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SOCI - Standing Committee

Social Affairs, Science and Technology


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

Issue 7 - Evidence - April 28, 2004

OTTAWA, Wednesday, April 28, 2004

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.m. to study on 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.


The Chairman: Senators, we have with us today representatives of three provinces, Alberta, British Columbia, and Nova Scotia. Thank you all very much for coming from the far ends of the country.

As you know, we have been doing a study on mental health sort of as a sequel, but not quite, to our other study. It is a sequel in the sense that we are focusing on a specific part of the health care system rather than the broad acute care system, which we did before. It is not a sequel in the sense that the problems and the delivery system are clearly different. The piece of work stands on its own.

Our schedule keeps getting interrupted by things like Parliament being prorogued and in a couple of weeks, presumably, Parliament being dissolved. Nonetheless, we soldier on through these changes in the schedule.

Our plan is as follows: We will issue an options paper that will outline the issues and dealing with them as we see it. We will issue that late this year before we adjourn for Christmas. During the first six months of next year, we will do a series of cross-country hearings to get reaction to the various options. Therefore, we will be back to see you on your home turf because we will visit every province while we do that. After that we will issue a final set of recommendations in the fall of 2005.

We are delighted you took the time to come talk to us today because you are the people responsible in many ways for delivering those mental health services that are technically part of the Canada Health Act and overseeing other services that are not technically part of the Canada Health Act, and which are funded by public funding, NGOs and others.

Clearly, one of the issues we have been struggling with is how the system ought to be structured. If one were to set out to design a health care system in Canada from scratch today, one would not produce a system in which only hospitals and doctors are funded at 100 per cent. There would be different delivery system with people at one end of the income scale paying nothing and people at the other end paying something.

The reality is that we are where we are. The question is how do you change the system to deal with the kinds of things that you people see on the ground. We are delighted to have your input, and we will be back to get more input from you in the first quarter of next year.

As I understand it, we will begin with Ray Block, CEO of the Alberta Mental Health Board. He has with him Sandra Harrison, an executive director with the Alberta Mental Health Board. We will then turn to Dr. Jim Millar, Executive Director of the Mental Health and Physician Services for the Nova Scotia Department of Health. Irene Clarkson is the Executive Director of Mental Health and Addictions from the British Columbia Ministry of Health.

Thank you all for coming. Mr. Block you will begin and then we will continue with the others on the panel.

Mr. Ray Block, Chief Executive Officer, Alberta Mental Health Board: Thank you. I understand all of you have copies of my materials so I will be skipping a long at a fairly high pace. I will not cover everything in the material.

The Alberta Mental Health Board is honoured to have this opportunity to present to the standing committee. The board is one of 11 health authorities established by the Alberta Ministry of Health and Wellness. There are nine regional health authorities and two provincial bodies — the Alberta Cancer Board and the Alberta Mental Health Board. The ministry also has established the Alberta Alcohol and Drug Abuse Commission. The Alberta Mental Health Board, to which I will refer from here on as the AMHB, services our jurisdictional responsibility.

The AMHB is the provincial regional health authority that has been designated by minister to play an important advisory role for mental health reform. The Alberta Mental Health Board is working closely with the Mental Health Patient Advocate of Alberta to enhance advocacy for mental health in the province.

Like all jurisdictions, Alberta is undertaking health reform. On January 8, 2002, the Premier's Advisory Council on Health released its report, the Mazankowski report, on how to put Alberta's health care system on a sustainable foundation. The report recommended that mental health services be fully integrated into regional health service authorities.

The Minister of Health and Wellness, the Honourable Gary Mar, accepted the recommendations and directed that mental health services be integrated with regional health services by the end of March 2003. The minister showed tremendous foresight and commitment in making mental health a priority. He directed that a plan for future direction in the mental health system be developed collaboratively by authorities and in partnership with the ministry. He asked that an inclusive process be used and that the plan build on past reports and link with other government initiatives.

I am pleased to report that the mental health services were successfully transferred from the AMHB to regional health authorities effective April 1, 2003. Health authorities have also collaboratively developed a comprehensive provincial mental health plan that sets the direction for improving mental health and mental health services across the province.

While health authorities are very excited by the potential implications of the plan, it is important to stress that together we are just embarking on this plan and much work remains to be done. The plan was tabled with the Minister of Health and Wellness last Friday. We will be happy to ensure that you receive a copy once the minister has reviewed it.

It is very important to understand that ``Advancing the Mental Health Agenda: A Provincial Mental Health Plan for Alberta,'' is the plan of the health authorities collectively. It was developed by a steering committee comprising representatives from each of the health authorities, the ministry, the Alberta Psychiatric Association, the Alberta Medical Association and the Alberta Alliance on Mental Illness and Mental Health. It is based on our experience, best practice and the input from more than 1000 Albertans through a consultation process.

It is anticipated that the consortium — the AMHB, regional health authorities, professional associations and stakeholders — will begin work on a process for advancing, tracking and reporting progress. The authorities are looking forward to sharing progress with Albertans as we incorporate the mental health plan within the regional health authorities' overall health plans.

What do we mean by mental health? It is critical to understand that mental health is more than the absence of mental illness or disorder. The determinants of health influence the optimal development of children, youth, families, and communities. Mental health and well-being is profoundly affected by a range of factors including income, social status, housing, physical environment, social support networks, educational levels, and employment circumstances.

Under the heading ``The Need for Action,'' I have included statistics on mental health services and needs. However, in the interest of time, I will not recite them in my oral presentation.

There are many critics of mental health. The AMHB is very mindful of these criticisms and supports the provincial mental health plan as a framework for reform. Let me say that with successful implementation of the provincial mental health plan, the AMHB envisions a future wherein stakeholders join forces to battle mental health openly and in public — a future where science comes to the table, where advocates and caregivers speak collectively not only of stigma, but of the need to eliminate systemic discrimination. We envision a system where we work together toward recovery rather than accepting lifelong disability as inevitable for those with health disorders. The AMHB envisions quality in the lives of those who must learn to live with mental health problems. We envision playing a key role in promoting and realizing respect and support, and a system wherein stakeholders learn from survivors and their families. We want a system that celebrates caregivers as heroes.

The AMHB sees an enriched mental health system that brings hope to consumers and their families, that educates the public and infuses clients and service providers with care and support. We see partners building resiliency and intervening early when they recognize signs that someone may be ill. The AMHB envisions a system that has successfully reframed mental illness as a public health issue worthy of support and investment.

Reports indicate that equitable and timely access to a range of quality services is the number one priority for consumers. Consumers and advocates indicated they want better outcomes for all Albertans, but they most often mentioned the urgent needs of children, youth and Aboriginal communities.

In respect of the scope of services, Alberta is proud of its work in mental health. In 2002, the Canadian Council on Health Services Accreditation granted the AMHB a full three-year accreditation. This was the first time a province- wide accreditation survey was undertaken in Canada. It was also the first time tele-mental health video conferencing technology was used for these purposes. In the accreditation report, the Canadian Council on Health Services, CCHSA, recognized the AMHB's numerous achievements and referenced 10 good practices that contribute to the field of mental health care.

With the handoff of services to regional health authorities, a framework for mental health services was developed. Service components included in the provincial mental health plan are based on the Alberta Children and Youth Initiative Mental Health Policy Framework. The framework is relevant for all the population; it identifies three strategic directions, supported by effective collaboration across the full range of service providers. They are: support and treatment, risk reduction, and capacity building. Under these three strategic directions, the scope of 10 distinct services are listed for your review.

The provincial mental health plan calls for service delivery models that reflect a strong, integrated case/care management orientation. This approach will strengthen the alignment of mental health planning and link primary care with other service providers. Finding entrance to, and making smooth transitions into mental health and other support systems should not be a puzzle for clients to solve. Case management also needs to be considered at a cross- jurisdictional level.

In respect of funding, approximately $472 million was budgeted on mental health services in Alberta in 2002. This amount does not reflect all expenditures related to mental health services. One of the challenges we face is the dearth of comprehensive and comparable data on cost and spending for mental health services across Canada. There is a need for improved administrative data for our own planning purposes.

Work is needed on a comprehensive workforce plan that meets the needs of mental health consumers, employers and the education community.

Excellence in mental health services depends on research that informs and guides decisions, helps set policies and priorities, improves outcomes for consumers, and supports ongoing innovation. The AMHB is prepared and has a capacity to play a significant role to collaborate and facilitate the development of a pan-Canadian approach for establishing a renewed Canada mental health research agenda.

