A Strong Provincial Focus for the Addictions and Mental Health Sector in Ontario

The Need for Health Care Reform in Ontario

In September 2004, the Province of Ontario announced its intent to implement far-reaching reform in the health care system to create a "comprehensive and integrated system of care that is shaped with the active leadership of communities and driven by the needs of the patient."

The Centre for Addiction and Mental Health (CAMH), the Canadian Mental Health Association, Ontario (CMHA, Ontario) and the Ontario Federation of Community Mental Health and Addictions Programs (the Federation) support the government's goal of taking health care in Ontario to the next stage, to a system focused beyond acute care on keeping people well. Our organizations have long advocated that only a system that reflects the hospital-community continuum and that integrates physical and mental health will meet the needs of people with mental illness and addictions.

We support the government's Transformation Agenda for the same reasons we have supported health care reform initiatives in the past. These policy directions are good for the overall health of Ontarians and critical for those who suffer from a mental illness or addiction. People with mental health issues and addictions need services that break down the traditional silos present in the system today and they need mental health and addiction services that are an integral part of the overall health care system. We think the government is focusing in the right areas to address these needs - primary care reform, investments in community-based services, expanded access to homecare and long-term care, and local health integration networks.

Because making change to a large and complex system is fraught with challenges our organizations are working hard to provide the best advice possible to ensure the success of the government's planned reform.

Initially our three organizations focused our activities on bringing expertise and analysis from the addictions and mental health sector to the LHIN planning process. Earlier this year we began working together to develop advice regarding province - wide capacities needed in the system. With this submission, we are turning our attention to what is needed beyond LHIN structures to enable and support change.

What Capacities are Needed for Addictions and Mental Health?

Mental health and addictions have long been "orphans" within the health care system. Although 1 in 4 Canadians is likely to experience a mental health or addiction problem at some time in his or her life, most of these problems are untreated. People seeking mental health or addictions services are unable to access the help they need, or, because of the stigma associated with these conditions, do no try to access it. For the Transformation Agenda to be successful from the perspective of our sector, it must demonstrate both understanding of this situation and an intention to improve it. This involves continuing to build and reform the service system, not simply improving access to existing services and better integrating them with other parts of the health system.

Our goal is to ensure the strongest possible province-wide focus on mental health and addictions through the transformation process. Mental health and addictions services in Ontario have undergone substantial change over the past three decades, since the first introduction of the Community Mental Health program. However, in health system terms, it is still quite a young and complex system and requires leadership to continue to develop. The latest Ministry policy document-Making It Happen and Setting the Course -now over five years old, and the work that was done for the nine Mental Health Implementation Task Forces, provide a good base for moving forward. A continued focus on the unique circumstances of people with mental illness and addictions is necessary

to ensure that the services and supports they need are developed and connected in ways that will allow them to make the best use of these resources to improve their lives.

We have developed the following Critical Success Factors for Mental Health and Addictions - our vision for a transformed mental health and addictions system. Our advice to government has been developed based on these factors, and it is with these factors in mind that our sector will measure the achievements of the Transformation Agenda:

Addiction and mental health care will be fully integrated within a transformed system.
Consumers and families will be involved in all aspects of planning, decision-making, implementation and service delivery.
People across Ontario will have access to the best mental health and addiction services in their communities, supported by widely shared research findings, best practices and professional development.
There will be a continuum of mental health and addiction services and supports from community-based to hospital care, and including consumer and family initiatives.
Access to housing, income, employment, social supports and other determinants of health will be acknowledged and supported as critical aspects of treatment and recovery.
Mechanisms for addressing the historical marginalization, stigma and under-funding of addiction and mental health services will be in place.
Equitable and transparent mechanisms will be in place to guide funding decisions for the sector.
The needs of diverse, rural and remote communities will be met.

As the Government's transformation agenda proceeds we will work to develop the indicators to measure the extent to which these critical elements of the new system are met.

What Capacities are Needed in Government?

Our research and consultations have highlighted a trend that has posed serious concern in other jurisdictions, namely that there is a drain in resources and capacity from the health ministry to regional authorities when governments move from centralized to regionalized systems. This leaves a significant policy and planning gap in government.

