what has been missing or underdeveloped in the past.

Finally, we suggest working with NGOs and provincial and territorial governments to look for ways of increasing community capacity to improve our response to mental health issues.

With regard to the possible scope of action for First Nations and Inuit, this constitutes a different relationship because of questions of service delivery as well as mental health promotion and prevention. The federal government, in keeping with its special relationship with these populations, will continue to work with First Nations and Inuit people to more effectively address mental health program and service delivery needs, suicide prevention and mental health promotion in a culturally appropriate manner.

Overall, the proposed federal approach is one based on national leadership, which would include collaboration. Knowledge development, which includes research and dissemination and implementation of what we have learned, and community mobilization.

The steps we see as required and have begun include: consultation and consensus-building with experts and key stakeholders, developing a national strategy for mental health promotion, prevention of mental health problems and disorders, and early intervention. We also envision a strategy to help address mental health promotion and service needs of First Nations and Inuit people.

We welcome questions and discussion.

The Chairman: I want to ask you several questions that relate to your last three slides.

In your proposed federal approach, you use all the right words. What I really want to understand is whether there is any substance behind the sounding.

You talk about consultation and consensus building. You talk about development of a national strategy, and you talk about building a framework. These are standard words for activists.

In your opening you provided quite a magnitude of numbers, particularly those related to young people and to the Aboriginal community. As well, the are difficulties relating to a national health care service when the federal government is not responsible for delivering it. Can you try to put some flesh on a few of your points? I noticed in your last three slides you talked about possible scope, not what you are doing. You used "possible scope" twice and "proposed federal approach" once.

My broad question is how do we move from words to action? What would that action be? The final question is, what can we do to help kick whoever needs to be kicked to make this work?

Mr. Lips: That is an excellent question. The mention of mental health in the Speech from the Throne is a signal that it is time to move forward and increase our involvement in mental health. Much of what I have spoken about is forward-looking.

The question you raise about how we turn these nice words into something concrete is partly to be addressed through consultation. I know that with the First Nations and Inuit there have been extensive consultation about the needs of those communities.

We have started to talk to experts. The kinds of things that we, as a federal government, are able to do are not going to change dramatically. We can pursue information strategies both with professionals and with the public. We can pursue collaborative strategies with the provincial and territorial governments in terms of facilitating their work. We can work, for example, in the area of best practices and guidelines for services. A possible avenue is some kind of project funding for community level projects that would assist communities in developing their own resources to address mental health issues.

A research component that is very important. I use the term "applied research" because, of course, basic research is very important as well. One of the things that has held back the mental health file over the years - not only in Canada but internationally - is that initially the evidence base for many of the possible interventions was not particularly strong.

Now we have evidence from several areas indicating promising avenues, but many of these interventions still need to be tested in the real world at the community level. That takes resources and a collaborative approach. I would see the federal government becoming involved in that area.

With regard to knowledge development, there is a research aspect; there is a dissemination aspect; there is a social marketing aspect. In all of these are areas in which the federal government has considerable experience and expertise that could be brought to bear on mental health issues.

With respect to community mobilization, we would depend on close collaboration with voluntary associations and professional associations at the community level and nationally.

The full shape of the strategy needs to be developed, but these are the kinds of pieces that we have envisaged at this stage. Through consultation, we may discover new that we have not thought of or brought forward. There is a health human resources side that needs to be addressed. It is a large issue. Our ability to address it will depend on resources and on the evidence base that we have.

Ms Garrard: We are prepared to start building on the momentum and the climate that exists today. I think there is that recognition and evidence that makes it more timely to come in and make that noise louder on this issue.

As Mr. Lips has said, we are just starting to work on a consensus. There are many obvious pillars already in place. The federal government and Health Canada can certainly draw more attention to this area.

The Chairman: What is your time frame for developing a strategy? It always helps to get something in the Throne Speech, but Senator LeBreton and I have been involved in writing those over the years, so pardon us if we do not always take that as an overwhelming signal.

The real issue in Ottawa is money. Mr. Lips twice commented on resources. Have the financial resources available for mental health issues increased dramatically?

Ms Garrard: No. There has been some recognition within Health Canada and there have been some internal reallocations. To do justice to this issue, there would have to be a significant increase in dollars.

The Chairman: That has not yet, at this point, been committed?

Ms Garrard: It has not yet been committed. We are looking at the opening in the Speech from the Throne as a promising signal. You are right; it competes with many other issues. For the federal government to be a serious player on this field there would have to be some serious resources. There do not have to be huge increases to see visible movement. We have been encouraged by increased data coming out of Statistics Canada on increased instances in improved surveillance.

The information dissemination on the Canada Health Network is another way of getting information out to the communities. We have a partnership with the provinces on all the related health issues, which include physical and mental health issues. The arena is ripe here. We would certainly be pushing it as far as we can from a bureaucratic perspective.

The Chairman: We have other ways of pushing it that may be useful. What is your timetable for the strategy?

Mr. Lips: We are working very hard to develop some kind of preliminary outline by the fall; or actually by summer, and then moving forward with that.

The Chairman: You mean summer next year?

Mr. Lips: No, we hope to have at least a general outline this summer.

The Chairman: That is good, because we can then talk to you when we continue our study in the fall.

Senator Graham: I am not quite as cynical as you are, Mr. Chairman.

It is one thing to recognize the need in the Speech from the Throne, which is an important step. Another thing, as the Chairman was suggesting, is: Are there budgetary amounts allocated for that specific purpose?

At the same time, you just do not take figures and throw them up against the wall and say, "Here is $1 billion," and go out and do what you will with that amount of money. You must respond to specific proposals.

Have you been asked, or have you generated, specific proposals? I believe you indicated a moment ago that you were in the process of doing that. Perhaps you can expand on what you are doing in that area.

Mr. Lips: I am not sure to what extent I can expand beyond what I have said. We are beginning consultations and outlining possible strategies. Clearly, there is a big difference between recognizing the need and actually getting the resources to address it.

Ms Garrard: We expect our consultation to enrich the strategy and ideas and to give us a better sense of where the priority first steps are. We will be looking at some costing and options that will allow us to build a very convincing case for additional resources.

Senator Graham: I do not think the government will say, "Here is a bunch of money." They have to respond to specific proposals. This is part of the process.

The Chairman: Which is why I asked what the strategy would be.

Senator Graham: We will be making recommendations and we want to help you.

Ms Garrard: This will be taking place over the course of the summer and fall.

Senator Morin: I would like to talk about the health care delivery system. I realize it does not come under federal responsibility. At one time, as you know, the federal government was very much involved and actually covered the hospitalization of all psychiatric patients in the country. That is why, in Quebec, we sent all the orphans to hospitals. It was so that the federal government could pay for them.

We have moved away from that, not so much for scientific reasons but for economic reasons, I am sure. We have taken all these patients out of hospitals and sent them into the community. Of course, this is not covered by the Canada Health Act. There is very little direct federal money going into that.

There are acute problems apart from suicide and so forth. If you are looking at it from a delivery-of-care perspective, the major problem is that all these patients are now in the community. They are homeless.

A large proportion of social problems result from the fact that these patients who are no longer institutionalized are now in the community. The governments have saved on resources by not having to give them to the hospitals, but they did not take those resources and put them into the community. If you want to be simplistic, that is the problem of the health care delivery system.

We all say there should be community-based care. Of course there should be, that is where the patients are. It is not a big discovery. They were in the hospital before and now they are in the community. We must treat them.

There was a recent press release about a community-based approach in Victoria. Can you expand on that, please? What do you see as the federal role in terms of that approach? What are your comments on the situation?

Mr. Carl Lakaski, Senior Analyst, Mental Health, Health Human Resources Strategies Division - Health Policy and Communications Branch, Health Canada: From the federal perspective, there is an advisory committee structure that reports to the Conference of Deputy Ministers of Health. One of the advisory networks working groups is the Federal/Provincial/ Territorial Advisory Network on Mental Health. It consists of senior federal, provincial and territorial government officials from across the country who discuss mental health issues that have a national scope to them.

A couple of years ago we produced a document called, "Best Practices in Mental Health System Reform." It speaks directly to the issue you are talking about, senator. It looks at the core service requirements for a continuum of care from hospital to community. Those documents are currently being used in provincial capitals to redesign their mental health systems. Not every provincial government responds to the full range of core options that we have recommended, however, they are picking and choosing them according to how well they fit into their current mental health system.

