Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 17 - Evidence - June 2, 2005 - Afternoon Meeting
REGINA, Thursday, June 2, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 12:55 p.m. to examine issues concerning mental health and mental illness.
Senator Wilbert J. Keon (Deputy Chairman) in the chair.
[English]
The Deputy Chairman: First, let me thank you for coming here today and helping us with our task of preparing the final mental health report, which we hope to complete towards the end of the year. Hopefully, it will have an impact and achieve some of the things you want.
We will begin with Robert Allen, Executive Director of the Registered Psychiatric Nurses of Canada.
Mr. Robert Allen, Executive Director, Registered Psychiatric Nurses of Canada: Good afternoon, on behalf of the Registered Psychiatric Nurses of Canada I would like to thank you for the opportunity to address issues of mental health and mental illness with your committee.
Registered psychiatric nurses appreciate that your committee members have taken their time, interest and energy to address mental health and mental illness issues through meeting with Canadians across the country.
I suspect that your committee has heard much about mental health and mental illness from many experts. I am here today ready to offer you a concise oral presentation using a psychiatric nursing lens. I also have a brief prepared by the Registered Psychiatric Nurses of Canada, which has been submitted to your committee.
First, it may be helpful to know that the mission of the Registered Psychiatric Nurses of Canada is to provide a unified, national and international voice for registered psychiatric nurses. Since I am here today to speak on behalf of RPNs in Canada, it may also be helpful to provide you with a succinct overview of the profession I am here to represent.
Registered psychiatric nurses form the largest single group of regulated professionals in Canada that provide mental health services. Although RPNs are one of three recognized groups of nurses within Canada, people affected by mental health and illness are the public that RPNs primarily serve.
RPNs collaborate with diverse professionals, allied community volunteers and family members to prevent, support, restore, rehabilitate and promote the mental health of Canadians.
Approximately one-fourth of the profession now has a baccalaureate degree, primarily related to psychiatric nursing. A small number within the profession hold a master's degree and an even smaller group prepared at the doctoral level.
Currently in Canada, there is a scarcity of undergraduate programs available in psychiatric nursing, and no graduate or doctoral programs intended specifically for registered psychiatric nurses. Further, there are no nursing practitioner programs in Canada designed to prepare RPNs to engage in advanced psychiatric nursing practice as clinicians in primary care settings with people affected by mental health or mental illness issues.
Registered psychiatric nurses may be best described as practical professionals that constantly learn from the people they serve.
What Canadian registered psychiatric nurses have learned may be best shared with your committee by posing three basic questions: What? So what? And, now what? These questions will introduce the five points that the Registered Psychiatric Nurses of Canada would most like to emphasize to your committee.
The first question: Is there a clear and present danger that mental health and mental illness issues will affect Canadians during their lifetime? The answer is, certainly.
So what? Mental health and mental illness create a staggering burden of disease that translates into disability and, at times, death.
Mental illness requires early intervention. Combating stigma may be central to people seeking and receiving appropriate and timely help.
Children and youth, First Nations people, immigrants, people affected by brain injuries, seniors, people living in rural and remote areas of Canada, people with developmental challenges, offenders, and lesbian, gay, bisexual and transgender people are frequently under-served or fail to register on the Canadian mental health or illness radar screen. Human resources for mental health are often forgotten.
Now what? Federal leadership and collaboration with and among the provinces and territories to develop a national action plan on mental health is urgently needed to close the gap between the burden of mental disorders and the often inadequate resources. People living with a mental illness or mental health problems have a right to the same quality of care and services as people affected by physical illness.
The media can be a vehicle or a barrier to promoting the mental health of Canadians.
Policies and practices at a provincial and national level are needed to ensure people affected by mental health or mental illness issues are afforded the basic rights identified by the Canadian Charter of Rights and Freedoms. Funding and resources to serve the unique and diverse needs of Canadians is essential.
Educational programs should be in place across the country to prepare adequate numbers of mental health professionals that are regulated and licensed to practice in Canada.
The second question is: Is there a link between substance abuse and mental illness? The answer is, definitely.
So what? Excessive alcohol or drug consumption risks the health of Canadian families. Substance abuse affects the well-being of future generations and translates into social costs through crime, injuries and violence. Prescription, illicit and social drugs are used by many Canadians to medicate away symptoms of mental illness, or cope with daily living.
Mental illness and addictions frequently appear together in people as concurrent disorders. There are a myriad of illicit drugs that result in the illness, disability and death of Canadians.
Now what? Continued development and maintenance of effective partnerships with government, mental health professionals and community agencies is a priority.
Care, compassion and respect for the well-being and dignity of the people served are imperatives to effectively addressing the social costs.
Historical barriers and boundaries that have in the past impeded operational and system integration between mental health and addictions services need to be dissolved to create seamless and meaningful services.
Relevant competence and knowledge are critical for professional and allied personnel that respond to service needs across the addictions and mental health continuum of care, from early intervention to treatment and rehabilitation services.
Drug intervention treatment and rehabilitation are important for Canadians. The World Health Organization has recognized since 2003 that for every dollar invested in drug treatment seven dollars are saved in health and social costs.
The third question is: Is together better? Indeed it is.
So what? Primary health care services may be a path to share and integrate mental health care for Canadians. Good intentions are not enough, professionals serving people affected by mental health or illness issues require relevant technical and interpersonal competence.
Family physicians are unprepared to address the volume of mental health or illness issues that present regularly in their offices. The critical mass of psychiatrists in Canada is small. Graduate and doctoral programs designed for registered psychiatric nurses should be afforded comparable federal and provincial funding and the support generously bestowed upon other health professions.
There is a lack of research in the frontline delivery of mental health services in Canada and a need for evidence-based practice.
Now what? The delivery of mental health care is complex and relies on the connection and collaboration of many working in partnership and sharing responsibility with professionals, clients, communities, and municipal and government organizations to integrate services and to improve mental health.
Relevant primary health care concepts through interdisciplinary education that results in competencies in mental health promotion, cultural safety and interpersonal relationships are essential to effective primary health care teams
There is a need for nursing practitioner programs designed for registered psychiatric nurses so that they may support and supplement the work of family physicians and psychiatrists. Registered psychiatric nurses with advanced clinical skills may be invaluable human resources, particularly to primary health care teams in rural and northern areas in Canada.
There is a need for interprovincial collaboration for graduate and doctoral level preparation in psychiatric nursing for RPNs. Research and funding for research is an imperative to provide evidence for quality mental health care.
The fourth question is: Is purposeful action more powerful than crisis reaction? Of course it is.
So what? Mental health promotion and prevention require a higher priority. Policies and legislation that support the mental health of all Canadians need to be strengthened.
Children and youth, First Nations people, immigrants, people affected by brain injuries, seniors, people living in rural and remote areas of Canada, people with developmental challenges, offenders, and lesbian, gay, bisexual and transgender people need access to appropriate and timely mental health promotion and mental illness services.
The determinants of mental health promotion require collaboration by federal and provincial governments to address the mental health of Canadians in a meaningful way. For example, governments can no longer ignore the vicious cycle of poverty and mental disorders.
Professional human resources for mental health are aging, and educational programs are few compared to other health professions.
A level playing field of funding, support and recognition is needed for mental health research.
Now what? Provincial and national mental health action plans need mental health promotion components. Rational, comprehensive mental health policies and legislation need to be reviewed and revised.
Early intervention, primary, secondary and tertiary prevention and mental health promotion are necessary components for a Canadian continuum of quality mental health care.
Social supports, relationships, social status, personal health practices, health services, medication use, physical health and environmental conditions are the determinants of mental health, which can no longer be ignored or minimized for they affect how Canadians cope with work, play and love everyday.
Collaboration is a cornerstone to addressing the determinants of mental health effectively.
There is a need for succession planning and adequate educational programs for mental health human resources to ensure that there will be adequate clinicians, educators, administrators and researchers into the future.
Funding and research chairs for registered psychiatric nurses and other mental health professionals are essential for the discovery of what works best for Canadians that live with mental health issues, illness or disability.
The final question is: Are re-framing and revitalizing mental health services an urgent priority? The answer is, absolutely.
So what? Canadians are disabled and dying because mental health and mental illness remains invisible and underfunded.
Cultural safety is central to helping the diverse Canadian population, for it transcends age, gender, sexual orientation and ethnicity.
Relevant mental health services for lesbian, gay, bisexual and transgender people have long been ignored.
Mental health services have over-relied upon families or volunteers to be service providers. Self-help groups provide significant support to persons with mental illness, and are adjuncts to mental health professionals.
Now what? Mental health needs an immediate injection of human and fiscal resources.