We believe that a strong provincial government and a strong Ministry of Health are critical to lead change of the magnitude proposed in the Transformation Agenda. Government policy, funding and accountability mechanisms for health must be modified to respond to the new and changing environment and the provincial government must ensure that the following are in place for the health system as a whole:

Continued strong political leadership with a clear vision for health care in Ontario and the commitment to maintain the focus on the change agenda;
Continued strong leadership at the staff level as well, with accountability to the government for leading and maintaining the momentum for change;
Clearly defined roles and responsibilities for the different parts of the system;
Clearly articulated provincial goals and objectives for the health system as a whole, to provide a framework for change, and to include a policy and planning focus at the provincial/cross-regional level to complement the work of the LHINs;
Effective inter-ministerial and inter-governmental mechanisms to address current obstacles to transformation and to build a foundation for the future;
A capacity to reallocate resources between LHINs, based on information about service usage and trends so that reallocation strategies are transparent and aligned with broader system goals and population health needs; and
Information management systems to support the collection and use of system-wide data by LHINs and other parts of the health system.

We also believe that broad expectations for the role of clients/patients and other stakeholders should be defined by the government, in keeping with the commitment to a system that responds first and foremost to consumers. Particular attention must be paid to groups that are frequently marginalized, such as Aboriginal people, racialized communities and mental health and addictions consumers.

In addition, we believe that for the mental health and addictions sector, distinct policy direction and accountability mechanisms are required, to ensure that the transformation process does not erode or marginalize mental health and addiction services further in favour of other health care priorities. Rather, the transformation process must strengthen mental health and addiction services to more effectively meet needs.

What Capacities are Needed in the Health Care System as a Whole?

There are a series of critical cross-regional functions and capacities that our research shows do not get the attention they need and are also sometimes lost in regional systems. These are critical to creating an integrated, coordinated system.

Policy frameworks - for example, required LHIN "Service Baskets" defining the range of services to be required in each LHIN, Concurrent Disorders, Role of Primary Care, Diversity Policy, Requirements for Consumer Involvement as well as Public Participation and Community Involvement, and so forth.
System-wide performance monitoring - meaningful measures and mechanisms for regularly reporting on the status of the health care system as a whole, as well as for each region/LHIN.
A focus on health promotion and prevention - to refocus the system from acute care to improving population health and promoting a broader view of health, including a focus on the broader determinants of health. The literature demonstrates that there must be:
- Explicit and high-profile commitment to these activities.
- Clear accountability for performance in these areas.
- Mechanisms to ensure the voices of the dispossessed are heard.
Health human resources and workforce development - to have the right mix of practitioners and community supports in place where they are needed; to ensure continual learning and dissemination of new knowledge; to shift the focus to primary care and health promotion; and to support areas that have been neglected - cultural competence in care, alternative and complementary care, mental health and addictions, and concurrent disorders.
Best practices dissemination and research - to ensure that regionalization does not, as it often has, neglect this critical area, special emphasis must be placed on: delivering large-scale research projects to inform policy and practice; broadening the scope of research and gaining full involvement of consumers and the communities that deliver services; developing and disseminating best practice guidelines; building an academic community committed to evidence based practice and sharing their research broadly; developing effective system-wide performance management systems; and providing resources to support these activities.

How to Implement in Ontario?

As we stated above, our goal is to ensure the strongest possible province-wide focus on mental health and addictions through the transformation process. We know that creating new structures and layers of administration is rarely a popular strategy for government or the public. However, our sector consultations and research suggest that some mechanism or special purpose body is needed to bring focus and leadership to our issues for continued reform in the system - some kind of provincial entity that will ensure a strong emphasis on addiction and mental health issues province-wide and lead the changes that are needed.

It has also been clear that clients and client organizations need strong province-wide capacities and tools to participate in LHIN planning. Although we have been supporting client organizations in their efforts to participate in LHIN planning, these organizations need their own resources to do this work as LHINs are established and into the future.

Moving Forward: Our Recommendation for a Strong Central Focus on Mental Health and Addcitions

We are recommending the creation of a formal network or authority, of addictions and mental health clients, service providers, researchers, and planners across the community/hospital continuum to fulfill cross-regional functions and develop tools for our sector to participate in LHINs and other health care reform initiatives. Drawn from the sectors it will affect/influence, this network/authority would have a mandate formally accepted by government, with staff and resources to carry out a leadership role for the mental health and addictions sector in the health system.

