Health Committee on April 10th, 2014

[James Lunney, Conservative, Nanaimo—Alberni, BC]

You said population health—very good. Okay. I think they are not mutually exclusive.

[Dr. Roger Bland]

No. I like what you said.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

The third-largest health care providers' primary contact in this country are actually doctors of chiropractic.

Does it strike you that the third-largest primary contact—do you see them involved in collaborative models? If not, why not?

We're talking about the scope of health care providers.

[Dr. Roger Bland]

I can't think of any situation I know of where chiropractors have been involved. They tend, as far as I know, not to practise in close collaboration with other health care providers.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

There are some very good examples of better collaboration. St. Michael's Hospital has had a program going on for many years.

But it does strike me as odd since maybe 40% of the cases seeking help in a physician's office are musculoskeletal cases that there's clear evidence chiropractors are getting very good results with, and there are 9,000 of them out there.

It seems to me there's something missing in that collaborative model.

[Dr. Roger Bland]

When the Canadian Collaborative Mental Health Initiative was in place, there were 12 organizations involved in this, and chiropractors weren't one of them. I don't know why.

Psychologists were part of it.

[Dr. Karen Cohen]

Can I say something?

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Absolutely. Please do.

[Dr. Karen Cohen]

If that was the Mental Health Initiative, there was another one around EICP, which was primary care across health, not just in mental health, so perhaps the chiropractors were involved in the latter one as opposed to the mental health one.

In terms of your point about collaborative practice, I just want to make one point. In tertiary care facilities where other health care professionals who are not covered by provincial health insurance plans are salaried, there's terrific support for collaborative care.

I spent 10 years working in physical medicine rehabilitation helping people with spinal cord injuries and chronic pain adapt and manage their conditions. Chiropractic probably would have been involved at some point if not in the tertiary care facility itself.

That works exceedingly well. It's not that health professionals don't know how to work collaboratively. The funding model breaks down when it's in community, when it's in primary care.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Well, that being—

[The Chair, Conservative, Ben Lobb]

Your time is up, unfortunately, Mr. Lunney.

Ms. Fry, you have the next round, for seven minutes, please.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Mr. Chair.

I think that as we look at scope of practice we cannot separate it from looking at some of the better ways of delivering health care. It used to be, as you well know, that health care was delivered in a hospital by a physician or a licensed dentist, and that was what the Canada Health Act covered. Today one is realizing that it's a costly way to deliver care, and that there are, as all of you are saying, a lot of other people who can, in a multidisciplinary team, provide extremely good care by appropriate caregivers.

I want to ask Dr. Cohen a question. If one looks at the ideal multidisciplinary practice in a community care setting, it shouldn't, I believe—and I would hope you agree—be there only to look at management of chronic mental disease. Could it not be that one could link with schools in such a way that psychologists, say, could be hired by a school board to detect early childhood behavioural problems, early bullying, the early things that could lead to suicide and other psychoses? That could then be brought into the community care team with a primary care physician, with a psychiatrist if needed, etc. Could you see that being a good model? I know that the U.K. has that model. It's an extremely good model.

[Dr. Karen Cohen]

I think you raise an excellent point. Health happens in a lot of places, not just in hospitals and not just in doctors' offices and schools.

One of the things we've often suggested in terms of the best deployment of psychologists' skills...and, like psychiatrists, we're only one member of a large team. It might be a social worker or a peer support worker or so on who's the best person for the problem. But really, it's at the front end and knowing what the problem is...I think it's really critical to have the expertise of someone who can assess and diagnose, to know where the person should be triaged, and then there's great room in the middle for a lot of care and a lot of kinds of providers.

Psychologists do work in schools. The challenge is that schools face funding pressures. There are fewer and fewer resources. People don't want to wait a year and a half on a waiting list to have their child's learning disability assessed, or whatever it is, and then go to the private sector, and then there may be some breakdown in communication back with the public sector.

But I think you raise an excellent point.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I understand that schools are under funding pressures, but if this is going to be a new model of delivering multidisciplinary care in a community setting, could it be that the health portfolio provides that chunk for that kind of school, a psychologist system...? You may need, I don't know—you'd probably know better—one psychologist for six schools, etc., but I think that really is going to be at the front end of preventing some issues.

I wanted to ask Dr. Bland this, because I met with some psychiatrists when I was in Halifax. I was always very impressed and moved by something that one of the psychiatrists said to me. He was a forensic psychiatrist who had been working in the prison system for 11 years. He quit and went back to do pediatric psychiatry because he believed that if you could get the kid before the age of four you could prevent a lot of the hard-wiring that goes on and that leads to certain behavioural problems later on. That links to the school thing that I was talking to Karen about.