In respect of accountability, the process we use in Alberta to develop the mental health plan has been well received. At the recommendation of the Aboriginal consultants and the Alberta Mental Health Board Wisdom Committee, the steering committee has addressed Aboriginal issues throughout the plan rather than establishing a separate Aboriginal mental health strategy. Federal strategies for Aboriginal mental health on reserves should harmonize with the mental health plan and implementation strategies.

The development of cross-regional, provincial and coordinated pan-Canadian processes for facilitating the gathering, exchange and analysis of information is also needed.

In summary, Mr. Chairman, we believe that strategies that build capacity, reduce risks and provide treatment and support will help Canadians realize optimal mental health. Mental health issues should be viewed through a population health lens. Increased funding is required for provincial health ministries to better meet the mental health needs in their jurisdiction. Considerable investment in mental health research is integral to sustaining excellence in advancing leading practice in mental health. A pan-Canadian strategy would be beneficial for gathering data, sharing and comparing information. Federal investment in the education of mental health work force, including community workers, is required. Finally, a matter for discussion at a future federal/provincial/territorial conference of ministers of health is reciprocal arrangements relating to access and payment for community- as well as facility-based mental health services.

The Chairman: This not a substantive question, this is just for information. Is the document ``Alberta Children and Youth Initiative Mental Health Policy Framework'' a public document? If so, could you send us some copies?

Mr. Block: Absolutely.

The Chairman: In respect of the plan, I gather the minister has not yet signed off on. At some point, when you get that signed off on, could you send us some copies of that too?

Mr. Block: I talked to the minister on Friday and he will not be long with it. I expect I can have it to you very soon.

The Chairman: In fact, I am meeting with him in a couple of weeks anyway, but if you could get that, that would be great.

Dr. Jim Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health: Honourable senators, thank you for allowing me to present to your committee. I applaud the work you are doing. Many studies have been done on acute, long-term and primary care, but I think this is the first in Canada to look at mental health from a national perspective. I was personally pleased to see in your first report on health care that you felt mental health was important enough to have its own report.

I will talk to you today about the importance of mental health to Canadians, the current state of mental health services internationally, nationally, and in Nova Scotia, and then present some thoughts on what is needed to enhance the mental health and well-being of our citizens.

Mental health is important because it affects 20 per cent of our population, has a tremendous economic impact, and is a risk factor for other illnesses. I am sure you received a great deal of information on these items so I will cover them quickly.

More than 450 million people worldwide suffer from a mental or behavioural disorder, and 20 per cent of Canadians will be affected during their lifetime. In a one-year period, 4 to 5 per cent of Canadians will suffer from a mood disorder, 0.3 to 1 per cent from schizophrenia, 12.2 per cent from anxiety disorders and 2.2 per cent of women from eating disorders. In 1999-2000, the seven most common mental disorders accounted for 3.8 per cent of all general hospital admissions in Canada. This is a gross underestimate of the need as the vast majority of people are treated on an outpatient basis.

Mental illness carries a tremendous economic cost. In 1993, it was estimated that the total economic burden of mental illness was $7.3 billion in Canada. By 1996-97, this had grown to $14.4 billion. In the U.K., it was estimated that psychosis alone cost the economy £1.2 billion. This is compared with heart disease, diabetes and hypertension combined at £1.6 billion. In developed countries it is estimated that 35 per cent to 45 per cent of absenteeism is related to mental health problems. Each year in the U.S., 4 million days are lost to absenteeism, and more than 20 million days are lost to reduced productivity while at work. The economic burden is particularly hard on our young adults who make up the most productive segment of our society.

Indirect costs attributable to mental disorders outweigh the direct treatment costs by two to six times in developed countries. Many of these costs are borne by family and friends. Not treating mental disorders leads to increased costs through decreased economic activity, quality of life and family and interpersonal relations, as well as increased hospital admissions and suicide.

Mental illness is not only a problem as a disorder in itself but also as a risk factor for other illnesses. Depressive symptoms have been shown to be a predictor of increased utilization of future medical services for other illnesses. Even mild depressive symptoms are predictive of increased risk of coronary artery disease. Those suffering from chronic depression are 4.5 times more likely to suffer heart attack, and four times more likely to die from it. This relative risk is at least as high as cigarette smoking, obesity, diabetes and hypertension. Mental illness can contribute to, result from, or share a common causal pathway with cancer, heart disease, and chronic obstructive pulmonary disease.

Internationally, much is being done in the mental health field. The World Health Organization has carried out significant research in the last decade and developed many tools that underdeveloped countries can use to develop improved mental health programs.

Even the United States appears to be paying attention to mental health. President Bush has formed the President's New Freedom Commission on Mental Health, which has made several recommendations to improve the mental health of Americans.

Nationally, we are not doing as well. Provinces individually have been struggling with providing appropriate services and develop various models from the Mental Health Commission of New Brunswick to the Alberta Mental Health Board. The federal government has not provided leadership in developing a national strategy.

Federal legislation puts the treatment of mental disorders at a disadvantage. Senator Kirby mentioned that the Canada Health Act only covers general hospital and physician services. Psychiatric hospitals are specifically included and are not subject to reciprocal billing arrangements between provinces. Most mental health services are provided in the community by non-physician providers and thus are not covered. In many provinces, the amount of mental health services that can be charged to provincial plans by general practitioners is severely restricted. This is unfortunate as 80 per cent of mental health services in most provinces are provided outside the formal mental health system by primary care practitioners who are not appropriately prepared to provide these services. Shared care, where the formal and informal systems collaborate to provide mental health services in the primary care setting, is a hopeful alternative that is being slowly implemented.

Criminalization of the mentally ill is an increasing problem. With the changes to the Criminal Code of Canada — much needed of course — the courts and lawyers are much more willing to use the mental health provisions to find defendants not criminally responsible. As inpatient mental health beds in residential care facilities have been reduced, police officers and others have started to use the justice system to shortcut the system and get people off the street and into treatment that may not be available in the community.

It is difficult for the various Canadian jurisdictions to work together. The Council of Deputy Ministers of Health has stopped funding the Federal/Provincial/Territorial Advisory Network on Mental Health. This has cut off a major venue for sharing and joint planning. Some jurisdictions continue to get together but struggle with funding. The numbers of meetings and jurisdictions participating has dropped off over the years. Special projects are funded on a formula basis with Ontario covering the majority of costs, with Health Canada the second. Quebec does not participate.

Nova Scotia is not unlike other Canadian jurisdictions. Mental health funding has lagged as a portion of total health spending. It has dropped from 5 per cent in 1995-96 to 3.8 per cent in 2003-04. This is on a par with middle- income countries worldwide, which spend between 2.7 and 3.5 per cent. High-income countries spend close to 7 per cent.

Nova Scotia is poised to move forward with mental health reform. Strategic directions have been developed. Standards for the delivery of core mental health services have been adopted — a Canadian first. An integrated database that combines several provincial databases is close to finalization and it will allow us to track mental health outcomes in a population health framework. If you are interested, these documents are available on our Web site. The address of that Web site is in the brief I have given you.

Much needs to be done if we are going improve the mental health and well-being of Canadians. It will need a common vision, leadership, and a framework. The vision for mental health must be true to the World Health Organization definition of health. ``Health'' is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It must also put the same time emphasis on mental health as society does for physical health. It is unacceptable for people with chest pain to wait to determine the cause. If the cause is cardiac, people want immediate attention. Unfortunately, those with emotional pain do not get the same consideration. They will probably wait to seek help, wait further to see a professional caregiver, be treated with outdated and inappropriate methods, and continue to suffer much longer than is necessary.

The vision must also recognize the importance of the individual and the informal mental health system. Only about 20 per cent of mental health services are provided by the formal system. The informal system must be involved in planning, implementing and delivering services in the future. Consumers must be involved in planning and developing the system as well as their individual care plans. It must also recognize that mental health is a basic human right.

Strong leadership is required if there is to be any change in the way we provide mental health services. This committee is showing some of that leadership. Disparate groups need to be brought together. The leadership must have the resources and the clout to make a difference. It must have the respect of consumers, advocates, professionals, academics, researchers, bureaucrats and politicians.

Politicians need to be part of that leadership. They must show the political will to make difficult resource allocation decisions, and then stick to them. They must pass laws that will reduce stigma and discrimination against those with mental disorders and they must become advocates for this component of our society.

There needs to be a national framework to support the vision and leadership. The framework must bring society to an understanding of the need for mental health, be national in nature, recognize the need for research, and provide for a national data system to enable research and improve interventions.

First, society must understand the importance of mental health. The data provided earlier shows the importance of mental health in its own right, as well as it being a risk factor for other major illnesses and a cause of major disability. The public needs to understand that mental illness is a brain disorder similar to physical illness that can be diagnosed. People can be treated, and many fully recover.

