Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 6 - Evidence - April 20, 2004
Ottawa, Tuesday, April 20, 2004
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 7:00 p.m. to study issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the Committee shall be authorized to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Hello, Ms. Hefford and Mr. Casey. My colleagues and I are delighted that you are with us, and we want to pick your brains for a while.
Let me set the scene by describing the kinds of issues we would like to hear your views on. We did a major study of the Canadian acute care system of hospitals and doctors, which is covered under our medicare system. We put that report out about a year and a half ago. Various bits and pieces of it appear to be moving towards implementation, although, as you know, like anything else in the health care system, it is full of controversy and there is opposition from all quarters. You might find it interesting to note that our committee, which consists of a number of Liberal and Conservative senators and one independent, nevertheless produced a completely unanimous report on what is, in many ways, the most controversial public policy issue in the country. That alone made the document worthwhile in many ways.
As we were going through that, it became clear to us that if there was any system that was even more badly run or perhaps more badly organized than our acute care system, it was the mental health system, for a variety of reasons, and nobody wanted to talk about the problem. There were far more silos. With the exception of mental hospitals, it is, by and large, not covered under our medicare program and so on.
We have embarked on a second major study, this one being the mental health system. We found it useful when we did the previous study to get some understanding of how other countries have handled the issue of mental health. Australia was one of the comparisons we used when we did the acute care study, and we have heard from a number of people both inside and outside Canada about the relatively innovative approach you have taken compared to many other countries, including ours.
We have never had a national mental health strategy. There is no national mental health act. It is a subject that has simply not become part of the federal purview at all, because in our case, health care is delivered through the provinces. In your case, it is through the states.
We are at the early stage of our work. We are trying to understand in a broad way what has worked well and what has worked badly in your system. Knowing what you know now, if you were beginning where we are beginning, which is essentially with a blank piece of paper, in the sense that it is not a question of having to change existing legislation and so on, what would you do differently and what would you do the same with respect to, first, the national policy side of mental health, and second, with respect to delivery?
Even though, like you, the federal government does not deliver mental health services, we will inevitably stray into what is clearly provincial territory because we will talk as much about the delivery of mental health as we did when we focused on how you ought to deliver acute care services. We do not feel terribly constrained by the niceties of which level of government is actually responsible for delivering the service. We are trying to lay out a road map for both levels of government, if you will.
I would like to begin by asking both of you to give us your overview of what is working well and what is not, with respect to both mental health and addiction, because our actual work plan is mental health, mental illness and addiction. To that extent, we brought the addiction service question into the mental health study, as opposed to leaving it out there as a separate silo.
That lays out the background of where we are. We appreciate your taking the time to be with us. Why do we not begin, Mr. Casey, with some comments from you, followed by Ms. Hefford, and then open it up to questions from my colleagues and myself.
Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, Department of Health and Ageing, Government of Australia: Just picking up on your themes about what we have done and what we might have done differently, as you know, our system is very similar to that of Canada. Prior to the early 1990s, the federal government had no involvement, responsibility or interest in mental health care at all.
The story goes that the federal health department had half a nutritionist who was responsible for the federal government's interest in mental health care, very much located in states and territories, very much located historically in the old systems of asylum, lunacy and the British system that came here in the 19th century.
It was interesting that the drive for change in Australia really came from the states and territories lobbying the federal government to take a role and become involved in mental health care. We had a number of scandals in the 1980s in relation to mental health hospitals that really focused on civil rights and issues of abuse. The interest that the federal government started to display in mental health reform was partially driven by some concerns that the fiscal responsibility for income support and employment services, which were the downstream consequences of poor mental health care, were actually a federal responsibility. The argument was put that the federal government is incurring large levels of expenses but has no control upstream in terms of improving our response to mental health. That was in the late 1980s and early 1990s.
In 1992, all health ministers agreed through the national Australian health ministers' council that there should be a national mental health strategy, and the federal government put in about Aus. $140 million over a 5-year period as "hump" funding to attempt to support a change. There were some key objectives, but they were very much focused on what we would call the "public specialist mental health system." That system deals with people who have acute illnesses — psychoses, bipolar disorder — that population that has historically been cared for in asylums. We estimated in the mid-1960s that we had about 30,000 mental health beds in Australia for a population at that time of about 12 million people. We now have somewhere in the region of, in the public sector, 5,000 psychiatric beds for a population of 20 million.
The major focus in the first plan, which was agreed to in 1993, was on changing the service mix in relation to the public specialist system. It was not about downsizing the asylums because they had already been downsized. In the early 1990s, there were only about 9,000 psychiatric beds left in the country. The major deinstitutionalization was the start of the institutionalization that took place between the mid-1960s and the late 1980s. It went on through a number of closures, but there was very little in the way of a policy or a strategic program attached to that.
In 1993, much of the focus was on the public specialist system, and the fundamental changes have been to shift the service balance to decrease the reliance on in-patient care and to increase the amount of resources going into community care.
The federal government's role has been largely through providing only about 2 or 3 per cent of the state/territory expenditure to give them some investment potential to start to hump fund change.
In 1997 or 1998, through doing a national epidemiological study, we probably woke up to the realization that the major mental health problem for the whole community was not in relation to psychosis, bipolar and the low- prevalence disorders, but it was, in effect, in relation to the high-prevalence disorders.
As a result of work such as the Global Burden of Disease Study by Murray and Lopez, we expanded the policy focus to take a "whole population" view of mental health care.
This is important for two reasons. Under our health financing system, it has for the first time brought into play those parts of the health care systems, particularly general practitioners, that deal with the bulk of people who have high-prevalence disorders such as depression and anxiety. This was an area of health funding that the federal government did have responsibility for, so for the first time, it, in a sense, became our business as well.
The second important point was that in doing that, we have engaged in large-scale mental health literacy campaigns throughout the community, because we realized that people's knowledge of mental health problems was very low compared with the epidemiology, which was very high; and second, we became very aware that the stigma attached to mental health was also high, and therefore people who were experiencing mental health problems were not even seeking care in any of the health care systems that were available.
That has led us to some major problems in relation to trying to sustain and support our general practitioner workforce, looking at mental health in our schools, and having a much broader population health approach to this problem.
What would we have done differently? Probably the major thing that has emerged over the last 10 years for us is that because we were a health department, we focused on the health aspects of mental health care, but what we have become much more conscious of is that without an appropriate social care model that focuses on all the needs of people with mental health problems, we will only go so far.
Yes, we have had some major reforms in relation to the service system. However, what we have not been able to do very well yet is to provide the employment responses, the housing responses and the social care models that ensure people who are living with a mental illness — and I think that is the term we use now, it is not something that will be cured, necessarily — are able to do so with the maximum social interaction and social participation that in itself will help to keep them stable and will help towards recovery. Medical treatment alone will not be an adequate response for people with mental health problems.