Quality and excellence need to be the highest priority for Canadian people with a commitment to evidence-based improvement and research through a full range of dynamic and progressive mental health and mental health promotion programs and services.
Cultural safety, mental health promotion and primary health care competences for professionals providing mental health services are needed as basic education.
Education and guidelines are needed for mental health professionals to support relevant mental health services for lesbian, gay, bisexual and transgender people to understand the diversity of sexual orientations and gender identities in context, if mental health or substance abuse issues are to be effectively addressed.
People affected by mental health or illness issues should not be expected to rely on random acts of kindness for social support networks. Families and volunteers should not be expected to soldier on as service providers with sparse economic or professional resources for support. Self-help groups afford people with mental health, illness and addictions issues social support, and require financial support.
In summary, mental health and mental illness issues are complex to tackle, but there is hope. The sustainability of our health system for future generations rests upon placing more emphasis on the relationship of mental health to health generally. Mental health and mental illness issues must be addressed as critical components to an overall health care system.
Prevention, promotion and early intervention of mental health problems and mental illnesses have great potential to contain the cost of the delivery of health services generally.
Realizing results from mental health prevention and promotion programs takes time. A long-term commitment and the collaboration of politicians and policy makers at all levels are needed.
Although a national mental health action plan will assist to address short-term needs, implementing programs that address long-term goals requires a sincere commitment to the welfare of Canadian people from governments at all levels.
Finally, the Registered Psychiatric Nurses of Canada asserts support for the Canadian Alliance of Mental Illness and Mental Health in their quest for a national action plan for mental health.
The RPNs of Canada stand with your committee and others that have and will appear before you to speak up and speak out for all Canadians. The work of this committee has great potential to make a positive difference for all Canadians, and ultimately may save lives.
The Deputy Chairman: Thank you very much, Mr. Allen. I want to ask you a question before turning you over to Senator Callbeck who, by the way, is a former minister of health of Prince Edward Island and former premier of Prince Edward Island, so she has extensive experience in the health field.
In our hearings so far, one theme that has come through over and over is the need for community services: in other words, providing an infrastructure for integrated social and medical services; essentially primary care. We could then build the mental health system into those institutional services, many of which are in place even if they do not function well.
This brings me to the question of the nursing profession's role in all this and it seems to me that nurses are the cornerstone of success in community facilities. Indeed, in some of the smaller communities the entire resource will be a psychiatric nurse clinician. In my past life in medicine, I had considerable experience with clinical nurse specialists and I was truly impressed.
I wanted to raise this with you and have your response because, in satisfying the needs of the tremendous void in services to correct problems in mental health and mental illness and addictions, I think there is a huge need for nurse clinicians in psychiatric services. I would like to hear your response to that.
Mr. Allen: I agree with you. I think there is tremendous potential for the role of a psychiatric nursing practitioner at a community level, especially in rural and remote areas. Unfortunately, at this time there are no programs in place for that function.
There is, though, an evolving role of registered nurse practitioners in the medical area, and some aspect of that is related to mental health.
Our members have chosen the field of mental health because they love working in that area even though it can be a difficult, challenging and demanding area to work in. There is a stigma attached to not only the whole area of mental illness but to our profession, which makes us tend to be an invisible profession.
In Saskatchewan, there is a second degree program where people who have degrees in various areas are able to obtain a nursing degree within a two-year period of time, so that they would have two degrees. We would certainly like to see them specializing in the area of mental health as there is a huge, untapped resource out there.
The Deputy Chairman: Also, in Manitoba they have a two-year program for nurses that could be capitalized upon for registered psychiatric nurses.
I will come back again to the communities. In the large metropolitan areas such as Toronto, people are saying that they want a community they can identify with and that they know how to access. It would help them work their way through the system. They do not want to go to the emergency room of the Toronto Hospital, or wherever.
When we talk about community services we frequently think only of rural services when, in fact, they are needed most in the big metropolitan areas. I hope you agree with that.
Mr. Allen: I do.
Senator Callbeck: Thank you for your presentation. You say that educational programs should be in place across the country to prepare adequate numbers of mental health professionals that are regulated and licensed to practice in Canada.
What would you say is the federal government's role in bringing that about?
Mr. Allen: The federal government's role primarily is to establish a plan or model for Canada dealing with mental health. I am not an expert on federal-provincial jurisdictions and rules and areas of responsibility. I know that in relation to First Nations people there is a tremendous gap in the way services are divided. There is an absence of access to services because of the jurisdictional issues as to whether it is a federal or provincial government responsibility. I think the federal government could take more of a leadership role in that area.
Senator Callbeck: You have mentioned historical barriers and boundaries that have in the past impeded operational and system integration between mental health and addictions services, and that these need to be dissolved to create seamless and meaningful services. Could you expand on that?
Mr. Allen: Perhaps I could give you a real life example. Once or twice a year, we hold a psychiatric clinical conference in Saskatchewan for our nursing colleagues. I heard one of the professors in psychiatry describing how he is still being referred to as a "shrink" by his medical colleagues.
There are barriers, boundaries, limitations, professional turf protection, and those sorts of things that are very real and very difficult to overcome. That is part of what is being referred to.
Other boundaries are boundaries that we have traditionally established and said that is medical, that is not my jurisdiction when, in fact, all these areas are interrelated. There needs to be more interdisciplinary education. There is tremendous potential to have health care professionals see themselves as part of a team as opposed to individual, standalone practitioners. Whether you are an optometrist dealing with someone's eyes or a dentist, you are dealing with the whole person as far as their medical and mental issues go.
Senator Callbeck: Where in Canada are there courses available for registered psychiatric nurses?
Mr. Allen: At present in Western Canada there is a Bachelor of Science in Psychiatric Nursing program in Manitoba. British Columbia has received approval for a Bachelor of Health Science in Psychiatric Nursing at Douglas College, and Kwantlen University College is also in the process of establishing a degree program.
Saskatchewan was the first province to have legislation established in 1948, and since that time we have been educating registered psychiatric nurses. We are presently negotiating with the nursing education program in Saskatchewan for additional mental health competencies within the program.
The Deputy Chairman: We will now move on to the Farm Stress Line Advisory Group.
Ms. Lil Sabiston, Chair, Farm Stress Line Advisory Group: Good afternoon, everyone. I am from Kelliher, Saskatchewan, a small town about 200 miles from here. I was not able to work in the field due to heavy precipitation this morning, so it is my pleasure to be here.
I am a farm woman, first and foremost. I sit as chair of the Alcohol and Drug Advisory Council to the Minister of Health of Saskatchewan. I am also a board member of the Mental Health Advisory Council. Today I am here as chairperson of the Saskatchewan Farm Stress Line Advisory Group and I am happy to make this presentation on their behalf. Our presentation is entitled, "From Our Experience."
First, we express our thanks to the Senate committee for the opportunity to present our perspective here today. This submission is not intended to address all the issues raised in the committee's Report 3, Mental Health, Mental Illness and Addiction: Issues and Options for Canada. Rather, it is our intention, in keeping with the title of this paper, to address issues that fall within our experience.
As such, I will begin by introducing the Farm Stress Line Advisory Group, following by a description of the operations and work of the Farm Stress Unit. I will then proceed to reflect on the cultural context of service provision to agricultural producers and rural communities in general.
It is who we are and who our clients are that we feel deserves the attention of the standing senate committee.
The group is currently comprised of 11 organizational representatives who have demonstrated an interest in the human dimensions of agriculture. Its members represent a wide range of organizations, including the Prairie Women's Health Centre of Excellence, Farmers With Disabilities, Saskatchewan Alliance for Agricultural Health and Safety, Saskatchewan Association of Rural Municipalities, Saskatchewan Society for the Prevention of Cruelty to Animals and Agricultural Producers Association of Saskatchewan, to name a few.
We provide consultative support on the direction and plans for the telephone line and in promoting the service; our time is volunteered.
The Farm Stress Line began operations in February of 1992 and has been taking an average of 1,000 calls per year from producers. Calls are wide-ranging and reflect the pressures farm families are under, which contribute to high levels of stress and are exhibited in their mental and physical health.
The service is a program within Saskatchewan Agriculture and Food. It is the only farm stress line service that is a line item in a provincial government's department of agriculture budget.
The mission is to provide confidential peer telephone counselling, support, information and referral services that respond to the needs of rural families. Counsellors at the time of recruitment are farmers whose experience is supplemented by an extensive training program.
The consequences of the pressure created by farm debt issues are often the subject of the calls received by the farm stress line.
Our recommendations follow.
