1996 ANNUAL REPORT,
PROVINCIAL AUDITOR
WHITBY MENTAL HEALTH CENTRE
MINISTRY OF HEALTH
CONTENTS
Thursday 27 February 1996
1996 annual report, Provincial Auditor: Whitby Mental Health Centre
Ministry of Health
Ms Jessica Hill, assistant deputy minister, mental health programs and services group
Mr Ron Ballantyne, administrator, Whitby Mental Health Centre
Mr Dennis Helm, regional director, mental health programs and services group
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Chair / Président: Mr Bernard Grandmaître (Ottawa East / -Est L)
Vice-Chair / Vice-Président: Mr Richard Patten (Ottawa Centre / -Centre L)
Mr Marcel Beaubien (Lambton PC)
Mr Dave Boushy (Sarnia PC)
Mr Gary Carr (Oakville South / -Sud PC)
Mrs Brenda Elliott (Guelph PC)
Mr Gary Fox (Prince Edward-Lennox-South Hastings / Prince Edward-Lennox-Hastings-Sud PC)
Mr Bernard Grandmaître (Ottawa East / -Est L)
Mr John Hastings (Etobicoke-Rexdale PC)
Mr Jean-Marc Lalonde (Prescott and Russell / Prescott et Russell L)
Ms Shelley Martel (Sudbury East / -Est ND)
Mr Richard Patten (Ottawa Centre / -Centre L)
Mr Gilles Pouliot (Lake Nipigon / Lac-Nipigon ND)
Mrs Sandra Pupatello (Windsor-Sandwich L)
Mr Derwyn Shea (High Park-Swansea PC)
Mr Toni Skarica (Wentworth North / -Nord PC)
Also taking part /Autres participants et participantes:
Mr Erik Peters, Provincial Auditor
Clerk / Greffière: Ms Donna Bryce
Staff / Personnel: Mr Steve Poelking, research officer, Legislative Research Service
The committee met at 1056 in room 228, following a closed session.
1996 ANNUAL REPORT, PROVINCIAL AUDITOR
WHITBY MENTAL HEALTH CENTRE
MINISTRY OF HEALTH
The Chair (Mr Bernard Grandmaître): Good morning. This morning we have Jessica Hill, the assistant deputy minister; Mr Dennis Helm, the regional director, central east; and Mr Ron Ballantyne, the administrator of the Whitby Mental Health Centre. Ms Hill?
Ms Jessica Hill: Thank you. What I'd like to do is begin by describing the mental health system that Whitby is a part of and provide just some overview remarks.
To begin with, we have 333 community mental health programs across the province, 21 children's mental health programs which are connected to general hospital outpatient services, and 305 homes for special care. In addition, we have 10 provincial psychiatric hospitals, five specialty hospitals, and 65 general hospital schedule 1 units.
Currently there are 2,900 provincial psychiatric hospital beds in the system across the province, ranging from hospitals with approximately 211 beds up to hospitals with 633 beds, which describes the London and St Thomas hospitals.
We have been in the process for a number of years of working to develop an integrated and coordinated mental health system of care. This has been referenced in policy documents since 1993, the policy framework being described as Putting People First. It has always focused on trying to build a system of care so that patients and clients do not fall between services and that a continuum of care is delivered.
We have tried to focus on the consumer first, with priority given to the severely mentally ill, not exclusive to the severely mentally ill, but priority being given to this population. What we're trying to build is an appropriate mix of inpatient services and a strong community system. There is considerable evidence from other jurisdictions that by providing a very strong community system, you can improve the quality of life for these individuals. All sectors, including hospitals, physicians, voluntary organizations, community mental health programs, housing services etc, are part of this system.
Quickly, I'd like to describe the way in which we have, as a ministry, held the provincial psychiatric hospitals accountable for the management and delivery of the services and resources that are provided.
We give them an annual budget allocation. We require submission of annual operating plans, including annual budgets for approval. This is something we require of all providers of service in the mental health system. They are reviewed to ensure consistencies with policies and priorities of government. We have monthly summary reporting information on financial and activity data. We have quarterly and year-end detailed reporting of financial and activity data, and it is reported in the public accounts. We are of course required to comply with Management Board directives and guidelines.