Those would be my brief opening comments about the journey that we have taken. In summary, we found it important not just to focus on what was the traditional mental health system, the asylums and the low-prevalence disorders, that we needed to take a broader population approach; the second thing is that we did not give sufficient focus to the social care, income, employment and housing aspects, and again, certainly housing is very much a state and territory responsibility. In our third plan, to which ministers have just agreed, we are now starting to put a lot more focus on the concept of recovery and maintenance of care in the community than we would have even thought about 10 years ago.
The Chairman: Thank you for that overview. We will have a number of questions on it.
Ms. Hefford, do you want to make comments on your strategy? You call it a "drug strategy" and I would call it "addiction." Could you comment in particular on how the linkages between the mental health strategy and your strategy work, or are you in fact two silos operating separately?
Ms. Jenny Hefford, Assistant Secretary, Drug Strategy Branch, Department of Health and Ageing, Government of Australia: Very broadly, Australia has had what we call a "National Drug Strategy" system since the mid-1980s. It is something that we have revised and refined over the years and it has been a learning experience at all levels, both at our federal health level and within state governments, right down to a local service and practitioner level.
In the latest iteration, there are things that I think we are certainly doing much better. One of those is that we have a much more collaborative approach now across sectors and through various levels of government. We now have a strategy into which the federal government has put $1 billion over the last five or six years, and it involves health, law enforcement, education and customs at a federal, state and local level. We think that we are actually getting better at working through the issues because we have this cross-disciplinary, cross-sector approach. That means, for example, that we have been able to introduce early diversion programs for young people who are identified by the police as in possession of cannabis or small amounts of other drugs, and who are given the opportunity to choose not to have a sentence of any kind recorded but to go into assessment and treatment. Some of those things have been very successful. We have had between 30,000 and 40,000 young people diverted out of the judicial system and into treatment through that sort of process.
That said, despite the effectiveness that we would ascribe to our current three pillars, which are supply reduction, demand reduction and harm reduction and involve those various areas of government both at a federal and state level, the issue you are talking about now is the one where we would have to say we have been least effective. I would support a lot of the things that Mr. Casey has said, in that we would still have to say that one in four people with a substance use problem also has an underlying mental health problem. In fact, as many as 60 per cent or 70 per cent of clients of drug and alcohol treatment services have an underlying or undiagnosed mental health disorder.
We probably deal least well with those clients, for all the reasons that you have suggested, that they fall between the gaps, they fall between the pillars in terms of either mental health and acute care settings or addiction and drug/alcohol treatment services. I have some suggestions for how you could look at some of those issues based on our experience, but I am happy to leave it at that and see where you want to go from your questioning.
The Chairman: Thank you both for that, and we will come, Ms. Hefford, to where you think we should go in a second.
Can I clarify several points? Ms. Hefford, when you talk about a drug strategy, do you include alcohol in that? You did not mention it and so I am wondering where alcoholism fits. Does it fit in the health care system, in the mental health system, or is it part of the drug strategy?
Ms. Hefford: There are a few things I will say about that. If you are asking me about the broad issue and the cost of drug-related harms in Australia, our biggest single issue is tobacco, which probably parallels the Canadian experience. The second biggest issue is the misuse, inappropriate use or diversion of pharmaceuticals, and below that we then have alcohol and poly-drug use. Poly-drug use is becoming the single biggest issue across the country for us, and probably this also parallels your experience. Every heroin user has also been using Benzos. They have also always been drinking. Most drug and alcohol treatment services — and we fund services that treat equally problems of addiction related to illicit and licit drugs — would all say that the most common scenario is that someone would present and claim to have a problem with a particular drug, but their secondary issue is almost always alcohol.
We fund services that would treat these in similar ways and we do not discriminate in the funding that we give to alcohol or other drug treatment services. We simply fund the IOD sector, alcohol and other drug treatment sector, to deal with issues of addiction from presenting clients.
Does that answer the question?
The Chairman: What that says to me, and which is good, is that you have a very broad interpretation or definition of drugs, in the sense that it includes alcohol, incorrectly used drugs and tobacco. Is that correct?
Ms. Hefford: That is right.
The Chairman: You are now in your third five-year plan, in the sense that this is your third strategy?
Mr. Casey: Yes. We say one strategy, three plans. We are in the third five-year period. Ministers have recently agreed to a further plan for five years. Each one builds on the previous one. We are moving now into what will eventually become a 15-year commitment. It remains under the banner of the National Mental Health Strategy.
The Chairman: I gather from what you have said that your focus has increasingly been on delivery. You recognize that you have to go beyond the narrow definition of "mental illness." You have broadened it to talk about the entire person and social delivery as well as health care delivery.
Am I correct? Since 1992, over the last 12 years, there has been the development of a broader concept of mental illness and, therefore, a broader set of tools to deal with the problem?
Mr. Casey: Yes, that is basically correct. That summarizes it. National coordination has now become much more important to us, not just in our role as the national government but also in assisting the states and territories. It has become much more relevant to some of the broader federal government objectives that we seek to achieve.
An example of that would be that through our epidemiological studies, we have been able to look at a subpopulation, those people who are in receipt of government assistance through pensions, unemployment benefits, et cetera. The prevalence rates for mental health problems amongst that subpopulation are much higher than in the general population. For sole-parent recipients of social security payments, we have prevalence rates for depression and anxiety of 40 per cent compared with the general population level of only a fifth of that.
This becomes relevant for the government when we are trying to increase social participation and return to work of people who have been on social security benefits. When the treasury is bringing forward data about population projections and the dependency ratio for an aging population, this becomes a relevant policy issue for our social security portfolio. It becomes a relevant policy issue for our employment and work-based relations portfolio.
In that sense, it is becoming more relevant to federal objectives, rather than the national government merely trying to assist the states and territories to run the health service more efficiently. It is becoming more of an entire government focus rather than just a health curative focus.
The Chairman: I am fascinated by the amount of data you have. Who is funding these epidemiological studies? I may be wrong, but I do not believe those data exist in Canada.
Mr. Casey: I do not believe you have done a national epidemiological study. The federal government decided to undertake our epidemiology study in 1995. We had the American epidemiology information. Quite frankly, our data are not much different from theirs or any other country. However, unless they are Australian data, they do not have the relevance for policy development.
We carried out three studies in 1997. We carried out a household study in Australia. We did 10,600 interviews to gather our statistics. That is where we got our adult population information. We did a similar study for children and adolescents. We went to 3,500 homes and interviewed parents and children to get a better understanding of what it was like for people with low-prevalence disorders such as schizophrenia. We funded three catchment area studies throughout the country, mainly in urban areas, but we also took in some of the fringes. Those catchment studies identified all those people in the area who were known to agencies as having mental health problems and sought to interview them.
We have a very good epidemiological base. That cost us Aus. $5 million between 1996 and 1998. We thought that that was a very good investment. Without those data, we would not be now able to address some of the policy issues and have a good understanding of the population.
When we got those data, we took them to the population under the slogan, "one in five." That was our slogan for five years. It was to increase public and political awareness of how significant mental health problems are to the community, and from which we could then develop some of our programs and policy responses.
