1999 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE

CONTENTS

Wednesday 1 March 2000

1999 Annual Report, Provincial Auditor: Chapter 4(3.09), mental health program, community-based services activity
Ministry of Health and Long-Term Care
Mr John King, assistant deputy minister, health care programs division
Mr Dennis Helm, director, mental health, health care programs division
Ms Gail Czukar, manager, mental health legislative policy unit
Mr Tom Peirce, consultant, health reform implementation team
Ms Diana Schell, counsel, legal services branch

STANDING COMMITTEE ON PUBLIC ACCOUNTS

Chair / Président
Mr John Gerretsen (Kingston and the Islands / Kingston et les îles L)

Vice-Chair / Vice-Président
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)

Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John Gerretsen (Kingston and the Islands / Kingston et les îles L)
Mr John Hastings (Etobicoke North / -Nord PC)
Ms Shelley Martel (Nickel Belt ND)
Mr Bart Maves (Niagara Falls PC)
Mrs Julia Munro (York North / -Nord PC)
Ms Marilyn Mushinski (Scarborough Centre / -Centre PC)
Mr Richard Patten (Ottawa Centre / -Centre L)

Substitutions / Membres remplaçants
Mr Dan Newman (Scarborough Southwest / -Sud-Ouest PC)

Also taking part / Autres participants et participantes
Mrs Claudette Boyer (Ottawa-Vanier L)
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Mr Steve Peters (Elgin-Middlesex-London L)

Clerk pro tem / Greffier par intérim
Mr Douglas Arnott

Staff / Personnel
Mr Ray McLellan, research officer, Research and Information Services

The committee met at 1039 in committee room 1, following a closed session.

1999 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE

Consideration of chapter 4(3.09), mental health program, community-based services activity.

The Chair (Mr John Gerretsen): I'd like to call this meeting to order, which is a continuation of the hearings held by the standing committee on public accounts dealing with chapter 4 of the 1999 Annual Report of the Provincial Auditor, and specifically dealing with the mental health program, community-based services activity.

I'd like to welcome you, Assistant Deputy Minister, and your delegation. You'll have about 15 to 20 minutes to make your presentation, and afterwards we'll throw it open to the members who are here.

Mr John King: Good morning, Mr Chairman. I'm sorry we're a little late. We were waiting for someone to come and get us rather than be here, so I apologize.

The Chair: That's all right. We were almost going to hold the parliamentary assistant hostage until you got here.

Mr King: I'm not going to comment on that.

I'm John King. I'm the assistant deputy minister for health care programs at the Ministry of Health and Long-Term Care. I am joined this morning by Dennis Helm, who is the director of mental health for the health care programs, and also Gail Czukar, who is the manager for mental health legislative policy. On behalf of the ministry, we are pleased to meet with the public accounts committee today.

Let me begin by saying that the ministry is committed to ensuring all Ontarians can rely on quality health care.

A strong Ontario economy has made it possible for the provincial government to increase health care spending by $1.5 billion since its 1995 commitment of $17.4 billion. In fact, we expect to increase funding by another 20% over the next five years to meet future needs.

In 1998-99, the ministry's actual operating expenditures totalled $18.9 billion. This year, the budget is expected to be $20.9 billion. That's over one third of the entire government budget.

Of our total health budget, the ministry spends over $2.4 billion on mental health programs and services. Programs supported by this funding include community-based services, homes for special care, provincial and specialty psych hospitals and general hospital psychiatric units.

The ministry directs $406 million toward community-based mental health services in Ontario. This year, this $406 million was an increase of almost 90% over 1994-95. This includes 335 community-based mental health agencies, 152 homes for special care, and 84 supportive housing providers, together with $1.3 billion in other mental health services such as OHIP, drug programs and long-term care, $5.4 million in program administration, and $869 million toward hospital-based services. We arrive, then, at the total commitment of $2.4 billion per year in mental health services.

With respect to the Provincial Auditor's report, in 1997 the Provincial Auditor assessed the ministry's performance on community-based services activity. The goal of the community-based services activity is to develop a system that will support people with mental illness living fulfilling lives in the community. The activity funds community mental health programs, including community-based mental health services, children's mental health programs, residential homes for special care, and the community psychiatric payment program.

I am pleased to say that the ministry has made substantial progress in the areas outlined by the Provincial Auditor.

Under mental health reform, the auditor recommended that the ministry should periodically evaluate its progress in meeting the mental health reform targets. Our response is that the ministry has begun benchmarking progress and outcome through the multi-year community mental health evaluation initiative. This initiative involves outcome evaluation projects, focusing on case management, crisis response and consumer-survivor and family initiatives. The project team includes the Ontario Mental Health Foundation, the Centre for Addiction and Mental Health, and the Canadian Mental Health Association, Ontario division. The initiative also allows us to closely monitor bed ratio shifts within the mental health system.

The research projects funded through the multi-year community mental health evaluation initiative are in the early stages of implementation. These projects will provide the ministry with vital information regarding cost-benefits and outcomes related to core community mental health functions. Once the data become available, the ministry will be in a position to revisit and refine the mental health reform targets.

As well, the auditor recommended that we should develop and compare the costs and outcomes of community-based care with those for institutional care for various levels of service or care. The mental health minimum data set is intended to enable ministry staff to analyze and compare the cost of community care and institutional care. The following mental health minimum data set activities are underway.

Since 1997-98, community mental health year-end reporting includes newly developed reinvestment fund indicators.

A psychosocial rehabilitation tool kit has been developed and is being implemented and will provide rehabilitation outcomes, such as change in hospitalization rates and change in housing, employment, education and financial circumstances. The PSR tool kit will collect and report most of the minimum data set client information.

A minimum data set client data snapshot survey has been completed. For those community agencies and hospitals that participate in the snapshot, we are now able to answer questions regarding service availability, clients and utilization patterns.

The results of the minimum data set client data snapshot and the technology survey have been distributed to all mental health provider organizations. Work is underway to develop the minimum data set across the province.

The ministry's IT priority review board deferred the development and implementation of the mental health minimum data set project due to other priorities in the Y2K compliance. We are now reviewing IT priority projects with the completion of the Y2K project.

With respect to operating plans, the auditor recommended that the ministry ensure that all information submitted is in accordance with ministry requirements. The ministry has streamlined and simplified reporting requirements by refining the operating plan guidelines and process requirements it distributes to mental health provider organizations. We have utilized the streamlined operating plan package containing all information required by the ministry since 1997-98.

As well, the auditor recommended that the ministry require operating plans to be submitted, reviewed and approved on a more timely basis. The time frame for the operating plan process depends on the government's estimates-budget process. This has had an impact on the timing of the issuance of the operating plan guidelines and process requirements. In spite of this organizational challenge, the Provincial Auditor has acknowledged our progress. We have consistently sent out packages before the commencement of the fiscal year in each of the past three years. The health care programs division, through the regional office structure, will coordinate all hospital and community operating plan processes as much as possible.

With respect to performance monitoring, the Provincial Auditor recommended that the ministry define acceptable levels of care and establish performance benchmarks and outcome measures and monitor programs against them. We have defined levels of care and systems outcomes in the ministry's recent document entitled Making It Happen: Implementation Plan for the Reformed Mental Health System and Operational Framework for the Delivery of Mental Health Services Reports. Released in August of last year, Making It Happen enables regional and local planning processes to align and rationalize community mental health services.

We are ensuring we implement the objectives of Making It Happen in a timely manner by establishing mental health implementation task forces. These task forces will operate in all health regions across the province. The northeastern task force has already been established, and additional task forces will be announced shortly. The task forces will provide advice to the ministry on the allocation and reallocation of community investments to support policy directions. We will base performance benchmarks, targets and outcomes on the multi-year baseline data captured by the mental health minimum data set that I mentioned earlier, as well as on data captured by the district health councils and the mental health implementation task forces.

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With respect to management information systems, the Provincial Auditor recommended the ministry should accelerate the development and implementation of an appropriate management information system. The ministry, in response, completed a technology survey in 1998 which has enabled the ministry to assess and evaluate direct electronic transfer alternatives. Community mental health programs' budget systems, financial logs and sessional fees systems have all been implemented. These are being further refined following the completion of the year 2000 projects.

With respect to the community psychiatric payment program, allocation of funds, the auditor recommended that the ministry ensure that sessional funding is allocated on a reasonable and equitable basis rather than on a historical basis. Through the implementation of the commission recommendations and directives, the ministry now ensures that new or reconfigured priority services are receiving appropriate sessional fee allocations. This allows us to make sure that medical and specialist support is available.

With respect to monitoring, the auditor further recommended the implementation of a procedure such that timely information is received on the use of sessional funding, and sessional funding is spent in accordance with ministry guidelines. The ministry has implemented a computerized community sessional fee logging system that enables timely follow-up. Also, the reporting compliance is improving through ongoing verbal and written reminders to government agencies. By the 1997-98 year-end, sessional fee reports had a compliance rate of almost 100%.

With respect to homes for special care quality of care, the auditor recommended that the ministry mandate compliance with the minimum standards of care as a condition of licence renewal. The ministry is developing a comprehensive supportive housing policy for people with serious mental illness that will set out standards and monitoring mechanisms for all supportive housing, including the homes-for-special-care program. These standards and monitoring mechanisms will help to ensure a consistent approach to the programs being funded by the ministry. The policy might have legislative implications for the Homes for Special Care Act.

With respect to processing of payment and recoveries, the Provincial Auditor recommended that we improve our procedures to help ensure we recover the payments made on behalf of the residents of homes for special care that we are entitled to. The ministry has implemented a computerized homes-for-special-care information system. The modifications to the system include the capability to produce aging reports. Therefore, we would be able to facilitate a more efficient recovery process.

Under respite care grants, the auditor requested that the ministry should assess whether it should continue to provide respite care grants for staff relief. On August 12, 1998, the government approved a rate change within the Homes for Special Care Act to increase the per diem payment level from $27.63 to $34.50, which is consistent with other residential housing programs providing similar types of services. Respite care grants will cease on April 1, 2000. This will not affect client care adversely because of the increased payment rate which came into effect on September 1, 1998. The increase will ensure that appropriate levels of resident care and services continue to be provided by homes for special care while a comprehensive housing policy for people with serious mental illness is being developed.

In conclusion, I believe the ministry has demonstrated significant movement forward on the recommendations of the Provincial Auditor. The ministry has shown a commitment to Ontario to create an integrated and comprehensive mental health system that emphasizes prevention and access to services and improves public safety, and I believe we are delivering on that commitment. Beyond even the scope of the auditor's report, since June 1998 we have announced significant investment to mental health community-based services.

In December 1999, we announced $19.1 million to expand community-based mental health services to a total of 51 assertive community treatment teams and to enhance court diversion, psychogeriatric outreach, case management and crisis support services.

In March 1999, this government announced its provincial housing strategy, which included $45 million in each of the next three years to provide housing and housing supports for people with serious mental illness. Of this $45 million, $20 million was identified for initial release to provide permanent housing and supports to approximately 1,000 people with serious mental illness who are intensive users of emergency hostels. This strategy is in addition to the $2.5-million homelessness initiative in 1997-98 that enhanced services to Ottawa, Hamilton and Toronto.

In 1998, we announced $60 million in funding to support enhancements to community-based mental health services, additional forensic beds and court diversion, and long-term-care services for the mentally ill.

Finally, I'm proud to report that all of the service enhancements resulting from the $23.5-million community investment fund in 1997-98 are operational. The community investment fund increased community services and supports for people with severe mental illness. The service enhancements included case management, crisis response, family initiatives and consumer-survivor initiatives. These initiatives will ensure that all Ontarians have timely access to services they need.

We are strengthening the continuum of care for people in need and we will continue to do what is necessary to improve and enhance access to these important services.

That is all I have to say, Mr Chairman, for the formal portion of this program and we're happy to answer any questions that the committee may have, with the support of my colleagues.

The Chair: Thank you very much for your presentation. The third party will not be represented here today as Ms Martel apparently is ill. What I propose we do is limit each question-and-answer period to 15 minutes so that there will be two go-arounds before lunch today. We start with the government side.

Mrs Julia Munro (York North): I appreciate the opportunity that you have provided us in being here today.

There are a number of issues obviously in the course of the morning that we'll have an opportunity to speak to and get some response from you. One of the overall issues that I think would be appropriate to start off with this morning is the whole issue of integration and the fact that while there are so many very important pieces in health care in general in the province, and it's certainly something our government has taken some leadership on, the question of integration is one that people find particularly important, being able to access service. I wondered if you could give us an update on the way that integration between mental health services and health care in general is taking place, particularly at the regional level, because obviously that's where the individual Ontarian is looking for some kind of access point.

Mr King: As I mentioned, the Ministry of Health and Long-Term Care budget is almost $21 billion, and of that portion, the health care programs division, which I am responsible for, is a total of about $14 billion. This includes all of the health care programs other than physician services, labs and diagnostic imaging.

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Recently, the ministry identified the need to look at regionalization of their health care programs division. We are in the process now of setting up seven regional offices. These regional offices will be scattered throughout the province and they will include hospitals, mental health and long-term care. Although we have not moved to a regional structure in the other parts of the system, it is very important that the ministry move in this direction and provide services locally, have local access and a single point of entry for our stakeholders.

If you can picture this, you can see that we would have the hospital personnel, program personnel, long-term-care and mental health personnel all working side by side. This is in our hope to provide an integrated service delivery mechanism for clients, patients and residents in Ontario. By this, I think it really strengthens the continuity of care that we're trying to promote. So we're integrating at the regional level. That is very important to the ministry, but it also will promote for our stakeholders who enter the system that concept of integration in their communities.

I might emphasize that now we have ministry people outside of Toronto at the local level who will also monitor our activities out there and the accountability that everyone is expecting for the dollars that are spent on health care.

I hope that shares our integration strategy with the ministry. There are other things that we can elaborate on as far as the integration with mental health services is concerned, which I'm sure will come up later.

Ms Marilyn Mushinski (Scarborough Centre): When we're talking about moving from institutionalized care to a more community-based care, I understand that you have set up some ACT teams, or assertive community treatment teams, and I'm very interested in how you arrived at this particular model. I'm going to probably be asking you a supplementary question on the regionalization aspects of that, because I have some particular concerns as it pertains to my own riding of Scarborough Centre, and how it responds also to Mr Newman's report, 2000 and Beyond. Could you tell us a little bit about the program and then I'll ask a few more questions.

