Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 15 - Evidence - May 9, 2005 - Afternoon Meeting
HALIFAX, Monday, May 9, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:20 p.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
Mr. Chairman: Senators, our first witnesses this afternoon are Ms. Nancy Beck, Mr. George Tomie, and Ms. Carole Tooton.
I will ask each of you to make your presentation and then we will ask questions.
Ms. Nancy Beck, Director, Connections Clubhouse: Thank you.
I come today with very mixed emotions, honoured to be invited to speak and to share my experience, nervous because it is a huge responsibility to share the personal stories I am about to tell, and saddened that today, May 9, 2005, one in five Canadians people are suffering from a mental illness which we have the knowledge to address.
It would be very easy for me to sit here and give you a presentation on what we need to do to improve this situation. We have the knowledge. Over the last 20 years, I have participated in the creation of more working documents than I wish to admit to. When I counted them up last night, I found 37 documents I helped to create. These reports are sitting on the shelves in my library. The action taken on these reports has been insignificant.
I am convinced, after having read your report, that you fully understand the context and the issues and I believe you have the power to act. My goal today is to urge you to act by giving you a small glimpse into the lives of the people I work with every day. Their very personal stories are contained in my reports. It is through their stories that I will present the challenges facing many Canadians living with a mental illness and/or an addiction, their families and those of us trying to make a difference.
Lisa is a young woman of 22 years, living in a common-law relationship with two children. She is in the forensic unit right now because after repeated attempts to be admitted to acute care failed, she consciously committed a crime in order to get help so that she would not harm her children. This is her history; her future is limited.
Joan, 27 years, is a quiet young woman; both of her parents died 10 years ago. She is living in a long-term care facility at $1,300 per day because affordable housing and community supports are not available. There is no discharge date in sight. You can do the math.
Tom moved here from Cape Breton to attend university. After several stays in acute care, he is now living in a residential care facility with 20 other people. Tom is 26 years of age. The average age in the residential care facility is 52. He has lost hope.
Scott, 36, wants to go to community college. He has three case managers, one from the mental health program, one from income assistance, and one from supervised housing, none of whom is listening to what Tom wants to do with his future. They are very busy carrying out their mandate and maintaining him as a mental health client in a risk-free environment. His case managers consider school too stressful for Scott.
Janet, 44 years, dreams of reconnecting with her family. She was diagnosed with a bipolar disorder and has an addiction. When both these diseases are active, Janet cannot get help. The system plays a "you have to get the other disease treated first'' game. When she is not doing heroin, Janet spends her days trying to convince someone to help her with both her addiction and her disorder.
Kim, 44 years, was a teacher. Her physician tells her she cannot return to work. She has a serious and persistent mental illness, yet she looks after her family, her home, volunteers and desperately feels she is ready to go back to work. However, she needs a physician's letter in order to return to work and that letter is not forthcoming, so she waits at home.
Michael, 39 years, survives on Canada Pension Planbenefits. Tall, thin, with a wicked sense of humour, he is living on the street. He earns $10 more than income assistance allows, so he is not eligible to receive a pharmacare card to payfor his medications. He is homeless, he is psychotic and he has type 2 diabetes.
Jane is 40 years of age, had the job she always wanted; she worked as a part-time bank clerk for 10 years. Recently, she was switched to a generic compound because it was a few dollars cheaper. As a result, she is unstable, unable to work and on disability benefits. She is waiting for the government to approve the newer, atypical anti-psychotic. Her wish is to return to gainful employment and not be dependent on disability payments.
Patty is a registered nurse and community activist, living with the stigma of both a mental illness and an addiction. It has taken 10 years to convince an employer to give her a chance. Discrimination is alive and well, even within the ranks of our mental health system.
Joel, Carrie, and Aaron, are all under 24 years of age. They are young, talented people diagnosed with mental illness. Their futures are not bright. These young people require support to return to work and they are competing with those who do not have a mental illness in an environment that discriminates against people with mental illness. Who will the employer choose?
Jacob is an artist who has had his work displayed at the National Gallery of Canada. He is depressed and wants his family doctor to follow him. The family doctor says he does not have the expertise or the time to provide the psychiatric attention Jacob needs. Jacob refuses to attend a psychiatric clinic where the resident doctor changes every four months.
Diagnosed with psychosis, nineteen-year-old Marie is in need of acute care. Well, we are not quite sure where this brilliant,first-year college student should receive her care, and, as we speak, the professionals are meeting to try to figure out where she belongs. She falls into the canyon that exists between child, youth and adult services. When the professionals make a referral to the adult system, 500 people are already on that waiting list.
Marianna is a 47-year-old beautiful, free-spirited Aboriginal woman, who, when she is well, supports herself by cleaning homes. She is mentally challenged, has schizophrenia and indulges in alcohol from time to time. Marianna was passed from one case manager to another. Now, we bring her food and medications on the street.
Clyde is a 72-year-old veteran with schizophrenia. He requires a couple of hours a week of personal care and a couple of hours to help prepare meals. As a mental health client, he is not able to access home care and against his wishes, the recommendation is that he receives long-term care. We estimate it would cost $400 a month to honour Clyde's wish and help him remain in an apartment that he has lived in for 15 years.
I have a hundreds more stories that I could tell, but I am sure that you are familiar with this picture, having gone across our beautiful country.
These are real Canadians and they are some of the bravest people I know, suffering for the most part from illnesses that are treatable in a country known for its quality of life.
Each of these examples highlights the daily challenges faced by people living with mental illness and addictions and by those of us who are working in what we call "the system.''
Essentially, our system is a non-system. It is broke and it requires a major transformation. Forensic services have become all too familiar to me and others. It is now a treatment place of choice. The courts can mandate the treatment to get in and they can mandate the treatment when you are discharged.Age-appropriate, culturally relevant services are not available; we barely have the generic version.
Accessibility of services is an indicator of how well the system is working. Locally, unless you are in a life- threatening situation, you go on that waiting list I spoke about with 500 people waiting before you.
Opportunities for housing, employment, and education supports are too rare. Coordination and collaboration across government departments and NGOs is almost nonexistent. The "blame game'' that results in buck-passing is the usual experience, together with a fierce competition among community players for very few dollars.
Pharmacare policies are very shortsighted and they prevent people from accessing state-of-the-art treatments as the first line. The mental health budget is eroding. We do not have the resources to overcome the challenges before us, whether they relate to service or infrastructure.
The government has been remiss in exercising its power to enforce some of the necessary changes. The existing culture has not embraced the evidence that is available regarding mental health.
How do we change from thinking and acting like an industrial-age economy to thinking and acting like a knowledge-based economy, using the information at our fingertips while still developing new knowledge?
What else can I say? It is my privilege to work in a situation recognized by the Federal-Provincial-Territorial Advisory Network on Mental Health as the best practice in 1998. The program I work in is focused on giving people hope and opportunity. To accomplish that, we focus on what matters to all Canadians and that is citizenship and the rights and responsibilities that accompany it: access to health and mental health, gainful employment, education, meaningful relationships, inclusion, community participation and opportunities to give back to society.
I learned many years ago that people who have serious mental illnesses are no different from you and me. Their needs are exactly the same. They want and have a right to a life that is meaningful and productive.
This is the 21st century, yet, as I tell this story, one would think it was a story from another era. It baffles my mind.
In closing, I want to say that I am also a mother of three teenage boys who are at that very vulnerable stage and there is a history of serious depression in our family. If one of my sons had one of these serious illnesses, I would want the system to respond immediately, within the moment, and in a way that respects their age and embraces the youth culture.
I would like the system to focus on recovery and tooffer alternative health choices, but should patients require pharmaco-therapy, the newest and the best pharmacological compounds should be the first option, not the second or third, while the kids are losing time. And I would want those services to be delivered in the office of a primary care physician who has received specialized training in mental health.
I challenge each of you to respect and act on the findings of your standing committee, and that the outcome of your report is a call to action that results in a national action plan. I also want to tell you what it should include.
The plan should focus on a population health model, paying attention to prevention, promotion, community care, clinical care, education, research and advocacy. Health Canada's website has incredible resources around the topic of population health. They have been doing research in this area for decades, but I have yet to see that evidence put into operation.
I also would like to see the integration of mental health and addictions. I would like to see support for a primary care/shared care agenda. I would like to see increases in and protection of the funding envelope for mental health, with funding arrangements that are not solely focused on government programs.
We need to better respect the diversity within the Canadian population. We need to provide a range of supports and accesses to state-of-the art treatments, and I think we also need to understand social and corporate responsibility. It will take many players to be successful with our changed agenda.
I have just learned about Lily Canada, which has recently formed a foundation that will see $1.5 million targeted at solutions for wellness this year and $5 million next year. That money will funnel into community programs across the country, promoting solutions for wellness.
How do we encourage other industry players to follow this example?
The plan should also include provincial incentives that support the transformation of our antiquated system to a system that respects contemporary mental health issues and attaches funding to provincial priorities and outcomes negotiated with the federal government. Most importantly, there has to be a framework with clout that holds the provinces accountable to deliver on what they have negotiated, no change, no outcome, no money.
Now, I know all this is a tall order and I would also add that I would like it right now. Ms. Tooton, do you support that?
Ms. Carole Tooton, Executive Director, Canadian Mental Health Association, Nova Scotia Division: Absolutely.
Ms. Beck: I know that it is definitely within our reach.
In closing, I want to end with a quote brought to my attention by a very dear colleague, Stan Kutcher, attributable to the World Health Organization. It says:
...we have the means and the scientific knowledge to help people with mental and brain disorders. Governments have been remiss, as has the public health community. By accident or design, we are all responsible for this situation.
It goes on to say,
We have one option and only one option — to ensure that ours will be the last generation that allows shame and stigma to rule over science and reason.
The Chairman: Thank you for your terrific presentation. Do you have a brochure on your organization that is separate from your presentation? If you do, would you please send us a copy?
Mr. George Tomie, Facilitator of the SOS Support Group and family member of a mental health consumer, as an individual: Mr. Chairman, members of the committee, I would like to thank you for inviting me to speak on behalf of the Halifax chapter of Survivors of Suicide.
The late Jerry Geisler and his wife, Mary, started this support group in 1999 when they saw a need for a support group to help others after their daughter finally completed the act of suicide following several unsuccessful attempts. The Geisler's moved from New York to Nova Scotia to be near their grandchildren, and while living here, they decided to help others through the pain of losing someone by the act of suicide. After much determination and hard work, they founded the Halifax SOS Group, which still exists today.
We owe much to Jerry and Mary for their hard work and dedication. To date, this is the only support group for survivors of suicide in the Province of Nova Scotia and at one time was the only support group east of Montreal.
I am not only the facilitator of the group, and I am a survivor as well. Volunteers who at one time came to us for support have remained to help others find some peace in their lives following their loss.
We stress that we are not professionals but people who have lost a loved one through the act of suicide. Through our own stories, we help others share their grief and find a path to recovery. The group also offers to go to those who are unable to attend our meetings due to distance or other circumstances. New members contact us and we explain how the support group works, where we meet and how often we get together. We also encourage them to bring someone for support if they choose to do so. Many people are reluctant to come to meetings. They are not comfortable in group settings. In this case, either Mary or I will speak to them on the phone for as long as they want to talk or arrange to meet them at a place of their choice.
The support group maintains a contact list with names, phone numbers and email addresses, and we encourage contact between meetings. We try to convey to them that they are not alone on this journey; they have the love and support of all at the meeting to help them through their grief. I have seen people come to a meeting for the first time so devastated that could not speak, and months later, I have seen the same people laugh for the first time without fear of guilt and shame.
We also provide names of professionals or organizations that can help them as well. The main goal of the group is healing through sharing and support. Survivors are told that the group is not a "quick fix'' solution to their situation and that the healing will take time. How long it takes depends on the individual. Some heal quickly, others take longer and there are those who never recover.
Those who never heal are stuck on the question of "why'' and can never get past it. They feel hurt, let down by the system and professionals who are in place to help, and they come to the SOS group, not only to vent their frustrations, but to find the support and understanding they need to survive.
People often ask why we call ourselves "survivors'' if we are not the ones who attempted suicide and lived. The answer is simple. The dictionary defines the word "survived'' to mean not lost, continuing. For those left behind, that is what we do every day. We continue to question the reasons behind suicide and to deal with the hurt and the loss we are left to face.
In order to understand what suicide is all about, the veil covering this act must be removed. How do we do that? Firstly, we must understand what causes someone to want to complete the act of suicide and, secondly, we must understand that suicide is an action caused by an illness. Society must learn that people who commit the act of suicide often see it as the only solution to an insurmountable problem. Once society understands, then and only then will the veil be lifted and the stigma and myths surrounding this act removed.