Epidemiology was essential for bringing the community and the workforce to a common understanding of how the problem was being experienced in Australia.
The Chairman: Thank you for that. We will have to ensure that we get those kinds of Canadian data, because they do not exist.
I will turn to our deputy chairman, Senator LeBreton, who, interestingly enough, as one of her non-Senate activities, is the National President of an organization called Mothers Against Drunk Driving. She has had a long interest in the issue of addiction. I am delighted to have her as deputy chairman of the committee.
Senator LeBreton: The Chair's questions were a good lead-in to what I will ask. You talked about the mental health literacy campaign. One of the problems that we certainly found in our early studies was the issue of stigma.
Depression is one of the major problems. There are so many people who will question identifying a member of their family, or themselves, for that matter, as suffering from a mental illness because of the stigma.
I am interested in knowing how the mental health literacy campaign worked. Was it successful because you used these data? Who funded it and how long did the campaign last? Do you have any immediate feedback results on how this campaign and the issue of understanding mental health made its way into the population? Also, did people accept the campaign and allow you to gather more information as a result?
Mr. Casey: Let me respond to that, senator, by saying that in the mid-1990s we did a major, double-funded television, cinema and newspaper advertising campaign. Its only objective was to make people aware there were mental health problems.
We were really seeking to encourage a much more positive attitude, and I believe the television commercial slogan was along the lines of, "how much they suffer depends on you." It portrayed a number of scenarios in which we showed the difference between how we respond to and care for people who have a physical illness, and then how we respond to people who have mental health problems.
While we did not see a major shift in the population's attitudes toward mental health problems, even now people still remember the advertising campaign, so it did stick in their minds in some ways.
Following that, though, we have become much more targeted. We produced quite a lot of information leaflets, which we distributed through pharmacists, community organizations or whatever, and we probably gave out about 2 million of those in a two-year period. We have a mental health promotion program for our high schools, and nearly 70 per cent of them are now running that program. We have about 2,000 high schools.
This is really about changing the way in which young people start to learn about and experience this. It is coming through their curriculum and is very much a strategy focused on the next generation.
We have established a company, funded by government, called "beyondblue." It is a not-for-profit private company with a corporate objective of promoting a better understanding of depression. They fund a number of programs, so we have a major study ongoing on postnatal depression and are looking at bringing screening programs into our health care system. They are very much engaged in the media and have become the public face of mental health comment.
We have the National Mental Health Council that brings together all the mental health stakeholders in a federally funded organization that is there to speak to the federal government on behalf of the mental health community. Consumers, their families, politicians, non-government organizations, we have one organization for them all.
I think that was a major achievement, because one of the difficulties for government is being told different things by different people. Then, in making a decision, you will make some unhappy; but we have brought them together and told them to come to us with one voice. That has worked very well, and again, they have become a very important public focus for these activities.
There have been a number of elements rather than one strategy. Our recent data have shown us that we have improved mental health literacy in the Australian population by about 10 percentage points since 1996. Those data are shortly to be published and were gathered through a tracking study done by the Australian National University. We have just started to get their data, which are showing that it does make a difference to how well the public recognizes, understands and knows how to respond to people with mental health problems.
In the Australian community, 60 per cent of people surveyed say they either know someone at work, at home or a family member or a relative whom they believe has a mental health problem. Their perception of the problem is there. Their fear about being involved in it, the stigma, was still there. However, from tracking what happens in the media, we are able to see the way in which the positive stories have an effect.
We also had the National Media Strategy, where we worked directly with the media to promote more positive messages about mental health and suicide prevention. That strategy operates in the journalism schools and the universities, where we are teaching journalists about how they should approach these issues when reporting them to the community in a way that is not stigmatizing.
There has been a major funding strategy on the part of the federal government, because we see this as our responsibility. It is about the population as a whole, as opposed to the service delivery, which we see as a state and territory responsibility.
Senator LeBreton: Would I be right in assuming that a lot of this has addressed the issue of stigma? If people do not have to live with the fear of stigma, and they treat mental illness like any other illness, is it correct to say that because of these campaigns, it has been dealt with quite significantly?
Mr. Casey: I think it has been dealt with to an extent. We have no comparative data from any other strategies to assess whether something like a 10-point improvement is a good or a poor outcome. We have not seen anyone else look at this issue and track it over a period of time.
What we can say is that our hospital contact data and our health service contact data show that there is a greater proportion of the population seeking care than was the case when we did our epidemiology study. We would conclude from that that they are now at least more prepared to seek treatment — and of course there are many effective treatments.
We also know that we do not know enough about treating all conditions. One of the downsides is that people are looking for treatment — and this is particularly true where you have mental health and addiction problems combined — but we do not yet have the strategies for necessarily good outcomes from those treatments. We are still working to understand how best to treat people with co-morbid conditions.
No doubt we are seeing more people seeking care. We see that as a response to people feeling less stigmatized themselves. The downside is it is putting some pressure on our health system, because mental health preparations, mental health content, are increasingly higher as a proportion of all health services than comparable conditions. Therefore, we are starting to see a greater demand coming through in our data.
Senator LeBreton: I was very taken by Ms. Hefford's statement that 30,000 to 40,000 young people — and I am particularly interested because of my work with Mothers Against Drunk Driving — have been diverted out of the criminal justice system into the health care treatment system. How did that happen? Did you catch them before they got into the criminal justice system, or did they land there and you got them out before they became lifelong residents of that system?
Ms. Hefford: It has taken several years, and in large part, it has depended on getting a fundamental shift in policing attitudes. What we now have are police on the beat whose starting position is not how can I arrest this person, but how can I prevent this person from ever being in this situation again?
That means that young people who are found to have some cannabis, marijuana, on them, for example, are taken to the local watch house and given an explanation of the options — that they can be held over for consideration by a magistrate the following morning and may or may not have a criminal conviction recorded against them, or they can agree to go for counselling and assessment, and into treatment services if the assessment suggests that is warranted.
The great majority of young people, particularly first-time offenders, will choose to go the counselling-assessment- treatment path. Of course, we have to have protections in there so that if young people fail to show up for that counselling session, they forfeit their right to go that way. They are brought back and sent down the other path, toward the criminal justice or judicial system. However, it has been very successful.
As I said, it has required a shift in policing attitudes. It also requires that you have counsellors, assessment services and treatment services available right across the country. There is no point in offering this option to young people and then saying there is no capacity in this regional centre for us to provide you with that. It has meant ramping up the services in those areas.
It is fair to say that both the police and the judicial system were initially hesitant about the way this would work. They now see this as being of enormous benefit, because the great bulk of their time is spent working with the really hard cases, the really criminal end, and they are not what they would see as wasting their time with 14- and 15-year-old first offenders truanting from school who have been found with a small amount of marijuana in their pocket.
For us, there are some other advantages. We now have, I think for the first time ever, a downward trend in hepatitis C rates. Hepatitis C has been an issue in prisons in Australia for many years, and we know that people who go to prison on a drug-related offence will often end up coming out of the correctional system with a bigger drug-related problem, and some blood-borne viruses into the bargain. We had a downward trend in HIV/AIDS data for something like eight years in this country. Now, in the last couple of years, we have seen a downward trend in hepatitis C rates, which we think is a huge breakthrough.