Mr King: I did want to comment on the move from the institution to the community. A number of years ago the balance between the institutional and community care was about 75% institutional, 25% community. Our goal, of course, is to bring everything closer to home. That's not only in mental health but other services in health care. We are now at an average of about 60% institutional, 40% community, so it's very important that we build up the community supports as we are deinstitutionalizing clients and patients.

We were very fortunate to do some benchmarking on ACT teams in the States, and we have created a model here in Ontario. I'm going to have Dennis Helm elaborate a little more on the ACT teams, because I believe very strongly that this is a real success story for Ontario, to develop this team approach that really delivers that support in the community that the patient would have otherwise received in an institution. We are now able to deliver that in a community setting.

Mr Dennis Helm: When we started the reform activity in looking at our goals of restructuring the system from an institution-based to a community-based system and looking at the restructuring of the psychiatric hospitals, we wanted to look at a best-practice model that really linked directly with our goals in that area. As John mentioned, through a review of activities in other jurisdictions, we developed a commitment to the assertive community treatment concept, which is basically involving many disciplines in terms of providing supports and services to clients. They are basically a self-contained clinical team that provides intensive treatment and rehab to about 100 clients per team. So it's very intensive. These supports are provided on a 24-hour-a-day basis, 365 days a year.

When we established the best practice of assertive community treatment teams, we wanted them to have a very direct relationship to the restructuring in our psychiatric hospitals. As you know, the commitment had been made to ensure that community supports are in place before we consider any bed downsizing within our psych hospitals, and the treatment teams were identified as a key program to make that link. So when we established these treatment teams, and we're now up to 51 full or partial teams-they're in various stages of implementation-for the majority of these 51 teams we have developed a sort of contract with the providers that they must have a direct link with the psychiatric hospitals so that if there are patients in the hospitals who are ready for discharge into the community, there is a direct link to these treatment teams. We felt that this intensive interaction would be a perfect discharge mechanism from the psychiatric hospitals into the community with these kinds of supports, which in turn link with other service providers, including housing.

So as a best practice, we are in various stages of implementing these and we have established an evaluation mechanism whereby this best practice, or this instrument, will be evaluated along with other reform priority investment tools. They will be evaluated and reported back to the ministry in terms of whether any adjustments should be made and to look at the cost-benefit analysis and especially the quality-of-life point of view.

Ms Mushinski: I wonder if you can just tell me, as you implement this particular aspect and other mental health reforms, how you can ensure that the specific needs of various communities within Ontario are being met. For example, the needs of a very diverse community in Scarborough Centre probably are quite different from those in a far-reaching and remote community in the north. I'm wondering how the mental health reforms address those specific divergent needs of the province.

Mr Helm: When we identified the community treatment teams, as an example, as a priority 4 investment, ministry staff led a community-based activity working with service providers, and I'll use Toronto as an example. We worked with existing community service providers here. We looked at the work that had been done by the district health councils in terms of identifying the service priorities.

We were keen on the assertive community treatment team concept but we wanted to make sure that any investments really reflected the regional needs that have been identified. So, for example, working with the Toronto service group and the district health council, we looked at the priority target populations that they have identified; it could be a specific ethno-racial community, a forensic group. Developmentally disabled groups specifically had been identified, with a developmental problem plus a mental health problem. So through our implementation process we have the flexibility to work toward different target populations, and we did address the needs of specific communities; for example, in Toronto, having a treatment team established that specializes in services for the developmentally handicapped population with a mental health issue as well.

As another example, and even elsewhere in the province, treatment teams and all of our community investments are expected to have a forensic component as opposed to a parallel forensic system in the community. So treatment teams are expected to have a forensic capability. Within Toronto, because of the population and the demand, we did provide some specific funding to one team to truly develop a forensic capability so they in turn could work with other treatment teams in the city to help spread that expertise around forensic clients and the services they require. So we do try to address the specific population needs as much as we can.

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Ms Mushinski: I have one question about housing. Can you tell me what the ministry is doing to address this? I'm particularly interested in this. I was on a Canadian Mental Health Association task force 25 years ago looking at supportive housing models in the community. I just have a serious concern that we may be abandoning some of those earlier policies for supportive housing. Could you tell me what the status of the ministry's supportive housing strategy is for the mentally ill, please?

Mr King: I think you're touching on two areas. One is the operations, with things such as the homelessness strategy, and also we have some policy and strategy development in housing.

I'm going to ask Dennis to refer to the operations. I'm sure Gail will have some comments on the housing strategy that's being developed now.

Mr Helm: The housing service really has been identified for quite a long time within the mental health reform strategy, that adequate housing is critical for our target population in terms of moving out of an institution into the community, and with the homelessness issues that have been identified across the province.

In 1997-98 was really the beginning of our homeless strategy, and that was when $2.5 million was identified for reinvestment in three areas of the province: Ottawa, Hamilton and Toronto. It was identified specifically that we needed support services to address the mental health issues of people living in hostels and shelters. That was the beginning of our initiative into this area, really a result as well out of the homelessness studies that were undertaken in various cities in Ontario, including Toronto, and in the provincial review of homelessness and housing. So we started that process.

Then in 1999 there was a significant step, in our view, for our target population, when it was announced that there would be a three-year, $45-million commitment for each of those three years to look at again housing and homelessness for the mentally ill. In phase 1, which took place in 1999, a total of just over $20 million was allocated-about $14 million of that was provincially allocated-again first targeting the cities that were identified with the lowest vacancy rates and perhaps the highest homeless population, and those were Ottawa, Hamilton and Toronto.

We have been working very closely with the communities in terms of moving this along and working towards the establishment of 1,000 units. That could be a combination of rent supplements, which are specifically geared to an individual in a rental situation, plus then capital, perhaps acquisition of units, and renovations.

We are proceeding to implement those and we are very pleased with the achievement we are making, considering that in previous years very little had been done in terms of our target population for housing. So the achievement of having 1,000 units that we're working towards was very welcome.

The Chair: Is that 1,000 in the province?

Mr Helm: A thousand in these three cities right now. That's phase 1. We are implementing that now, and progress has been made. There will be a phase 2 and a phase 3, which we will combine. Just to remind you of what I said, there was a three-year commitment, $45 million per year. I just talked about the first-year first phase.

For phases 2 and 3 we are looking at very shortly going out for a request of interest from parties across the province. We are allocating the remainder. At the end of the day the full $45 million will be annualized in community supports.

We are allocating the remainder of the funding to all regions of the province, based on population, and with a specific addition, in terms of a funding ratio, for those areas where we expect there will be some in-patient restructuring in the psychiatric hospitals, to make sure that we are in every community in the province, but to a greater extent in those communities that will be experiencing a restructuring of in-patient services. Our commitment is to have the community supports in place before the downsizing takes place. So we are in the midst now of this phase 2, where we will be going out and requesting expressions of interest so we can be working with the communities and identifying where the remainder of that funding will go.

Ms Gail Czukar: As Dennis mentioned, there has been activity in this area for some time. The ministry has been working with two other ministries to develop a comprehensive housing strategy and housing program; so municipal affairs and housing and MCSS have been involved in this as well. The ministry developed a committee to advise it on the housing policy. That committee included members of the service providing community, consumers and consumer groups as well as homes for special care providers to give them advice about what the housing policy should encompass. That policy is under development, is being approved as we speak, and should be ready for release soon, but the intention is to have a consolidated provincial program that will look at a number of these different programs and put them together-the domiciliary hostel program, homes for special care, the supportive housing and so on-so that there will be a consistent approach, with consistent standards, in supportive housing. So that work is underway and should be released soon.

The Chair: We went over the time a little bit. We'll make it up in the next round. I'll turn to the official opposition.

Mrs Lyn McLeod (Thunder Bay-Atikokan): As you can see by the number of us who are here, we have a number of questions and concerns in the area of mental health and we too appreciate the opportunity to talk with you about mental health. I think too often it doesn't get the focus that it needs, so this is really a welcome opportunity.

We'll start by following up on Marilyn Mushinski's questions about the whole area of supportive housing. I'm glad to hear the details of the three-phase program to provide supportive housing in communities.

My concern is the adequacy of the support that is provided in non-hospital settings. I'd like to preface my questions by asking whether or not you have any statistics yet on the number of people who are currently in psychogeriatric beds in hospitals that are scheduled to close and how many psychogeriatric beds will remain for that population of people. In other words, we know the proposed loss of overall beds, but I wonder if you have something on the loss of psychogeriatric beds specifically.

Mr King: Mr Chairman, is it okay if we continue to direct questions over to the experts here, perhaps, when we get into some of the details?

The Chair: We want to hear from the people who have got the answers.

Mr King: That's why I brought this entourage today, so we'd make that we have the right answers for people. I apologize that I don't have all the answers.

Mr Helm: In terms of the psychiatric numbers-I'll talk specifically about the provincial psychiatric hospitals-I don't have statistics with me, but in terms of the psychiatric hospital system across the province, as you know, it is going through a divestment transfer process. A key element of that is to do a patient survey of every client in the hospital, and psychogeriatric clients are included in that. We are finding that there are a number of psychogeriatric clients in the provincial psychiatric hospital system who could be perhaps better housed in the long-term care system or in the community with supports. That information is being used to formulate a discharge plan that would then be looked at and co-ordinated with our community activities, such as a community treatment team, that might be appropriate for psychogeriatric clients perhaps who are able to live in the community if they have the supports in place. A key requirement is that those persons must have the supports assigned to them before they go out into their own apartment or shared accommodation, either through a treatment team or through an existing case management program, for example, that we have in the community.

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That is being done in all psychiatric hospitals across the province. We have this baseline data that would help us, with the funding we have now and as new funding is announced through mental health task forces which we might get into. That would be information they would use as well to determine where the resources should be allocated, what kind of service providers should be funded for different types of services, which could vary from region to region.

Mr King: I was just going to add to that, if I might. This is why we feel it's so important that the ministry regional offices are set up so that the link with mental health and long-term care, in this example, is a strong link so that we can ensure there's a smooth transition with these patients.

Mrs McLeod: Is it possible to get statistics on the change specifically in psychogeriatric beds? Is that information you'd be able to provide?

Mr Helm: In terms of what is planned?

Mrs McLeod: What's proposed, yes.

Mr Helm: We could probably gather very high level data, not patient-specific obviously, but just the general findings of what they would need, how many might be appropriate for a long-term-care facility or, if they go to the community, the types of supports. We could put together that broad, high-level information if that would be helpful.

Mrs McLeod: It would be very helpful. I'll be very upfront about my concern and the reason I'm focusing at this point in our discussion specifically on psychogeriatrics. I notice that there's an adjective that has come into this-Mr King used it again this morning-and that's that as you look toward community supports in the deinstitutionalization process, you're looking at those who have a serious or severe mental illness.

One of my concerns is, all right, where do the seniors with Alzheimer's or with dementia fit into that picture? Can I assume that a senior who has Alzheimer's or a dementia of some sort at a fairly advanced stage is considered to be somebody with a serious or severe mental illness? My concern in asking about the psychogeriatric beds, because I understand that there's a significant reduction in the proposed psychogeriatric beds in a hospital setting, is, where are these people going to go?

If we look at support in a community setting and a supportive housing setting, an Alzheimer's patient typically needs a secure setting. They typically need 24-hour supervision. I'm aware that there are Alzheimer's patients now who are in wings of long-term-care facilities. You've mentioned that's one of the alternative placements for people who might now be in a psychogeriatric bed in a hospital setting. There's obviously a huge difference in funding that's available to that individual for support if they are in a psychiatric hospital or if they were to go into a chronic-care bed, which I think is the setting for most of the psychogeriatric beds with the deinstitutionalization, compared to them being in a long-term-care facility at $70 a day with a copayment or being in supportive housing, a special care home, where I think you just said the rate was $34 a day. Of course, the other alternative support is a home situation where it becomes tremendously costly to provide one-on-one 24-hour supervision.

I'm really concerned about where this population, people who are currently in psychogeriatric beds, is going to go, and following that, with an aging population, where the expanding population of people with Alzheimer's is going to go.

Mr King: This is also a good example of where this has gone beyond the mental health program. We just recently announced an Alzheimer's strategy for the province. We have initiatives underway right now for Alzheimer's patients. They are gathering that information on the local level. Again, coming back to your point, we are also very concerned about how the Alzheimer's patients are being cared for and treated, not only in institutions but also in the community setting, to have supports in place. There's a whole other strategy in place for the Alzheimer's patient that has been recently announced.

Mr Helm: I think it's important to stress and we want to be clear that within our mental health reform strategy we are maintaining a range or a continuum of services. There will be psychogeriatric beds in our system even post-transfer to a public hospital. We will have community supports for those, where appropriate, who can live in the community, and if people are more appropriately relocated to a long-term-care facility. The mental health side of the ministry and long-term care have been working together for the last couple of years on how to ensure the best quality of service for a mentally ill client in a long-term-care facility.

You may be aware of one of the previous announcements. Out of the $60-million announcement in June 1998 was a training initiative for mental health workers to be assigned to long-term-care facilities to provide not only behavioural support but also programming support to try to get at some of the issues you were referring to.

Mrs McLeod: I appreciate the broad view. I'm going to leave my questions at this point because I want to give my colleagues an opportunity.

My concern is I know there are psychogeriatric patients now in-let me rephrase it, because I think language may be a part of our problem here. People with advanced Alzheimer's and dementia are in long-term-care facilities now. I don't believe that $70 a day is enough to provide support at the level which that patient needs. What is the ministry doing to really identify the care needs of those individuals and ensure that the dollars match the care needs? I'm not seeing the specifics to give me comfort that as more and more people develop severe Alzheimer's or are discharged from hospitals, we're going to have the dollars in place to meet their level of care needs.

Mr King: Under another initiative that's happening in the long-term-care side, they are doing a levels-of-care study right now, addressing some of these issues, and also looking at the funding system in long-term care to address not only complex continuing care but then the chronic care, long-term-care funding system for this type of patient. So it is being addressed. We were focusing a little more on mental health here, but there are other branches of the ministry addressing some of those dollars.

That $70 a day is not the long-term-care rate; it's not the chronic care rate right now. I'm not sure where the number you're quoting is coming from, but the long-term-care patient rate is around $100 and the chronic care rate is closer to $300 a day. Many of these patients are presently housed in that setting. We are looking at that funding system right now for the future.

Mrs McLeod: I cross my fingers and pass it on to my colleagues.