The legacy for Canadians should be health and long life. How do we achieve this? We need new disclosure procedures for families, new laws regarding bullying in the schools and better advertisements on depression and violence. We need more programs dealing with depression in public schools through PDR courses, education programs aimed at parents to help them better understand depression and its link to suicide. We need to eliminate the stigma of suicide. We need to develop a directory of services where individuals can obtain help and proper protocol for first responders. Lastly, we need legislation concerning media coverage of suicides.
I want to end with this quote that I saw not too long ago: "The most violent action in society today is ignorance.''
The Chairman: Thank you, Mr. Tomie.
Ms. Tooton: Mr. Chairman, I have prepared a presentation that you all should have in front of you, but after listening to the comments made by consumers and family members and then hearing my colleagues I will move beyond my presentation.
I would just like to say that within the package I have given you, I have included the Canadian Mental Health Association's framework for support. The community resource base model was developed back in 1984 as a way in which consumers could be appropriately included in the community. It occurred around the time when deinstitutionalization was happening and we needed a mechanism, a framework for people to re-enter the community. It has since grown into the knowledge resource base model and the personal resource base model and we now frame it as the "three pillars of recovery.'' It gives an indication that the thinking has changed, the language has changed and we are now talking about recovery, something that is new, but on which we need to focus more attention.
I have also included a discussion paper that CMHA, Nova Scotia division, along with community allies developed around the Mental Health Act that is currently being discussed and debated and I am sure, before this is over, will be a reality here in Nova Scotia.
I have also included the obituary and a letter from a family whose daughter completed the act of suicide a short time ago. They felt that the memory was too fresh for them and they could not bring themselves to make a presentation, but they wanted it passed along, so I have included that as well.
Now, because I am not speaking from my prepared notes, if I go on too long, please just stop me. I was very much stunned this morning by the number of references made to education and the need for education. In my paper, I think I refer to it as "mental health literacy.''
CMHA here in Nova Scotia will be celebrating a hundred years in 2008. We preceded our national organization by 10 years. In fact, before mental health clinics were part of the MSI system here in the province, it was CMHAs that actually funded and supported those clinics and, yes, as I say in my paper, actually paid for psychiatrists' salaries. So, we have a history here in the province.
One of the things that CMHA is noted for is its public education and health promotion and prevention programs. As I sat here listening to the number of people speak about the need for more education, I thought, my goodness, here we are. We have wonderful material. Our national organization has been really good at getting funds to do research and support materials. In the past couple of years, we have developed a handbook for daycare centres, and most recently, a high school handbook about mental health and how to recognize the signs and symptoms of depression. We have a guidebook for university students. We have a handbook that employers can use to talk about mental health issues in the workplace, which gives concrete examples on how to accommodate a mental health issue in the workplace.
Everyone in Nova Scotia should know about all these things because we have them all, but guess what? They do not. The reason for this is that we do not have the resources to deliver the material. I was embarrassed to hear that our pamphlets are not at our mental health clinics. We have many of them in our office, but we do not have the funds to distribute them. We have two people that work in our office.
I do not mean to whine about this, but I want to make the point that what is wrong with our system is that we do not acknowledge who does what best and allow them to get on with doing it.
When the mental health services moved into the community from the Nova Scotia Hospital, there was not a lot of acknowledgment of what was already occurring in the community. We compete with psychiatric nurses and social workers who do health promotion and public education. They send us their notices every week and ask us to put them up on our bulletin boards and advertise so that the public can take part in the programs. At the same time, we hear about the waiting lists. Is there not something that could be done differently? Could we not realign our resources? Could we not collaborate in a partnership to deliver information?
In the Kirby report, there was a reference to NGOs and the number of NGOs in the community. How can we encourage these organizations to work more closely?
Ten years ago, when I first started working with CMHA I learned that the only way we could get our message out was to work in collaboration and partnership with other organizations. I have worked with organizations that deal in cross-disabilities. It is amazing how you can sit around the table with many organizations that are dealing with physical disorders and you have to remind them, as we heard earlier today, about the kinds of accommodations and work strategies that you need in place for people with mental health issues.
I think the various components of the system, and by this I mean the formal and the informal, need to come together and solve their own issues before we can move on in improving the quality of care for individuals who access those services.
Before talking about legislation, I want to address the issue of discrimination. It is not so easy to define the word "stigma,'' but we can relate to what "discrimination'' means and understand that it is not right. We are not just looking at discrimination as it affects individuals, but we are looking at how it affects the system.
Why is it that here in Nova Scotia, less than 4 per cent of the health care budget goes into the delivery of mental health services? I cannot help but think that there is a level of discrimination associated with that percentage.
The fundamental health care system in Nova Scotia, the minister was very pleased to announce two weeks ago, received an increase of $2 million each year for the next two years. It may sound like a lot of money. I was reading the paper the next day and saw the wonderful new MRI machine at the Victoria General Hospital that cost $3.4 million. When you put it in perspective, I question the importance of mental health and mental illness.
I want to discuss the topic of suicide prevention. I think it is a trend across the country that suicide falls under the category of "injury prevention.'' What is worrisome to me is that it once it is in that category the system forgets about it.
We have a campaign with big billboards and TV advertisements talking about preventing injuries in the workplace. The billboard on Barrington Street says that there are 70,000 work-related injuries in Nova Scotia each year. If we believe the statistics, mental illness will affect over 250,000 people in our province. We do not have a campaign for that problem which is four times worse than on-the-job injuries.
We are the last province in Canada to introduce a mental health act although the process started a good number of years ago. In the fall session of the legislature, we introducedBill 109. Our division office and two or three other community agencies and a handful of dedicated people who have been fighting this issue longer than I have were really, really hopeful that this government would build on what has happened across the country and seize the moment and put forward a truly progressive mental health act.
The name itself must conjure up some notion of what should be in that act. It should not be an act that speaks solely to the involuntary treatment of mental health consumers. The legislation needs to include the notion of health promotion and prevention and the elimination of discrimination. We need to include that people require after care, not just with medication, but also with employment, proper housing and adequate incomes.
You have heard this before; if the legislation does not direct how the services and support will flow, then it will not happen.
I think it has come down to the fact that any mental health act is better than no mental health act, so we will take what we can get for the moment. We see that as another challenge for us in our ongoing fight because this will have a huge impact on the individuals who access services.
Someone earlier today mentioned research. In a world where all our decisions are supposed to be based on best practice, research is required. Our division office is still referring to research done in the mid-1980s when there was money available to do research. The researchers asked mental health consumers what they needed to stay well in the communities, not what they needed when they were ill. Their answers, simply put, "A house, a home, a friend.'' We need to look at the consumers' perspective.
Some of the research funders insist that there needs to be a collaborative approach to research. It cannot simply be the scientist or the physician leading the research, but collaboration with community partners and consumers. The funders mandate the research, and we get many requests for letters of support after the fact to verify that at least there has been some connection to the community. We need to be part of the process from the very beginning. We need to come together to discuss what kinds of research opportunities are important to the community because I think there is a real need for more community support and more consumer directed research.
You probably do not understand how long some of us have been waiting for this opportunity and why I struggled so much to put down on paper what I wanted to say because there is just so much that needs to be said.
I have worked at the local level with individuals who are senior mental health consumers and I identify with the needs that they have. Since I have been at our division office, I have seen a completely new group of individuals that are virtually unaccounted for within our system and seldom addressed. These individuals are desperately trying to do it on their own, and they are just looking for a little bit of support.
A young man called me and said that although he cannot work in his chosen field because of stress, that he has a job painting houses. This man has a M.A. in Education but is gainfully employed painting houses outdoors in the summer and indoors in the winter. His inquiry was whether we could help him with his stress medication that costs over $500 per month. You see, his employer does not offer group insurance coverage, and the monthly expense for his medication is prohibitive on his salary.
I would have loved to have been able to say, "You called the right place because, yes, this where you come to get that type of assistance.'' However, that is not the case here in Nova Scotia. I think what we have done is over served some people and underserved others. We need to sort this situation out because people are falling through the cracks.
I would just like to finish with three words: resilience, hope and recovery. I believe the resilience of individuals has helped them to survive and move on despite the system. There is hope, and if we did not think there was hope, we would not be here. There is recovery. For example, I worked with Roy when he was going through some very bad times and I know the value of what he did this morning. It is a win-win situation. People learn and people recover through opportunities to share.
The Chairman: Thanks to all of you. You have touched on some of the issues that are of concern to us. Ms. Tooton, you spoke of two issues that Ms. Beck also raised indirectly. You said it was important for organizations, "to solve their own issues first,'' given the multitude of organizations.
One of the things that we are wrestling with is trying to figure out where to go from here and you heard witnesses this morning talking about the difficulty of navigating the complexities of the system. One of the reasons it is so complex is that there are so many organizations.
How does one deal with the fact that all the organizations are autonomous and have their own mandates?
Trying to get organizations under one roof in terms of working together is always difficult to accomplish. We are stuck with the problem that what we have now is a non-system. One of Ms. Beck's examples was a woman with three caseworkers, all of whom have different agendas.
How do we ultimately, either by persuasion or brute force, turn what is not a system into a system by effectively getting or forcing cooperation on the ground?
It has to be at the community level. It has to be done at the level where you people work.
Ms. Tooton: I think it is happening at the community level and where we run into obstacles is when we try to interface with the various systems. I have given you an example about a wonderful initiative that I have been involved with since 2002. This opportunity for consumers to live in housing facilities allows them to build equity, and save money while they are living in this housing facility. That came about because there was cooperation among community organizations and the private sector. We brought in consultants and architects to help us with this program. Since the inception of this initiative, we have acquired some federal and provincial funding, and now there is a bit of money to raise community support. I do not think we can wait for systems. I think that we need to come together and make it happen and prove through example that it can be done.
The Chairman: You may have a particular group of people that are able to accomplish that goal, but generally, that kind of cooperation requires extraordinary leadership and it is often very difficult to find. We would like to get a system in place that produces action that is not so totally dependent on being fortunate enough to have the right people in the right place.
Ms. Tooton: Well, I am going to take it from a little different angle.
I do not think that we have an abundance of organizations that can support people, but I believe we need to have a variety of resources available to allow individuals to have the opportunities to choose what they need to help them move on in their road to recovery. I do not think we can expect there to be one fix for everybody.
The Chairman: I agree with you, and this takes me over toMs. Beck. We are now into the problem of navigating the system that people talked about this morning. It seems to me and I may be wrong, but what you need is a single caseworker. I mean, in fairness to the people who suffer from a mental illness, you have to have someone who can help them through the system. I understand your argument fully, but the other side of the coin is it would be better to have someone who can help them navigate their way through the system.
Right now, they get lost in a system that has so many players that they cannot possibly find their way through.
Ms. Tooton: I think the Cancer Society answered that question here in Nova Scotia. They actually have navigators that help people navigate the system. I am not sure when they meet the consumers, perhaps when they are identified by their physicians or when they are in hospital, but they actually have people, perhaps volunteers, who assume that role. When Roy Muise talked about peer support this morning, I see that as an excellent area where peer support could occur.
Ms. Beck: It is a complicated situation and I do not think that there is any easy answer. I think there is fierce competition among small community organizations and they are fighting against each other for very few dollars. That political scene does not allow them to work together closely because there are just not enough funds to do it. It might mean that I will get funds that Mr. Tomie will not and that creates a political dynamic where it might become impossible for us to work together.
I think the biggest challenge is that the formal system and the community system are mindsets that are canyons apart in terms of how they think, act, and feel in the mental health field.
I come from a community development background and I interface with a system that focuses on acute care, disability, hardship, and control, without an emphasis on health promotion and the philosophy of recovery. People in the system need to hear about health promotion and recovery. The obstacles develop when that sector tries to work with the formal system.
In terms of this cooperative concept, we have recently completed an extensive strategic planning process here in the capital district, which includes over 500 shareholders across all sectors, including the corporate sector. One of the initiatives for which we hope to get funding from the provincial government is a navigator, a person who is living with the illness and who is capable of providing that navigation for another person who is involved in the system. Thus, it not only solves the problem, but also creates jobs for a whole host of people who we know are employable, but are currently unemployed.
Mr. Tomie: Well, our group is more of a volunteer support group, so we are not looking for funding. What we are looking for is changes in the system so that people know we are available. Ms. Beck and Ms. Tooton are correct that there are many organizations trying to provide the same service.
In our group, Mary Geisler and I act as the navigators. We are the people that tell a consumer that the group is appropriate or if the consumer should go to the Schizophrenia Society, for instance. We navigate survivors if bipolar disorder or other forms of mental illness caused a death.
The Chairman: Mr. Tomie, you would support the navigator concept.
Mr. Tomie: Oh, yes, we need to have that service.