There may be merit in recommending a change to the method of remuneration, providing funds to the client as long as it does not promote a change to our present publicly financed system.
To provide culturally appropriate services to farmers, ranchers and their families, service providers must have a sensitivity and respect for their culture, and hire staff that have an intuitive understanding of rural life.
There is a need for system coordination. We believe that a sorting out of the roles of various mental health and addictions service providers may be worthwhile. It would require full respect of the non-governmental service providers. Additionally, there is a need to core-fund the volunteer sector.
There are barriers to accessing mental health and addictions services. To overcome the barriers we must define and profile service delivery in ways acceptable to the farming and rural sector. This defining and profiling would require considerable promotion and public education.
Agencies must be willing to respond to the needs of children and adolescents within the given agency's mandate. We are aware that school counsellors in rural Saskatchewan are faced with the challenges of rural life in an agricultural climate that has not been positive for many years.
We are willing to assist First Nations people when invited. We believe that the leadership must remain with the Aboriginal community.
We support the notion of health care service providers specializing in the care of seniors. In the farming sector, retirement begins with the sometimes traumatic decision to leave farming. There are business issues such as leasing out the farm, and the concerns of a vulnerable elderly person, perhaps uncertain about the details of the rental agreement. Such service providers ought to understand this reality in dealing with farm people.
There would be limited benefit to farm families from recommendations regarding workers' compensation and federal income security programs, as on the farm they are self-employed and in off-farm work may have limited income and benefits.
Combating stigma requires shaping delivery in a form that is compatible with the perspective of the community. The delivery agency may have to be non-traditional to make it work.
Additionally, success requires considerable commitment of public education and profiling. A high profile does not necessarily translate into an increased volume of clients.
The Saskatchewan Farm Stress Line Advisory Group urges the Senate committee to consult with the Calgary-based Centre for Suicide Prevention, as the centre is the leader in that area.
The farm stress line would be supportive of the New Zealand model of mental health support workers if they have an understanding of rural life, and the service delivery agency was compatible with rural people.
The advisory group supports the funding of a national information database of research and technology but there must also be an adequate level of funding for community-based organizations who presently suffer from a failure of government to provide core funding.
The Saskatchewan Farm Stress Line Advisory Group is well aware of the impact that a shortage of funds has on the lives of people in rural communities, which are becoming remote communities. The federal government should have a role in alleviating this.
For your information, Saskatchewan holds over 40 per cent of the agricultural arable land in Canada. Saskatchewan also has the second-largest beef cow herd in Canada. Agriculture is a major economic driver in this province. The mental health of farm people is paramount as it affects the long-term viability of the agricultural sector, farmers' families and their livelihood.
I would also like to read a report that was shared with us by the Farm Line in Ontario.
The Farm Line is the first source of information, support and referral for farm families experiencing symptoms associated with stress.
Farm families are referred to appropriate professional and public services available in Ontario when information and support are deemed insufficient to meet the emotional and psychological needs of farm family members.
By providing a point to access support by means of the phone helpline and informational resources, as well as the resource both directly on line and by means of the phone helpline, farm families can more efficiently find the support services and professional assistance they need to manage their situations. As such, the Farm Line can be viewed as an intake and referral service for Ontario farm and rural populations in relation to interpersonal, psychological and financial subject matters.
I think this would apply to most stress lines across Canada.
The Deputy Chairman: Thank you very much indeed, Ms. Sabiston.
Mr. Imhoff, would you like to supplement the presentation?
Mr. Ken Imhoff, Manager, Farm Stress Line Advisory Group: Not at all. If there are questions that I can assist Lil with then I will do so.
The Deputy Chairman: We heard from Manitoba yesterday and I was impressed. I think it is a truly wonderful initiative. I am not clear how well organized Ontario and Alberta are; can you tell me that?
Ms. Sabiston: I am somewhat familiar, although I think Ken can probably answer that better than I can.
Mr. Imhoff: Most farm stress lines are actually modelled on the Saskatchewan one, with the exception of Nova Scotia. This is mainly because the Saskatchewan line was the first one.
Ontario is a not-for-profit organization and struggles daily to keep the phone lines open.
There is a tendency on the part of people who are involved in granting funds, whether public or private, to lean towards what is familiar to them. Farm stress line systems are an unfamiliar area, which makes it difficult to convince them that there is a legitimacy around funding those agencies. That is why you will see allusions in the thicker part of the document to the need to take a hard look at core funding of not-for-profit organizations. I suspect there would be more initiatives for direct farm stress lines and people connected with the culture if there was some understanding that the drop away of core funding of agencies has been disastrous for many not-for-profit organizations.
Alberta does not have a farm stress line. It has a toll-free mental health line, which I suspect receives a range of calls from farmers as well.
The stigma mentioned by our colleague, Mr. Allen, makes it particularly difficult in a farmer and rancher community. These people do not see themselves within a mental health context even though they may be suffering from related difficulties and challenges.
The Deputy Chairman: Yesterday, in Manitoba it was pointed out that in the rural communities where people are close to each other and know each other well, they are uncomfortable being identified with a provincial counselling service. They prefer the label of a farm stress line, which to them does not carry the same stigma.
As programs evolve, and telephone counselling lines and stress lines become more and more prolific, I suspect that arguments will be raised that they should be integrated into other programs. I think you will need to have your arguments ready to counter that suggestion.
Ms. Sabiston: The farm stress line is readily available to people when they need to speak to someone and cannot wait for six to eight weeks. Sometimes these problems pop up and the farm stress line here in Saskatchewan gives easy access to people that are our peers. They know what we are talking about when we talk about the high price of fertilizer or the high price of fuel because they have lived it. As a farm person you feel the unity with that person you are talking to, and often that is what is required.
The Deputy Chairman: In Manitoba, the farm stress line I believe operates from 8 a.m. to 8 p.m., it is not a 24/7 service. Is your service 24/7?
Mr. Imhoff: We run from 8 a.m. to 9 p.m., Monday through Saturday and, with the exception of Christmas and New Year's, all statutory holidays. Probably 24 hours would be better. However, I am not certain the funding would be sufficient for that. It is difficult to design a system that is financially efficient and at the same time meets the needs of the people.
We do not get a lot of evening calls; first thing in the morning is when we receive our highest level of calls. Calls tend to be seasonal but not as one would expect, at seeding time and harvest time; it is prior to seeding and after harvest. That is when the financial issues surface. People are looking for operating money in the spring and paying bills in the fall.
The Deputy Chairman: Are you aware of anybody running into difficulty because they could not get access on Sunday?
Mr. Imhoff: We had a few calls of that nature at the beginning. We have continued to test that by using message manager systems, and we have found there is rarely a call later in the evening. At the advisory group's annual planning meeting, every couple of years we discuss with our advisory group whether it would make sense to expand the hours, and what the implications would be. The advice so far is that it seems to work with our current operating hours.
The Deputy Chairman: Do you have an answering service with a message saying, "We are sorry we are not available right now; we will call you back in the morning"?
Mr. Imhoff: We use a message manager system. There are issues around confidentiality, and farm people do not like answering services. People tend to be surprised that they get straight to us. As manager of the unit, I do not have an answering service for that reason. They are busy people who are not impressed with getting answering services — especially if it is in two languages.
It is very direct; we are either there or not. Even our call queues are set at zero because people will not wait in a queue. That is the nature of the people we deal with.
Senator Callbeck: I am impressed with what I have heard about the farm stress line. I am from Prince Edward Island where agriculture is the main industry. I understand the importance and why it is absolutely necessary.
You take an average of 1,000 calls per year, are many of them repeat calls from the same persons?
Mr. Imhoff: Our emphasis is on short-term peer counselling. I estimate that about 20 per cent are repeat calls. I could probably count on one hand our repeat callers. Our goal is to deal with the short-term issues and refer them to the services that we encourage them to use when they are ready.
Senator Callbeck: In other words, if they call because they need information about selling their farm, would you refer them to somebody?
Mr. Imhoff: I do not think we have ever had a call from someone who was planning to sell their farm.
Senator Callbeck: I am amazed that you have not, given the state of agriculture.
Mr. Imhoff: Depending upon the year, around 30 per cent of calls are from people who are in financial difficulties or insolvent. They may call and ask what they can do; the banker is knocking on their door and their power is being cut off, et cetera. They want to know how to deal with these complex situations. Our staff are familiar with the Farm Debt Review Act. The legislation in Saskatchewan is somewhat more complicated because we have not only the federal Farm Debt Review Act, we also have the Saskatchewan Farm Security Act, which is provincial.
We do not have an opportunity to look at their books nor do we wish to. We help them sort out their goals and what they need to do accomplish them, and to identify for them what their resources are. This could mean referring them to the farm debt review people, the farm security people or others.