There are a number of system requirements that are necessary to have that kind of community-based system, including the appropriate kind of policy, the appropriate kind of governance and funding mechanisms in place, as well as monitoring and evaluation. Of course, there are human resource requirements, which are different than the human resource requirements that are required for the mental health system, which is heavily institutionally based.

The advisory network on mental health has been making progress. We have been working with them to develop model programs and standards.

Senator Morin: Under the Canada Health Act, the federal government protects hospital-based treatment and medical treatment. Is it not the case that for psychiatric patients these two areas are not important? What is important is community-based treatment which is not covered by the Canada Health Act.

Mr. Lakaski: That is not exactly the case. The Canada Health Act is still very important for people with mental disorders for the delivery of medically based mental health services.

Senator Morin: Drugs and nursing, to name but two, are not covered by the Canada Health Act.

Mr. Lakaski: I agree with you. Something like a pharma-care program and a home-care program that actually recognized people with mental disorders as legitimate clients would be very helpful, as would the integration of mental health services with primary care. This is something else the department is doing. We are supporting two initiatives that are attempting to integrate treatment and services to people with mental disorders more fully into the primary care system so that family physicians will not continually have to refer people with mental health problems to psychiatrists or specialists. They will be able to treat them directly within their offices.

[Translation]

Senator Pépin: I quite agree with the development of policies and the fact that work is being done at different levels of government. I am very happy to learn that, at present, initiatives are being undertaken with different governments to be able to care for in situ for those patients suffering from mental illnesses.

We know that the majority of patients are not in institutions, but are outside of institutions. At present, practically speaking, there is nothing. I am very happy to know that general practitioners will be able to attend to and monitor their patients and that these cases will not necessarily be referred to psychiatrists who, for the most part, do not go to see the patient. They must be consulted.

You are working on policy development, but will we be able to help young street people? Will they be monitored so that we can be sure that they are taking their medication? Will they have daily access to the services of nurses and of doctors?

One of the difficulties is that we are releasing these patients from institutions and we are putting them out on the street. At present, it is a given that their illness will recur and that we will not be able to cure them.

In the institution, they benefited from treatment and guidance that they no longer have. It is fine to develop policies, but are we able to do something very practical out in the field? The patient would definitely benefit from that.

[English]

Mr. Lakaski: Fortunately, or unfortunately, depending on your point of view, the various services that would be required to meet the demands you have discussed lie within the provincial domain. They have the jurisdictional responsibility for actually developing and delivering those services.

I agree that the majority of people in need of those kinds of services are in the community and not in the hospitals. I would not want to diminish the impact of medical treatments for people with mental disorders.

The full range of appropriate community-based mental health services is a decision that must be made at the provincial level. You are correct in stating that with the process of deinstitutionalization, the dollars did not follow the patients into the community. They were used for other purposes. We have no influence on how provincial governments will decide to use those dollars. All we can do is provide a national focus for the types of problems that are created when services are not provided to people who need them in the community.

[Translation]

Senator Pépin: I quite agree that there must be meetings to discuss approach policies and to talk about money. You tell us that you must focus on these priorities. The federal government and the provincial governments are not practical enough when it comes to setting out their programs. The people working in the field who need the services do not get them.

[English]

Mr. Lakaski: I can only agree that people out there are not getting those services. The problem is in developing mechanisms for ensuring that.

Senator Kirby, you mentioned earlier that you would be pleased to do anything you could to help. If you have any relations with the Parliamentary Standing Committee on Health, it would be nice if that committee would ask the Minister of Health - as has been recommended - to decide to study mental health issues.

The ministry has the resources to launch a major study of mental health across this country. From what I gather, it has yet to decide whether to focus on mental health issues. If you have some influence, you could do some arm-twisting. That would be wonderful.

The Chairman: If that sort of specific suggestion, arm twisting within the government, would help, we would be glad to do it.

I have one supplementary question following up on Senator Pépin's question. I know we cover psychiatrists, because psychiatrists are doctors. Are the services of psychologists covered under provincial health care programs?

Mr. Lakaski: They are if those services are offered within general hospital settings.

The Chairman: Which is how much, 1 per cent? I am exaggerating to make a point. The answer is they are not covered.

Mr. Lakaski: The provinces under the Canada Health Act have the ability and the right to include the services of other mental health professionals, if they decide to do so. Obviously, because of cost containment, that is something they are probably not going to do.

The Chairman: Do you know if it is cost containment or lobbying by the psychiatrists to prevent others from getting into the field?

Mr. Lakaski: Over the last 10 years, psychiatrists have, in fact, adopted a much more comprehensive approach to the delivery of services.

The Chairman: I return to the days of chiropractors. Is this the chiropractor case again, or is this a money issue?

Mr. Lakaski: The fight occurs over things like being able to prescribe drugs. Psychiatrists maintain it is their responsibility as medical professionals to prescribe drugs and that responsibility should not be shared with psychologists.

The Chairman: It is a significant touch of the chiropractor issue. You put it more delicately than I did, but that is fine.

Senator Morin: I think psychiatrists are really overworked in this country. There is a tremendous shortage of psychiatrists everywhere, especially ones that are community-based. Most of them are hospital-based. As you said, it has changed. You see psychologists now in general hospitals - you did not see that before. They are present and they see patients. I do not think the problem is there. I think it is financial.

I do not think psychologists are asking for the right to prescribe. We have material here that indicates they do not ask for that. What they do ask for is the right to follow side effects. I do not think they are asking to prescribe drugs.

Mr. Lips: I just wanted to make a general point that we need to be careful not to get side-tracked into issues around fee-for- service. There is a whole issue around fee-for-service, its impact on the existing health care system and whether it would solve the mental health problems of the country to expand the fee-for- service problem into several different disciplines. That is an open question.

Senator Callbeck: I want to ask about the work of a couple of committees that have representation from the federal government, the provinces and the territories. I am sure there are more than two set up, but there is an Advisory Network on Mental Health, and an advisory group on mental health and well-being of children. How long have those committees existed?

Mr. Lakaski: The Advisory Network on Mental Health has existed in one form or another for 25 years. Its status has changed from that of an informal committee to one that officially reported to the Conference of Deputy Ministers, and back to an informal committee now again reporting to the Conference of Deputy Ministers.

The advisory group on children and youth is a much more informal committee. It does not have a direct reporting relationship up the line to the Conference of Deputy Ministers as it now stands. It has met very infrequently and has only existed for maybe seven years.

Senator Callbeck: Every year they submit recommendations?

Mr. Lakaski: No, they do not necessarily submit recommendations. They develop work plans, and they do work in their respective areas. They do not necessarily submit recommendations to the Conference of Deputy Ministers.

Senator Callbeck: My understanding was that that advisory committee submitted recommendations to the Deputy Ministers and that the other group had recommendations to the Advisory Committee on Population Health. What happens to those recommendations, and what is the federal government's role in seeing that those recommendations are reviewed and something is done?

Mr. Lakaski: The Advisory Network on Mental Health has not made recommendations to the conference of Deputy Ministers. The one on children and youth does occasionally report, but not in a very systematic manner, to the population health committee. I am not sure what would happen to its suggestions or recommendations.

Senator Callbeck: What does the Advisory Network on Mental Health report to the deputy ministers?

Mr. Lakaski: It reports on what it has done and the work it is doing.

Senator Callbeck: It makes no recommendations?

Mr. Lakaski: They could. Because they have not done so to date does not mean they cannot make recommendations to the Conference of Deputy Ministers. I would like to emphasize that it is a provincial/territorial committee. They work on a consensus basis. Making any strong recommendations to the conference of Deputy Ministers requires that everyone be on board before those recommendations go forward.

Ms Garrard: I would comment generally about the work of all the advisory committees, and many report up to the Conference of Deputy Ministers of Health. I believe you heard of some of the others.

There is a huge competition at the ministers' and deputy ministers' table for any of the issues relating to health and what is the shared interest. Therefore, mental health issues compete with all the other issues. That may be symptomatic of where we are.

The particular groups to which Mr. Lakaski has referred are bringing together the government officials who are working directly in this area to work on shared interests. They have themselves determined their own priorities. Much of the work is collaborative and involves sharing the evidence and working on aspects of guidelines.

Many of our recommendations have gone to the Conference of Deputy Ministers with respect to primary reform, cost drivers, pharma-care, health and human resources, which have ripple effects on the mental health issues we brought to the table. I would not want you to think that there are no recommendations, because some have been made and have gone to those deputies that touch upon mental health.

Senator Callbeck: What is the federal role on those recommendations if they go to a provincial-territorial table?

