A presentation made by David Copus, Chair of CMHA Alberta, appearing before the Minister’s Advisory Committee on Health on October 19, 2009.
Dear Mr. Horne, Ms. Prowse and Members of the Minister’s Advisory Committee on Health:
As Chair of the Alberta Division of the Canadian Mental Health Association, I am pleased to present to you today on behalf of not only our provincial office but our eight regional offices across Alberta, our Centre for Suicide Prevention and, most importantly, on behalf of the many thousands of Albertans living with mental illness.
I am joined by Brenda Wentzell, who is a CMHA Board member with both the Alberta Division and Edmonton Region, and sits on their respective Social Policy Committees, as well as our Division Executive Director, Tom Shand. I will make a brief presentation, and Brenda and Tom will join me to help answer your questions.
Firstly, I would like to thank you for the opportunity to provide input into this process. Although the time frame given did not allow us to explore the subject areas in any great depth, the outline provided an excellent framework from which to build our commentary.
We have focused our presentation on the principles for renewed health care legislation that the committee has shared. I will not attempt to comment on all the points provided, but will focus on discussion on those directions of most importance from a perspective of mental health and mental illness.
With regard to discussion of the whole, I think it is fair to say that the guiding principles and themes suggested appear to us to be progressive and positive, but it is difficult to anticipate how they may ultimately be interpreted or what nuances may be attached that are not immediately obvious. Therefore, we have chosen at this time to not give overall endorsement, but rather to provide input as to those values that we hold dear. We see this as one step in a process and we look forward to reviewing your recommendations to the Minister and to further input into whatever changes will be forthcoming in future health-related legislation.
A perfect example of potentially misleading nuances can be seen in the two starting principles with which you were working:
We are supportive of the first, being “the public health system will serve the interests of all Albertans regardless of their ability to pay” – although this might be better stated as “Alberta’s publicly funded health care system.”
We are less certain of what is meant by “access to publicly funded health care will be fair and effective” as the nuances of the terms “fair” and “effective” are not known.
The explanation that this means “publicly funded” and “accessible” is reassuring, but adding in “patient-centred” is an entirely different point not encompassed in those two principles. While we are strongly in favour of patient-centred” care, we are also aware that it can be interpreted in many ways (for example, when is it meant to include family and when is it only patient?). It has been our experience that the term ”patient-centred care” is commonly presented as a value in today’s health care principles but, in practice, it is often largely in name only.
I cite these examples not to attempt to wordsmith the text provided, but rather to point out the complexity of the task at hand, both for yourselves and for those of us asked to comment.
I would like now to speak to the seven principles provided. In short, all seven are solid and important to our health care system and to the legislation supporting it.
In looking at each from a mental health and illness perspective, we observe the following:
1. Comprehensive, universal, portable, accessible and publicly funded
These are all laudable goals but far from what those living with mental illness experience today in Alberta.
Care of mental illness today in Alberta bears little resemblance to a system embracing those principles. While the health system does a good job of serving the needs of most of those institutionalized with severe mental illness, it has nowhere near the capacity or ability to provide even adequate support or treatment for the vast majority of those thousands of Albertans living, and trying to cope with and recover from, mental illness.
We receive calls daily from individuals with mental illness, or their family members, who are frustrated because they cannot get access to the treatment that they need in order to get better. Even those fortunate enough to be able to see a psychiatrist often find that their visit involves only examination of the effectiveness of medication, while not providing them therapy. And for many, they do not have a health care plan to pay for private therapy or funds to pay for it on their own.
Waiting lists for existing resources are long, leaving people’s mental health in jeopardy. And most community resources, such as those supplied by CMHA, are often designed to provide support services, not direct care.
Therefore, while the principles may be, and need to be, in place to support comprehensive, accessible and publicly-funded care, this is not the reality for many Albertans when it comes to timely and effective treatment of mental illness.
2. Quality, appropriateness and efficiency
These are also solid goals, but again not consistently in place, at present, from one program or area to another. There are substantial opportunities for improvement in this area as the system moves towards increased consideration and application of the entire continuum of services and supports, both in the AHS system and in the community.
3. Focus on wellness and public health
This, too, is a laudable goal. As is reflected in our name, the Canadian Mental Health Association believes strongly in the importance of building mental health and not just treating mental illness.
Too often, mental health is only a term that is used as a euphemism for mental illness. Promotion of mental health and prevention of mental illness are both important goals, if we are to make progress on reducing the amount and impact of mental illness.
Mental health is not an absence of mental illness. It should be understood that people living with mental illness can be in good mental health, and conversely, that people without a diagnosed mental illness may be in poor mental health. Mental illness is common and should not be something to be embarrassed about, but mental health affects us all.
It has also been shown that as high as the cost of mental illness is to our health care system and our society, the lack of mental wellness, as expressed in limiting one’s ability to flourish, is an even great cost.
For these reasons, we strongly endorse the focus on wellness and public health. It is also an area that organizations like AHS, with its focus on acute-care treatment, does not generally do well. Therefore, we would suggest that governments look to invest more extensively with other partners to help deliver wellness and promote good health.
4. Patient-centred care across a continuum of health services
This principle too is consistent with our core values, although it may be advisable to separate this into two sections, as providing care through a continuum of health services is significant enough to be regarded as a principle unto itself. That principle, if extended fully, looks not only through the lifetime of patients but also at the integrated planning and delivery of services through various service providers, including those provided by the NGO sector and its community-based service delivery programs.
As was noted earlier, the role of family or one’s personal support network must also be taken into consideration.