Serving in an advisory capacity to government, the mandate of the proposed Provincial Network/Authority would include:

Providing independent, expert advice to government to support government's broad policy making, health system planning and resource allocation functions;
Reporting on the functioning of the mental health and addiction system to the government, providers and consumers;
In co-operation with providers, consumers and other key stakeholders, leading the development of an overall strategic plan for addiction and mental health services in Ontario, with a multi-year direction and fixed targets (which can then be adapted and implemented by LHINs);
Providing advice to the Ministry on resource distribution and coordination of mental health and addiction services in the province as a whole and across the LHINs;
Recommending health promotion and prevention approaches for mental health and addictions; and
Recommending cross-regional policy, funding and measurable performance monitoring tools, based on an analysis of data about the performance of the sector, to support the activities of LHINs within a broad mandate set by government.

In addition, a Provincial Network could assist in:

Organizing the participation of the addiction and mental health sector in cross-sectoral or cross-regional reform initiatives like primary care, e-health, and workforce development.
Convening clients, families and addiction and mental health care providers through mandated mechanisms for input and decision-making.
Providing or contracting for the services to develop the plans and provide some of the functions described above.

We believe that such a network or authority will:

Provide much needed leadership and focus on addictions and mental health issues at the provincial level.
Create a critical mass of expertise and capacity so that our sector can actively engage in LHIN planning processes and other health care reform initiatives.
Draw on the expertise of those who receive and deliver addictions and mental health services across the community/hospital continuum.
Build on existing sector organizations, thereby limiting the creation of new organizations or new layers of administration.
Provide a coherent picture of what our sector needs through engagement with the consumer and provider community.

We believe that increasing our sector's capacity, to work with government through the creation of a Provincial Network/Authority provides more opportunities to integrate our issues into the overall transformation agenda, than it creates risk of isolating them.

Our recommendation for a strong provincial network or authority builds on our experience working together. CAMH, a teaching hospital with a broad mandate in research, education, clinical care and health promotion is working closely with CMHA, Ontario and the Federation, organizations that represent community based providers of supportive housing, consumer self help programs, case management services, psycho-social rehabilitation, crisis supports and other services. This collaboration models the very integration of hospital and community that the government intends to achieve. Although there will be challenges posed by the power and resource differences amongst participants of the network, we have much experience navigating these issues on which a provincial network or authority can build.

Mental health and addictions needs a strong central group, drawn from a broad base of providers from across the province, to ensure that there remains a focus on this historically marginalized sector. Research of other jurisdictions has shown that without such focus our sector will suffer in a regionalized system.

Conclusions

We believe that, for the Transformation Agenda to succeed, the right mix of regional and centralized functions must be put in place. In our view, the right mix includes LHINs that are empowered and enabled to truly perform their function, but within a clear framework provided by a strong government and a strong health ministry. We also believe that other mechanisms and structures are needed at the cross-regional level to bring focus and leadership to critical functions often lost in regionalization. As mentioned earlier, these critical functions include: policy development; performance monitoring; health promotion and prevention; workforce development; and best practices research and dissemination.

An explicit province-wide focus is needed to ensure the inclusion of marginalized groups and sectors. It is critical that government take leadership in this area to ensure that other local pressures do not override it.

As a sector that has long been marginalized, we believe that special measures are required to bring our sector and the programs and services we provide into the mainstream. These include: a government structure that reflects a distinct program priority for addictions and mental health; policy frameworks that require LHIN's to integrate addictions and mental health within their planning processes; protected or minimum funding levels for mental health and addictions in each LHIN; and a requirement for consumer participation at all levels of planning and decision making.

We have also recommended the creation of a formal Provincial Network/Authority for Mental Health and Addictions, to ensure the strongest possible voice for our sector as the Transformation Agenda unfolds. We are eager to work with the government to ensure the success of the Transformation Agenda at both the regional and provincial levels, and to ensure an equitable and appropriate role for mental health and addictions in the health care system of the future.

A Strong Provincial Focus for the Addictions and Mental Health Sector in Ontario

Related Links