Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 17 - Evidence for June 5, 2003
OTTAWA, Thursday, June 5, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:04 a.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Honourable senators, we are here to continue our study on mental health. We have four witnesses this morning. The first is Michael Grass, who is the past-chairman of the Champlain District Mental Health Implementation Task Force. Some of you may know that Ontario had nine regions set up under the Ontario government to review the delivery of mental health services. The Champlain District included Ottawa and all of Eastern Ontario up to Kingston.
The second speaker will be Dr. Dominique Bourget, the president of the Canadian Academy of Psychiatry and the Law. Third, we have Tim Aubry, an associate professor for the Centre for Research and Community Services from the University of Ottawa; and fourth, Dr. Jeffrey Turnbull, chairman of the Department of Medicine and the Faculty of Medicine, also from the University of Ottawa.
I know a number of you have submitted papers. I would like you to make your opening comments brief, because this committee likes to ask a lot of questions. If you could focus your comments, we are quite capable of subsequently reading your briefs. We will then go directly to questions. Please proceed, Mr. Grass.
Mr. J. Michael Grass, Past-Chair, Champlain District Mental Health Implementation Task Force, As an Individual: Honourable senators, it goes without saying that it is an honour to appear before you, particularly on a topic as important as mental health.
Contextually, mental illness is the last taboo of society. Society has bridged the gap of women's rights and sexual preferences, but has not had the courage to confront mental illness in a meaningful way. Society has moved through the Industrial Revolution and the information revolution, and is now in the economy of mental performance. The shift from physical to mental performance in the workplace means that any company's or country's most important asset is the value of its people. The commercial value of human thought content in products, services and policy is well documented. The state of mind of a company's employees and a country's citizens — not its backs, arms and legs — will mean the difference in the 21st century in a highly competitive world.
From levels of depression and anxiety to more serious illnesses of bipolar and schizophrenia, mental illness is costing billions of dollars in lost days and unproductive performances every year. Mental illness ignored does not disappear. In addition to the cost to business, cost increases are shifted elsewhere — to the correctional system, the social welfare system, the emergency rooms, et cetera. One way or another, we all pay in more ways than we could imagine.
It does not matter whether he or she is a productive lawyer — the Canadian Bar Association reports increasing levels of depression and addiction — or potentially productive students, teenagers and university students, facing increasing levels of fallout. Mental illness hits everyone — rich, poor, male, female — of every race and creed.
I have seen two sides of mental illness: first, as a parent of a young man whose dreams for his future were cut short at age 18; and more recently, as chairman of the Champlain District Task Force. With respect to the latter, I wish to make several observations from my experience.
Remarkably, given its rate of increase in an economy and society driven by mental performance, this last taboo of society — mental illness or mental health — is the least funded and the least discussed by schools and governments, including politicians and bureaucrats— society's gatekeepers. It also has the most poorly organized system of support. Some might say that society's gatekeepers have been asleep.
Also as remarkable during my time on this task force was the number of well-written reports and studies prepared over the last 10 years on mental illness that have not been acted upon. Reports sit on ministry and government shelves. Mental illness is just not good politics. Everything has been written, but no one had drawn together the reports into a coherent plan. No one had acted upon them, while people suffered and the system got worse.
Equally as serious is the minuscule level of research money as compared with other areas of illness, which suggests that significant breakthroughs are still years away.
I am positive that the last taboo needs a national commitment to make change in organizational construct, in funding, in education and in community support. Some will say the change is beginning, but unless there is an organizational construct, progress will slow, as mental illness is clearly an "orphan child" to more powerful lobbies in our health system.
I have set the change components in that order as the process of change is imperative; but it is clear in my mind that meaningful change will not occur without these components in place working interactively. Some might say that society's gatekeepers are frozen in inaction, lacking in leadership and planning.
It is also remarkable to me that two well-documented concepts in mental health, which could reduce and minimize cost to the system in the years ahead, do not hold sway in systems planning and funding. The two concepts of early identification and intervention, particularly in conjunction with high schools and universities, for example, and recovery-based planning, particularly in regard to a stronger rehabilitation system, are not bought into and acted upon in cross-ministry initiatives among education, social services and health in Ontario.
Just think of the novelty of identifying an illness early on in its progression; and providing an appropriate recovery support for cognitive, social and employment impairments, which can minimize cost to society and provide dignity and self-esteem to the individual. Both the U.K. and Australia have adopted these concepts in how they respond to the challenges of mental illness. Some might say that society's gatekeepers are unwilling to change to adopt concepts proven elsewhere.
Lastly, it is remarkable to see the continued level of commitment from front-line workers in the mental health system. Never have I seen such an under-resourced — in respect of monetary and human resources — more poorly organized group of workers who legitimately could be, and are, critical or cynical about the system's lack of progress, yet who continue to perform at a high level.
On the other side of this equation, no one could have set out to put together a more disjointed management construct. The silo-driven nature of management and boards militates against a cohesive, planned, interactive system of services and agencies with no duplication. Some might say that society's gatekeepers just do not get it.
In addition to my task force experiences, I have been asked to comment on two topics that are part of your round- table schedule of review; namely, deinstitutionalization and rehabilitation. Both are complex topics where implications and flexibility must be considered in order to do justice to those suffering with mental illness.
Deinstitutionalization — to its extreme — has seen serious implications as the U.S. found under President Kennedy, where homelessness and the criminal system were the principal beneficiaries. In my view, deinstitutionalization makes sense for most — not all — but only if the community has the service capacity; if society has been informed in an appropriate public education policy; if safe and affordable housing exists; and if enhanced employment opportunities exist. Can you imagine a time-sensitive institutionalized consumer is suddenly discharged to find employment in a stigmatized society where a "not-in-my neighbourhood" housing policy exists?
To successfully embrace deinstitutionalization, one needs to embrace a recovery philosophy for the individual and all of the appropriate treatments and supports that it assumes so that people living with mental illness can create new goals and engage in society as productive citizens.
Successful deinstitutionalization assumes a continuum of integrated services, where it is seamless to navigate between each service as recovery takes hold and an individual moves from discharge, through skills enhancement, to housing and employment. Currently, the mental health system does not provide the if's to the degree required and, therefore, the criminal system, families, et cetera, are forced to respond in well-intentioned, but often detrimental and untrained ways.
As I have said earlier, rehabilitation is an area where mental illness needs significant action. During and following all psychotic conditions where the significant symptoms are to be treated, cognitive, social, recreational and employment impairments of varying degrees must be faced or the current stigmatization will continue to isolate those with mental health challenges.
