International Journal of Law and Psychiatry, Vol. 23, No. 3–4, pp. 345–359, 2000 Copyright © 2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/00 $–see front matter
PII S0160-2527(00)00034-0
Canada’s Mental Health System Paula Goering,* Donald Wasylenki,† and Janet Durbin,‡
Current Context Canada, with a population of slightly over 30 million people, is a self-governing union of 10 provinces and 2 territories. Federally, legislative power is vested in a Parliament that includes an appointed Senate and elected House of Commons. At the provincial level, legislative power is vested in an elected legislature and extends to education, municipal affairs, direct taxation, and civil law. Provinces also hold significant responsibilities for the delivery of health care, housing, and social services. The cornerstone of the Canadian health care system is a national health insurance program called Medicare. Administered by the provincial and territorial governments, and regulated and partly financed through block transfer payments by the national government, Medicare pays basic medical and hospital bills for all Canadians. The federal government sets standards in order to maintain common values and elements within distinct province-sponsored health insurance plans, which are responsible for delivery of services and regulation of services and professionals. Historical Context Early legislative milestones in Canadian health care include the Hospital Insurance and Diagnostic Services Act (1957) and the Medical Care Act (1966), which made insurance for hospital and medical services available to all Canadians. In these acts, the federal government agreed to contribute funding to provincial health insurance plans that met five principles: accessibility, universality of coverage, portability from province to province, comprehensiveness
*Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. †Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. ‡Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Address correspondence and reprint requests to Paula Goering, Department of Psychiatry, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada; E-mail:
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of services, and government administration. The Canada Health Act of 1984 reinforced these national standards and allowed the federal government to apply financial penalties to provinces who breached these principles (e.g., by introducing user charges). In 1995, health expenditures in Canada totaled $75.2 billion, comprising 9.6% of the national gross domestic product, compared with a U.S. rate of 14.2% (U.S. Bureau of Census, 1997). Canada’s achievement of superior performance on key measures of health status with a lower rate of investment has generated considerable interest among Americans in Canada’s health insurance program (Lakaski, Wilmot, Lips, & Brown, 1993; Rachlis & Kushner, 1994; Rochefort, 1992). The history of mental health care in Canada parallels the U.S. experience, beginning with the management of the mentally ill in poor houses in the early 1800s and then in provincial mental hospitals from in the mid 1800s until well into the 20th century. As these facilities became increasingly overcrowded, with little treatment available, the philosophy of deinstitutionalization emerged to shift care into psychiatric units in general hospitals and into the community. The result was a drop in bed-capacity in Canadian mental hospitals from 47,633 to 15,011 beds between 1960 and 1976, with general hospital psychiatric beds increasing from 844 to 5,836 (Wasylenki, Goering, & MacNaughton, 1994). As in the United States, initial enthusiasm for deinstitutionalization dampened with the awareness that many discharged patients were leading impoverished lives in the community, swelling the ranks of the homeless and those in jails. In response, in the 1970s provincial governments began to flow funds to community mental health programs. Despite ongoing interest in enhancing community supports, this sector of the mental health treatment system remains underfunded, consuming only about 3% of provincial mental health budgets in 1990 (Freeman, 1994). Proponents of mental health reform continue to stress the need to shift resources from inpatient to community care.