Senator Cordy: I want to thank you all for coming and helping us develop our report because, above all, we want to be practical and draft a report that does not just sit on a shelf.
Mr. Tomie, you talked about legislation regarding media coverage of suicide.
What can the media do to try to reduce the stigma or discrimination that is certainly rampant for those suffering from mental illness?
Mr. Tomie: I can only speak from my personal opinion and from my situation. The media loves to sensationalize the story.
When we approach the media to do something other than sensationalize a story, they tell us to go to blazes because that is not what sells newspapers. That is what the president of CBC told me. I called CBC because in the course of a television program regarding suicide, they had used my son's picture and that of another boy who died the month before, without permission, suggesting there was a connection between the deaths because they were best friends. I think they need to have the permission of parents or the loved ones in order to televise those pictures.
They should also be very careful about what they print because what they put in print has an enormous influence on readers. If we have teenagers that are walking a fine line between life and death, this could have an impact on what they choose to do.
I know Ms. Beck and Ms. Tooton will agree with me that the terminology surrounding suicide is so outdated it is not even funny. People still use the words "committed suicide.'' You cannot commit suicide. You can commit robbery, you can commit abuse, but you cannot commit suicide. You can complete the act of suicide.
We need more education and I think the newspapers and the media in general should educate the public. They should present the story, but do it in a positive rather than destructive light.
Senator Cordy: How can we legislate this? It seems that we should not have to legislate it, but I understand exactly what you are saying because you look at some of the pictures that are in the paper and you just think, "If I were a family member, how would I react?''
Mr. Tomie: I guess it is going to come down to getting together with the media and setting rules. Maybe "legislation'' was the wrong term, but there should be rules and guidelines that they need to follow as well. I do not think that putting somebody's picture on the five o'clock news is acceptable, especially for the parents.
Senator Cordy: I agree.
Mr. Tomie: I know what it did to the other father who also lost his son. The poor man did not get off the couch for a month. Now, to see his son's picture on television, what do you think it is going to do to him?
I do not think they are playing fair ball. Let us put it that way, they are out to sell papers and that is their only concern. There is no damage control afterwards and I think that is what we need.
Senator Cordy: I agree with you.
Ms. Tooton: We engaged in an interesting research project last year. We ran it as a lottery for six months and we encouraged Nova Scotians to send in articles or stories or even advertisements that they heard on radio or TV that they thought were disrespectful of mental health and mental illness issues or suicide. Well, the first three weeks were terrible because the media do not take kindly to criticism. We got calls from all over Canada and even from as far as Ohio interested in this initiative. At the end of the six months, we drew the prizes, people won and we are now in the process of establishing meetings with the editorial boards to discuss these issues and to solicit the cooperation of the press in developing guidelines.
I mean, we have media guidelines now. This is not the first time we have been through this process, but we are hopeful that if we engage the press and ask for their input and collaboration, we may get more of a buy-in in this way.
One of the things we have learned through the initiative is that the reporter may want to give a good report, but he does not develop the headline, and so often, the headlines become the sensational part of the piece.
Senator Cordy: Your initiative had both positive and negative feedback. Do you feel you gained valuable information from the lottery?
Ms. Tooton: Yes, and we are going to continue monitoring the media because even though they were good for those six months there is evidence of slippage now.
Senator Cordy: Sometimes the feedback in the media whether positive or not at least brings the story to the attention of the public.
My next question concerns accountability. As the chair said, we are in a juggling act between the provinces and the federal government. It is difficult to ensure that the provinces spend federal dollars wisely.
My question is should federal government funding be targeted funding for the areas of mental health and mental illness or wellness?
Ms. Tooton: Yes.
Ms. Beck: Yes, absolutely. You know how a health care system works and that acute care requires big dollars to operate. Money comes in to the districts that have a host of programs, and any new money that comes in goes to programs that are in deficit funding. The small programs do not have the million-dollar budgets.
Our programs will not see any on the $4 million over four years of federally funded money for Nova Scotia. We will not see a penny of that money. Nothing will go toward changing our antiquated acute care system that contributes to our problems in mental health care.
I would like to see an accountability framework identified together with the province and that the province is accountable to deliver. If they do not deliver, then they would not get the funding.
Senator Cordy: If the money is not coming to Halifax Regional Municipality, what is happening in Cape Breton, Guysborough, and Yarmouth? Are there programs in the rural areas?
Ms. Beck: Yes, but the money would come into the provincial government and then the government would distribute to the districts, but there would be strings attached. Is there anyone from the government here today?
Senator Cordy: There will be someone here later on.
Ms. Beck: An accountability framework would hold the districts responsible to the negotiated terms, so it becomes a circle of continuous quality improvement.
Senator Cochrane: I want you to elaborate on the new, revised mental health program for Nova Scotia. You said that they have just enacted a new act within the mental health program. Would you elaborate on that a little more, and what are some of its deficiencies? What are some of the things that are not sufficient in it?
Ms. Tooton: The act has not been passed in the legislature. It was slowed in its progress during the second reading. We have a minority government and I think we are all familiar with how minority governments work. Without the full support of the two opposition parties, it was not able to move forward. However, it is my understanding that during this sitting it will be reintroduced and I understand that the Liberals are now interested in supporting it, so it will go into law amendments and then on to the third reading. I hope that by the fall we will have our mental health act.
I do not know if you really want to ask me this question. As I mentioned already, we as an organization would prefer to see that people could access the mental health system in a voluntary way rather than forcing them into involuntary treatment.
When you say "mental health act,'' I think you conjure up the notion that it talks about mental health and does not focus exclusively on mental illness. In fact, that is what has happened here and I think that is common to the other mental health acts across the country. Professor Archie Kaiser is addressing the committee tomorrow and he is most knowledgeable about the mental health act and will be able to speak to it far better than I will.
Senator Cochrane: Mr. Tomie, would you tell us about the places where you meet with the individuals who are not comfortable meeting in a group context? Have you ever considered using the schools in the evening when they are not in use? Would that be a good place to have people meet?
Mr. Tomie: When I spoke about people who did not want to come to the group setting because they are just uncomfortable, I usually go and meet them at their homes. They are more comfortable in familiar surroundings and they are able to talk more freely. Some want to meet me at a Tim Horton's where there are many people around so that we are not alone, one-on-one. I usually leave it up to them to make that decision.
In Cape Breton, I developed a program and took it to60 classrooms, and because of the program, many kids came forward for help and then I ran into the brick wall. The same situation applies here in Nova Scotia. I cannot go into the schools and present the program because the schools will not send me an invitation. The education system carries the stigma that if children hear about suicide they will complete the act of suicide.
The group is still not well known even though we have been in existence since 1999. I know this is hard to believe, but even though Mr. and Mrs. Geisler and I have contacted just about every organization in this province, including police, Victim Services, RCMP, our biggest referral still comes from the coroner's office. I even approached the Funeral Directors' Association of Nova Scotia because there is a navigator employed in most funeral homes to help survivors to access support groups.
Usually when somebody comes to our group, we ask them how they found us and often they say that the information came from the Internet. One person went to the States for help and their referral sent him back to us.
We are the only group in the province that runs everymonth regardless of attendance. Whether there are two people or 22 people in that room, the group does not stop, not like some programs.
Senator Cochrane: Do you have groups just in the Halifax region or do they operate in other places like Antigonish and Sydney?
Mr. Tomie: The group is for everybody. People from as far away as Antigonish and New Glasgow come to our group. We are the only group. There is no other group in the entireprovince. We are the only group as far as I know that runs on a month-to-month basis for the year, although a new group is beginning in Quispamsis, New Brunswick.
Ms. Tooton: We are somewhat hesitant now to do presentations in the schools. We get many calls especially for grade 11 classes, where part of the curriculum deals with psychology. We worry that after our presentation that the school does not have a system in place to deal with any problems that arise out of the presentation. We need to know that the teachers and guidance councillors have the proper strategy to deal with a student who realizes he or she might have a problem with depression or thoughts of suicide.
We are hesitant because we know that a proper follow-up strategy is essential to the success of our program. If the school does not have a strategy, it struggles to find the proper professionals in the system.
The Chairman: Just as a matter of curiosity, do you mean that the school system denies that it is efficient and their solution to their denial is to avoid raising the issue of mental health in the first place?
That is wonderfully progressive. Sorry.
Senator Cochrane: Have you spoken to any of the superintendents within the boards?
Ms. Tooton: I do not know. It seems that individual teachers invite us to speak. We have tried to be a part of the professional development day's strategy putting our agenda out there and offering to meet with teachers, but it is not an easy thing to do and we have not been terribly successful.
Senator Cochrane: You might try the superintendents because they are the people who direct everything else within the school system. You might try that approach.
Senator Cook: Ms. Beck, everything that you set out in your wish list is what I would like, too. I think, Mr. Tomie, you are making a difference in people's lives.
I am not a lawyer and I need to go back and look at the legislation.
Is it possible for provincial regulation to support a federally framed piece of legislation and could it make the system accountable, whatever the content? Would it be enforceable?
Ms. Tooton: I am not an expert either, but I think the reason why organizations like others and ours have spoken around a national strategy for mental health is that we look to the federal government to direct the focus of the spending within the province. If part of the strategy were to identify comprehensive mental health legislation, then I hope that the provinces would attempt to match that legislation in their own jurisdictions.
Senator Cook: How can one create an adequate piece of federal legislation with all the necessary components and regulations with enough elasticity or manoeuvrability that it would apply to the legislators of the provincial jurisdictions?
I mean, regulations are subjective to a piece of legislation. I am wondering if it is possible to achieve that goal.
Ms. Tooton: Well, I would say it is worth a try.
Senator Pépin: I have a supplementary regarding the education of teachers to the issue of mental health. I believe that the education of the teachers is a priority.
You said that people think that if you speak about mental illness and suicide it will encourage the children to come forward with their concerns, or indeed, to perform the act of suicide.
I come from a small town, and I believe that the reaction you receive is due to fear and that is why you do not receive many invitations to speak to the students. They are worried and they do not know where it is going to end.
Ms. Beck: I think you are right, senator. This morning, my husband asked me if there would be anyone here to represent the teachers because mental health is a big problem in the school system.
The Chairman: Senator Cordy, prior her appointment to the Senate, was in fact a teacher for many years.
Mr. Tomie: I want to address that point because talking about it is not going to make them do it. I am going to refer back to the topic of teaching sex education in school. Are they worried about the kids having sex? Well, of course, they are, and the children learn the consequences of their actions if they have unprotected sex.
How do we teach a child how to handle depression and what to do about it if we do not discuss the problem? We cannot live in the dark ages. The problem with suicide is that for years we swept it underneath the carpet. We must ask ourselves just how many of the so-called accidents at work and single-car accidents were really suicides. We will never know the answer to many of those questions.
Senator Cordy: Sexuality is a new concept within the school system, so perhaps there is hope that we will soon discuss the issue of mental health.
Mr. Tomie: Well, we have to start somewhere. You do not just educate the kids; you have to start with the teachers so that they know what to look for in their behaviour.
I always tell teachers not to be scared to ask. I say that if you think a child is writing something or saying something that does not sound right or look right to you, ask him if he is contemplating taking his life. One of two things can happen: They may think you are crazy for asking, or they were thinking about it and you took the time to ask them if they needed help. If we do not ask, we will never know, and if we do not try, we will not succeed.
The Chairman: Ms. Tooton, with respect to your comment on stigma and discrimination, we have actually started referring to "stigma'' as the politically correct way of saying "discrimination,'' because that is exactly what it is.
Thank you all for coming. We appreciate your taking the time to be with us.
Mr. Doug Crossman, Manager, Mental Health Services, South Shore DHA: Thank you for this opportunity and welcome to Halifax.
I represent the views of a group of stakeholders working in collaboration to create an integrated chronic disease prevention strategy. We hope that some of the things we outline for the Senate committee will initiate discussion and debate.
You probably are all familiar with the fact that mental health problems are among the leading causes of premature death and disability across the world. We believe that the cost of mental illness in Nova Scotia is about $250 million a year and those are just the direct costs; that figure does not include the indirect cost of lost productivity.
It is interesting that in 2003, some of our research indicated that only about 40 per cent of individuals with mental health problems actually sought treatment for those problems. There is no question that the sigma of mental illness and suicide remain a significant issue concerning mental health and mental illness.
Notwithstanding the research in regards to the burden of death, disability and lost productivity on our population associated with mental health and mental illness issues, in Nova Scotia, the public share of mental health resources has consistently shrunk. We are now probably at about 3.5 per cent of the total health budget, and as Ms. Tooton was indicating earlier, that trend does not seem to be reversing.
However, when we looked at some of trends surrounding mental illness it became obvious that we are not very good at identifying the relationship between physical and mental health issues and we have a tendency to focus on the supply of health services to the population as opposed to understanding the demand. We need to ask why people are coming to our health services in the first place.