Some hospitals provide one or two-week programs but these in no way address the programs that could be better served in two- to three-month residential rehabilitation facilities. I am a director of the rehabilitation centre in Ottawa and I have seen the level of commitment and resources to rehabilitation for physical injuries, there and elsewhere for other illnesses such as cancer and diabetes, over longer periods of convalescence. The balance of fairness for rehabilitation has fallen heavily to the physical from the mental side of the human anatomy.
Lastly, a challenge for governments is to find the right formula to support the mental health advocacy organizations. The reasons that the mental health system is in such poor shape is because of the disjointed and under- funded lobby and advocacy efforts that exist for mental health/illness, who simply do not get the message out as compared with cancer, diabetes, heart and stroke. The public and government just do not know enough about the issues. Historically, the advocacy organizations have not been able to inform and show how big a problem mental illness is for society.
It has been said that mental illness is an "orphan child." I prefer to profile it as the last taboo. Interestingly, in the years to come, where mental over physical performance is a key to the country's and individual's quality of life, we have yet to address mental illness in a convincing way.
I wish you much success in making the case to all Canadians.
Dr. Dominique Bourget, President, Canadian Academy of Psychiatry and the Law: Honourable senators, I wish to thank this committee for inviting me to attend this morning. The issues of deinstitutionalization and rehabilitation are at the core of the provision of mental health services.
My perspective is that of a forensic-trained psychiatrist who has worked for 20 years with mentally ill offenders, assessing and treating those people suffering from severe and persistent forms of mental illnesses. I am primarily a clinician, working with those individuals who come in conflict with the law. I also work with schizophrenic people and people suffering from other kinds of mental illnesses at the Royal Ottawa Hospital. I provide expertise to the court on mental disorders, criminal responsibility and assessment of risk. In addition to this, I am quite interested in research as a coroner in the Province of Quebec. I do research on mental disorders and violence, including homicide.
I am not a policy-maker, but I do have comments that I wish to make today. Certainly, they may sound quite naive to this committee.
Historically, deinstitutionalization developed in the 1960s with the advent of a new anti-psychotic medication, Chlorpromazine, in the 1950s. From there on, it became almost more a necessity than a goal. Some people who were institutionalized and suffering from severe mental illness saw their conditions improve with treatment. Therefore, they could re-enter the community. Thus, we saw the decline of psychiatric institutions and mental health services moving from there to the general hospital, short-term interventions for management of acute episodes or relapse, and longer- term care moving into the community with the necessary development of a variety of community-based resources.
In the 1990s, the recovery vision became more prevalent. Recovery meant more than the relief of symptoms or the treatment of the illness itself. We started to develop this notion that people with mental illnesses also had to recover from the stigma — and I am sure you have heard that expression before — and they had to recover from the effects of the treatment settings of the institutions, from lack of opportunities for their self-development, lack of employment and loss of their dreams.
Forty years later, deinstitutionalization and social rehabilitation are still issues of very significant concern. We find that the rehabilitation of many chronic patients has not been as successful as anticipated. We also know that there is a sub-population of psychiatric patients who will always require the resources of an institution because they are too ill; available resources cannot meet their needs; they present a high-risk to themselves or others if they are released from hospital.
When we are dealing with deinstitutionalization of persons with severe or persistent forms of mental illnesses, we sometimes need to be concerned about risk. I will not spend much time giving you statistics and numbers, but there is a well-known association between mental disorder and criminal behaviour — including violent crimes. However, we need to acknowledge that violence is not a core attribute of mental illness itself. It must be placed in a context. Potential for violence depends on the illness and personal factors which, when we understand them, help with better predictions.
I would like to comment on the special issues with the forensic patients. By "forensic patients," we mean mentally ill persons in conflict with the law.
Conflict with the law is often an entry door into the system. The issues of deinstitutionalization and rehabilitation for these patients call for special considerations and principles. We need to balance the risk to society with the rehabilitation needs of these patients. These mentally ill offenders who work towards community reintegration face many challenges such as finding suitable lodging and accessing community-based services.
The bridge between the forensic institution or the forensic setting and the community mental health services is often very difficult for those people. It is also very difficult for them to find adequate accommodation. There is a need for hospital-sponsored, community reintegration programs that would link forensic patients with community resources and programs offered in the community.
Forensic patients often require a "cascade approach" towards deinstitutionalization and rehabilitation. That is, deinstitutionalization is not simply the act of moving someone from an institution into the community and giving some community resources. We must think of this process as a "step-down approach." The individual moves from the high- secure setting to the medium-secure setting to the regular psychiatric units to, perhaps, a community transition house — which are really lacking at this point — and then towards a supervising boarding home and ultimately, it is hoped, towards full reintegration with support in the community.
In summary, I would like to reiterate that access to resources and services in the community is still problematic for a number of the patients who are served by the hospitals and institutions. In particular, forensic patients or mentally ill offenders are still experience discrimination in the community and are not allowed access to some of the services such as the community treatment team that other patients have. This is still an issue that we are struggling with for our patients. Thank you.
Mr. Tim D. Aubry, Associate Professor; Co-Director, Centre for Research and Community Services, University of Ottawa: Honourable senators, I thank the committee for the invitation to present to you today on this round table on deinstitutionalization and rehabilitation. My perspective is that of a community mental health researcher who has been involved in research in the past 15 years that contributes to the integration of people with severe and persistent mental illness.
My remarks will cover four areas. First, I will define briefly the population that includes people with severe and persistent mental illness. Second, I should like to say a few words about how deinstitutionalization has affected this population. Third, I should like to briefly discuss the current state of community support and psychosocial rehabilitation programs. Fourth, I will provide my opinions on future directions for taking the mental health service system and making it more effective and relevant for the population of people with severe and persistent mental illness.
With respect to the definition, people with severe and persistent mental illness are those who have a diagnosis of a major mental disorder such as schizophrenia, bipolar disorder or personality disorder. The illness has a chronic duration and it affects a person significantly in one or more life areas. Conservative estimates of the size of this population put it at about 2 per cent of the general population. That would amount to more than 600,000 people in Canada currently.
This notion of deinstitutionalization has formed the cornerstone of mental health policy in provinces over the last three decades. We have wrestled with how one properly and effectively moves people away from living and being served in institutions to taking on productive lives in the community. This has been quite a challenge and has not been realized in any way to date. There is wide recognition that we have a ways to go before we can help people lead meaningful lives in the community. There is consensus in the mental health field that one of the reasons we have not been able to realize community integration is because community sources have been under-resourced. Provincial governments have been slow to move funding from institutions into the community. The resources have not followed the consumers of the services.
In this context, this has led to many problems, including homelessness. A significant group of people who have severe and persistent mental illness are homeless. Those who are housed live in substandard housing. They tend to live in poverty. They are not employed. They are marginalized. They have very few social relations with non-disabled people, other than professionals and family members. In my own research on integration, it has become clear to me that these people find it very frustrating living in the community. They find that the kind of life they can lead is empty and dissatisfying as a result of their social isolation and not having anything productive to do.
