Submission to the Standing Senate Committee on Social Affairs, Science and Technology

Introduction

About the Centre for Addiction and Mental Health
The Centre for Addiction and Mental Health (CAMH) was created in 1998 through the successful merger of the Addiction Research Foundation, the Clarke Institute for Psychiatry, the Donwood Institute and the Queen Street Mental Health Centre.

CAMH, a teaching hospital fully affiliated with the University of Toronto, is the largest addiction and mental health facility in Canada. It operates clinical, health promotion, education, and research facilities in Toronto, and conducts internationally recognized biological, clinical and social research. Its influence extends throughout the province with 28 satellite locations that ground CAMH clinical, health promotion, research and education efforts in the needs of Ontarians, and ensure that new knowledge is translated into addressing mental health and addiction problems in local communities.

Summary

CAMH is pleased to build on its previous responses to the Standing Senate Committee on Social Affairs, Science and Technology with this current submission. Following many of the themes of the committee's Issues and Options paper, this submission focuses on the role of the federal government, offering direction in regard to some of the specific questions posed, as well as identifying some particular goals in the area of addictions. Our core message is grounded in the key elements of a national action plan on mental health and addictions, and the capacities needed both within and outside government for ensuring a coordinated and informed approach to the implementation of the plan.

Investment in the Mental Health System and Beyond

The need for federal leadership to address addictions and mental illness in Canada
The Standing Senate Committee's close attention to mental health, mental illness, and addictions, long overlooked within the health agenda, is much needed and appreciated. As the committee has heard, the burden is high, with 1 in 5 Canadians likely to experience a mental health, substance use, and/or concurrent disorder problem within their lifetime. Despite increasing emphasis on community-based care, many of these people are not able to access needed services and supports, there are increasing numbers of people with addictions and mental illness living lives of poverty and isolation in the "community" or living in prisons, and many services continue to be delivered within an institutional framework, fostering dependency rather than recovery.

There is an urgent need for sound investment in a national agenda for seamless community-based mental health and addictions care and support, involving a coherent set of related strategies where linkages are explicit, and knowledge shared. This would require coordination of a national action plan on mental health and addictions with both a national drug strategy and with the National Framework for Action to Reduce the Harms Associated with the Use of Alcohol, Other Drugs and Substances.

The continuum of services and supports arising out of all these coordinated frameworks must encompass hospital to community, the full lifespan, and the needs of various populations for mental health promotion and illness prevention as well as treatment and recovery. Just as important, in order that all consumers are included in community life and able to maximize their potential for recovery, a holistic approach to mental health at national, provincial and territorial levels must incorporate services and supports outside the traditional health care system: self-help approaches, support for families, and linkages to essential elements of community such as housing, education, and income.

Critical Success Factors
With a strategic approach by the federal government to mental health, mental illness, and addictions in Canada, and commensurate investment in building and implementing the strategy on the basis of existing provincial and territorial capacities and initiatives, it will be possible to address current deficiencies. If the approach is successful, the following changes will be apparent:

• Focused leadership will be evident at all levels of government as well as in the service and voluntary sectors.
• An integrated continuum of services and supports that adhere to a set of explicit guidelines will be in place, from health promotion and prevention through to recovery, from hospital to community, and across the lifespan. 
• The needs of all Canadians will be taken into account, including diverse populations, rural and remote communities, and people with mental illness that is co-occurring with substance abuse, physical disabilities, or cognitive disabilities. 
• Consumers and families will be involved in decision-making, planning, implementation, service delivery, and evaluation.
• Respective roles of various levels of government will be clearly and collectively defined within a national policy framework that identifies common national goals, standards, and desired results.
• Resources and technical assistance for implementation will be available to provinces and territories, built on a foundation of accessible research findings, best practices, and human resource strategies. 
• The fundamental importance of mental health promotion, illness prevention, and early intervention will be recognized, and the growing evidence base in these areas will be translated into practice, with identified priority directions and incentives for action. 
• Determinants of health such as housing, education, income, and employment will be explicitly acknowledged as significant mental health as well as physical health issues.
• Canadians will be more knowledgeable about mental health, mental illness and addictions, and stigma and discrimination will have decreased.