Organization of Mental Health Service System Provision of mental health services is the responsibility of provincial ministries of health. Services provided directly by mental health divisions usually include provincial psychiatric hospital services (PPHs) and community mental health programs. More recently, as newer administrative models, such as regionalization, have evolved, PPHs either have been devolved from direct Ministry of Health administration to autonomous incorporation or have been placed under the aegis of regional health boards. While community mental health programs often operate under the direct supervision of the mental health division, in some provinces they have the status of transfer payment agencies, receiving funding from the mental health division, which is administered independently with ministry supervision. General hospital psychiatric unit services (GHPUs) and physician services for mental health conditions are publicly funded in Canada but typically are administered by divisions of the ministries of health responsible for overall hospital services or physician payments. General hospitals are autonomous corporations governed by boards of
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directors representing their communities and their operations are governed by provincial legislation in the form of public hospitals acts and, in the mental health field, by the provisions of provincial mental health acts. Other supports and services that are essential to the maintenance of mentally ill individuals in the community, such as financial entitlements and housing, typically are administered by other ministries within provincial governments or by municipalities. In some provinces, innovative arrangements between the Ministry of Health and Social Service Ministries have led to coordinated approaches but, in general, coordination between treatment and essential support services is lacking. Until very recently the provision of mental health services in Canada has been characterized by fragmentation, lack of mechanisms to coordinate or integrate services, and little accountability (White & Mercier, 1991). The mental health system has been described as consisting of three solitudes (Wasylenki et al., 1994)—PPHs, which are separate from the communities they serve and from other providers; GHPUs, units which operate as part of autonomous hospital corporations, free to determine their priorities; and community mental health programs, which tend to be small, overburdened with demands for care and with little influence on the system as a whole. A fourth solitude would include mental health professionals, such as psychiatrists, practicing independently and receiving public funds but also disconnected from other elements of the delivery system. Three approaches have been developed in Canada to achieve better integration of mental health services. These include decentralization of ministry of health management functions, regionalization, and/or the creation of mental health authorities or agencies. In Ontario, which is Canada’s largest province with roughly 35% of the total population (11 million), the Ministry of Health embarked upon a plan in 1998 to create seven health regions, each administered by a Ministry of Health Regional Office headed by a regional director. This plan is to be implemented by the year 2000. With regard to mental health services, the regional offices will undertake system management functions to attempt to rationalize resource utilization and to achieve higher levels of service integration. Most provinces in Canada have rejected a decentralized Ministry of Health model in favor of the creation of regional health boards. These boards either are elected or appointed and have responsibility for the planning and operation of all health, including mental health, services for a defined population. Thus, in the regional model the system governance and management functions pass from the Ministry of Health to boards composed of local citizens. In both models, there is a role for the provincial ministry of health in setting standards, establishing priorities, and determining benchmarks for mental health services within regions but the extent to which mental health budgets will be protected remains to be seen (Gourlay, 1998). The third model, creation of independent mental health authorities or agencies with control of the entire mental health budget for a region, was implemented effectively in the province of New Brunswick, which established a provincial mental health commission with seven regional mental health boards from 1988 to 1996. Responsibility for all mental health services in the province, including 13 mental health clinics, 7 general hospital psychiatric units, and the 2 provin-
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cial psychiatric hospitals was transferred to the Mental Health Commission with regional management functions delegated to the regional boards. Between 1988 and 1994, budgets for community mental health centers rose from $6.6 million to $16.4 million, and community support services funding increased from $700,000 to $2.6 million. In concert, there was a 33% reduction in numbers of beds at both provincial psychiatric hospitals, and admissions to psychiatric units in general hospitals increased by less than 10% (Health Canada, 1997a). Fiscal Issues Current concerns relate to the federal role and to economic pressures to reduce deficits and halt rising health-care costs. In particular, the current federal government has cut over $6 billion dollars in the annual transfer payments for provincial social