We have received periodic audits from our internal audit branch of our psych hospitals. This goes back to 1987, and in that period we have audited North Bay Psychiatric Hospital, Hamilton Psychiatric Hospital, Queen Street Mental Health Centre, North Bay Psychiatric Hospital, Kingston Psychiatric Hospital, Penetanguishene Mental Health Centre and of course Whitby.
Again through the Provincial Auditor's office there have been two provincial audits: one of the Whitby Mental Health Centre and one of the Queen Street Mental Health Centre. My understanding is that in 1987 there was a provincial audit across the provincial psychiatric hospitals.
I'd now like to ask Mr Ballantyne to describe quickly the Whitby Psychiatric Hospital and the audit recommendations.
Mr Ron Ballantyne: Whitby Mental Health Centre, as it's now called, serves a population base of well over two million people in the 905 greater Toronto area. We have a catchment area which includes North York east of Yonge Street, East York, Scarborough, Durham region, York region and Victoria, and that includes four district health councils in that particular service area.
The range of services that we provide includes six program areas. This, for example, would involve adolescents and young adults; skills training treatment; an education program oriented largely to individuals with serious psychosis and schizophrenia; a community response program which is outpatient services and inpatient services focusing on crisis intervention and short-term assessment and treatment; a psychogeriatric program for individuals over 65 with major psychiatric disorders; a psychiatric rehabilitation program also focusing on individuals who need intensive treatment, inpatient day treatment and outpatient treatment, to return to community living; a special populations program which focuses on the dual-diagnosis population; the psychotherapy unit which focuses on treatment of individuals with serious behavioural and personality disorders; and the program focusing on individuals who have neuropsychiatric disorders, neurological disorders.
We also have under development a medium secure forensic program of 40 beds. That program is to commence some time in the next six to nine months and we have the first purpose-built secure unit in the province for that function. We serve forensic patients now, approximately 50, but not as a formal medium-secure environment.
We also provide a range of outpatient services for about 1,300 to 1,400 outpatients. That includes a variety of day programs, day treatment programs, day hospital programs.
In our service area, our catchment area, recently the community investment funds that have been allocated are approximately $1.8 million. This covers a range of services from crisis intervention to consumer-survivor initiatives, peer support, family networks, housing programs and the like.
We are accredited by the Canadian Council on Health Services Accreditation. We have been part of that program now for well over 15 years. Our facility has received three consecutive three-year awards and we will actually be surveyed by the CCHSA, as it's known, in a week's time. This particular body exists to assess, using national Canadian standards, the facilities in the country pertaining to various aspects of mental health service delivery. The surveys actually give us an opportunity to identify opportunities for improvement as well as areas of excellence. The last survey was completed in November 1993 and, as I mentioned, one is upcoming in 10 days.
The process that we followed for the Provincial Auditor's report was that in 1995 the auditor spent a number of months with us and came forward with the recommendations that are contained in the 1996 report. We found it a very constructive process at our facility. It was a means by which we were able to focus in on areas that the Provincial Auditor felt needed some attention and also needed some clarification. We saw it clearly in much the same vein as the Canadian Council on Health Services Accreditation process. We saw it as an opportunity to help us as a public facility become as publicly accountable as possible and to make major strides in improving on some of the areas that were identified for improvement. We'd like to thank the Provincial Auditor for the opportunity to be part of that.
Interjection.
Mr Ballantyne: Yes, actually, thank you. Of the recommendations that have been made, we have proceeded to act on all those recommendations in some fashion. That process began as soon as we were aware of the recommendations of the Provincial Auditor prior to the actual public release of the report.
With the recommendations focusing in on waiting lists, we have established a comprehensive database and means of monitoring waiting lists for the facility to answer the concern of the auditor that we were not monitoring waiting lists as well as we could and to analyse the length of time that was necessary to access our services.
We are in an area where the number of psychiatric beds per population is at and below the provincial target of 30 per 100,000 when you combine general hospital and provincial psychiatric hospital beds. So inpatient resources are, by and large, at a premium, and I think that's all the more reason why the auditor felt it was important for us to rigorously monitor waiting lists and to assess how that's proceeding.
With respect to program evaluations, we had in place prior to the audit a voluntary process for all our clinical programs to participate in programming evaluation. The majority of them had. Again, the audit recommended that we be more rigorous in that, and we support that and have proceeded on that basis to address that particular recommendation.