It is usually people who are facing a situation that is out of their control, and they need to regain some control of their lives. We look at things they can control, things they cannot control, what resources they have, and coach them from there. There are always linkages between farm debt and personal issues that affect family relations such as suicide and depression.
Senator Callbeck: I am surprised you would not have more repeat calls from people who have asked for help, you have referred them and then they come back because they did not receive the assistance they needed.
Mr. Imhoff: Occasionally, we get a call from somebody who says they tried what we suggested but it did not work, so what next. Our numbers are not high; 1,000 calls a year. That is because we have been steadfast in our goal to focus on the short term, and put people in contact with the resources on the ground.
We often find the self-help groups and not-for-profit organizations are most helpful because of the stigma that is, unfortunately, associated with mental health services. They may be effective but it is difficult to get people there.
Senator Callbeck: Do you have any information as to whether people actually access the self-help groups that you refer them to?
Mr. Imhoff: Farm people simply do not like follow-up. We are a confidential peer-counselling service; we do not have call display and do not know who we are talking to. Anonymity is important to our callers. On occasion, we have checked on some callers that we were concerned about; the impression we got was that they did not like us calling them even when we had received permission from them to follow up. Evaluation is practically impossible for us due to the confidentiality that is important to farm people.
Senator Callbeck: Obviously, it must be working though, or they would be continuing to call you back.
Ms. Sabiston: Often, we learn things by word of mouth. I have referred people to the farm stress line, since I am not a psychiatric nurse or anything like that, but I realized that help was needed so I gave them the number. I have later been thanked by those people and advised that it was very helpful. Those are the kinds of comments that we hear and that make us believe this service is really helpful.
Senator Callbeck: I notice it is a line in the provincial budget. How much do you receive?
Mr. Imhoff: A little over $400,000.
Senator Callbeck: Are the counsellors full time?
Mr. Imhoff: They are part-time and they are paid. I always say, to the amusement of farm people, that off-farm employment is the third pillar of agriculture; this is the off-farm employment for our counsellors.
The Deputy Chairman: It is an interesting analogy because the theme that keeps coming through from witnesses is fundamentally, give us a chance to help ourselves; give us the infrastructure to get our lives back in shape and we will do the rest. It is tremendously interesting to see how anxious people are to volunteer to help each other and share their difficulties, if they are given a chance.
Mr. David Nelson, Executive Director, Canadian Mental Health Association, Saskatchewan Division: Thank you very much, I am pleased to be here today.
Our association has been in Saskatchewan for more than 50 years, and has existed nationally for more than 80 years. We have branches all over the country, including 13 branches here in Saskatchewan. In our division office, we are really trying to collect input from a wide variety of areas.
The mandate of the Canadian Mental Health Association, CMHA, is to promote the mental health of all people and to support the recovery and resilience of people with mental illness.
CMHA strongly supports increasing the role of community stakeholders in the mental illness and mental health communities in public policy development. In particular, we support the users, sometimes called consumers, of mental health services in this regard.
I will speak about some of the key issues and potential solutions as our association sees them.
Perhaps one of the most important issues that is reflective of the stigma and lack of political will to act on many studies and recommendations that have been made over the past decades in mental health, is the lack both nationally and provincially of a plan for mental health, what is sometimes called a national or provincial strategy. Such a plan would help to assess, organize, fund and evaluate both current and much needed new services in mental health.
Following are some of the key principles in the development of a strategy. First and foremost we must consider the upfront, upstream kind of resources for preventative, population and health-determinant issues to prevent the need for services downstream.
It is necessary that services include flexibility of service provision, individualization of services, individual client-centred approaches, a great deal of consumer choice between services, and the least restrictive environments and services used where possible. A continuous, seamless service provision between systems is really critical, and is something that is missing currently.
We prefer community-based services whenever possible, and a continuum of services that recognizes the cyclical and episodic nature of many of these illnesses. Key to these services is reinvestment of savings from institutional programs into building community infrastructure. This reinvestment has not happened adequately in Saskatchewan nor do I believe it has happened adequately in any other jurisdiction that has moved to deinstitutionalization.
Cultural diversity and appropriateness are also very important.
Another key issue is primary care and specialist services. Most persons with less severe mental health problems are provided services by their family physician or other counselling services. However, many physicians and other professionals do not receive an adequate amount of training about the effect mental health has on overall physical health, including those who develop a mental illness diagnosis.
For those requiring specialized services, the shortages of psychiatrists in this province can result in an inappropriate wait for services, an inappropriate number of changes in psychiatrists, and an overburdening of those psychiatrists who are available.
Following are some suggestions for possible solutions.
Nurse practitioners on a primary health care team could take on many duties currently supplied by psychiatrists, particularly in rural and outlying areas. This use of nurse practitioners would enable more effective use of available psychiatrists.
The use of telepsychiatry in specific cases, especially in northern and outlying areas of the province, would be very useful, particularly if combined with nurse practitioners. We believe the use of telepsychiatry and nurse practitioners could dramatically increase the availability of services.
Stigma reduction is key. Stigma and stigmatizing attitudes can hinder social integration, cause feelings of guilt and shame, hinder the timely access of treatment, and affect quality of life. Stigma can result in negative consequences such as unemployment, lack of housing, diminished self-esteem and weak social support.
Perhaps the most damaging key consequence of stigma is that we harbour dramatically lower expectations for people with a mental illness and easily accept a quality of life for them that we would never accept for ourselves. (Jones 2001)
I think that one quotation speaks to the reasons for the lack of mental health services in Canada. In many cases our services are more like third-world services existing in a first-world country.
We believe stigma is fuelled by a lack of understanding and education, and perpetuated by sensationalist media and other industries, such as movies and television. A key part of any national or provincial strategy must include a focused stigma reduction plan which stresses positive recovery stories, which are becoming much more frequent. A strategy must directly tackle myths and misconceptions regarding mental illness. It should utilize properly funded population health and health promotion principles, such as the reduction of barriers to good mental health and affirmative action policies to ensure meaningful participation by persons with mental health problems and illnesses in our society.
We need to develop intersectoral and intergovernmental partnerships and collaboration to seek out and eliminate stigma-producing and stigma-perpetuating stereotypes. We must make use of multiple strategies that work on all levels of society and that tackle the issue in many places at numerous times, and that extend well beyond basic health education.
We need to focus on upstream issues such as poverty, unhealthy housing and work environments; and implement a positive method of improving the conditions and environments in which people live, work and play.
We must also evaluate and provide accurate information based on researched evidence. We need much more mental health research in this country.
A key health determinant is inadequate housing. Many persons in this province with mental health issues and illnesses live in substandard housing or housing unsuitable for their condition. This determinant of health or mental health has a great bearing on a positive or negative outcome or recovery.
Significantly more resources are needed for the federal Affordable Housing Framework Agreement, and the creation of a new housing rehabilitation fund is critical.
I would like to speak of a positive new initiative in this province that is, I believe, groundbreaking. It is the Saskatchewan Rental Housing Supplement. This supplement has just begun; they are putting the final touches to it. It will assist persons with all types of disability to improve their housing situation, and extends well beyond the stereotypical ramp and washroom modifications generally needed by the physically disabled. It will provide resources to those with mental health problems on a continuing basis to assist with renovations such as larger windows, enhanced security, noise control and housing closer to services.
We commend the Government of Saskatchewan for their forward thinking with this new program, and we believe that federal funding for this and similar programs across the country would greatly assist in addressing the housing problems of the mentally ill.
Income security is another significant issue. It is a critical key determinant of health and mental health. The current level of social assistance has had only minuscule increases over the last decade and a half. Due to the cyclical and episodic nature of many mental illnesses, the current system of income support designed for short-term use does not begin to provide adequate supports for those with mental health issues and illnesses.
Steps must be taken immediately to ensure that social assistance rates are increased by the level of inflation over the last 15 years; at present they are much below that level. Adequate training should be provided to those working with persons with mental health issues in the social services area to enable them to provide adequate support and communication, taking into account the cyclical nature of these illnesses.
We must ensure seamless integration between employment support programs and social assistance programs that recognizes the non-linear progression towards employment of most mental health consumers.
The justice system is an important area. Research has shown that a high percentage of those incarcerated have a mental health or mental illness problem. There are also well-known problems of how to stream someone with a mental illness who is in trouble because of breaking the law.
Several models of mental health or treatment courts exist across Canada that should be supported and researched to provide an adequate understanding of the dynamics, benefits and applications of these innovations in the court system.