Ms Garrard: We are one member around an FPT table. We are a different level of government and our role is different. Over the last number of years, it has changed, especially when there are additional resources, or if there is increased interest in health, or when there is an increase in the health budget. There has been a fair bit of active work collectively on the FPT table to improve aspects of health. We play a different role, for sure.

Senator LeBreton: Your slide, "Opportunities: New Climate for Action," Senator Kirby and I were joking about this, but I think it is significant in that this issue was raised in the Throne Speech. That is probably a first. In the whole area of new climate for action, we have had witnesses before us on the issue of genetic research. When we speak about mental health, how much of your efforts are to be put into preventive treatment? We obviously see this particular illness even in young people. Perhaps the cost to society and the cost in real dollars would be significantly less if we adopted a real preventive program.

Mr. Lips: That is an excellent point. Certainly, the main thrust of our strategy development, as we see it now, is towards mental health promotion and prevention of mental health problems and disorders.

Prevention covers a wide spectrum of possible activities from the biomedical and genetic at one end to the psychosocial and environmental at the other. We would take a balanced approach.

I am aware that the Canadian Institutes of Health Research - the Institute on Neuroscience, Mental Health and Addiction, reflects that broad scope of research. I am sure that much of the research that is funded through that institute will address very basic neuroscience issues connected with mental health.

We want to ensure that the research addresses a broad spectrum, including the psychosocial interventions and the applied research. Certainly, we would, especially as a federal government with a limited role in health services delivery, look at focussing on mental health promotion and prevention.

Also, the literature indicates some very promising findings in terms of early intervention, even with the major mental illnesses, the psychoses. That is an area of great interest and focus.

Senator LeBreton: For people depression, and in other cases, people who have addictive tendencies, genetics could probably isolate a significant number of the population to predict with some accuracy that they might fall into these categories. Family doctors could be watching for such illnesses before there is any outward sign detected.

Mr. Lips: That is a double-edged sword. Despite the tremendous advances in genetics and genomics in recent years, we are not at the stage where we can predict even the psychosis that has a clear genetic dimension to it. There is a real downside to identifying people before they develop symptoms and labelling them. That must be looked at extremely carefully.

The other thing is that, without going into genetics, we know that depression correlates strongly with income, for example. It correlates with many psychosocial factors that do not require us to look at the genetic level.

We should not neglect those; we need to keep an eye on the genetics research and make sure that we exploit it as best we can. It should not distract us from what we know about psychosocial and economic determinants of health, where we do not need huge scientific breakthroughs to act.

This is an area for continuing research and for careful ethical scrutiny, when it comes to predicting mental illness.

Senator LeBreton: I am pleased to see the whole stigma of this illness disappearing. I read somewhere - possibly in a U.S. study - about gender. The study showed that women had a higher incidence of anxiety and depression. I wonder whether the stigma factor comes into play for men who may be just as susceptible. The stigma factor allows that they are not as detectable in the statistical data. Perhaps women are less fearful of seeking help.

Do you have, in your statistical database, information to indicate whether that stigma may apply more to men than to women?

Mr. Lips: You have flagged an important issue. There are important gender-based differences in mental health and mental illness. I was asked to mention the report funded by the Women's Centres of Excellence for Women's Health, "Hearing Voices: Mental Health Care for Women." The report brings out some of those very points - not only the different expression of mental illness in men and women, but the different reaction to mental illness when men and women seek service. This is obviously a very important thing that we must pursue. There are not only biological differences, but also cultural and systemic differences in the way of mental health.

Senator LeBreton: There are societal differences as well.

Mr. Lips: Yes, there are societal differences. That is an important issue that we need to address.

Senator LeBreton: In order to make men feel more comfortable, would it be a part of the whole program of public education?

Mr. Lips: Research has shown that men are much less likely to seek help.

Senator Morin: We must be declared sick; we should declare ourselves sick.

Senator Pépin: You cannot do that.

The Chairman: For clarification, you said that there is a direct correlation between depression and income. I assume we are only talking about adults. It is my understanding that, if you look at children, the depression problem among children is not correlated with the income of the parents. Is that correct?

Mr. Lips: There are studies that indicate both may be correct. That may be confounding factors.

The Chairman: Really, I was trying to understand depression among children. Is it as common among well-off families as it is among the poor? I know that is not true for adults.

Mr. Lips: One issue, when we talk about depression, is that we are talking about a very broad spectrum of mental health problems, ranging from problems that are pretty clearly biological to problems that may be partly biological and partly psychosocial to problems that may be pretty much entirely psychosocial - learned responses. It is hard to generalize.

In terms of biological illness, it does not discriminate much between social classes. We would expect these other dimensions of depression to vary by social class.

Senator Pépin: We know that 20 per cent of children who suffer from mental illness.

[Translation]

A specific risk factor with children is poverty. Would living in a multi-ethnic family also constitute a risk factor? If children live in a family where there is a violent environment, they can certainly become disturbed. I would like to know what can be done to lessen these risks. At present, are the federal and provincial governments taking the necessary steps to help these groups? How can we help them?

You have spoken about prevention. One of the most important things is to begin to deal with children. There are factors which may make them predisposed to psychological problems. You seem not to agree with the idea that children from different ethnic groups are at greater risk.

[English]

Mr. Lips: You mentioned as risk factors, poverty and ethnic nature of the family. First, I do not think the research shows that belonging to a particular ethnic group is a risk factor for mental illness, at least among children. I would be hesitant about that.

The Chairman: Does that include Aboriginals?

Mr. Lips: It is not a question of ethnicity. I think it is a question of social determinants. Obviously, ethnicity has an impact on your social situation, your life experience. If you are and immigrant, for example, there are psychosocial issues related to how well you are accepted. Do you experience racism as a child in school? Do you have difficulty communicating because English or French is not your first language?

The research shows that children in single-parent families are more at risk and this seems to be not just a function of income. It seems to apply even when income is accounted for.

One of the things the federal government did over the last many years was publish a booklet entitled Helping Children Cope with Separation and Divorce. It was one of our most popular mental health interventions. We published thousands of those books. There is a hunger for information to help children cope with these situations.

We know that children of parents who have mental illness are also at risk. There have been programs at the community level through some provincial governments aimed at addressing that population and trying to insulate and inoculate these children against the problems that they will face.

Exposing children to violence in the home is not good for their mental health at any time. There is an interdepartmental family violence initiative that has tried to address problems of that nature. There are programs at the federal level addressing racism and diversity. In a general way, many of those risk factors have been addressed, but there is plenty of room in addressing them in a more focussed way from a mental health perspective.

[Translation]

Senator Pépin: I was a member of the committee on children and divorce. I know that, at the beginning of 2002, we are going to conduct a follow-up and make some very relevant recommendations. We said that, during a separation, the children and the family had to have significant follow-up. We do hope that this will be one of the recommendations that will be implemented.

Looking at our population, we realize that it is indeed aging, and that the majority of people will be older than 65 very soon. At present, are governments thinking of this perspective? Is thought being given to Alzheimer's, and to the depression that is often suffered by the elderly? Have any plans been made as to what to do about this? What should be avoided when we discuss prevention for the elderly?

[English]

Ms Garrard: Many provincial governments have begun to address the issue of Alzheimer's specifically because of its unique care requirements, which include has both health care and mental health. Certainly, in the early stages of Alzheimer's, there is a mental health component. People who are caring for someone with Alzheimer's have a mental health component. When you look at the total package, there are caregiving issues, formal care issues, and diseases management issues.

A number of provinces have set in place an Alzheimer's strategy, which is a multi-dimensional strategy. From a federal perspective, we continue to do surveillance on this issue. We have funded a study on health and aging to specifically look at issues of aging and Alzheimer's and it is becoming one of priorities on the health table, but it is still competing. We do know that as increasing numbers of people pass the age of 80, there will be an increase in the volume of people suffering from Alzheimer's. It is quite a dramatic increase. It is something that, as a country, we need to be prepared for across the service delivery system.

Mr. Lips: The picture with respect to mental health for seniors is quite mixed. It is often assumed that aging is inevitably associated with declining mental health. The survey data do not bear that out. In fact, there has been a shift in reported distress and depression as reported in the National Population Health Survey. In the past seniors would have ranked higher in distress and depression, now it is actually young people who rank highest.

That could reflect a number of different things. It could reflect measures over the last many years to improve the economic and social security of seniors. It could reflect many things about the economic and social security of adolescents and young people.

Alzheimer's is perhaps the biggest single thing on the horizon. It is a huge problem. It has a mental health dimension, although I would not characterize it primarily as a mental health problem in our terms.

