From the Editor
Will they cut a deal?
It’s the question that will be discussed for weeks to come.
But for those of us in mental health, a possible deal is more than an item on the evening news. After all, a new federal-provincial accord could be important, with more money for mental health services. And let’s remember: right now, just 7 cents on every dollar of health spending goes to mental health (in the UK, by contrast, spending is 12 cents on the dollar).
But we hope for more than just a new deal. We hope for a smart new deal – one that will help improve mental health services.
What are steps the federal government could take?
This week’s Reading considers the new report issued by the Canadian Alliance on Mental Illness and Mental Health (or CAMIMH), an alliance of sixteen member organizations, including the Canadian Psychiatric Association, the Canadian Medical Association, and the College of Family Physicians of Canada. This thoughtful document lays out a five-point plan for bettering mental health services from coast-to-coast-to-coast. Spoiler alert: the plan calls for more spending, yes, but also efforts to improve access, better measurement of the system, and a targeted basic income to help less affluent Canadians.
Also in this reading – tying back to the UK – we look at an article from The Guardian about making mental health services stronger across the Atlantic.
The two pieces offer a strong contrast: about where our debate is in this country – and where mental health services could be with some needed reforms.
Ottawa and Reform
“Mental Health Now! Advancing the Mental Health of Canadians: The Federal Role”
Canadian Alliance on Mental Illness and Mental Health
THE TIME IS NOW!
In its role as advocate for the mental health of Canadians, CAMIMH believes the time is now for the federal government, in strategic collaboration with the provinces and territories, to accelerate investment in mental health programs and services.
“CAMIMH strongly supports Prime Minister Trudeau’s commitment to develop a First Ministers’ Health Accord with the provinces and territories and, as was articulated in the 2016 federal budget, his government’s intent to improve access to high quality mental health services in Canada. CAMIMH also notes the importance the Prime Minister placed on mental health by identifying it as a priority in eight Ministerial Mandate letters. This is unprecedented and sends a strong message that the time is now for mental health! This attention is long overdue. CAMIMH applauds the federal government for its leadership and looks forward to working with them to advance the mental health of Canadians.
So begins a paper by the Canadian Alliance on Mental Illness and Mental Health. The authors put forward a plan to reform mental health services. Statistics showing the need for mental health reform – done with colourful graphics – enlivens the document.
Let me pick up on the latter: though I’m “in the business,” the information is still striking. Consider, for example, the comparison of mental and physical illness:
Or the focus on hospital stays:
This simple graphic that reminds us of the depth of our problems in addressing the needs of Aboriginal communities.
The CAMIMH plan consists of five larger recommendations:
1. Ensure Sustainable Funding for Access to Mental Health Services
It calls for an increase in funding, pushing from 7 cents on the health care dollar to 9. It advocates that the moneys be spent wisely.
Canadians deserve timely access to the right combination of evidence-based services, treatments and supports, when and where they need them.
To that end: “Respecting the flexibility each province and territory requires to set its priorities, CAMIMH has identified areas where investment will improve timely access to care, by focusing on the objectives of mobilizing the capacity of the mental health system and improving the overall integration of services and programs. Federal infrastructure funds could be used to support this work.” The authors advocate an emphasis on areas like collaborative care, noting that proper care requires other health care providers beyond physicians, including psychotherapists and social workers.
2. Accelerate the Adoption of Proven and Promising Mental Health Innovations
It recommends the creation of a Federal Mental Health Innovation Fund – requiring an investment of $100 million over five years, paying for innovative program expansions.
It also suggests that a provincial-federal partnership work to promote greater system change. Borrowing a page from the UK, they advocate an IAPT-style program here.
The United Kingdom’s Improved Access to Psychological Therapies (IAPT) program has recovery rates in excess of 45 per cent and has seen more than 45,000 people move off sick pay and benefits following successful treatment. IAPT treatments are delivered by a range of service providers with different stepped care roles (e.g. psychologists, counsellors and/or therapists, and social workers).
3. Measure, Manage and Monitor Mental Health System Performance
It notes: “There are no comparable pan-Canadian mental health indicators to assess the performance of mental health programs and services at the federal, provincial and territorial level.” Yet, such performance indicators – drawing on the work started in a handful of provinces and by the MHCC – would be essential to improve service delivery.
4. Establish an Expert Advisory Panel on Mental Health
Noting the federal Liberal campaign commitment to create a Pan-Canadian Expert Advisory Council, it advocates the creation of a Panel to exchange perspectives and strategies – in effect, a national think tank, complementing the work of the Mental Health Commission of Canada.
5. Invest in Social Infrastructure
It advocates spending to reduce poverty. To that, the plan calls for “a targeted basic income to support all Canadians who are vulnerable because of age, labour market status or ability be explored.” Further, it invites Ottawa to “build on the success” of At Home/Chez Soi in ending chronic homelessness.
A few thoughts:
1. This document is an achievement. For years, groups with common purpose have pulled in different directions; in this five-point plan, they have pulled together and spoken in one coherent voice.
2. The plan is thoughtful. Sure, more could be said – for the record, I would have liked to see more of an emphasis on e-therapies. But overall, “Mental Health Now!” is solid.
3. I particularly like the international comparisons. In public policy, we often forget that countries across the western world are struggling with similar issues. So, as we ask how to improve access to evidence-based psychological interventions, the British experience – clearly outlined in this document – is very relevant.
4. One minor criticism: I wish the paper included a patient story or two.
5. One major criticism: I wish the paper emphasized more of the good work already being done in Canada. One of the reason I’m so hopeful about the future of mental health services is because we live in a country that hits – to use the boxing metaphor – above weight in research and innovative service delivery. I’ll pick a couple of examples: Strongest Families Institute, a non-profit out of Nova Scotia, helps families of children with anxiety, using DVDs, workbooks, and telephone support – Finland and Vietnam are now piloting versions of their programs; At Home/Chez Soi, funded by the Mental Health Commission of Canada, has re-shaped the conversation on homelessness here, and across the western world. The former isn’t mentioned in the CAMIMH report; the latter gets passing mention.
Reform and the UK
“Can call centre therapy solve the NHS mental health crisis? Fast-track treatment aims to ease growing problem in the UK, but critics say it is the clinical equivalent to online dating”
The Guardian, 25 January 2016
An NHS counsellor lets out a deep sigh as she puts the phone down. Her latest caller has revealed a further bout of self-harming. She fans her face to cool down after another tough counselling session on the frontline of Britain’s mental health crisis.
This cramped call centre in an industrial park in west Oxford is one of dozens of locations where the NHS is finally starting to grapple on a mass scale with illnesses such as depression and anxiety.
The despair caused by a largely hidden national problem spills from the phone lines daily, and this team of 30 counsellors gets frequent reports of suicidal feelings. Patients include everyone from stressed Oxford dons and high-flying students to landscape gardeners and harassed mothers. Problems range from ‘social anxiety, behavioural avoidance, phobia of toilet, wine.’
This is no fringe issue in the health of the nation. The NHS believes people with mental health problems die 15 to 20 years earlier than the average, but the system is struggling to cope.
So opens an article written by Robert Booth in The Guardian. In it, Booth outlines some of the problems experienced by those with mental health problems. He focuses in particular on IAPT.
He writes of a program under strain:
· The caseload of IAPT is 1.3 million patients – 50% higher than when it was first proposed.
· The dropout is around 40%.
· Quality is uneven, with people in southern England having a dropout rate that is 5% lower than in other areas.
Booth has written critically about IAPT before, and he does again in this article.
Many of these criticisms are reasonable (like the inconsistency of delivery across the country). But it’s important not to overlook the incredible successes. Start with the fact that IAPT has moved so many people off government support (and back to the workplace) that it has paid for itself. Another point not mentioned by Booth: IAPT has allowed millions – yes, millions – free access to psychological interventions who otherwise would not have had CBT, or any other evidenced-based psychotherapy.
Let me add a thought: What a great set of problems to have. We shouldn’t minimize the issues facing British mental health patients. That said, consider the service: accessible evidence-based therapy, free at the point of use. Wow. Let’s not whitewash the challenges, especially the uneven quality of services (northern vs. southern England). But with the proper reforms, we can hope that one day a Canadian newspaper would write about the problems of such a Canadian service.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.