Funding should be available for research, which would provide a better understanding and provision of adequate treatment for persons suffering from a mental illness who are incarcerated.
Psychiatric home care or supports are also important. The current system of home care throughout the province and, in general, throughout the country provides only for physical care. The system cannot and does not provide adequately for mental health care.
Indeed, because current home care is so entrenched in medical-model physical care, mental health home support may have to be designed as a separate subsystem of standard home care. This subsystem will need a different mind set and training to assist those many thousands who are not connected to the formal mental health system but require support on a cyclical basis while staying in their home, as opposed to expensive and disruptive hospital care.
In closing, there are many good programs and best-practice models in this province and in this country. In the past, Saskatchewan has had a leadership role in deinstitutionalization, and many good program models have been developed. The problem remains, however, that there has not been the political will to make serious and persistent efforts to replicate the good models throughout the province.
The lack of provincial standards and of an overall plan, and the resultant lack of resources for mental health, has resulted in a patchwork-quilt approach to services across the province, and by extension, across the country.
Those in rural and northern areas are particularly hard hit by great distances to services, the lack of services that allow integrity to local community and family supports, and adequately resourced mental health services in their location.
A raising of the profile of mental health by the Kirby report and the opportunity to provide input to the Senate committee are greatly appreciated. We sincerely hope the work of both groups will result in much needed changes in our province's, and our country's, mental health systems.
The Deputy Chairman: Thank you very much, Mr. Nelson. You have covered the waterfront that we have heard repeatedly across the country. Yesterday, we had the privilege of hearing from a group in Brandon about their infrastructure for community services, which combines primary health care and social services in the community of Brandon in an ingenious way. To date, it is by far the best model we have seen, as we have held these hearings.
They have the capability of embracing virtually all aspects of the problems you have addressed. Since you are so close to them I think it would be worthwhile to look at that as a model.
Certainly, Dr. Howard Chodos, who fundamentally writes our report — Senator Kirby and I and the others just take the credit — will include in the report, I am sure, a structure built around this model, as we make our recommendations.
Senator Callbeck: I have a question on the new provincial program for housing. Will that money be available only to people that own houses or to landlords as well?
Mr. Nelson: The supplement is strictly for people who are in the rental market and it will not go to the landlords. It will follow persons when they change homes.
It was originally begun for people who have physical care needs such as ramps and washrooms, and it takes into account that usually there is a premium for those kinds of accommodations. We have advocated for a long time that those with less visible disabilities such as mental illnesses, those who are deaf and hard of hearing, and those with learning disabilities, et cetera, really need a similar program.
When we researched the literature and tried to find research on the point, we discovered there was very little. There is an understanding of the need for supportive housing for the relatively small minority that have more intensive needs. However, many more thousands out there have mental health issues and mental illnesses who are renting on their own or with minimal support.
This new program will use a different approach. For example, if you are suffering from depression and you receive only $320 a month, which is the base social assistance rate here, you can try to find a house that has much better window space so that you have some sunshine in the winter to prevent seasonal affective disorder. This would allow you to tie in that need, and to receive an extra stipend to assist with rent costs for any house you might move to.
The supplement would also apply if someone has a cross disability that requires them to be in a quieter area.
Senator Callbeck: Is this program patterned on one in another province?
Mr. Nelson: No, I understand it will cut some new ground for less physical disabilities. It is not in place yet; it is still being designed. This morning I was at a meeting with the department and stakeholders and it will probably be in place this fall and will be evaluated by government and by the community.
I believe it has amazing potential for assisting people to move out of the areas of housing that are negatively impacting whatever their disability may be; not just physical disabilities, although certainly they are included.
Senator Callbeck: How does a person become eligible?
Mr. Nelson: Anyone who receives social assistance and rents accommodation is eligible. We have designed a new system, a state-of-the-art call centre for social assistance. However, for people with disabilities it has issues, especially for this type of program.
It will be a self-referral system but there must be some corroboration, not necessarily from a medical person, but from someone who knows them and who can say, this person has this particular need because of their disability.
There will be many ways of applying, including on-line, the call-in system, attending an office or by mail; whatever works best for that person.
Senator Callbeck: You recommend that consumers be able to choose among services. Should government decide which services should be funded?
Mr. Nelson: There should be some choice such as every other type of consumer has. Unfortunately, because of the standard in mental health care, which is either nothing or a very under-funded system, there really are no choices for people. We are not saying that everything should be duplicated but that the system standard should be raised so that if you do not want this particular area of service, you can choose something else.
That sometimes seems to fly in the face of the single-entry point and that type of thing. However, I think it is understood that even though you have a single-entry point in mental health or in other disability issues for convenience and coordination, you need to have back doors there too. Many mental health consumers, no matter how bad their need is, will not go to a hospital or even to a formal clinic. They may be much more likely to go to a mental health association or other community-based organization, gradually get involved and then perhaps with help from these organizations, get into the formal system. We are saying there needs to be some choice there in an equality-based system.
The Deputy Chairman: Thank you all very much for your time.
Our last panel of witnesses represent the Saskatchewan Psychiatric Association. We will begin with Dr. Thakur.
Dr. Annu Thakur, Member, Saskatchewan Psychiatric Association: Good afternoon. I want to extend sincere thanks from the Saskatchewan Psychiatric Association for undertaking such a monumental task to unify the issues related to mental health and mental illness at the national level. It is timely and will help not only at the national level but I think at the provincial level, too. We will have much more direct access to inform the government about what is happening in our province.
We have prepared this 10-page typed presentation and I have brought with me "Appendix A" and "Appendix B" for your information. I have also brought another booklet, which is available for your reference.
First, I will give you some demographic information. Saskatchewan differs from most other provinces in that its population is widely dispersed, with approximately one-third of the residents living on farms or in communities of less than 500.
The population is predominantly of European origin, although the First Nations population is rapidly on the rise. Most residents speak English, although Cree, French, Ukrainian and German are spoken in some communities. We have visible minorities of people coming from Asia and South America who mostly live in urban centres.
Saskatchewan became a province in 1905. The province's first mental hospital was opened in North Battleford in 1914. Outpatient services were offered on a regular basis for the first time in 1946, as Saskatchewan became the first province to introduce universal hospital care insurance.
During the early 1950s, the patient population in the province's two mental hospitals exceeded 4,000. An additional 900 mentally retarded persons were cared for in an associated institution.
Psychiatric nursing was developed as a profession in 1948. The Saskatchewan Plan, which is a treatment philosophy emphasizing community-based services as an alternative to institutional care, was developed in 1955.
In 1962, Saskatchewan became the first province to introduce universal medical care coverage.
Community mental health services were developed, and a regionalized service delivery structure evolved during the 1960s. Inpatient populations declined, and in 1971 the Saskatchewan Hospital in Weyburn was the first Canadian mental hospital to be closed.
Primary responsibility for services for the mentally retarded was transferred from Saskatchewan Health to the Saskatchewan Social Services in 1972. New mental health legislation that significantly extended patients' rights was proclaimed in 1986.
Because of the time constraints I will skip over parts of our written presentation.
The province is divided into health regions. We are using Saskatoon Health Region as an example. It is the largest region in the province and serves a population of 375,000 in more than 100 cities, towns and rural municipalities around Saskatoon.
It is one of the most complex integrated health agencies in Canada. Saskatoon Health Region has 10 hospitals including three provincial tertiary hospitals, eight primary care centres, four urban public health centres and 11,000 staff members. Its total annual budget is $536 million or $1.47 million daily. Of that amount, 79 per cent is used for salaries and benefits and 64 per cent for the delivery of hospital services. We do not know how much is allocated to the mental health and mental illness portion.
Mental health services provide a wide range of community-based and institutional programs for the residents of Saskatchewan and district, and support the Saskatoon Health Region.
I will highlight a few mental health services available through the Saskatoon Health Region: intake services, services for children, youth and adults, rehabilitation programs and acute care services. Community-based organizations include the Canadian Mental Health Association, Crisis Management Service, the Crocus Co-op, the Saskatoon Housing Coalition and Autism Treatment Services of Saskatchewan Inc. All these services work in an integrated fashion.
In Saskatchewan, there are approximately 200,000 children from kindergarten to Grade 12. At any given time, 10 to 15 per cent of children will have significant features of mental health issues with varying degrees of impairment. This means that between 20,000 to 30,000 children and adolescents in Saskatchewan have mental health problems.
There are serious problems in providing services to these children. There are only 10 child and adolescent psychiatrists in this province, which is far below the national average. For example, there are over 20 child psychiatrists in the city of Winnipeg. Saskatoon is a university hospital and teaching centre, yet we do not have a dedicated inpatient unit to meet children's health needs when a psychiatric disorder is present. We struggle to admit them to the paediatric ward, and on occasion, we have had 11-year-olds admitted to an adult psychiatry ward because we lack facilities.