With respect to capacity to consent to treatment, these are very important concerns for us, and again we appreciate the auditor raising these. These are matters which we take as probably the most important recommendation in the report and we have taken major steps within the facility to ensure that our medical staff and other professionals who are providing treatment to patients -- again, we're talking about a very vulnerable adult population by and large, and some adolescents, as I noted. This is a population where the ability of the facility to properly assess and to engage in accordance with the law the consent process, the capacity to consent and, where consent is given, to comply with the legislation is very critical, and, in a situation where someone is assessed not to be capable to consent, then to proceed through the substitute decision-making process in a fashion.
We feel that our practices were faulty in that our recording, as noted by the Provincial Auditor, was not to the standards it should be, and we have taken considerable steps to correct that.
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With respect to the recommendation having to do with mechanical and chemical restraints, we have reviewed and revised our policies with both of these particular issues, mechanical and chemical restraints. We feel they're state-of-the-art policies. They certainly reflect the legislation. Again, they reflect sensitive practice to individuals in vulnerable states, in some cases posing considerable danger to themselves or others. Our practices are consistent with what is required by the law and we have put into place a data monitoring system so that we can better collect restraint uses, both mechanical and chemical, and can monitor trends over time in that respect.
The fifth recommendation was one which pertained to the payments for long-term-care facilities. Perhaps you wish to speak to that one, Ms Hill.
Ms Hill: Essentially the ministry has over a period of time considered the issue of a copayment for psychogeriatric patients or long-stay patients in the psychiatric hospitals, but currently it is not considering implementing one at this time.
The Chair: You are not? I'm sorry.
Ms Hill: We're not considering introducing a copayment at this time.
The Chair: Thank you. Mr Helm, would you like to add to this presentation?
Mr Dennis Helm: Specifically in regard to the copayment, I don't think I have anything more specific to add. We looked at the various options that were available to us and compared practices in other jurisdictions within the health system. We felt that at this point it was best from our point of view not to pursue implementing copayment.
The Chair: Thank you. We'll start with Mr Patten and give each caucus maybe 10 minutes and then we'll alternate.
Mr Richard Patten (Ottawa Centre): Thank you very much for joining us this morning.
I'd like to make one overall comment, and it's about the whole system here. We're talking about an audit that took place at least 14 or 15 months ago. Presumably it started earlier than that, so in a sense the information goes back a fair amount. I can see, Mr Ballantyne, that you've responded to a number of these situations already at that time. We're talking about an audit that was done on the old facility, which was not when you were in the new facility, and you're talking about different ways of operating, presumably, by virtue of your new facility and some of your community programs, all that kind of thing.
I think the committee needs to have -- this is a comment about the committee and our information system -- a quicker update. I feel that we're dealing with a lot of old information here, and while some of the questions are valid to be asked in transition in moving from one facility to the other, the fact remains that it's still 18 months ago or 15 months ago or whatever it is on that.
One question I'd like to ask overall, Mr Ballantyne, is related to your new facility, and I know of the need in the area because when I was Minister of Government Services I reviewed that project and very much felt that there was a need for change for many years. Could you describe to me today, in comparison to what you had before, how this has enabled you to address serving in a different manner presumably -- you may disagree with my analysis, but in a different manner, especially in terms of working with the community -- the patients who need treatment?
Mr Ballantyne: First of all, with respect to the new facility, we clearly have state-of-the-art premises from which to operate our programs in which individuals who seek our service can benefit. The environment is literally about a century ahead of what it was, and the standards of the physical environment have changed dramatically. We meet all current regulations and so on, which wasn't always the case. In that respect, it has created a much better opportunity for us to advance our programs.
Most of the recommendations are focused on our programs and our services, not the facility. In that respect, nevertheless, we have designed a facility that reflects current populations. Over the 80 years of the existence of the Whitby Mental Health Centre, whom the facility has served has changed dramatically: a much more seriously, in some cases, longer-term population, where issues such as physical restraint or chemical restraint are very important in some respects, particularly when there's danger to self or others.
It also gives us an opportunity -- and this was witnessed by our open house when 5,000 people, members of the public, showed up to see the facility on one Sunday afternoon. It creates an attractive environment to help the public understand what mental illness is, what programs are available to meet the needs of the seriously mentally ill, and to be able to respond to their particular requirements.