Senator LeBreton: My last question is on diverting young people. Do you have a mechanism in the educational system whereby they are made aware that these programs are available to them, if in fact they ever do get themselves into that situation?
Ms. Hefford: There is no simple answer to that. The three pillars we use are supply reduction, which is about border controls and closing down clandestine drug laboratories and so on, removing the product from the streets; demand reduction, which is about school-based drug education and government-run campaigns to reduce the demand; and harm reduction, which is about our treatment services and diversion programs for young people. I would like to say to you that those three pillars mean that young people are aware of the pitfalls. However, the reality is that for a proportion of young people, school-based drug education programs are ineffective, partly because they have an undiagnosed trauma or background of abuse, which means that their life experiences are not touched by those education programs.
That is a real issue for us. We seem now, in this discussion, to be moving from where Australia has been and some of our data to what we might change in policy terms if we were given the capacity. I can go on to do that, or I can wait until you want to get to that part of the discussion.
Senator LeBreton: That is fine.
The Chairman: You are on to it now, in terms of where you would go as opposed to where you have been, so why not go ahead.
Ms. Hefford: All right. The issue for us, as I have been saying, is undiagnosed, untreated trauma in young people, or abuse of young people. We know that these are precursors to young people either ending up on the streets or with an addiction problem or substance use problem linked to a mental health problem.
As to where I would go, I think there are a number of points. One of them is to look very carefully at earlier interventions. That means not just early interventions on the part of the health care system. You somehow have to enlist the support of police, school counsellors and others who might see things that are indicators of future trauma. Police attend car accidents where a member of a family is badly injured or perhaps killed. If there are young people present to witness that and they are not directed into counselling and support at that point, then you can expect that a few years down the road, such a young person will be a teenager with an undiagnosed trauma in a dysfunctional family. School counsellors pick up on truancy and other behaviour problems. It is trying to find ways of linking those commonplace, everyday issues and having those early interventions available so that young people who have those experiences are identified at an early stage as people whom the system needs to watch, who need access to more support and more care.
The other thing is we need to be conscious of the fact that we do have dysfunctional families. The family is not always the place for a young person to get the best support and assistance. On the other hand, some dysfunctional families can be helped, and young people can be helped when more support is directed to those families. Mr. Casey has talked about the need for a national mental health council such as we have in Australia. We need to accept that consumer advocacy is just as important in substance abuse as in other areas. It is not something we have done very well in this country but I think it could be shifted.
We saw the rise of a movement around supporting carers over the last 10 years. Carers are people who care for the frail, old or have a disability. We saw a huge rise in Australia in the amount of advocacy, support and understanding for carers who were caring for someone in their family who was frail and old and who would otherwise have been hospitalized or ended up in a nursing home.
We provided a lot of support and a lot of community understanding and recognition of what those people were doing. We need to think about how you would empower the consumer advocacy groups around substance abuse. There are parents and grandparents, even children, who are, in part, caring for or trying to support someone who has a substance use problem. We do not recognize those people and we do not have targeted supports for them. We do not have a recognized advocacy role or a lobbying role for them. We need to perhaps try to do some of that, to bring some greater public awareness to these issues and to help bring them out of the stigma category in which they still exist.
There is no doubt that people with a substance use problem in Australia are often self-medicating because they have a mental health problem, but are also dealing with a stigma associated with their substance use. We know that some GPs do not particularly want these people in their waiting rooms. We know that some pharmacists do not want these people coming in for their methadone or buprenorphine treatment, or even for clean needles. We know there are many barriers to accessing care and treatment and support, and we need to find ways of breaking down some of those.
I might leave it at that because I think I have taken it perhaps to the point where it is fair to toss it back to you.
I would like to parallel what Mr. Casey said about data. We actually have a National Drug Household Survey. Every three years we do a census of 27,000 households and we collect data on prevalence of use of all drug types. We use this to help us target treatments and identify where services are needed. It has been very valuable. I cannot emphasize too much how valuable having the data can be in dispelling some of the myths and in helping you target, geographically and regionally, the right service and setting in treating the right issue.
The Chairman: Thank you. We would totally agree with you on the data. I gather your data are collected by the equivalent of our Statistics Canada. It is the government?
Mr. Casey: That is right.
The Chairman: I want to come back to some cost questions. Let me turn next to my colleague, Senator Morin, who in his previous life was dean of medicine at one of the country's biggest medical schools.
Senator Morin: I would like to refer to a recent international review by a group of experts who stated that Australia leads the world in, amongst other things, mental illness prevention. I know some of this has been alluded to earlier, but what specific measures do you have for mental illness prevention and do you have any evidence that it is in fact effective?
Mr. Casey: I am not sure what that publication was. I think one of the difficulties is people often confuse the terms "promotion" and "prevention." I would not say we have yet found ways in which to prevent the onset of illness. What we are working on is how we might be able to prevent episodic relapse.
We have done a lot of work in the area of early psychosis assessment services, but I do not think that any of us know enough about mental illness to know whether we can specifically prevent the onset.
Having said that, though, we are currently, through our "beyondblue" national depression initiative, undertaking a major study in schools looking at whether specific psychosocial interventions through the classroom can prevent the onset of depression and anxiety in adolescents. That trial intervention will not be completed for another two years. That is a specific attempt to see, in a randomized, controlled way, whether in fact we can change the prevalence rates and the incidence of depression and anxiety in an adolescent population in comparison with what we would expect from our epidemiological data.
I think we have promoted a much better understanding of mental illness. We have certainly restructured and enhanced our health care system and, to a lesser extent, broadened that into the other areas of social and health policy, including the police force. If, in that sense, it has had an impact on preventing people developing mental illness or in assisting early intervention, then I think we have done something, but we do not have any specifics — and I do not know of any else who does; I would love to hear about it if they do — that could prevent the onset of illnesses.
Senator Morin: Thank you very much. My second question deals with the private sector mental health services. In Canada, we have no private sector at all as far as physicians and hospitals are concerned. I was surprised to see, if my figures here are correct, that 50 to 60 per cent of all people seen by a specialist in the mental health sector are seen in the private sector. For us, this is completely unheard of.
What is your impression of the private health service? If you started over again, would you still keep it? Do you think there are advantages in having it? Do you think there are disadvantages? What is your impression of the quality of care and the availability of the private sector health care?
Mr. Casey: That is a pretty broad question. I will try to break it down.
When we talk about the private sector in Australia, it is probably a bit of a euphemism. The public sector represents those services directly financed and run by state and territory governments, such as hospitals and community health systems — that historic constitutional responsibility for health care provision. When we talk about the private sector, we are talking about those services that are subsidized through our medicare system. In fact, government picks up 60 per cent of the cost of those services through its medicare funding.