Do you see this linking to preventing a lot of the forensic psychiatry that's needed in a prison system? I wondered if you could also comment on why there have been no ads for prison psychiatrists or psychologists from the federal government—that you have seen—because this is absolutely necessary in a corrections setting.

[Dr. Roger Bland]

I can't comment on why I haven't seen them. Maybe I didn't find them.

You're asking other questions.

Most adult psychiatric disorders have their origins in childhood or in adolescence: about 70% or 80%, excluding dementias. Mental health programs in schools used to be a big feature of mental health services. They disappeared for a long time. They're now reappearing. Certainly, Alberta has put a substantial amount of money into developing mental health programs in schools.

Not all schools need the same level of mental health program. There are some real problem schools and problem populations going to those schools who need far more intervention than some of the others. So it shouldn't be that every school should have a cookie-cutter program, but I do think this is very useful. School mental health, for detection, is a very useful mechanism.

Whether you can actually prevent adult disorders, I don't know. Remember that the child guidance movement started in 1928. It was set up on the premise that if you only treated the children you'd have no adult mental disorders. It hasn't quite worked out like that.

[Hedy Fry, Liberal, Vancouver Centre, BC]

No.

As I'm told by a group from Dalhousie doing a great deal of research on this now and working with children in schools for early diagnosis, a lot of these kids end up in the prison system for various reasons that they feel could be prevented or in some way mitigated before they get into the prison system.

[Dr. Roger Bland]

If you look at the prison population and at the proportion of people who have been physically abused and sexually abused, who have substance use problems, it seems to be a population with a lot of disadvantages and a lot of strikes against them. It's also not that easy to treat. If you can prevent family abuse, child abuse, sexual abuse—and there are programs aimed at that—through national public health programs preventing abuse, it would be a very significant move.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

How am I doing on time?

[The Chair, Conservative, Ben Lobb]

You have 40 seconds to go.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I just saw one such school doing this work in an inner city in Saskatoon. It was remarkable the results they were getting after three years. They have a psychologist there. It's a one-stop shop, really, for parents and kids and everybody. The school has become a hub for prevention and intervention at an early stage.

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is Mr. Wilks, please.

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

Thanks, Mr. Chair.

Thank you to the people who are here today.

I just wanted to quickly comment, Mr. Chair, on something Dr. Bland said with regard to RCMP mental health training; I'm retired from the RCMP.

This is touched on at Depot in Regina, but the reality of the situation is that for most police officers across Canada, they're probably the first person to see someone with a mental health issue. To be quite blunt, they don't have the time. If they come across a situation, their job is to just hand it off to whoever it needs to get handed off to and get to the next call. They recognize that it's a significant issue, but it's not their job. It just isn't.

I'll leave it at that, because I have some questions I want to ask.

Our government established the Mental Health Commission of Canada to develop a mental health strategy. I understand that you people may be part of that. I was wondering if you could give some comments on that. It was a good first step, but how do we go from there?

Karen, perhaps you can start, and then Dr. Bland.

[Dr. Karen Cohen]

The investment in the Mental Health Commission was terrific. The strategy is excellent. The challenges for the strategy are implementation, I think, because there are so many authorities of implementation in health, as you know. Care is delivered provincially and territorially. So it's a matter of taking those recommendations and building the collaboration and goodwill to make the changes on the ground that I think will be the biggest challenges to the mental health strategy.

Certainly our organization has been involved. They now have a number of really wonderful initiatives looking at guidelines for e-mental health, suicide prevention; I think certainly they have the time and attention of all stakeholder communities. Sometimes, for me, it's like picturing a bunch of people milling around outside a bus. We all know where it needs to go, but we're not quite sure who can get up and drive it.

I think that will be the biggest challenge.

[Dr. Roger Bland]

I would agree with your comments.

I think there's an awful lot in that strategy, and I don't think anybody could say we're going to do 100% of that. I think it will be a case of finding the things that are feasible and doing them, both feasible in terms of practical, the ones you can do and the ones you can afford, and moving down the road.

With regard to your police comments, I go out about 150 times a year with the police. I go out with RCMP in Sherwood Park and St. Albert and some of the rural areas. I also go out with the city police in Edmonton. There's no comparison in how they deal with things. The city police seem to be far better able to deal with mental health crises.

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

We'll agree to disagree on that.

I wonder if you could comment on the extent that psychologists are integrated into the health care system in general.