programs since 1993. This means that cash transfers are paying an increasing smaller portion of the Medicare bills paid largely by the provinces. Since 1978, the portion paid by the federal cash share has reduced from 27% to 11% (Kennedy, 1998). Many are concerned that this will undermine the federal government’s ability to uphold the principles of Medicare. Another trend is an increase in private sector health care expenditures (paid out of pocket or by private insurers), which the Canadian Institute for Health Information reports now represent 30.3% of the total health bill, in comparison to 23.6% in 1975 (Canadian Institute for Health Information, 1998). These trends have engendered a great deal of controversy and public debate, and there are calls for increased federal spending, a renegotiation of federal/provincial roles, and a redefinition of coverage to possibly include national pharmacare and/or home-care programs. Within provincial governments these changes have increased the pressure to contain mental health-care expenditures. There are numerous methods by which Ministries of Health finance mental health services and the single-payer system is far from simple is this respect (as illustrated by Rocheforte’s [1997] description of the funding patterns in Nova Scotia). The bulk of mental health spending goes to hospitals via global budgets and physicians via fee for service. There are provincial variations in mental health budgeting, but the reader can get a general sense of how dollars are spent through a description of Ontario, where in 1992 total cost for mental health were $1.28 billion representing approximately 8% of all health-care expenditures. More than half of the mental health dollars went to provincial psychiatric and general hospitals, a third was paid to physicians and 10% to community mental health programs (Goering & Lin, 1996). Because government has more direct control over hospital and community mental health expenditures there has been a great deal of interest in these sectors. Long-Stay Beds In Canada, long-stay mental health beds have been located, almost exclusively, in PPHs. The usual pattern is for each PPH to be responsible for meeting the intermediate- and long-stay bed needs of a geographically defined catchment
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area. The total bed complement in PPHs in Canada fell from approximately 50,000 in 1960 to approximately 11,000 beds in 41 PPHs today. Further bed reductions are planned in most provinces, along with a shift in the role of PPHs. All acute care will be provided by GHPUs with priority being given to persons with severe and persistent mental illnesses. Community supports and services will be enhanced significantly, with emphasis on intensive models of support. The role of PPHs with regard to inpatient care will be tertiary, that is, they will provide specialized treatment and rehabilitation services for individuals whose needs for care are too complex to be managed in the community. The Ontario Health Services Restructuring Commission has recommended closure of 5 out of 10 PPHs, and set a target of 35 beds per 100,000 adult population for hospital-based mental health services by the year 2003. Only 14 of these 35 beds are to be used for longer-term mental health care. With adequate specialized outreach and alternative residential settings in place, a more aggressive reduction of longer-term care beds to between 7 and 10 per 100,000 adult population might be feasible (Wasylenki et al., 2000).
Community Mental Health Services It generally is argued that in Canada, as elsewhere, failure to achieve an ideal of community-focused mental health care is a result of insufficient resources. In most provinces an overreliance upon hospital and medical treatment has resulted in unbalanced systems of care. Availability of community mental health programs varies from region to region within provinces, and programs have not consistently served people with serious mental illness (Goering, Wasylenki, & McNaughton, 1992). This is not surprising because little centralized direction and regional coordination has been provided. Provinces are beginning to address this problem through a redirection of resources combined with more allocations for community care. Case management is becoming a critical resource for ensuring that needs for community care are met. Case management programs in Canada are either intensive, attempting to provide directly a comprehensive continuous treatment and rehabilitation program or generic, being less intensive, less specialized and less comprehensive. It is estimated that 25% of individuals with severe and persistent mental illnesses who are in treatment require an intensive approach (Goering, Durbin, Cochrane, & Gehrs, 1994). The preferred model for intensive case management in some provinces is assertive community treatment (ACT). Canadian jurisdictions also have begun to develop community-based crisis response systems as an alternative to a hospital-based emergency service to deal with exacerbations of severe mental illnesses. A crisis response system is a series of connected interventions ranging from least to most intrusive, and typically including phone lines, walk-in clinics, mobile crisis teams, free-standing crisis centers, hospital emergency departments with holding beds, and inpatient psychiatric units. These systems are well-developed in the province of Manitoba where most regions of the province rely heavily on mobile crisis teams and free-standing crisis centers to support individuals with severe and persistent mental illnesses (Health Canada, 1997a).
