Finance Committee on May 11th, 2017

[Ron Liepert, Conservative, Calgary Signal Hill, AB]

Is CIHI doing anything like that?

[Glenn Brimacombe]

Very much, and it ties into the performance of the mental health system, because a lot of the metrics in CIHI are acute-care-based, and as you've heard today a lot of the investments that are needed are community-based. We need to square that circle. CIHI is beginning to do some of that work and the Graham Boeckh Foundation is already involved in leading some of the work with five provinces right now. There are opportunities there that we really need to take advantage of when it comes to squaring the circle.

In terms of accountability, I would hope that all provinces would be reporting to their respective residents about the investments they're negotiating with the federal government so we can see what's happening on the ground.

[The Chair, Liberal, Wayne Easter]

Dr. Cohen, and then Mr. Boeckh.

[Dr. Karen R. Cohen]

I have a comment about CIHI.

Many of the witnesses have commented that much of the care that's provided in Canada is in the private system. CIHI does not have that data, so the interventions of psychologists and social workers and counsellors are not captured. We made some appeals to CIHI to include mental health providers, and although they have data on some, social workers and psychologists are not among them.

The countries Patrick referenced that have done something innovative to enhance access to mental health services have done that nationally. The U.K.'s program to enhance access to psychological therapies, or Australia's better access program to psychiatrists and psychologists, was done nationally.

We have challenges in how we administer health care here. But when you have a centrally funded program, and you can bake your accountability into the program and the training of the people delivering care, it's a lot easier to implement and you have more accountability in what's delivered and more data on which to shape it going forward. Indeed, they have metrics for over 90% of sessions delivered under that program. They have got 45,000 people off of sick pay and disability, and have recovery rates approaching 60%.

[The Chair, Liberal, Wayne Easter]

Mr. Boeckh.

[Ian Boeckh]

I think these are really good questions that you're asking. How do we make this money really count and actually change the system?

We have some insight on that because we've been working with multiple provinces to create joint ventures to really transform the system for child and youth mental health care.

You see, the problem for them is that they have a very complex system and so many priorities, and it's very hard for them to change the system. If you can come along and help provide some extra money to them, and show them how it can be done, and sort of make it easy for them, then you can do it, and I don't think having a very prescriptive approach is really going to work, because at the end of the day, the provinces have to run the system and they have to own it.

I urge you to look at some of the joint ventures we have. British Columbia is the leader in this and they've started to create integrated youth service hubs in various communities across the province, and they've created a branded service that is called Foundry. You can look it up. This really brings service providers in the community and gets them to think of how they can create a stepped care model, so we can do what Patrick and Kim have talked about, have the light services for those who only need that, and clear pathways to care for the more specialized services.

With things like this, health transfers, there's always a rush to get money out the door, but I think if the federal government is really motivated, and it brings its various organizations that do things in mental health to bear on this, you really can influence the system.

All of the provinces for years and years have stated they want to do a much better job at mental health care. They want to be more patient oriented. Usually it doesn't happen, but I think the federal government can do a much better job of coordinating and really making it easy for them. That's the key.

[The Chair, Liberal, Wayne Easter]

Thank you.

Go ahead, Mr. Dusseault.

[Pierre-Luc Dusseault, NDP, Sherbrooke, QC]

Thank you, Mr. Chair.

I would like to thank all the witnesses for being here today. It's extremely important to hear their comments on the budget implementation bill, particularly with respect to the health transfers that have been announced for next year.

I would like to quickly go back to these investments and compare them with those of other G7 countries. Canada ranks last among the G7 countries in terms of health spending, but can you elaborate on that? How much of that, percentage-wise, is spent on mental health? Also, will the investments in the budget for this year and those promised for the next few years allow us to rise in this ranking?

[Dr. Patrick Smith]

Yes, and I think this is also documented in the Mental Health Commission's mental health strategy. We have a mental health strategy from the commission, but it's not an action-based strategy that we're talking about here.

The G7 country with the lowest spending on mental health other than Canada is at 9%. They invest 9% of their overall health spending in mental health. We're at 7.2%, so we're 2 percentage points behind the next lowest.

When the U.K. found that they were quite behind, they began making dramatic investments. But their investments have been yielding savings in other areas of health, which they've reinvested. They've also yielded savings in corrections, which they've reinvested. They're up to 13%, and they still don't think they're at the right level. Just to give you a sense, we're at 7% and they're at 13%.