I will share some general observations on the current state of community support and psychosocial rehabilitation programs based on my experience with an initiative known as the Community Mental Health Evaluation Initiative — a multi-site research study here in Ontario funded by the Ontario Ministry of Health. It is intended to help inform the development of innovative community mental health practices. It involves seven studies in communities across Ontario in the areas of case management, self-help initiatives, and crisis services. Some of the findings that are emerging from this project provide us a window on the state of practice in the area.
We are finding that home-based support can make a difference in these projects. Programs such as assertive community treatment and intensive case management can help very disabled clients live in the community. However, at this point, there are not enough of these services to go around.
Self-help initiatives for consumers and family members also appear to make a big difference — not only to the consumers and families but also to communities and mental health services in general. Currently, however, these services in Ontario have less than 1 per cent of the mental health budget allocated to them.
In our project here in Ottawa, we have had the opportunity to do some costing. What does it cost to support someone with a severe and persistent mental illness in the community? We found that on average it costs $35,000 per year to support someone in the community. That is a very modest sum of money. However, when we look at the breakdown of those costs, one-third are taken up by medical and health services — including mental health services — and hardly anything is being allocated for education, vocational training, leisure or recreational activities.
In this initiative, as we are following 800 consumers — people with severe and persistent mental illness — we are finding out that recovery in the community is possible. To recover, people need good health care, an income, decent housing, and meaningful activities such as work and education to pursue.
I would like to make some suggestions for mental health reform based on this picture that we have of deinstitutionalization, current state of psychosocial rehabilitation services. First, we need to build on the progress we have made. I am an optimist. I think there has been some progress in moving our resources into the community. We need to continue in that direction. Certainly, hospital-based services have an important role, but it is one of stabilization, crisis support and specialized treatment. If people are to recover, it will happen in the community.
Second, a value that has been pervasive in mental health reform across North America is involving consumers and family members in planning and developing mental health policies and programs. If we are to develop a national action plan on mental illness and mental health, this value needs to be enshrined in the plan. We need to ensure that consumers and family members have significant input into its development and implementation.
Third, given the picture that has emerged in terms of the type of life that we have assisted people with severe and persistent mental illness to develop in the community, it is clear that the traditional health care on its own will not do it. We have to push in planning mental health services beyond formal health care. We must move into other sectors, such as income support, housing, education, and employment. If the needs of this population are to be addressed, the national action plan really must expand its scope beyond formal health care.
The fourth issue is housing. The first generation of community services has focused on housing. The housing tends to be congregate and specialized. However, when you ask consumers what type of housing they want to live in, it is the same type of housing that most people want to live in: They want to live in "normal" housing. They want to be supported to live in the community the way other people do. In the field, this is known as "supported housing." Government programs and policies really need to facilitate consumers being able to live in this preferred housing option.
I have mentioned home care and home-based support, which is portable and flexible. These are a type of second generation of programs in Canada. If we are to develop a national plan on mental health, resources should be allocated so that all persons with severe and persistent mental illness can access this critical kind of community support.
Sixth, there is a third generation of services that is necessary if the population is to achieve true integration. These are the services that will help them return to school and participate in the workforce. We have models of supported- education programs, supported-work programs, which have been developed in the United States, but we have seen few of them make their way up here as yet. We need to import some of these best practices to Canada and find better ways to integrate them into our mental health service systems.
Finally, there is a need for research that can assist with the development of effective, relevant psychosocial interventions. A national plan should include significant emphasis and support for research and evaluation that can inform the development of evidence-based practice in the psychosocial rehabilitation area.
In summary, I think we have the beginnings of a community health system in our communities and provinces across Canada. However, much work and reform is still needed to properly address the multiple needs of people with severe and persistent mental illness who are living in the community. I believe that the federal government, through such mechanisms as the national action plan, setting national standards for health care, and targeting resources for specific services can and should play a leadership role in actualizing these reforms.
Dr. Jeffrey Turnbull, Chairman, Department of Medicine, Faculty of Medicine, University of Ottawa: I would like to thank you for giving me this opportunity to speak.
You might wonder what the chair of medicine is doing speaking at a mental health task force. My interest — both clinical and academic — in poverty and health has brought me. I will speak you to today about a subgroup of individuals who have severe and persistent mental illness: those who find themselves in our shelter system. I will describe a project that was initiated two years ago and concluded as of April of this year. I will tell you the results that we have achieved in that. I think it has special relevance to the discussions as they relate to the concerns of deinstitutionalization and — in part — partial reinstitutionalization.
Within a kilometre of here, every day there will be approximately 1,200 individuals who will seek refuge in our shelter system. These individuals historically had been white adult males, but now we see an increasing percentage of Aboriginals, the elderly, immigrants, and single mothers with families. In this population, we were particularly concerned with individuals with serious medical conditions, and that is what brought me into this process in the first place.
You cannot actually deal with a medical illness until you have addressed the prevalent psychiatric disease that exists within this population. Some 40 per cent of our population have drug and alcohol addiction, and a similar percentage have underlying psychiatric disease, so we see that the majority of our patients who find their way into this environment have significant addictions and mental illness.
These particular individuals find themselves in a homeless shelter principally because of their difficulty in searching out relevant and meaningful health services, which are not available to them because of their unique characteristics and a system that is designed specifically for the typical, white average, middle-aged individual with a reasonable income and education. Our system is very good for those individuals in many circumstances. However, in this particularly unique cohort of individuals, they find themselves unable to access meaningful health services, both psychiatric and medical.
Consequently, we try to look at an initiative that would provide meaningful, flexible health services for the homeless community right on-site. The project that I will describe to you is now completed, and that is what it chose to do. We were funded with $997,000 annually from HRDC, and we had $1 million in matching community resources. For a community that has very little, you can imagine that that was a major initiative to commit those sums of money.
Our partner agencies, as you can see from the information that I provided, were numerous. It is a complete community initiative to try to address this overwhelming problem that we all recognize is essential.
We chose to provide integrated health services for this community that link with our existing health services from both for a mental health perspective and a physical health perspective in our hospital environment. It was based on their needs. It was flexible. It was based on a harm-reduction model. We recognized the need to look at an integrated approach that dealt with housing and health, and it had to deal with all our partner agencies.
We tried to link our health services together with an electronic health record, which we think is innovative and has been incredibly successful. We took these individuals and created spaces in each one of our shelters, which they had grown to call their own homes. You have to recognize the circumstances of our homeless in this setting. These are no longer emergency shelters; these are their homes. That is where they will live the majority of the rest of their lives.