In the community, we are struggling to provide care to many children with chronic mental health needs. I am referring to issues relating to autism and autism-related disorders, and other psychiatric illnesses.
The average wait for a child or adolescent to be seen is approximately a year to 18 months. If it is an emergency, they will be seen but they are frequently required to attend at the emergency department and take up valuable time and resources in such a process.
The burden of care is with primary care physicians who encounter tremendous difficulty accessing support systems such as family therapists, family counsellors and other mental health therapists. Some of the centralized intake programs employ individuals who do not necessarily understand the needs of the families and individuals. This situation can cause a delay in service delivery.
Another difficulty is the lack of infrastructure for child psychiatrists who are working in the province.
A major problem is the unmet mental health needs of incarcerated young people in our province. One of our holding facilities for young offenders is Kilburn Hall in Saskatoon. Over 4,000 young people are put through this program every year, and yet there is only one nurse employed there.
The situation in this province is that children's mental health needs are largely unmet. There are long waiting lists and a lack of dedicated inpatient facilities, as well as difficulties in accessing services in the community.
The research program is well organized at the University of Saskatchewan's Department of Psychiatry. There are studies taking place in neurosciences, epidemiological and population mental health studies, clinical studies of various neuropsychiatric disorders, and research into more effective treatment of neuropsychiatric disorders. The department also contributes to the training of the next generation of scientists and clinicians. Now that we have a synchrotron, we are looking forward to expanding our research activities.
Another area of concern is the mental health workforce in Saskatchewan. The shortage of mental health professionals in the province has been a chronic problem. I have given you as "Appendix A" a paper written by John Conway for Saskatchewan Health. It was written in 2002 and is available on the Internet.
Retention of psychiatrists in Saskatchewan is a challenging problem. There is a chronic shortage of psychiatrists in the province, which is a problem that has continued for over 20 years.
In this regard, we have made several presentations to the government: "Forgotten Constituents" in 1983; the Murray commission in 1990, which Dr. Keegan will speak about; "Physician Resource Plan" in 1994; "Crisis in Psychiatry Services" in 1996; "Psychiatry Human Resource Plan Province of Saskatchewan," in 2001; and "Saskatchewan Mental Health Sector Study" in 2002.
For a long time the province has relied on foreign-trained psychiatrists to provide psychiatric services. These foreign-trained psychiatrists have often chosen to leave the province once they were fully qualified. Regina, one of our key psychiatric strongholds, has particularly suffered many blows through this phenomenon.
Other foreign-trained psychiatrists who stay in the province are often reluctant to, or cannot, be certified after many years of acceptance of their qualifications in their native country. This situation sets up an artificial two-tiered system of different licensure and certification, which leads to resentment due to the inability to bill the fee for service. This ability to bill gives the psychiatrist a sense of respect in practicing psychiatry.
About 30 to 40 per cent of the graduates who remain in Saskatchewan choose to locate in Saskatoon or Regina. That pattern again precludes psychiatric services to rural communities.
Saskatchewan Health has been reluctant to provide alternative funding, believing that psychiatrists prefer fee-for-service remuneration. This belief is far from the case now and needs to be re-examined. Regina has been provided with much more alternative funding due to the historical reasons mentioned above and the necessity for the recruitment of foreign psychiatrists.
I was advised by the College of Physicians and Surgeons of Saskatchewan yesterday that we have a total of 68 psychiatrists in our province. This number is far below the national average of one for every 10,000 people. Unfortunately, 34 of those 68 psychiatrists practice in Saskatoon. However, this is understandable given that the service area for Saskatoon Health Region comprises 340,000 people. As well, the health region and the university have specific responsibilities related to teaching duties, administration, subspecialization and research, which require additional resources and different approaches to providing clinical services.
Considering the size of the mental health region and these additional responsibilities, there is now a pending crisis as 26 per cent of psychiatrists practicing in the region are above age 55, with 11 being above age 65.
There is a shortage of subspecialists in the areas of child and youth, geriatric, and forensic psychiatry. The Canadian Psychiatric Association has recently announced psychosomatic medicine as an academic subject. However, we do not have any consultation-liaison component, as such, at the university.
In addition, the ability and desire to do full-time clinical practice for Saskatoon regional practitioners varies greatly. The university-based, full-time group generally practice no more than 50 per cent of their time because their mandate requires educational and research commitments.
The recruitment of women to psychiatry has had an impact. Of the 34 practitioners in Saskatoon, 13 are women. However, a significant number of female psychiatrists choose to practice less than full-time because of home commitments and child-raising responsibilities. Probably because of the average age of the psychiatrists in the health region, 30 per cent have indicated a desire to do less work in the next five years.
Even though we have 34 psychiatrists, there is a wide variety of reasons they have less than full-time clinical practices.
As requested in your Report 3, we have prepared recommendations and wish to discuss a patient-client approach concentrating on three elements: dysfunction, disability and death.
We need to address the mental health needs of children and adolescents. This would reduce chronicity and perhaps prevent the further consequences of mental illness in this age group. A national action plan is needed in this regard.
Early detection of psychosis and intervention is important. It is well known that if schizophrenia, bipolar disorder or chronic psychotic symptoms are detected at an early stage we can reduce breakdowns, they can receive education and perhaps would be able to benefit from employment in the future.
Medication for mentally ill patients is important. The prescription drugs vision under the First Ministers' 10-year plan to strengthen health care, was announced in September 2004. Does this ensure that mentally ill and addicted individuals will get the prescription drugs they need?
Currently in this province, mentally ill patients who receive social assistance often cannot afford to pay for prescriptions because they are on four or five medications and must pay $2 for each one, which they cannot afford.
There is a need for a program whereby mentally disabled patients can be looked after in the community. This program could prevent further deterioration in cognitive function, and facilitate integration into the community.
Saskatchewan is a mosaic of immigrants, and there are important minorities to consider, such as French-speaking communities, Métis and First Nations. My own work is primarily with First Nations people. Issues involving mental health and psychiatric disorders must be addressed in a culturally sensitive way.
The Aboriginal population of Saskatchewan is rapidly increasing. I will highlight some of the problem areas relating to First Nations people.
There is a significant co-morbidity in regard to mental health and substance abuse disorders, especially alcoholism and gambling, among both Native youth and adults. This fact underscores an important and largely unmet need to provide culturally appropriate treatment of such co-morbidities.
A large number of First Nations people are homeless, incarcerated or victims of physical and sexual trauma. Research is needed to understand how the lives of our Aboriginal population reached such a stage, and to develop appropriate methods for assessing and managing their mental health.
Acculturated Natives have their own unique problems. They are cast out by their own members, and present several psychosomatic and mental health problems.
Many First Nations patients describe painful and unique histories of growing up in residential schools. They are vulnerable to depression and suicidal impulses. They are likely to experience increased needs for mental health care in comparison to the non-Native population.
We need to develop a coordinated approach to mental illness for all Canadians. This is truly a multicultural country and we must address the specific needs of minorities, visible or not, especially those who do not speak English.
Depression is a common cause of disability, and employers can play an important role in accommodating the recovering mentally ill person's return to the workplace. Federally-funded programs could assist in public and workplace education to reduce the apprehension and ignorance surrounding mental illness. I know your committee has addressed this in your Report 3.
The incidence of suicide is increasing in Canada. A national suicide prevention strategy could incorporate programs to raise public awareness of this issue, and provide for some kind of intervention.
I will finish my presentation here and allow Dr. Keegan to speak on the subject of regionalization, the successes and challenges for mental health and addictions.
Dr. David Keegan, Member, Saskatchewan Psychiatric Association: I have two objectives in my presentation. The first is to describe the success we have seen in Saskatchewan since the regionalization in the 1990s, first as districts and then regions. This has created strong opportunities for integration.
The second objective is to highlight the challenges that we have seen from the vision of the 1990 Murray commission, which was a vision plan for health in Saskatchewan. The plan integrated into it strong comments about mental health and addictions that, unfortunately, were not followed.
The final point I will speak to first. It relates to the need for a strong national policy. Clearly, from reading your documents, that is the way I see your committee heading. We propose this for both mental health and addictions, and that this recommendation be buttressed with a clearly defined commitment to a certain level of funding for both addictions and mental health. This commitment should be enshrined in a document, either a mandate or a mission statement, and this document should have life for five or 10 years.