Mr Steve Peters (Elgin-Middlesex-London): I have two questions. The first is in the area of the supportive housing policy that's being developed. As we're seeing this move from institutions to communities and the policies being developed-and you said that consultations are taking place-I would like to know who all is being consulted. In particular, I'd like to know whether municipalities are being consulted on this move towards the development of supportive housing. The municipal councils are going to be hearing from the neighbourhoods that may be proposed, and I would like the assurances to know that as these policies are being developed, everybody who is potentially going to be impacted or affected by the move from the deinstitutionalization is going to know what is going on and what is being proposed.

Mr King: First of all, with the project that has just recently been announced with the 1,000 units that were referred to in those three communities, it has been an area of difficulty going into local communities and their saying, "Not in my backyard," that type of experience. That was our first phase. We've learned a lot from this process that will certainly be incorporated into the phase 2 and phase 3 that we're dealing with. Dennis will probably want to comment specifically on your issue with respect to notification and education in this area.

Mr Helm: From an operational point of view I can address a few things and then maybe Gail will in terms of the broader consultation. In phase 1 of the housing that I mentioned, for example, and our planned phase 2, once it is started we spend a lot of time in the community with service providers, who are already in housing perhaps, but really anyone within the health-MCSS system will be brought to the table and be made aware of what opportunities we have. Through that consultation process we will be talking with providers, the city, consumer groups and family groups specifically for that community about the dollars we have available, how we might best allocate them to meet the reform agenda, the bed-pressure issues and the support services. So on the implementation side we try to be as inclusive as possible with all members of the community before we make a recommendation within the ministry as to where the dollars will be going, and for what services.

On the policy side there was another opportunity for input.

Ms Czukar: As I said, the committee that was struck to give the ministry advice about the development of the housing policy included people who are out there and who have had a lot of experience in trying to set up programs and have run into exactly the kinds of issues you are talking about, so that experience was brought to bear. But I think what you're talking about is really an implementation issue and will come up when the policy is being implemented.

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The Ministry of Municipal Affairs and Housing was involved in that and will be giving us further advice on how to roll that out in a way that is going to be compatible with the municipalities' agendas as well.

Mr Peters: The Health Services Restructuring Commission, when it issued its report for the London and St Thomas psychiatric hospitals, talked about the construction of a new 65-bed forensics unit at the St Thomas site. At some point-and hopefully I can get this answered-that directive from the restructuring commission changed from 65 beds, and it is my understanding it may be down to about 49 beds. From what I understand-and I'd like some clarification-that may be as a result of some of the new beds that are going to be created in the Hamilton area, but there are some questions that I've had from within my own constituency. We're at 65 beds; we're talking 49 beds now. At what level, at what point, is it going to be said, "We can't justify constructing a new forensics facility," that 49 beds isn't the right number? I'd just like to know where things are going with forensics.

I'm concerned with forensics, having lived in a community that's had a forensics unit for a number of years. The auditor talked a bit about a needs analysis of the forensics beds. I'd just like assurances that we're not going to be seeing any changes in the standards, what the level of a forensics patient is now-it may change. For people who currently may be in a forensics bed, something may change so that it can be said that they may be suitable to be out in the community. It's a concern. If I can't get it today, can I get some further information about where things are going as far as forensics is concerned?

Mr King: We certainly do have a direction on forensics. You started out with the analysis of the commission. The commission really did provide advice on specialty beds, tertiary beds, long-term-care beds, but not with respect to forensic. They left that with the ministry to develop a strategy. We have developed a strategy for forensic beds, but due to a number of changes that are occurring with the court system etc, we're also re-looking at that number right now. We're reviewing beds for forensics in the province.

Specifically for the London-St Thomas area, the divestment of the PPH is going to St Joe's in London in the first tier and then it will move throughout the community of southwestern Ontario after that. We can be more specific if you like on some of the forensics there. We have one of our consultants here with us today if you would like more information on that.

Mr Peters: I can leave you my card.

Mr King: OK, that's great. This is something that is dear to Dennis's heart, as far as forensic beds. I think it's an area that we all want to make sure we monitor very carefully, the numbers in the province and where they are located. So Dennis has some comments with respect to that.

Mr Helm: The forensic strategy for health has been developed through a committee that I chaired with other ministries, with MCSS, with the Attorney General and the Solicitor General. Through that interministerial committee we developed a provincial strategy for forensic across all of those ministries, and then within the Ministry of Health we also produced a strategy, and specifically a bed strategy, because as John King mentioned, the commission left the siting and sizing of forensic beds up to the ministry. We did our review, we looked at what best practices existed across the province and came up with a general ratio for secure beds of 3.8 beds per 100,000 population. That has been, and is, leading our plan in terms of bed numbers and location.

Through the reform agenda and using that bed ratio, we are looking at establishing 144 new forensic secure beds in various locations across the province. We feel that once they're up and running with all the other community supports in place, that should go a long way to helping with the pressure we are currently facing. As time goes on, as with any reform, you always re-evaluate and reconsider the direction, and that's the review that John mentioned. We are proceeding on this basis for bed implementation. What we will be looking at is, is that ratio appropriate or is it not?

In terms of your specific question about reinvestments or about recent announcements, I know there had been some discussion on London-St Thomas bed forensics and Hamilton. When the Hamilton announcement was made for 52 medium-secure beds, that did not take beds away from anyone. I know, and maybe that's what you're getting at, that in London-St Thomas there was a plan to maintain the beds they have there and at the same time, over a period of time, enhance services in London-St Thomas. So when we announced 52 beds for Hamilton, that was to set up a secure system they never had before for the Hamilton catchment area. We announced Toronto and Whitby as well. The beds that will be coming for London-I think it was nine in addition to what you have now-will be the regional secure system there.

Our goal is to have a regional secure system in every region of the province, maintain a maximum-secure setting in Penetang-the expertise is there; the numbers warrant that.

We're looking at non-bedded issues as well, because forensic services aren't only related to beds. Through community treatment teams-as I mentioned earlier, we've established a forensic specialty-we've supported the forensic court here in Toronto, which has been very important in terms of moving things along, and we have established a number of forensic court workers across the province as well. So there is that bed component that we're looking at, and announcing beds, plus the community side.

Mr King: Mr Peters, we also identified a number of other questions that you had in your remarks. Gail has a comment she'd like to make.

Ms Czukar: You mentioned that you didn't want to see patients being put out in the community perhaps because of a lack of beds or not enough beds in the system. I just wanted to make it clear that that's not really the prerogative of the ministry. Decisions about whether people are to be kept in custody in a hospital or given custodial discharges lie with the Ontario Review Board. That's the body that makes decisions about what kinds of conditions to put on people if they are going to go to the community. Currently, of course, the hospitals that are designated under the Criminal Code-because this is a Criminal Code matter-are the psychiatric hospitals that Dennis has been talking about, the Centre for Addiction and Mental Health and the Royal Ottawa hospital. Under the Criminal Code, patients can only be attached to those hospitals, as it were, by the Ontario Review Board, and those decisions are made by a panel of five experts.

I just wanted to address that point, that it's not up to the hospital to say, "We're out of beds today so this one is going to be out in the community."

The Chair: We have four minutes left for each caucus at this stage.

Ms Mushinski: I still have a couple of questions and I'd like to follow up on that just a little, if I may. I think this whole area of mental health, mental illness, protection of individuals is very complex and certainly leads to a lot of confusion in the general public's mind about the rights of individuals over the rights of the community. Can you tell me what role the ministry has in terms of public education to make sure that government policy is disseminated into the community while at the same time protecting the rights of individuals?

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Ms Czukar: In 1998 the minister announced the mental health reform implementation as well as a mental health law education project and review of legislation. The mental health law education project has been ongoing since that time. It's headed by Michael Bay, who is the chair of the Consent and Capacity Board for the province. He knows this area of the law intimately, and he has done many, many sessions around the province for mental health service providers, police officers, emergency workers and the general public. Families and consumers have attended these sessions. I'm told that they're extremely well attended and very well liked. He's done a number of those and has provided information on people's rights but also on the powers of hospitals and police officers and physicians to ensure that people who are not able to look after themselves because of a mental disorder or who may be a danger to themselves or others are appropriately brought to hospital for assessment and commitment.

He has recently been focusing on issues with respect to cold emergencies or emergency treatment of various sorts. He distributed a poster on mental health emergencies to all the emergency rooms in the province shortly before Christmas to ensure that people who work in hospital emergency rooms know when they have the authority to hold people for assessment and for commitment.

Those are some of the steps the ministry has been taking to inform people.

Cold emergencies: I guess various municipalities have their own systems in place, but certainly here in Toronto the municipal officials have their criteria when they decide that a cold emergency is to be declared, when the temperature's going to drop to a certain point, and then certain special measures can be taken. These powers, however, in the Mental Health Act are not related to cold emergencies; those powers are always there. It's simply a question of a more objective standard about when someone might be showing a lack of capacity to care for themselves due to a mental disorder if they're choosing to sleep on the street at minus 40 degrees or something.

Ms Mushinski: My other question has to do with accountability. As we're moving services from institutionalized care to more community-based care, how do we monitor accountability of the service providers or the community deliverers of mental health service?

Mr King: In general, I think "accountability" is the strongest word that we would like to use in the ministry right now-accountability for all the dollars that are moving out into the province. We have established a number of accountability frameworks for reporting from the field-indicators, outcomes and how the money is being spent. I'll have Dennis directly respond to your question on what we're doing as far as the move from institutional to community-based is concerned, but I did want to leave with the committee that accountability is one of the biggest areas where we're moving in the ministry, to ensure that all areas where we're delivering health care are where we would like to ensure that those dollars are being spent in the right place at the right time, and also that the outcomes are effective.

Mr Helm: Many of our recent investment initiatives have been very focused on a certain model-for example, community treatment teams, intensive case management-building upon our existing accountability frameworks, which include the annual operating plan process where they identify what they have done the year before and what they plan to do in the coming year. As John said in his opening remarks, we're co-ordinating that with the submissions out to the public hospitals and specialty hospitals so that everything comes together.

In addition to that normal reporting, there is a requirement up front that they report specifically, at least for the initial period of time, on the achievements made specific to the investment that they have just received, whether it's a community treatment team or some other function. We're very clear: With these investments and best practices, we develop standards within the ministry and share them with all the service providers so that when we enter into a contractual arrangement, they know exactly what is expected of them. They monitor and report specifically on the community investment fund initiative or community treatment team initiative to us as part of our ongoing activity in terms of operating plans and reviews.

In addition to that, we have been, as we mentioned, identifying some very specific legal agreements. Again, through the community treatment teams there's a legal agreement that we will have with the provider in terms of what is required from the psychiatrist who will be on staff on the treatment team: the roles, responsibilities, and the reporting back. We want them to be very focused on their 100 clients, we want a very strong link between that model and the restructuring in our inpatient psychiatric hospitals, so we want to make sure there is a clear link between those two, meaning hopefully some clients from our psych hospitals who are able to be discharged go into a treatment team and are linked with housing in that way. So we spell all this out in terms of expectations and it's a formal agreement and part of the operating plan process that we have put in place.

Mr King: I might also add, if I could, with the accountability of moving from the provincial psych hospitals to the divestments, that we will also have an accountability framework in place to ensure that movement is consistent with provincial standards. So there will be service agreements at the new sites that will house these beds, as well as the tier 3 when they actually move out to other sites throughout the province, to ensure that we maintain the same standards that are presently there in the provincial system.

The Chair: That's the time period. To the opposition, 10 minutes.

Mrs Claudette Boyer (Ottawa-Vanier): I'm mostly interested in the homes for special care. You mentioned that in your phases 2 and 3 you would support the different outgoing programs. I do have in my riding a hostel program, which is in a house of special care. You've mentioned-I think we were talking about care grants-that first it was $27.

Mr King: Yes. It was increased.

Mrs Boyer: So when was it $27 a day, as a per diem?

Mr Helm: It was increased in September 1998.

Mrs Boyer: It was increased to $34?

Mr King: Correct.

Mrs Boyer: Now, all your outgoing consultation and everything would be a different program. Is there a possibility to increase this allotment?

Mr Helm: It's difficult to know what the outcome will be, but clearly through the consultation process of the housing strategy, I would think, and Gail could comment on this, that items would be put forward for discussion in terms of structure, relationship, and I would assume per diem rates will be raised in that forum.

Ms Czukar: I can't say whether they will be raised or not. We have to get advice on that. But as I said, the idea is to make the different programs consistent and to ensure that service providers are getting consistent funding for meeting the same kinds of needs. That's what has to be evaluated in the final analysis in deciding what the right level of funding is for all of the programs.

Mr King: Our understanding is that the increase in the per diem has assisted greatly. We have not had a great deal of feedback, a great number of individuals coming back and saying that's inadequate at this time.

Mrs Boyer: Why I'm asking this question is because I know that for this resident I'm talking about, absolutely it's not enough. They've met with the Ministry of Community and Social Services to see what the regional municipality could do about it, and I was just wondering if you had heard about it. Why I'm very concerned about this is that I was told that if they don't get more per diem, these people-and there are about 175 in this house-will be put on the street because the money is not there to take care of it and they will become homeless.

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Mr King: I think what's happening here is we're probably talking about-

Mrs Boyer: The hostel program.

Mr King: -the hostel program, which is under the Ministry of Community and Social Services. It's in municipalities, so it's really outside of our jurisdiction on this. I'm not sure I really want to comment on those areas.

Ms Czukar: It's still the same issue, because the effort of the domicile housing strategy is to make the hostel program, supportive housing and homes for special care consistent and to make the funding consistent for meeting the same levels of standard.

Mrs Boyer: So they would still get the $34 and they should have another financial implement by another ministry? Is that what you're trying to say?

Ms Czukar: No, it'll be made consistent across all of the ministries. So if there's going to be an increase and the people in that kind of housing have the same kinds of needs and the same needs for programming and so on as people in homes for special care and those rates are raised, then the others should be raised too. That's the effort of the housing strategy.

Mrs Boyer: When I asked different ministries I was told they couldn't do it for just one; they had to do it to the province. I was answered back that it was about a $25-million increase. I think it's a mental health issue, because most of those 175 people are mental health patients and there should be an interchange between different ministries. It's going to be another problem at the end of April if we put these people on the street. They're going to be another burden to another program.

Ms Czukar: As I said, we are working closely with MCSS and the Ministry of Municipal Affairs and Housing to ensure that doesn't happen. I don't think anybody is going to be put on the street.