You mentioned Allan Rock, and I think it's important to piggyback on these two issues. There is precedent when Allan Rock was health minister, and we were the only G8 country at the time that didn't have a drug strategy. The Paddy Torsney committee, as many will remember, set out to examine that. The federal government created Canada's drug strategy, made investments, but they also set aside investments with Health Canada for the drug treatment funding program.

I've been at the provincial level. We get provincial funding for health, but the drug treatment funding program was developed and disseminated federally, just as Karen was saying in regard to all these other things, so there is precedent. The provinces worked with this direct funding from the drug treatment funding program, managed out of Health Canada federally.

I know it's not an easy thing to address. On a piece of paper, 2 percentage points a year means nothing, but when you consider how significant the gap is, 2 percentage points year over year over year, that's how big the gap is. In some provinces and some areas of the country, it's like the emperor has no clothes. There are more gaps in mental health services than there are services.

The transformation and investment needed, in the wisest way—you can't just throw money at it—is going to need more coordinated action, as other countries have demonstrated. It's going to need some kind of federal transformation fund in addition to what you're transferring to the provinces.

[The Chair, Liberal, Wayne Easter]

Mr. Dusseault.

[Pierre-Luc Dusseault, NDP, Sherbrooke, QC]

Thank you for those clarifications, Mr. Smith.

Mr. Culbert, I'd like to give you an opportunity to respond to what was said earlier. You mentioned several figures on the return on investment in health generally, but do you have the same kind of numbers for investment in prevention? Indeed, according to a common expression, an ounce of prevention is worth a pound of cure. Do you have any analysis that shows that prevention is much more cost-effective in the long term than just intervening once the damage is done?

Also, would it be possible to direct part of the federal investment to prevention, rather than investing solely in treatment?

[The Chair, Liberal, Wayne Easter]

Mr. Culbert, go ahead.

[Ian Culbert]

Thank you for the question. There are a few different layers there.

There is a lot of good data on return on investment for a lot of preventive upstream interventions. For example, for every dollar we invest in vaccination we save $16. I mentioned before road and vehicle safety; for every dollar invested it's $40. The one figure I gave you for around mental health was that for every dollar invested in mental health and addiction, we save $37 in both health care costs and social costs. My colleagues probably have more precise information regarding that, but it's clear that it's always cheaper to prevent an illness than to treat and cure one, be it physical or mental.

I'll go back to the earlier question. It certainly would be a question better posed to the next round of witnesses from the Privy Council Office, but our understanding is that the funds for the provinces for mental health services are going to be paid out of the consolidated revenue fund, not out of the health transfer fund. That is a significant difference. Funds transferred through the health transfer fund cannot have strings attached to them, and that has been the bugaboo of the federal government with the provinces and territories from day one. My understanding is that these are targeted funds and that negotiation now has to happen as to how specifically they're funded. However, the funds to each province that are earmarked for mental health services cannot now be redirected back into physical health services, hospitals, you name it. That is an important distinction. That is why in the budget the transfers are reported separately from these special funds for mental health services and home care. This was the specific intention of the Minister of Health in negotiating the health agreements—there was no health accord this time around—and why it was difficult, why there wasn't a single health accord, and why the minister has had to go to bilateral agreements with all of the provinces and territories except one.

Once in the health system, though.... While a great deal of work has been done to moderate the stigma associated with mental health among the general public, I think within certain health professions—and I'm making a broad generalization here—mental health is not taken seriously by health professionals. A surgeon, a cardiac surgeon or neurosurgeon, is still at the top of the heap, and I think the mental health sciences are still considered as being the touchy-feely people who have conversations and talk to people. Until that attitude changes, you're going to see health systems that continue to direct the funds toward the sexy stuff and away from the stuff where key investments are required.

Thank you.

[The Chair, Liberal, Wayne Easter]

Thank you.

We're over time, Pierre.

Mr. Sorbara.

[Francesco Sorbara, Liberal, Vaughan—Woodbridge, ON]

Thank you, Mr. Chair.

Welcome, everyone. It's great to have everyone here this afternoon.

I'm going to keep my remarks very short, and I'll just ask one quick question. This is an issue that we're sort of happy to talk about because I think we're going in the right direction. It's basically a non-partisan issue, but our government is going in the right direction, I think, with funding. However, it's also a very sad or melancholy issue to have to talk about mental health because it does impact so many Canadians and costs our economy literally tens of billions of dollars every year.

Recently, I was able to participate in the Kids Help Phone walk up in York Region, up in Vaughan. It was very well attended. I think the Kids Help Phone raised $250,000 that day. It was just a great event, and the stories that were told were very touching. There also was the CAMH One Brave Night for Mental Health, called “the one-night stand”, where people stayed up for the entire evening in support of mental health. There seems to be a lot going on to end the stigma and to ensure that we help kids and all Canadians impacted by this.