As a consequence, we took a 15-bed unit at the Union Mission. We made this into a hospice program for homeless individuals who were dying of their drug and alcohol addiction, HIV, hepatitis B, hepatitis C, et cetera. We had a 20- bed convalescent unit, at the Salvation Army. We considered this to be a step-up or step-down unit, to decrease the frequency with which these individuals accessed crises intervention and the cost related to that, at a hospital or judicial system. In addition, we had a 20-bed managed alcohol program at the Shepherds of Good Hope. Finally, we have a community outreach program where, today, for example, we will be looking for individuals under bridges, in fields and in different parts of the city.
At any one time, we have 60 to 80 and possibly 100 individuals on our roster. We have cared for well over 200 to 300 individuals and we have tried to provide meaningful health services for them as a pilot to see if this is an effective way of providing some kind of institutional support for individuals who otherwise lack it.
We linked closely to our providers of mental health services for these individuals. As an internist who knows very little about psychiatric disease, I have had a crash course and relied heavily on colleagues who have informed me a great deal about it.
I will tell you what has happened. Over the past two years, we have had a successful evaluation. We feel this is an ideal model of partial reinstitutionalization. We provided integrated health services for this community. At the hospital level alone — I am not talking about judicial or any other service — we have reduced the cost of crisis intervention and hospital days to a point where we have a net cost saving of $3.3 million per year. For an investment of $997,000, we have a cost saving of $3.3 million in these individuals.
You might think that that is a great deal of money, but you must recognize that in some of our earlier work these chronically homeless individuals might cost the system between $170,000 to $200,000 per person per annum in access to hospital services, judicial services, 9-1-1, et cetera. These people are accessing health services frequently and ineffectively — they do not get really good health care — but it is very expensive process.
Were we effective in terms of health services delivery? We looked at aspects of compliance, self-care, and their perceived satisfaction with the quality of care and other quality of care indices. From the perception of the client, the client care workers and allied health professionals around them, the results were all exemplary. All were in the highest level. They felt they had achieved a much greater level of self-care, compliance with medication, integration into programs, et cetera.
During the implementation of this project, in addition, we recognized the importance of education, not only for the community but also for the clients and allied health professionals. We have received international recognition.
We want to continue to serve this population in a similar approach. However, we are looking at aspects of addressing the needs of women in this context, long-term care, medical detox, and improving our interaction with our colleagues in psychiatric treatment, because there still seems to be a need for us to better interdigitate with those individuals.
This has been very successful. It is an example of providing integrated services to this population — integrated in terms of effectively interdigitating with the other health providers in a traditional system and making that system something that the homeless can access and use. We are providing some degree of institutionalization, yet we are also providing them independence and a sense of self-worth that they can be masters of their own fate while having a system to rely upon and be assured is there for their well-being.
The Chairman: I thank all of you for the comments. It is useful for us to talk to people who are actually out there on the street as opposed to just policy-makers.
My question has two parts. I am trying to understand something. When you deinstitutionalize someone, you move him or her off the health care budget. Correct me if I wrong, but I am assuming that the money that would have been spent on them had they stayed in the health care system did not follow them, Therefore, in some sense, someone else has to pick up the bill. Where is the money coming from to treat patients who are mentally ill but not inside the confines of an institution covered by medicare?
My second question is related to that. How does the coordination work? You talk about a whole variety of services that need to be provided to a patient. My sense is that there are certainly many groups involved in this. Someone is doing housing; someone is providing medical services; someone is providing education and training. Is this process adequately coordinated? My impression is that in fact it is awful.
If it is not, what do we need to do to increase the coordination because, first, it is better for the patient, and second, it is substantially more efficient?
I will begin with Mr. Grass, because he looked at it overall. It seems to me the issue of coordination and money are related.
Mr. Grass: I am a private businessman in venture capital involved in organizing and reorganizing companies. Speaking only to the mental health system, when one looks at it in all of its silos, each of which has a management, a board, an accountant and everything else that goes from 20 to 100 manned agencies, we could not possibly have constructed something that is so singularly unintegrated. We could only have hoped to do that in a first-year course; and a third-year course we might have improved. I am trying to say that the very nature of the construct militates against coordination — not that they are not all well-intentioned and not that they are not all competent in their own rights. However, it is the nature of the way in which some of these smaller boards are conceived and the lack of direction and coordination with the ministry. Historically, the Ministry of Health and Long-Term Care has sent the money down a chute to an entity.
Our findings point the finger at the ministry but that is not our intention. We merely provided them with the inventory of all their agencies, what the agencies were doing, the number of people involved and the duplication of their consumers across these various agencies.
That is illustrative of the nature of the entity that we are funding. We must somehow look at a construct that has a strategy and a philosophy for dealing with this group of consumers — whether it is my colleague's 2 per cent number or a larger number who are less severely handicapped but are clearly handicapped in terms of the nature of their impairments. However, we define that, we need a set of constructs within these agencies linked to the ministry where we can legitimately understand how these people's lives are being improved.
It is fair to say that the ministry under our task force has taken on much of what we have put forward. How quickly they are able to implement it with fiscal constraints, et cetera, time will only tell. However, it is the nature of the executive function to fight over a small piece of the pie so, when money comes available, the CMHAs, the housing agencies and the employment agencies all fight for the same dollar, and the decisions are not equitable. The decisions favour the loudest crier or the loudest lobby.
We need a much more systematic, planned construct to help the community increase its capacity, whether for the forensic group or for other community groups or for Dr. Turnbull's undertakings. That is clearly our biggest challenge.
Resource allocation of money is always a challenge in any of these issues. Resource allocation to mental illness in any of the budgets that I have seen — primarily in Ontario — is seriously underfunded. By looking at the numbers, we can see that the World Health Organization talks about one in four or that other organizations take that as high as one in ten. In terms of numbers of people and money, society is simply not allocating the resource appropriately.
In respect of the individual who has left the hospital, I am not sure if your question was, "are we assuming that he will take advantage of the community services such as they are?"
The Chairman: No. My question was: Where does the money come from to look after him?
Mr. Grass: In many cases, he is not looked after; he is the homeless individual who goes to Dr. Turnbull's program. When he leaves the forensic services — if indeed he is capable of being released in a structured way — and if the services are available, he may be able to stay with an agency. If the services are not available, which is more often the case, he probably ends up somewhere in Dr. Turnbull's system.
The Chairman: Does anyone else want to comment?
Dr. Turnbull: My suspicion is that if such a patient ends up in my area, the net costs will be distributed amongst many different ministries, such as justice, health, social services, et cetera. Those costs will be far in excess of what they might have been before that distribution. That would be my impression. However, I find that these people are found to be chronically homeless with severe and persistent mental illness. They are the most difficult to treat. Although they constitute a small percentage, they are receiving ineffective care at a very high cost to many different ministries — not just one ministry.