Any understanding of mental health must also focus on stigma reduction. Stigma harms mental health consumers in two ways. First, it leads to discrimination. They are considered to be different, the cause of their own problems, not worthy of respect in society, and dangerous. Second, consumers are less likely to identify themselves and seek help if they know they will be discriminated against. Treatment is delayed and suffering is prolonged.

Stigma reduction starts with policy-makers and care providers. Legislation is often a leading cause of stigma and discrimination. I was surprised to see that Transport Canada's regulations bar someone who has suffered from schizophrenia from ever holding a master's ticket, which is just one example. One only needs to visit the local emergency room to see stigmatization by health care providers. Mental health clients wait the longest. Their privacy is violated. Their concerns are not dealt with appropriately.

Second, a national framework must extend beyond just mental health services delivery. It must deal with how government and organizations consider the mental health of Canadians in all their actions and policies. Mental health is a determinative health. There is no health without good mental health.

The framework must set standards for service delivery covering all aspects of mental health from prevention, promotion and advocacy, through community-based services to inpatient and specialty services. It must consider the full life span. Since most mental illnesses have their roots in childhood and adolescence, there must be a new focus on child and youth mental health. It is time to treat our youth and prevent the long-term sequelae of mental illness.

The U.K. and Australia have developed national plans and Australia reports on its progress every five years. It is time that Canada does the same. Mental health needs to be included in the Canada Health Act and there must be further legislation to ensure that a national framework is developed and implemented. It is only through this that the 20 per cent of Canadian who suffer from mental disorders gets their fair shares of the resources. Four of five per cent of the health spending is not enough.

Third, the need for research must be recognized. Research is needed to inform policy, treatment, and prevention activities. There must be resources to do base research, practical research that informs ongoing diagnosis on treatment and research that information policy. Research on public awareness and stigma reduction should receive special attention.

Finally, there is a need for information. A national data system will assist in research into appropriate interventions and improve access to services. The issue of database security must be dealt with. Society sees technology as medical equipment. The public demands the latest MRI, PET scanners, cardiac catheterization equipment and the like, but balks at information technology. Equipment is helpful in mental health, but much of what we do depends on data and the decision support systems that turn data into information that is suitable for prevention, diagnosis, treatment and planning. Information technology is not a waste of resources and it does not detract from patient care — it is a necessary adjunct.

Can we do something to improve the mental health and well-being of Canadians? The answer is a resounding yes. We as a nation have the political will and resources to build a national health care system that is the envy of much of the world.

How do we do it? I suggest the need for a national committee made up the equal partnership of consumers, non- government organizations, policy-makers, care providers and researchers. It would be tasked with recommended a national strategy, proposing national guidelines and standards, suggesting special funding enveloping, monitoring outcomes and reporting to Canadians on a regular basis.

In conclusion, it is time to do more for the mental health and well-being of Canadians. The economic and emotional impact on the country is enormous. There is a need for national strategy to address this important issue. The piecemeal work being done in isolation by the provinces, territories, and advocacy groups is leading to duplication of effort and wasted resources. A national strategy will reduce the suffering of the 20 per cent of Canadians whose have at mental disorder and reduce of major Risk factor for other illnesses.

The Standing Senate Committee on Social Affairs, Science and Technology is showing leadership by reviewing this important aspect of our health care system. All that is needed is the political will and the understanding to overcome the barriers to moving forward with mental health reform.

I have left more complete brief with references with your staff to inform the work of your committee. Thank you, again for the opportunity to present to you. I look forward to your final report and working with others to improve the mental health and well-being of Canadians.

Mr. Irene Clarkson, Executive Director, Mental Health and Addictions, British Columbia Ministry of Health Services: The Ministry of Health Services in British Columbia thanks Senator Michael Kirby and the members of the Standing Senate Committee on Social Affairs, Science and Technology for recognizing the importance of supporting individuals and families who live with mental illness and addictions. This is an opportunity to shape federal strategy. It is a valuable process, and most of all, it is a message to Canadian citizens that mental illness should receive equal priority to physical illness.

I will share with you a story of what we are doing in B.C, the changes we have made, and then make some recommendations from our learning. We hope it will be helpful to you.

Over the past four years, the British Columbia Ministry of Health Services has embarked on mental health reform in B.C. and more recently, over the past two years, has integrated addictions reform into our mental health reform activities.

I would like to share with you the vision for the health care system for mental health and addiction services in B.C. We envision a comprehensive, integrated, evidence-based health care system — that is the whole health care system, not just a separate system — that provides health promotion, prevention, treatment, and recovery-oriented mental health and addiction services. When we say recovery-oriented, we mean meeting the person where they are at, providing information, making sure they have access to the treatment they need, or if not treatment, the supports they need to succeed in their life.

This system of care will be consistent with the outcome of improved mental health of British Columbians: reduced disabilities, increased resiliency and self-care, and reduced need for health services. I emphasize the reduced need for health services. It is not reduced access. It is different.

Therefore, in B.C. we have about 4.2 million citizens in our province. Approximately 640,000 unique individuals access services for mental health related concerns or disorders each year. That tells us that we need a system that is not only comprehensive and integrated but that also can manage the varying levels of client need and their spread across our province. To face the issue of how we can do this, B.C. has been restructuring their health authority and their ministry governance systems to set us up so that odds of us succeeding are increased.

Many years ago when I was a director of nursing for psychiatry in B.C., we had 128 plus unique hospital boards that ran our hospital's acute care. We had multiple ministries involved in providing all kinds of community services. As a director of nursing, I found that it was impossible to assist my staff in the limited time we had to help our clients and families connect with the services they needed. There were multiple barriers, different languages, and different registration requirements. It was impossible.

Then B.C. moved to a system where we had 52 health authorities. That was not enough of a change. We still had multiple ministries providing services, different admission criteria, different language, and the amount of time we spent as professionals trying to find out what services were available was ridiculous.

The current government has moved to a new governance system. We now have five health authorities — geographic health authorities — that manage the direct service delivery and one provincial health service authority that manages the provincial high-end type services.

Over the last two years we have seen that this has created opportunities to create a more equitable system with coordinated range of local, regional, and provincial mental health and addiction services for all British Columbians regardless of where they live in the province. We are not there yet, but the opportunity for the integration and reduced duplication has certainly been increased.

The other opportunity that this provided was to create more effective and efficient services coordinated by a single accountable agency within regions, large enough to recruit and retain mental health and addiction professionals and to achieve economies of scale that we had never been able to do before. That process was certainly helpful to us.

Additionally, we could create a more accountable system of care because we created regional performance contracts that set out in detail how health needs will be met and more clearly articulated expectations for all concerned. That is an ongoing process. It is difficult to create those contracts, and we are working hard to change them, make them more effective with health authorities assistance and other feedback. However, it is the first time in B.C. we have actually held anyone accountable much for anything in health care. It is pretty exciting event.

As we were doing that work, we also took the high-end tertiary psychiatry beds located at Riverview Hospital and we been devolving them to our health authorities. In addition in 1997, the community mental health services were devolved to health authorities. Two years ago, we devolved addiction community services to health authorities, as well as our supported independent living program that was managed centrally by the ministry.

For the first time in history of B.C., we have the full range of services located under single governance bodies. Their ability to reduce duplication, support integration and reduce barriers to service is there. Certainly, we need to turn our minds more to what we will do now that we have done this difficult task. It is not over. It is certainly a growth experience for all concerned.

We were very fortunate that this government created a Minister of State for Mental Health and Addictions. I have been working in the field of mental health care now for 35 years. This is the first time I have ever seen this. The creation of this position supported cross-ministry accountability for the impact of program changes on our target populations. It also supported discussion at the cabinet table of addictions and mental health issues in an open forum.

For us in the ministry and for our health authority partners, that meant that there was actual discussion about mental illness, which is different from mental health. We often say ``mental health,'' but we are afraid of mental illness not mental health. Many of the moral issues attributed to people with addictions were discussed for the first time at a cabinet table. It has been an amazing to watch that over the last few years. A voice for mental health and addictions was created at the highest levels of our government.

Within the ministry, we not only underwent a reduction of the number of people in our areas. At the same time, our areas were integrated. We had to challenge ourselves to think of mental health and addictions together. Mental health and addictions actually sits under strategic initiatives and innovation. That was an interesting placement for that program, because it said that we could not sit still. Our job was different. It is very difficult to become a steward of the system as opposed to someone who was involved in direct service delivery.

We established goals for the ministry, which are different from goals for health authorities. Our goals relate to stewardship. I do not have time to share the details on each of the strategies, but I will highlight the goals for you.