Specific Priorities for Addictions
Although the critical success factors listed above focus on mental health and mental illness, they are also relevant to addictions. There are some additional factors of particular note for the addictions sector, which includes problematic substance use. If current gaps in the area of addictions are to be addressed, there will need to be: 

• Clear acknowledgement of the importance of addictions within a national approach to mental health and mental illness in Canada, grounded in explicit goals and policy directions, and a commitment to addressing addictive behaviours. 
• A national drug strategy in place, based on the pillars of treatment, harm reduction, prevention, and enforcement, and coordinated with a national plan on mental health and addictions. 
• Recognition of the impact of problematic substance use, not only on individual health, but on the economy, on potential for injury, on mortality, and on crime.
• More equitable investment in addiction and problematic substance use, commensurate with the significant revenues acquired from some of Canada's most vulnerable people with alcohol and gambling problems. 
• An integrated and comprehensive network of addiction and mental health services and supports offering appropriate, continuous resources that can be effectively accessed by people with complex needs in a timely manner.
• Validation and legitimacy for the critical place of social supports outside the formal service system for people with addiction and substance use problems.
  • Recognition of roles played by family members and significant others, including tangible support for family organizations.
  • Technical support for self-help/mutual aid approaches for people with addiction problems and their families, delivered through a mechanism such as a national self-help/mutual aid information clearinghouse.

The Direct Role of the Federal Government

Need for Leadership: A National Action Plan
Because of the complexity of mental health, mental illness, and addictions issues, a multi-faceted strategy is necessary, built around various linked elements and clear timelines. The federal government must take the lead, working in close collaboration with the provinces and territories, in developing and implementing a national action plan that coordinates and builds on existing provincial and territorial action plans.

The Issues and Options paper asks about the approach and elements of such a plan.

A recovery approach to a national action plan will ensure that every step, from health promotion through prevention and treatment/support, will work toward strengthening people's degree of hope for the future, their connections to community, and the sense of control, meaning, and purpose that will help them carry on with their lives.

The plan must put consumers and families at the centre of reform. It must also consider the needs of diverse communities, address addictions issues as well as mental health and mental illness, and include four priority themes. These are: strengthening the system through a national policy framework, building the information base, promoting mental health for all Canadians and recovery for those with addictions and mental illness, and reducing stigma and discrimination. They are elaborated below.

Strengthening the system through a national policy framework
As the Standing Senate Committee has noted, Canada does not have a mental health system per se, but rather a tangled array of services and supports that are difficult to navigate. To begin to build an integrated continuum of care, the federal government must work with the provinces and territories to create a national policy framework on mental health and addictions that includes goals, adequate funding, and accountability mechanisms. The process of developing a national policy framework would involve the following functions:

• Implementing a consensus-building process with stakeholders and all levels of government to identify common goals and national targets and benchmarks. 
• Defining roles of various governments and ministries.
• Building partnerships and collaborative initiatives to ensure that complementary action plans are in place at federal and provincial/territorial levels. 
• Defining a comprehensive range of services and supports, including the social determinants of health and consumer and family self-help initiatives.
• Developing guidelines and tools that can be used by provinces and territories for accountability, funding, and best practice implementation.
• Building a national commitment to client-centred care and evaluation. 
• Involving human resource professionals and consumers and families in determining human resource needs and delivering services and supports.

Building the information base
A comprehensive information base, built on federal/provincial/territorial collaborations, is necessary to inform the plan's implementation. In order to create an information system that is coherent, the federal government must ensure that existing structures are coordinated in a strategic fashion. Functions needed include:

• Gathering consumer and family feedback on the effectiveness of services and progress toward reform. 
• Tracking performance, utilization and outcome data in order to develop meaningful reporting measures.
• Building on existing systems to: 
  • Gather and disseminate integrated electronic health records and personal health information systems, 
  • Determine and disseminate evidence-based best practice guidelines, and
  • Develop research priorities to guide practice and policy.
• Conducting research with the Institute for Neuroscience, Mental Health and Addictions of the Canadian Institutes of Health Research (CIHR) as a focal point, with clear linkages from consumers and families to researchers and professionals. 
• Facilitating knowledge translation, information sharing and exchange.