Mrs Boyer: So that could be an initiative that could be taken towards the commitment that you have to provide supportive housing.

Ms Czukar: Yes.

Mr King: We'll take those comments back.

Mrs Boyer: Thank you. That's what I wanted.

Mrs McLeod: There are lots of questions. Maybe in the few minutes left I'll ask you about another targeted population that we've had concerns about, and that's the number of people who are incarcerated in Ontario who actually should have been admitted to a psychiatric hospital but there was no bed, or perhaps part of your answer will be "or could have been supported in a community setting with treatment if the community supports had been there."

I don't know if you have numbers on the number of people who have been incarcerated, who have been recognized as having mental illness and needing some form of treatment.

Mr Helm: I don't have any statistics with me, but I can say that we have been doing a number of things to try and minimize the backlog there. For example, we're working very closely with our psychiatric hospitals so that when someone in the jail system is identified for an assessment, depending on the severity of the case, we're trying very hard to do the assessments, if appropriate, in the jail setting. It's faster, it can be done quickly, at least an initial determination. That's something we're trying to do, so it doesn't necessarily have to be a transfer to a bed that might or might not be available.

We've put in a number of forensic court case workers across the province to be there even before an issue goes to court, to try and have it diverted. We've been very successful in a number of cases to get people diverted for very minor cases out to the community as long as they're linked with supports and services.

Those two things have been helping a lot. There are some cases where a client might be in jail who really does need a bed setting, and we try very hard to transfer the person into the closest psychiatric hospital. If we have to go farther afield, we do that.

The bed strategy that I mentioned isn't fully operational yet, but we have announced a number of beds. Hopefully once those are in place they will address some of the pressures. As we continue with community programs such as treatment teams with a forensic component, for example, and continue to enhance court diversion workers, once these beds are in place we will hopefully address some of it.

Mrs McLeod: Do you mean the supportive housing beds you were speaking about earlier? I'm just not sure which beds you were referring to.

Mr Helm: Sorry. If they have to go into a psychiatric hospital bed-

Mrs McLeod: Are you talking about going into a forensic bed?

Mr Helm: Yes. Is that what you were talking-

Mrs McLeod: Actually, I think it's not.

Mr Helm: OK. Sorry.

Mrs McLeod: I really think the forensic issue is quite different from the issue that I'm raising, which is people with mental illness who haven't been able to access treatment or who may be in a crisis stage and actually do need hospitalization at that moment in time, but there is no psychiatric bed to take them, and so the police have no alternative but to take them to jail. You know that I come from northwestern Ontario. That has been a huge concern in our region, and it has been a concern for police officers, who say, "We have no place to take them except to jail because they are a danger to themselves or to others."

We're also in a community where we're about to have a 50% reduction in the numbers of beds that are currently available as psychiatric beds in a different setting, and I think it's going to be a real dilemma for the police officers to know: "Where do we take people now? Do we take them to one of 17 beds in the acute care hospital that are designated for psychiatric?" If it's a supportive housing situation, which is the alternative, I suspect those beds will all be full. So we still have a crisis component: Are we going to have enough beds for crisis situations to deal with a population which is now being incarcerated totally inappropriately?

Mr Helm: According to our current plan-and to be honest, we don't know 100% whether it will be sufficient; that's why we want to do a review-we have on the books to create 144 new forensic secure beds across the province, and we've started that implementation in terms of announcing certain cities to get the construction going. That should help.

Mrs McLeod: I think the forensic is a separate issue, because they are people who are dealing with the court system. I'm talking about mentally ill patients who have no contact with the court system, who don't belong in front of the courts, who belong in a mental illness treatment program.

Mr Helm: Schedule 1 beds in public hospitals are also part of the reform strategy. We are enhancing schedule 1 or acute beds across the province, in addition to what I mentioned, the 144 forensic beds.

Mrs McLeod: That's in lieu of beds that are now in psychiatric facilities.

Mr Helm: It's in addition to the beds in psychiatric facilities. In psychiatric facilities, in psychiatric hospitals, the beds that we've identified for possible closure down the road are very specialized beds that we feel we might not require once the community supports are in place. So we're putting in forensic secure beds in those settings, but at the same time we are putting in acute beds, like schedule 1 mental health beds and children's beds, in the general hospital sector.

Mrs McLeod: But there is, certainly in my region, a very significant reduction in the net number of acute psychiatric beds.

Mr Helm: At Thunder Bay Regional?

Mrs McLeod: Yes.

The Chair: Could I just ask some clarification on that. In the health care restructuring commission report that came out just about a year ago at this time, it's my understanding that the number of psychiatric beds in the province were actually going to be reduced from something like-I don't know-

Mrs McLeod: It was 50%.

The Chair: -2,900 to something like 1,760 beds by the year 2003. Is that not a reduction, then? I'm reading right from the ministry's own health restructuring commission report. It says that the 2,900 mental health beds there were in 1995-96 are going to be reduced to 1,767 by the year 2003. Is that the issue you're raising, Mrs McLeod?

Mrs McLeod: Very much so. The bottom line is, we have people in jails now who presumably need to be in a crisis bed, and those crisis beds currently-there are some schedule 1 beds, obviously, but the majority of them are in psychiatric hospitals. The system currently isn't offering enough flexibility to prevent those people from being incarcerated. My concern is, with a 50% reduction in the overall number of beds-if we don't have flexibility now, how are we going to deal with those people in crisis in the future? Are we going to have more people in jail?

Mr Helm: I think that through the bed strategy for the entire system-when the commission talks about beds that should close, within our ministry we look at bed closures only at the point when it makes sense, where we have the community supports in place. The plan is to go in a certain direction. The actual implementation could have flexibility as we get there. If we feel community supports are in place and some bed restructuring is warranted, we would pursue that on a case-by-case basis.

To come back to some bed numbers-I know you were talking specifically about forensic, but there are other ones.

Mrs McLeod: No, I'm actually talking about acute crisis beds.

Mr Helm: Children's beds, for example-

Mrs McLeod: No, I'm talking about acute adult psychiatry.

Mr Helm: Acute forensic only. OK.

The Chair: Not forensic; just acute beds.

Ms Czukar: I think there's some confusion here. The reason that Dennis keeps coming back to forensic is that the police can't pick people up and take them to jail without charging them with something. When they charge them with something, in our system they're a forensic client. At that point, there are the diversion options and there are other options in the system. When they're being held in jail because there's no other bed, we identify that person as a potential forensic patient.

Mrs McLeod: I understand. Look, I know we need forensic beds for people who need a forensic, secure setting, but these are people who are being charged and become labelled as forensic patients because they couldn't access a system that was not in jail.

Mr Helm: In terms of acute beds, period, we have 195 acute beds that are planned to be put into the system across the province.

Mrs McLeod: So, 195 versus the closure numbers of acute beds; a net increase of 195 acute beds?

Mr Helm: It's 195 new acute beds. The closures tend to take place on the side of specialty and tertiary beds. According to the commission, we're over-bedded on the PPH side, to be honest, on the specialty side. So we're downsizing on the specialty side after we have community supports in place. The acute side is under-bedded now, so we have to raise the number of acute beds and forensic beds.

Mrs McLeod: It is possible, Mr Chair, to get some data tabled with the committee?

The Chair: We'll get back to that this afternoon. It's 12 o'clock now. We'll recess, and we'll resume again at 1:30.

The committee recessed from 1202 to 1334.

The Chair: I'll call the hearings back into session, and I believe we're over on the government side now. Any questions at all by anyone?

Ms Mushinski: I'd like to continue my line of questioning with respect to outcome evaluation. I think one of the auditor's outstanding concerns was that there needs to somehow be a comparative evaluation done of the cost of home-based or community-based care versus the cost of institutionalized care for the mentally ill. I'm assuming that some of these cost evaluations have been conducted with respect to moving from institutionalized care to community-based care. Could you comment on that?

Mr Helm: When we do our financial planning for mental health reform, we do some costing forecasts on, for example, the cost of bed services. As you know, part of the plan for restructuring is to close beds down the road and reinvest that money into community support. So we do have costing on that side.

Ms Mushinski: Yes. Could you repeat that? I think it's important that we understand that.

Mr Helm: When we start with our mental health reform agenda, which includes community investments plus inpatient downsizing, we do costing exercises of putting a cost per bed, for example, in a psychiatric hospital so that when the time comes when we feel community supports are in place that then warrant a review of possibly closing some inpatient services, we have a cost value on those beds. So when those beds are closed, we have an actual dollar value, pot of money, available to us to then reallocate to various areas of the province, based on our planning.

When we evaluate and reallocate money elsewhere in the province, as I mentioned earlier, it's really focused in on best practices and to address the needs of that community.

A while back, when we started reinvesting into the various areas and into best practices, we set up an evaluation process to evaluate reform overall, including our bed ratios, our shifts and the effectiveness of best practices. As John mentioned in his opening remarks, we have an evaluation exercise that's just starting with the Mental Health Foundation, the Centre for Addiction and Mental Health and the Canadian Mental Health Association-Ontario. They will be doing an evaluation process to report back to us primarily, from our point of view, on the quality-of-life indicators that come out of this. Clearly, our reform agenda is to improve services, have them closer to their home community etc, and the best practice model. So we want some feedback: Have we been successful in that regard of quality of service, changing the circumstances in their lives, and also how effective has it been from an economic point of view, but perhaps more importantly, from a social service quality point of view?

Ms Mushinski: So the in-patient downsizing exercises aren't as a result of being wedded to any particular economic exercise but are more from the perspective that our government believes that community-based care provides better quality of service as well as quantity of service for the patient.

Mr Helm: That's correct, yes. As we go through the reform exercise, it is not a cost saving exercise. We have been clear that any savings in terms of bed closures, for example, come back to us corporately in the ministry to reallocate all of that funding out to the community. Equally, on the psychiatric hospital divestment process, it is not a cost saving activity at all; it's a commitment to transfer the resources, and in some cases additional resources, to ensure that the mix of services is maintained and improved. We're not faced with a cost constraint exercise here at all.

Mr King: This is consistent with the strategy also in the hospital system, that we're moving from a dependency on the in-patient side to the community. I just wanted to follow up on the question earlier because I felt like we'd left that bed situation up in the air.

Mrs McLeod: I don't mind; if we don't have time for that, we can do that later.

Mr King: That's fine; I'll do that later.

Mrs McLeod: I'd be happy to have it now, but we will come back to it.

The Chair: We'll wait until we finish this.

Ms Mushinski: You don't mind him cutting into my time, then?

Mrs McLeod: No, I offered it back. I thought that was really a non-partisan thing to do.

Ms Mushinski: You can have it.

I think Bart had a question.

The Chair: You have about 15 minutes.

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Mr Bart Maves (Niagara Falls): I just wanted to say that the report we're here about today is actually the follow-up report. The auditor came back after the 1997 report to do a follow-up report in 1999. We often get ministries in here, and the members of the committee give them a good grilling on things occurring in their ministries and pick on some of the things the auditor has pointed out. I do want to remark, though, at the outset of my comments that the opening line of the auditor's 1999 report is, "Recommendations relating to the following areas of our 1997 report have been substantially implemented ...." There are several areas. I'm not going to read them; anyone can do that on their own. They include, though, the definition of acceptable levels of care, homes for special care respite grants, and a variety of other things. I want to congratulate the ministry for implementing those recommendations over the past two years, since the auditor did his initial report.

One thing in this 1999 report concerns me. The Provincial Auditor talked about four areas: mental health reform, performance monitoring, management information systems and homes for special care quality of care. There are five or six things that he points out: progress in meeting mental health reform targets, comparing the costs and outcomes of community-based care with those for institutional care, outcome measures and monitoring programs against them, and a few other things.

In the ministry's response, they all are dependent upon the completion of the mental health minimum data set. I note that the ministry's response to the auditor is that this has been deferred because of the year 2000 and the effort there. In your remarks, Mr King, you referred to the mental health minimum data set, but there doesn't appear to be any timeline as to the completion of that. In order to fulfill some of these remaining recommendations, which are actually stemming from the 1997 report, that data set has to be completed. So I'm a little bit concerned that we may still be looking at a few more years down the road and it could end up four or five years after the auditor's initial 1997 report before you are able to implement some of these things. Can you give me any comfort on the completion of the data set and the timelines?

Mr King: I'm not sure I can give you any comfort; I will certainly respond to the issue that we have right now in the ministry. The year 2000 project took a lot of time and energy from all of us in the system and we did have to put a number of projects on hold. We had to prioritize to ensure patient safety in the system, and that's why the Y2K had the attention it did.

We have prioritized a number of projects right now at the ministry. As you may or may not understand, we also are doing the same with the CCHCs in the system. We have information systems that we're trying to deal with in the community health centres. The hospitals are still looking at a new funding formula. So there are a number of priorities in the system.

We have identified that this is a priority for us in the mental health system and we will continue to put that priority forward, but it has to be taken into consideration in context with all the priorities in the system. But I'd like to assure you that we believe it is very important to have this information from the field so that we can do comparisons as well as benchmarking and to ensure the accountability. Those will be our priorities for all of the areas. We hope that will be addressed in the next two years.

Mr Helm: If I could add, there are a number of other accountability mechanisms that we are following through on. Hopefully the minimum data set will be approved and we can go forward, but in the interim we are proceeding in a number of other significant areas.

In the mental health area, we have refined the annual operating plan process, which is fairly standard in many program areas, meaning simplified it, and, as I mentioned earlier, we built in a very specific accountability component for new initiatives. If new money is given for a community treatment team, they report specifically on that in terms of the clients, the issues. So we are collecting some of the information that has been identified by the auditor and through the minimum data set.

Also, on the hospital side, to ensure that we get the appropriate data once our psychiatric hospital services are divested to public hospitals, we have gone through an exercise of altering the chart of accounts, which is the standard reporting requirement for our hospitals. So when a public hospital does assume responsibility for our psychiatric hospital services, they are able to report in enough detail on the mental health side so that we have the baseline data about the clients, their medical diagnosis, their requirements for discharge. One other thing we have is the psychosocial rehabilitation tool that is used in the community that we have supported, and that's another mechanism for client data, assessment data. Together that helps meets some of our information needs, but hopefully the minimum data set would bring a lot of that together.

Mr Maves: By definition, then, is it going to take a certain number of years of experience in compilation of data before you're going to be able to derive any conclusions from that data?

