Health Committee on April 10th, 2014

[Janet Cooper]

It's a collaboration, it doesn't have to be a prescription—

[Terence Young, Conservative, Oakville, ON]

So a patient can go into a pharmacy and just say, “I think I have high blood pressure—

[Janet Cooper]

No.

[Terence Young, Conservative, Oakville, ON]

—what are you going to give me?” Do they have to go to a doctor first?

[Janet Cooper]

They would have to. You would have to get that diagnosis. A pharmacist would not start anti-hypertensives on a patient without some kind of collaboration with a physician.

[Terence Young, Conservative, Oakville, ON]

Okay. I note, by the way—

[The Chair, Conservative, Ben Lobb]

Mr. Young—

[Terence Young, Conservative, Oakville, ON]

—in British Columbia, they pay doctors to not prescribe, which results in a lot of—

[The Chair, Conservative, Ben Lobb]

Excuse me, Mr. Young.

[Terence Young, Conservative, Oakville, ON]

—interventions that are good for patient safety.

[The Chair, Conservative, Ben Lobb]

Thank you.

This brings a close to our first hour of our meeting.

I would like to thank all our guests today—really great presentations.

What we will do is suspend for a minute or two, and then we will ask our guests who are in for the second hour to come up and get ready. You're going to get an upgrade in the second hour because Ms. Davies is going to take my position. You're going to get a real chair for the next hour.

We are going to suspend, and we will be back in a couple of minutes.

[The Vice-Chair, NDP, Libby Davies]

I think we are ready to begin again. We are ready to go to our next hour of the committee.

We have two witnesses.

Ms. Cohen, chief executive officer of the Canadian Psychological Association, thank you for being here.

Our second witness is Mr. Bland from the Canadian Psychiatric Association. Thank you for attending today.

We will begin with Ms. Cohen. It is up to 10 minutes for your presentation.

[Dr. Karen Cohen, Chief Executive Officer, Canadian Psychological Association]

It should be eight minutes, actually.

Thank you very much for the invitation to join you today to talk about best practice and barriers for health care professionals in Canada.

First I'll talk a bit about the Canadian Psychological Association. It's the national association of Canada's scientists and practitioners of psychology.

There are about 18,000 regulated psychologists in Canada. They are employed by many publicly funded institutions, including health care centres, family health teams and primary care practices, schools, universities, and correctional facilities. Correctional Services Canada is in fact the country's largest employer of psychologists.

Increasingly, however, psychologists practise in the private sector. Across sectors, their scope of practice includes the psychological assessment and diagnosis of mental disorders and cognitive functioning, the development and evaluation of treatment protocols and programs, the delivery of psychological treatments, and research.

Needs for mental health services in Canada are considerable. One in five Canadians has a mental health problem in a given year, the most common problems being anxiety and depression. The fastest-growing category of disability costs is depression. The annual cost of mental illness to the Canadian economy is $51 billion, while the impact on productivity in the workplace is estimated at tens of billions of dollars annually.

Forty per cent of disability claims to Treasury Board are related to mental health, a figure not atypical for large employers. The significance of the gaps related to mental health was recently acknowledged by Treasury Board when Minister Clement announced that federal employees and retirees will see their coverage for psychological services double as of October 2014. The CPA applauds the federal government for this needed benefit enhancement, particularly for having made it within its climate of fiscal restraint.

The importance of this announcement by Treasury Board is underscored by the very significant barriers created by the way in which health care is funded in Canada, particularly mental health care. Only about one-third of those who need mental health care will receive it. This can be attributed to stigma, but also to the lack of access to service.

Psychologists are Canada's largest group of regulated, specialized mental health care providers. Their services are not funded by provincial and territorial health insurance plans. In the private sector, Canadians either pay out of pocket for psychological service or rely on the private health insurance plans provided by their employers.

The coverage through private plans is almost always too low for a clinically meaningful amount of psychological service. Imagine cardiac care without access to cardiologists or obstetrical care without access to obstetricians and midwives. This is the situation we find ourselves in in the case of psychological services and mental health. While much has been made of not wanting to create a two-tiered health care system for Canadians, when it comes to mental health service, arguably we already have one.

Psychological treatments work for a wide range of mental disorders as well as contribute significantly to the management of chronic health problems and of such conditions as obesity, heart disease, and chronic pain. They are less expensive than and at least as effective as medication for a number of common mental health conditions.