Promoting mental health for all Canadians and recovery for those with addictions and mental illness
It is important for the national action plan to make an explicit commitment to a population health and health promotion/recovery approach that involves federal, provincial, and territorial initiatives for addressing the mental health needs of all Canadians, including those with addictions and mental illness. The plan can support this direction with functions such as: 

• Including access to determinants of health in its agenda in order that issues such as housing and income support can be addressed to support recovery.
• Facilitating cross-departmental linkages for policy development. 
• Developing a framework for addressing mental health and addictions issues in the workplace.
• Supporting a broad range of self-help approaches. 
• Ensuring that the full spectrum of prevention, early intervention, treatment, and recovery is covered. 
• Incorporating health promotion principles into all clinical and support services.

Reducing stigma and discrimination
Because stigmatizing attitudes and discriminating actions are pervasive, impeding people's progress toward integration and recovery, federal government leadership to combat these threats is necessary.

It has been demonstrated that proximity to people who are the objects of stigma can diminish public fears and misperceptions. Therefore, building on the Promoting Mental Health priority above, initiatives that foster community inclusion require particular attention, not only to enhance the quality of life and prospects for recovery of people with mental illness and addictions, but also to help reduce stigma in the population at large.

Functions that can help reduce stigma and discrimination include:

• Facilitating access to adequate income as well as mainstream housing, employment, education, and recreation for people with mental illness and addiction. 
• Raising public awareness about appropriate workplace and education accommodations and providing technical supports for implementing them. 
• Supporting, evaluating, and implementing evidence-based mental health literacy and public education initiatives as part of a broader set of strategies to change attitudes, beliefs and behaviours.
• Providing training for service providers and interventions with the media within this broader set of strategies.

Moving Forward: Implementing the Plan Through Linked Mechanisms

The Issues and Options paper asks about how to coordinate and better integrate the federal approach to mental illness and addiction, and how to build a patient-centred, recovery-oriented system.

A coordinated approach to implementation will require action within and outside government. Government action will provide the overall vision and leadership. Action external to government can track the implementation through data, research, and benchmarks to ensure that the plan is effective, relevant, and accountable to consumers and family members. The following discussion explores the capacities needed for proceeding on these two different fronts.

Internal Capacity: Coordinating the Plan Within Government
Particular capacities must reside within the federal government in order to move forward in the development of a patient-centred, recovery-oriented system.

Capacities Needed

• Strong collaborative leadership with a broad-based population health approach. 
• Clarity of vision, principles, goals, priorities, and benchmarks for national leadership that draws on existing strengths in the provinces and territories.
• Provision of innovative ideas, processes and structures for building on and pulling together provincial/territorial initiatives to develop an action plan with multi-year direction and fixed targets.
• Capacity for building participation and agreement with provinces and territories and facilitating development of complementary strategies at provincial, territorial and regional levels.
• Ongoing technical and financial support for implementation in provinces and territories.
• Commitment to inclusion of stakeholders in the development and implementation of the plan. 
• Grant programs to support implementation of the plan in areas such as research, policy development, capacity building, communications (mental health literacy and anti-stigma activities), and model programs of national significance.
• Communication of information about the plan to the public through electronic and other media.

A Mechanism for Focus and Leadership
In order to build and maintain these capacities, government leadership must be consolidated in a fixed point of responsibility for the national action plan, with joint ownership by federal, provincial, and territorial governments as equal partners. As recently as the late 1980s, there was a robust and effective Federal/Provincial/Territorial Advisory Committee on Mental Health. The subsequent demise of this committee, along with other symbols of a federal presence (such as a Mental Health Division in Health Canada and a peer-review journal), has not only constrained the federal government's ability to act on the issues, but has discouraged stakeholders and dispersed their energies.

The Federal/Provincial/Territorial (F/P/T) Advisory Committee of the past can serve as a reference for the focal point that is needed today. However, its current incarnation as an Advisory Network with limited roles and responsibilities is inadequate for the important task at hand. Now more than ever, a strong, clear, and broad mandate for this kind of structure is needed. 

Membership and Mandate
Led by Health Canada, and consisting of senior government officials with responsibility for mental health from the federal government, provinces, and territories, this mechanism must have strong, dedicated staff support as well as a direct reporting line to Deputy Ministers. This will ensure that mental health and addictions issues have a clear place on the agendas of the Council of Deputy Ministers and Council of Ministers of Health.