Mr Helm: I think it would take probably one full year to get things up and running. If through the ministry we can confirm the minimum data set is a go that we've always been planning on, then we have to go into a full piloting. We had a limited pilot to see if the tool works. We have to apply it more across the board, look at the technology survey that we've completed, and see what upgrades are required in our programs for them to deliver that data. I think that would take about a year, which would take us to the end of the next fiscal year, and then hopefully full reporting could start at that point. In the interim, we would rely on the other data mechanisms that I've outlined. That's all tentative time frames, but my best guess.

Mr Maves: Similarly, the auditor's fourth recommendation under homes for special care was that you should "mandate compliance with the minimum standards of care as a condition of licence renewal." I have two questions in this regard. The first is, does the ministry agree with that principle?

Mr King: Absolutely.

Mr Maves: Secondly, this also is dependent upon the ministry developing a comprehensive housing policy that will set out standards and monitoring mechanisms for all supportive housing. This is separate, apart and distinct from the mental health data set. So where are we on the development of that comprehensive housing policy?

Ms Czukar: As I was mentioning this morning, that comprehensive housing policy is in the approval process and it should be, we hope, approved shortly and be available for the next stage of implementation. As I mentioned also, the notion of standards of care has to be applied not just to homes for special care, but to the other forms of housing that are going to be covered by the policy, ie, supportive housing and domiciliary hostels. These programs now have different funding mechanisms. They are not licensed programs like HSC. HSC has legislation; dom hostels operate in quite a different way. The need for consistency is there. That's what the policy and strategy are aimed at. There will be consultation on implementing that policy so that there is a link between the standards of care, the levels of funding and the licensing.

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Mr Maves: Do you think we'll able to have that up and running for the 2001 fiscal year?

Ms Czukar: That's certainly the hope.

Mr Maves: OK.

The Chair: That's 20 minutes right there.

Mrs McLeod: I know my colleagues have questions for this session, but just let Mr King respond, if he wishes to, on the bed issue.

Mr King: Yes. I wanted to get back to this because I felt we left it somewhat confusing at the end. I think we were talking about different levels of care. The commission has basically directed us on the divestment of the PPH hospitals, and that will involve PPH closures. The numbers are clearly documented. I can get the numbers for you.

At the same time, the commission has also directed, based on certain bed numbers and formulas throughout the province, the opening of additional beds. Until the year 2003, we will consistently open beds in the whole area of children's mental health and acute mental health beds, which are the majority. We will also have some tertiary and certainly forensic beds. It's really a timing issue. In the next four to five years we're going to have more beds than are required in the system, and then as the community supports are built, we will begin to downsize on the specialty side.

As far as the acute numbers are concerned-and you were actually giving us some numbers of going from 2,900 to 1,700-there is a decrease in the number of specialized beds, but at the same time we're also increasing on the other side. There are certain communities right now that have more beds than they will in the future.

You had also asked about Thunder Bay. There will be a decrease in beds in Thunder Bay, but these beds are also moving out to other communities, like London-St Thomas, Windsor and other areas in southwestern Ontario.

So it's really somewhat of a timing issue. If you want specific numbers, we could always come back to that at some point. But I did want to clarify that because I felt we left that very confusing. I try to explain things in the simplest terms. If I didn't explain that well, then we'll have somebody else try.

Mrs McLeod: I think probably one of the difficulties is the HSRC does not actually refer to acute beds, and maybe that's because acute beds are considered to be schedule 1s in acute care hospitals, and the HSRC recommendations don't distinguish when they look at the beds in the psychiatric hospitals. They just have a lump-

Mr King: Number.

Mrs McLeod: They call them all chronic beds, except for the forensic, which are separate. If I take the Thunder Bay example, we have already 24 schedule 1 beds in an acute care hospital. Those are to go to 30.

Mr King: Correct.

Mrs McLeod: They were supposed to go down to 17 and, revised, they're going to 30. So that, I understand, is an acute care bed. But at the same time, we have 118 beds in the psychiatric hospitals that will go down to 51. This is not counting any forensic beds. So 61 beds net is the loss. I don't know, because the HSRC report doesn't distinguish it, what portion of those are psychogeriatrics, and where my concern should be with psychogeriatric beds and where my concern would be with what I called acute, but I probably need a different term. It's people in crisis.

Mr King: Right.

Mrs McLeod: As I said, police right now have an alternative potentially to take them to a schedule 1 bed, although that would be highly unusual. Most often they would take them to a psych hospital and there would be a crisis admission. It's those beds that I was trying to get at. Certainly there's a significant loss of beds from the psych hospitals, which is the figure my colleague was using.

Mr King: The other part that I think we're missing in that equation is the community supports, though, because that's what we're trying to build up in the system as we downsize those beds, and also have the ACT teams in place.

Mrs McLeod: I appreciate that. I also, by the way, appreciate the fact that there has been a hold put on the closure beds until community supports are in place. I acknowledge that and I'm appreciative. I guess what I'm looking at in terms of the planning is to make sure that we retain a flexibility so that we can respond to people in crisis. I think there is a real concern about whether or not the number of beds remaining in the system is going to be adequate to provide that flexibility.

Mr King: Again, I feel that we are dealing with a direction that has been given, and we will continually monitor this also. We continually monitor all the resources in the system.

Mrs McLeod: Rather than pick up on the reference, I'm going to turn it over to my colleague, who has a number of questions.

Mr Richard Patten (Ottawa Centre): Thanks for being with us today. I have two categories of questioning. One is related to some services in my own area, which I probably know better than the general field. I'm relating it, though, to the area of mental health reform.

You may be familiar with the Royal Ottawa Hospital, which is an ancient facility, 85 years of age. It was originally designed for patients who had tuberculosis and therefore it was a good place for people to walk around. The place was designed very well. It's now an old facility with patients who stay there sometimes three to a room, divided by curtains. It's completely inappropriate for long-term stays. With the decommissioning of Brockville, I know not all of the beds-there are about 300 beds, something in that neighbourhood-but roughly 180 will be redistributed and some of those will be going to Ottawa because a lot of the patients who are in the long-term arrangement are from Ottawa.

They have a dilemma. I know it's not easy for you folks, because you've got the auditor and you have the restructuring commission and you have your own government and your own ministry and everybody looking at what you're doing, but the hospital is faced with dealing with the recommendations of the restructuring, or at least the ministry is. They like very much your document Making It Happen. They think that is extremely well done, and they have put together a vision of what they believe fits within that framework. But they can't respond to both. I hope there's no one here from the restructuring commission. They like this approach because they think the other one is quite limited and is a patchwork, sort of "We'll catch up and just make a little bit of an addition to this place." How do you deal with a situation like that?

Mr King: If that's a general question, we have been working with all of the communities that have commission directions and we are proceeding on the commission directions because they were, by law, the way we were moving. If there were some concerns with certain communities on what the directions did say, they were asked to refer that back to the commission.

John Oliver, my colleague, is the assistant deputy minister for restructuring. John and I would meet on a regular basis with the commission to see if we could assist those organizations. They then would go back to the minister with advice if there were to be changes. So we did have a process in place to try and work on that. Failing that, we would follow the commission directions, and that is really the way we're moving now.

I mentioned earlier that I do have someone here from the hospital restructuring implementation team. If you would like to direct a question specifically about the Royal Ottawa Hospital, we can maybe address that as far as the divestment from Brockville is concerned.

Mr Patten: No, I won't take the time of the committee to do that, but I would like to chat, if I might, with one of your officials later or whatever, if that's OK.

Mr King: That's fine.

Mr Patten: I'm just saying that the document-and I had a chance to read it. By the way, that's not for general distribution, is it, Making It Happen?

Mr King: Yes, it is.

Mr Patten: I think we could only get it through the library.

Mr King: It is available.

Ms Czukar: We have many.

Mr Patten: You have extra copies? OK.

Mr King: We should have brought some copies today. I'm sorry about that.

Mr Patten: That's both the operational framework and the implementation document?

Mr King: Yes, that's correct. We can make sure you receive copies of that.

Mr Patten: The document on best practices I thought was quite helpful as well.

However, having said that, the restructuring commission says the fact that-and this is from its most recent report, I gather, which was in February. So that's a year ago. I wonder if this is still true. They're saying, "Little has happened over the last two and a half years to move the PPH changes forward"-provincial psych hospitals-"has not only stalled the progress of mental health reform in all regions of the province, but it has contributed greatly to the increased scepticism about mental health reform in general."

They go on to say, "In particular, there's a lack of confidence among providers, individuals with mental illness disorders and their families that a ministry-led process will be able to respond expeditiously to local circumstances."

Is that an outdated judgment, do you think? What has happened in the interim, because that's a year ago that that was made?

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Mr King: I'm not sure I really want to comment on the commission. They basically have made their comments based on their observation. We are working as best we can with those communities that are affected. I think if we see that there are major issues and it's not in the right direction, then we will try and improve that situation.

Mr Patten: They're talking about setting up these regional, local structures.

Mr King. We are proceeding with the task force groups. The mental health task force groups would then look at how they can best effect the community supports. It's local decision-making, having local consumers on the committee.

We've just had our experience with the first committee in the north. It's been a very good experience. They have just made their recommendations to the ministry, which we are reviewing at this time. I think we're seeing that there is definitely local community involvement in determining what's best for those communities that are going to receive community supports with the divestment process.

Mr Helm: In the interim, in terms of community investment and planning, where there isn't a task force yet in place, the ministry is very keen on making sure the process of divestment, of reinvestment, is up and running. So ministry staff are taking the lead with the community players in looking at the system design that should be put in place post-divestment of the psychiatric hospitals. We're leading the divestment of the psychiatric hospital process, and we are also leading the community consultations and planning for the allocation of the new investments.

We're proceeding, making sure all that is moving along, and when the task force is up and running, the ministry staff hand off to the task force the work that they've been doing, because we don't want things to be on hold until a task force is place. So we are doing our normal work and then we will pass it on to the task force and support the task force to make sure the momentum isn't lost.

Mr Patten: One question that was asked this morning by Ms Mushinski was the integration or integrity issue. I look at this in terms of there being a whole variety of things that cross over between ministries, and I'll tell you, it drives people crazy, no pun intended, literally. They get played off against each other: "We don't have money; go over and see them." The same institution-different ministries literally have different standards for physical design standards. It drives these organizations nuts.

I think, for example, in the area of mental health, of the children's mental health centres, and I visited a number of them recently. I guess their funding comes from Comsoc. How do you work together? Why isn't that all under one rubric called mental health, regardless of age, that you've got a responsibility to work through?

Mr King: First of all, I believe our relationship with the Ministry of Community and Social Services is very good. I think we're actually improving on our coordination.

I spoke earlier about the regional offices. The regional offices, where possible, when we move them out to their communities, will be housed with the community and social services teams. So that way we are building on that integration of ministries. We have some joint cities now that are dealing with this.

One area, if I can mention it, that drives a lot of people crazy is the reporting and having different reporting back for different ministries that fund the same organization. In that way, we are also working very closely with community and social services to streamline that process. We have a joint cluster group dealing with information systems so we're asking for the same information.

I really believe, sir, that we are improving that relationship, and I think we're always moving forward as best we can to help streamline the process.

We also have a joint position now for integrated children's services which is between Comsoc and the Ministry of Health and Long-Term Care. This will address a lot of children's issues, a two-ministry team.

Mr Patten: We all have a lot of questions, but I'll confine myself to one more. The children's mental health centres' waiting list has expanded, as you know. With the schools now having less funding for special education, children who have some mental health issues to work through in many cases are on a waiting list just for assessment. So people are being forced to go privately. That obviously puts pressure on children's hospitals etc, so it works its way back into the system. There's a very critical situation that is occurring here that requires some expeditiousness.

I'm going to ask you, in light of those particular pressures and your planning frameworks, do you have the resources to move ahead or to turn up the gas on your timetables in terms of the target dates that you had before? Even the restructuring commission is saying that, although I know you don't want to comment on what they say. You had a choice how you used that money. Remember that.

Mr Helm: We have a specific plan in terms of investments for children's inpatient reinvestments. Within the Ministry of Health we're responsible for implementing the HSRC directives around new children's mental health beds across the province. As we go through that process, we work in partnership with MCSS to make sure the beds we have been directed to put into a certain community fit in with the MCSS overall children's service plan for that community. So we are working with them.

In some cases where bed enhancements require capital construction, which could take a number of years, we have asked the hospitals to try and fast-track proposals that come in to us: What can we do in the next year or so, maybe in the existing building if it's cost-effective etc, with the longer-term plan of having the beds fully operational at the end of the day? We want to look at immediately getting something in place and in the longer term to completely fulfill the HSRC directives, and that's within our responsibility, working in partnership with MCSS.

Also within our responsibility, the Ministry of Health and Long-Term Care funds 21 children's mental health outpatient programs through hospitals. We have been working very closely with our MCSS partners to look at a number of things that would provide a better service, perhaps standardized assessments in our system and in their system, as an example.

The government's last budget talked about a $20-million announcement to implement some of the work that Margaret Marland did. We are working in partnership with MCSS around those activities on common assessments, and other service models are being looked at. We are making progress and we want to fast-track the services to the children's population as quickly as we can because of the need that has been identified.

Mr Patten: I'll come back later on.

The Chair: That's 20 minutes, so I will turn back the-and I owe you five minutes from the last time.

Interjections.

The Chair: I plead guilty, and the auditor didn't even have to remind me. Go ahead, Ms Munro.

Mrs Munro: There seem to be some themes emerging from much of the discussion that has taken place here today. I'd like to follow up on a couple of those.

One of them is the whole issue of best practices. I wondered whether you could give us some insight into two aspects of best practices, the one from the point of view of what you have seen as best practices to promote mental health reform; secondly, I'd be interested in any comments you might have with regard to other jurisdictions and where we stand in relation to those other jurisdictions that you might have looked at to provide us with some sense of our position with regard to those other jurisdictions.

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Mr King: I will lead off on that because I think you've raised a good point on best practice and benchmarking. We can always learn from other jurisdictions. We should not reinvent the wheel all the time. The ACT teams, for example: We did pick that up from some of the American system. The ACT teams are really a best practice. We are seeing constant results from that. Personally, having been involved in Windsor to see the ACT team working, which is also involving the hospitals, the community, the mental health agencies, long-term care-it involved London, St Thomas-there was an incredible group of people working together to resolve this issue of the patients, providing the best resource available in the community. That is a specific example of best practice that we have adopted here.

I'm sure Gail has some other areas that she wanted to cover.

Ms Czukar: When you're asking about other jurisdictions, I might address both together. Best practices was the subject of a 1997 federal-provincial-territorial report that was put out by Health Canada on behalf of a national working group. That report detailed best practices and has in it examples from other jurisdictions, both in Canada and outside of Canada, in terms of what best practices are. There's a lot said in Making it Happen about what the best practices are. As I said, we have many copies of these documents that we'd be happy to provide. We don't have them here, but we can get them to you.

I might just run through what some of those best practices are. John has mentioned ACT, assertive community treatment, teams that are being implemented, as we reviewed this morning. Intensive case management is another best practice. It's linked to assertive community treatment teams but it's not the same thing. Crisis response services-there are two levels of this. One is the service level, which I'm addressing now, and the other is systemic best practices, and I will get to those. There is crisis response, supportive housing, outpatient care, consumer self-help and self-employment initiatives, vocational, educational programming and family self-help programs. Those are the services that this document says are the best practices that we should look to be implementing as we implement mental health reform. We are working on all of those.

At the system level, it's not enough to just have these discrete services. You have to have some other things. You have to have integration and integrated access, program evaluation, accountability mechanisms. We are working on developing an accountability framework specific to the restructured mental health system, in addition to general accountability work that's going on in the ministry that John referred to.

So those are some of the best practices that are set out in the 1997 report, based on experience in a number of jurisdictions.

Mrs Munro: You've also touched on another theme. That is, of course, as clearly emerges from your immediate comments and from comments made earlier today, the whole question of the integration. That was my opening question this morning, and we certainly have heard in a number of ways where initiatives have gone in the direction of creating greater integration.

When I asked the question this morning, you talked about the regional offices. More recently, this afternoon, you talked about the fact that, where possible, those regional offices are being set up with MCSS as well. I wondered whether or not down the road you see the possibility of the inclusion of the ACTT group with the CCAC or is there a possibility that they may work together? Obviously, the ACCT is going to have to work with the hospitals and other health care providers. I just thought we needed to know what the crystal ball tells us.

Mr King: Certainly with the regional offices, the regional teams will be reaching out to those communities to involve mental health, the hospitals, long-term care, which includes CCACs, in addition to community health centres and public health, the district health councils also being part of that. We see some focus groups coming together and to locate some of the programs where they best should be located. I would never say that we would never see that occur, for example, an ACTT with the CCAC, because I think we're very open to what works best at the community level.

The north is different than the south. Things happen differently all over this province and we need to allow the freedom for that to occur. So that really is the vision that we're moving forward. Our ministry vision is as close to home as possible and the affordability of the system in the right place.

We have to be open to the type of thing that you're proposing in the future and, of course, we believe strongly in integrated systems that are working together for the best interests of the patient, the client or the resident.

Ms Mushinski: I'd just like to follow up on that, if I may, just for a minute. As the integrated services pertain to mental health services in the province, I'd like to zero in a little bit on children's mental health needs. Mr Patten touched on what I believe is a serious problem and it's perhaps this entrenched culture that is found within the bureaucracies; I'm not sure. If we truly want to achieve one-stop shopping for the mental health services of our kids, as well as all Ontario residents, how do you overcome this traditional model of community social services? On the one hand, Children's Aid is required legally to deliver those services. If that is a barrier, how do we overcome that? If we've identified these barriers, who deals with them? Are there things that we should perhaps be suggesting as policy amendments to deal with the removal of barriers to achieving this kind of perfect model in a perfect world?

Mr King: Again, I think that you picked up some themes; perhaps we have also picked up some themes from you. We believe that we need to move forward in integration not only within our ministry but with other ministries. I believe you're going to see some new developments with community and social services and health in the future, especially in the area of children's services because this is where it's been identified that there are some overlaps and some areas we need to work on.

We agree with you. How quickly we can make that happen and the barriers that we need to overcome are something that we'll certainly bring forward if it's an issue.

Ms Czukar: I was just going to say that I will be very happy if we find the perfect model for this system and address all of those barriers in the near future. Dennis addressed some of the specific mechanisms that we've been working on to try to integrate these systems. I think common assessment tools are essential to integration and we're certainly looking at those, not just in the children's system and using those between the two ministries, but across the mental health system. That's what long-term care did. When you talk about CCACs, they started with assessments for levels of care and assessments for community services and CCACs use a standard assessment to determine what services people need in the community. We have to move that way in the mental health system, both for adults and children. It's a very important mechanism.

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Mr Helm: In addition to what I referred to earlier, I should have mentioned as well that the MCSS initiative, Making Services Work for People, is calling for coordinated access between all children's activities. Local working groups are being established under that sort of policy framework and the Ministry of Health will be represented on all of those working groups. So that's another example of us going the next step and working together with MCSS in a very formal way.

Ms Mushinski: So there are some real attempts to try to remove some of the jurisdictional jealousies that have come along with the system.

You may have touched on this, although I'm not quite sure I heard it this morning. I know you referred to the ratio of government funding to hospital-based and community-based having changed. From 1994 to 1995, you said the ratio was 75% hospital funding to 25% community funding, so there's been a considerable shift in four or five years from that ratio to 60-40. Did you mention this morning-I can't remember if I heard it or not-that the ministry had set some short-term and long-term targets to change that ratio and, if so, how you want to accomplish that?

Mr Helm: The ratio at the beginning was 80-20, and that was 80% institutions.

Ms Mushinski: When you say at the beginning-

Mr Helm: That was at the beginning of reform in 1992-93. The goal we wanted to get to was a 60-40 ratio of 60% community and 40% hospital. We're at a 60-40 ratio now, but it's 60% hospital and 40% community.

Ms Mushinski: Did you set any time lines to that goal?

Mr Helm: I think generally speaking we had said within the 10-year time frame of reform.

Ms Mushinski: So by about 2002-03.

Mr Helm: Yes, 2002-03 was our initial goal.

Ms Mushinski: You'd like to see the ratio change from 75-25 actually to 40-60.

Mr Helm: Yes.

The Chair: How many people are we talking about in total? When you're talking about a ratio, do you have any idea as to how-excuse me for just a moment.

Mr King: We're talking about dollars.

Ms Mushinski: That's government funding.

The Chair: I understand.

Mr King: It's split between the community and the institutional.

The Chair: You have no idea how many patients this represents in total, is that correct?

Mr King: I'm sorry. I don't have those numbers.

Interjection.

Mr King: When we're dealing with that, we're really just talking about the health budget also.

Ms Mushinski: I assumed you had mentioned those figures in terms of mental health, but you're saying overall health spending?

Mr King: No. The question was, is this health as in mental health, not community and social services? That's what I thought you were talking about. It's just mental health targets that we're dealing with here, but it's for the Ministry of Health and Long-Term Care.

The Chair: The percentages that you're talking about are the percentages of dollars that you're spending in each, not the number of patients who may either be in an institution or-

Mr King: No. Percentage of dollars.

Ms Mushinski: Is that consistent with Comsoc's targets as well? We're talking about setting standards here.

Mr Helm: I'm not aware of Comsoc having a fiscal shift ratio goal. It's more of a policy thing.

Ms Mushinski: It's a policy thing?

Mr King: They don't really have institutions either, so it's not the same that we would have.

Mrs McLeod: I want to come back to a number of issues that have been touched on already today. First of all, I think it was a question Ms Mushinski asked earlier this morning, and that is, the commitment to ensuring that all of the dollars that are saved in the closure of psychiatric hospitals and psychiatric hospital beds are going to be moved into community services. The first part of my question is, does that mean that those dollars will all stay in that community and region? My understanding is that the dollars are going into a central pot for redistribution.

Mr Helm: Yes. The reform strategy is that, as you mentioned before, some areas are identified perhaps as being overbedded at this point. Therefore, at the appropriate time, those beds could close and the money be brought forward. Because of that, it was felt that the best strategy is to bring the cost savings from those beds to the ministry centrally, to then look at the provincial needs across the province and allocate out where needed, maybe some back to that home community, maybe to another community.

Our concern was that if a community or region is overbedded for historical reasons, it might not be equitable to close those beds and keep the money in that community because it would maybe continue in terms of having overreinvested, if that is the case. To have the best approach to equity, it was decided to bring that money corporately and then we would decide which regions are lacking or which were most in need from an equity point of view.

Mrs McLeod: I appreciate the intent, but I think we have several dilemmas. I suspect that they're shared dilemmas, but let me pose the questions.

You've indicated in the auditor's report that your evaluation projects that are looking at institution-based or hospital-based costs versus community-based care are just in their early stages in terms of beginning to yield information. We're talking about a 10-year reform project that's now seven years into play, and we're talking about evaluation projects that are now three years into play and we still don't, as I understand it, have any data that guides the resource allocations in terms of institutional versus community, let alone the comparative costs of the two. Is that a fair conclusion for me to come to, based on what your response to the auditor's report is?

Mr King: I would like to take a stab at that. I think that we certainly have a better idea than that as far as, "Is this the best place to put the dollars?" The less reliance on institutional care is well documented-

Mrs McLeod: I don't want to argue with you philosophically. I agree. I'm really concerned about where we're going to get the dollars to do this well.

Mr King: The reinvestment is there, and the commitment's there for the reinvestment into the community side.

Mrs McLeod: Of existing dollars that are in the PPHs right now?

Mr King: Of existing dollars. There are some extra dollars going in too, because we're also putting dollars in the system now that build up the community supports. So I think that there has been a great deal of investment and a great deal of thought given to this approach. You're right; we do need to have more reporting on the evaluation side, and perhaps we haven't moved as quickly on that side. But this is a timing issue for us.

I think you've made some good points, and we'll take that under consideration. I think it's important that you've raised that.

Mrs McLeod: I appreciate that. The timing issue's crucial. I don't want to take time to get into a debate about philosophy, because there is no debate about the philosophy. It's just a question of, "Are we going to have the services in a combination of community and facilities that we need?" I think everybody here would agree that that's the goal.

Mr King: Agreed.

Mrs McLeod: I'm looking at the HSRC recommendations in terms of community investments, and I'm not sure, given the fact that we don't have the evaluation project data in yet, exactly what they use to determine the dollars. But they are looking at a $63-million to $87-million investment, depending on what standard we're prepared to accept as far as a recidivism rate is concerned. They state that this reinvestment translates to $55,000 to $77,000 per PPH bed closed. Mr Helm earlier mentioned that you'll have a cost per bed. Do you have that cost now, and does the cost per bed that is being closed correspond in turn to the reinvestment that the HSRC says is needed for community service?

Mr Helm: We've done calculations in terms of the average cost savings in total per bed just as a general rule. It depends on the hospital as well. Some hospitals have a lower per diem than others. But as an average, $400 to $450 per bed per day is often a benchmark. We have used the varying rates by PPH to determine, if those beds close, what will the dollars be, the total amount that would come back to us?

Mrs McLeod: And the figure would be?

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Mr Helm: About $48 million is identified as a rough benchmark for the value of those beds.

Mrs McLeod: That suggests to me that we're already close to $30 million short of what the HSRC said was the minimal-I shouldn't say "minimal"-that's enough for investment.

Mr Helm: That's not our only source of funding. That is the cost related to the beds. If they close, we have that money to keep and reinvest. In addition to that, through our annual BPA process, we are requesting and receiving new funding, like the $19 million that was announced in December, the $60 million that was announced in 1998. That is new money.

Mrs McLeod: I'm appreciative of this. Here's where I'm seeing this as a dilemma, because we've seen what has happened on the acute care hospital side where the cuts were made to the acute care hospitals before either the community supports or the long-term-care supports were in place. We've had chaos for a year.

You said very clearly and the minister said-and for me it was a landmark decision I've already acknowledged today was an important one-"There will no closure of psychiatric beds until we are assured that the community supports are in place."

But a few moments ago I heard you talk about the process-and as you said, a timing issue, Mr King-because the divestment process, which is being carried out with the Ministry of Health's leadership in an essentially closed-door situation, is going ahead. You said that you don't want to slow down too much on it and that at some point it will be ready to go and you'll turn it over to the implementation task force.

By the way-and I want to come back and talk about mental health agencies-I think there should be more publicity given to the fact that your implementation task forces are being put in place, because that has been a huge issue of concern, as the HSRC identifies. Based on what I've seen locally and what I'm hearing by word of mouth, the people who are on the committee are good people and they restore confidence, and you should be telling people about that. But they have a 12- to 18-month reporting time before they can come to you with advice on what is needed for community support.

My dilemma is that I'm really concerned that divestment is marching ahead and it's going to be 18 months before we even know what we need in the community, let alone how much it costs, because the evaluation projects on how much it will cost to provide support in the community aren't in place yet. How can we be sure that we're not going to lose psychiatric beds through the divestment process before we've got all the community supports in place as promised?

Mr Helm: When the divestment process goes ahead, it's important to look at it as a transfer. I'll use Lakehead. Everything currently operated at Lakehead will be transferred as is to St Joseph's. There won't be any restructuring, no bed closures at all at that time-everything is being transferred over-so at the time of transfer, there shouldn't be a fear of downsizing that day.

When it goes over, then there is clearly the HSRC directive that they need to plan for closing 74 beds in Lakehead over a certain period of time. But then it's our job, with the task force and with St Joseph's, when they propose, "OK, now we're ready, we can close these beds," to make sure that the community supports are in place-the community investment fund money that we gave them a number of years ago, some of the $19 million that we just announced in December. We would have to be convinced that all of those are in place. One of the conditions of funding some of that was a clear link with a psychiatric hospital. Some clients could be, through the patients' assessments, identified for discharge. We would need clear documentation that with the community investment fund and the $19 million, part of which went into the northwest, you can now move maybe 50 clients.

If that is the case and they have the supports, then the ministry would propose internally to close a portion of the beds. Those 74 beds would not close just like that, according to the schedule outlined by the commission. It has to be evaluated by us and with the community and, if it's not ready, those beds will stay open until they are ready.

Mrs McLeod: What is the target date now for the closure of the psychiatric beds?

Mr Helm: For those beds? Just on paper, the 74 beds, or 68 beds in Lakehead, are to close in 2001-02. That's on paper.

Mrs McLeod: Just staying with the local example, if the implementation task force is just now having its first meeting-

Mr King: It's just beginning.

Mrs McLeod: It's due to report in 18 months. I don't know if we've got a target date on your evaluation project being completed so that you have a good handle on the cost of community care versus institutional care, but how does that tie in with that target date for closing beds?

