Submission to the Standing Committee on Justice and Social Policy on Bill 8: Commitment to the Future of Medicare Act, 2003

Introduction to CAMH

The Centre for Addiction and Mental Health (CAMH) is the largest mental health and addictions facility in Canada. It was created in 1998 through the successful merger of the Addiction Research Foundation, the Clarke Institute of Psychiatry, the Donwood Institute and the Queen Street Mental Health Centre. CAMH is a teaching hospital fully affiliated with the University of Toronto and has been recognized internationally as a Pan-American Health Organization and World Health Organization Collaborating Centre.

Building on the legacies of four outstanding organizations, CAMH offers a unique model for understanding and helping people with addiction and mental illness, for preventing substance abuse and for promoting mental health. We operate central clinical and research facilities in Toronto, Ontario, as well as 26 satellite offices across the province that work with partners to improve the quality and accessibility of services within the addiction and mental health system. While CAMH's work focuses on the needs of Ontario communities, our impact extends across the country and internationally.

CAMH Response to Bill 8

Further to our oral presentation on February 23, 2003, CAMH welcomes the opportunity to make the following written submission on Bill 8.

1. Preamble:

CAMH is pleased that the Preamble to Bill 8 affirms the system of publicly-funded health services as fundamental to Canadian values.

However, we recommend that the Preamble be amended to acknowledge the needs of Ontario citizens who suffer from mental illness or addictions and to recognize the importance of mental health and addictions services to the health care system.

The impact of mental illness on Canadians is staggering. Over 1.5 million Canadians are currently experiencing clinical depression, a disorder that affects 15% of Canadians at some point in their lives. Twenty percent of Canadians in any given year suffer from a broad range of mental illness or addiction, and 3% suffer profound and persistent disablement. Despite these facts, mental health and addictions services are largely absent from mainstream health care reform initiatives and are often not explicitly recognized as an integral part of this system.

As a striking example, the Canada Health Act specifically excludes "a hospital or institution primarily for the mentally disordered" from the definition of "hospital". As a result, there is unequal access to mental health and addictions services across the country. Although Ontario funds these services, not all other provinces do. This is not acceptable. The exclusion is offensive and discriminatory, and should not remain part of our law or Medicare system. While Ontario does not have the jurisdiction to amend federal legislation, we strongly urge the Premier and the Minister of Health and Long-Term Care to lobby their federal counterparts to make the changes necessary to address this injustice.

Recommendation 1: The Premier and the Minister of Health and Long-Term Care should lobby their federal counterparts to amend the Canada Health Act to include "a hospital or institution primarily for the mentally disordered" in the definition of "hospital".

With respect to the Preamble of Bill 8, CAMH supports the Canada Health Act's principles of comprehensiveness, accessibility, portability, universality and public administration and we ask that the Standing Committee consider these principles in terms of the communities CAMH serves.

We ask that the Preamble be amended to explicitly recognize that all Ontarians who have mental or physical illnesses are entitled to the equal benefit of publicly-funded health services, according to their needs.

We support the references in the Preamble to catastrophic drug coverage and home care as essential components of the health care system. We endorse the recommendations made by the Canadian Mental Health Association, Ontario that amendments be made to the Preamble of Bill 8 to ensure that people with mental illness and addiction problems are entitled to the equal benefit of these publicly-funded programs.

We have redrafted the Preamble with our proposed amendments (please see Appendix A at page 9).

Recommendation 2: The Preamble be amended in accordance with Appendix A to recognize the importance of mental health and addiction services in the publicly-funded mental health system and that these services are essential for the mental and physical health of Ontarians.

2. Health Quality Council:

CAMH supports the creation of the Health Quality Council to monitor and report to Ontarians on the issues of access to publicly-funded mental and physical health services, utilization of health human resources, consumer and population health status and health system outcomes.

CAMH specifically supports reporting on these issues in the mental health and addictions sector. CAMH is willing and able to assist in the development of information and reporting technologies and processes to improve these measures. Such information will create better transparency in the sector and will help all Ontarians to better understand our publicly-funded health care system.