Private services, in our case, would include general practitioners, because they are funded through medicare, or a psychiatrist in private practice. About 83 per cent of psychiatrists in Australia run private practices and do not work for the state mental health systems.
We also talk about the private hospital sector, which is available to people who have private health insurance. In Australia, everyone is covered by medicare. In addition, about 40 per cent of the population would have private health insurance. That private health insurance provides access to private health facilities, and that includes mental health services.
The insurance companies would like to get rid of psychiatric care from the schedule of services for which they have to pay, and they have tried in the past. The difficulty with mental health care is so little is known from the point of view of risk assessment, how low it should be, what the success rate should be, and what they should expect in terms of an ongoing pattern of care. If you break your arm, it gets fixed and you go on with your life. Subject to not falling again, your arm should be fine. With a mental health problem or psychiatric problem, that is not easy to articulate from the point of view of any understanding of the problem.
Our private sector is a mix. Private psychiatrists have tended until now to be very much in a primary treatment role. We would like to move them from seeing themselves as treating people with psychiatric and mental health problems to people who, because of their level of expertise, act as consultants to others. In the same way that consultant physicians, in relation to physical health, are the source of support and assessment for the general practitioner, we would like to move our private psychiatrists much more towards that role, and we are currently looking at our financing strategies to encourage them to spend more of their time acting as consultant psychiatrists rather than treating psychiatric illness.
For our general practitioners, another part of our private system, the federal government introduced a program three years ago that is specifically designed to reward them financially for spending more time with people with mental health problems. It gives them access to referral to psychologists as an essential part of the mental health treatment team, and it also improves their education and training and provides them with emergency consultation services so that they do not feel they are left to deal with the problem alone if they engage with their patients' mental health problems. We have been told that if you are a GP and someone comes into your consulting room and you think they have a mental health problem, you keep quiet, because if you open the dialogue, you will still be there 20 or 30 minutes later, and of course, fee for service is the treatment model. We have encouraged them by saying that if it will take 20 minutes, we will pay them extra for taking the time. Currently, about 15 per cent of our GP workforce has enrolled in this program. We have about 3,500 GPs who are now enrolled in this program and recognize themselves as people who can offer slightly more and better mental health care. That is a new program.
The private hospitals will probably face some restructuring because ultimately, given the treatment services, their capacity to treat and the consumers' increasing desire to be treated at home and not in a psychiatric hospital, there will be less demand for private hospital beds for psychiatric care. We are encouraging the private provider industry to begin moving its service structure again towards community care, while still providing psychiatric care through the insurance premiums that people choose to pay. Sometimes, government regulation of the insurance industry gets in the way of good care. We are trying to look at the regulations to ensure that patients are still protected in relation to the premiums while allowing the providers to be more flexible in terms of the care that they provide and not create a barrier to good community care by forcing them to provide only in-patient care.
Our private sector is very complicated, but it does treat a pretty large proportion of the population, and the overall private sector, psychiatrists, GPs, and the private hospital providers, have all become part of the National Mental Health Strategy. It is not just a public sector strategy. We have engaged them. In a way, if you want to be involved in mental health care in this country, you have to join the club and be seen to be part of the strategy, or else you will be sidelined in any of the key policy decisions made in the country.
I have to say, in all honesty, that private psychiatrists have been the most disappointing in that respect, not because of a lack of willingness on the part of their leadership, but because they do not seem to be able to get take their eyes off the consulting couch for long enough to understand what is happening in the world. We are still working with them.
We think the private sector is an integral part of our health care system. The government's policy is such that people have choices in terms of where they receive their health care. In some states and territories, if you become a regulated patient or you are compulsorily admitted for psychiatric care, you can receive the care in a private hospital. That is not the case throughout the country but we are encouraging all states and territories to do that. If people have paid for private insurance and they need to be admitted to a psychiatric hospital, albeit under legislation, they are still entitled to receive the treatment for which they paid their insurance premium. We are trying to encourage all states and territories to have private facilities available because the government's policy is one system, multiple choice. I hope that answers some of your questions.
Senator Morin: It certainly does.
The Chairman: That was a wonderfully complete answer. If you are trying to persuade psychiatrists to move into more of a consulting role and do less primary care, does that mean you see the primary form of counselling coming from the general practitioner? Does your publicly funded program pay part or all of the cost of counselling services from, for example, a clinical psychologist, specially trained social worker or other people who are trained in that field but are not doctors?
Mr. Casey: Historically, our medicare system only provided rebates for medical services. The provider had to be a doctor. Increasingly, there is recognition that health care providers do not necessarily have to be doctors. In a recent initiative under our medicare system, as well as these sorts of more-options-better-outcomes GP programs, the government is starting to provide funding for the purchase of non-medical services as part of a multidisciplinary primary approach to health care. It is an emerging policy shift. The government has put its toe in the water and has begun to fund some levels of allied health care through our medicare system. I think this will increase. At the moment, there is a barrier to our primary care focus in mental health. One of the most effective treatments, particularly for common disorders, would be a combination of pharmacology and counselling psychotherapy, cognitive behaviour therapy or other therapy. We have a government subsidy for pharmacology and we are now increasing the government subsidy for counselling, psychotherapy and CBT. This is the shift that we are undertaking. We are starting to engage our psychologist workforce as part of a multidisciplinary health care system. That is part of the emerging picture and why we asked our psychiatrists to act more as consultants in the primary care area because we see it as the setting in which many mental health problems can be managed.
The Chairman: I have two comments. Primary care, from your point of view, is essentially the point of entry to the system, which it was not historically. Is that correct? It is now the primary point of entry.
Mr. Casey: That is the direction in which we are trying to shift the focus.
The Chairman: You talked about shifting to fund the services of non-physician health care providers. The issue that would immediately arise in this country is that it had better be done by increasing the size of the pie rather than by redistributing some of the funds that now go to the medical profession to another profession. In other words, have you increased the pie or have you changed the emphasis to accomplish this? Have you changed the distribution of the pie?
Mr. Casey: At this stage, we are increasing the level of available funding and putting it through our Australian divisions of general practice, which are like management groupings of GPs, across the country. We are putting any additional support money into general practice. The government recently introduced some access to medicare payments, but we are not quite sure how that will work. We are increasing the resources. The reality, in any of these change processes, is that to be seen taking from Peter to pay Paul will always create enormous political difficulties in terms of engagement. Going back to our start on this over 10 years ago, we did need some new money — hump funding or investment funding — so that we could put new measures in place. We did that and our data show that we have saved money. For all of the funding for our newly structured community-based mental health services in the states and territories, we can actually show the source of the dollars. We publish an annual report that monitors the progress of mental health change in the country and we track where the money goes. It is important in any reform process to keep your eye on the dollar, because there are many people who would steal any money that they see lying around in the health care system.
In fact, one of fears of the federal government 10 years ago was that if we were to give money for mental health, then the states and territories would simply take it and spend it somewhere else. We had an agreement with them that they would maintain their level of funding if the federal government added to the pie. We actually tracked the dollars and the states and territories had to report to a system of monitoring expenditure. We do not need that system now, 10 years later, because governments, realizing how important this is at a jurisdictional level, would not use the money for something else because it has become such a political issue in the communities.