The Chairman: Dr. Turnbull, you nodded your head when I asked the coordination question. That was a clear negative; is that correct?
Dr. Turnbull: That is right. As a person who is new to this and standing outside, I think it would be difficult to design something that was so ill-coordinated.
The Chairman: From your perspective and Mr. Grass's business perspective, I understand that you have both reached exactly the same conclusion.
Dr. Bourget, do you have a comment?
Dr. Bourget: We see a gap between the hospital and the community. One phenomenon is that when the patients are discharged to the community, their only link with the mental health system is often through their doctors whom they continue to see at the out-patient clinics to receive their prescriptions. Once in the community, unless they are in a supervised boarding home funded through the Ontario Disability Support Program, ODSP, system, they are left with few resources in terms of community support.
We have been thinking about how we could take the institutional out-patient clinics and create a better bridge with the community. That may help in terms of coordination. If there were something to bridge the gap between the in- patient unit and the various community services, that would help. Although this may not be the ultimate solution, we thought that perhaps we could export doctors from the institutional clinics to community clinics and link them with other services. There is no single, simple mechanism of referral currently and there is no accountability for those patients who are in the community. That is one of the difficulties.
Mr. Aubry: I mentioned that we had done some costing in Ottawa. This is for a clientele different from that of Mr. Turnbull in that they are linked into the system and they have a support worker. I mentioned the figure of $35,000 per year, of which one-third is for health costs. Incidentally, we included income transfers in that figure. Another one-third is for the income support that people receive. The final one-third is for a mix of things such as social services, which are funded in many different ways; for interactions with the judicial system; and for costs that are borne by families, which are significant. Many people think that for the community mental health system, the biggest piece comes from families who receive no resources when a family member is ill. Some transfer of costs occurs.
Coordination is a definite problem. Historically, the community mental health system developed from the ground up — it was a grassroots enterprise. Family members and concerned citizens developed agencies in areas they thought could make a difference. After 20 to 30 years, there is now a whole range of services available that are not well coordinated. It is a problem.
I mentioned home care support, which is commonly known in mental health circles as "case management." The home care support is an attempt by the mental health services system in the community to help consumers navigate this uncoordinated system. One of the roles of those case managers is to serve as advocates. They support people to try to get the services that they need.
Senator Cook: I come from the Province of Newfoundland.
The Chairman: With that accent, she always insists on telling everyone.
Senator Cook: I merely was stating that we are a smaller population.
To answer your question, when the deinstitutionalization of clients began, the funding went to health and community services. I know that because I was a member of the health care board at the time. The block funding went to health and community services, and it stayed there. It still provides that service today. The enhancement programs came from the NGOs.
I am proud of a program that my church, the United Church, accomplished in partnership with health and community services. A big chunk of money came from the service and mission fund of my church. The linkage stays with the Department of Health and Community Services. The enhancement programs move back and forth. The money and the resources are there, as is the little board on which I sit.
A social drop-in centre looks after between 90 and 100 clients a day. The core funding for that is from community services, but the enhancement, again, comes from us with initiatives as a volunteer board. We have maintained that linkage.
Mr. Grass: We did find — and I think that goes to something you just spoke to — that when the environment is relatively small, some of the communities, such as Renfrew, have fewer choices in the numbers of agencies. They are better able to deal with the political nuances and force things together in a coordinated way. From our review and from talking to colleagues in Saskatchewan and Manitoba, it is clear that smaller communities are better able to provide a set of coordinated services because there are simply fewer political and monetary choices to make.
There is broad recognition that integration is important. I do not know about the ministerial issues that you face, but clearly, size creates a bigger problem in this issue.
Senator Cook: The outcomes are measurable at first glance.
Mr. Grass: If you were speaking to the outcomes as a result of the integration, I would absolutely agree. The integration and the ability to follow and support the individual to these different ports of call in their housing, social, recreation and cognitive needs are absolutely proven time and again to enhance the condition of the individual. The individual is better off. There is no doubt about that. The experts could tell you more. I have listened to many people over the last 18 months and I am convinced that that is the case.
Senator Cordy: You mentioned that those suffering from mental illness, particularly those who are homeless, would go to out-patient clinics to get prescriptions. Does this mean that they do not have continuity with the same doctor? Are they seeing a different doctor each time they go in?
I have also heard that those suffering from mental illness often have difficulty receiving treatment for physical ailments when they go in. They have difficulty having the doctor listen to them.
Dr. Bourget: In respect of the first part of your question, I cannot speak about how systems operate across the country. At the Royal Ottawa Hospital, which is a fairly big centre, there is continuity of care for the forensic patients. The same doctors who would take care of the patient in the in-patient unit would also be in the out-patient service.
As for the second part of your question, I am not quite sure that I recall exactly what you asked.
Senator Cordy: I have read that sometimes a person who has a mental illness will go into an emergency department with a physical ailment, and is not taken as seriously as someone who does not have a mental illness might be.
Dr. Bourget: That is possible.
Senator Keon: I found your presentations fascinating. It is truly an interesting spectrum that you have covered.
We have had many people come to tell us what is wrong with the system, but we have not had anyone come forth who has been able to tell us what construct would fix it. I would like you to attempt to do that. Obviously, you will not tell us this morning the solution to such an enormously complex problem, but I would appreciate if you would try and do that.
I want Dr. Turnbull to lead off because, as you know, Dr. Turnbull, I have been familiar with what you have been doing. I think that it is brilliant. It is one of the best-designed programs I have seen in a very long time. It is doing something for which our society has a tremendous need.
My interpretation of your program is that it is person-centred, not patient-centred. You are identifying persons that have a need, and you are following that person and trying to design something around him or her that will fulfil the need. Even better, you are measuring the outcomes at the end of it. This is absolutely tremendous, and I commend you on it.
However, I am also acutely aware of the system and the gap between operational and research funding. Your research funds will dry up, and there will be no operational funding to continue a program that could be the beginning of a little bit of daylight at the end of the tunnel.
My question is to the panel: What construct could possibly address the enormous fragmentation that exists in this area?
Dr. Turnbull, how on earth do you plan on getting a program funded that has no identification anywhere in the operational funding of health or social programs?
Dr. Turnbull: Thank you, Senator Keon for your kind words.
I will address the latter point first and then say a few words about the former question.
You asked how we can move from research of a successful initiative that has been implemented and get it into the spotlight for a provincial ministry that is otherwise very stressed with their financial constraints.
We have had many challenges. First, this is not a population that has much influence. They do not vote to any degree. They are not politically sensitive from a lobby perspective. Second, we fall within many different silos within a traditional ministry. This is not housing, it is not judicial, it is not health; it is all of those things. When one approaches a provincial ministry, the ministry then turns to the next. As we know when times are tight, that is an easy process to do.