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Another element of community support in most Canadian jurisdictions is supported housing. To facilitate patient discharges from PPHs, a number of provinces have made commitments to increasing supplies of housing stock and providing flexible support services that are not linked to specific housing units (Fox, 1998; Health Canada, 1997a). In Canada, the provision of supported housing requires collaboration between provincial ministries of housing and health as the actual housing stock must be supplied by one ministry and the supportive services by another. Physician Roles in Mental Health Care The major proportion of primary mental health care in Canada is delivered by general practitioners (GPs) working alone, in groups, or in conjunction with specialists, including psychiatrists. All GP and psychiatrist services, including mental health services, are fully insured by publicly funded, single payer provincial health insurance plans, with few or no restrictions on the type or amount of mental health care available. These plans do not usually cover services provided by other mental health professionals. A recent Ontario study on utilization of GP and psychiatrist mental health care is likely indicative of practice across the country (Lin & Goering, 1998). In 1992/93, three quarters of users of physician mental health services in Ontario received care from GPs compared with about 9% of users who received care from GPs and psychiatrists together, and only 10% who received services from psychiatrists alone. However, the mean number of GP visits for mental health services was about 2, compared to 15 for GPs and psychiatrists, and 10 for psychiatrists alone. An analysis of claims by fee code indicated that most GP mental health services were for psychotherapy (54%) and counseling/education (39%) while psychiatrists mainly provided psychotherapy (58%), inpatient psychiatric care (13%), and assessment or consultation (9%). During the last 5 years in Ontario and British Columbia, use of physician mental health services (GPs and psychiatrists) has increased faster than use of physician services for other health problems (Hamdi & Bigelow, 1998; Lin & Goering, 1998). There is increasing interest in Canada in developing models of shared care between GPs and psychiatrists to enhance the capacity of the primary mental health care sector (Kates, Craven, Webb, Low, & Perry, 1992). Stronger, more direct working relationships between these providers is expected to result in better coordinated, more economical care. Shared care may involve prompt availability by telephone of psychiatrists to GPs to discuss mental health issues, or psychiatrists working, at least part of the time, on-site with primary care service providers. General Hospital Psychiatric Units Secondary level inpatient and ambulatory care is provided in Canada by approximately 370 GHPUs providing 10,000 inpatient beds. These units are funded through general hospital global budgets. Mandated GHPU services in most provinces include inpatient care, outpatient care, day care, emergency care, and consultation (Clarke Consulting Group, 1997).
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GHPUs have an important role to play as one component of an integrated, community-focused crisis response system. Mobile crisis teams, the core component of the system, may be based in GHPUs. More typically, the team is located elsewhere in the community but depends upon the GHPU for 24-hour emergency psychiatric assessment. An increasing number of GHPUs have developed some type of nonmedical crisis response capability. Models range from having one skilled psychiatric nurse per shift to carry out assessments in the emergency department to a full nonmedical crisis team with authority to admit to holding beds. Holding beds also have become important components of GHPU crisis/emergency services. These beds, which do not require admission to hospital, generally provide up to 72 hours of observation for patients in a secure environment adjacent to the emergency department or inpatient ward. GHPU assessment and treatment services include: brief stay (15 days or less) inpatient treatment to diagnose and stabilize acutely ill individuals; day hospitalization and/or home treatment to avert inpatient admission or minimize length of inpatient stay; and outpatient ambulatory care for individuals with multifaceted problems whose care needs to be integrated and monitored closely. Inpatient programs generally follow principles of crisis stabilization with an aggressive approach to medication management, illness education and discharge planning. Usually a small number of intensive care beds are located in a secure area on the unit to allow for the management of very disturbed or disturbing behavior. Day hospitals are part of acute care programming, are often located on-site and contribute a high degree of flexibility to GHPU functioning. Home treatment programs aim to avert admission to inpatient programs by providing intensive therapy in individuals’ own homes. There are relatively few psychiatric home treatment programs existing in Canada. Outpatient ambulatory care should focus on individuals with complex care needs to avoid duplicating what is provided in the community. Consultation and family education refer to community-focused activities whereby staff