In the beginning, if the federal government had put money in, you could bet your bottom dollar the states and territories would have taken it and spent it somewhere else. We actually did monitor and still monitor expenditure. It is in the nature of federal government-state relationships in a federation. There is always a sense of healthy skepticism between the national and the provincial governments. Therefore, recognizing that and doing something to ensure it did not become a barrier was an important goal of the original architects of this strategy, who recognized that we needed to monitor where the money was going.
The Chairman: Obviously, provincial or state politicians are identical regardless of where you live in the Commonwealth. We have had extraordinary experiences in a variety of federally funded programs such as health, post- secondary education and others, where exactly the same thing occurred. The federal government increased contributions and, strangely enough, somehow the total amount of money spent never increased. There was always some sleight of hand so it was difficult to pin down exactly how it was done. I served for a period both as secretary to a provincial cabinet and deputy secretary to the federal cabinet, so I actually did see the sleight of hand from both sides.
Senator Cook was intimately involved in developing community-based health care centres, as opposed to the non- institutional type of health care centres, in a number of small rural communities, where major hospitals and institutional care were not possible. She approaches the subject from what you called the broader social policy side rather than the classic medical side.
Senator Cook: Community-based centres provide the social peace that brings a person with mental illness back to normal living, if you like — the ability to cope or acquire some life skills to move on with life.
My first question is where is the social worker in the continuum of care for that person when we move into community-based services? What role do your NGOs, the volunteer sector, play in the rehabilitation and the care of the individual?
Mr. Casey: Are we talking about mental health services here?
Senator Cook: Yes.
The Chairman: We want to hear from Ms. Hefford on the same issue in terms of addiction or drug services.
Mr. Casey: I will answer for mental health services and ask Ms. Hefford to talk about how that is managed in relation to the drug services.
With respect to the social worker, the psychologist or the mental health worker, we have a mixture of professional groups that work in mental health services. I could not give you one picture for the whole country because it varies greatly.
However, if I take, for example, the State of Victoria, which probably has the best-structured service mix — and I am talking about people who have low prevalence, severe disorders such as psychosis, bipolar and so forth — we have community mental health teams that are area based. The state government runs them.
The State of Victoria also spends about 10 per cent of its health dollars on buying support services from the non- government sector. Those services are arranged from within accommodation services, so it is staffed accommodation in the community, residential hostels, or even group homes where a small number of people would live, supported either on a roster or 24-hour basis, depending on their level of disability, by paid staff from non-government organizations.
The community mental health teams visit people in the home. They provide support, and they would also refer them to other services while they are living in the communities. They might be living with their families; they might be living in a shared situation with others.
What we are finding more is that the most difficult problem facing people with a severe and persisting mental illness such as schizophrenia is not the health care they receive. Most of them have a health care professional, most of them are in touch with services and most of them are receiving medication. The idea that people with schizophrenia are living under the bridges and in the back streets of the cities, while it is true of a proportion, is not true of the general population with those illnesses. Where they miss out most is on social engagement and participation.
I do not know if you have heard of the Clubhouse model, which is like a day centre, run by consumers for consumers. We find that if somebody is involved in that model and then goes on to an employment placement program, he or she stands a much better chance of having successful employment outcomes than someone who has not been through one of those social training programs.
We are, in our third plan, as I said at the outset, putting much more focus on the idea of recovery, rather than just looking at treatments. Recovery, for us, is the life that people have to lead while they will likely continue to have this illness, and the risk of acute episodes, for anything up to 20 or 30 years. We want to focus on living in the community and living with the illness, but in a much more supportive and socially responsive way that would prevent them from becoming users of health care services by having frequent episodes of illness that would lead to hospital readmission.
Neurologists also tell us that the more times that you have a psychotic episode in schizophrenia, the greater the brain damage that will occur and the more likely it is you will have recurring psychotic episodes. Even in a treatment sense, it is much better to maintain and care for people in a more stable environment, given that they will spend long periods of time in recovery and are unlikely to ever be cured of some of these very severe illnesses.
Senator Cook: Does the federal system fund these programs, are they funded by the state or does the state deliver them on behalf of the federal system? How do you funnel the money to those community-based programs?
Mr. Casey: The states and territories are responsible for funding services. The federal government does fund some services, but more in terms of demonstration projects. Increasingly, we have become directly involved, as Ms. Hefford said, in funding some drug services. Generally, states and territories provide and fund services. The federal government funds the states and territories.
When the federal government provides health funds to the states and territories, a specific element of that funding is for mental health care reform. We use that money to help the states and territories reorient the way in which services are provided.
None of us is naive enough to believe there is an endless bucket of money that can continue to be poured into service provision. Like any other country, we probably do not spend enough on mental health care, given the disability burden that it imposes on the communities. I do not think we are any different from any other country in that respect. However, we are able to help people reorient and re-engineer their systems to be more effective, and that means moving some of the resources away from a focus on health care and health treatment alone and understanding that that alone will be a wasted investment if you do not have other services.
Different states and territories make their own decisions. Victoria spends 10 per cent of its health budget on non- government organizations as parts of its mental health financing. In New South Wales, however, it is 4 per cent. It is interesting that those states and territories that have the most political difficulties to deal with are those that spend the least on community care. A state government with high spending on community care is less likely to experience political trauma around mental health.
Mental health is a significant political issue in Australia. We have quite a strong consumer-led voice, and in fact, the patron of our National Mental Health Council is the under-treasurer in the federal government.
There has been a significant development in engaging the political leadership in the country as part of the mental health community, and that has been a specific strategy of ensuring that the political leadership is well informed and also well respected for its positive response to mental health care at both the state and federal levels.
We have a very articulate consumer movement that is well educated. Obviously, it is inappropriate for us to be engaged in lobbying our own governments. The government funds its own lobbying mechanisms, but through an articulate mechanism that is responsive to the needs of government, the political leadership and its constituency.
Senator Cook: Your national drug formulary provides free access to prescription drugs outside a hospital setting, subject to an annual threshold. I would like you to help me understand that. Does access to the drugs flow through the system to the consumer?
Mr. Casey: It is more the other way around. Everyone has access to those drugs that are approved by the scheme and makes a copayment.
If you are a health card holder, a social security recipient, you will pay approximately $3 per prescription. After your payments reach a certain threshold — and I cannot remember exactly what it is — you pay nothing.
We have a safety net for people who are high users of any form of pharmacology. Every time I fill a prescription for myself or a member of my family, it costs me $23 or $24, regardless of the cost of the drug. It is a fixed copayment. If I were a social security recipient, I would only pay $3.
Access to pharmacology is structured in such a way that that should not be a barrier. Other than to the extremely poor or people who have no disposable income, it should not be a barrier.
Senator Cook: Mr. Chairman, we have not asked about indigenous people. I think it would be remiss of us not to do so, in light of the fact that our next study concerns our First Nations people. I am interested in hearing about your indigenous people. Do they live primarily in rural areas, urban areas or on reserves? What is the level of mental illness?