The first goal was a comprehensive integrated client system of health care services for persons with mental disorders and substance use disorders. To support that, we put forward, and are still working on with partners, our provincial depression strategy, anxiety strategy, and addiction strategy. We also worked with the Ministry of Child and Family Development on their child and youth mental health plan.

To help health authorities create a comprehensive system, we funded the Mental Health Evaluation and Community Consultation Unit at the University of British Columbia. They do not do research. They help us create evidence-based policy and support health authorities to do the same. That function is different from research. We needed a way to support evidence and examining the practice and policy at all levels. That is a very challenging job. We are fortunate to have some very expert people to assist us.

In addition, the ministry works with the Michael Smith Foundation for Research. They gave us the wonderful opportunity to identify areas of research required in mental health and addiction.

The next goal is a primary health care system that provides early detection and evidence-based care to persons with mental disorders or substance abuse disorders. In B.C., over 65 per cent of our clients who access services do through their general practitioner. There are more 4,500 GPs in B.C. For each GP on average, 15 per cent of their individual clients have mental health disorders. This tells us that we need to be working with the GPs.

On average in B.C., each month there are 10,000 new presentations of mental health disorder or addiction disorder. That does not mean they are new clients. It means that for first time it is recognized that they have a mental health or addiction disorder. The concept of ignoring the general practitioner's part of the health care system will not hold for us.

The next goal is a chronic disease management approach within health services and primary health care system. We are shifting our thinking from episodic care. We are very good at episodic care, but we need to do more to support the individual and family in managing their illness. First, they are a person, and second, they have the experience with the illness. We need to be working to reduce recidivism and relapse and to support that person to have a quality life.

The fourth goal, which is one of the most exciting, is the permanent communications infrastructure to improve mental health literacy. You cannot help people if they cannot understand what you are saying. You cannot have a physician supporting an individual if they do not understand the language the physician is using. We cannot have early identification and reduce the stigma if do not know what we are talking about. This initiative started two years ago. It is truly one of the most exciting initiatives in which I have been involved in my career. I would love to give you more information at another time.

In addition to that, B.C. also has the B.C. health guide and a 24-hour, seven-day-a-week nurse line with access to pharmacists. This gives the people in B.C. access to quality health information, no matter where they live. The information is available whether they have a mental or physical illness.

We think these steps will support health authorities. They will also support the child and youth mental health plan because we are partnering with them. Also, we expect to shift the culture of B.C. over the next 10 years in terms of our level of mental health literacy.

That is exciting.

The last goal, not the least by far, is to implement core functions in public health that include mental health promotion, healthy child development and prevention of mental disorders and addictions. Our public health act is being reviewed and core functions are being identified so that we are confident that we are heavy on the prevention, promotion and early identification side. It is not enough to provide treatment; we need to be there earlier.

Those are our major strategies. The expected outcomes are improved mental health in the population; reduction in substance use problems in the population; and prevention of mental health problems, mental disorders and substance use disorders. Remember, mental health problems can lead to mental illness, but they are not a mental illness. Sometimes we get confused on that point. We also expect reduced impact and disability from mental health problems and mental disorders, and substance use disorders on individuals, families and the communities is another expected outcome. We work with our other ministries to do that. We also expect a reduced need for health services. We expect that the discrimination and stigma experienced by persons with mentality disorders and substance use disorders or problems will be reduced.

We would like to make a number of recommendations that are based on our experience to date. We are monitoring our system and have prepared two baseline reports. We are working hard to create better indicators, which we can share at a later time.

The B.C. Ministry of Health Services strongly supports mental health and addictions reform, which includes the comprehensive client-centred system of care closely linked with primary health care providing for chronic disease management approach and ensuring quality information for clients, families and the general public. It should incorporate the social determinant of health in policy and service delivery.

In that context, we are recommending an integrated national policy framework that is comprehensive and addresses the continuum of mental health promotion, prevention of mental disorders and substance use disorders, early identification, intervention, treatment, monitoring, relapse prevention, harm reduction, and rehabilitation and recovery.

We also recommend a national mental health literacy program at a high level that includes funding for the provinces to implement mental health literacy programs that build on the national initiative. Canadians need to know what mental health is. They also need to know what mental illness is. They need to know how to take care of themselves and the people they love.

A national mental health and addictions policy framework needs to ensure that it includes more than health services. It must take into account the social determinants of health including, quality housing, supportive employment opportunities, return-to-work programs, educational opportunities, income supports, social support networks, and opportunities to participate in the community as productive citizens. Therefore, we would like to see not only a larger silo, but also an integrated plan that pulls the other silos together.

We would also like to see a federal commitment to enhance mental health and addiction service infrastructure. That means resources to deal with significant and urgent health care problems and the social burden of disease. Then, we would like to see provinces held accountable for outcomes rather than specific programs or service models.

Fifth, we would like to see federal support for primary health care reform. The first contact with the system determines subsequent access, and it can be one of the most powerful ingredients in the path to optimal health if we make sure that first contact is effective.

Finally, we would like to see the federal government encouraged to look at their mental health and addiction portfolio and planning structures. We would like to see some integration at the federal level that would reflect current best practices and a direction in service delivery and provincial policy. We require a shift from parallel tracks toward integrated national mental health and addiction strategies. Canadians need a health care system that does not shuffle individuals from one system of care to the other, but rather a system that ensures that every door is the right door.

The Chairman: I thank all of you for those comments. That will open up a very interesting discussion period. By the way, I know Mr. Block has to leave relatively soon, but as I understand it Ms. Harrison will stay and participate.

Before turning to my colleagues, can I ask all of you a general question that has been troubling us for some time? I think Dr. Millar said that about 80 per cent of the treatments that go on in mental health fall technically outside of the formal mental health policy area, in the sense that they are not part of the hospital doctor system.

How have your various provinces gotten around the problem that a huge number of mental health services given to residents of provinces are not part of the publicly funded system, at least directly? Now, it is confusing. It may be that some of the group homes, for example, are funded through some other department — a department of community services or whatever.

How have you gotten around what seems to me to be an almost intractable collection of delivery systems that do not fit a government structure that is conditioned to deal with narrowly defined health in one place, or homelessness in another or assisted housing in another? Have you been able to get your hands around all of that?

Mr. Block, will you begin?

Mr. Block: That is an excellent question and a difficult problem. We have taken some initiatives in Alberta. I mentioned that we have developed a provincial mental health plan. Within that plan, we involve nine separate government ministries over and above health and wellness and ourselves. The plan, when it was finally signed off, included all the other nine ministries. We felt this was a first step bringing together the different pieces. In the accreditation that I referenced earlier in my comments, this was noted as one of our best practices and received a commendation.

When we look at strategies to bring those pieces together, it clearly has to be a collaborative partnership with many groups and organizations. We are not there yet, as I suspect you will hear from the others, but that is the first place — to bring all the people together and recognize that the determinants of health are as important as other aspects.

The Chairman: Can I ask you a follow-up to that? Am I right that a fair number of services would not even be caught in what you did, because they are not publicly funded? That is to say, either individuals pay for it themselves by way of counselling or services, for example, or drug therapy plans are covered by an individual's drug plan.

What portion of the mental health services that people in Alberta get is, in fact, not in the envelope because they are not publicly funded?

Mr. Block: I do not think I could give you a number today.

The Chairman: Any feel for it?

Mr. Block: I think it is high. The non-government organizations are certainly heavily involved in all aspects, but honestly Senator Kirby, I could not —

The Chairman: Are they part of your plan?

Mr. Block: They participated in that plan, yes.

Dr. Millar: In Nova Scotia, we are not addressing that issue very well for adults. Because of historical funding arrangements, housing for mental health clients comes under community services, because there were 50-cent dollars available to community services but not to health.

There is some private-practice psychology and social work available. When I said that 80 per cent is provided outside of the formal mental health system, most of that in Nova Scotia is still provided within the health system, however, it is provided by general practitioners, who often have not mental health training.

For children we have done a better job. It has been through the goodwill of people in the various departments. We have what is called a child and youth action committee, which has been in operation for about eight years. It started out with senior people from departments of education, justice, community services, and health getting together for coffee. It has grown to a formal structure where we meet every two weeks, and we develop joint plans for developing new programs. We implemented some this past year through health, but when we went to the cabinet table, all four departments went together and supported it.

We have been able to move the children's agenda forward somewhat. It is still very much underfunded, very much under-resourced, but there is some goodwill and intent to work together to try to develop the appropriate treatment services — residential services, in-school services and those sorts of things.

The Chairman: Do you have any documentation on your children's program that you could send us so that we can understand the structure and how it works?

Dr. Millar: I certainly could.