Obviously, we realize it will be a challenge to achieve dedicated funding. This proposal would recognize areas with significant population and epidemiological issues, such as mental health and addictions. It is very difficult with the competition that occurs in health care today for these two services to move forward.
We also recommend there be a strong commitment by the federal government to protecting funding for mental health and addictions in the provinces, either in a block or targeted fashion.
From that I would like to return to the two objectives I mentioned. First, it is clear to me, having worked in an integrated model of health care, that an integrated model can provide options than a non-integrated or not-regionalized system cannot provide.
Areas relating to primary care would benefit most from dedicated funding. The two major concepts that I believe have potential benefits for health care are early intervention approaches starting with children, youth and young adults, and what is called the chronic disease management programs. I am sure your committee has heard about these.
Both of these would use a team approach linking right at the centre of primary practice — family practice, primary care nursing with social workers, psychologists, psychiatrists and other resources being available to buttress that entry point and hopefully, able to intervene early.
Chronic disease management is being studied presently in our province with respect to diabetes, lung disease and other conditions. This management would be ideally suited, as has happened in Australia, to depression, because it is such a large problem.
One challenge with many of the conditions involving mental health and addictions is that they are not usually a one-shot quick fix; they are generally chronic conditions.
I recommend that you examine whether there is an opportunity to have the so-called ring-fenced funding that might be dedicated to those areas to ensure and encourage the best team approach, and also possibly the best bang for a buck.
It is too early to say whether early intervention and chronic disease management will fulfill the promises. I realize there are all kinds of technological needs but this is a human resource approach that, I think, could work. I do not have a lot of evidence to support that but it would be one area for a national policy to emphasize, and maybe sneak in some targeted funding.
My second point is the downside of regionalization and that is why I have raised the Murray commission document of 1990. We have appended the section on mental health, addictions and social policy from that, although the complete document is available to the public.
The reason I have raised it is that regionalization can be proposed as a way that all systems could work well together, and could use epidemiologic and population health formulas to distribute funding. In fact, that was the argument I heard from our Saskatchewan government, which is antithetical in a way to the Murray commission.
The Murray commission had a lot of input from people working in mental health and addictions who were frightened of regionalization because there was a sense that if you lost a strong central authority and closeness to government or power, the regions could very well not do what was sought.
The government's argument was that with regionalization it would be close to the boards locally, and boards would recognize the tremendous challenges there are for mental disorders and addictions.
Unfortunately, that has not been the case; the competition has been hot and heavy at the regional level, and mental health and addictions have not thrived.
The Murray commission did not identify a funding amount for mental health but did outline a ring-fenced plan that encouraged the government to emphasize mental health and put more money into it.
It also envisioned a commission that would be similar to the addictions commission of that time, which was called Saskatchewan Alcohol and Drug Abuse Commission, SADAC. Just as the Murray commission did, what we call in the vernacular the Kirby or the Keon commission will approach government to say, we need to do these things.
I am saying that the downside is that one has to be aware that what may be presented as good arguments may not be followed in the future.
The Murray commission had a good idea to make sure that there was some organization that would fight in a significant way that governments had said was okay. Unfortunately, mental health did not get its commission and SADAC was disbanded. It was all sent to the regions with small numbers of people in government.
Regionalization in mental health and addictions has not occurred as the Murray commission recommended in Saskatchewan. It has occurred in a non-protected, non-ring-fenced or non-encouraged way. Therefore, even though there is tremendous potential in the area of mental health and addictions because of regionalization, it needs the support of some central authority relating to government. This authority will make sure that with budget cuts, the need for more technology, long wait lists in surgery and medicine, the stigma, and other reasons that keep addictions and mental health from thriving in health care, mental health care will prevail.
That is all I want to say. I believe Saskatchewan has done well to regionalize. Saskatchewan has done many things that have been forward-looking. Unfortunately, although forward-looking, often budgetary issues in Saskatchewan, whether they be deinstitutionalization or regionalization, tend to somehow leave mental health and addictions to settle down towards the bottom somewhere.
The Deputy Chairman: I thoroughly enjoyed that presentation and I will discuss it with you a little later.
Dr. Dhanpal Natarajan, Past Chair, Saskatchewan Psychiatric Association: Thank you very much for giving me the opportunity to be here. Because of the time factor I will focus only on the technology, telepsychiatry and telehealth aspects that I feel are extremely important in any health service delivery system.
After listening to all the provinces at the Council of Provinces Committee of the Canadian Psychiatric Association, it is strikingly clear that the distribution of psychiatrists is more towards the bigger cities, and there is always a problem in recruiting and retaining psychiatrists in smaller regions.
As department head, I have been active with recruiting in Regina. In my experience, every time I have spoken with a recruit they have asked and expected our centre to carry out academic and research activities. When they learn that it is not as good as they expected, they do not come here.
The same problem happens in the smaller regions where there is a chronic shortage of psychiatrists, and positions are not filled; they are not filled simply because of a lack of academic and research activities.
Being aware of that problem I thought of introducing televised Psychiatric Grand Rounds. That began in March, and we have connected various small regions and included them in the Grand Rounds, which are important to maintain your academic knowledge. The Royal College of Physicians and Surgeons expects all physicians to accumulate credits every year. Psychiatrists must acquire 400 credits in a period of five years. Televised Grand Rounds is a means of providing that opportunity to accumulate credits in the smaller regions.
That is the only point I wanted to make, the need for technology. We in Saskatchewan are attempting to make an impact on that. There is an article in the Medical Post news this week, a copy of which you already have.
Dr. Thakur: I think that completes our presentations.
The Deputy Chairman: You may not be aware that Senator Callbeck is a former minister of health and a former premier of the province of Prince Edward Island. She has dealt with these issues at a high level, and has been a tremendous asset, of course, to our committee.
If I may begin with you, Dr. Natarajan, then I will come back to Dr. Thakur and Dr. Keegan, and then turn you over to Senator Callbeck.
Although you have made progress, your primary problem and the primary problem across the country is organized infrastructure. You are short of psychiatrists, no question about that. If there was an organized infrastructure for the expertise of psychiatrist to filter down to the small communities I think the problems would be somewhat alleviated, temporarily at least; they will not be overcome. As long as you have a child who needs a child psychiatrist and there is not one available, you have a real problem. There is no doubt about that. There is a lot of expertise if it could be distributed the way it probably was envisioned 10 years ago here.
Patients do not like to be called clients but I prefer to call them clients because I think it delivers a message that they are the ones who drive the system and they will eventually get what they want. They have usually driven industry to give them what they want.
When you listen to the clients, they tell us that the major defects in the system now are access to community services; opportunities to organize and help themselves; and access to social services when they do not have appropriate housing and income, to give them assistance with their problems in life if they are in a down time and cannot cope with them. They would like those community services to be able to guide them to you folks when they need you. There will be times when they do not need you, and the people in the trenches can take care of them.
Dr. Natarajan, how much infrastructure do you have now in this province that allows you to communicate the way you should be communicating?
Dr. Natarajan: The infrastructure we have in Regina allows us to do the educational activities but not to incorporate that into clinical service. We have a committee that is working on trying to expand the telehealth facilities. I would say that is still at a primitive stage compared to other provinces. More units are needed in the smaller regions so that we can involve more of them.
Particularly because of the shortage of psychiatrists, if we have the units all over the province in smaller regions, we could have clinical service also delivered so that a patient does not have to travel all the way to Regina. We do not have much at this time in our province compared to Alberta.
The Deputy Chairman: Do you think there is an adequate number of psychiatric nurses, for example, nurse clinicians in psychiatry, to help you?
Dr. Natarajan: I would say there is a shortage of nurses.
The Deputy Chairman: You have huge manpower problems no matter where you look?
Dr. Natarajan: Yes.
The Deputy Chairman: And woman power problems, person power problems — I am a little old fashioned, excuse me, Dr. Thakur.
Dr. Keegan: I think you will find the Conway report, "Appendix A," helpful because it is a recent document, 2002, which was requested by the government to examine human resources within mental health and addictions broadly. I think that will give you some insights. It is across the piece.
We are from the Saskatchewan Psychiatric Association but we could speak equally from the psychiatric nurses' standpoint or the standpoint of psychologists or social workers.
The Deputy Chairman: Before I read it, and I will, in a word tell me what it says.
Dr. Thakur: It says that there is an acute shortage of all medical professionals in all specializations. It also says that one in five people in Saskatchewan will require psychiatric help, and there are no proper services available. The community rehabilitation programs are also short to provide these kinds of services. The situation is more serious for the chronically mentally ill or seriously mentally ill patients.
In social work, they lean more towards social services rather than providing services in the psychiatric model.