We have been successful only by the sheer compelling financial argument that they have agreed to fund us for one more year. However, I suspect that unless there is some dramatic change between now and then, further funding may be difficult and those individuals who are receiving meaningful care right now will not continue to do so. That represents a huge challenge.
The solution has to be that the ministries of health must start breaking down those traditional silos in which they work and start to be innovative in approaching populations groups and be willing to say, "Yes, there is a bit of psychiatric disease here so we will have to go to mental illness. There are some housing issues, some judicial issues and certainly there are health issues." Up until now that has been very problematic to try to break those silos down.
Senator Keon: Dr. Turnbull, if you were to receive funding, what construct, what organization do you think could receive that money? What would you call it?
Dr. Turnbull: This is a great question, because are struggling with this right at the moment. As you know, for lack of any other meaningful partners, the university has taken on the health services delivery for this community. You might ask what in the world is the University of Ottawa doing providing health services? That would be a wonderful question for which I would not have a good answer.
What partner would you give it to — our Community Care Access Centre, CCAC, which provide home care? That might be a reasonable place for it. This really is delivery of services outside of an institutional environment, whether it is a home or not a home. In that environment they are used to working across disciplines.
Would we put it into our community health centres, which is also a reasonable place to put it. They are a group of individuals who are traditionally underfunded but nevertheless do have that capacity to bridge disciplines and provide meaningful services at a community level.
We must look at some interdisciplinary group rather than putting it into just a hospital sector or just into a mental health sector, frankly because this bridges so many disciplines. I can only speak for my own environment, though, and this is the homeless community. I cannot speak for psychiatric disease and the care for psychiatric disease of people with persistent mental illness in another context. However, if and I were to fund this and it is for the homeless, I would look for one of those interdisciplinary groups.
Mr. Aubry: I would like to comment on the question of what would fix the system. Four points come to mind that could help. We have talked about the first point and it certainly has been repeated in many discussions ever since the beginning of deinstitutionalization. That is, how do you get resources into these community-based services? As Mr. Grass has mentioned, they are underfunded. It is essential to starting to build the system.
How do you develop capacity? The programs are there. There are psychosocial programs that have very good research that demonstrate they can make a difference, whether it is in housing, vocational areas or educational areas. There are practices that can make a difference. The question is how to get them funded. That is essential. That is an area where the federal government could provide some leadership.
Second, I mentioned capacity. I come from an educational institution at the university. If we are going to put resources into community-based programs, we will have to train people and re-train people to work in that sector. That involves all the disciplines — medicine, psychology, or occupational therapy. That becomes an important piece to building a system.
There is this talk about a national plan. There must be some core values that drive that kind of plan. In relation to this population, the core values should include the whole business of social inclusion, community integration, and recovery. That is where it is going to happen if we are to get people assuming normal roles in society as much as possible.
The last thing — and this falls outside of my area of expertise — is how we govern this fragmented system. It seems we will have to do some restructuring, but it will have to happen at the local level. If there is some kind of governance that is set up it will have to be regional rather than provincial.
Dr. Bourget: In line with what Mr. Aubry just said, people with persistent and severe mental illnesses such as schizophrenia are often communicatively impaired. It is very difficult for them to reach out. There are resources, but they are fragmented with a little here and a little there. They do not know where to go and when to go.
It is no wonder that so many come through the legal system when their conditions get so bad that eventually they commit a crime or the police pick them up and bring them to the forensic hospital. From there on it becomes the entry door and then they get the services.
I do not have the solution to this very difficult problem, but it might help if we look at a construct where ideally there would be one door, through which the different people presenting there would benefit from a full assessment, and from being connected from a very early start to a social worker. Their needs would be assessed carefully and they could be connected to the serves they need. That is something that would help in this situation.
Mr. Grass: This is a good question. I will speak with respect to the situation in Ontario, and to a small degree about the situation in other provinces.
The extent to which people have moved along in treatment for mental illness varies. Some situations are better than others. In Ontario, I have learned that sometimes when there is a set of problems you need to cocoon the problem. More often than not, you do not even understand the numbers underneath it. To answer your question, I would cocoon the mental health system. It does two things. First, it allows you to understand the ministry and the people of Ontario to let them know what they have. It allows you to assess the people and their ability to work together towards integration. Everyone will say they will integrate, but everyone will find a way not to integrate.
You have to cocoon for a period of time. What else does that do? I would do it with the same budget and/or the limited more recent budget for a year or two, for a period of time to allow you to understand what you have underneath you.
In addition to understanding the mental health system, you will begin to understand what the concepts of regionalization really are, how they could possibly work, and how you get through to regional authorities on all those other deep-seated philosophical questions, which the lobbies all approach from different angles. It will allow you to manage a system to a point where you are giving a better service and you have a better understanding of integration. It will teach you, as we learn in business, how to bring together a set of separate operational constructs into one set of governances that will allow you to make outward resource allocation decisions that are fairer. Perhaps we will learn more about how that could effectively be a regional authority, or any of those other questions that will face us in the years to come.
For this mental health system, because the question was directed at it, there clearly needs to be a cocooning of that system. To follow Dr. Turnbull's comments, the funding must be independent — not allocated to the CCACs or any other community organization. There should be an independent governance authority possessing a set of evidence- based, decision-making abilities over a defined period of time, a manager and a set of intelligent resources who can begin to make decisions on integration. They will understand the population they are serving and lobby appropriately both within the community of services and the government to answer the question of a set of people and an amount of money. We clearly have not answered that question.
In Ontario, there is an allocation of money in the provincial budget that goes to mental health. Is that a fair amount of money for that group of people? If it is just that amount of money, then what set of resources can we provide if we all agree on a public education program over some period of time? We see these numbers of mental health patients increasing. Do we agree that that allocation has to be appropriately increased?
An intelligent coordination of that cocooned effort that can make the right lobby to help to help the ministry get over this time of inaction, this notion that it is better not to make a decision than to make a real decision. To go in a direction is to create that direction.
I am certain that that could be done. It would cross a number of conventional politically correct positions that exist in our system today. It is a difficult proposition. It needs a strong commitment. The federal position could start with a significant public education program and continue through an understanding of cross-ministry initiatives. It leads the federal government to encourage the provinces — some to a greater or lesser degree — to cocoon the mental health system for a period of time and presenting, at the end of each year, what they have learned on some evidence-based practice, and what decisions have been made as a consequence of the lobbies that exist.
I do not believe that the mental health system should be separated into its own silo when we already have many individual silos within the system. Ultimately, after it is cocooned, it needs to be brought back into whatever model of primary care that should exist in the future as we try to understand what the appropriate model for the broader health care system is.