The Chairman: What do you do with the private sector groups that are out there that do not fall under the auspices of government?

Dr. Millar: We do not do anything. They are out there on their own. There are advocacy groups providing some services. I have what is called a mental health steering committee, which is the group that has developed our standards and strategic directions.

The Chairman: Does that include non-governmental people?

Dr. Millar: Yes, it does. It also includes direct consumers who sit on that steering committee and help us to make the policy.

The Chairman: Mr. Block, did you have direct consumers in the development of your plan?

Mr. Block: Yes. If I could add, within the plan we had 500 written submissions from the public. We felt that was quite a good response.

The Chairman: That is amazing.

Ms. Clarkson: The system in B.C., under health authorities for mental health and addictions, includes mental health boarding homes, residential, addiction supportive recovery, and addiction facilities. The community system — actually under health authorities — also includes a supported independent living program, which is providing supports into the home. There is also a rent supplement initiative, through B.C. Housing. The community side for mental health is about between $450 million annualized to $500 million.

We did a cross-sector look about three months ago, and B.C. spends just under $1 billion each year across the full sector, which would mean our pharmacare program — because clients have access to plan G, and other benefits when they have low income — the medical services plan, the addiction services now under health authorities. In total, it is about $1 billion or maybe 8 to 10 per cent of our total budget and growing. The Ministry of Health services has an annualized budget of more than $9 billion.

The issue is not with the non-profits, because health authorities do RFPs and contracts. The majority of mental health boarding home and like services are contracted out. Health authorities contract for those, as they do for many of the addiction services, hence there is a partnership between health authorities and those non-profit agencies.

The Chairman: That tells me that a number of your services, although publicly funded, are farmed out to NGOs, maybe even some for-profits. That is not the issue, but they are farmed out.

Are there pieces of the delivery that are not publicly funded? There is obviously a fair bit in the counselling area that is not publicly funded. They are not included in any way, shape or form in the mental health plan as such. Is that right?

Ms. Clarkson: I am not clear what you mean by ``not included.''

The Chairman: Are the data that you have related to public expenditure? How much, in addition to the $1 billion that you mentioned, would you guess individuals are paying for privately funded services? My guess is that it is a pretty big number.

Ms. Clarkson: Other sources include employee assistance programs, which have bee reviewed recently but the report has not been released yet.

The Chairman: In B.C. or nationally?

Ms. Clarkson: In B.C. the report looks at workplace initiatives. A concern is how we will approach the issue of ensuring appropriate access to cognitive behavioural therapy. Currently, community mental health units have psychologists who provide that therapy. That is one area that has shown the most opportunity and promise in terms of evidence-based intervention. The private psychologist system is there and it is a healthy system, but if you do not have access to funding, you would be waiting at a community mental health unit for access. That is a real concern.

The Chairman: I assume that is true in the other two provinces, as well. I also assume that public funds are not used to access private counselling services?

Ms. Clarkson: A health authority is free contract for those services and some of them do.

The Chairman: In the same way companies hire employee assistance plans?

Ms. Clarkson: Exactly.

Senator LeBreton: Dr. Millar, you said something about stigma and the treatment of people with mental illness problems that we have heard repeatedly. Even in the hospitals, health care professional put them last on the list.

Australia seems to be so far ahead of us in on this particular issue. They were big on the national mental health literacy program — not only for the people who potentially might suffer these illnesses, but also for the public at large on the question of stigma.

My first question is addressed to Dr. Millar, however the others should feel free to jump in. In addition to starting with a very significant program of mental health literacy, is there some system that should be put in place in order to re-educate the health professionals? When we get people into the health care professions, is there an area into which we should be streaming a specific number for training to deal with this huge, growing illness? People are trained for cardiac and other kinds of illnesses. Are we missing the boat, so to speak, on properly training health care professionals in mental health and mental illness area?

Dr. Millar: That is a very good question. Yes, we are missing the boat.

Take physician training, for example. Before a student physician has to make a choice for the Canadian residents matching service, he has not yet had a psychiatry rotation — he is lucky if he has had a general practice rotation. He has to make a decision on what he will spend the rest of his life.

When nursing was a three a three-year diploma program, students spent a significant amount of time in mental health nursing. Under the four-year bachelor program, some nurses can actually get through without taking any mental health training at all. Mental health has now become a post-graduate course.

In Nova Scotia, we recently stopped our post-graduate specialty program for mental health nursing. When I worked in Saskatchewan, they had registered psychiatric nursing programs; I think Alberta still does, but we do not have that anywhere else in the country. Training of our front line health providers is sadly lacking in mental health or psychiatry training.

You mentioned the Australian program. We were very fortunate to recruit Dr. Steven Kisley from Australia. He is heading up my anti-stigma committee in the province and trying to help us out. We planned to first tackle emergency rooms. We got such a backlash that we backed off and tackled the press instead. If you have been reading Maclean's and National Post, we made headlines on our crazy idea of checking up on the press. Some people were surprised at the reaction from the press. I was not. We hit a raw nerve, and they reacted like anyone does when a raw nerve is hit. It is a huge issue. Our training system has to change.

With shared care, where mental health professionals actually become part of primary care practices — be they social workers, psychologists or mental health nurses with input from psychiatrists working in general practice settings full- time. There is a chance there to start educating people with hallway consultations as well as the normal consultations in the coffee room chatter.

However, that needs to be expanded. It is happening slowly. We are moving in Nova Scotia to try to get some of that out.

Mr. Block: One of our board members is the new Dean of Medicine at the University of Alberta. He is interested in seeing us advance training and education for general physicians. He would love to work in collaboration with other interested provinces.

I met yesterday with the members of the Canadian Medical Association. We were talking about putting together a national committee agenda on this area. We think it is worthy of federal support. We will be issuing letters from the CMA, and probably the CPA, requesting participation from all the provinces some time later this fall.

Ms. Sandra Harrison, Executive Director, Planning, Advocacy and Liaison, Alberta Mental Health Board: When we developed the Alberta provincial mental health plan very recently, we did involve academics. We also involved people who are teaching nurses, doctors and psychologists. We asked them the questions that you are asking. These are difficult questions to answer.

It became clear to us that the academic stream is not always in synch with the demand and need in the field. We have agreed that we need to work more closely to think about trends coming up: What is the demand and need for certain professions? Are the schools getting ready for that? Are they responding to the real needs or what they think they might be? There is some disconnect.

We involved community groups in our planning process. They told us that there is a big untapped resource in the area of the development of the children's mental health framework and the provincial mental health plan. They told us that they could be part of the mental health workforce and provide support for what is being done. They can also help communities and children. We identified that we can help those community groups with some training.

I always feel a need to jump in when we talk about training professionals in order to expand the thinking a little bit. There are others outside particular groups of professionals who can be a tremendous resource in the area of mental health, especially when we talk about expanding mental wellness to include the determinants of health and community wellness as well.

Ms. Clarkson: In British Columbia, the BCSS, the British Columbia Schizophrenia Society has been getting their tool kits into schools and working with youth. Some of the research shows that kids' attitude on addiction, use of alcohol and other substances is set by grade four. What they believe to be acceptable behaviour is set that early. It is interesting that we teach them about the Canada food groups but we do not teach them about the mental health food groups. What is good for one's mental health? What coping skills can one have?

In B.C., the Ministry for Family and Child Development have a real cool tool kit that will be put into every school in B.C. that is similar to a program that was launched in Australia. It teaches kids at the grade level of four how to manage anxiety. What is stress? What is anxiety? What are the coping skills? Australia has had really good results.

We need to remember that an adult chooses to go into a certain field. However, most of our attitudes are formed very young. By the time we are teenagers, we are quite set in our ways about many of our beliefs. It is much more difficult to change beliefs later through mental health literacy for adults than to give children and youth training in mental health literacy.

I must give kudos to the Ministry for Child and Family Development in B.C. and the education system because they are beginning to think differently about how we support youth to gain skills instead of just screening them for early signs of illness. That is such a different approach.

Senator LeBreton: British Columbia appears to be well-engaged in health care reform. When I listened to you speaking I was glad my son and my two grandchildren live in British Columbia.

Each of you is making great progress, obviously, in your own provincial jurisdictions. Is there any capacity, at the present time, for you to share your information with each other? What kind of system is in place to share what is being done in B.C. with Alberta or Nova Scotia? Is there any oversight body at all? Perhaps Dr. Millar could start.

Dr. Millar: I was the chair of the Advisory Network on Mental Health, which is no longer funded by the Council of Deputy Ministers of Health. That group continues to meet twice a year at various venues in the country. Those who host the meeting show off the things that they are doing. Things of interest from other parts of the country are shared.