Recommendation 3: The government should create the Health Quality Council and give it a specific mandate to ensure that it studies and reports on the mental health and addictions sector.

We endorse the Canadian Mental Health Association's specific recommendation for Bill 8 that the members of the Health Quality Council include experts in "family issues" and "physical and mental health service provision" as well as patient and consumer issues.

Recommendation 4: Clause 2(3)(a) should be amended to read:

"2(3) In appointing the members of the Council, regard shall be given to the desirability of appointing,
(a) experts in the health system in the areas of patient, consumer and family issues and physical and mental health service provision; …" [our proposed amendments are underlined]

3. Accountability Framework:

CAMH supports the government's initiative to identify opportunities for greater accountability within the health care sector. Specifically, CAMH submits:

there is room to make improvements to the existing accountability mechanisms in the health care sector that will benefit everyone;
there are strengths and weaknesses to the current arrangements between the Ministry, hospitals and other health care agencies;
we support the government's efforts to develop a wide range of accountability mechanisms that are graduated in their approach;
the principles of consultation, collaboration, transparency, and the public interest should guide the development of any new accountability arrangements;
Ministry expectations for hospital performance and health care outcomes must be clarified and developed in consultation with hospitals and our associations;
in collaboration with health care providers, the government must develop unique indicators and measurement tools for the mental health and addictions sector as the indicators and measures developed for general acute care service delivery have limited application to our sector;
hospitals and patients could benefit from the development of clear and harmonized performance indicators; and
new accountability arrangements introduced through this legislation and subsequent regulations must not undermine the role and responsibilities of hospital boards and therefore, any new accountability agreements Ministry should be made with the hospital boards and not directly with hospital staff.

We welcome the opportunity to work with government to identify an appropriate accountability framework for the health care sector.

As an initial suggestion, if one of the primary objectives of the legislation is to address concerns regarding hospital spending and budget mismanagement, we respectfully submit that the government could strengthen the role of auditors as a means of achieving greater accountability. Instead of requiring increased financial reporting to the Ministry, auditors could be required to report on the discrepancies between hospital spending and the hospital budgets submitted to and approved by government. Hospital boards could be obliged to sign auditor reports to ensure board accountability for the results. [This is the paragraph that needed clarification - could you please review it]

We are available to participate in on-going discussions about the creation of new and improved accountability mechanisms for the health care sector.

Recommendation 5: In developing new accountability arrangements, the government should be guided by the principles of consultation, collaboration, transparency, and acting in the public interest.

Recommendation 6: The government should continue the dialogue with hospitals and our associations to develop the appropriate accountability structures that acknowledge the role and responsibility of hospital boards and the mutual obligations of health service providers and the government to achieving increased accountability within the health care sector.

4. Disclosures of Personal Information to the Minister:

As drafted, Bill 8 would permit broader disclosure obligations of personal information from hospitals to the Minister of Health and Long-Term Care than would be permitted under Bill 31, the Personal Health Information Protection Act, 2003 currently under consideration by the Legislature.

We are pleased that the Minister has indicated that he will introduce amendments to this Bill to delete the Minister's authority to directly collect, use and disclose personal information.

Recommendation 7: The provisions dealing with disclosure of personal information to the Minister of Health and Long-Term Care should be redrafted to be in keeping with the proposed model for disclosures to the Minister of Health and Long-Term Care as set out in Schedule 1 to Bill 31.

5. Accessibility:

We believe that mental health and addictions services must be accessible, effective and adequately funded for all people needing help.

We are especially concerned about the potential de-funding of addictions services and would support actions that increase access to mental health and addiction services.

Further, CAMH is concerned that the accessibility rules in section 9 of Bill 8 could have an unintended consequence of restricting health services by prohibiting hospitals to make necessary direct payments to physicians. We welcome the opportunity to work collaboratively with the government and the Ministry of Health and Long-Term Care to discuss mutually agreeable alternatives that ensure services continue to be accessible to our clients.