In any business or family proposition that we all have, you need to get hold of it. You need somehow to create a construct under which everyone is managing within an umbrella of direction and thinking, to answer your question.
Senator LeBreton: Mr. Aubry, you talked about self-help initiatives. I would like you to expand on what that entails. How do we get people into a self-help stage and how are programs like these self-help initiatives administered? Is there something happening right now that is moving this particular initiative along?
Mr. Aubry: In the mental health sector and around this issue of deinstitutionalization in North America, there has been a fairly strong consumer-driven movement, which is driven by people who had significant experience with the psychiatric system getting together and forming coalitions. Sometimes it is at a very local level. Sometimes it is at a provincial level. There are even national coalitions.
Those initiatives involve supporting each other, providing a voice politically and advocating for important change. There have also been some economic development self-help initiatives that are quite interesting. In such initiatives, groups of consumers and ex-consumers have got together to look at whether they can start small businesses. There are examples of those in Toronto.
We have also self-help initiatives for families. They have been important and have played a public education and support role. Perhaps Mr. Grass knows more about that than I do through his involvement. I refer to a group like the Schizophrenia Society, which is very family-based.
There is a type of self-help sector that is out there. It is kind of haphazard and it does not receive a significant amount of resources. However, we are finding evidence that it is another piece to the system that can make a difference to people. It is a more natural kind of support.
Senator LeBreton: Is this sort of a volunteer, bottom-up kind of system? How did it get started?
Mr. Aubry: It is largely a group of people getting together and saying, "As a group, we need to try to support each other and try to have a voice. Let us see if we can get some seed funding to get going." I do not know the exact number in Ontario, but there at least 40 now exist.
Mr. Grass: Self-help and advocacy groups that exist are an important question. I am familiar with the Schizophrenia Society. I know the president and a number of the officers, both for Ontario and for Canada. A number of individual groups that have come together to share their personal experiences. In many cases, this has been the result of frustration with the system. The problem with all of them — and again, they are extremely well-intentioned groups, and they have served family interests — is that they have not taken the jump. They are only now realizing that as many groups, they are not a successful lobby. In fact, they are doing a lot of work — they are meeting next week.
However, until they are able to get together to show the size of the mental health problem, and lobbying it in an informed and professional way, the likes of yourselves and provincial and federal politicians really do not get a good sense of how significant the issues are that their loved ones face.
The issues of self-help and advocacy groups are extremely important challenges and topics to articulate. They should continue to get together to inform, however, they must understand that they cannot do it in many multi-groups. Like any construct, there are the individual family health issues that must be dealt with and then they need to come together to provide an informed and broad-based opinion to committees such as this or those at the provincial level. We do not want a fragmented, uninformed view.
We must find a set of circumstances and constructs — what the advocacy is informing in an apolitical, unbiased way about the significance of mental illness in its broadest form. However, self-help is an extremely important issue.
Sen. LeBreton: What is your advice as to how we could motivate them to form this critical mass?
Mr. Grass: I think they are doing it. Like a lot of these things, it is a question of pace and time. For example, the Schizophrenia Society is meeting soon with several of the other organizations to talk about this. At the end of the day, one of the biggest problems will be to become more professional, to create the appropriate lobbyists and executive directors who can articulate the cases. What is the funding level that we need that we cannot raise from our within our own groups, from our lottery or whatever other "well-intentioned" but small-time issues?
How do we get the appropriate funding to them, such that they do not become a political force but they become an appropriate society communicating the right issue force? That is a challenge that I encourage you to encourage the advocacy organizations and find a balance there.
Senator LeBreton: Dr. Bourget, you talked about forensic patients, and how you move them and link them into the community. Mr. Grass talked about the not-in-my-backyard syndrome. How do you then deal with this? Are there any successful models in this country or the United States or the world where they have been successful in dealing with forensic patients and integrating them into the community, or is it an area that is unresolved because of the not-in-my- backyard syndrome?
Dr. Bourget: I am not sure what happens in other countries. I can speak for Ontario, Quebec and the rest of the Canada. It is very difficult because these people face a lot of stigma. I am not speaking of the low-risk forensic patients who have family support and can usually easily reintegrate into society. These people would also do well in the supervised boarding homes, with psychiatric follow-up. They can be connected with our clinics and some services in the community through the CMHA.
I am talking about the patients who committed serious crimes when they were ill — those who are considered moderate to high risk. Even when the psychosis has abated, they have responded to treatment and are ready to enter the community, there is a problem with lodging in particular. Where will they go? Many of them cannot live independently; and the supervised boarding homes will not want to take them in — mainly because of fear and stigma. Therefore, these people have a length of hospitalization that is longer than it should be because of the lack of resources in the community and also because of a lack of education and understanding. A lot of work needs to be done in this area.
One of the proposed models is a forensic transition house, not to reproduce yet another level of institutionalization in the community, but to serve as a bridge between the forensic hospital and the supervised boarding home. Supervised boarding homes usually are not supervised 24 hours a day. There may be one staff at night. The workers are usually not trained in mental health. Often these are people who decide to operate a supervised boarding home and get subvention. Sometimes we need settings that are a little more structured and secure for these individuals.
Mr. Grass: In addition, the convalescence issue of mental health is one of great interest. As a society, we do not provide much convalescence. We have, even within the Royal Ottawa Hospital, a one and two-week program, and expect these people to go back to their families or out into the community and get on with their lives. Other illnesses, as you well know, provide considerably more lengthy times in convalescence.
With respect to children, there is an ongoing discussion at CHEO and among professionals in the community, pertaining to some form of short-term, two-to-three month intervention program — not institutionalization — that deals with a number of the impairments and issues that arise on the road to recovery, before the support of housing and other issues.
The question of recovery period in convalescence is another challenge that you could articulate. There are those who could explain it more articulately than I. Simon Davidson and other doctors at the Royal Ottawa Hospital are all very keen to introduce this issue and better understand how we can reintroduce and reintegrate these people in a more consistent way. Clearly, we are not doing it.
Senator Callbeck: One topic that has not come up this morning is tele-mental health. Can it play a role in helping people with mental illness return to their community or become fully integrated into society?
Mr. Aubry: Do you mean teleconferencing from a distance?
Senator Callbeck: Yes, and counselling or whatever. Is this being discussed at all within this area?
Mr. Aubry: It is being discussed in mental health and there are some pilot programs. In fact, I know there is one such program in Hull, but it tends to be in relation to outpatient, more acute types of difficulties that would be more transitory.