I administer a mental health program in Lunenburg and Queens Counties and I am involved in a range of other activities in our service delivery system. Frequently, we separate mental illness from the rest of the health system.
Our group includes a variety of people from Dalhousie University, the Department of Community Health and Epidemiology, the rural health initiative and the Population Health Research Unit, CMHA, consumers, the Chronic Disease Prevention Alliance of Canada, and so on. We feel strongly that we need fundamental changes to the way we think about service delivery in regards to mental health. We think that there are some significant policy and program implications connected to that change of thinking.
Nova Scotia has one of the highest chronic disease and disability rates in the country coupled with very high-risk factors in smoking, obesity, physical inactivity, depression and social anxiety. This province has the lowest disability- free life expectancy in the country. Given our high rates of chronic disease, we also have high rates of chronic medical and psychiatric illnesses which coexist and which worsen overall health outcomes.
Whether we focus on one disease or whether we focus on many, we all understand there are similar risk factors across the board. Physical inactivity, obesity, smoking, and adverse life-style choices are definite risk factors, but there are also significant social conditions that affect mental illness such as the obvious ones like poverty, poor housing conditions, poor education and drug and alcohol abuse.
In Nova Scotia, our recent research indicates that Nova Scotians with psychiatric disorders have a mortality rate 2.5 per cent higher than the general population. This province also has a more significant rural population than the rest of the country. The urban/rural split in the rest of the country is around 78 per cent to 22 per cent; in Nova Scotia, it is 64 per cent urban to 36 per cent rural. When you look at chronic disease, our rural population is less educated, older, poorer, more socially isolated and less healthy than our urban population. Nova Scotia has one of the largest urban/ rural income gaps in the country.
We are bringing this to your attention because we think it is a critical issue in your deliberations. We do not think it is acceptable policy or funding practice to see such a discrepancy between the needs of a population and the funding percentage that the population receives from the Government of Nova Scotia. We need to focus not only on increasing and on improving the supply of services, but we must also look to the demand side. We have asked ourselves why the demand for services is so high in such a small province, and realized that one answer is to understand the demand.
What are the factors that bring people to our service? We are concerned right now about the supply side. Not only are we looking at a relatively small percentage of the overall budget, but also some recent research pertaining to core services in the province indicates that there is a $17 million gap between required core services, and the availability of those services across the nine districts in the province.
Our province has an annual growth rate and a health budget of about 9 per cent. It has a relatively slow economic growth rate that does not even come close to that 9 per cent in terms of overall growth. If you add in the high disease and disability rates and a growing public impatience toward lack of services, the question answers itself.
I heard your discussion with the previous group and media attention. Well, waiting lists makes the news, as do shortages of health service professionals.
With these driving factors, it is very difficult to assume that we will make up that $17 million gap tomorrow or in next budget year or in the budget year after that simply because of the growth of wages and salaries and so on.
Although we would applaud increased budget share, if I can call it that, I do not think these efforts should be at the expense of developing an integrated, population-based approach to improving the mental health and well-being of Nova Scotians.
If we assume that the role of governments is to improve the general health and prosperity of the population, then I assume that your committee must argue for a mental health policy and program capacity that balances the service issues with an increased provincial capacity to address the evidence-based determinants of a population's health and well-being.
With the development of the new Public Health Agency of Canada, there has been a great deal of talk that we have a new idea of public health in Canada. Well, it really is not a new idea. For those of us who have been around forever, we know the focus must be on upstream health promotion and prevention, and less on downstream interventions. The proposed definition of public health is the science and art of promoting health, preventing disease, prolonging life, and improving quality of life through the organized efforts of society.
We believe that organized efforts in legislation and public institutions will bring about the needed changes. We need to talk about how to get the resources to poorer provinces and districts, like my own, and how to tie the resources to overall health goals and ideas that the federal government, the provinces and the local communities can embrace.
The group that I work with is developing a strategy regarding integrated chronic disease prevention. We believe this strategy is comprised of some fundamental components. Our idea of capacity or integration of services is on-the- ground capacity. It is capacity of districts and local communities to provide the kind of programming that promotes health and integrates mental health to enhance the emotional well being of the population.
We need better information systems and better population surveillance systems to monitor what we do and offer outcomes orientation. Frequently, we do not talk about outcomes. We talk about service utilization, which means the demand has grown on our service and so we need more money next year for more services. We should focus on what we are doing to improve the overall health of the population as opposed to expanding the service industry.
Cross-sector collaboration, with its many barriers, is the other capacity issue. I think we need to focus on the population health outcomes in order to level out some of those barriers. Some fundamental changes are required in how we organize and fund our public programs, and we need to tie collaboration to funding.
Frequently, when we talk about health policy, we talk about it in terms of one-size-fits-all, but we know that the health determinants in a rural population are quite different from those in the urban population. The only area of population growth in Nova Scotia occurs here in Halifax. I am not referring to the casino per se, but you know what I mean — although that may be true given the addiction problems with gambling.
Our rural population is declining, but so is their budget share, so although many of our health issues are centred in rural areas, there is a greater per capita spending of public resources in urban areas to increase what one academic on our committee calls "social capital.'' Her argument is that social capital is deteriorating in rural communities.
I am sure that Mr. Galipeault and others today will talk about social capacity and the resources we need to create infrastructure and make supports available in our communities.
As to the prevention side of the issue, one particularly good example of going across jurisdictions is our busing policy. When we close a school and bus children an hour to school, they lose that sense of social connection to their community and to their schools. As research from B.C. shows, this idea of social and school connectedness is directly related to school performance and the development of social problems over the life of the child.
Incidentally, we are developing a discussion paper, which we will give to the committee by the end of May.
The Chairman: Is that discussion paper the framework paper?
Mr. Crossman: Yes, that will be the framework paper.
Ms. Tooton spoke to the zero percentage of the budget going into the promotion of mental health and the prevention of mental illness. I think Mr. Galipeault will agree. I mean, there are odds and sods around, but what we are doing in the districts is borrowing from clinical services in order to work off the side of our desks to do prevention programming. We are robbing Peter to pay Paul. We do have interesting workplace-based programs, school-based programs and suicide prevention programs but they are at the cost of using resources designated for other purposes. At this time, we do not have a capacity definition for the flow of dollars for mental health promotion and illness prevention.
The idea of primary health care is critical. There is no question that the majority of people in Nova Scotia see their general practitioner for problems relating to mental health. MaybeDr. Stokes has better data than I do, but probably somewhere near 40 per cent or 50 per cent of GP case loads deal directly with mental health problems, and only 40 per cent with mental health problems are actually getting help for their problem.
We have to look at different models that work in rural communities. Many of the shared care and primarily health care models in mental health are urban-based models, so we have to look at ways of developing models in rural communities and integrating mental health into primary care practice to get better outcomes.
In terms of improving chronic mental illness management practices, you must take into account many factors. Sixty per cent to 80 per cent of the people we deal with smoke and the vast majority are physically inactive and suffer from obesity problems. We must factor in co-morbidity, poverty, diabetes and heart disease as well as the risk factors already mentioned into our population with psychiatric disorders. If you only focus on schizophrenia or depression, you will arrive at questionable outcomes. The funded mandate of the program is to deal with psychiatric disorders, so we have to look at a way of going across borders in terms of public health and mental health issues.
Mr. Galipeault will talk much more about consumer participation, so I will leave that subject to him. We are making major attempts to engage consumers into having input into what we do. We are providing resources to consumers for programming; however, we need to do much more in the area of the philosophy of recovery, which Mr. Galipeault will also address.
We need to make fundamental institutional changes to sustain this integrated strategy. The province has the mandate to deliver health services; I do not think Nova Scotians believe that the federal government delivers health services to them. You may know this better than I do, but there does not appear to be any legal impediment to the federal government becoming engaged with the provinces, particularly in this area of health promotion and health care service delivery. We do not believe there are any barriers there.
Federal institutional structures should find a way to integrate mental health discussions into their models. One model is the former Canadian Heart Health Initiative, funded under the former National Health Research Development program. The Heart Health Initiative indicated that chronic heart disease was rampant in the country. They turned their resources to that disease which in turn led to the development of programming. I think it is fair to say that the Heart Health Initiative really drove the focus on chronic disease prevention in this country. That program has since disbanded and there are other initiatives, like the Canadian Diabetes Initiative and so on, but much of what is going on based on the efforts of the Canadian Heart Health Initiative.
There are ways of dedicating or locking in federal money, or non-portable money. Other sectors cannot draw funds from our non-portable budgets. Sometimes that works; sometimes it does not, depending on the agency.
At this time, there is neither dedicated federal funding for mental health care services nor coherent organizational structure for mental health within that institutional sector. When we look at funding and sustaining an integrated framework formental health, this province is completely preoccupied with waiting lists and a massive deficit situation. We spend 40 per cent to 45 per cent on our health care budget in this province as a percentage of overall budgets. There are some very fundamental economic problems on the supply side of the equation. There are some critical problems of not integrating service development and delivery across silos.
We recommend the development of a national response team to ensure that when you are finished your collaborations, a group of stakeholders come together to discuss this matter, particularly the issue of integration and how mental health should be promoted. I think there needs to be more social marketing.
As part of its mandate, the Public Health Agency of Canada is integrating a nation-wide chronic disease prevention strategy. Of course, the agency has other important matters in its mandate but they must consider chronic disease prevention programs as well.
I will leave you with those thoughts and then we can open up for questions later.
The Chairman: Thank you and we look forward to getting your framework document when it is complete.
I would like to introduce Senator Jim Cowan, who is the newest Nova Scotia senator. We are delighted he is with us this afternoon.
Mr. Jean-Pierre Galipeault, Owner, The Empowerment Connection: I want to focus my statements more specifically to mental health and mental illness. As Mr. Crossman mentioned, there is little attention given to mental health promotion, prevention and recovery, although recovery is getting a lot of airtime these days.
As I mention in my brief, in 1977, my doctor diagnosed me with bipolar disorder and although I was stuck for many years, it was a catalyst for me to seek ways to avert relapses and keep myself well. Not only is it important in my personal life, but I have developed my own business around it and now I act as a consultant with respect to promotion, prevention and recovery.
In November 2001, I opened my consumer-run and operated business. My colleagues and I are all mental health consumers. One of the highlights of the business is that we have developed a method to help people onto their road to recovery. The Recovery Toolkit: A Pathway to Empowerment, to my knowledge, it is the only one of its kind in the country. The toolkit puts emphasis on people's strengths and capabilities and methods of personal development, and it provides assistance in developing plans to stay well, to avert relapses and to recover from illness.
I received my diagnosis quite a few years ago and it is fair to say that many Canadians with a mental illness treat that illness with medication. I spent almost 12 years trying to find theright medication. Perhaps I am a slow learner, but when I found a self-help group, the light bulb went on.
I helped develop a group in Pictou County where I learned more from my peers than I did in the previous 12 years dealing with what I call the "formal mental health system.'' I learned by listening to how others kept themselves well and what they did to maintain their mental health. I tried some of their methods and some of them worked. The group experience led me to develop a personal recovery plan and in 1996, I went off my psychiatric medication. I am not an advocate of this generally, but I decided on this course because of concerns about long-term side effects. I have not taken any medication since then nor have I received any formal mental health treatment since the year 2000.
I want to talk to you a little bit about mental health promotion. I know we do not have a lot of time, so I will try to keep it brief.
The Centre for Health Promotion in Toronto encourages individuals and communities to take control over their lives. It also speaks to equity, social justice, personal dignity as well as a supportive environment and individual resilience. Some components of mental health promotion include maintaining a positive attitude, having fun, a proper diet and exercise and getting enough sleep. These very basic factors combined with knowledge of the illness can go a long way to promote your good mental health.
Last year, I had the good fortunate to work with Doug Crossman in developing a mental health promotion strategy. We enhanced the existing website to reflect some basic but useful information pertaining to mental health promotion.
The toolkit is concerned with mental health promotion and we ask our consumers a number of questions, such as, "How do you know that you are assisting yourself in promoting your mental health?'' "What does mental health promotion mean to you?'' Who in your life supports you the most in promoting your mental health?'' "What resources exist in your community that help promote your mental health?'' "What barriers exist in our community that prevent you from promoting your mental health?'' "Which of the following do you consider most helpful in promoting your mental health: yourself, family member(s), friends, other consumers, social services and personnel, alternative or complementary therapists?''
We are heading in the right direction, but the subject needs more work and research.
In terms of the prevention of mental illness, we need to do a lot more work, but if we look at some of the determinants of health, it gives us an indication of what we can do now.