5. Protective of infirm and vulnerable Albertans
This principle certainly applies directly to varying degrees to those living with mental illness. For instance, in considering privacy rules for patient information, improper sharing of information relating to a person’s mental illness can have dire consequences for that individual in terms of potential discrimination or fears of such.
We should also emphasize that people’s status can change as to their capacity. CMHA advocates strongly that the principle of recovery be a major goal of the health care system and our society, particularly when it relates to people with a mental illness. The role of helping people to enhance their mental health and to help them gain more control of their lives is a philosophy that we would like to see applied not only across the health care system, but also throughout our public services, in areas such as justice, housing, employment, education and social services.
6. Accessibility regardless of ability to pay
CMHA strongly endorses this principle. Given that mental illness can impair one’s ability to work and make a decent living, this is fundamentally important to those we serve. Increased accessibility also enhances recovery, thereby decreasing long-term costs of treatment and social services, while improving people’s quality of life and potentially their income.
7. Best care according to best evidence
This, too, appears to be two principles rolled into one. Care according to best evidence relates to supporting and making use of research. The right care, at the right place at the right time and by the right provider, relates more to quality of care and accessibility, which has already been discussed. However, we should not lose the importance of doing and using good research. Certainly in mental health, research is far behind that done in most areas of physical illness and much more is currently unknown than known in this science. Advances in research, including new medications, are making a significant difference in the treatment of those with mental illness and it must continue to advance.
The directions suggested in this section are essentially sound, so we will expand upon certain areas, again relative to a mental health and illness perspective.
1. Optimizing capacity and competencies of all health service providers
Making optimal use of resources is certainly wise and an area of potential improvement. However, in doing so, don’t restrict consideration to only AHS employees. While there is certainly significant room for improvement within that workforce, there are many health care providers outside of that formal system, including the NGO sector and in home environments.
While community-based care is dealt with somewhat under the theme of access to service, it is important to recognize the potential capacity of the caregivers who can provide that care, as they may require additional training or supports in order to optimize their effectiveness and meet the standards required.
2. Access to care and services, in the right setting
Full consideration of NGO and home-based community services needs to be recognized and supported, not just as a fallback position when bed reductions are being considered in our institutions, but their needs and capacity to serve must be built into the overall planning process if they are to be counted upon and be effective.
There are thousands of people providing supports and services for friends and loved ones from their homes. If this were properly recognized and supported, this network of home support would expand, thereby relieving pressure on institutions and more formal care. Much of the bed blocking that currently prevents optimal use of beds in all levels of facilities could be alleviated with stronger support for home-based care. This certainly is applicable, but by no means exclusive to, people living with mental illness.
We would also suggest that the concept of care “closer to home” could be built into this theme. This is an important consideration both for the patient and the family. This is particularly true of those with mental illness for whom family and community supports are important factors to successful recovery.
3. Integrating care across the full continuum of health services
This is important and can be exemplified by the recent merging of mental health and addiction. Often those with concurrent disorders were rejected service at one because of the existence of the other. The philosophy of every door is the right door is important because people are complex and not one-dimensional.
Further, it is important to coordinate services beyond just the health care system. For instance, Senator Kirby of the Mental Health Commission of Canada has said that about two-thirds of the costs (and needs) of mental health are outside of health care, including housing, justice, employment, education, families and other social services. This means that whatever changes are proposed to health care legislation need to be coordinated with changes in other areas of public policy.
This is particularly important in light of the current moves towards reducing the reliance on acute care beds and moving care into the community. Appropriate community supports are the only way for such a transition to be successful. Not only will community health services need to be expanded, but also, supports in housing, employment and social services will be needed. Otherwise, any financial savings in health care will be costs borne by other parts of the public system such as policing and justice.
4. Make decisions based on best available evidence and technology
As mentioned earlier, research in some areas, such as mental health, is clearly lagging behind other areas of care and much could be gained by improvements in this area. Access to research worldwide is certainly of benefit but, by having the research done in Alberta, attracts top minds to our province, thereby stimulating thought, attracting other specialists and forward thinking people and creating centres of excellence that have great overall benefit.
This area may also be where access to best possible medication is dealt with, an area of great concern and interest to those living with mental illness. Too often, leading-edge new medications are being held up by cost considerations, if they don’t show an ability for improved treatment. What is often not weighted heavily enough is that the newer medication has far fewer or less severe side-effects which not only increase its value in terms of quality of life for those taking it, but also increase the likelihood that people will stay on their medications. The potential consequences of people with mental illness going off their meds are very costly, both in terms of their medical setback and increased long-term cost of support and treatment, but may also have an impact on safety to the individual and others.
5. Support for change
We are also in support of this point, as people need to have reason to do what is best for themselves and for society as a whole. For instance, by only providing people access to certain drugs when hospitalized may be reason enough for a person to seek hospitalization. Another sad example from a mental health perspective is those patients who will self-harm or claim to have formed a plan for suicide in order to be accepted for treatment. Addressing deteriorating health as a criteria for committed treatment through Bill 31 is an excellent example of legislation that should positively change patterns of behaviour for some people. It is also an example of how the system not needs to ensure that there is enough capacity for treatment of these individuals.
In summary, we commend the Health and Wellness Minister for his efforts to ensure that our legislation allows the government and health care system to operate more effectively. We thank you for the opportunity to provide input into the principles guiding these changes and hope that the points that we have made will add to the quality and comprehensiveness of this work, particularly as it may benefit those Albertans living with mental illness.
Presented by: David Copus, Chair
Canadian Mental Health Association, Alberta Division
October 19, 2009