of the GHPU provide client and program-centered consultation to community programs and agencies and also organize programs of psychoeducation and support for relatives and friends of patients. Finally, GHPUs in Canada increasingly are expected to participate in integrative activities such as inter-hospital planning and the development of strong working relationships both with community supports and services and with regional tertiary care programs. Tertiary Care The preferred model of mental health service delivery in Canada relies heavily on increasingly intensive community supports and services operating, in local areas, in conjunction with general hospital psychiatric units (GHPUs) and a regional tertiary care centre. This continuum is able to provide services for individuals whose needs are complex and who require highly specialized resources. Particularly vulnerable are individuals with more than one significant condition, each of which traditionally has been dealt with by a different system of care—for example, individuals with concurrent disorders (mental illness and substance abuse), older people with psychiatric disorders (psychoge-
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riatrics), individuals with mental illness and developmental disability (dual disorders), and those with neuropsychiatric disorders (including acquired brain injury). Access to tertiary care should require referral from secondary care and criteria for access should include need for higher levels of management and security, staff expertise, and staff and program resources as well as more detailed and specialized assessment and treatment. Increasingly there is an emphasis on developing organized systems to insure that individuals meet criteria for tertiary care and receive the most appropriate level of care. There is increasing interest in portable and community-based tertiary care models to delink delivery of tertiary care from particular settings or time frames. Alternative models include small, homelike, well-staffed residences and specialized interdisciplinary outreach teams based in a hospital or community that provide back-up and support to families and providers in a variety of settings. As well, assertive community treatment teams enhance community programming and provide effective care for individuals in all groups who are extremely disabled and have histories of heavy use of mental health services. The availability of tertiary care back up often results in greater willingness among primary and secondary care providers to accept individuals with difficult conditions and behaviors. Level of staff expertise is a critical element of tertiary care. Tertiary care providers require advanced training and a commitment to serve the population. Because of these requirements, tertiary care programs often are affiliated with academic health science centers (Wasylenki et al., 2000). Individuals with Complex Needs Until recently in Canada substance abuse treatment services were planned and delivered separately from mental health services. In some provinces, such as Alberta, Saskatchewan, and New Brunswick, a separate administrative structure, such as a drug and alcohol commission, was formed. In others, such as Ontario, a separate branch of the Ministry of Health was responsible for substance abuse services. Growing awareness that administrative separation of services has impeded effective treatment is stimulating efforts to integrate mental health and addiction services. One result is the creation of the Centre for Addiction and Mental Health in Toronto, a merger of two psychiatric facilities and two addictions centers. It is hoped that this new merged organization, with a budget of approximately $150 million annually, will develop model programs of effective services in both areas and for individuals with concurrent disorders. Forensic services in Canada target individuals unfit to stand trial; not guilty by reason of insanity; or subject to a court-ordered remand for a psychiatric assessment under the criminal code. A small number of patients may be under temporary medical absence arrangements from correctional facilities, having been convicted of an offense but considered currently mentally disordered and in need of hospitalization. Once again, different provinces have developed somewhat different models. In British Columbia, until very recently, a separate forensic commission existed outside of the generic mental health system. In Ontario, forensic services are provided by provincial psychiatric hospitals through the operation of relatively small, medium secure regional forensic units. As well, in Canada there are three maximum security
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forensic hospitals, one each in British Columbia, Ontario, and Quebec. Currently there is concern in most provinces about the number of mentally disordered individuals being processed through the criminal justice system. Alternatives being developed include mental health training programs for police officers, court diversion programs, and assertive community treatment teams that focus on forensic clients. In the 1990s, homelessness has emerged as a major social problem, particularly in Canada’s large urban areas. In Toronto, with a population of approximately 2.5 million, it is estimated that there are 25,000 homeless individuals. It is understood that the major causes of homelessness in Canada are structural—primarily related to an increase in poverty and a decrease in affordable housing due to conservative fiscal policies focused on deficit reduction. It also is understood that there is an association between homelessness and mental illness. In a recent Pathways to Homelessness study in Toronto (Tolomiczenko & Goering, 1998), two thirds of a representative sample of 300 homeless individuals were found to have a lifetime diagnosis of mental illness and two thirds had a lifetime diagnosis of substance use disorder. There was considerable overlap between the two subpopulations, with 75% of those with mental disorders also diagnosed with a substance use disorder. Of interest, only about 11% of the sample suffered from psychotic disorders, with the great majority of diagnosed mental illness consisting of depression. Although there has been no system-wide approach to addressing the problems of the mentally ill homeless, it is acknowledged that what is required is a combination of affordable housing and intensive support. Human Resources Currently there are 3,600 psychiatrists practicing in Canada, and approximately 13,000 psychologists and 11,000 nurses who indicate that mental health is their primary area of responsibility. Education and training is shared by the formal educational system, employers, and professional organizations. There is typically a long interval between the introduction of new program models and changes in the basic training of mental health professionals. Systematic attempts by provincial governments to provide continuing education that prepares the workforce to function within reformed systems of care are needed. The province of Manitoba has provided leadership in this arena (Health Canada, 1997a). The mix of mental health professionals is deployed somewhat differently than in the United States because of the funding mechanisms. Most nonmedical personnel work within agency or hospital settings on a salaried basis since fee-for-service reimbursement is limited to physicians. There are serious problems with the distribution of psychiatrists, who tend to congregate in urban centers, leaving large geographic areas underserviced. User Perspective The last two decades have seen dramatic changes in perceptions about the capabilities of consumers and components of community support. This de-
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rives, in part, from the emergence of the consumer and psychiatric survivor movement in Canada, the United States, and other parts of the world in the postdeinstitutionalization era (Everett, 1994). The Canadian Mental Health Association- National (CMHA), a nongovernmental nonprofit organization, has been a leading force in altering views across Canada about consumer capacities and necessary elements of a system of care. Its major policy document, A New Framework for Support for People With Severe Mental Disabilities (Trainor, Pomeroy, & Pape, 1993), insists upon the inclusion of all stakeholders and sectors in planning and providing mental health care, and replaces an undue emphasis upon professional services with greater attention to natural supports, self-help, and access to basic needs (e.g., housing, income, work). It also explicitly recognizes the value of experiential knowledge. The Framework has stimulated policy and program development across Canada. While provinces vary in their accomplishments, there has been steady progress in developing linkages between mental health and generic community supports; increased involvement of consumers and families in service design and delivery; and support for consumer and family organizations. Ontario made a significant funding commitment to consumer groups in 1991 when it allocated over $3 million to the Consumer Survivor Development Initiative to implement a province wide base of consumer controlled organizations. A novel aspect of the Initiative is that it disallows funding for traditional service models that featured clients and providers, so that limited dollars can be used to explore new support models. The Initiative is now an established component of the Ontario mental health system, and consumers and families continue to be priority groups for reallocated dollars although they still receive a small percentage of overall mental health funding (Health Canada, 1997a; Trainor, Shepherd, Boydell, Leff, & Crawford, 1997). Public Opinion and the Media Public opinion has somewhat less direct influence on policy-making in a parliamentary system where special interest groups are not as powerful as in the United States and decision making is more centered in the public service bureaucracy (Rochefort & Goering, 1998). Still, Canadian provincial and federal politicians are clearly influenced by the opinions of their constituency, and the media is the most common mode of communication between the public and their government. Coverage of mental health issues tends to be centered on a few key topics with homelessness, suicide, and violence receiving the lions share of attention. At times this coverage influences development of mental health policy. For example, a number of recent threats and subway pushings by individuals with mental illness (many of whom were not taking prescribed medications) flamed public outrage and supported the efforts of the families of the mentally ill in advocating for a change in legislation to introduce community committal. Shortly afterward, the Ontario government announced its intention to pursue this course of action. Sometimes media coverage is done in a particularly constructive and responsible manner. A 7-day series written by a journalist funded by the Atkin-