People with depression who are treated with psychological therapy tend to relapse less frequently than those treated with medication. Successful treatment with psychological therapies results in decreased use of other health care services, with the costs of treatment being more than mitigated by reduced costs attached to those services.

Recent research suggests that combining psychotherapy with medication enhances treatment compliance, reduces the subjective burden of disease, and is associated with lower suicide rates. For anxiety disorders, psychological treatments are first-line interventions and generally are as effective as medication.

The Council of the Federation commissioned a health care innovation working group in which I participated as co-chair of the Health Action Lobby, or HEAL. It has tasked itself with three priorities, namely pharmaceutical drugs, appropriateness of care inclusive of team-based models, and seniors care. CPA joins HEAL in calling on the federal government to participate in this important work.

For Canada to innovate and improve the way in which it delivers health care to Canadians, we need to work as collaboratively to change the system, as we do to deliver care. If we want a health care system that will deliver cost- and clinically effective care, then we must re-vision policies, programs, and funding structures through which health care is provided.

For its part, the CPA commissioned a group of health economists to cost out alternate models of making psychological services more accessible to Canadians. CPA has been bringing the findings of this report and its recommendations to all of Canada's stakeholders in mental health: employers, governments, and private sector insurers. We hope that, like Treasury Board, stakeholders will take seriously the individual, workplace, and societal cost offset of making psychological services more available to Canadians who need them.

Although there may be no appetite to spend more on health care, little spending now means spending more later: more on health care utilization, more on absenteeism, presenteeism and disability at work, and perhaps most importantly more in the costs borne by individuals and families.

A second issue affecting psychological practices is chapter 7 of the Agreement on Internal Trade. The AIT mandates provincial and territorial regulatory bodies to create the mechanisms necessary to support the mobility of professionals across Canada. The challenge is that, while regulatory bodies have considerable responsibility for mobility, they have little authority in establishing the criteria for mobility.

Entry to practice standards for psychologists vary across the country. What has resulted with AIT is that mobility has become based on the least rigorous of these standards rather than upon the very robust standards for training in psychology established and maintained by the Canadian and American Psychological Associations for decades, standards that define training in psychology across North America. It is CPA's position that entry to practice standards for Canadian psychologists should be at the doctoral level and based on these accreditation standards.

Finally, there are gaps when it comes to training, recruitment, and retention of Canadian psychologists. We have heard about the very significant needs for mental health services among members of the military. We know that recruitment and retention challenges are faced by public employers of psychologists such as correctional and educational facilities. There are generally three factors that impact the success of recruitment and retention.

First, employers need to participate in the training of the resource they want to attract and retain. We have suggested that the federal government consider the development of a federal residency program to enable doctoral students in psychology to complete training in federal departments where there is need.

Second, employers need to pay attention to compensation. Federal employers of psychologists have historically offered salaries lower than those offered by other public sector employers for similar work.

Third, employers need to pay attention to conditions of work. Workplace success depends on the meaningful engagement of individual employees and teams. We have recommended to the Department of National Defence, for example, that they consider putting clinical psychologists in uniform, giving them a chance not just to work to support the delivery of health care, but to deliver their considerable skills in shaping its delivery as well.

In sum, our recommendations to the committee on health are as follows: we urge the federal government to participate in the health care innovation working group with the Council of the Federation. It is through collaboration that we will successfully re-vision how health care can best be delivered to Canadians. We ask that the federal government review the provisions of the Agreement on Internal Trade to permit alignment with the robust systems of training and credentialism long established by the profession. We urge the federal government to participate in the training of the resource it needs, and upon which its success depends. The development of residency training programs and careful consideration of the conditions of work will go a long way to enhancing recruitment and retention of health care professionals.

The CPA would be very glad to assist work towards these goals.

Thank you.

[The Vice-Chair, NDP, Libby Davies]

Thank you very much, Ms. Cohen. You were actually under eight minutes.

Next we'll turn to Dr. Bland.

Welcome to the committee, and you have up to 10 minutes to make your presentation.

[Dr. Roger Bland, Member, Professeur Emeritus, Department of Psychiatry, University of Alberta, Canadian Psychiatric Association]

Thank you very much, and thank you for asking the Canadian Psychiatric Association to make a presentation to your committee today. We have chosen a limited number of topics but invite a broader discussion of these topics and any other questions that the committee may wish to raise afterwards.