The community support services that have been developed and that have been shown to be effective, are provided in-vivo, meaning they are provide in the community, in people's homes. I am not familiar with even any pilot programs in that area for people with severe and persistent mental illness because there is such an important premium put on developing a long-term trusting relationship with professionals and service providers. It is an interesting idea and I suppose it arises when there is a problem with providing services in outlying regions, but I am not aware of any of those kinds of programs currently.
Senator Callbeck: Does anyone else want to comment on that?
Dr. Bourget: I am not sure that there is a role for this in terms of the topics that we have discussed today. However, there have been initiatives in tele-mental health for providing consultative services to more rural areas — mostly for consultation purposes. From a practical standpoint, one of the difficulties was in finding suitable time, from both ends of the system. Another issue that arose was the issue of how this system would be funded.
Senator Callbeck: Mr. Aubry, in your brief you presented future directions for mental health reform. You said that if people with severe mental illness are to have true integration back into Canadian society, we must have services and supports to help them return to school and get employment. You mentioned in the United States there are some programs that are truly impressive. Could you elaborate on one or two of those?
Mr. Aubry: Yes. I refer to them as a "third-generation" of services because I think we have made some inroads. The first generation was housing, the second generation was what is called "case management," or home care. For a lot of individuals with severe and persistent mental illness, the onset was late adolescence or early adulthood, it stopped them in their tracks. They leave school; they are not able to get going in the workforce. Third-generation services would include evidence-based programs that help people return to school. Usually there is a support there, a particular person, or a small group of people that help plan whatever kind of education that the person wants to pursue, provides some advocacy in getting into particular programs, and then supports the person while they are there. The similar kind of process is used in the workforce where, there is a support helping people prepare to return and then to re-enter the workforce.
The rate of effectiveness of these programs is in the range of 40 per cent to 50 per cent. These are not sheltered workshops; these are programs that get people into the actual labour market. However, a certain kind of coaching is required to help the person get ready to return to work and then deal with all the difficulties of actually starting a job and structuring one's life to full- or part-time employment.
Senator Callbeck: How long have these programs been in existence?
Mr. Aubry: I would say they go back over 10 or 15 years or more. They are continuing to be developed. There is continual research.
Senator Callbeck: Is the percentage increasing all the time?
Mr. Aubry: It is like the development of any kind of new intervention. There is a period where we have to find out what makes a difference and gradually improve it. The kind of research with which I am familiar suggests that it is something that can be effective.
Mr. Grass: There are three things in life: a house, a job and a friend. A number of initiatives in the United States have been highly successful. Obviously, many of these people are not going to realize the levels of quality of life they might initially have thought of. However, in many cases they are, over time, getting involved in job-action programs. There are efforts called the "Club House" in the U.S. and a number of programs where people have taken on menial jobs at the beginning and moved into truly competitive jobs in the community. Often, these jobs are at the lower levels, but at least they are progressed beyond the point that they might have been and are out of the house doing something and getting paid for it.
We could give you a number of examples that have been in existence for some time, but it is not something that we have embraced in a significant way in Ontario.
Senator Cook: There are gaps in the system: Psychiatrists are in short supply; trained people are in short supply; the judiciary and police need sensitivity training in this whole field. How do we go about that? We are where we are with how the system is organized and managed today.
Mr. Grass, I am intrigued by the cocoon principle. You advocate a cocoon principle and then integration. I would like to hear how you would manage the cocoon stage, a time frame and if you have any ideas such as core values, evidence-based information, whatever, to integrate.
Mr. Grass: With respect to the cocoon principle, I would not see a time frame beyond two years. I do not believe that it should become a life onto itself. I believe that mental health is no different from physical health and it should be a part of the system. It would be absolutely wrong to silo mental health in the way that it is already siloed into a number of services.
We must find a commitment within our federal and provincial philosophy to address what is the answer to our health system and how this cocoon would move back into the system. That should be accepted right from the beginning.
There is no reason to believe that the mental health issues should be separated. They have their own set of issues. However, we have worked issues unique to cancer and other illnesses and brought them under one umbrella as part of the whole system. Why can we not find a similar answer in mental health?
I have put a lot of detail into a substantial report, a copy of which I believe your committee has. I would hope that you have a chance to read it, because I believe that it provides a path on the cocooning toward moving back into the primary care system, whatever that may be.
Senator Cook: What we are really all about here today is seeing how we, as a society, cope with people who have special needs. How we go about it will be a challenge.
Mr. Grass: We are challenged to find the right balance. We are all faced with fiscal constraints. More often than not in resource allocation, I have always taken the cocoon and not asked for any more capital. I just tried to understand what we have within the cocoon and then the steps become obvious after that, frankly.
You understand the group that you are trying to support, or the product you are trying to sell. I am not trying to say there is a direct relationship, because we all know that health and the commercial side are far different. However, you have to understand the issues and the biases within your own cocoon. We clearly now have so many of them that we cannot control all of them. We must find a way to corral our thinking.
Senator Morin: As a retired chairman of medicine, Dr. Turnbull has selected the most unusual type of research. I would advise him, for his next project, to have a ward-based research program so the residents might do the work for him. Instead, here he is visiting the homeless and so forth. I am not sure it is very dignified for a chairman.
I would like to thank and congratulate all four witnesses. It has been an extremely instructive session.
The Chairman: I would like to finish with one piece of homework for everyone, which builds on Senator Cook's and Senator Keon's questions.
In the end, this committee will do what it did in its first report: It will give very concrete, specific and doable recommendations rather than come out at the very general philosophical level, which a number of other reports have done. All of you said right up front that this is an unbelievably uncoordinated, fragmented system, which is obviously colossally inefficient. That is the nature of fragmentation in anything. Second, it is not nearly as good for patients as other systems would be.
Mr. Grass has suggested some specific ways of dealing with that and we have his report that presents some specific proposals. I would like the rest of you to think about it and give us your thoughts, keeping the following in mind: We fully understand that no one will voluntarily give up their independence. There is Will Rogers' line that everyone is in favour of progress but no one is in favour of change.
Therefore, some element of persuasion — in the "godfather" sense of persuasion — may be required. One of the requirements may be that people do not get money unless they agree to be integrated into a particular system. While it may not be politically correct for us to suggest such a strategy, that is unlikely to be a constraint on where we end up.
We need some hard-nosed advice from those of you in the field on what really needs to be done. Forget for the moment that people may not do it voluntarily. Forget that we may have to find ways of persuading them that what they need to do is the right thing to do. The more detail you can give us over the next little while — give us a call, drop us a note — on what that structure should look like would be enormously helpful.
In the end, to simply say that the system needs to be coordinated better is a total waste of our time and everyone else's, because we all know that. The issue is how to get it done. We cannot figure out how to do it unless people like you on the ground tell us how. If you would accept this minor assignment, that would be extremely helpful to us.
Thank you all for coming. It has been a great morning.
The committee adjourned.