Recommendation 8: The government should work collaboratively with stakeholders, including CAMH, to discuss mutually agreeable alternatives to section 9 to ensure that the access to health services is not unintentionally limited.

6. Consultation Regarding the Regulations:

CAMH is concerned that Bill 8 leaves significant details to be determined in the regulations. We urge the government to include the proposed 60-day consultation period prior to the passing of the regulations under this legislation. This consultation should not be restricted to a few major stakeholder groups that represent the traditional interests of the health care system.

Recommendation 9: A provision should be added to the legislation to require a 60-day consultation period prior to the passing of the regulations under this legislation.

Recommendations

We look forward to working collaboratively with the government to finding solutions to the concerns raised above.

In conclusion, CAMH recommends:

1. the Premier and the Minister of Health and Long-Term Care should lobby their federal counterparts to amend the Canada Health Act to include "a hospital or institution primarily for the mentally disordered" in the definition of "hospital";

2. the Preamble be amended in accordance with Appendix A of this Submission to recognize the importance of mental health and addiction services in the publicly-funded mental health system and that these services are essential for the mental and physical health of Ontarians;

3. the government create the Health Quality Council and give it a specific mandate to ensure that it studies and reports on the mental health and addictions sector;

4. clause 2(3)(a) should be amended to read:

5. in developing new accountability arrangements, the government be guided by the principles of consultation, collaboration, transparency, and acting in the public interest;
6. the government continue the dialogue with hospitals and our associations to develop the appropriate accountability structures that acknowledge the role and responsibility of hospital boards and the mutual obligations of health service providers and the government to achieving increased accountability within the health care sector;

7. the provisions dealing with disclosure of personal information to the Minister of Health and Long-Term Care be redrafted to be in keeping with the proposed model for disclosures to the Minister of Health and Long-Term Care as set out in Schedule 1 to Bill 31;

8. the government work collaboratively with stakeholders, including CAMH, to discuss mutually agreeable alternatives to section 9 to ensure that the access to health services is not unintentionally limited; and

9. a provision be added to the legislation to require a 60-day consultation period prior to the passing of the regulations under this legislation.

Conclusion

As the Standing Committee considers this legislation and prepares to table amendments, please consider our recommendations and the need to protect and support Ontario's mental health and addictions communities.

Thank you again for this opportunity to provide our written response to this legislation.

CAMH Contact Person

If you have any questions with respect to this submission, or if you require further information about our response, please contact Gail Czukar, Executive Vice President of Policy and Planning and General Counsel to CAMH at 416-535-8501 ext. 6923 or gail_czukar@camh.net.

Appendix A

We recommend the Preamble to Bill 8 be redrafted as follows, [our proposed amendments are underlined and bolded]:

"Preamble"
The people of Ontario and their Government:

Recognize that Medicare - our system of publicly funded health services - reflects fundamental Canadian values and that its preservation is essential for the physical and mental health of Ontarians now and in the future;

Recognize that the promotion of health, and the prevention and treatment of disease includes mental and physical illness;

Confirm their enduring commitment to the principles of public administration, comprehensiveness, universality, portability and accessibility as provided in the Canada Health Act;

Continue to support the prohibition of two-tier medicine, extra billing and user fees in accordance with the Canada Health Act;

Believe in a consumer-centred health system that ensures access is based on assessed need, regardless of the diagnosis or health problem, not on an individual's ability to pay;

Recognize that all Ontarians, regardless of whether they have a physical or mental illness are entitled to the equal benefit of the publicly-funded health care system;

Recognize that pharmacare for catastrophic drug costs and home care based on assessed need, regardless of the diagnosis or health problem, are important to the future of the health system;

Recognize that access to primary health care is a cornerstone of an effective health system;

Believe in public accountability to demonstrate that the health system is governed and managed in a way that promotes efficient delivery of high quality health services to all Ontarians;

Affirm that a strong health system depends on collaboration between consumers, health service providers and governments, and a common vision of shared responsibility; …"