Depression and suicide are issues for the very aged. The highest rates of suicide are for men older than 80. In general, as I say, it is a mixed picture. In some ways, mental health seems to have improved among seniors in the past couple of decades.

Senator Pépin: I am very happy to hear that.

Senator Graham: I am also somewhat comforted by the last comment and by the chart to which I want to return.

Mr. Lakaski, you have mentioned that the federal government really has no influence on how provincial governments use the money that may be allocated in this regard. What kind of role does the federal government have in supporting community-based care for the mentally ill?

Mr. Lakaski: Again, we rely on the knowledge-development role, monitoring and evaluation, standards, talking about models of appropriate services. It is my understanding that we cannot direct provincial governments to put certain services into place; it is their decision to do so. They can be moved in that direction by an evidence base indicating that these kinds of services and programs would deal with the problems they are facing.

Across this country, mental health system reform is ongoing and has been for the last several years. The interest has definitely been in putting into place services in the community to deal with the mental health problems of the population.

The pace may not be as fast as we would like, but they are certainly responding to those issues as best they can, given the resources that they have. Certainly, as reflected in the deliberations of the Advisory Network on Mental Health, there is a progressive attitude towards this issue, which is in accord with the best scientific evidence we have in terms of the different kinds of treatment options and service options that people should be offered. I am referring to the chart on page 5. You begin your survey at page 12. Your first category is 12 to 17. Have you any statistics with respect to, for instance, the group 8 to 12 or ages lower than those shown here? Is there any particular reason that you did not include such a group on this chart?

Mr. Lakaski: You are talking about the height of stress, urban and rural.

Senator Graham: Yes.

Mr. Lakaski: One of the problems in Canada, and one of the problems that I hope our strategy will address, is that we do not have the appropriate monitoring or data gathering systems in place to enable us to provide us with a time series covering the range of issues that we would like to have. Frequently, when you see gaps, it is because we do not have the data. We do not have the information to put in place.

Senator Graham: Would it be useful to have that?

Mr. Lakaski: Oh, yes.

Senator Graham: We often talk about the formative years or the most important years among young people being at the very beginning, whether at the age of two, three, four or eight to twelve. I think it would be very important and interesting, but specifically important, to have that kind of analysis.

Mr. Lips: There are initiatives underway to improve health surveillance among children. One of the surveys is the National Longitudinal Study Survey of Children and Youth. I would expect that this study would, in the years ahead, provide us with more of the kind of information that you are looking for.

The Chairman: That is a perfect example of the role of the federal government on the research side. No one can argue that it is a jurisdictional issue.

I thank all of you for coming. We look forward to seeing you in the fall when you have the strategy. I am glad you told me when you were going to get it done.

Senators, we have one other panel. The Senate sits at 1:30 today, so we must end at 1:25. I suggest to the presenters, who have given us some excellent briefs, that they compress their presentation. You have all been in the room and understand the nature of this particular group is that they like to ask questions.

I will suggest that we begin with Mr. Upshall and Ms Pape as a joint presentation on behalf of the Canadian Alliance on Mental Illness and Mental Health, followed by Mr. Ross, Assistant Deputy Minister of the Department of Health and Wellness for the Province of New Brunswick. Mr. Ross, we had your Deputy Minister before us a few weeks ago. Then we will finish with Mr. Service.

Mr. Phil Upshall, Chair, Canadian Alliance on Mental Illness and Mental Health: Honourable senators, I appreciate the opportunity to appear before you, and the Canadian Alliance on Mental Illness and Mental Health appreciates the opportunity to present before you this morning.

The discussion on depression, bipolar depression and issues that arise from living with that illness are personal to me. It is an issue that I am able to discuss at this stage of my life, and if there were interest, I would be happy to talk about it from a male perspective. I can assure you that it is a unique perspective.

Here today with me is Ms Bonnie Pape from the Canadian Mental Health Association and a member of the Canadian Alliance on Mental Illness and Mental Health, as well as several other members of the Alliance.

You may recall that I appeared before you last year when you were dealing with Bill C-13. I told you at that time that the Canadian Alliance on Mental Illness and Mental Health is a unique advocacy operation in Ottawa because we are vertically organized. We have professionals, service providers and consumer survivor groups. Because of that construction, we are able to provide incisive advice and advocacy for our issues.

One of our difficulties, however, is that because we are not horizontally structured, it is difficult to find funding money. With cutbacks in the late 1990s, it has been difficult for the individual associations to keep up their services. If you are looking for recommendations, one of the recommendations you could make is to suggest that groups like ours receive some type of base support so that we can continue our advocacy.

Last year, while we were talking about Bill C-13, I filed our call to action. I believe you all have copies of it. It should be useful to our discussion. You may recall that your report indicated specifically that the committee supports raising the profile and status of mental health issues within the medical and research community and, accordingly, suggested the governing Council of Canadian Institutes of Health Research pay special attention to mental illness and mental health.

We certainly appreciated that recommendation. As you know, the Institute for Neurosciences, Mental Health and Addictions was structured, and I am fortunate to be a member of that institute's advisory board. We have had a number of meetings. It is a huge institute. If you have any questions in that regard, I would be happy to try to respond or provide you with information that could assist your deliberations.

One of the other documents that we filed with you last year was a copy of a workshop document that we had put together to promote a new surveillance system on mental health and mental illness issues. That document is in the hands of Health Canada. Again, if the committee is looking for a recommendation, we hope that you would see fit to suggest that Canada needs a surveillance system and that Health Canada work towards putting that in place at its earliest possible opportunity.

I will ask Ms Pape to provide you with an overview of the brief that we have filed with you. We are here today to answer any questions you have. I would be remiss if I did not express the appreciation of the Canadian Alliance of Mental Illness and Mental Health to the Federal/Provincial/Territorial Advisory Network on Mental Health, and particularly to Carl Lakaski and Ken Ross. They have assisted our organization, provided us with incentive to produce the call to action and been very supportive along the line. Their assistance could be even greater if their level of priority within the government structure was improved. With that, I will ask Ms Pape to take over.

Ms Bonnie Pape, Canadian Mental Health Association: Honourable senators, it is useful that we heard our Health Canada colleagues first, because the discussion was very informative and your questions were excellent. Much of what you have discussed is in our brief. I promise not to repeat it, as much as possible.

We can add two things. I remember your question, Mr. Chairman, to the Health Canada team about whether there were any specific proposals. Our call to action contains a semi-specific proposal about what we would like to see in terms of a national action strategy. We will focus on that.

In addition, I think something we bring that is qualitatively different is who we are. We are not academics. We are not policy-makers, particularly. We are the people who live with these issues. We are the consumers, the family members, and the people who work at the community level. We know from our own experience what the impacts and the burden are. We will not talk too much about the numbers, which you know well. You have also heard about the impact and the burden. I heard from what you said that you do understand it. If you want to hear it from the streets, that is the perspective that we can bring.

In terms of following along with the brief, I will skip right through and just touch on the burden as we see it. This is on your page 3.

We see every day the suffering that goes along with mental illness - the suicide, the disability and the poverty. You can hear about these things theoretically at the associations. However, the suffering associated with mental illness has a profound impact on people. I know many of you have seen it in your communities. I think we all know about the impact of mental health problems, the less disabling situations that also impact our lives, disrupt them and impact productivity. We will deal with all of those issues.

The Health Canada witnesses touched on human resource demands. We do not need to elaborate on that; you have heard that in other venues. There is also the proliferation of knowledge. I know other groups might be talking about how the knowledge base is increasing and the fact that it is available electronically, which implies that we really must ensure that the latest and best evidence is applied in our approaches. That is another pressure on the system that we expect will increase in the future.

We will focus on what I think is a more distinctive aspect of our own issues. That is the need for a holistic approach. Granted, access to services is vital, and is not adequate at this point. However, what we heard, even in the previous discussion, about the importance of the psychosocial elements implies that simply increasing and improving the service system is not enough.

It is interesting to ask people who have had mental health problems, or who have mental illness, what is important in their lives in keeping them healthy. They talk about determinants of health. They do not call them the determinants of health, but they talk about the service system, and treatment. They also talk about the need for an adequate income, housing, social support and the personal coping skills and health practices that can help them maintain their mental health. Those are the kinds of things that we all need. The service system needs to create strategies that can help these things happen.

Another factor that has been emerging in the past 10years is this concept of recovery. Recovery is probably not new. I would say that it has been happening for many years but maybe not referred to by that term. Recently, consumers have been writing about their own recovery. This personal writing has been validated by studies that show the course of serious mental illness does not necessarily need to be a declining one. People can get better - not that their illness is gone, but they can take charge of their lives. The illness does not control them but they can control the illness and its effects, in terms of their lives and the psychosocial aspects.