There are different definitions of recovery, but my business, The Empowerment Connection, defines recovery as,
Occurring when a person's psychiatric diagnosis or emotional and psychological trauma is no longer the central focus in that person's life, but simply becomes a part of who that person is.
We must remember that people also have to face the task of recovering from the effects of external and internalized stigma, learned helplessness, institutionalization, poverty, homelessness and the wounds of a broken spirit.
There has been a fair amount of research done since he late 1980s concerning recovery and I am pleased to say that a lot of the research has been done by consumers themselves.These findings indicate that approximately 50 per cent of individuals remain symptom-free or significantly improved at 20-, 30- and 40-year follow-ups.
There needs to be a strong therapeutic alliance between the consumer and the professional with whom they are dealing. Remember that recovery does not usually mean symptom-free and people can continue to experience symptoms but function quite well in their everyday lives.
Hope is a fundamental factor in the recovery process and connecting with others on a human level is very important.
These factors link closely to chronic disease prevention. The group method is an example of some of the work that will continue.
How do we get there in terms of paying more attention to mental health promotion, prevention and recovery?
I suggest three approaches: consumer involvement, peer support and destigmatization. One of the growing trends in policy development across the country is that of consumer participation, which includes peer support initiatives, mental health system planning and design, mental heal system service provision, policy development and system evaluation.
There have been others like myself who have been at this for many years who have been promoting this approach and I am happy in one way to say that it is happening, certainly here in Nova Scotia and other provinces and territories across the country. However, a lot of the consumer involvement has been relegated to consultation, so more work has to be done in this area to give consumers a real voice and a real role within and outside the formal mental health system.
Recent research shows that peer support is not only critical to mental health transformation and recovery, but also important to mental health literacy and mental health promotion. We have some fine examples of successful consumer- run initiatives, many of which are in Ontario.
Two factors helped me and still guide me to this day. One is maintaining hope that I can get better, I can stay well, and the other is peer support. Those two factors were critical to my survival, to my getting well and to maintaining my mental health.
Stigma is another component of the problem and all of the efforts in mental health policy development, system reform, consumer and family member involvement will be unattainable without making some efforts to address the issues of stigma and discrimination.
The comments from fellow consumers is that we need to develop a national and provincial anti-stigma campaign while educating the media, the justice system, school teachers, students, politicians and policy makers.
I recommend the development of a national mental health strategy that uses existing mechanisms and structures; I do not see the need to create more bureaucracy. The incorporation of this strategy into a chronic disease prevention approach is important.
I recommend the increase in investments into mental health promotion, prevention and recovery. We need to ensure the meaningful participation of consumers in any national mental health strategy and/or policy development. There should be investment in and support of recommendations of such collaborative initiatives as the one outlined by Mr. Crossman. We must develop a national anti-stigma/discrimination campaign that will provide the public with ongoing information about the issues.
Mr. Stephen Ayr, Director of Research, Capital District Health Authority: I, too, am a mental health consumer and you can read about some of my story in my report.
What I want to talk about specifically is the fact that since January 11 of this year, I have involved in the strategic planning process within the Capital District Mental Health Program. I am very excited about this process and I have met some wonderful and gifted mental health consumers, family members, service providers and academics. I believe that it is a direct result of my involvement in strategic planning that Louise Bradley, Director of Mental Health and Forensic Services at Capital Health, asked me to speak to you on her behalf today. I thank Louise for this opportunity and hope that I can do justice to her request.
It is an honour to be speaking here today with Professor Aidan Stokes, acting head of the Department of Psychiatry at Dalhousie University.
I will address six items in response to your third report, Mental Health, Mental Illness and Addiction: Issues and Options for Canada. On page 10 you ask,
Should the federal government (and each provincial/territorial government) establish a mental health/addiction advisory committee that is representative of a wide range of individuals with mental illness and addiction to facilitate the development of a patient-orientated system?
My answer to that question is a resounding "yes'' and I emphasize that such an advisory committee must have the authority to enforce recommendations. Additionally, in order to be person-centred and focused on recovery, there must be substantial legislated representation on the advisory committee by those who fully understand the issues and who live most directly with the results; that is, the end users of mental health services.
As one part of the strategic planning process within the Capital District Mental Health Program, there is a proposal for a new policy board, Koinonia. One of the proposed functions of Koinonia is to approve the Capital District Mental Health operating budget. The suggestion is that five consumers, representing 26 per cent to 33 per cent consumer involvement, sit on the 15- to 19-member board. The question is when a mental health Koinonia-like organization will exist for all of Nova Scotia and, for that matter, the entire country.
Item number two is funding for mental health services.Mr. Crossman spoke about this issue and I support his initiative.
I do want to make some recommendations following up on what Mr. Crossman and his group of collaborators,including myself, have developed. I recommend the development of a national response team to, first, hold a key stakeholder/ decision-maker response conference in Ottawa to advocate for the recommendations of the commission. I recommend the creation of a national mental health social marketing campaign to sustain attention to these mental health issues for a minimum of one year.
I recommend that the Public Health Agency of Canada, the new Health Council and Health Canada focus on primary health care renewal and position mental health issues as a necessary part of the emerging mandates.
I recommend the development of a research-based Canadian mental health development initiative to finance demonstration projects at the local health authority level.
In response to the question regarding "ring fencing'' I will answer for Louise Bradley and say "yes,'' there is indeed a requirement for protected funding of mental health services in Nova Scotia; that is, non-portable budgets. Furthermore, during the past 30 years, overall health budgets have grown substantially, but Nova Scotia's mental health budget has grown at a much slower rate and the divergence is widening. The question is what is mental health's fair share of the Nova Scotia health budget?
I am aware that protected funding is very difficult to maintain, and the problem is that if a protected budget starts out small, it remains small. However, despite the shortcomings and with due consideration of the flaws in such a system, we should have protected funding of mental health services in Canada.
The next issue is housing. I need not say anything more than if the issue of housing is not addressed, then it is unlikely that any provincial mental health reform will have an impact on the problem.
The fourth issue is the artificial division between youth and adult mental services. In your third report on page 11 you say,
Child and adolescent mental health services and supports have been called the "orphan's orphan'' of the health care system
In Nova Scotia, on a per capita basis, the adult mental health system receives three times as much funding as for children and adolescents. I would like to see a removal of artificial divisions between youth and adult mental health services in this province.
Item number five is remuneration for consumer participation. This is in response to the question posed on page six of your report.
What are the incentives and should they be introduced into the system to stimulate the changes required to make the system truly patient/client oriented?
Yes, the system should introduce real incentives for consumer participation into the system. As a direct result of the strategic planning process, we have identified a number of priorities and moved forward with the development of a cooperative called the Citizens for Mental Health Cooperative. Mental health consumers operate this new cooperative. Enclosed in my report you will find a number of identified priorities of persons living with mental health issues, concerns, or brain disorders.
The sixth and final item I wish to address is that real mental health reform requires a cultural shift. Lesley Southwick-Trask has produced a document entitled Healthy Minds Blueprint, which I can provide to you if you so desire. She says that there is a fundamental disconnect among Nova Scotia government departments: the Department of Health, the Department of Community Services and the Office of Health Promotion and fractured non-government organizations and community groups. This disconnect has created significant blockages to recommendations that would improve the well-being of people living with mental health issues and mental illness. We need to address those issues I suggest that we establish an organization that can set strategic policy direction and resource allocations related to mental health in Nova Scotia, such as the previously discussed Koinonia organization.
I would like to thank the Committee for giving me this opportunity to present my views today and I certainly look forward to the committee's final report and the implementation of its recommendations.
Dr. Aidan Stokes, Acting Head, Department of Psychiatry, Dalhousie University: Mr. Chairman, I shall try to be brief. I have some notes, but I will send on these notes later on. I will not go through them in detail.
I support Dr. Ayr's submission and mention that the consumers transformed the strategic planning process. We generally look to consumers as consultants, but we quickly became aware that the consumers believed they had a key role in any planning process and they became extremely active in the process itself. The consumers peopled the committees, chaired the committees and vigorously debated how their contributions might help and have an impact. I have to say that the consumers seemed to have a much broader view of their needs than we professionals do. I think that the professionals, the NGOs, the administrators, the academics and so on all had some views on various approaches, but in terms of looking at the issues broadly, the consumers did it best.
In your report, you noted that we should be looking at something that should be recovery-based and consumer- focused. If we accept that consumers are the best source of information about their needs and their interests, this realization willnot only affect the provision of care, but also will affect research and education. Consumers clearly wish to take an active role in the management of their health. What canbe done in terms of prevention? What are the benefits ofnon-drug treatment activities, such as diet and exercise and alternative treatments, such as acupuncture and herbal remedies? If these are not successful, perhaps then they can go the route of pharmaco-therapeutic agents.
This has implications for our practice as professionals because we believe that we pay some attention to the healthy living approach, particularly in the management of depression and anxiety, but our knowledge of alternative treatments is minimal. For instance, we have some knowledge of St. John's Wort and its uses, and we know there is evidence to support the use of acupuncture for the treatment of depression, but for the most part we know very little of alternative treatments for mental health problems.
Do we have an obligation to research alternative treatments? I believe the answer is "yes.''
How can we involve consumers in more effective education on the subject of mental health? There is probably some concern about stigma and on the power differential in getting our patients to speak to our students. Certainly, at the undergraduate level, it has a tremendous impact when we bring a consumer in to speak about a disorder or an illness, but we often do have concerns about exploitation of those individuals, and that often does limit participation.
Of course, education of the public is another issue. My view is that the best anti-stigma tool is an active and credible consumer organization. If they go out and speak, that will really make a difference.
In terms of encouraging consumer participation, we must recognize the value of consumer input. We must hear from culturally diverse consumers and caregivers. One thing we are not very good at is involving the immigrant population.
We also have to recognize that consumer representatives may need training, education, and support in terms of doing their job well. There must be resources to support participation. The consumers need clearly delineated responsibilities and have their participation evaluated for efficiency. They should be remunerated. I support consumer involvement.
With regard to your recommendations, I urge that evidence inform any changes that you will make. The committee needs to refer to the principle of fairness and that means that there should be equity in access and equity in care to make sure we have well funded services.
We should integrate out services within the health care system and the community, and provide ready access to all the other forms of support, social services, education, housing, and justice that our consumers need.
The problem with ring fenced funding is that you start small and you stay small. We have not received the necessary percentage of funds. I think that if it is suggested that there will be increments to funding that will come specifically for mental health, I think that would be fine, but it certainly should remain within the health budget. If, in fact, there is support from the federal government with respect to mental health and it is linked to mental health, that would be optimal, but I have some concerns about a discrete budget because sometimes it is capped, whereas the other parts of the budget tend to increase.
Mr. Chairman: I would like to respond to a couple of points that two or three of you raised. One is with respect to the ringed fencing idea. I understand the fears with regard to ringed fencing or protected funding and agree that it is not the proper strategy. It might not be the proper strategy but it might be necessary in order to get the process started. That is the risk of doing things with the status quo.
A couple of you recommended a national response team, which I interpret to mean that there needs to be some way of getting organizations, NGOs and others, involved in pressuring governments to implement a lot of the thing that we recommended. Obviously, we cannot very well do that. I mean, we cannot organize our own lobby group in favour of ourselves, as much as we would like to. I say that as a challenge to the NGOs in the country. What happens to our report when it is out will depend very much on the extent to which the NGOs themselves can get organized and conduct a national lobby campaign.
One of you commented on the role of consumers in anti-stigma campaigns. We agree with you absolutely. I agree with the proposal of evidence-based research, the very best anti-stigma campaign ever was in Australia, where the spokespersons were consumers. In fact, in a couple of cases, it was quite clever because they told a story in which there was no mention of them being a mental health consumer until the very last five seconds of the ad, which made it very effective. You are 100 per cent correct on that point.
Mr. Ayr you suggest to remove the artificial barrier between youth and adult services. On Friday, the people working in the area of children with mental health issues said that there is more similarity between child psychologists and paediatricians, a much greater commonality of interests and experience, than there is between child and adult psychiatrists. They argue for a different dividing line. They would have the dividing line between all of children's services, mental or physical, and all of adult services, mental and physical.
I started life as an academic, as did a number of other committee members, so we understand the importance of evidence-based practices. I agree that is where we have to go, but I think we have to be very careful that we do not go there right off the bat. At this beginning stage if we require that everything be totally evidence-based it will slow down the process. If we have to wait for all of the evidence we will never get anything accomplished because, as you know, there is very little research on this subject. We do not know what works and what does not work other than anecdotal evidence, and so on.
Having put forth the topics of evidence-based practices and youth versus adult mental health services, I would like to hear people comment and then I will turn it over to Senator Cook.
Dr. Stokes: With regard to the evidence-based question, if the evidence is not there, if it cannot be evidence-based, then let us go to best practices if that is what we have, and I think we do have best practices for most things.
