 
It is hereby declared that
the primary objective of Canadian health care policy is to protect, promote
and restore the physical and mental well-being of residents of Canada
and to facilitate reasonable access to health services without financial
or other barriers.
Canada Health Act, 1984, c.6
s.3
We are almost forgotten,
You know, the misbegotten,
Those who see a different light,
A light of darkness bright.
Give Us a Chance
Michael Mann
Yellowknife, N.W.T.
January 2000
I want to thank the Commission for this opportunity to present a view
of the future of health care in Canada that includes in its core, services
for people who suffer from addiction or mental illness. The primary objective
of health care policy, as stated in the Canada Health Act, is to promote
physical and mental well-being. Yet, we are often a group that is left
out of debates about Canadian health care. The definition of "hospital",
as defined in the Canada Health Act, specifically excludes institutions
primarily for the "mentally disordered."
Thus, we are seen as secondary to the central issues of reform. We arenít.
The reforms you are considering will have a strong impact on the patients
we serve.
The Centre for Addiction and Mental Health is located in Toronto and
is the largest mental health and addiction facility in Canada. We are
a teaching hospital and research facility that has been recognized by
the World Health Organization. We run clinical programs, support communities
in health promotion and prevention programs, work with government on policy
development and resource allocation and strive towards eliminating the
stigma associated with mental illness and addiction.
In my short time today, I want to do two things ñ provide you
with a snapshot of the burden of mental illness and addiction in Canada,
and, recommend ways in which the Commissionís work can ease that
burden.
Mental Illness and Addiction
in Canada
i) Disease Burden
Twenty percent of the general population suffers from a mental illness
or addiction in any given year and 3% experience profound suffering and
persistent disablement (Offord et al. 1996; McEwan and Goldner, 2000).
The impact of this is staggering: over 1.5 million Canadians are currently
experiencing clinical depression, a disorder that affects 10-15% of Canadians
at some point in their lives (CAMH, 2001). One of every eight Canadians
will be hospitalized for mental illness at least once in their life (Cleghorn,
1991), more than are hospitalized for cancer and heart disease (Health
Canada: Federal-Provincial-Territorial Report, 1999).
According to the WHO these illnesses account for the greatest degree
of disability, worldwide. The disability is complicated by the effects
it has on employment, social relationships and family functioning.
Addictions are devastating. One in 10 adults report problems with their
drinking. Over 6,500 Canadians died in 1995 as a result of alcohol and
over 80,000 were hospitalized for alcohol related health problems (CCSA,
1999).
Smoking causes even more deaths. One in six deaths a year in Canada,
or 34,700, is caused by smoking (CCSA, 1999). Over 28% of Canadians 15
years and older smoked daily.
Of particular concern is the general increase in the numbers of youth
reporting use of multiple substances (illicit and legal). For example,
the percentage of students in Ontario reporting use of four or more substances
doubled to 17% in the 90s (Roberts et al, 2001).
ii) Economic Burden
Left undiagnosed or untreated, mental health and addiction problems cause
large productivity losses. They have been estimated as amongst the most
costly of all health problems. Health Canada has reported that lost productivity
due to workers being on disability or due to premature death was more
than $8 billion in 1998 (Stephens and Joubert, 2001).
It is also estimated that substance abuse cost the Canadian economy more
than $18 billion in 1992 which represented 2.7% of gross domestic product
in that year (CCSA, 1999).
Health Reform
to Support Mental Health and Addiction Issues
So what can be done? This submission is not advocating a set of actions
for mental health and addictions alone. Rather, we are highlighting those
ideas that make sense for our community and for the health care system
overall.
-
Include mental health and addictions in the definition of
health and illness
Mental health and addictions services are a key component of primary
and acute care. We cannot exclude the hospitals that care for those with
mental illness from the Canada Health Act. This stigmatizes and
discriminates against sick people and reinforces an artificial distinction
between physical and mental illness that serves no one well. We encourage
the Commission to end the separation, and recommend that dealing with
mental health issues be considered part of defining overall health and
well-being. We see a strong role for the federal government in this sector.
Support should be given at this level for a national action plan and policy
framework on mental health and addiction within national health care policy.
-
Take a broad view of the policy levers that will improve health
A broad view of health supports the use of policy levers outside the
traditional health care system to generate improvements in health (Evans
and Stoddart, 1990). Income, community supports, housing, employment and
self-help advocacy have been demonstrated to improve clinical status,
reduce hospitalization and encourage people with mental health problems
to stay in their communities (Health Systems Research Unit, 1997).
Health reform initiatives must move beyond the funding envelopes of hospitals
and physicians and include the broader supports we know make a difference
to health status.
-
Include health promotion in reform efforts
Health promotion efforts early in life make a difference to health outcomes
and life expectancy later in life. One out of every five children in North
America shows signs of an emotional or behavioural problem. Many of these
children have more than one problem, including poor school performance,
learning disabilities, increased school dropout rates, substance abuse
and violent behaviour. The consequences of these problems can last a lifetime
(Centre for Studies of Children at Risk, 2002). Effective health promotion
programs, focused on young people early in life, have been demonstrated
to make a difference. Yet health spending on young people is minimal,
and in some provinces is not even included in the health portfolio. Resources
need to be redirected and focused on programs to prevent mental health
disorders and addiction problems in youth.
-
Expand public coverage under the Canada Health Act
We agree with the five principles of the Canada Health Act. In fact,
we think they should apply to more than acute care institutions and physicians.
In 2002, as we contemplate a broader, more comprehensive view of what
makes us healthy, mental health issues and institutions, including psychiatric
hospitals, should be part of the whole.