Ms. Hefford: We are having a little discussion here because neither of us has a strong background in what we would call indigenous health. However, I will kick off by saying that the majority of indigenous Australians do not live in remote areas, although the proportion that do have substantially greater problems around access to and support through health care systems than those who live in metropolitan areas.
Indigenous people fare far worse in our system in terms of all substance use. Prevalence rates for smoking, for example, are far higher among indigenous Australians than among non-indigenous Australians. Substance abuse issues, particularly with alcohol and petrol sniffing, are extreme in some indigenous communities.
Indigenous people have lower health ratings than non-indigenous Australians. The average life expectancy of an indigenous person is some 20 years lower than for a non-indigenous Australian.
If you wanted to have a more detailed discussion about indigenous Australians in terms of the kinds of programs that we have run and where we think there are opportunities for success, I suggest that we set up another session with some of the people who have worked extensively in this area. There are people with quite a lot of background and expertise in this who would be able to give you a great deal more assistance than either of us. We can only talk about the issues around mental health and substance use for that population. I think you would need to have a conversation about the broader health outcomes and health indicators for the whole of the indigenous population.
Mr. Casey: To add to that, about 1.5 per cent to 2 per cent of the population would be indigenous Australians. Everything that Ms. Hefford has said would be reflected in mental health care, that we would know that what we refer to in indigenous communities — and increasingly now use the language in the broader community — is not that they have psychiatric problems or mental illnesses, because culturally that is very challenging. We talk about the emotional and social well-being of the indigenous community. In some ways, that starts to mirror some of my previous comments about the general community. Our view of the state of one's psychological well-being and where that sits on the continuum between what we might just call normal psychological stress and when it become illness, and the relationship between those sorts of illnesses and the illnesses of schizophrenia or bipolar disorder, is coming much more to the fore in Australia. That is because the government has recently considered a report on the relationship between neurological and psychiatric disorders.
If we put the broad issues of neurological and psychiatric mental health problems together, the way in which our brain and our nervous system combine, we find that that far outweighs the total burden of any other health condition. It leaves cardiovascular disease for dead — excuse the pun — in terms of the burden it imposes on the community.
Increasingly, we are moving to looking at the relationship between the mind and the body, to use the old Descartian separation of 400 years ago.
I also have responsibility for national health priorities. As well as mental health and suicide prevention, my area also covers our national health priorities, which are CVD, diabetes, asthma and cancer. Increasingly, we are finding that there is a high correlation between people who are experiencing physical health problems that create the greatest health burden on the community and those who have a high level of co-morbid mental health and psychosocial problems.
That is an enormous challenge to the way in which we deal with the historical focus on our physical health system, if there is a strong underpinning around the psychological well-being of the individual. I suppose that is part of an attempt to say that the indigenous people have a lot to offer us in understanding the relationship between how you experience your world from your psychological and your social perspective, and what implications that has for how you physically can live your life in terms of a sense of wellness. That is coming back into our thinking, because they link the two. Your physical health and your mental health have to be linked together. We are starting to learn from that that perhaps we should look more closely at how those things interrelate, which goes back to the chairman's comment at the beginning of this discussion about why we have moved to a much broader population health focus in all of the programs we are working on. We cannot just see health in terms of treatment and medicine; we must see it as part of a broader social well-being issue for the community.
I will not speak about it now, but that has led us into a number of discussions with our economic agencies, such as treasury and employment, because these become key issues in their policy thinking as well. We have talked about the social health burden. What we have not touched on is the economic burden. What is starting to interest our central agencies, our finance areas in government in Australia, is the data we can provide them on the economic consequences of a poorly managed mental health/substance abuse system. What is the economic impact on the community? The numbers are enormous.
We have just started to explore that as part of this broader policy focus. This is because it is a national government issue.
We do not deal with the day-to-day issue of providing care for individuals, but we are starting to deal with some of the policy repercussions and the policy opportunities that arise in the larger society when there is a focus on better mental health care in the community. That is part of the exciting challenge of the next 10 years.
Senator Cook: Mr. Chairman, we have seen once again that one size does not fit all. Surely, in looking at the total person, we will need to look at people's culture as we work toward wellness and learn to understand their traditional methods.
Mr. Casey: I think that our Office of Aboriginal and Torres Strait Islander Affairs on the hill would be very happy, perhaps another time, to talk about some of the programs. It is the one area of health care provision for which the federal government has a direct responsibility.
The Chairman: The situation is exactly the same here. Secondly, on the data that Ms. Hefford gave, if we had substituted "Aboriginal Canadians" for "indigenous people," the numbers would have been very close. It is absolutely amazing to see the similarity, on the other side of the world, with a federal state with very much the same background of an indigenous people. The similarity is quite striking.
That does lead me to ask several questions and I want to begin with a strategic question. When you do your epidemiological studies, do you include an adequate statistical sample of indigenous people? Is that how you collect your data with respect to them? Do you know, Ms. Hefford?
Ms. Hefford: Yes, we ensure that our studies include sampling that is statistically accurate. We have a number of survey and data collection mechanisms. Our knowledge is a compilation of all of those. Probably the most controversial involves people who are actually trained to survey injection-drug users. We actually do that on a regular basis. It means that we know what they are injecting this month. We know how much they pay for it. We know the sources they tap to access it. The question is important to us not just from a health perspective — if they overdose, hospitals will know what is being commonly used on the streets at the moment — but also from a policing point of view. It tells us about the shift in whatever is being traded on the street. It tells us the dollar cost. That is linked to crime rates in particular areas. A whole range of government organizations finds this information valuable.
The Chairman: Yet you are able to collect that information. The right wing in this country would go ballistic if anyone were collecting those data or, at the very least, turning them over to the police. I am amazed you are able to collect those data without that kind of public outcry.
Ms. Hefford: As I said, it is the most controversial of our data collections but it is very valuable. We do not do it within the department. Obviously we outsource that data collection. There has been some controversy, too, about the fact that we actually ask 13- and 14-year-olds about their drinking and smoking habits. Those are illegal activities for that age group in this country as well. There is a reasonable parallel there. Unless you are able to ask young people who gave them the alcohol, how much they paid for it and how much they are drinking, how do you target school-based drug education programs? How do you talk to parents about improving their parenting skills? How do you address all those other issues?
The Chairman: That makes sense to me. I am fascinated that you can do it.
Mr. Casey: If you included the whole population in a household survey, it would be very hard to over-sample indigenous populations to get a representative view. It is much more likely, epidemiologists would argue, that you would do some form of catchment or intensive state-based assessment. There is a feeling in the indigenous community that they have been researched to death and yet nothing has changed. They feel that the media quite often use the results of research done in indigenous communities in a very stigmatizing way. The community is very sensitive about engaging with researchers.