With regard to the cut off in terms of child and adolescent, the difficulty, of course, is that the most serious illnesses, such as schizophrenia, depression and bipolar disorder, do not wait until adulthood, but arrive during adolescence when their impact is actually much greater. I think that there has to be a link and support at that crucial time in a person's development.
We have an unusual situation here in Halifax where ifat 16 years you fall and break a leg, you go to the Queen Elizabeth II, but if you have a mental health problem, you go to the Izaak Walton Killam, IWK hospital. God help you if both of those things happen at the same time.
The Chairman: You send your leg to one place and your mind to the other.
Dr. Stokes: Clearly, there is concern about the access to services for children and adolescents. Mr. Crossman mentioned the figure of 40 per cent. Well, of course, for children and adolescents, it is down to 20 per cent; less than one of five children, who require care, receives that care. So, that is an area that needs attention.
The Chairman: In at least two provinces, of which Ontario was one, if you are 16 or under, you are eligible for Children's Aid and a variety of things. If you are 19 or over, you are eligible to be treated by the adult assistance program. If you are 17 or 18, you are not eligible for coverage.
Dr. Stokes: Yes, and nobody wants to know about that problem.
The Chairman: Do they actually have such cases? What do you do with someone receiving publicly funded treatmentuntil 16 years of age and then is ineligible for treatmentat 17 and 18 years of age? Does that happen in Nova Scotia?
Dr. Stokes: No.
The Chairman: It is true in Alberta and Ontario.
Dr. Stokes: I think it is in terms of support from community services they are legislated to go to age 19, but they have to do it until age 16 and may do it subsequently; "may'' meaning, "No, go away.''
The Chairman: So in practice, it is the same situation.
Dr. Stokes: It is somewhat the same.
The Chairman: De jure and de facto, right.
Dr. Stokes: Yes.
Mr. Ayr: I want to make a comment on evidence-based practices versus "practice-based evidence.'' That term means that we go ahead, try something out, and see if it works and then obtain the evidence. This dichotomy needs more debate.
Dr. Stokes addressed the issue of adult and youth mental health services, and Louise Bradley would like to see this artificial line between youth and adult mental health services removed for a number of reasons. Ms. Bradley believes that individuals fall through the cracks, and that the youth services and the adult services fight over the same limited resources.
I mentioned that adult services on a per capita basis receive three times more funding than the youth services. We need to take a closer look at this and one of the ways to do that is to remove that artificial division.
Personally, I became ill for the first time as a 13-year old and did not know it and it was not until my third year in university that I became very seriously ill and had to seek treatment. Had I known prior to that and if there had been some kind of an integrated service in place, perhaps my route to wellness might have been different.
Mr. Galipeault: Pertaining to the evidence-based practice, I think we have to be careful when we talk about evidence-based and best practices. From my perspective, according to whom is it a matter of evidence-based and best practice?
This whole best practice approach scenario was developed in the 1990s by academics and mental health professionals. The reason I say we have to be careful is I want to know if consumers are involved in the research, and who is driving that research?
A literature review is one of the beginning points to research. A literature review does not capture the anecdotal evidence that consumers have and can contribute to research, things like story telling. I add this as a note of caution because often the consumer voice is not heard because of the method that is used.
Mr. Crossman: I work in a formal system and the quality assurance business and I am constantly inundated with requests about, "Is this evidence-based, what you are going to do?'' You go through that kind of organizational discussion in regards to what you are doing. To me, the whole evidence industry has become just that and sometimes I worry about the tail wagging the dog. The more we silo services, the greater that industry will grow because there will be a greater focus on each piece of research.
Back in the late 1970s or early 1980s, the Canadian Mental Health Association was talking about the "framework for support,'' but they were really talking about social determinants. They recognized that employment, housing, social support and education probably make a difference to a persons mental health.
There is considerable evidence that those determinants have an impact on all the population and the new evidence shows that poor overall health is killing mental health consumers, not mental illness.
If we really want to use evidence, let us focus on the organization of public services. Is there any evidence for not integrating a range to focus on individuals in the population? I think there is incredible evidence. The practice is totally different. I think evidence is a complex issue, but it has to be based on the population and what keeps you well.
On the other hand, not to contradict myself, I have to agree with Dr. Stokes that you just cannot do anything to anybody. There has to be accountability and restrictions.
To follow through on alternative practices, we run volunteer auricular acupuncture groups in our clinic. There are not many trained acupuncture psychologists, but we do have some in our clinic. We know that our consumers suffer from sleep disorders and anxiety and we have turned to acupuncture to find a remedy for those ailments.
There is a bit of evidence in the literature, but we went to the practice-based evidence first. We decided to try the acupuncture with the realization that it could not kill anyone, we hoped.
The practice-based evidence showed that sleep disruptions and anxiety decreased dramatically with individuals consistently involved in that program a couple of times a week. These were mental health consumers, not people simply worried about whether their car got washed this week or something, but people with real issues. So, there is a sense that we have to experiment at the same time as we have to protect consumers so that what we are applying is not in the realm of fantasy, that there are some restrictions on what we do in the health business.
The Chairman: We totally agree with you that the problem is that the vertical organization of the government is out of step with the horizontal services.
Val Traversy has been doing some work with you and he and I both know how impossible it is to reorganize big governments, so let us begin by looking on the ground.
I would like you to think about how to provide those services on the ground. Forget about all the stuff that is going on up above you. Consider instead if it is, possible to create the needed interdisciplinary structure.
If we are going to make a change, it has to be what we used to call in the old days "street smart.'' It has to be doable on the ground. We will worry about the big guys whose noses are out of joint, but we have to know it works on the ground.
Senator Cook: Mr. Crossman you referred to new public health and you talked about practice-based evidence, which I find very interesting.
Should the mental wellness aspect of this study be an integral part of the new public health or should it be a stand- alone mental health/mental illness piece?
I understand the need for cross-sector collaboration, and I was encouraged by your talk about the rural factor, as I come from Newfoundland. You talked about the Canadian Heart Health Initiative.
Yes, any strategy must be consumer-driven. This is generally agreed.
Well, that was my daughter's first job in Newfoundland when she graduated from university. She loved every minute of it and met many people.
I want to know what you do after the initiative. It was a good program and the outcomes were good. You said that the initial uptake would be by the provinces that feel that such an investment is necessary to their health plan. You either use it or lose it. So, all of that wonderful information about better living may or may not be used by the province depending on how much money is in the budget, I would suspect.
My provocative question is what impact does the justice system have on mental health and mental illness? I sometimes hear that our jails are becoming the mental institutions that we depopulated in the 1970s, and I wonder what we will do with that problem.
These are my observations and my questions. I am concerned about federal programs with wonderful initiatives and great outcomes and whether, based on the whim of the provinces, they go anywhere. What have we learned? A lot of time, money and effort go into these initiatives.
Mr. Crossman: In terms of sustainability, the Heart Health Initiative ran from 1989-02. A considerable amount of money went into the process and it was very successful. The Canadian Heart Health Initiative presented a new way of doing business, a new way of looking at the world and a new way of organizing resources to meet the needs of the population.
The politics of why things do and do not survive, I will leave to the politicians to figure out, but here in Nova Scotia, other priorities such as the tremendous demand for shorter waiting lists and shortages of professionals are very important issues.
I am not suggesting that at the next First Ministers Conference, you say, "All in favour, put up your hands,'' and if you get two hands, you go ahead. I am looking at the idea of recommending some demonstration projects. Senator Kirby is right that we have to reorganize things on the ground and I think if we do that, then we hope money will flow.
The Hearth Health Initiative indicated that to address such topics as mental health, public health, addictions and so on in terms of silos is fundamentally wrong. It does not work; however, it does not take away from the fact that we need specialized services. If I am having a heart attack, and no offence toDr. Stokes, I do not want him coming to my rescue. We need specialized services in our health care system. That is not the argument. We simply need a better balance in our system. I think if we look at addressing the broader health issues, we have to come up with structures that flatten the silos.
Separate funding has not worked in Nova Scotia. We already have separate funding. We have non-portable, separate funding that comes to us every year. Our allocation of resources per need in the population has not increased. I am not particularly open to the idea of creating some sort of stovepipe that money may or may not come down over time. I think that we have to organize differently the way we think about health problems first.
Your question concerning justice revolves around the youth question. What we end up doing is a lot more work that is intersectoral. We have to bring a range of agencies together to figure out what to do with this kid because it involves community service, justice is involved, health and maybe even schools and so on.
You suggested the idea that we are filling our prisons up with people with mental health problems. When people commit crimes, they commit them for various reasons. It is likely that many people in many institutions do not receive the support and care that they need.
If you are asked me if I would recommend more funding for the inmates at the cost of a trade-off with another program I would have to think about it. There is no question that it comes down to is trade-offs in our present system. If we do not give funds to shorten the waiting list at one of our largest hospitals in the province, then we cannot give funds to somebody else. We need to reorganize services and funding and I think the federal government can support that because if I end up arguing with the representative from justice, I may win, he may win, but somebody loses and that is fundamentally how the system is set up.
Dr. Stokes: With respect to the prisons, I think it has to be accepted that most of the people in prison are not very well adjusted and that is one of the reasons they are in prison. If you look at that population, I guess "mentally handicapped'' is the significance of that dual diagnosis. Concurrent disorders with drug and alcohol abuse are a major issue and our mental health services in the prisons are not as good as they should be, and I agree that they need attention. The federal government is generally responsible for the penitentiaries.
The Chairman: Oh, absolutely.
Senator Cordy: We were talking about the media earlier and one of you commented about "waiting lists make the media,'' so if we are looking for a positive impact in the media, waiting lists are one example.
Government, you also said, was preoccupied with waiting lists and I would say the general public is also preoccupied with waiting lists. However, when the general public looks at waiting lists, they are looking at waiting lists for cataract surgery or hip replacement surgery or heart surgery, and very rarely do you hear people talking about waiting lists for getting into the mental health system. We have heard today that there are 500 people waiting just to get into the system and these do not include the people who are already in the system who are waiting for help.
It is always a tie-in when we are talking about mental health issues because you cannot exclude public education and the whole issue of stigmatization.
The number of people who are touched directly or indirectly either by family members or friends or colleagues at work is staggering. However, the communities are not crying out for more mental health funding.
How do we go about making sure that the public gets involved in demanding resources for the mental health system?
Mr. Ayr: I think one of the things is that consumers who have experienced the system need to tell their stories and the public needs to hear them. I mean, there are many people who suffer from mental illness that have really incredible stories to tell about successes in the arts and music and literature and we just do not hear those stories. I think we need to focus on the positive stories.
Mr. Galipeault: One approach is the old grinding approach, what I am starting to call the "one-block-at-a-time'' approach. A couple of years ago a manager of a mental health program in downtown Dartmouth asked me how we can make sure that consumers are viewed as full citizens. I think part of the answer is those of us who are involved in this has a responsibility to assist in this regard. I told her to take a one-block or a two-block radius of the program location and hold a town hall meeting and have consumers present and talk to the citizens in that area. I told her to start knocking on doors, dropping off flyers, inviting people out and letting them know how consumers contribute to the economic well-being of that two-block community and how they contribute to the cultural mosaic of that community. You work those two blocks for a period of months or a year and then you spread out to two more blocks. I think it is a long, slow approach, but I think it is part of the solution.
Dr. Stokes: I think things are changing and I think the very fact that we have this committee going right across the country is one aspect of the change. Some of these changes are reflected in the fact that the Department of Health within the Government of Nova Scotia is setting core standards for mental health and is evidenced by consumer involvement and the undertaking of an anti-stigma campaign. I think these are some of the changes that have occurred. It is not going to be any one thing. It is going to be many things, but I do believe that many things are changing.
Senator Cordy: I think that if people could hear the personal stories that this committee has heard, it would go a long way in reducing the stigma across the country.
Mr. Galipeault, your brochure says that in addition to helping consumers of the mental health sector, you also provide for the business sector. Are you getting any calls from the business sector?
Mr. Galipeault: No, I have not had any calls from the business sector.
Senator Cordy: Are any of you getting calls from business to ask how to be more inclusive of people who have been clients of the mental health system?
Mr. Crossman: Just in terms of your general question, Iagree with Dr. Stokes that any approach to these issues must be multi-tiered, but just in terms of the business community, I think a critical point that is frequently left out of these scenarios is the cost to business of mental illness. Michael Wilson is involved in the economic round table, as you would well know, and I think now advises the government on some of these issues.
Mental health and mental illness is a tremendous cost to business in the country and so we do not need to discuss that point. What we do need to talk about is how to convince employers.