Second, as others have argued, public funding for the costs of medications
prescribed outside of institutions should be a priority. This is very
important for our patient population as many need long-term pharmacotherapy
to maintain employment, housing and other community connections.
Third, we also support the proposal that home care be covered under the
Canada Health Act. Again, our patient group often need some, sometimes
minimal, support to stay in their homes in their community. Research has
shown that even the very difficult-to-house populations can benefit from
supports such as staffed community residential housing where homecare
resources are part of the support package (Health Systems Research Unit,
1997). But, the resources must be there.
-
Speed up primary care reform and include mental health and
substance abuse
You have noted, during your public hearings, the need for primary care
reform as fundamental to any further improvements in care delivery in
Canada. We agree and would urge strong recommendations in this regard.
Patients with mental illness and addictions will benefit greatly from
a team of care providers, 24 - hour access to care, a focus on health
promotion and wellness, and coordinated case management. Please make sure
they are included in rostering plans and are not seen as a separate group
to be dealt with later.
As well, health professionals in these new teams will need more education
and training in dealing with mental illness and addictions. Training programs
and health care employers should be encouraged to expand curricula in
this regard.
-
Improve health human resource planning
Like other areas in the health care system, mental health and addictions
suffer from a lack of coordinated planning for its health professionals.
There is no central planning mechanism to ensure appropriate distribution
of these resources across communities or to co-ordinate hiring. Those
who work in their own community practice decide where they wish to locate,
the hours of operation they wish to keep and the type of service they
wish to provide.
The distribution of medical and psychiatric resources geographically
is a concern. Billings to the provincial health insurance plan show differences
in the percentage of the population accessing mental health services from
a range of 6.6% in one area to 12.7% in another (Lin and Goering, 2000).
We are not suggesting a separate planning process is required for mental
health service providers. However, we would encourage that mental health
professionals be included in whatever recommendations the Commission may
be making about health human resource planning overall. It should take
into account the distribution issues as well as ensuring those with the
most severe conditions get access to services.
-
Forget about increased private financing
Many will come before you and provide the evidence about the advantages
and disadvantages of considering an expanded role for private financing
in our future system. For our community -- it does not matter whether
we are talking about user fees, co-payments, medical savings accounts
or private insurance -- none of them will work. The resources don't exist,
the collection infrastructure wouldn't work, and those with frequent contact
with providers would be the most penalised as they would be less likely
to continue seeking care if a financial impediment was put in the way.
Services for our population are vulnerable to begin with. Looking to private
financing as a way of reducing the cost to the public system is unacceptable.
Over the last 10 years, we have made tremendous advances in knowledge
about the genetic, medical, and psychological bases of mental illness
and addictions. But, we must continue to advance the science. It is
an investment in our collective future.
-
Put citizens at the centre of a reformed health care system
The mental health sector has long advocated for the inclusion of consumers
and their families in any reform initiatives. This principle should apply
to the reform of the system overall. Our clients have real knowledge
of Canada's health care system. We need to find new and better ways to
involve citizens in decisions about their care and their care system.
Summary of Recommendations
In summary, we are very supportive of the Commission's mandate and the
direction the Commissioner is heading. Our recommendations are offered
as part of improving Canada's health care system and improving services
for our clients.
Our recommendations are:
- Include mental health and addictions in the definition of health and
illness
- Take a broad view of the policy levers that will improve health
- Include health promotion in reform efforts
- Expand public coverage under the Canada Health Act
- Speed up primary care reform and include mental health and substance
abuse
- Improve health human resource planning
- Forget about increased private financing
- Invest in research
- Put citizens at the centre of a reformed health care system
References
Adlaf EM and Lalomiteanu A (2000) CAMH Monitor eReport: Addiction
and Mental Health Indicators Among Ontario Adults, 1977-2000. Toronto:
Centre for Addiction and Mental Health Research Document Series No. 10.
Canadian Centre on Substance Abuse (1999) Canadian Profile 1999. Ottawa:
Canadian Centre on Substance Abuse and Centre for Addiction and Mental
Health.
Chan B (1999) Supply of Physicians' Services in Ontario. Atlas
Reports - Uses of Health Services. Toronto: Institute for Clinical Evaluative
Sciences.
Centre for Studies of Children at Risk. www.mcmaster.ca/cscr/core
Cleghorn J and Lee B (1991) Understanding and Treating Mental Illness.
Toronto: Hogrefe and Huber Publishers.
Evans RG and Stoddart GL (1990) Producing health, consuming health care.
Soc Sci Med 31(12): 1347-63.
Health Canada (1999), Federal-Provincial-Territorial Report, 142.
Health Systems Research Unit (1997) Best Practices in Mental Health
Reform. Discussion Paper Prepared of the Federal/Provincial/Territorial
Advisory Network on Mental Health.
Lin E and Goering P (2000) Fiscal Changes for Core Mental Health Services
Delivered by Fee-for-Service Physicians. Atlas Reports - Uses of Health
Services. Toronto: Institute for Clinical Evaluative Sciences.
McEwan K and Goldner E (2002) Accountability and Performance Indicators
for Mental Health Services and Supports. Vancouver: University of
British Columbia.
Offord D et al (1996) One year prevalence of psychiatric disorder in
Ontarians 15-64. Can J Psychiatry 41:559-63.
Rochefort DA and Goering P (1998) More a Link Than a Division: How Canada
Has Learned from US Mental Health Policy. Health Affairs 17(5):110-127.
Roberts G et al. (2001) Preventing Substance Use Problems Among Young
People. A Compendium of Best Practices. Ottawa: Health Canada.
Stephens T and Joubert N (2001) The Economic Burden of Mental Health
Problems in Canada. Ottawa: Health Canada Series: Chronic Diseases
in Canada. 22(1).
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