This also implies that the system needs to respond not just with treatments, which is one of the factors in recovery, but also with other responses that deal with not just relieving symptoms but with discrimination, poverty, segregation and promotes choice and self-help, as well as wellness. These are all factors that people talk about when they talk about what helps them recover.

This sounds like a big slate to fill for health services or mental health services. The Canadian Alliance on Mental Illness and Mental Health is hopeful, although we see the burden, we live with the suffering and we frankly are discouraged about some of the situations. We do believe that there are ways out of this. The way that we see makes the most sense is to have a national strategy. This fits very well with the way Health Canada is talking and we are delighted to hear that.

Before a national strategy can take place, we believe we need a national dialogue. We believe there is a growing consensus among Canadians about what needs to happen, but we need to hear that. We need to understand what Canadians are saying. That can inform the development of a national strategy.

This has not happened yet, but the Canadian Alliance on Mental Illness and Mental Health has proposed some plans that we are suggesting could reasonably be part of a national strategy. Those plans also have been covered partly by what the Health Canada team talked about: A national research agenda, a national information base, a national public education strategy - Mr. Lips called it "mental health literacy" - and a national policy infrastructure. We have divided it into those four areas, but I know you have covered many of them in your discussion earlier.

I will take a couple of seconds to tell you this story. When the chairman asked if it is happening in Canada, it made me think of what happened in our office this week. We hired someone new to look at policy. As a first step in informing herself, she had gone to the web to look at how other organizations and other countries are framing their policies. She came back to me and said that she had found a national policy for Australia, New Zealand and Britain, and had gone to the different government department sites but could not find Canada's. She wanted to know where it was. We had to tell her it was not there yet. It is clear that it is a strategy that seems to be working for other countries.

The policy infrastructure is one I want to give you an example about. That is a broad way of approaching mental health and mental illness. Essentially, it speaks to the need for national guidelines or standards in certain areas, such as innovation, human resources or promoting self-help.

The example I want to touch on is home care. I know you are hearing a significant amount about home care these days. I know it is a wonderful approach that has much potential. I want to tell you, though, that in general it is not working for people with mental illness at this point. People with mental illness often are not eligible for home care unless they have another primary diagnosis. When they do get home care, the services are often not appropriate to mental illness, which has very specific needs.

That is tragic because we know from small pilot studies that home care can make a big difference in the lives of people with mental illness, particularly those with complex needs. Home care can even prevent the need for institutionalization.

Senator Morin: Is there a difference between community care and home care in your mind? If so, what is it?

Ms Pape: Community care might be broader. Home care specifically refers to care in the person's home. Of course, it implies a person must have a home, which is another story. Community care might reach out to the community as well. Lately, I think home care does try to reach out to the community.

Senator Morin: Much of what I am hearing now is for mental illness, community care, then you seem to put more emphasis on home care more than on community care.

Senator Graham: Could you give us an example of community care?

Senator Morin: Give us an example of both.

Ms Pape: Community care could be much broader; it could be community programs that deal with not just the person's home life, but with the ability to find employment, to find education, recreation.

We are suggesting that if there were national guidelines for home care that ensured access and appropriate kinds of supports it could make a big difference in people's lives. This is a reasonable, legitimate role for the federal government to play.

We wanted to discuss special populations. I will not talk too much about our Aboriginal peoples because you have had that discussion. I will only emphasize, as you well know, that they know best what is needed for their population and must be included from the beginning, of course.

You have also touched on children and youth. I want to frame this subject in terms of the fact that we have this knowledge practice gap with children and youth. There is a difference between what we know and what we do. We know that the kind of interventions you were talking about earlier do work. The research shows that with children and youth. They not only relieve suffering in the present, but can help prevent future problems. There is a double "bang for the buck there." However, children and youth are very low on our national agenda. The mental health needs of this group are not even mentioned in the national children's agenda. It is alarming that 20 years ago the distress of children and youth was at the lowest end of the population while today it is at the highest. Something is not working and it does not make sense because we know what works. I know Mr. Lips mentioned early psychosis intervention. It is a very promising strategy. It is starting to be implemented in Canada.

A national strategy could help spread the information across Canada. There are some standard ways to approach this so that people would know what the best practices are. They would know what the research says and that we have a strong approach to early psychosis intervention.

I am leaving you with an urgent call for a national strategy on mental illness and mental health. To repeat what is in our brief, we are urging you to first, endorse the need for immediate national action as proposed in our call to action. Second, recommend to the federal government that it take leadership action in building a strategy on mental illness and mental health. Third, recommend that the visibility of mental health and mental illness issues within Health Canada and other federal government departments be increased. Fourth, recommend greater interdepartmental and intergovernmental collaboration, which is necessary to address the needs and the issues that impact the mental health of Canadians. Doing so will make a big difference in the lives of Canadians.

The Chairman: Thank you. Our next presentation is from Ken Ross, Assistant Deputy Minister in New Brunswick. We are always delighted to have provincial public servants appear.

Mr. Ken Ross, Assistant Deputy Minister, Mental Health Services, New Brunswick Department of Health and Wellness: Honourable senators, I will not talk about the challenges. I think that Ms Pape and our colleagues at the federal level eloquently stated it. It is in my brief to you.

I want to talk about a balanced approach in a couple of contexts. The first is that we do not do too badly when people come into crisis and need for service. I can say that across the country there are excellent pockets of practice where assertive community treatment is a form of community care. We have mobile teams that respond to crisis. We have in-patient and ambulatory care.

We seem to fail dramatically in the key determinants of health. People must be healthy in society and mentally healthy. The senators have expressed it. It is housing, income, vocational opportunities, education, social inclusion and links to other parts of the community. We do not do a good job in that, and there is an opportunity here to move forward.

There has been a dramatic downsizing in our tertiary hospitals. Different provinces have handled it in different fashions. In my province a decade ago, 75 per cent of all expenditures for mental health went to two tertiary psychiatric hospitals, 25 per cent went to 13 community health clinics and seven regional hospital psychiatric units.

Today that figure is exactly reversed. There is 25 per cent in the two hospitals. There is 50 per cent in the community mental health centres. There is 25 per cent in the psychiatric units. It can be done.

When we look at a balanced approach, though, we need to understand that we are not talking only about balance in the context of provision of care. We are talking about a balance of stakeholder ownership and contribution. I think that you have heard reference to that during the last presentations.

In this context, I am referring to people who use the system, consumer survivors, their family and significant others, community members who are very concerned and interested in mental health and mental illness issues and people from the formal service system, the caregivers.

We need to understand that we have much better gains in society when we bring scientific, experiential, customary and traditional knowledge to the table. We have used that as a working model in our province for a decade. Two things happen when people from those jurisdictions come together. First, everything that we are discussing is improved because not one of us is as smart as all of us. Second, it is difficult to obtain consensus in a pluralistic society. That is part of our uniqueness as Canadians. We find that people will come away from discussion and debate, sometimes heated, with a better understanding and appreciation of where the other person's view and vision is coming from. That goes a long way in terms of arriving at consensus to move on problems and seek solutions.

We have some tremendous opportunities to build. There is a somewhat unanimous voice among the voluntary and NGO sector, the consumer survival sector, and the government sector, whether provincial, territorial or federal. That is a unique opportunity. That does not exist in other aspects of our health care system.

To build on that, we must recognize that we have some outstanding evidence, reports and plans. You heard reference to them today from the advisory network and some of its publications.

"A Call to Action" is another example. The Canadian Mental Health Association developed a very powerful series in the mid-1980s called the "Framework for Support." We do not lack intellectual energy or knowledge. We lack the action to make it have a meaningful impact in people's lives. I have attached in my brief, the paradigm that comes from the "Framework for Support." I think this is the most useful paradigm to develop social capital that we have today. It can be transferred to areas other than mental health. It is applicable to many areas.

In this paradigm, the person is at the centre and stakeholders work in the interests of a person. They work not from a moral obligation to assist the person in need. Stakeholders include family members, consumer survivors, formal systems of which I am a part and the community at large - churches, overnight shelters, boys and girls clubs, YM/YWCAs, social clubs. They are the richness of our community and fabric.

When you bring these forces together and start to develop trust and common ground to work on reciprocity occurs. We start to see good things happen at lower cost because people are interested in moving ahead in the interests of the individual. They are not interested in staking out territory or their organizational claim to something. They are looking at an idea that if you help me, I will help you. That is a very powerful buy-in.