We have developed an intervention between three private sector businesses, one in forestry, one in fishing, and one in publishing and our own organization. We did health risk assessments of 340 employees across those businesses and each employee received a confidential report of our findings. The employees discovered whether they are obese, if their cholesterol level is up, if their stress level is normal or high, if they are depresses, if their anxiety levels are normal and whether they are getting along in their workplace. Some people may throw it in the garbage or some people may read it and learn a lesson from the information.
The most important thing we have accomplished is we have demonstrated and we have linked the cost of those issues directly to the bottom line of the employer. The findings indicate that absenteeism and accidents and so on cost the employer money, and when you particularize the issue to the individual, you start to see some change in behaviour.
At the other end, I think we need more government leadership. I think we should stop pussyfooting around where we put our dollars in health care and start talking about the health of the population. That is what we are doing in Nova Scotia and it is great. We have seen smoking rates drop; physical activity will probably increase in the next few years, and so on. However, it is in the political sphere that we need to start talking about the health budget quite differently. We need a health care budget where we promote the health of the population, and the participation of employers is critical in the entire scenario.
Senator Pépin: Dr. Stokes, we are speaking about educating the public and the teachers. What about the education of medical students, because I have the feeling, and I may be wrong, that the general practitioners feel that mental illness is outside of their realm of medicine. If we were sure to educate the medical students, we would sensitize them to understand that mental illness is an issue related to health. We know that all too often, the diagnosis comes too late, and our doctors need to be aware of and sensitive to these issues.
Hospital staff always asks patients about allergies and about their medical history, but they never ask about mental illness. If we start to ask that question, it will become part of the normal routine and easier to speak about mental health. It will not be set aside or considered separately. Medical students should receive special training about mental illness and that could ease everything if it part of the general education.
Dr. Stokes: We hope to do many of the things that you have mentioned. In fact, we are revising our curriculum within the medical schools to offer more psychiatry, but it has to be integrated into the program when the students performpatient-doctor exercises.
I think that it is standard that a patient coming into one of our teaching hospitals would answer questions concerning surgical, physical, mental, and substance use history.
Our family practitioners need more support and education and help to improve their skill sets because more than 50 per cent of their patients will encounter mental health issues and they are often the first and only people that they are going to see. This problem must be recognized.
Another issue we are going to have to address is that of inter-professional education, meaning educating nurses, pharmacists, social workers, psychologists and physicians.
The Chairman: If there are no other questions or comments, I thank all of you for coming. You have been very helpful and your presence has been much appreciated.
Senators, our next presenters are from the Nova Scotia Department of Health. Linda Smith is responsible for children's mental health and John Campbell is responsible for adult mental health. May I say to the witnesses that at about a quarter to five, Senator Cook is going to take over as chairman because I have a number of interviews to do just after five and it is a fixed time frame because it is the electronic media.
Ms. Linda Smith, Acting Executive Director, Children's Mental Health Services and Addictions Treatment, Mental Health Services Branch, Department of Health of Nova Scotia: Thank you for the opportunity to speak to you today.
You have been here all day and in the interest of time, you can read our overhead presentation. I will proceed with a few highlights, and then we will perhaps have some dialogue.
In our province, we deliver our mental health services across the lifespan, from children to youths and then adults. That is a little different from some provinces that split children between several departments.
We have over 50 community mental health clinics and inpatient units in eight of our nine district health authorities as well as the IWK health centre and we have emergency services in all of the districts.
We have worked very hard in the last three years involving well over 200 stakeholders in developing a set of mental health core program standards and indicators to match the standards. Along with assisting and providing quality service and some equity around the province, it has served as a way for the various districts to do an annual self- assessment of their performance against the standard. The gap in that self-assessment is what assists us with future business plans.
The key priority areas include enhancing community support programs for mentally ill patients with severe and persistent mental illness who are no longer in institutions but are truly in the community and in need of housing, employment, and activity programs to provide them with some structure throughout their day.
We need to enhance our crisis and emergency services and provide a more rapid response to individuals. Children and youth mental health services across all of our five core program areas need enhancing.
We established our mental health steering committeein 2001. It is an advisory committee to the branch in the Department of Health and is comprised of individuals from the various districts, the IWK, consumers and advocacy groups and a representative from the Department of Community Services. The committee has developed not only the standards but also programs to monitor the health of the nation; that is, whether, in fact, our mental health services are making any difference as we go forward.
We have a considerable way to go before the full implementation of our standards, possibly five to 10 years. New money has come our way, but it is just a beginning.
We believe that there needs to be a national strategy on mental health because a collaborative effort will produce a better result. The responsibility to create a strategy should not rest on any individual province.
Mr. John Campbell, Director of Adult Mental Health Services, Mental Health Services Branch, Department of Health of Nova Scotia: Ms. Smith mentioned our approach to mental health reform and I think it provides a good template for an effective strategy. Our strategy begins with a steering committee that sets out the standards for service delivery, monitoring and evaluation and dealing with consumers and their place within the mental health system. Our committee deals with both the informal and the formal system and deals with issues of stigma as well as prevention, promotion and advocacy.
I have to congratulate the committee on an excellent document that has brought and increased awareness to the people within our mental health system and to the stakeholders with which we work.
While listening to the end of the last discussion, you were talking about the public getting on board and I think that is a major issue and something that you will have to address with your commission. The synthesis of your work and the recommendations you offer are very, very significant and we applaud that work and wish you every success in achieving your goals.
In terms of what we want to do to see a comprehensive and effective system, we are doing a lot of good things, but we could be doing more. We need to have more collaboration because mental health is everybody's concern. We need to collaborate with other divisions within the health system, or if we take a population health approach, we must work with our partners in other government departments.
As you said in your report, the development of a national independent database is the foundation of a good system. The 2000 community health survey relied on epidemiologicalstudies that we generalized from other countries. The Canadian Community Health Survey 1.2 was a start, but it was not in-depth enough to identify the prevalence of the major mental disorders that we have to face in our society. It was not broad enough to capture the range of individuals that suffer from mental health problems. It did not contain the kind of good information that a larger sample could give us from a planning point of view. We need this information.
Even so, the survey has been effective. Nova Scotia and Ontario were the only two provinces that purchased additional samples from Statistics Canada to be able to analyse that information and provide some direction to our district health authorities to assess the mental health needs within those districts.
The survey's sample size in some cases was smaller than we would like, but it did provide valuable information. We would like to see a broader expanded survey that includes an individual's lifespan. That information would provide us with information on which to plan for future services.
We need to develop an information system that can measure the mental health status of our clients, our communities, and of our population. We need to evaluate our policies, our programs and our services. We need to develop quality assurance programs. We need to look at how effective our services are so we can begin to make choices based on the cost effectiveness of those services.
You mentioned the federal-provincial toolkit. This is a good first step, but it is very abstract. We would like to see a second stage that includes examples of its implementation and the indicators in use. We would like to see the second stage give direction to provincial-level systems. We need to go beyond this toolkit.
We need effective knowledge translation; practice has not kept pace with the research. We spend time and effort facilitating this process through the development of standards based on best practices and bringing the content experts to bear on those standards in giving direction to the mental health system through those standards. We need to do a lot more than that.
I use the example of the shared care consortium and their recent initiatives in developing toolkits for the implementation of shared or collaborative care initiatives dealing with special populations. It can actually give direction to various jurisdictions and locales in the institution of those kinds of shared care initiatives.
We have looked at and made good use of some of the monograms from Health Canada dealing with best practices in such things as anxiety disorders, substance abuse treatments and mental health reform. They have wide circulation and provide translated information from research to practice. They have had an impact, but it is only touching the surface of what we need to do.
What have we done in Nova Scotia? I think this has some relevance to what we are talking about today and what you are looking for in terms of your commission. We have developed core program standards dealing with our template of services. We have looked at some specialty programs and the standards associated with those programs. We have come up with a strategy for districts to assess compliance to these collaboratively developed standards. We have also piloted a Health of the Nations Outcomes Scale (HoNOS) in three of our district health authorities and we are now embarking on a one-year demonstration in one district health authority. The National Health Service in the U.K. has embraced the Health of the Nations Outcome Scale throughout their mental health service. It is a valid, reliable and relatively easy-to-use system of evaluation. It takes about five to 10 minutes for a clinician to do and it gives very good outcome information.
We use the CCHS to provide district profiles to each of our district health authorities, so that they could use that information on a district basis to give some direction to their priorities in terms of their mental health system.
We have also initiated the use of Cognos web-enabled software, which is, as I would describe it, everything that computers promised, but never delivered until today. Cognos enables us to analyse large databases and to cross- tabulate variables in meaningful ways to give relevant information to mental health directors, managers and clinicians.
We are engaged in a training program with all our mental health directors, so we have ambulatory mental health information and inpatient CIHI information available through Cognos cubes that mental health directors can manipulate and cross-tabulate. They can look at such variables as demographic information, residence information and diagnostic information. Again, it is only a beginning, but it is a very valuable tool. When you have seen mental health directors engaged and enthusiastic about data, I think that goes a long way to saying that it is relevant.
We have linked our mental health surveys to our administrative data so that we have been able to look ata 1995 Heart Health survey, look at symptoms of depression as identified in survey and then look at subsequent health care utilization in cardiovascular disease. We have actually been part of a publication of those studies in the annals of epidemiology and psychological medicine.
We have Dalhousie University's Population Health Research Unit here, which stores our administrative data, allows us to be able to link various databases, and helps us to get a profile of our provincial mental health needs.
The Public Health Agency of Canada in the Atlantic Maritime Provinces has given us the designation as the National Collaborating Centre for the Social Determinants of Health, which says something very positive about what is going on here in Nova Scotia. We also have world-class mental health epidemiologists here at Dalhousie University.
I say all those things because Nova Scotia would be pleased to be involved in any demonstration project associated with the development of a national information database.
The mentioned items are but a few of the things that we need to begin to build upon to achieve the goal of a comprehensive system. We need to have society's vision in concert with our own vision, and more emphasis on prevention, promotion and advocacy efforts is necessary.
The previous group talked about "population health'' and getting away from an emphasis on solely the delivery of health services by considering the health of the population and overcoming the stigma that interferes with a person's ability to access services.
A number of national strategies including the Ontario-Canada Labour Market Agreement for Persons with Disabilities, and the National Affordable Housing Strategy that have a direct impact on mental health. These programs need to be coordinated, not just at a local but also at the national level.
Most important, we need collaboration. We have compartmentalized our services, not just in mental health, but also in many areas related to the health of the population. We must move out of our silos and infuse services with the capacity to address mental health aspects within these services. We must blend shared care with primary health care and the police and emergency/crisis services, with community services. We must deal with the mental health issues of offenders and seniors in long-term care and the challenging behaviours associated with them. We must work with organizations that govern affordable housing and employability. We have to turn our efforts to injury and chronic disease prevention strategies at a national and regional level. We need to work with caregivers in non-governed organizations and those social agencies that are dealing with the needs of our population.
Again, I applaud the work of this commission. I think we must support a comprehensive national action plan for mental health. We need to have standards based on a collaborative framework involving all stakeholders; that is, not only the experts and decision makers, but also the consumers and service providers. Stigma must be addressed at a national level. We need to build a national database, a national research agenda, funding envelopes to support strategic initiatives, and a national strategy on chronic disease prevention and suicide prevention.
The Chairman: Thank you for your presentation and I am going to ask one question before I ask Senator Cook to come and take over. In fact, I do not need an answer right now, but you can send it to us by post or email.
You just referred to a strategic initiative fund of some kind. I think the Primary Health Care Transition Fund, transitional only and not ongoing funding. I believe that it was not the standard federal strategy of sucking the provinces in and getting them started on something and then walking away, right.
This was an experimental strategy designed to help you move from point A to point B, with the result that when the transition is over, you have a better running system.
We have received many suggestions to give 12 or so examples of "an innovation project,'' or, "a transition fund,'' in our next report. One of the things that made our original report on the acute physical care system so effective was that we did not just speak about concepts but also gave examples of the concepts in practice.
I am not trying to pin you down but I would like to have a number of illustrative examples with me when I take the concept of an innovation fund to people whose immediate reaction will be, "Why should the Federal Government put any money into anything?''
If you could think about that and let us know, that would be great.
Senator Joan Cook (Acting Chairman) in the chair.
Senator Cordy: Dr. Ayr spoke about cultural shifts earlier; you indicated sort of the same idea that we have to go through a cultural shift, and work within provincial departments as well as municipalities and the federal government because everybody has different jurisdictions. The bottom line is people just want good health.
Are the departments of health, community services, housing, education and justice working collaboratively?
This morning Carole Tooton told us about the man who works as a house painter although he has a master's degree in education. He loves his painting job, but had no health care proviso with his job contract and, therefore, is unable to get his medication.
Are we breaking down any silos in Nova Scotia?