We have just completed a major study in Western Australia, largely with federal government funds but also state and private funds, on Aboriginal child and youth help. That study will be of enormous value. It was done in cooperation with the indigenous community because they trusted the researchers. They trusted that the information would be used to improve their world and not just by the media to once again demonstrate the hopelessness of the indigenous population.
The Chairman: Can I circle back to Mr. Casey's opening comments? Is this a reasonable conclusion for me to draw from what you have said? You should realize that we are back where you were in 1992. We do not have a national mental health strategy. Most provinces do not have a significant mental health strategy. There is certainly no coordination. We are really back at your first five-year program.
You said a couple of very important things. First, you got the support of both the state and the national governments. That alone, on any health care issue, is a huge achievement. I infer that you then spent the next five years not only launching programs, but also creating a huge communications focus. I do not use that word in a bad sense, but it seems you recognized very early on that progress in this area required bringing the whole population with you. If the public did not buy into the importance of the program for economic reasons, then despite your slogan about one in five being affected, it would be impossible to get public support for the amount of money you invested. You could not begin to change the delivery system as much as you have, nor, as you put it, could you make the program sufficiently politically important that politicians could not whittle away at it.
It seems to me that you went out and built a constituency over that first five-year period. Is that a reasonably fair conclusion?
Mr. Casey: We probably did not start building that constituency until towards the end of that first five years. We needed to do a lot of preparation work. We started changing how the services operated — closing beds, opening more community services. The attitude of the Australian community was no different from other communities. Mental illness was something you would rather not know about. If you saw anyone whom you thought had a mental illness, you would cross the street and keep clear of him or her. Only people who experienced it within their families would have any understanding, sympathy or positive attitude towards it. Yes, we believed we had to change the community's attitude. You should probably start in the middle.
The Chairman: At the provincial level, we have already gone through the deinstitutionalization phase. By the way, that was driven in large measure by attempts to save money and not directly focused on improving services.
Do you have a packet of material containing some of those early communication pieces, whether literature, television ads or videos? I assume you used a wide range of communications techniques. If you do, it would be very helpful if you could send them to us.
Mr. Casey: We would be happy to do that.
The Chairman: Can you recall, in ballpark terms, the annual cost of the communications program in the later years, when it was fully up and running?
Mr. Casey: That initial public campaign cost us about $6 million.
The Chairman: Is that $6 million per annum?
Mr. Casey: That amount was spent over two years.
Let me tell you what we currently spend at the federal level and of what that is made up, besides the general health financing that goes through medicare. I will not talk about that.
I have about $6 million annually in my national budget, besides which I have staff, which generally goes toward what we call the National Mental Health Plan. On top of that, I have a budget for what I would call national program implementation — putting things into schools, running and funding media campaigns, developing our strategy — of about $20 million a year. That is what the federal government is spending on what I would call policy and program reform.
On top of that, we might be spending some money on services. We are clearly spending money through medicare. The GP program is costing us about $40 million a year. We are not talking large amounts of financing. The epidemiology study cost us $5 million, but that expenditure was probably spread over two and a half years. We are not talking about enormous levels of government funding to develop a policy and program framework. However, I can send you some information about our finances, what it has been costing the federal department to become the national leader in mental health reform.
The Chairman: That would be helpful. The public is way ahead of governments on this issue. There is a huge yearning in the country for someone to take charge. It would not take a huge amount of dollars from a communications standpoint — you clearly have to have some program money — to begin to generate the kind of constituency that would enable many of the changes that you have made to be made in this country. It would be useful for us to know that. It is like looking at the evolution of the automobile over time. You can understand how the communications program has changed. That would be very useful to us.
We talked about how this is tied in with community health services. Is it tied in with public health in any way? Is public health in a totally separate silo as well?
Mr. Casey: There is a national public health part to that.
Ms. Hefford: I might have a go at answering this question. Within our departmental structures, the addiction/ substance abuse issues are dealt with within our public health area and regarded as public health issues.
I am conscious of the fact that I have given you no sense of the structures of service delivery and implementation in addiction services. I know we went through that with mental health. We did not with substance abuse.
The acute care sector, the hospital sector, has a very limited role. It provides detox programs and deals with ODs, overdose deaths — the very high end, where things have gone monumentally wrong.
The primary care sector is largely focused on managing opiate dependency. General practitioners prescribe methadone and pharmacists administer methadone-type programs. There are 30,000 Australians currently in methadone programs across the country.
State governments fund the acute care sector. The federal government funds the primary care sector, GPs and the pharmaceutical benefits scheme. Alcohol and drug treatment services are split about 50/50 between state governments and non-government organizations. In Australia, the community sector plays a large part, particularly the traditional church groups. Organizations like the Salvation Army and the Catholic Church run treatment services and night patrols and provide syringe programs largely funded by the federal government, with some level of state government intervention.
There are agreements on many public health issues between the federal government and state governments. We describe them as a partnership. There are agreements whereby the federal government provides funding for activities like national syringe programs and state governments take on responsibility for administering them.
As we have moved further into dealing with drug use issues in Australia, the breadth of things covered in public health programs has increased. It has gone from simply being about health delivery to being much more about things like police diversion of young offenders, counselling by court and judicial services, and things like the issuing of clean syringe injecting equipment.
All of the things that we now would say are part of the public health partnership in Australia have gone beyond the actual delivery of what we would have previously described as health care services. They relate to those other, broader areas, in the same way that we include family planning counselling in public health issues in Australia.
What is really important in the way these issues are managed, from your perspective and in terms of where you are, is the conversation you were having a few minutes ago with Mr. Casey about establishing a constituency. In Australia we have done the same thing on the drug abuse side; we have established a constituency. We have put money upfront to make that happen, but because that constituency now exists and there is a high level of acceptance of that, we get very good value for very little investment, particularly in communication-type activities. For example, we have meetings where the senior health representatives and senior police representatives from all states and territories come together with federal representatives, and the outcomes of those meetings are press releases, communiqués, the launching of reports or the announcement of agreed-upon new guidelines. Every time you do that, you get publicity and a reinforcement of your communications strategy without having to pay for it.
If you can get that constituency working for you and that level of shared understanding and commitment, you can get value in terms of the community accepting where you are going. In our experience, the non-government sector, particularly church and community groups, has been very accepting of government willingness to show leadership in this area. You can get a significant amount of effect for very little further investment in dollar terms.
The Chairman: As one of those who have been involved in developing programs to sell various government policies, I am absolutely amazed at how well you have done. It is a huge tribute to you. It goes back to the comment that Senator Morin made, when he quoted that article that said that you were clearly leading the world in this area. That is certainly the impression I have had in the last several hours.
Thank you for taking the time from your busy day to be with us. If you could send us the communications material, that would be really helpful.
As we go through this process over the next year and a half, we may well come back to you with more specific questions. It is clear that we are at least a decade behind you. We will try to close the gap, obviously, but to avoid reinventing the wheel or going down some of the dead-ends that inevitably you must have gone down before you ended up where you are, we would love to have the opportunity to pick your brains again.
Thank you very much on behalf of all of us. We have really appreciated it.
The committee adjourned.