First, let me introduce myself. I'm a psychiatrist and the deputy editor of the Canadian Journal of Psychiatry, a researcher and former chair of the department of psychiatry at the University of Alberta, and a former assistant deputy minister for mental health in Alberta. I am a member of the joint Canadian Psychiatric Association and College of Family Physicians of Canada shared working group and have been since 1998.

The Canadian Psychiatric Association, founded in 1951, is a voluntary organization, and represents approximately 4,500 psychiatrists and 600 residents. The association advocates for the mental health needs of Canadians and for the highest standards of professional practice.

The CPA—that is, the psychiatric, not the psychological association—works with governments and other mental health stakeholders, and we provide continuing professional development and promote research. The Canadian Psychiatric Association is not a licensing body, does not control education or training requirements, and does not set fee or payment schedules for psychiatrists.

Perhaps one might ask, what is a psychiatrist? Psychiatrists train first as medical doctors, then undergo a further five years of training in behavioural medicine before being certified through national examination. The ability to integrate medicine, psychiatry, neuroscience, psychology, and social science is a skill set unique to psychiatrists. Perhaps more than any other medical specialty, psychiatrists work with multidisciplinary teams. Increasingly we are called upon to work within a collaborative team framework; that is somewhat different from a multidisciplinary team.

Moving on to what is a relatively innovative way of delivering health care services, what does “collaborative care” mean? It involves practitioners from different specialties, disciplines, or sectors working together to offer complementary services and mutual support to ensure that individuals receive the most appropriate service from the most appropriate provider in the most suitable location as quickly as necessary and with a minimum of obstacles. It is built on personal contacts, mutual respect, trust, and the recognition of each partner's potential roles and contributions, and also on effective practices that are preferably evidence- and experience-based.

Collaborative care can be seen as part of the overall picture of primary care reform advocated by the World Health Organization. Canada adopted the principles of primary care reform from the World Health Organization, and all provinces have supported them to a greater or lesser degree.

However, after initial enthusiasm and in our case the support of the Canadian Collaborative Mental Health Initiative, which involved 12 organizations and was funded by the primary care innovation fund, the federal government seems to have somewhat lost the initiative in pursuing collaborative care. It would be appreciated if the federal government could reiterate its support for primary care reform and ensure that it includes a strong mental health component.

Increasing the number of specialists does not necessarily increase the health of the population and may in fact make it worse and more expensive, whereas increasing the number of primary care providers does improve population health and tends to reduce costs in the long run. The task, then, of the specialist is to ensure that the primary care providers are well supported and have ample access to different levels of specialist service, preferably as close to their work site as possible.

Psychiatrists and family physicians have worked together for 15 years to promote collaborative care and have had considerable success in having the concept adopted by both organizations. There are now many programs in place across Canada that provide ample evidence of its uptake.

One document produced by the Canadian Collaborative Mental Health Initiative analyzed the evidence behind best practices in collaborative care. It found that collaborative relationships require system-level collaboration, preparation, service reorganization in many cases, and time to develop.

Co-location of services was important to patients. Systematically following up on patients, rather than leaving it to chance or “see me when you feel like it”, produced better outcomes. Patient education delivered by other health care professionals improved patient outcomes, and giving patients treatment options improves their engagement in treatment.

Collaborative care also significantly reduces stigma, which is a major factor in mental health. Payment systems, however, which are usually provincially set, can be an obstacle to collaborative care and there is no consistent payment system and therefore no consistent way in which collaborative care is really supported.

Looking at mental health and some of the federal services, there are several collaborative opportunities here. First, as an employer, the CPA applauds the pilot of the national standard for psychological health and safety in the workplace at Health Canada and encourages its wider adoption.

With regard to the RCMP, training the RCMP in mental health crisis intervention would be a good move. Some of this happens, but clearly not enough. For example, some police forces have adopted the mental health first aid program and put large numbers of their members through that program, but not, I believe, the RCMP.

For the military, the prime problem facing the military seems to be the management of post-traumatic stress disorder and the comorbidities that go with that. New programs have been developed and seem to be reasonably effective. The problem of military families involved in this, though, may not have been adequately dealt with and they may need further support, as may some of the self-help groups that are being started, often on a voluntary basis, in some locations for the military.