The distinct mandate would include the capacity to ensure government financial investment in the plan's priorities, and to provide a clear vision and direction as the plan unfolds. Because mental health, mental illness, and addictions transcend traditional health boundaries, this mechanism must also be able to reach across a range of departments and levels of government in order to ensure broad-based and coordinated action that takes into account the many determinants of mental health.

External Capacity: Supporting and Informing Implementation of the Plan Outside Government
The Issues and Options paper asks whether there should be a committee to facilitate a patient-oriented system, and how to ensure stakeholder involvement in the development of a plan.

A committee is advisable for facilitating both a patient-oriented system and stakeholder involvement. To help ensure that the action plan is working as intended to meet the needs of consumers and families within a patient-oriented system, there must be a monitoring and advisory capacity in place outside government.  The following section describes the external capacities needed to keep the plan on track, and answers the Issues and Options paper's question by describing a committee of diverse stakeholders where these capacities would reside.

Capacities Needed 

• Monitoring and evaluation of various elements of the national action plan such as strategies and priorities, programs and services, targets and benchmarks, delivery models, funding, and roles of stakeholders.
• Retrieval of data and information on systems, targets, and best practices to inform analysis and development of policy advice for government.
• Coordination of policy, service delivery, and experiential perspectives for reporting to stakeholders and government on the implementation of the national action plan.
• Collaboration with professional associations at all levels to evaluate the human resources component of the national action plan in accordance with identified goals.

A Mechanism for Focus and Leadership
In order to keep the plan on track and working well for the people it is meant to serve, independent expert advice must be available to inform the government's policy directions. An external mechanism or committee could provide consistent feedback from a diverse set of representative stakeholders, thereby bringing focus and leadership to the implementation of the action plan. This mechanism would consolidate the various monitoring, evaluation, and advisory functions needed to keep the plan accountable and effective.

Membership and Mandate
The committee's policy advice must draw not only on academic, service delivery and policy expertise of researchers, providers, and planners, but also on the expertise of consumers and families who know from their own lived experience whether or not the plan is meeting their needs. To monitor the implementation of the mental health action plan from the perspective of users of services and their families and bring their concerns into the process, it is essential that these stakeholders be supported to participate in this mechanism and link with their constituency base in the provinces and territories.

Supported by the federal government, the multi-stakeholder committee must function in collaboration with the provinces and territories, and connect with or build on existing structures, processes and partnerships. Existing resources for this committee to tap, besides the Centre for Addiction and Mental Health, include national voluntary organizations working in mental health, as well as the Canadian Centre on Substance Abuse for information on addictions issues; the Canadian Institute for Health Information for data on services, Statistics Canada's Canadian Community Health Survey for needs assessment, and Canadian Institutes of Health Research to inform its work. The creation of a CIHR Mental Health Network for knowledge translation and information dissemination would provide a means to achieve that subset of functions. The committee should also have the authority to provide or contract for services to fulfill its functions.

The committee's role is to consolidate, coordinate and analyze the implications of the information available from this variety of sources, in order to provide evidence-based policy advice on implementation of the plan. Some of the areas on which the committee would provide advice and feedback include allocation of resources, development of measurable performance monitoring tools, and strategies for mental health promotion, prevention, and recovery-oriented approaches. In order to fulfill its function, it will be necessary for this committee to have adequate resources and staffing as well as mandated mechanisms for input and decision-making, including regular reporting and access to the F/P/T mental health body and the Federal Minister of Health.
 
Supporting Coordination and Integration

The Issues and Options paper asks about how to shift the burden of coordinating services and supports to the system rather than affected individuals and their families.

CAMH suggests that the enhanced and strengthened internal government F/P/T body, informed by the new external committee proposed in this submission, can provide the necessary vision and leadership to ensure coordination of the elements of an accessible system.

By tapping the expertise, leadership, and connections of the proposed new linked mechanisms described above, the federal government can encourage coordination of policies, strategies and structures that will promote integration and continuity of care:

• For a client-centred system that is easier to access and navigate.
• With flexible integration models tailored to needs of local communities.
• To support integration of mental illness and addictions sectors.
• To link mental illness and addictions services with other health and social services, particularly primary care and home care, and support collaborative approaches.
• To support partnerships that harness expertise outside the mental health field to address issues such as addictions, problematic substance use, suicide, health promotion, and crime prevention.