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son Foundation to investigate mental health issues, provides an example (Simmie, 1998). The series began with the juxtaposition of two narratives describing the lives of individuals who had experienced severe mental illness. Scott Simmie revealed his own history of bipolar disorder, including an initial psychotic episode that occurred while on location in Eastern Europe as a public television producer. His harrowing attempts to get treatment; the unsupportive response of his employer; and his slow, fragile progress to recovery are all described in moving detail. In the same edition, he also gives the story of Edmond Yu, a bright medical student who became ill with schizophrenia. After many years of unsuccessful treatment and continued deterioration, Edmond was shot to death by the police, who cornered him in a bus after he had hit a fellow passenger. Both stories were told with courage and compassion that elicited the interest and sympathy of readers from all walks of life. In the subsequent articles, a combination of careful research and specific examples were used to inform the public about problems and potential solutions. The latter included a description of a typical day for an assertive community treatment team in the inner city and a profile of several successful consumer-run businesses. The combination of personal account and careful investigative reporting created a powerful series that was educational, destigmatizing, and much appreciated by mental health consumers and providers. Unfortunately, such coverage of mental health by the Canadian press is the exception, not the rule. Relevant Legislation, Mental Health Acts, and Community Treatment Orders Canadian law reflects the structure of Canadian federalism, with a division of responsibilities between provincial and federal governments. Civil law, contracts, wills and estates, and health law, including the regulation of health care professionals are primarily within the province’s jurisdiction while criminal law is governed at a federal level. Regarding mental health care, provincial legislation typically deals with hospitalization of involuntary patients, treatment of mentally incapable individuals, substitute decision-making related to personal care and management of property, and protection and disclosure of clinical records. The federal Criminal Code defines how mentally ill offenders are to be assessed and treated in Canada (e.g., assessment for fitness to stand trial, criminal responsibility, disposition where unfit or not criminally responsible, and hospital orders). While there are many commonalities across provinces and territories in mental health legislation, differences do exist (e.g., in adult guardianship laws where there is variation in mechanisms for protecting individual rights) (Arboleda-Florez, Crisanti, & Holley, 1995; Schneider, 1996). In mental health, the need to balance the rights of the individual and the protection of the community is an ongoing concern. Most provincial mental health acts allow for involuntary detention in psychiatric facilities of individuals who are determined to be a danger to themselves or others, or who cannot take care of themselves. Across the country people are debating the value of changing mental health acts to include Community Treatment Orders (CTOs), a legal mechanism for ensuring compliance with treatment outside of hospital, and three provinces have legislated involuntary community commitment— British Columbia, Saskatchewan, and Manitoba. In Saskatchewan, CTOs were
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adopted to provide more support to families and a more streamlined mechanism for hospital admission during a crisis. However, the need to respect civil rights and limit the criminalization of mental illness was recognized, and six stringent conditions must be met before the legislation can be applied. The order is in effect for a maximum of 3 months and requires the opinion of two physicians, one of whom must be a psychiatrist, to be enacted. Only 63 CTOs have been issued over a 3-year period within a population of approximately 6,000 people with serious mental illness. In a recent government consultation with diverse stakeholders in Ontario, introduction of CTOs was not endorsed. People appear to be primarily concerned with increasing availability of community services and engaging people willingly into treatment (Canadian Mental Health Association, 1998). Future Trends It is clear that the next decade will see a continuation of the shift to community care that has characterized previous decades. Most of the provinces in Canada have recently released mental health policy statements that reaffirm their commitment to decreasing hospital beds and establishing more community supports. The challenge will be to implement these policies on a widespread basis so that the goal of community integration for those who are most severely ill becomes reality rather than rhetoric. As implementation proceeds there are a number of issues