My question comes out of a case that came to my office. A father came in asking for help for his daughter. The question in this case was that the resources available in downtown Toronto in this situation were not equivalent to the resources in York Region. At his age, he couldn't drive his daughter downtown daily to get the treatment and then come home. It was too arduous for him. There seems to be, I feel, a gap between the resources and what's happening in the core of the city versus the outer area. The region I have the privilege of representing is not really rural. It's actually quite urban up in Vaughan and York Region. I just want to get a general feel, from your familiarity, of the resources available in the suburbs versus downtown because that seems to be something that will come up, and it's come up in a couple of cases. How can we close that gap?

Thank you.

[The Chair, Liberal, Wayne Easter]

Who wants to start?

Kimberly, go ahead.

[Kimberly Moran]

I'd be happy to.

You're right. The York region is very much suburban; it's not rural.

I think you'll find that services, particularly in Ontario—and I can speak to those—have historically not been developed so that there is consistency among regions and you will thus find differences that need to be solved. These are going to be solved by really building, as Ian said, a systems approach to investments and making sure that every kid and family has equal access to services.

There will be times when there's going to be specialization and kids may have to travel a little bit longer, but we have to build our system of intensive treatment so they can easily get back home and have services very, very close to home. For right now, there are innovative models in Ontario that are ready to be scaled up. In-home intensive care is something that has proven to be really important in driving really good outcomes for kids who have significant mental health issues.

In our case—and we don't live too far from your riding, since we live at Leslie and Steeles—we had to go to downtown Toronto for treatment. In Toronto it sounds like a short distance, but it takes a long time, and our child there needed specialized mental health treatment and was there 24-7. Having to be in 24-7 care for almost six months had a tremendously traumatic effect both on the 11-year-old and, I have to say, on the family.

We have innovative models whereby my child could have stayed home. She could have stayed home with wraparound intensive treatment from psychology, psychiatry, social work, and all the allied health professionals providing services to both the child and the family to recover from these very serious mental health issues. It's really a necessity for investment to scale and spread these great ideas, but we need commitment in order for that to happen.

Thank you.

[The Chair, Liberal, Wayne Easter]

Ms. Cohen, go ahead.

[Dr. Karen R. Cohen]

I'll just add that I think your observation is also related to how we invest our public health care dollars. We invest them in certain providers—physicians delivering care and public institutions—and in downtown Toronto, there are a lot more hospitals than in suburban areas. If those dollars were instead attached to the needed service, we might have a different situation.

[The Chair, Liberal, Wayne Easter]

I'm from P.E.I., and we end up having to go to Halifax or wherever.

It gets worse, is what I'm saying, I guess, but I like your point on innovative models. With new technology, that's something we ought to look at.

Mr. Aboultaif.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

Thank you.

Thanks for your presence here today.

I listened to all of your presentations, and a common conclusion from what you said is that we don't seem to have a national strategy. The aim of paying such attention to mental health is definitely to get every Canadian to receive the same service. We know the reality is that we have different provinces, and each province has a different approach to the health care system, and sometimes the federal government or Health Canada will say that it can't interfere with the provinces on putting some kind of common strategy together.

The problem is big, and I heard that the $100 million is just a down payment. It's just maybe a nice try. This problem is not going to go anywhere. If anything, it's going to get worse as we live and the challenges are bigger and bigger.

How do we go on with the money? Are we looking to try to restructure the health care system to pull some money from places where it isn't necessary and put it into mental health? I need to hear from you. How do you envision moving forward, not just for tomorrow or next year but for the next at least 10 years?

The floor is open for whoever wants to start.

[The Chair, Liberal, Wayne Easter]

Ms. Morin, go ahead.

[Kimberly Moran]

I think you'll find that if you invest in the home and community care as we've been talking about today, you're going to see a corresponding reduction in all the pressure we're seeing in acute care hospitals right now. I think those investments will yield those kinds of results. The data has shown that in countries all over the world.

So I think that by investing in community health care, you will see that fundamental restructuring of the health care system that will reduce the pressure on acute care hospitals, which are very expensive providers of care.

[Ziad Aboultaif, Conservative, Edmonton Manning, AB]

How far would the $100 million go for what you need in Canada?

[Kimberly Moran]

We estimate that in Ontario, the child and youth mental health system itself requires $100 million to effect transformation. I would say that $100 million is always a good start, but there is much more that has to be done.