Specific Strategies
A strong and well-supported community-based sector can play a major role in helping to coordinate and integrate systems, both formal and informal components, to address the continuum of need from mental health promotion through to recovery. Therefore support for the community-based sector, including community-based research, is one place to start. Model programs that demonstrate strategies for coordination and integration of services can also catalyze innovation in this area, and must be fostered. Finally, it is important to situate mental health service reform within the broader context of primary care reform. As the Canadian Collaborative Mental Health Initiative points out, the successful integration of mental health services within primary care settings can address many issues already identified by the Standing Senate Committee.

The Indirect Role of the Federal Government

Need for Leadership: including mental health and addictions in national policies and programs
The Issues and Options paper asks how the federal government can correct its "ambivalent approach" about the place of mental health policies in its national policies and programs, and whether a specific position such as Minister of State for Mental Health is needed.

Just as people with mental illness and addictions often exist on the margins of society, mental health, mental illness, and addictions issues themselves are too often neglected in policies and programs from the local all the way to the federal level. Addressing this gap at the federal policy level can set an important example that will have cascading positive impacts at the other levels as well.

Some suggestions for next steps in this crucial agenda are: 

• Including mental health in health care reform and public health initiatives.
• Ensuring mental health, mental illness and addictions are included in definitions of health and illness.
• Remedying the exclusion of psychiatric hospitals from the Canada Health Act.
• Addressing the need for home care for people with mental illness and addictions, and providing funding for costs of medications.
• Involving the provinces and territories in determining conditions and terms for federal transfers as tools for ensuring the action plan is meeting the needs of Canadians. 
• Ensuring a clearly identified point of responsibility within government for mental health and addiction issues, such as the F/P/T government body described above. However, a position such as Minister of State for Mental Health must be approached with caution as it runs the risk of being a figurehead without real power, and thereby possibly sidelining important issues.

In response to the Issues and Options question about what form of home care program to follow, CAMH recommends:

• Creating a home care basket to include mobile crisis response teams, early intervention services, outreach, and intensive case management.
• Providing funding beyond short term and time limited. 
• Delivering services that are flexible and responsive to the differing levels of support people need, rather than focusing on "acute" needs. 
• Defining "home" broadly, including transient populations and those living in shelters.
• Building on existing community mental health and addictions treatment and care
• Considering the episodic nature of mental illness, as well as concurrent disorders and addictions, in planning.

Specific Population Groups

Addressing the needs of diverse communities
It is imperative that mental health, mental illness, and addictions services and strategies respond to the different cultural and linguistic contexts of clients and stakeholders. Because diverse communities such as First Nations and immigrant/refugee populations have specific mental health and addictions needs, relevant policies and programs must be developed to ensure these communities have access to services delivered in a culturally appropriate manner.

Suggested actions include: 

• Providing funding for housing, education and employment to help First Nations and other diverse communities develop their own services.
• Recognizing and including diverse populations (as well as various life stages) in development of policy and programs.
• Developing services geared specifically to cultural and linguistic diversity as well as more culturally responsive mainstream services.
• Recognizing particular mental health and addictions issues for people with complex needs such as physical or cognitive disabilities. 
• Supporting the development of technologies for facilitating access to services and supports for rural and remote populations.

People of colour, women, people with disabilities, gays and lesbians, transsexual and transgendered people, and many other marginalized community members must deal with individual and systemic discrimination. These experiences have a profound impact on people's mental health, as well as on their treatment and care. Not only must discrimination as a mental health issue be addressed in society at large and within the health care system, but federal government leadership is needed to ensure that Canadians from diverse backgrounds and experiences are able to fully access and participate in mental health and addictions care planning and services.

Conclusion

Charting a course to address the complexity of mental health and addictions issues in Canada is a significant challenge, but reform is both necessary and possible. The first step requires federal government leadership: to develop a national action plan in collaboration with the provinces and territories, and to build government and stakeholder capacity to ensure the plan will work effectively. With a plan founded on clear vision and principles, and fixed points of responsibility for focus and leadership both inside and outside government, a coordinated federal approach to a patient-centred, recovery-oriented system can be achieved. By taking these steps, the federal government will be making a significant and meaningful commitment to the mental health of all Canadians.

 

 

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