The mental health strategy document that Nova Scotia developed was based on a strategy that B.C. developed a couple of years ago. Our standards have been shared at those meetings and at CPA meetings.

As I say, with the lack of funding and the provinces cutting back on travel, it is very difficult for some of the smaller provinces to attend those meetings and to get the information. We still send it to them, but it is certainly much better when people are there.

Senator LeBreton: It is driven more by your own interest and commitment.

Dr. Millar: It is guerrilla warfare.

Senator LeBreton: That is a sad commentary, is it not?

Senator Callbeck: Continuing on that subject, you mentioned that the council of deputy ministers has withdrawn its support of trying to bring mental health workers across the country together.

Did they withdraw support because of financial reasons? Was it not a priority? Is there a better way to do this?

Dr. Millar: It is my understanding that the reasons were financial. I also used to sit on the committee for medical genetics. It also lost its funding as a result of other priorities and restricted funding.

Senator Callbeck: How long did this committee, which was trying to bring mental health policy matters together, exist?

Dr. Millar: I have only been involved for last three years, but it was around for at least ten years. They lost their funding about four years ago.

Senator Callbeck: Were they making progress?

Dr. Millar: I think so. We are still sharing. We have come out with a tool kit for performance measurement, which was done after the funding was cut.

Ms. Clarkson: It is difficult for committees like that to justify what is progress. If we learn from each other, and we challenge each other, then that, for us, is progress. However, there is a need in bureaucracy, for whatever reason, to create documents. If we create documents, it tells people we are doing something. Right?

That is not a bad thing; it is a good thing. However, it is difficult to keep cranking out documents so people know you are really doing something. Perhaps we should have production of documents once every five years as our criteria. The committee makes more progress in terms of challenging our thinking and supporting each other in our work.

Times have been tough across government. In our ministry, we now only have eight people on our team. We used to have 23 people. To get challenges to your thinking, you have to look to others, because people in your own ministry who are interested in mental health and addictions may have a certain knowledge level and you need others with a different knowledge level to challenge you. It is hard to find that because mental health and addictions are such niche areas in respect of the entire mental health system of care. You need to find people to think with.

That is the importance of creating a pan-Canadian strategy. It will bring many minds together long enough to challenge one another and come out with something of quality. Otherwise, we do operate by chugging along. Meeting twice a year good, but I do not know if that frequency would ever bring about a pan-Canadian strategy.

Senator Callbeck: You mention that several provinces have continued to support the Advisory Network on Mental Health. Which provinces are not supporting that?

Dr. Millar: Quebec does not attend. Newfoundland attended once in the four years. Prince Edward Island gets there when it can. Nova Scotia, New Brunswick, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia attend regularly. The territories have limited funds and have not been coming recently.

Ms. Clarkson: Nunavut did come at one time but they have not had the resources to attend. Their budget is very small; two meetings would absorb their entire travel budget.

When the funding was withdrawn, it truly meant that certain provinces could not participate.

Senator Callbeck: Mr. Block, you mentioned federal investment and the education of mental health workers, including community workers is required. Are you talking about a particular role for the federal government or just giving the cash? How will the provinces feel about this?

Mr. Block: There could be a federal role in that involvement. The demographics have increased the demand for mental health workers. We have to ramp ourselves up for that.

I have been talking in the realm of partnerships, collaboration and so on. Yes, I think there is a role for the federal government to play.

Senator Callbeck: What role do you see?

Mr. Block: The federal government once had a department specifically for mental health, but it no longer exists. There are people at the federal level involved in various areas of mental health. Perhaps the first step is to bring back the federal department for mental health. That could play the coordination role of bringing the parties together.

The Chairman: Was there actually a federal department of mental health or was there not a branch or something in the federal department?

Dr. Millar: There was a branch in the health department.

The Chairman: That branch does not exist any more; is that correct?

Dr. Millar: They have been scattered throughout the department.

The Chairman: There is no federal focus at all on the mental health system. How long ago did that happen? We can find out, but you might know.

Dr. Millar: Two years ago, I think.

The Chairman: Ms. Clarkson and Dr. Millar, could you respond to Senator Callbeck's question about what role you would see the federal government playing, assuming we could talk them into playing one? Recognizing that the provinces deliver the services, what is a potential federal role in the broad mental health area?

Ms. Clarkson: I have a perspective that is shaped by our culture and experience in B.C. I see the federal role is even more difficult than the role of our ministry — that is, stewardship of the mental health and addiction system of care. That means learning different approaches as to how you can set policy or incentives that create a path or direction that provinces are not only willing to follow, but also believe that it will reach certain outcomes.

The old way of doing things such as 50-cent dollars, getting community agencies to bid on grants, not involving the province, conflicting priorities and so forth caused a scattering of limited resources and caused people to head off in unique little directions. The national drug strategy was very nicely written. On the other hand, the approach to some of the funding and the way it is going, does not create the critical capacity in certain areas that will push you ahead. It appears that the federal government would benefit by rethinking how to support a devolved system to make the changes that will benefit all Canadians. That is a different kind of thinking than the old, ``Let's give them some money.''

Senator LeBreton: One of you suggested that there should be laws passed to reduce stigma. That would obviously be something for the federal government. What kind of law would that be? Where would it sit within the existing structure?

Dr. Millar: I raised that. I meant that we need to look at all of our laws to ensure that they are not discriminating against mental health consumers. The example I used was Transport Canada's regulations. We see it in all sorts of outdated legislation. That is not just federal, it is provincial. We still have the Insane Persons Act, in Nova Scotia, and other acts that use very inappropriate language.

I do not see a special act saying that mental health people will not be discriminated against, but we need to look at every piece of legislation and adjust the legislation to remove that stigma.

Senator LeBreton: Sensitizing would be one way to move the subject to the public agenda and into the public awareness; would you agree?

Dr. Millar: Definitely.

Senator Morin: I am interested in the federal role. I read your document, Ms. Clarkson. It is typical. In your recommendations, you talk about funding, support, more resources, federal support, and so forth. We are returning to the traditional role of the federal government, which is for resources, funding and support. I see your point; it is conditional support. You are saying that it should not be an open 50 cents on the dollar, but it should have conditions and outcomes. I buy that. The provinces are responsible for the actual care and delivery of care.

The main thing here would be resources. I say that because many of the other witnesses, especially professional organizations, have felt that Canada should have a national action plan on mental health. Many of these matters are provincial, however a national action plan might dictate more of this type of care and more of that. I am not too sure the provinces would be that happy to have a number of strict regulations concerning the delivery of health care.

That is an important issue. In theory, everyone agrees it is a federal role. Everyone agrees there is a role on the resources side. If there is more than that, I would like to have your opinion on it.

Ms. Clarkson: When one works in mental health and addictions, one asks for more resources at every opportunity because it is an under-resourced area. That said, the role I would see for the federal government — and I am offering my personal view here, I am not speaking on behalf of the Government of B.C. — would be to address two things: First, learning more about a topic and seeing how it can benefit people. Second, providing some type of incentive.

The federal government sometimes misses opportunities to create quality evidence-based strategies that influence people's vision of how an outcome can be achieved and provide some type of guidance that would make a difference. In B.C., we are looking at how we support the change in the way that addiction services are provided.

We took a data run and matched the provincial health numbers of people receiving addictions services with those who were currently receiving community mental health services. There was a 70 per cent match. We told people that we have a 70 per cent match. That does not mean 70 per cent of mental health clients, it means 70 per cent of current addiction clients receiving services in the publicly funded system are already registered — that is, they have a mental health diagnosis.

People did not believe us. We ran it again and shared that information again. People are now saying that if that is true, it changes the way we need to think about our clients and services. We can change people's behaviour by showing them quality evidence that challenges their current beliefs. In respect of the importance of data, the federal government could put much more effort into creating the quality systems of indicators to actually change people's behaviour.

If you want a physician to behave differently with his mental health clients, he or she needs to know that 15 per cent of his or her unique clients are those with mental illness. Have physicians thought about that? Physicians need to know certain things. People do not normally access aggregate data on a regular basis. There is an opportunity for the federal government to support quality data and to use it constructively to help people think and behave differently.

Dr. Millar: In my small province — our premier may not agree — we are less concerned about who has jurisdiction and more concerned about ensuring that people get the services they need. We become concerned when the federal government gives money such as the Health Transition Fund, which funds a very nice project for 18 months and then pulls the rug out from underneath us and forces us to seek alternate funding when we are already in a great deal of difficulty.

I see a large role for the federal government in conducting the research on mental health and mental health policy that is required for the anti-stigma campaigns. A lot of money thrown at anti-stigma campaigns that is totally wasted because it is aimed at the wrong group or it is broad, mass media sort of stuff.