We have an opportunity to do that as partners. There are a number of things that will need to change for that to occur.

In our country, we are overwhelmed with demand and supply. Before we go running to throw more money at problems, I would suggest that we look at how the supply is currently being used. I will use a quick snippet in terms of professional role change that will give some idea of where we need to apply this in terms of the mental health system.

We have problems in terms of recruitment of psychiatrists, child psychiatrists in particular. We have access problems, particularly in rural areas. We also need to change the practice modality. We really need to impact on solo office-based practice or solo intervention-based practice. We need to start linking the networks so that interdisciplinary teams work with psychiatrists. We need to adopt models of "shared care," such as the CPA has advocated, where the primary care physician has the benefit of skilled specialists such as a psychiatrist who could then transfer some of that knowledge and intervention to a much broader audience. We need to use telepsychiatry and telemental health to reach into remote areas.

Another opportunity upon which we should focus is some partnerships that are developing in this field. There is more constituent accord today than ever before, which is extremely important from a public policy point of view. If we could get political will to back up that constituent accord, I think that some dramatic changes would happen.

I will leave you with three areas that we could build on in a collaborative fashion by government sectors, federal, provincial and territorial, the NGO or voluntary sector and the informal sector such as consumer and family movements.

The first one is stigma. I have been in this field for about 25 years in both public and private settings. It is much different today than it was 25 years ago. There is a much better dialogue, but we still have a way to go. I would suggest that this issue bears the importance that a national anti-smoking campaign bears, for example. There is a role for the federal government because I saw Health Canada on an ad last night about anti-smoking as I was watching a show with my daughter. We need to concentrate on the issue of stigma.

A second area was referenced earlier by Ms Pape. We know many things from research application and knowledge exchange. We know how to do it better. We need to promote and encourage more knowledge exchange. By this I am suggesting that that exchange happen from families and survivors to professionals and back, from professionals to professionals and between professionals. We still have professionals that do not work as well together as we need them to work together. Knowledge must be exchanged from province to province, region to region, country to country. We have much knowledge, and we need to exchange that.

A final area is community mobilization. Again, I respectfully suggest that the federal government has some experience in this area. In my province, we found that family resource centres were an excellent initiative. They have reached into at-risk populations in rural and remote areas. The federal government is a significant funder and player in developing these resource centres, at least in New Brunswick. There is an avenue on which to move forward.

If you look at section 4 of the framework, you will see that all first ministers have signed an agreement to work in collaboration to identify priorities for collaborative action. The operative word being "action." There is a framework there. With the federal government's recently announced voluntary sector initiative, there are pieces now that should come together.

It is clear from the eloquent comments that preceded me that mental health issues are in our lives, homes, schools, workplaces, and communities. It is an important part of our society. It is important for individuals, for families and for communities. It adds to the economic, human and social capital that we have as Canadians. There is no health without mental health.

Dr. John Service, Executive Director, Canadian Psychological Association: Honourable senators, thank you for the opportunity to address you today. I would like to commend the Senate committee for taking on this important job and for having a round table on mental health. We at the Canadian Psychological Association appreciate that.

We are here today to talk about mental illness and mental health. I would like to set a different kind of framework; perhaps that could be part of our added value here today.

We in psychology - a discipline that is rooted in science and practice but particularly the science of human behaviour - look at this issue from a biological, cognitive, affective and social perspective. We know that how we think, feel and behave in our diverse roles in society has a tremendous impact on health status and our health system. It is essential to consider the fundamental contribution of psychological factors to the maintenance of good health, prevention of disease and injury, effective and accurate diagnosis and treatment, effective rehabilitation and relapse prevention, and the management of chronic illness and palliative care. Findings from scientific studies and clinical practice underscore the fact that we cannot adequately address health unless we look at the neuropsychological, cognitive, affective, behavioural and social factors that affect it.

I am always struck by the irony of the situation. We have a world-class health system in this country. It is deeply disconcerting to observe a health system that targets disease by performing apparent miracles with new tests and procedures, while at the same time investing relatively little time, energy and money to address the human experience of that disease - mental health issues and mental illness.

The centrality of psychological factors to health and illness is obvious. The unfortunate state of affairs results in tremendous unnecessary suffering for Canadians and increased cost to our health system.

I will provide some examples. Services for those with mental illness or psychological problems are inadequate and often not available. I worked for 15 years in the Aberdeen Hospital in New Glasgow, Nova Scotia in children and adolescent services. My waiting list for children aged anywhere from three to nine requiring care was two years. There is an awful lot of living that passes from the age of three to the age of five when they can see me, and I am one of the last stops on the train.

Second, as CBC reported two days ago, services for autistic children, for example, are not readily available. Do they fall within mental health? They certainly fall within our purview of psychological issues. We know that early intervention can positively impact them. That is a life-long impact. This mother said on CBC that she would move from province A to province B because she could not obtain adequate services for her child. It struck me that if that child had cancer, services would be available.

Patients with spinal chord injuries, diabetes, cardiac problems and those who become depressed and do not comply with their medical regimes can fall victim to serious injury and sometimes death. Access to services is unevenly distributed with relatively good access for upper income Canadians and often very limited or effectively no services for those less affluent.

Psychological services are offered to Canadians in four ways. First, service is provided through the public system - hospitals, community clinics and the like. Some hospitals and community clinics do not even employ psychologists, let alone offer adequate levels of psychological and mental health services. Second, service can be obtained by visiting a private psychologist. Payment could be through employment assistance programs, co-pay private insurance health policies or on a pay-as-you-go basis. These are the three other ways of getting psychological help, all of which are in the private sector. There is one method in the public sector. This means that those with adequate incomes having far more access than those without. It is frustrating to patients and us. The result of course is a two-tiered medical system for our kinds of services.

Psychological factors and mental illness factors do not occupy a prominent place in the continuum of care. They are a separate, segregated piece of the pie. This situation unacceptably increases the suffering of patients and their family, friends, and co-workers. It increases the costs of health care due to increased system use. CBC news reported this morning on a problem in Toronto about emergency use and patient bed use. We also have an overuse of physician services for mental health issues and psychological problems and an overuse of pharmaceuticals. It negatively affects the economic bottom line of corporations and businesses due to factors such as absenteeism and reduced productivity. As well, it increases the use of social welfare, criminal justice, and educational support systems.

At a Health Action Lobby meeting, one of our members said that a relative of his was on a long waiting list to receive some mental health services. If that patient were in the federal criminal justice system, she could be treated. Therefore, she should commit a crime. It was a joke - but it is black humour.

I will suggest some solutions. The health care system must recognize the fundamental role played by psychological factors in the health of all Canadians. Psychological and mental health services must occupy a central role in the continuum of care. These are "must-have" services. These are not "nice to have" services.

We must provide comprehensive psychological or mental health services for all Canadians, regardless of income, using a variety of private and public methodologies and vehicles. We must also ensure that all health services have mental health or psychological service components. This is particularly important in critical areas such as primary health care services.

We must provide adequate services and support for those suffering from serious mental illnesses. I am old enough to remember the closure of many facilities for the mentally ill and the mentally challenged with the promise that all those monies would flow into community services. We are still waiting for them.

I look forward to your discussion and report. Your first report was very helpful.

The Chairman: Mr. Ross, for clarification, you talked about the family resource centres you have in New Brunswick. What is a family resource centre?

Mr. Ross: They are funded through HRDC.

The Chairman: What are they?

Mr. Ross: They are groups of people, many of whom represent single mothers and those with a low income. They come together and they do early intervention things. For example, the one in Sussex - the small community in which I live - developed a self- help group for parents of autistic children. These groups enter a range of different community-based activities.

The Chairman: Does a government agency fund the groups?

Mr. Ross: It is funded by HRDC.

The Chairman: Not by you?

Mr. Ross: It is not provincial.

The Chairman: What sort of professionals run it?

Mr. Ross: It is a community development model, senator. It is not a therapeutic model. It is not run by professionals. It would employ someone who may have a university degree or may have many years of experience working in a community church organization or some other community institution.

It is community mobilization and community capacity building. It brings people together who do innovative things. It provides an opportunity for a community to show what it can do for itself and by itself. It is a "people helping people" model with some core funding from HRDC Canada to employ several workers. In the example I referenced in our community, there are two outreach workers in addition to the person who runs the program.

Senator Pépin: Does their role vary from one city to another, depending on the problems that they face?

Mr. Ross: It is the community that determines the response. That is correct.