Mr Helm: The task force, as soon as it's up and running, has a life of about 18 months or longer. They can come forward with recommendations as soon as they're ready. Two or three months into their mandate they might be ready to make recommendations. So it's the life of the task force that we're assuming is approximately 18 months; we expect recommendations before that. As I mentioned, the ministry staff have been working right up until now looking at the system in the northwest and where reinvestment should be put, and that will go to the task force. So a lot of the work has been done, and hopefully the task force will feel it's good work and they then move along on it and make the recommendations.

Mrs McLeod: Is the northwest one the second implementation task force?

Mr King: Yes, the second one.

Mrs McLeod: Of nine.

Mr King: Yes.

Mrs McLeod: When do you anticipate the other seven being established, and what do you see as their target dates?

Mr Helm: We're hopeful that throughout the end of this fiscal year and into the next fiscal year we will have them across the province.

Mrs McLeod: I just want to be sure I've understood what the plan is. The plan is to wait until those implementation task forces, one by one-not the whole province, but in any given community there will be no shutdown of a bed until the implementation task forces at the community level have made their recommendations and those recommendations are fully funded and operative at the community level?

Mr Helm: Partially right. If a hospital comes forward in the interim with a proposal that they feel they could close certain beds within the HSRC directive, we would have to look at it from a business case point of view to be convinced that it is ready. If there is no task force in place or if the task force is about to be in place, we would really want their input and their view in terms of what the system should be. If that comes in before the task force is in place, we would look at it very stringently because we are very concerned that the timing is right. So we might defer them. It depends on the information that day.

Mrs McLeod: Will Hamilton be setting up an implementation task force? Is that one of the areas?

Mr Helm: It will have one, yes.

Mrs McLeod: I'm not sure what the bed closure numbers are in Hamilton, but that might be an example where they are ready to move because it's a somewhat different divestment than it is in other communities.

Mr Helm: Hamilton is getting more beds, so they're not closing any.

Mrs McLeod: But the commitment that has been made not to shut down a bed-and you've repeatedly said and the minister has said that that's until the community supports are in place. You've now said at this stage in the process that the responsibility for advising you on the community supports is to be left to the implementation task forces. You've also indicated that the dollars for that community support have to be in place before you close the beds down. I was taking the HSRC's $76 million. So that means that before we see the shutdown of psychiatric beds, we're going to see up front about $76 million in community mental health. That's at least what it takes to replace psychiatric beds and, sure, you can then maybe, depending on what your evaluation study says, save some of that down the road. But in the first instance we're going to see an increase of about $76 million?

Mr King: I think you keep emphasizing the fact that-we do have a plan and we're following through on that plan, which involves local community planning. That's when you have the task force groups appointed to do the local planning, and it does take longer than if we decided what the community supports would be. I think you're highlighting the time frame here. We are working through that process. We would like to see these task forces roll out faster and, as soon as we can, try and get them moving so that they can move quickly locally, but we need to take the time that's necessary to plan for the community. You have basically reinforced what the plan is.

Mrs McLeod: I like the sense of the plan. I share the concern of how long it may take, but I'm also concerned that the dollars are going to be there, because it would be most unusual to have these upfront dollars before the closures are made.

Let me give a specific example, if I've got a few minutes left. One of the things that HSRC did not deal with initially was outpatient services. I'm looking at their reinvestment. You'll have to help me with this. Are "general case management" and "community service support and case management" jargon for outpatient services, or something broader than that, or does it not include them at all? Somebody is shaking their head back there. Is there some line that tells me we're looking at outpatient services in the HSRC's recommendation on community reinvestment?

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Mr Helm: We would be looking at outpatient services as part of our restructuring and our reinvestment in terms of allocation. Bed-saving dollars, for example, would be to outpatient services and community services like case management.

Mrs McLeod: I'm just looking at these lines. I know it's not supportive housing, I know it's not ACTT. There's intensive case management, general case management and community services supporting case management. I'm hoping that one of those three lines says "outpatients." I'm hoping it is, because at the time the HSRC made its recommendations in the Lakehead there was no recognition of the fact that there were 1,000 outpatients being dealt with between the two hospitals. There is still no capital provision. In the hospital restructuring that's going on, as the PPHs are to be closed, there has been no provision made for a physical space in which to provide the outpatient services or other community services. The HSRC still recognizes that in the $76-million figure there's no provision for capital. Where does the capital planning fit in? I know there's an acute care hospital being built in Thunder Bay, they've already finished the completions to the chronic care hospital and there's no space in those places for outpatients. So where are they going to be treated?

Mr King: I'd like to ask Tom Peirce to comment on Thunder Bay because that's part of the divestment.

Mrs McLeod: I don't want to make it specifically Thunder Bay. I think it's a general issue.

Mr King: We have capital as part of all the PPH divestment and we're dealing with them right now on the plans of the divestments and where they're moving within the existing hospitals, or if they're staying on existing sites or if they're building new buildings. That is identified in the psych hospital vote, so those dollars are there for capital.

Mrs McLeod: Maybe mine is an anomaly, because it isn't.

Mr Tom Peirce: My name is Tom Peirce. I'm a consultant with the health reform implementation team and I have been leading the local negotiations in Brockville, Ottawa, Kingston, Hamilton, London and Thunder Bay for the divestment of the PPHs in those communities.

With respect to the transfer of services, the HSRC indicated the capital they felt was required to transfer PPH programs to the receiving hospitals. That funding, as opposed to the general HSRC project funding of 70-30, is being funded at 100% in those communities. Any program being transferred from a provincial psychiatric hospital to a receiving hospital is being funded at 100%.

Mrs McLeod: That's on the bed side.

Mr Peirce: For all the programs that were identified to be transferred, and generally the hospitals are designed with ambulatory space included to handle outpatient volumes. As well, in terms of the savings, what is re-invested in the community may be reinvested in hospitals as traditional hospital outpatient, but some of what is considered outpatient activity may become community-based activity with community providers.

Mrs McLeod: That's exactly my point, though. I'd be interested in knowing if there are available data in terms of ambulatory space that is being provided for in the hospital restructuring process. I'm certainly aware of the bed provisions but I'm not aware of ambulatory provisions. My sense is that much of it is being left to the community and what we used to call outpatient is now a community-based service. My concern is because I think they were largely left out of the mix and they've been referred now to the community-based planning. Where is that going to take place?

Mr King: Rather than getting into specific details, in all of the local negotiations that are going on, the host hospitals receiving that, with the PPH as well as the ministry team, are planning those resources. The out-patient programs are part of that planning, and if parts of those outpatients are going to the community, that would be part of the planning. That is all part of the local negotiations. We can sit down and be specific about each one, if you want, or off-line we can talk about that. Of all the things that are happening, I think it's fair to say that we have had very good success with the communities that we're dealing with on the PPH divestment and moving to the local public hospital. I think in most cases it has gone very well. I have never heard of this concern raised, that we are not planning for outpatient services. That has not come to my attention. I'm assuming that has been part of the planning, but I'm going to check into that now that you've raised it.

The Chair: Just for clarification, are you behind in your critical path that you've set for this? I'm looking at the critical path that was in the HSRC advice to the minister, and this was supposed to have taken place in March and June of last year.

Mr King: Yes. We are behind somewhat in most of the restructuring projects in the province, and it's mainly due to the fact that some of the goals of the commission were very ambitious. We are somewhat behind, but we are hopeful that most of the PPH movement will occur this fall. We are behind, though, it's fair to say. You have the timelines in front of you. It has been very ambitious, for many reasons, whether it's acquiring land or zoning or whatever. There are many issues involved in this. So we're guilty. We're behind.

Mrs McLeod: Let me assure you, Mr King, I think the ministry has been put in a very difficult position with ambitious timelines that were set by the commission, so I'm not faulting. I'm anxious about the community component.

Mr King: And we hear you.

Mr Patten: Could I have a supplementary?

The Chair: OK.

Mr Patten: It's just on the same issue, the commitment around decommissioning psych hospitals, and then we can go back to Mrs McLeod. It's clear that, around the operational funds that is so, but in certain circumstances-the one I mentioned as a specific today, the Royal Ottawa-where you've got a huge psych hospital that is going to be closed down, is the value of that, whatever it is, whenever it's assessed, also part to contribute to any capital requirements that may be made as well? In other words, is that resource included in the commitment of decommissioning the transfer of the resource to the new constructs?

Mr King: We have specific formulas in place for all of the movement, whether it's operating costs, overhead costs of the new building, or the new corporation, so to speak, and what will move with them. That's all part of the local negotiations. I don't have the specific-

Mr Patten: Do you know what I mean? Do you understand my question?

Mr King: The question is, if this is how much it costs to run this facility here, will all those dollars be going, as well as the overhead, to run that building?

Mr Patten: No.

Mr King: Excuse me. I'm sorry.

Mr Patten: I'm saying that Brockville Psychiatric Hospital has an operational budget of, let's say, $1 million.

Mr King: Yes. Got you.

Mr Patten: It also has a huge plant; it also has land that, when that's decommissioned, has some kind of a market value. Is that market value, whatever it is and however it's sold, part of the commitment of the transfer of resources? Is that part of the basket?

Mr King: Now I understand you, but Tom's going to answer that.

Mr Peirce: The resources associated with the exact physical facilities and the sale thereof or decommissioning thereof are not part of this overall equation, because those facilities, on behalf of the government, are run by the Ontario Realty Corp, which handles all the realty holdings of the province.

There will be an operating budget provided to the receiving hospitals to conduct the programs. They will have an interim lease to continue using the facilities they are now in until such time as any capital projects are completed to house beds, for instance in Ottawa, and there will be capital allocations made through basically the HSRC capital fund, through the Ministry of Health capital branch, to build facilities in keeping with HSRC directions.

Mr Patten: That will be separate?

Mr Peirce: Yes.

Mr Patten: Separate from the operational money that's being transferred?

Mr Peirce: Yes.

Mr Patten: Over and above?

Mr Peirce: Again, it's funded at 100%.

The Chair: It's funded at 100%?

Mr Peirce: The approved capital costs associated with PPH program transfer to the public hospital are being funded at 100%.

The Chair: OK. Go ahead.

Mrs McLeod: Where to go next? Let me stay on the issue community supports. I'll leave the outpatient issue for now. I'm still concerned about it. I'm not sure where it fits, but I'll leave it for now.

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Mr King: We do hear you.

Mrs McLeod: One of the things that the implementation task force has been charged with is to ensure that there's community supports in place for the seriously mentally ill-again, the term is being used repeatedly-and for discharged psychiatric patients. I'm concerned about programs that have never been in place in communities, or never been funded or adequately funded, and I'm concerned about whether or not everything is on hold until the implementation task force report comes out.

I will give you a very specific local example: eating disorders clinics. They have not been part of the psychiatric facility. I'm not sure where they fit into your classifications of seriously or severe, but it appears that requests for expansion or for funding are being put on hold because of the restructuring process. That's what we've been told locally. My question is, is that a fact? Are program expansions like that being put on hold until the community restructuring is complete? It's a long time to wait, given the timelines we've been talking about. Or is the ministry open to looking at proposals on a step-by-step basis in the interim?

Mr Helm: Restructuring proposals are not being put on hold pending the task force, because the task forces will be rolling out across the province at different times. While acknowledging they will have a critical role in making recommendations, the ministry really wants to move things along so that we do not miss opportunities. When funding is available for investment in a certain community, ministry staff take the lead in the absence of a task force. Whether it's looking at an eating disorder proposal or a community treatment team or a forensic program, we work with the community to identify where that money should be invested to provide those services. If halfway through that process the task force comes along, we will pass all of our good work to them to finish off. But in the absence of a task force, the ministry takes the lead, so we're not slowing down while waiting for a task force. We want to move business along as quickly as possible but always be ready to hand off the responsibility with the appropriate supports from us to the task force when they're ready.

Mrs McLeod: I appreciate that. Was there a recent expansion of the eating disorders clinic program in Ottawa?

Mr Helm: Yes. In Ottawa and Halton there were recent expansions.

Mr King: And we are specifically reviewing the eating disorders right now, right across the province.

Mrs McLeod: Are we out of time, Mr Chairman?

The Chair: I'm not sure whether the government members still want some time.

Ms Mushinski: Yes. I don't have many more questions, but I do want to return to this area of children's mental health and the reinvestments that occurred as a result of my colleague's excellent report on mental health. I believe it was called Beyond 2000. That's, of course, Mr Newman's report.

My understanding is that there were some specific announcements of reinvestments made as a result of Mr Newman's report, or in direct response to his mental health review. I'm wondering if we could visit a couple of those, because I'm a little confused about how it works. It gets back to what I was referring to earlier with respect to the delivery that is actually done by Comsoc and how we can start to achieve some consistency of approach in terms of perhaps looking at some integrated services.

There was a $60-million investment that included $6.7 million to increase the number of institutional mental health beds, both forensic and acute. My understanding is that some service enhancements pertaining to operational requirements were pending construction and renovation of some Comsoc beds for children's acute mental health needs. Is that correct?

Mr King: That's right.

Ms Mushinski: Can you tell me what the status of that is and how that fits into the overall need for those acute forensic beds? I know Mrs McLeod alluded to those a little earlier. How are they actually being administered? Are they being administered by ComSoc through transfer payments from the ministry? If so, is that consistent with the funding of children's mental health requirements? Is it also consistent with the ministry's targets with respect to moving away from institutionalized care to community-based care?

The reason for my question is because I want to see how it fits with the overall policy direction that you're taking with respect to moving to community-based care. I think it's as relevant for children as it is for adults.

Mr Helm: The $60-million announcement in June 1998 was in direct response to Mr Newman's work, in terms of implementation. My response is similar to what I touched on earlier: Increasing the capacity of in-patient children's programs is the responsibility of the Ministry of Health, because it's in the hospital setting. When we do that, we work closely with our MCSS counterparts to make sure that the bed numbers and location that we're planning fit in directly with their children's strategy in that region.

Ms Mushinski: I take it that that strategy is fairly consistent with your ministry's strategy about the move from institutionalized care to community-based care.

Mr Helm: Yes. The move from institutional to community is a broad goal in terms of the fiscal funding shift. At the same time, though, in our strategy and with MCSS there is a need that we don't do that totally at the expense of in-patient services. We have service gaps on the in-patient side.

Even though we want to shift the funding formula or funding ratios, we do invest in new in-patient services which, actually, would increase the institutional side, but for very specific cases: children's mental health, forensic and acute. But overall we're spending more, even on the children's side, in the community than we are in the institutional side in terms of new money. It is consistent with the shift in strategy.