We need policy research. Ms. Clarkson complains about having only eight people. I have three — and two of those positions were vacant for two years — to do all of the work. I have formed partnerships with all our health districts and other organizations to be able to do that. However, I would like some support from a renewed mental health branch in Health Canada to do that national policy work and research and to develop a national database that we can access and share across the provinces — the indicators that Ms. Clarkson talked about.

In my view, that can be done nationally without stepping on anyone's toes and getting into provincial jurisdiction. If you want to send money, that is fine too. Just make sure there are strings attached to ensure that it is spent on mental health and not something else.

Mr. Block: I am not sure we need a national action strategy per se. However, coming together on points of common interest such as research, a common database, best practices and so forth would be a good place to start. However, I do not see that as a full, complete national strategy. It seems to me you have to walk before you can run. I would start with some points of common interest.

Senator Fairbairn: This has been a wonderful presentation from all of you today. What you are talking about is absolutely huge. I am listening to you talk about a pan-Canadian strategy for a national mental health literacy program. You say that ongoing improvement of mental health literacy in communities cannot be overstated, and you talk about how empowerment through information can be a powerful lever for change and beliefs, attitudes, reduced health care utilization, appropriate help-seeking behaviours and how we treat fellow citizens.

Not too many months ago, the human resources committee in the House of Commons for the first time in history did a study and produced a report calling for a pan-Canadian strategy for literacy across this country. Their conclusion, along with what you have said here today, has been incredibly interesting. You have told us that, within your very elevated community, there is a desperate need for better understanding among all of your practitioners, researchers and health professionals of exactly what it means to deliver mental health to individuals.

On the other side of the coin, I am suggesting to you an equally important part of that is that you have to then transmit that to Canadian citizens. Over 40 per cent of the adults that we have in Canada have difficulty every day in routine reading, writing and numeration — functional tasks that we take for granted. Put all that together and we just do not have a problem but we have an incredible opportunity.

I have been involved in this other part of the equation now for 20 years. The first time I got riled up about literacy — when I discovered what a problem it was, through a Senate committee — I was going out to change the world in Canada. The first speaking opportunity I was given came from the Mental Health Association in Alberta. They asked me to come to their provincial conference in Calgary and talk about literacy. Even back then, there was a meshing of the need for your side of the equation to understand its literacy better and the tremendous need to build linkages on the part of the patient — the individual in Canada.

You talked about how the consultation group comprising the deputy ministers of health has drifted off a bit for lack of financing. It would be a wonderful thing to get the board of the deputy ministers of health and the board of the deputy ministers of education — who are being tasked with this other part of the issue — together at some point to find the best way through it.

Mr. Chairman, it strikes me as such an important part of what you are doing — wanting to do, trying to do — to understand that the people you are trying to do it for, a huge majority of them are having the very same problem in their area. I have to hand it to the Public Health Association of Canada for picking this up. For the second time in about three or four years, at their national convention coming up in the fall, this whole question of literacy will be one of the key parts of the discussion.

It is a question of trying to help each other. Your work in mental health and removing its stigma is very tough. Have you come across this other part of the literacy issue — that it how difficult it is not only for your own people to understand everything they are doing, but also in communicating it to the people you want to help?

Ms. Clarkson, have you ever tuned in with Literacy B.C., which does a lot of work in this area?

Ms. Clarkson: There are specific types of literacy. There is literacy in the sense of one's ability to read and to comprehend information. Then there is health literacy. Then there is mental health literacy. There has been some good research in the United States. I can send the information to you.

This researcher interviewed clients following their visits to their physician's offices to assess how many of them understood what their physicians said to them. We have some serious issues in health literacy — literacy period — and in mental health literacy. The ability of any health professional to transmit information is severely limited by the very fact that we do not even address how to give information to people at different levels of literacy. You do not have to necessarily change the person's level of literacy, but you do need to recognize it and give information appropriate to that level of literacy. One of our key goals is to create information at different levels and in different modes. You do not always have to use the written word. You can use pictures, you can use a video, and you can use posters that take persons through different steps.

The challenge of mental health literacy is complex because research shows that many of our clients have a lower literacy level as a result of the impact their illness has had on their ability in school and their ability to continue to read and develop those skills. Therefore, we have some extra challenges to increase mental health literacy.

I think there is a role for the federal government in mental health literacy, because health literacy should be at the federal level — general basic information in multiple formats, in multiple ways. Why is every province trying to do this? We should be working together. Health literacy is always based on the federal and provincial support. The provinces manage the education system to create literate citizens, so it does tie together. I certainly see a role for the federal government in terms of literacy, health literacy and mental health literacy.

Dr. Millar: Ms. Clarkson is talking about a recent study in mental health. Some years ago when I was in medical school, a study was done on GP's offices. That study revealed that even literate people remember only 20 per cent of what the doctor said because it is such a stressful situation as so much is going on and they are concerned. That is why they give handouts, but that does not help the people who cannot read.

When I was working at an in-patient unit in a mental hospital in New Brunswick, I found that the people who sat in our team meetings who helped to plan the care of the clients included members of the housekeeping and dietary staff, so they were aware what the overall plan was. The patient was always more comfortable talking to them. We got more information from those people about what was going on with the client than the professional workers — the nurses, psychologists and us — did from talking to them. That is, in part, because the stress was not there; they spoke the same language

Therefore, ``literacy-literacy'' is a big problem to start with, but there are multiple methods of being able to break down that barrier and to get information back and forth as needed.

Ms. Harrison: I support the comments that have already been made. We have a diverse population in Alberta. We must consider new Canadians when discussing literacy as well. Our messages to them must be understood and accepted within a cultural context. There is the exchange of information as well, so that we understand where they are coming from when they are sharing information and messages with us. We had quite a discussion about that in one of our working committees around developing the mental health plan and system for Alberta.

I also think of the role of community workers — folks who see clients, children and families early. It is a good way to share. Perhaps it is a bonding experience with a child, but nonetheless a care system for getting messages across. That is really important.

I was surprised that the mental health workers themselves acknowledge that they need to be more literate. The comments were very interesting, and I support them.

Senator Fairbairn: It would be nice to think that that kind of situation in respect of daily operations and training might be in existence across the board.

Regarding the Alberta hearings, one area of the equation that is difficult to grasp is youth. There is a dropout rate in Canada of about 30 per cent. This is a result of myriad problems, but literacy is certainly part of that.

In your hearings, did you hear of some way of reaching young people through the schools to try to get the message out in plain language about what some of these stresses and strains are all about and how people can be helped at that level?

Ms. Harrison: Yes, we did. We heard those messages primarily through the other ministries that work with us around children's issues all the time. There are many initiatives involving collectives of people from the different ministries and different sectors working to develop curriculum in schools that can reach children where they are in the school in an age-appropriate way. The Alberta learning ministry has done quite a remarkable job in this way and is open to collaborative work with us. We feel very fortunate.

Senator Fairbairn: Dr. Fraser Mustard, who appeared before our committee in our first round of hearings a couple of years ago, has brought out a report that provides a new picture on early childhood development. By 18 months, the mechanisms are neurologically hooked up to learn and that also depends a great deal on the parents and their ability.

It is wonderful to hear that you are thinking and doing something about this cross-cutting issue because it is absolutely fundamental, certainly, to mental health, but also to health and the health of our population altogether.

Senator Morin: I would like to commend you, Ms. Clarkson, on your use of the chronic disease management approach for mental health. I am a strong believer in that. I think the salvation of our medical care system lies in that model because, as you know, we have more and more chronic diseases such as diabetes, heart failure and so forth. As you point out in your document, this model improves outcomes and reduces costs. I was not aware that this was extended to mental disease. I do not know if that is a first, but it is interesting.

Ms. Clarkson: Later this spring, we will release the first guidelines for B.C. physicians for a mental illness. These will be guidelines for depression. It is a first in terms of using the chronic disease management approach. As you said, chronic disease management strategies and protocols have been used in physical illnesses such as arthritis, asthma and other areas, for a fair while. This is a first for B.C. in that we have actually accomplished it through the help of many physicians and many other key people.

Beyond that, we are looking at chronic disease management in other areas of the system. We think what has been learned from physical disease can apply to persons who experience mental illness because people with mental illness can learn, change behaviour and predict. We are confident it will assist not only clients to have reduced disability but also the province to provide more appropriate care. It is exciting.

Senator Léger: I have been hearing the phrase ``mental health'' in respect of young people and youth. To me, ``mental health'' is judgment and common sense — you cannot acquire these skills from books or at university. They often take it out because of too much data and so on.