The Chairman: One of our members asked for a description of the distinction between home care and community care. We all understand what home care is. About two weeks ago, we had the executive director of the Canadian Home Care Association and the president of the Canadian Association for Community Care before us. The entire discussion was on mental health care. None of us managed to ask for a definition of community care.

Recognizing that we are not experts in the field, could you collectively give us a better understanding of the term "community care?"

Mr. Ross: Think of the kind of care an individual receives in a hospital bed, then mentally replicate that care in the community.

The Chairman: In the community, you mean?

Mr. Ross: The care is provided where the individual lives. That is my definition of where that community care starts. It starts with that individual in that neighbourhood. If the person needs prompting to take their medication, community teams prompt them. The teams do not have an office space practice. Their practice is in the streets and homes of the individuals. They knock on the door and tell the patient to take his medication. The team will do things based on symptomology. If the team notices that an individual is becoming agitated, they would start short-term intervention to bring the symptomology down.

It is moving the care into the community. If a person goes into crisis in a number of situations, the crisis is handled in the community, never needing the person to use an in-patient bed.

The Chairman: Who funds or organizes this?

Mr. Ross: In my province, it is done through our mental health division and forms part of the formal provincial government service responsibility. It is part of where the money went from the institution into the community.

The Chairman: To the best of your knowledge, is it the same everywhere else or does it vary?

Mr. Ross: I think that it varies greatly, even within provinces.

Senator Pépin: The CLCS in Quebec goes to homes and provides services in the community. They do not bring the patient to the hospital.

Mr. Ross: The service in New Brunswick is a variation of the CLSC model.

Mr. Upshall: Mr. Chairman, I am a member of the Mental Health Implementation Task Force for Toronto and Peal County. Mike Wilson is the chairman of that committee. You might find it useful to have him come and speak about the implementation of mental health reforms as it relates to act teams.

I am prevented by virtue of confidentiality from discussing in any detail what we are doing. I can tell you that it is an uplifting experience to be involved in it, although it requires a significant amount of effort. What we are trying to do is like turning around a supertanker. You may find an hour or an hour and a half of evidence from Mike Wilson useful.

The Chairman: There is a similar organization in Ottawa - I think that they call the "Champlain Region." I know what is going on there because I happen to know the chair of that group.

Ms Pape: Mr. Ross spoke about thinking of community care in terms of what people receive in the hospital. I do want to point out that when you think of the kind of services that people receive in hospital, it is not just clinical, of course. It is a roof over their head, three square meals a day, socialization, et cetera.

Trying to replicate those services in the community is a huge task. We want to make the point that this cannot be done by formal services alone. This is too much for one service system. We must turn to self-help organizations such as the Schizophrenia Society, the Mood Disorder Association, the National Association for Mental Health and other informal kinds of approaches. A broad-based strategy is needed.

Senator Graham: Ms Pape spoke about what is going on in the streets. There is an indication from Mr. Ross that that is part of the service. Is this the kind of thing to which you were referring in your opening statement?

Ms Pape: I was trying to imply the seriousness of the problem. I was pointing out the experience of people living with mental health problems. I was not speaking so much to what kinds of services they are receiving, as I was about their dealing with their daily lives. Not only must they deal with the poverty and homelessness, they must deal with the stigma and the effects of discrimination and prejudice that exacerbate the psychosocial problems. I was trying to give you a feeling for what that is like.

Senator Graham: I was intrigued, Dr. Service, when you mentioned autism. I have a personal interest. How difficult is it to identify a patient as being autistic?

Dr. Service: I am not an expert in autism. I know that it depends on the severity because it is a unique disorder and not widely spread within the population. It also depends on the ability of the professionals involved to be able to make an accurate diagnosis.

If it is quite manifest, then it is fairly obvious at a young age. If there are aggressive interventions at a young age, there is a good outcome for at least about 50 per cent of the patients.

Senator Graham: I said that I have a personal interest. I have a grandchild who has not yet been identified as being autistic, but who is a mentally challenged or a Down's syndrome child. We are having some difficulties in that respect. He is 10 years old.

I was interested in the chart that was presented earlier with respect to the survey that went from the ages of 12 years to 15 years. Could we obtain more information regarding the identification of these problems at an earlier age?

I am also interested in the word "stigma." It has been used several times. In one of your papers, you mention that all too often the stigma results in people delaying treatment and families denying that a family member may have an illness. Of course, it may be the individual himself or herself who is in denial. If it is a serious problem, it creates problems in the home, even though the family may recognize it. The family may wish that they could do something about it, but oftentimes their hands seem to be tied.

What recourse do they have? It is disruptive to family life if an adult is in total denial and refuses to take treatment. What recourse do they have apart from legal action? Perhaps we are pursuing a legal question, Mr. Chairman.

Dr. Service: You are discussing legal and ethical issues.

Mr. Upshall: You are also touching upon substantial parenting and community issues as well, senator. It touches upon the recognition that something is occurring within your family. Parents are frequently unaware of what is occurring.

I could speak to issues having been through the system. I can tell you that the correction system has far too many mentally ill people within its borders. Those people were placed within correction facilities because of lack of information at the family level and the inability or unwillingness to deal with the issues at the school level at the early intervention stages. It is a part of the continuum of which you speak. We must address those issues in a practical, reasoned way. There must be early childhood intervention for mental health.

I am not comfortable with anti-stigma campaigns, but developing an education process that helps people overcome concern about discussing mental illness is absolutely essential. It would save millions and millions of dollars and untold millions of heartaches.

In regards to stigma, I came across an interesting observation. Some of you may know Bill Wilkerson, the president of the Business and Economic Round Table on Mental Illness and Mental Health. It is a large round table group dealing mostly with large businesses. At a gathering of insurance physicians, Mr. Wilkerson said:

The stigma of mental illness is every bit as big a battle among physicians and medical students as it is anywhere else. Stigma among physicians deters the detection of mental disorders, defers or pre-empts correct diagnosis and proper treatment and, by definition, prolongs suffer ing.

He based his comments on an "informal and ongoing canvass" of medical educators. He added that:

The evidence is mountain-high that mental health issues belong on the front burner of the current health care debate in Canada - but aren't. The reasons include stigma, stereotyping and wildly inaccurate and misplaced fears in the public...

That is an indication of the depth of the issue when we talk about stigma.

Senator Graham: Mr. Ross, you said that you have been in the field a long time. You have suggested that there is a much better dialogue today with respect to stigma than there was 25 years ago.

Before I ask my final question, Mr. Chairman, I would like to congratulate this group because you certainly bring tremendous experience, information and passion to the cause. I assure you, on behalf of the chairman, as I am sure he will say that himself, that we will respond in any way possible to help the situation. I am very impressed with the way in which you have presented yourselves.

We talked about the need for more education. I am wondering what might be done in respect to education in our schools and in our universities. It seems to me, for example, on the question of stigma, that if we educate young people about their peers and the whole question of stigma or mentally challenged people so that they could take that knowledge home and relate it to a personal experience. They could have a positive effect in that environment.

Dr. Service: I have been in the business for about 30 years. I have noticed in my personal experience, senator, that there has been a tremendous shift in the attitude of politicians, government officials, and health planners in terms of their reducing stigma and their increasing understanding of this issue. I mean that from the bottom of my heart. When I first went to talk to folks like you as a psychologist 20 years ago they thought of me as some pipe-smoking person that had people lying around on a couch. That is not the way it is done.

That change is in part due to courses such as introductory psychology in universities. Huge numbers of students take that course. There are many courses in criminology, psychology, sociology and social work, and people are taking those courses. There is much more exposure for the university group.

I am disturbed by the language used in our schools - particularly in our junior high schools and high schools - that students use to embarrass each other. They call each other crazy, retarded and "schizoids." All of those words are used on the playground. It relates to bullying and the in-group, out-group phenomenon. High schools and junior high schools are overburdened. They are not therapeutic units. They are educational units, but they need more support and integration with mental health services to stop this. That is an area in which I would like to see more progress.

One other thing about stigma that strikes me is that our health system is based basically on five things - physician services, nurse services, hospitals, pharmaceuticals and wonderful wizardry - technology and machines.

Those five items drive a huge sector of our economy in society - health. There is not much room at the table when you are looking for money, programs and influence for these kinds of issues. Psychology is 2 per cent of all of the human resources in health, whereas nurses are 66 per cent and physicians are 10 per cent.

There is not the place to drive that mental health sector. There are huge profits to be made in high-tech, pharmaceuticals and the like. That in no small way drives the end product that ends up in every community.

We do not have huge corporations making billions of dollars world-wide in the mental health system. It is a different kind of economic reality. When you look at how the system is geared, how it develops and how it is stigmatized - it is to some extend stigmatized by that process.