Psychologists are very few and they prefer private practice because the health care services do not have a special program for them to have a team-work kind of approach.
Family practitioners are overburdened with their own clinical work, so they do not have much time to pay attention to mentally ill patients.
I have previously mentioned waiting lists to see psychiatrists. Dr. Conway recommended looking into this area and providing the funding required to improve the process. Unfortunately, his report has been put on the shelf.
The Deputy Chairman: It is a truly desperate situation.
Dr. Thakur: It is.
The Deputy Chairman: I was a heart surgeon before I retired. I would hate to think of someone waiting 18 months to get an aortic valve replaced.
Dr. Thakur: I have a private practice that is comprised mostly of First Nations people; people who are unemployed, most of them are on social services; the elderly; and minorities whose families came here two or three generations ago and they do not speak English well — they have had mostly labouring jobs and now they are old. That is the type of population that I serve.
I see on average four new patients a day. There are no ancillary services available for them because another part of the problem is that the services are localized in other areas and they cannot afford to travel. They see a psychiatrist, and that is the only person they can see.
There are demographic problems in regards to where clinics are situated, and where the rehabilitation programs are. Also, there is a long waiting list to get patients into those programs. The waiting list for mental health services counselling programs is six months.
I interviewed a suicide patient, a 25-year-old girl who was deeply suicidal. She stayed unconscious for seven days. I kept her in the hospital because I believed she needed counselling and support, and there is a six-months wait for counselling. Patients like that have nowhere to go.
These are some of the crisis issues that we face as practitioners in this province. Even in Saskatchewan where we have the facilities, we cannot use the services.
Then there is the problem that Dr. Natarajan referred to. The rural communities do not have psychiatric services, so there is a domino effect on the major centres like Saskatoon and Regina.
In Saskatoon, psychiatrists have commitments to teach, research and administrate. On top of that, there is a heavy clinical load imposed on them; not only a clinical load but they have to look after subspecializations. It becomes practically redundant and you get burnt out. Then you say, "To heck with it, I do not want to stay here any more; I will go somewhere else."
Recently, we had four residents who had just qualified, and together with Dr. Raymond Tempier I was working hard to keep them here. I submitted several documents to the Mental Health Services and the office of the Minister of Health, and they could not find the alternative funding. We pointed out that this is the direction the whole nation is taking for psychiatrists, that they need niche funding, like fee for service. At the same time, for indirect services to reach out to clients, they need alternative funding, which our system does not provide. Our residents, who are given these kinds of options, plus research and teaching obligations, go somewhere else.
The Deputy Chairman: For health professionals such as psychologists, social workers and so forth, if you have the people in a given area, are you able to get funding to pay them, or is that a problem as well?
Dr. Thakur: The problem is that they cannot dip into the Medical Care Insurance Branch, MCIB. They have to be paid on a salary, and there are not enough positions. I think they are negotiating to be able to bill MCIB but we do not know where that is at.
The Deputy Chairman: Is funding a problem even if you can find somebody to work in that area?
Dr. Keegan: I think the majority of psychologists, other than ones that are in the training programs and educators at the university, tend to go to private practice where they bill the clients directly or through an employee assistance program. The mental health program has long waiting lists and so if there are any other options, they are encouraged.
A number of graduating clinical psychologists or social workers work on their own in individual offices. That is why I emphasized the excitement that could occur with a shared-care model around primary practice. If there was funding available in a block way, where psychologists or social workers could work in a team approach, it could have advantages of drawing them back to working with family physicians. I am not suggesting they are not doing good work, because counselling is very much needed but it is not integrated, it is private practice. Most counselling that takes place in the province is in the fee-for-service sector by psychologists, social workers and other disciplines.
The Deputy Chairman: Yesterday, we heard from a community service in Brandon. They have somehow been able to put together a multi-disciplinary team and have psychiatrists come in from Winnipeg a couple of times a week. They have the infrastructure there that allows them to take care of the patients from a medical and social point of view. I was impressed.
Dr. Keegan: It sounds interesting.
The Deputy Chairman: I would love to do a walkabout there, and if I can find a free day I will go back and see if it is real, because it sounds exciting. They appear to me to be the only people across the country able to do that. Everybody else is hitting all these barriers and silos of position descriptions. This person is fee-for-service funded and this person is private, and they are not able to put the package together to get that multi-disciplinary team up and running.
Let me come back to you, Dr. Keegan. Senator Kirby and I have not tried this on the real brain power of our committee yet but we have been wrestling with the idea of whether there should be a national commission with a sunset clause. In other words, give it 10 years, give it a shot of money, let it do its job and then let it self-destruct.
You have lived through that provincially. What do you think of that idea nationally?
Dr. Keegan: My sense would be that the Murray commission's view on mental health and addictions was advanced thinking. The commission was very supportive of regionalization. They developed a whole map of regionalization but they said there were weaknesses in it. It needed some strong authority such as a commission at arm's length from government, such as SADAC. SADAC was the alcoholism commission, which was at arm's length. That could have led to increased funding or, at least, targeted funding that said to government, this has to happen.
It would have to be a group that would say, we are keeping our eye on mental health and addictions funding.
My experience has been, with the enthusiasm about what the Murray commission envisioned and then how it has turned out, with little central authority, little autonomy and little targeted funding, mental health and addictions have wallowed, in a way.
I think mental health funding could be marginally up from its 2.3 per cent of the budget in 1989 to maybe 3 per cent. In Saskatoon, it is about 3 per cent of the budget. We have amalgamated mental health and addictions because we believe in integration; that mental health and addictions should be together. I checked yesterday and combined, they receive 4.1 per cent of the Saskatoon Health Region budget, which is $580 million. That figure encompasses all mental health and addictions services, with 3 per cent for mental health and 1 per cent for addictions.
Obviously, the Murray commission envisaged that the funding would increase, but instead it has been static. I do not think we have lost funding but I think it has been incrementally low. Therefore, that would be my recommendation, if you are listened to and have the clout as a committee.
The only sunset clause we had when they introduced regionalization was the Minister of Health said for two years you cannot touch mental health and addictions funding, to reduce it. They did not say it had to be increased. They told the regions and districts they were ring-fencing but that had a two-year sunset clause. After that, there has been competition and fighting for funding. As you know, mental health and addictions do not do very well in head-to-head competition with high-powered, acute-care medical service needs. From your experience as a cardiovascular surgeon, you know where we are, compared to that.
Dr. Thakur: Let me give you one example. Recently in Saskatoon, we had a children's treatment centre at a local level. We call it a Community Adolescent Treatment Unit, CATU, and it was run as an NGO for with $300,000 a year in funding. Saskatoon Health Region had a gross deficit so they closed the CATU and kept the money. That is the state of affairs with the health region. When there is a deficit, the mental health services suffer. We could not persuade them to keep it. When we went to our MLA, I got a thick presentation from his office saying that it was not functioning at its best so they closed down the centre and put the money into the Saskatoon Health Region. The necessity of providing the services was not mentioned. Child psychiatry and staffing is so limited, and we lost the CATU. That is one example of what has happened in our health region.
Dr. Keegan: I want to assure the senators that mental health is not being picked on; it was across the board because the region was in deficit but mental health was not protected. It was not that we were necessarily picked on but we were not protected.
Dr. Thakur: Ring-fencing might help in that.
The Deputy Chairman: You will be spared a difficult cross-examination from the former premier and minister of health because we have run out of time. Senator Callbeck is gracious enough to listen, and has allowed me to carry on.
We are deeply appreciative. Thank you so much for coming here and sharing your thoughts with us. We have learned a great deal from Manitoba and Saskatchewan.
Senator Callbeck and I were just commenting that we are learning a lot more from the small provinces than the big ones. The big ones are a mess; the smaller ones are getting their acts together, which I think says something about the need for community services.
Dr. Keegan: Not that I should have or need the last word, but I think Saskatchewan has been so forward-looking, and I think we have survived in mental health and addictions, because there has been enough structure in place. Mental health was regionalized in the 1960s into eight regions. I think the Saskatchewan plan has sustained us and we would be dead in the water if we had not had that.
The Saskatchewan government has put into place infrastructures over the years that make me pleased to be a native of Saskatchewan, and to have stayed here.
On the other hand, we have always realized that when the going gets tough and the funding is not there, there will be cuts, and in mental health and addictions, what we thought we were moving ahead on, we settle back again. We are really looking with optimism to your committee, I can tell you that.
The Deputy Chairman: Paradoxically, we have to admit that anybody in the health field has to be proud to be from Saskatchewan.
Dr. Thakur: Thank you very much for allowing us to present our point of view.
The committee adjourned.