Would you agree that when there are mental health problems with youth, it is rather the parents?

Dr. Millar: I am not sure I would go that far. Children of adults who have mental illness are at much higher risk of having a mental illness. However, children also suffer mental illnesses on their own.

Senator Léger: You said illness, but what about health? You made a nice distinction between the two.

Dr. Millar: Certainly the family situation can be conducive to good mental health. It is one of the major pieces. As Ms. Clarkson was saying earlier, it is by the time they are in grade four, they have only been in school for four years and at home for six years. As the Jesuits say, by the time they reach the age of seven a child is the person he will be for the rest of his life.

What is learned at home certainly leads to better things. However, it is easier to change people's attitudes when they are children than when they are older.

Ms. Clarkson: Mental health is not a state. Mental health is having the capacity to manage one's life, feelings and the daily grind. Therefore, children or youth are in the process of developing mental health skills. They are learning to manage how they feel, approach and resolve problems and how to manage anger.

Children who have a head injury or a mental illness are severely disadvantaged in developing some of those mental health skills. If the parent does not have the skill to support the child to further develop those skills then that child becomes more and more at risk. That said, parents are not responsible if their child develops schizophrenia.

Senator Léger: That is an illness.

Ms. Clarkson: People with a mental illness also have mental health. You can have the experience of bipolar disorder and still manage joyous situations and challenges. That is mental health. ``Mental health'' is your tool kit for grappling with the world. If you have the experience of a mental illness, we can still help you to you strengthen your tool kit about managing the world.

As a person can have mental health and asthma, or mental health and a broken leg, a person can also have mental health and have a mental illness. It is a mistake to assume that people with a mental illness can neither develop further skills towards mental health, experience joy and happiness, nor manage troubled lives. Of course they can. That is all about a person's mental health tool kit, which helps him or her to manage the mental illness.

Senator Léger: The word ``seniors'' has not been mentioned at all. Are we safe in the future?

The Chairman: We are certainly past the point of being able to learn.

Senator Léger: Seniors also need help. I am referring to health, not illness.

The Chairman: Does anyone have a comment in respect of seniors?

Ms. Harrison: There are many factors that influence one's mental health. I would hate to blame it on any one person — parents, for example. Various factors include whether a person feels safe, is well cared for or in a loving situation. Does this person have meaningful experiences? Does he or she have control over his or her life? Can they manage situations? That applies to children and to seniors or older populations as well — it applies to all of us.

In Alberta, the discussions we have had in respect of the mental health plan have dealt with the growing population and some of the illnesses relating to that population. However, we were also told — and I am not a clinician so I am getting more than a bit off my scope here — that there are increasing concerns in respect of the early onset of Alzheimer's disease in the group aged 50 to 60 years. As this is a growing demographic, we need to be prepared to deal with that.

Of course, seniors deal with many issues around quality of life and that can influence mental health as well.

The Chairman: I should like to thank all of you for coming. You came a great distance. We look forward to hearing from you again when we do our cross-country circuit in 10 or 11 months.

Would you think about one thing? I am not looking for an answer now. One thing that would help us is if you could tell us what we can do to help you. What I mean by that is, you are all in the process of, in three different provinces from one end of the country to the other, trying to develop services for people that we would very much like to help, as you do. It would be helpful to have your thoughts on what we can do as the final output in this report that would be most beneficial to you in terms of helping the people that you are trying to help.

We will be back and chat with you at some time. However, I would appreciate your thoughts — I am not looking for an official government statement at this appointment. I will be in touch probably with each of you separately. It would be to pick your brain and get some thoughts.

Thank you all for coming. We appreciate your being here.

Senators, we have a quick piece of business in respect of Bill C-24. Bill C-24 was introduced to deal with a specific situation of a specific member of Parliament who is retiring, and who got caught in a gap that nobody realized had been created when they decided that M.P.s could not collect a pension until age 55.

A number of us around the table, certainly in the opening witnesses when the minister was here — notably Senator Lynch-Staunton and myself — felt strongly that there should have been a better way to deal with this rather than have to go with the policy that changed it for everyone. On the other hand, there was a significant degree of sympathy around the table for the particular individual, who was caught in this particular circumstance.

Through consultations between myself and Senator LeBreton, we drafted a set of observations that the two of us support that fundamentally point out that (a) we do not like the process; (b) we think there should have been a better way of doing it, and we have had private sector witnesses saying there was a better way of doing it; and (c) some of the evidence suggested we were just treating members of Parliament the same way senior public servants are treated was not totally accurate in the sense that this proposed benefit goes beyond the benefit that senior public servants get.

Having said all that, I guess as much out of sympathy for the particular case as anything else, the observations suggest that the committee would grudgingly — I guess that is not a bad word — support the bill without amendment, subject to our also including with it the draft observations.

I think Senator LeBreton that is a reasonable summary of where certainly you and I were. Does anyone else want to make a comment?

Senator Lynch-Staunton: I think it is the wrong way to go. It opens the floodgates to others who are not in need to qualify, which is not the intent. For what it is worth, a quick calculation shows 60 members of the House right now who are in the range of 50 to 55. How many will be eligible in the years to come, I do not know.

We are being asked to make a major change to the benefits program for retired members of Parliament, which, as we were told the other day, is to bring them to the same level as civil servants, without our appreciating the fact that civil servants have to be on pension at age 50 before they get benefits. Of course, the pension is reduced because they are eligible at 55, and if they want it at 50, they have to adjust accordingly.

The Chairman: Correct.

Senator Lynch-Staunton: I will not support the bill for that reason. While there is one particular case for which there is compassion, there had better not be another one. I hope the government is listening and will find a way, with its insurance carriers and others, to put into the next agreement provisions to cover cases of exception and not force us into the embarrassing situation of saying, ``It is the wrong way to go, but that is the way we have to go, because otherwise we will be neglecting a needy person.'' That is not our role. That should be done at another level, not the legislative level.

The Chairman: Absolutely. Remember our opening discussion. I was saying that as someone who happens to chair a human resources committee on a corporate board, we would have dealt with it not as a policy change but a transactional change dealing with a specific individual.

Senator Lynch-Staunton: I find that the observations give the matter a fair appreciation. As I have said, I hope that these observations alert the government that it should find a way to avoid having to approach this problem again.

The Chairman: Indeed, if I have approval of the committee, I would suggest that I forward the observations, along with a covering letter from me, to both the secretary of the Treasury Board, which is where it would rest, and the Clerk of the Privy Council, which would effectively make the observation that that this was done more grudgingly than it might appear.

It would be my personal judgment — I would not ask the committee to agree at this point — that if we were put in a similar position again, I do not think the bill would pass. I would not vote for a similar bill in a similar situation again because there are other ways to deal with it. That is certainly my intent, unless someone should tell me I should not do that.

Senator LeBreton: I think that the government will be cognizant of the fact that because of this bill, they will have some very interesting negotiations with PSAC. When they were before us, PSAC supported the bill in principle because they saw the potential for themselves in terms of negotiating a package like this. Come the next session of Parliament, perhaps the government will need to take another look at the Parliament of Canada Act and try to address things in a proper way and therefore avoid a huge expense to the taxpayer in the negotiations with PSAC.

The Chairman: It is a problem they created themselves, particularly because they testified that this was nothing more than what the public service had, and then the union comes and says, ``By the way, we do not have it.''

Senator Fairbairn: If you are sending a letter, I hope it will reflect some of those comments.

The Chairman: Yes.

Senator Cook: I have a concern for the privacy for the individual, because the name of that individual was bandied about with no sign of privacy.

Senator LeBreton: We never used her name.

The Chairman: We were very careful to not do that.

Senator Cook: I heard Minister Saada name the person in his testimony.

Senator LeBreton: I did not realize he had done that. However, she has now spoken publicly herself.

The Chairman: The committee was scrupulous on that account.

Senator LeBreton: We did not even identify the gender.

The Chairman: We were scrupulous, certainly the two of us, in writing observations, to always use the phrase ``a retiring parliamentarian.'' We were very careful.

Senator Cook: On page 4 of the recommendations, you are say, ``a better approach might have been to amend.'' That is a little soft.

The Chairman: ``Would have been to amend.'' I am happy to make that change. It is too soft, and it could have been done that way. I know the evidence said it could not have been, but I am sceptical.

Could I ask for a motion to dispense with clause-by-clause?

Senator LeBreton: I so move.

The Chairman: Is there any objection? Could I have a motion to report the bill unamended but with (a) the observations and (b) the change that Senator Cook just made?

Senator LeBreton: So moved.

The Chairman: All in favour? Anyone against?

Thank you very much.

The committee adjourned.

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