The last step it that it is stigmatized by old, archaic ways of remunerating people. There is one psychiatrist for every 8,000 Canadians according to our most recent studies. Psychologists do similar things as the psychiatrist, except that we do not prescribe drugs. There is one psychologist for every 2,500 Canadians, yet we cannot get remunerated for taking the load off primary care physicians and others. There are these systemic, historical chunks of the system that do not allow us to move forward.

Senator LeBreton: As you will be able to tell, I am focussing on the stigma issue. When I was listening to Dr. Service at the beginning, I wrote down that stigma seems to exist in this system as well.

Dr. Service: No question.

Senator LeBreton: Someone used the analogy of trying to turn around an ocean liner, and I often use it myself. It is like trying to turn the Queen Mary around in the Rideau Canal.

Senator Graham has been on the topic of prevention with other witnesses. Do we not have the cart before the horse? Could we not turn this around and use the growing knowledge base in genetics and patterns in certain communities.

Someone mentioned how we can mount anti-smoking campaigns. Drinking water can be moved very quickly to the top echelons of public input. Has the association though about how to reinvent the approach to mental health by looking at the preventive side in order to cause a better result.

Mr. Upshall: I will mention our "Call to Action" for the thirtieth time. We would like to bring together, by way of consensus through a framework discussion, an opportunity to dialogue among Canadians that would drive the decision-making process.

We would ask Health Canada to assist us in developing that consensus. By the very nature of that discussion to reach consensus, we would move early intervention and health promotion activities forward.

We would also be able to raise the profile of mental health and mental illness issues within Health Canada. If you are seeking stigma, you need look no further than what gains the profile. When cost cutting comes along, what is cut back?

Mental health issues have always been about and by the weakest individuals in our society. Unfortunately when that occurs they are the easiest to target because they have no voice. That is true. I say that without any condemnation of the wonderful people who I know work at Health Canada.

It has been true in the deinstitutionalization in the provinces, as well. If we could start a dialogue and raise the awareness of the issues amongst our educators and the public at large, it would be similar to that which the United States Surgeon General did in his report. I think that you are aware of that report entitled, "The Decade of the Brain in the United States." After much work, they came up with a framework for action. That is what we would like to do.

That report has impacted dramatically on how the United States sees mental illness amongst them and how they see the need for early childhood activities including nutrition programs in school and activities that impact development.

In 1999, the United States Surgeon General issued a call to action on suicide. Our suicide issues are greater than theirs are on a per capita basis. That report is sensitive. It has raised issues.

If I could say this again, we would really appreciate your considering a recommendation to endorse our call for action and request Health Canada to assist in that activity.

Senator LeBreton: Not only would a rise in public awareness impact on the providers of the system, but it would also be of benefit for families. If people were more aware and started recognizing illness, it would reduce costs to the system and enable people to deal with other illnesses. Mental illnesses are sometimes the secondary factor. One illness may cause a mental illness to develop.

I support efforts to raise public awareness on prevention. We spend much time dealing with what is available to treat something, once it has happened. There is not enough emphasis on making it not happen in the first place.

Mr. Upshall: Senator, there is nothing cheaper for the health care system of this country than to promote good mental health at the basic stages. You would see a miracle happen. It would not be expensive. It would involve teams, such as those Mr. Ross mentioned, doing early intervention activities and educating on proper nutrition and care for the poor.

We would save a great deal of money. It costs a minimum of $100,000 per year to look after one person with fetal alcohol syndrome in corrections. We have thousands and thousands of such individuals, at a cost of $100,000 each. We could re-direct that money back to the initial structure.

Mr. Ross: You have described, senator, what could be a very powerful vehicle through a community mobilization process. To me, it all starts with families and young people. It starts with children growing up, and families dealing with problems and their links to the community. We could help people to not look at individuals because of their condition, but to look at individuals because of who they are. They are people who need connections, friends, and members of church and opportunities to play in local community recreational activities. They need the things that we all need.

Currently, in this sector in Canada, we have many players who are willing to go to bat around community mobilization issues. In our province 10 years ago, we had one consumer-run community activity centre. We have 23 now. We fund them out of a provincial division budget. They are self-sustaining. They are run by consumers with boards. You could go into rural areas, the Acadian peninsula, which is as rural as it can be, and there would be three community activity centres in these little pockets of communities. That is a form of mobilization that has gone a long way to de-stigmatizing mental illness.

In my community, on St. Patrick's Day, the local community centre held a corn beef and cabbage dinner with a local fiddler playing. The entire community turned out. There were 300 or 400 people eating dinner over a two-hour period. There is much awareness-building in that process. It is people connecting with one another.

My credo would be that we not try to make this another industry. Let us build on what our communities have the capacity to do and invest in the opportunities that way.

[Translation]

Senator Pépin: I must say that I am very impressed by your presentation. I should have liked to ask you more questions. Your group seems very active when it comes to policies. Given all the different levels of government - and it is important to work with them - there is an increasing need for groups like yours, since you work in the field and you can say what is good and what is not.

Perhaps there should be a system where people from different levels of government would establish policies, one where you could also give impact. Thus, you would be able to tell them whether or not the policies are applicable, feasible, and how they could be made more practical.

You have told us about all the difficulties you have experienced in the field. There should be some way found to allow you to work with the people who make the policies. You have spoken about "self-help". What does that mean? We were discussing support and guidance for young people and for patients suffering from mental illness. Can you give me a definition?

[English]

Mr. Upshall: I will address your first question, senator. Our organization is very fortunate to have been able to work with the Federal Territorial/Provincial Advisory Committee on Mental Health to bring our issues to the table. I think it is fair to say that there has been a fair amount of dialogue between us.

Frankly, there are areas upon which we have not agreed, but everyone has had open minds and has taken on the issues. The question for us is to get those issues up to the top and raise the profile.

I should tell you that we are meeting with the Deputy Minister of Health Canada in several weeks to again raise our issues.

The issue of advocacy, however, is somewhat less on the horizon because we do not have the opportunity to do adequate advocacy with MPs and senators the way other major health lobbies do. We rely on the fact that, particularly with MPs and their open offices, so many of their calls are related to mental illness. In some areas, 25 per cent of their calls each week deal with cries for help from constituents who deal with mental health issues.

Ms Pape: Self-help is my passion. Mutual support is a powerful resource for any age, for almost any problem from mental illness to distress - all the kinds of mental health problems that we deal with in our life. It is based on the principle that people know what is best for them. The best solutions come from other people who have experienced the same problems themselves; no one understands like someone who has been through it. They are able to offer practical advice and emotional support to one another. Once people reach the stage where they can give help to someone else, they are starting to take control of their situation. That is a keystone to mental health.

Mr. Upshall: If I could just add, I would not be here without the opportunity to have participated in a mental health self-help group for some time. It is an absolutely incredible healing experience.

[Translation]

Senator Pépin: I was very happy to hear you mention prisons. I was involved in this area for a while, and I always said that you have to look at these people's backgrounds. There are definitely many people in prison who have psychological and mental problems; you have confirmed it. I am very happy to hear you say that. I also noted, in the documents, that there is a high percentage of persons in prison who have mental problems.

[English]

The Chairman: Dr. Service, you will be interested to know that we are doing a teleconference with experts on the German health system on Monday. In Germany, psychologists as well as physicians are covered, so there is hope.

I would like to make one comment to all of you. I have been quite fascinated by the stigma comment. Both Mr. Ross and Dr. Service made the observation that they thought that stigma had declined substantially in the last 20 years, although much remains. I suspect that if you canvassed committee members, every single one of us knows at least one person amongst our family and friends who have experienced a mental illness problem. My sense is that that was probably not true 20 years or 25 years ago, partly because people did not talk about it and partly because the services were not there. To that extent, it is less stigmatized.

Although I must say that I am disturbed by the comments about the way children in junior highs and high schools think about mental health. That is very disconcerting.

It is clear that not only are you emotional about this subject, but the people on this committee feel very strongly about it as well.

Since we will come back in the fall with the Health Canada strategy, I hope you people will come back and make comment, favourably or unfavourably, from the point of view of the users.

Mr. Upshall: If I could just point out that in our framework document we talk about the international scene. You may be interested in this in your present discussions on phase 3. We have a section about how Canada lags behind the United Kingdom, the United States, New Zealand and Australia in terms of progress. If there were any way in which we could assist to bring Canada into the forefront, we would be happy to do that.

The Chairman: We are adjourned until 9:00 a.m. Monday morning.

The committee adjourned.

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