and trends that will need to be addressed. Mental health has to find its place within new provincial health care structures. Regionalization of health care has occurred in all of the provinces except Ontario. Quebec and Saskatchewan devolved and decentralized health care first; most of the other provinces have done so since the early 1990s. Although there are some variations in the governance and operating structures, what is common to regionalization is the concept of integrating mental health with physical health services and giving control over decision-making to local boards or authorities. Although separate regional mental health authorities have been successfully implemented in various settings (Mechanic, 1991), the impact of integrated regional health structures is less clear. A major threat is that already-scarce mental health dollars will be reallocated to other healthcare priorities. This has happened in the past within general hospital settings across Canada, where psychiatric units were often the “last funded, first cut” (Ross, 1998) unless special protections were put into place by the provincial funders. A similar phenomena has been reported in England by Martin Knapp (Mental Health Policy Research Group, 1997). Expectations of increased accountability from consumers, funders, and the public will affect many aspects of future mental health care in Canada. Although there is widespread opposition to managed care as exemplified in the United States and a “principled opposition to making individual patients the focus of cost-containment efforts” (Rochefort, 1997, p. 182), there is recognition that the pressure of financial constraints and the need to improve current practice will require new methods of organizing and financing care. There will be more attention paid to utilization review, measurement, and reporting of outcomes and clearly defining roles and responsibilities between levels of care.
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The funding of hospital and community services is likely to be tied more explicitly to performance and casemix factors. Physician payment will be less reliant upon fee for service and include more use of alternative payment plans and sessional or salaried positions. All of these innovations will put more pressure upon all aspects of the system to have comprehensive clinical and administrative information to describe and evaluate their activities and results. One of the unique aspects to mental health reform in Canada has been the Framework for Support conceptual model developed by the Canadian Mental Health Association (see section on User Perspectives). The values and philosophy articulated in this model have had national impact (Health Canada, 1997b), but there is much to be done before the policy is fully implemented. It will be particularly important as mental health relates to integrated regional health structures, not to lose sight of the other systems that represent broader determinants of health, that is, housing, income, jobs, and social connections (Ross, 1998). Further funding and development of consumer/survivor businesses and interministerial partnerships provide excellent vehicles for operationalizing these principles. A recent review of Best Practices in Mental Health Reform (Health Canada, 1997a, 1997b, 1998) prepared for the Canadian Federal/Provincial/Territorial Advisory Network on Mental Health summarizes evidence related to mental health reform and has become an important reference tool for most provinces. Available evidence on effectiveness of core services and support is compiled and outstanding model programs in each service area across Canada are profiled. As well, the best practices document identifies system reform strategies, that is, best administrative practices, for creating an environment conducive to implementing mental health reform. Implementation of evidence-based therapies and best practice models of service delivery are explicit aims of the mental health policies in most provinces. Ways and means now must be found to make the newer antipsychotic medications accessible to all those who could benefit and to ensure that assertive community treatment teams and other effective approaches to rehabilitation are available on a wide-scale basis. This requires the development of new policies and procedures as well as staff retraining. It also will entail sensitive responses to those who fear those rigid treatment guidelines and program models will be imposed from above with no room for innovation or adaptation. Enhanced investment in treatment and program evaluation is one way to address such concerns, but levels of funding for mental health research are currently quite low and relationships between researchers and policy-makers need to be strengthened.
References Arboleda-Florez, J., Crisanti, A., & Holley, H.L. (1995). The effects of changes in the law concerning mentally disordered offenders: The Alberta experience with Bill C-30. Canadian Journal of Psychiatry, 40(5), 225–233. Canadian Institute for Health Information. (1998). National health expenditures trends, 1975–1998. Ottawa: Author. Canadian Mental Health Association. (1998). Community treatment orders. Network, 14(2), 4–13. Clarke Consulting Group. (1997). Towards a reformed system of mental health care in Southwest Ontario:
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