Turning to federal prisons, over the last 40 years the incarceration rate has increased 75% in federal prisons. That's not numbers, that's the rate per 1,000 population. In a one-year period, 60% of federal offenders received mental health services, and 30% of women offenders and over 14% of male offenders had previously had a psychiatric hospitalization. Substance use problems affect four out of five offenders. Women prisoners had a 50% rate of self-harm, and 85% had been physically abused and over two-thirds sexually abused. I understand the Correctional Service has suggested that there is difficulty in recruiting physicians, and this may be true. But earlier this week I checked the Government of Canada jobs website and found no advertised vacancies for physicians or psychiatrists in the Correctional Service.

With regard to research, the federal government is perhaps the largest research funder in Canada, and there is a need to support demonstration projects on how collaborative care can help address common problems faced by health care systems, particularly with reference to underserved populations, such as the aboriginal, homeless, rural, and isolated communities.

Questions have been asked about multidisciplinary training, and many of the health science faculties in Canadian universities now offer combined courses for several health disciplines. While this is a strong move forward, there is probably still scope for further improvement. Instruction on how to work collaboratively as part of a team, including situations in which the physician may not be the anointed team leader, is certainly needed.

Residency training programs in psychiatry—that's now the post-M.D. specialty training—now include a mandatory experience in collaborative care. There is also scope for multidisciplinary continuing professional development programs. The Canadian Psychiatric Association has run some of these, but they are difficult to maintain financially, since they receive little support except for contributions from people who attend. It is not quite clear what the federal government's role in this could be, but encouragement of and support for continuing multidisciplinary professional development activities would certainly be appreciated.

Thank you very much.

[The Vice-Chair, NDP, Libby Davies]

Thank you very much, Dr. Bland.

We'll now begin our first round of questioning. It's seven minutes for both questions and responses.

We'll begin with Mr. Morin.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you, Madam Chair.

I am going to take four minutes and give the remaining three to my colleague, Mr. Boulerice. Could you kindly let me know when my four minutes are up?

[David Wilks, Conservative, Kootenay—Columbia, BC]

On a point of order, could we allow Dr. Bland to get his earpiece in?

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

My question is for Ms. Cohen.

You talked about barriers in terms of the general public's ability to access psychological services. Mental health treatment isn't among the range of services that provinces and territories provide under public health plans, at least not in Quebec. Please tell me if there are any provinces that do cover the cost of psychological services under their public plan. The bottom line is that access to treatment is seriously limited.

Do you think the federal government should give the provinces and territories financial support, perhaps increase health care transfers? The idea would be to bring mental health care under the umbrella of services available to Canadians through public health plans.

[Dr. Karen Cohen]

I'm going to answer you in English. I could try in French, but I'm going to answer you in English because I think that's actually a really tough question.

There are of course jurisdictions where psychologists are salaried by public institutions, and in fact, in essence, there is no charge to the patient or the client or user of those services. There are psychologists involved in primary care teams and family health teams, but increasingly what's happened is that public institutions face their own pressures, they decrease their salaried resource, and psychologists go to the private sector. When I graduated with my doctorate years ago, most of us went on to work for universities and teaching hospitals. Now, young psychologists are graduating to work in private practice.

It's a challenge. I think, if I'm to be candid, that we have a public medical insurance system, not a public health insurance system. We pay designated providers to deliver designated services in designated venues.

So it's tough when we're talking about providing collaborative and multidisciplinary care, particularly for chronic conditions, of which mental health conditions can be one, because there is no magic bullet. There is no one solution. There is no one health provider, be they a physician, a psychologist, a social worker, or a counsellor who has the answer. To support team-based care in a model that pays designated providers for service is a huge barrier.

Is there something the federal government could do in terms of targeting funds or transfers for mental health? I would probably leave that for economists more knowledgeable than I to answer, but there is certainly a need for a solution.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you.

[The Vice-Chair, NDP, Libby Davies]

Mr. Morin, you're just a little over three minutes.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

My second question will be quick.

For private insurance reimbursement, a lot of them request a prescription from a medical doctor. Do you think it adds an extra barrier that is not needed, especially for preventative measures?

[Dr. Karen Cohen]

Absolutely. There is no reason by regulation. Psychologists are regulated in our jurisdictions to deliver care. They can accept self-referrals. It is a requirement of some insurance programs and not others. It's a gatekeeping requirement. It's not a requirement that's at all tied to the scope of practice of the psychologist.

I agree with you. Not only does it create a barrier of access for the client or the patient, it also burdens the public health system, which is burdened enough.

[The Vice-Chair, NDP, Libby Davies]

Thank you.

Mr. Boulerice, you have three minutes.