Ms Mushinski: I wonder if you could just explain what the other reinvestments were with respect to Mr Newman's report and how much of that went into the new directions that pertain to the other 1999 report.

Mr Patten: Making It Happen.

Ms Mushinski: Making It Up?

Mr Helm: We made up Making it Happen.

Ms Mushinski: I thought that was a partisan shot, you know that?

Mr Helm: Directly out of Mr Newman's work was the requirement to look at and allocate the $60 million in reinvestment and to develop Making It Happen was also a direction to outline our strategy.

In the $60 million from June 1998-I'll quickly go over this-it was a provincial allocation. Every part of the province received base money and, in some cases, one-time funding as well for specific-

Ms Mushinski: So no federal enhancements, I take it?

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Mr Helm: No. Within the $60 million I'll just quickly run through the categories: $6.7 million was dedicated to institutional care. That means beds. This was forensic and acute beds specifically. Part of our dilemma, in terms of scheduling, is that they can only become operational pending construction and renovation, because they are linked to that, and also planning work with MCSS regarding children's acute care. So $6.7 million of that was for institutions; $46.9 million was specific for increased community mental health services in response to community needs and hospital restructuring. This is the beginning where we wanted to ensure that the community supports have the direct link to our psychiatric hospitals so that we wanted community supports that would clearly initiate or expedite the discharge of appropriate people from PPHs into community programs. That was a link. So included here would be assertive community treatment teams, case management, crisis and diversion.

Then we allocated $5 million in one-time money. This was to help facilitate the capital requirements of the new Centre for Addiction and Mental Health in Toronto. The remaining $1 million was an education program between long-term care and mental health to ensure that there's a mental health worker in long-term-care facilities to help address mental health service issues that arise.

Those together equal the $60-million plan. And those are up and running.

Mr Patten: You've got this plan that everybody likes so far to be implemented, but I'm going to ask you, are you folks involved in the pending amendments to the Mental Health Act? It's OK, I want you to.

Mr King: Actually, we also knew that we would probably have some questions on legislation, so we have one of our legal counsel here, Diana Schell.

Mr Patten: One question is that I noticed in your literature, in reference to the what's euphemistically, I guess, commonly called the "community treatment orders"-I wouldn't personally use that term-as an alternative to institutionalization, which is part of one of the themes of advancing the program beforehand, that it's not really addressed here other than the more assertive work of the ACTTs.

Mr King: This is Diana Schell, who is with our legal services branch for mental health services. I'm sure she would be more than happy to answer questions related to the legislation.

Ms Diana Schell: I would be happy to talk a little bit about the legislation with you and also the community treatment order issue. Mr King and Ms Czukar, this morning, referred to the minister's announcement in June 1998 with respect to the next steps in mental health reform and, of course, included the implementation plan making it happen. It included the educational campaign with respect to the current legislation. And the third piece is the review of the Mental Health Act and related legislation.

The review has been ongoing very actively for over a year now. It's primarily a legal review involving an internal working group that I'm part of within the Ministry of Health. It's a broad-ranging review. We're looking at mental health legislation in other Canadian jurisdictions, so the other provinces and territories. We're also looking at Europe, Great Britain, New Zealand, Australia, some states in the United States. I think other important sources of information that you would be familiar with yourself, sir, are in inquest recommendations, your own private members' bills. That's part of the review. We have also received a number of submissions from stakeholder groups-the Canadian Mental Health Association, the Schizophrenia Society. We recently got a paper from the Centre for Addiction and Mental Health, which just came across my desk this morning so I haven't read that. There may be others that I'm forgetting to mention. So, that's the nature of the review. For the moment it's internal and it's focusing primarily on legal sources of information.

With respect to the community treatment order issue, I share your concern about using the language "community treatment orders." People probably mean different things by that. Just looking at Canadian jurisdictions that say they have community treatment order legislation, we have Saskatchewan, which since 1995 has had legislation which specifically says "community treatment orders." A couple of years after that, Manitoba came on board with a very different kind of model that they called "community treatment agreements." More recently, late last year, British Columbia proclaimed legislation that it says has community treatment provisions, but they're actually leave-of-absence provisions.

Some of the jurisdictions that we've looked at elsewhere, for example, New Zealand, some of the Australian states, I believe it's 38 states in the United States, have community treatment order legislation which is of interest. It doesn't necessarily look like the Canadian legislation; the models vary significantly. But, given that there seems to be such a focus of attention in other jurisdictions, and it's certainly a focus of attention here for some groups, this is included in the legislative review.

Mr Patten: Can I have the estimate on the time? When is your estimate of your review completion?

Ms Schell: It's probably going to take some time to complete all of this. I don't have a final timeline on this when it has to be completed.

Mr Patten: I won't take it to mean that that's when the minister will be introducing legislation, by the way.

Ms Schell: It's hard for me to answer your question, sir, because frankly, given the size of the project, if I were working for the Law Reform Commission they would take two or three years to do this. There may be other requirements that have to be met which would cause us to do the best job we can in a shorter time frame. I'm sorry, that's the best answer I can give you.

Mr Patten: Thank you very much. I appreciate that.

Mrs McLeod: I just have a couple of other areas, and I'm not sure if my colleagues have some further questions. Before we leave the legislation, I think there's reference in the auditor's report and the ministry response that with the supportive housing changes and moving the people into the community there may need to be changes to the Homes for Special Care Act. Is that an ongoing consultation as well, and do you see the two pieces of legislation moving forward simultaneously?

Ms Schell: We will have to consider homes-for-special-care issues, but to date, the mental health legislation review project within the ministry has not specifically looked at that piece of legislation.

Ms Czukar: I might just add that in terms of developing the housing policy and housing strategy, if there's a need to change the legislation to implement this strategy when it's finalized as a result of consultation with communities and so on and so forth, if there were to be legislative changes coming forward on another front, then obviously this would be a good time to do it.

Mrs McLeod: Finishing up on my community-based program concerns, is the funding being maintained now for all community outreach programs that the psychiatric hospitals are currently running, for example, vocational rehab programs? That funding is maintained, there's no withdrawal of funding? So when we say no beds will close, we're also saying no programs will close?

Mr Helm: The programs currently funded by the PPHs are staying and being transferred. We, with the Ministry of Community and Social Services, are looking at programs that are being funded under the employment label, cost-shared with the federal government.

Some of our programs within the PPHs are in that category and we're doing a review. Do they need the criteria of the federal-provincial cost-sharing around employment? Our feeling is that they do meet and we don't anticipate any changes in that area, but we're still working with MCSS on that. But the intent is everything that's there now will be transferred over and continue to operate, in the short term anyway.

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Mr King: I should add that the public hospitals that are receiving the divestment are watching those budget lines very closely so that there aren't dollars removed from it. They are very sure to check and balance the system.

Mrs McLeod: If Mr Sturtevant had been here, I might have been tempted to use that as a springboard to talk about rehabilitation more generally, but I won't. I'll save that for another day. I know, Mr King. I could address the question to you.

Mr King: It's a little late in the day to start-

Mrs McLeod: I know there's a big project underway.

The second-last area I wanted to ask you about sort of comes from that last comment, because you mentioned hospitals that are receiving the divestments, and my concern still is on the community care support aspects of this. One of my concerns throughout this process-and I know it was a Ministry of Health concern too; I'm not sure exactly where the whole thing got off the rails-was the whole issue of governance of mental health. I'm extremely concerned that we are divesting to hospitals.

Again, I recognize this will take different forms in different communities. I know it's not an issue, for example, in Hamilton, where essentially the entire thing seems to be being divested to a hospital, including a lot of responsibility for community programs that are already in place, so maybe it will sort itself out there. But certainly in my home community, and I think it's probably fair to say in a lot of communities, we're going to have a presentation of responsibility for the delivery of mental health. Some of it will be to hospitals that are getting the divested programs from the PPHs, but there it's divided.

When it comes to community mental health, I'm not sure that I see anywhere in the system, including Hamilton, a body which is responsible for advocacy for mental health. The hospitals may advocate for their own particular segment that they are mandated to provide care for, it's the community health service system that gets left behind. I'm concerned that there's a fragmentation. It shouldn't be fragmented even if we can identify somebody who's responsible for advocacy for community mental health.

One of the very few things I probably agreed with the commission on was the establishment of community mental health agencies because I saw those as being a body that could represent advocacy-if not governance, at least advocacy-on a community level for mental health. The implementation task force I'm pleased to see in terms of its advisory capacity. If the same thing is happening in other communities as seems to be happening in mine, there will be a lot of confidence around the people being appointed. But I'm worried about what happens when they no longer exist and we're back to, at best, a fragmented system of advocacy or governance and, at worst, no advocacy or governance in the community mental health system at all. I'd just like your response on where you see the future in terms of community-based advocacy and governance.

Mr King: Back to the mental health implementation task force, I believe there will be some recommendations coming forward from those task forces on some of the issues surrounding governance. But we do not have that in the communities now. We have many agencies delivering these services now. I hear what you're saying and I think that's something we have to take under advisement for the future as far as the governance issue related to community programming is concerned.

Mrs McLeod: Is it even possible that the implementation task forces could recommend a third level of governance for mental health and be received favourably?

Mr Helm: We do look to the task forces to take the Making it Happen documents, which are our marching orders in terms of implementation, and theirs. In Making it Happen, we talk about the need for streamlined access, perhaps a lead agency. So we will be looking towards those task forces to do some of that work and make very specific recommendations in their region that program X perhaps should be the lead to coordinate access to the others, to streamline the assessment processes. That is part of their mandate, working very closely with the policy area and also with the regional office and myself. We want to make significant gains in those areas during the life of the task force, to restructure and streamline, so that if a task force does end, there is a legacy of improvement and coordination for outpatient and community programs.

Mrs McLeod: I did notice earlier on you mentioned the important aspect of regionalization as being conveying a sense of integration across the ministries, and one-stop access. I guess my hope would be that that translates in the community into at least integration of mental health itself, if not with other ministries or within the Ministry of Health.

Mr King: We actually expect that there will be recommendations forthcoming on that.

Mrs McLeod: Patient advocacy: Again we have a fragmentation in terms of where the patients are located. I know this is a sensitive issue for somebody from Thunder Bay to raise, but will we have patient advocacy councils for mental health patients in each of the settings in which there are mental health beds, or do they become absorbed into the patient councils of that hospital generally?

Mr King: The provincial office, as you know, will carry on in the first year of operation. We have offered that service to the new centres to see how they want to handle that. They may want to take it on their own after that, but they have to preserve the rights of the mental health patient to be protected, so we have to look at a mechanism for that. At the present time the patient psych advocacy office will remain in place until we start the divestment. We have negotiated that as part of the arrangement with each of them.

Mrs McLeod: But not necessarily the patient councils.

Mr King: No, not necessarily the patient councils.

Mrs McLeod: So the future of patient councils is somewhat in limbo?

Mr Helm: The future of the patient council would really be up to the new hospital.

Mrs McLeod: So they could be absorbed into the overall hospital patient council, if the hospital has one.

Mr Helm: Possibly, or they could have it separate for the mental health side, the same with the community advisory board of the PPHs.

Mr King: Many of those hospitals now have patient advocacy offices also, so they may just assume that role, as well as council.

Mrs McLeod: Patients tend to feel that they're two very separate things.

One last question: Maybe I'll just throw this out and not really expect an answer yet, because I don't think it's a fair question. For future reference, I'm going to be very interested in knowing where mental health fits with primary care reform, because if we're serious about comprehensive primary care, then it has to include mental health both for adults and for children. I think that's beyond the reach at the moment of any of the models that have been contemplated, but I hope it's something that is getting considered in ministry thinking.

Ms Czukar: Having worked on primary care prior to coming into this job a little while ago, I can say that in Hamilton, which is one of the primary care reform implementation sites, there had been in place institutional grants that brought mental health practitioners into health service organizations specifically to link up primary care physicians and mental health resources. That is being continued into the primary care implementation. I think the model is changing somewhat, but there is a recognition that that was a very positive aspect of what was going on in Hamilton and does need to continue in some way. I know that the primary care reform project is looking at that issue. It's not out there; it's being done.

Mr Patten: I just have one question, which may trigger two. You're looking for a group to play a leadership role in different regions around mental health. They may be hospitals, depending on the size of the area. I'm trying to relate it to the other side of the coin, outside of mental health. Governments-and I can remember being part of one-were talking over 14 years ago about community health and prevention and primary care, and it still ain't there. The hospitals still dominate totally. I could give you a formula right now that you would save hundreds of millions of dollars if the government would implement it, and it still hasn't happened.

What makes you think that your model of governance will really work, other than that you do have a mandate and you're going to perhaps impose the formula, so even if it is a hospital that takes the leadership, they will have to have these programs, and I think you've got a better handle on it? I guess my question is outside the frame of reference today, but in terms of general health care, why aren't you doing the same thing? The same principles of better service apply in that realm as well.

Mr King: I'm not quite sure how to answer that question, other than that I think the ministries are rolling out their offices and integrating their services and working with the communities to hopefully have some voluntary integration. That's where we're moving at this time.

Mr Patten: If you ever want that answer, just call me.

Mr King: Did you say $100 million?

Mr Patten: More than that.

The Chair: I'd like to raise one issue very quickly, and it's because it's in your business plan. I see that in 1998-99 you established a fraud program within the ministry. Have any results come in on that at all? Perhaps you're not the right people to ask about that.

Mr King: My colleague the assistant deputy minister for health services programs is really responsible for the program, but it has been fairly successful. I don't have statistics on that, but we could certainly get that for you.

The Chair: I have another question. I don't intend to embarrass anybody here, but I reread your speech again just now while we were talking and I noticed, when I added the figures on pages 3 and 4 as to how much has actually been spent in mental health, that the figures don't add up to $2.4 billion, but to $2.6 billion. What's the right figure?

Mr King: Actually, it was $238 million before-it's actually $2.6 billion because there is $200 million more that was added in there. We didn't do that just to make it look better today.

The Chair: No, no. I always add the figures up, you see.

Mr King: Sorry. The 1994-95 investment in community health was $238 million. This year it's $406 million, and that's why the number was changed. That made the difference of almost $200 million.

The Chair: Thank you very much. I appreciate that. Anybody else?

I'd like to thank you very much for attending here today and appreciate the answers you've given to the committee.

The hearing is adjourned until whenever we come back in April. We have a very short in camera session, however, to deal with the Andersen report and how you want to handle that.

The committee continued in closed session at 1523.