Ms. Smith: I think we are making progress, but we are not there yet. We have the Nova Scotia Child and Youth Action Committee that has representation from health, education, community services, justice and the youth secretariat. They have looked at what I will call "policies,'' the service delivery model, and tried to coordinate and take a focus that pulls the various departments together.
We have also started a continuum of care committee between both the Department of Health and the Department of Community Services. This is a high-level committee of the two deputy ministers with senior officials. The committee looks at exactly those kinds of issues where our policies and our procedures leave a gap where the client cannot get access to the needed services. I think we have made some progress and gains in that area.
We have entered into more of what we call exchange of service agreements and I will give you a few examples. We provide a longer-term treatment program service for children under the age of 12 through the IWK. Funding for that program began with the Department of Community Services and is now with health. We have entered into an exchange of services with the Department of Justice to provide all the health and the mental health services for children, youth and adults in the Province of Nova Scotia.
We have made improvements, but there are still large obstacles that are in our way. You mentioned medicare and particularly prescription drugs and that remains an issue for people with a mental illness as well as for people with other illnesses that do not have a pharmacare program. We income test these people and through income assistance they can receive something through the Department of Community Services. In some cases, we tend to provide the medication in health services if they are inpatients. This is indeed a problem area for the working poor who are entitled to some kind of benefits on income assistance, but may no longer receive coverage when they return to work.
Senator Cordy: It is really sad when you hear the stories of people who quit a low-paying job to go on welfare to get their benefits.
Ms. Smith: Absolutely. All they may need is help with medication, and yet we force them to give up meaningful employment to get it, which is certainly not good for anyone.
Senator Cordy: It is not good for the person and not good for the government.
Mr. Campbell: Our Department of Community Services recently changed their program to allow a one-year extension of the pharmacare coverage.
I want to reiterate that it is a real disincentive to employment and that we had hoped to solve the problem through either a drug coverage plan or a national pharmacare program.
Senator Cordy: That was in our other report.
Mr. Campbell: We have recently initiated some work originally conducted in Ontario by Dr. Kenneth Leclair on a PIECES Program: a nursing home building capacity program dealing with challenging behaviour. The program trains our people to become experts to support that increased capacity within the nursing home sector.
We have collaboration in the long-term care sector and the primary care sector. EHS, the Emergency Health Services, and the police and our mobile crisis service are beginning a project that we hope will result in collaboration at that level, too. In the Department of Justice, we have a joint forensics committee that brings together the various jurisdictions dealing with forensics, mental health, the justice system and Department of Community Services to bridge the gaps that exist within our services. We are looking at court consultations by our mental health professionals as a diversion for many of the individuals that come before the courts that are found fit and responsible, but at the same time, have committed minor crimes that are as much associated with mental health problems as anything else.
Senator Cordy: I agree, and legal aid has a program that works with the families of the young offenders, which very often involves treatment for addictions and so on.
I guess with my previous life as an elementary school teacher I cannot help but talk about young children and the problems that they face. I remember so many meetings with the parents, the teacher, the principal, the school psychologist and somebody from the IWK and it almost got into an "us'' and "them'' situation.
In many cases, the parents worried that they had poor parenting skills, and worried that somehow they were responsible for the problem. A child suffering from a mental illness often involves the whole family in crisis.
I have been away from the school system for five years. Are there advocates now for families of children in crisis to help guide them through the maze?
I ask this because a couple of weeks ago, a federal agency appeared before our committee and showed us a slide listing all the federal agencies and the NGOs and it was an overwhelming amount of information. Is there any type of an advocacy system in place?
Ms. Smith: I am not sure that I would necessarily say it is "advocacy.'' There have been some gains, but, again, we still have a long way to go.
Quite often, what is happening is there is a family in crisis because of difficulties around managing a child, and some children are harder to manage.
They were just born that way. They are more difficult to parent. That group is often on our waiting list because they do not have a mental illness and do not screen in for either emergency or an urgent case. They tend to stay on the mental health waiting list for much too long a period.
I do know that the IWK is working with Dr. Chuck Cunningham from Hamilton, looking at a way to deal with the wait times and the waiting list for exactly that kind of a family. They are looking at opportunities for running more groups and working in different ways to help that particular group of children and their families. They have tried what we are calling "family help,'' a demonstration project put together by Dr. Pat McGrath from Dalhousie and tested in three districts and at the IWK. The project brings primary care people, physicians, and teachers together with the families to best manage some of the challenges that the children face.
Special education with the Department of Education has received additional funding in this year's budget. I am not sure how that will all turn out, but there certainly is a need to enhance services for school psychologists, which needs collaboration among the education, health and mental health departments.
Senator Cordy: You are right; you have to cross the borders because even the wait time for a school psychologist can be up to six months.
Ms. Smith: Our time lines are very different for children, so six months in the life of a young child is a long time and that kind of wait time makes it a non-service.
I see that as a pressing priority on which we have been focusing and we hope we are making some inroads.
Senator Cordy: I am very interested in your comments about monitoring how things are working. How are you going about doing that? It is such a wonderful idea.
We constantly do things and, often, nobody checks to see whether things are actually working, so I was delighted to hear you talking about monitoring your progress.
Mr. Campbell: As I said, we have two primary databases of which we make good use. We have an ambulatory database here in Nova Scotia that is sort of our own and then we use the CIHI Discharged Abstract Database that gives us a host of variables and information.
I will give an example of something that we have started recently and that is, because of pressure on our inpatient beds, we have a bed utilization committee and we bring together the mental health clinical directors and administrators of our facilities to develop reports looking at comparative information, one district to the other.
Ten years ago or even five years ago, it would not have worked very well because everybody was a little bit suspicious about having to share information with everybody else. That is why working collaboratively through building relationships and trust is so very important in any kind of a system.
It is one thing to have information and it is another thing to have comparative information. The ability to compare one district to the next gives us very, very interesting information. You can look at the variable across all districts, then look at the outliers, and then ask people to explain the reasons for differences.
What has happened is that whenever you give people information and it is good and comparable information, there is reactivity to it and there is a valence about which way to proceed with this information.
Our mental health directors and our psychiatrists and people in charge of our inpatient units have been taking that information seriously and looking at their practices. It has had an impact on their practices.
In our outpatient information, we generally do counts. We are looking at diagnostic groupings of who is seeing who, for how long, how many people are being seen in what kind of a schedule; information that again is comparable, one district to the next, looking at particular kinds of benchmarks and making comparisons.
Now, we are doing it with information that is reasonably accurate, but it is not sufficient. As I had mentioned previously, we are looking at an outcome measure that we are implementing in one of our districts, that of Doug Crossman, one of your previous speakers. We are going to follow that for one year to see how it affects clinicians, the administration and the delivery of services in that area.
This is a scale that we pilot tested in three of our districts for a short period, looking at validity, reliability and sensitivity. The National Health Service in the U.K. is using it as its mandate. Now, if you have an outcome measure in mental health that is good because we do not have many good outcome measures.
Senator Pépin: You say that we need to collaborate and we need to move out of our silos and you also speak about shared care with youth and adults.
I will add the elderly to your list because I spend a lot of time visiting the elderly. An old woman told me that she was suffering from cancer and when I asked what kind of cancer she replied, "Oh, it is not physical, but it is mental.'' She added, "I feel I am all by myself. I am alone.'' The woman is a nursing home resident that houses many elderly people.
Do you have specific information regarding the elderly? I do not know exactly the term, but I could not resist the opportunity to add the elderly to your list and I was wondering if you have any information about that group.
Mr. Campbell: Again, this gets back to the issue of a piecemeal approach. We have talked about shared care and there is a national initiative in collaborative care. The Canadian Coalition for Seniors Mental Health is having its first conference in September dealing with best practices related to assessment and treatment. Dr. Kenneth Leclair and David Conn, Queens University and I think McMaster University are heading up that group. They will look at the issues related to the mental illness that individuals develop in older age, not necessarily old age, but in older age.
When I did my training at the University of British Columbia,I did a specialization looking at seniors' mental health,and the same issues apply today as when I graduated in1977: polypharmacy and the issues of stigma, particularly as it relates to seniors' mental health.
Seniors do not use mental health services in proportion to the population that they account for compared to any other age group. They do not. We can look across the system and see children and youth and what proportion use mental health services and you look at those over 65 years and see that they do not access mental health services. I applaud the Canadian Coalition for Seniors Mental Health; it is a national initiative that relies on people who have that interest.
In addition, we have initiatives related to collaborative care and affordable housing and we have a national injury prevention strategy and a chronic disease prevention strategy, all of which contain aspects of mental health, but all are separate and move in their own direction. I think that reflects the need for tying to collaborate at a national level.
Senator Cordy: I have heard both good and bad comments about Bill 109.
Are we the only province without a mental health act and what do you think about bill?
Ms. Smith: We are the only province that does not have a stand-alone mental health act. Our current mental health provisions are almost 30 years old and they embedded in the Nova Scotia Hospitals Act. It is an extremely outdated piece of legislation and not consistent with anything else across the country. Yes, we do need a new act.
When Bill 109 was introduced in the House at the end of September, it was the end of seven years of consultation with stakeholders. The Law Reform Commission had done a considerable amount of work over a five-year period, meeting with stakeholders around the province and presented a number of recommendations that they felt should be in the legislation. We had a large committee that represented providers, the legal community and consumers and provided a consultation document. We sent that out and then brought the responses to that along with what we had from the Law Reform Commission and Bill 109 was drafted.
The generally feeling is that it is in the middle, if I can put it that way, of where other legislation across the country is now. The purpose of the Mental Health Act is to ensure care for individuals who have a serious mental illness and because of the mental illness, do not recognize the need for treatment. The lack of ability to recognize their illness puts them not only at risk, but also at means that they cannot access a necessary service. We tried to create some checks and balances with regard to what obligation the province and the state has to do to assist those individuals and their families and with regard to ensuring that there is not excessive intervention in the rights of people to self-determine their care. That is the state of the bill now. We had aninformation day at the end of February that brought together about 200 people from around the province, key stakeholders, and again shared information on the particular bill.
We have received multiple responses from stakeholders and families and many consumers who now have recovered from their illness, writing to say what their views are on the bill.
It is really up to our elected officials to decide how to proceed. The bill was introduced, but it was not called for a second reading, so it is in a state of limbo at the moment.
The Acting Chairman: We hear a fair amount of support for a national mental health strategy, and I hear that confirmed every time I sit at a table like this one.
I would like your opinion on a national mental health act supported by legislation. Given the dichotomy between the provinces and the federal system, do you think it will be possible to have that piece of legislation with the appropriate regulations in place that the provinces would access?
Ms. Smith: It is not something to which I have given a tremendous amount of thought, but I will say that it might be very difficult to implement since health really is the responsibility of the province. I think you could have to ask a legal expert and somebody who is more familiar with constitutional issues, but I am not sure how you would be able to impose the legislation on a province because the province has to deliver the service. It would be difficult, but there could certainly be guiding principles and overarching direction.
The Acting Chairman: We are looking at the accountability factor. I am not a lawyer. I am thinking outside the box. I am looking at it from the perspective of framework legislation. The Fisheries Act, for example, is a very complex act supported by numerous regulations as the situation warrants.
Ms. Smith: We have the Canada Health Act, which has remained silent on mental health. If we had a federal act that was broad in that way or if there were amendments to the Canada Health Act to incorporate mental health, I think those things are certainly possible.
This piece of legislation, which is really a protection legislation very similar to, say, our child welfare legislation, which is the protection of children from abuse and neglect, it would very difficult to write and to put regulations in because each province has a slightly different system in terms of delivery practices.
The Acting Chairman: Well, at the moment, some provinces do have a provincial mental health act.
Ms. Smith: Oh, all of the provinces have one.
The Acting Chairman: Not all of them. I think there are two provinces that do not.
Ms. Smith: I am only aware of ours as not having stand-alone legislation, although we do have the provision.
The Acting Chairman: I am hesitant to name them because I could be mistaken.
Ms. Smith: I believe every province and the territories have a piece of mental health legislation or have provisions somewhere. Most of them have stand-alone legislation. I believe our province is the only province at the moment that still does not have it separated out of the Hospitals Act.
Senator Pépin: If I remember correctly, a year ago, the federal government gave money for health and the word "accountability'' was mentioned.
I agree that it will difficult to tell the provinces what to do unless we give money specifically.
The Acting Chairman: Well, the federal government is the keeper of the purse, so I guess there is room for negotiation. That is the reality, is it not?
The federal government has the power of the purse and we work in consensus in this federation, this wonderful country of ours, so I think even if we dare to think outside the box, we have made progress.
On behalf of all of us and the absent chairman, I want to thank you very much for taking the time to share with us today.
The committee adjourned.