Keep in mind here that we provide a broad range of programs for not a homogenous population of seriously mentally ill, but these are specialized programs that are provided on an economy-of-scale basis for a population of, as mentioned, 2.2 million people. This is done in conjunction with community mental health programs, which are certainly a significant partner in how we deliver our services and how effectively we can deliver our services, as well as with general hospitals with psychiatric units.
Mr Patten: I note that you said there was $1.8 million worth of community programs. Your budget is what, about $47 million?
Mr Ballantyne: It's $42.7 million.
Mr Patten: So it represents close to 9%, or something of that nature, in terms of the community programs.
Ms Hill, can I ask you a question? I'm asking the context because I think we will address some of the specific concerns of the audit committee. We've had the recommendations. The restructuring committee has now recommended three psych hospitals to be closed, and presumably there will be others.
Making the assumption that it's the older style of working rather than a more integrated approach, could you describe to me how the Whitby Mental Health Centre fits into this in terms of the future? Is this a state-of-the-art approach that is more integrated with the nearby community in a variety of services and works more hand in hand, rather than a more contained and independently oriented hospital of the past?
Ms Hill: I'll certainly be happy to respond to that question. First, though, I'd like to clarify that the reference to $1.8 million is new funding in the community investment fund. It does not represent all the community funding that the catchment area has.
Mr Patten: What would that represent?
Mr Ballantyne: I would suggest it's approximately $18 million to $20 million.
Ms Hill: That actually describes a better balance of what we're aiming towards. The Whitby Mental Health Centre was probably one of the facets that really allows for greater systems integration. It certainly is a modern facility and, as Ron has described, the linkages with the community existed before, but the environment contributes to that more effectively.
I think one of the most profound impacts is the destigmatization of the mentally ill when they receive care in such an attractive environment.
One of the challenges for the mental health system has been that many of the facilities are older, larger, and in terms of planning for a modern mental health system, determining the best way to provide in-patient care has been one of the areas we need to look at.
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Mr Patten: In terms of the copayment, how do you respond to the criticism of some people who say that people who are in long-term-care facilities or chronic facilities, if they're able to make financial contributions to their stay, are required to do so, and under legislation so are people in psych centres, but that hasn't been implemented? What is the rationale? I hear you saying you're not implementing it at this time. What's the rationale for it?
Ms Hill: Actually, the idea has come up several times over the last few years, and one of the things we've been doing is trying to determine, actually assessing, whether the patients are very different in our psychiatric hospitals than in the long-term care system or the chronic care hospital system. We've been working very closely with those other areas of the ministry.
The second activity has been that we are aware that one of the ways in which the psychiatric hospitals has been moving to provide tertiary specialized care services is through cooperative arrangements with long-term-care facilities, moving patients who can be more appropriately served in a long-term care facility so that the tertiary care resources can act as an appropriate support to those services. Many of our psychogeriatric programs have actually downsized considerably over the years, quite naturally through this process, so our resources have been moved more into what we call psychogeriatric outreach teams and specialized training.
In the mix of all those changes it was felt currently to be quite difficult to introduce the copayment. Many of the patients who are in the psychogeriatric beds have been there for a very long time. We understand that there may be some policy logic to having equity across the system. I don't think we've said we'll never consider it, but in the consideration of all the other things that are going on, the timing didn't seem appropriate.
Ms Shelley Martel (Sudbury East): Thank you, the three of you, for presenting here today. I want to begin by asking about your waiting list, because certainly the auditor has made note of the fact that it was not being tracked and you've told us today that you have a mechanism in place now to monitor that waiting list. Can you tell the committee how long your waiting list is now, and can you describe the nature of it?
Mr Ballantyne: The waiting varies from program to program. As you've heard and as you've seen in the literature, there are six program areas. For some of those programs there's no waiting list at all. For others there's a waiting list ranging from approximately five, 10 individuals who may have been waiting up to three months.
Again, we try to provide specialized services to meet the needs of a very large area. We do that by working with the general hospitals in particular, and largely we've been moving towards referrals from acute care facilities, namely general hospitals, to access our services that for general hospitals, because of the nature of their role and the duration of length of stay they adhere to, isn't possible.
So yes, we agree that this is an important matter and we believe we're in a much better state to address any concerns around that in the future.
Ms Martel: Do you give that information to the ministry now? