Network, Fall 2005
Quebec started the trend in 1989. Alberta has been on board for 11 years. And Prince Edward Island was doing it for years but decided in April 2005 to go in the opposite direction. The trend is regionalization — shifting responsibility for health care services from the provincial level to local communities and regions.
Now this province has taken its own first steps toward a “made in Ontario” model of regional health care. In September 2004, Minister of Health and Long-Term Care George Smitherman announced the creation of Local Health Integration Networks. Called LHINs for short, these new organizations will eventually be responsible for planning, coordinating, and funding the delivery of health care services within 14 geographical regions.
What does this transformation in health care mean for community mental health services, including the 33 CMHA branches in cities, towns and rural communities across Ontario? What does it mean for the health care system as a whole? And, most importantly, but perhaps the most difficult to know, what will regionalization mean for people with mental health problems and their families?
Ontario’s Plan for Transformation
Moving towards a regional system of service delivery is just one part of the Ontario government’s plan to transform the entire health care system. Smitherman says the goal is to make Ontarians the healthiest Canadians, which can be achieved by making the health care system function as a true system.
A new patient-centred and community-based health care system will relieve pressure on hospitals by investing in five key areas of community-based health care: long-term care, home care, primary health care through the creation of 150 family health teams, community mental health, and a revitalized public health system that focuses on prevention.
Yes, health care will become the responsibility of the 14 LHINs, but don’t confuse them with other types of regional health authorities, the ministry cautions. Unlike the models implemented in other provinces, LHINs will not directly provide health care services. Instead, they will work with local health care organizations, such as CMHA branches, which will keep their own voluntary boards of directors. Each region will have its own LHIN, but the boundaries will be “permeable,” so that people can still get health care from different regions if necessary.
While mental health advocates in Ontario have responded positively to the renewed commitment to community-based care, and the government’s investment in community mental health services, there are still questions about what we can expect from LHINs.
One way we can begin to answer these questions — and to know what questions to ask — is to look at what happened in other parts of Canada where regional health care systems have already been tried. If experience is a good teacher, what can Ontarians learn from the other provinces?
Partnerships among Mental Health Advocates
Mental health advocates in other provinces stress the importance of getting mental health on the agenda right at the beginning of the transformation process. The best way to do that is through partnership.
In British Columbia, alliances among provincial mental health groups have developed at different stages of the regionalization process. The most recent partnership is the broad-based BC Alliance for Accountable Mental Health and Addictions Services, which includes CMHA, BC Division. Alberta led the way in Canada with the development of the Alberta Alliance on Mental Illness and Mental Health to unify the voice of the sector. Tracy Ryan, executive director of CMHA, New Brunswick Division, says of the collaboration among players at her end of the country, including government, “We work together in this province. We have built strong partnerships.”
Ontario seems to have learned this lesson. Three of the leading provincial organizations — the Canadian Mental Health Association, Ontario, the Centre for Addiction and Mental Health, and the Ontario Federation of Community Mental Health and Addiction Programs — have developed a collaborative response to the transformation agenda. Together, they have supported their members, staff, clients and boards to ensure that mental health and addictions are a priority in the planning taking place in each LHIN region, as well as pressing for the same priority at the provincial level.
Promoting the Provincial Role
Mental health advocates recognize that one of the strengths of regionalized health care is that decision making is brought down to the local level. Grassroots organizations like CMHA branches and consumer self-help groups have always stressed the importance of community involvement in decisions about mental health prevention, promotion and treatment services.
But advocates in provinces where regionalization has occurred say that it’s still essential to have strong provincial leadership to guide the development of mental health reform. Without some structure at the provincial level, decisions about what to fund are decided in each region.
New Brunswick is at a mid-point in the process of regionalization. While regional health authorities have been in place since 2003, mental health services have continued to be overseen by the provincial Mental Health Services Division of the Department of Health and Wellness. This year mental health services will also become regionalized, and advocates are concerned. “One of our worries,” says Ryan, “is that we may in time lose the Mental Health Services Division, which means that we may lose the visibility and the strong focus on mental health that it provides.”
While regionalization makes a strong provincial voice all the more important, it can also threaten the existence and stability of existing organizations. Part of the problem is related to funding. In Alberta, provincial mental health organizations, like CMHA, Alberta Division and the Alberta Mental Health Self Help Network, a consumer-run organization, were told to apply for their funding through the regional health authority where their head office was based. According to Carmela Hutchison, president of the Network’s board of directors, provincial organizations were successful in “making the case to keep provincial organizations provincially funded.” The Network felt that this was essential in making sure they were able to adequately serve and represent their 2200 members in the nine different regions of the province.
A diverse range of advocates have recently formed the BC Alliance for Accountable Mental Health and Addictions Services. In addition to traditional partners, such as CMHA, BC Division and consumer-run groups like the CSX Mental Health Society and the CMHA Consumer Development Project of Okanagan, the Alliance also includes the John Howard Society of BC and the Vancouver Police Department.
One of the Alliance’s demands to government is the creation of a provincial mental health and addictions authority. This provincial authority would oversee planning and implementation. According to the Alliance, even when new funding is invested, “without a clear linkage to a provincial mental health and addictions plan and an accountability framework we will not know if funds have actually made a difference” (“From Marginalization to Recovery through Leadership,” March 2005).
Local Advocates in Every Region
In addition to a provincial voice for mental health and addictions, there need to be strong advocates at the regional level, where the major decisions around allocation of funding and resources will be made. “Consistency is going to be our biggest issue across the province,” says Ryan as the process of regionalization of mental health service takes place in New Brunswick.
Hutchison warns that regionalization can result in an uneven approach to planning and service delivery. In Alberta, for example, only two regional authorities, in Calgary and Lethbridge, have regional mental health advisory committees to provide consumer input on mental health issues. Hutchison says that these committees exist “because people in those regions actually got out there and took the initiative” to make them happen.
The potential for regional health authorities to be responsible for decision making on all aspects of health care, including mental health, means that mental health advocates have important work to do. “There’s a lot of education that needs to be done with the regional health authorities,” says Ryan, “because unfortunately each regional health authority board does not have an appointed seat for someone with a mental health background.”
Consumer Involvement from Start to Finish
Hutchison stresses that consumers and consumer-run organizations need to be involved from the get-go. “If they’re not involved in the beginning of regional planning,” she says, “they won’t be there in the end.” She warns that in a system where health care planning takes place at the regional level, “what doesn’t get in the plan, doesn’t get funded.”
Ontario has a long history of provincial funding for consumer-controlled organizations, and advocates are determined to see that consumer involvement continues and thrives in a transformed system. According to a paper prepared by four leading mental health and addiction organizations, including CMHA Ontario, one of the critical success factors for the new system is that “consumers and families will be involved in all aspects of planning, decision-making, implementation and service delivery” (“Consumer/Survivor Initiatives: Impact, Outcomes and Effectiveness,” July 2005).
Assessing the Impact on Consumers and Families
Does shifting control over health care services to local regions make a difference for individual consumers and their families? “In some places things got better, in some places things got worse, and in some places things stayed the same,” says Hutchison. In other words, “Overall, things are the same as before in that access to services is still a random process. We need to make it so that it’s not random.”
While one of the proposed benefits of regional health authorities is integration of services so that families don’t have to navigate a disconnected array of services, advocates warn that there are also potential downsides. In a situation where all services are provided by the regional authority, consumers risk being cut off from all their supports if they are banned as a result of their behaviour while in treatment, a situation that Hutchison has encountered in her peer support work.
Measuring the impact of regionalization on the quality of life of consumers and their families is challenging, since mental health services are only one part of what people need for recovery. Hutchison observes that consumer self-help groups that don’t receive government funding aren’t included in the regional health plans. They end up not being recognized as part of the mental health system. The result is that funded agencies may not refer people to these unfunded groups, and the resources and experiences they can offer people are overlooked. Other government-funded services such as housing or income security can also have a huge impact on consumers’ lives but aren’t always included in mental health planning.
According to the BC Alliance, regionalization has ultimately not led to any dramatic improvements in the day-to-day life of many people with mental health and addiction issues. The Alliance reports that, “despite previous initiatives in mental health and addictions service reforms that have resulted in some needed improvements and expansion of services,” people with mental illness and addictions are still disproportionately living in poverty and homelessness and inadequately housed, and are at increased risk of contact with the police and involvement in the criminal justice system.
In contrast, Hutchison says that consumers in Alberta have recently benefited from a significant increase in payments under the monthly provincial disability income plan (Assured Income for the Severely Handicapped), as well as an increased allowance in the amount of money that they can earn from work while still receiving support.
Regardless of final outcomes, advocates often describe the stress and confusion that accompanies the process of changing to a regionalized system. In many provinces, regional boundaries were developed and then restructured at a later date. For example, Alberta had 17 regional health authorities that were reduced in 2003 to nine. This instability meant confusion for advocates who tried to help people navigate the health care system.
According to Hutchison, at one point in the transition her local regional health authority couldn’t even tell her how many beds for psychiatric treatment were available in the region. There was, she says, “a lot of flux and confusion.” Ryan reports the same process in New Brunswick, where “everybody’s just working it out as they go along.”
Mental health advocates in other provinces have experienced benefits and drawbacks in the shift to regional health care. Often, the way people are engaged in the process is as important as the outcomes.
The final word of experience comes from New Brunswick: “Communicate, communicate, communicate,” stresses Joy Bacon, who took on the role of acting executive director for CMHA, New Brunswick Division in 2004-05, while Ryan was on maternity leave. “Communicate up, down, circles, lateral if you need to. You can never have too much information out there. People are going to speculate regardless. Unless you’re sharing the information, people will fill the void with their own ideas about what’s happening.”
Heather McKee is a community mental health analyst for CMHA, Ontario.
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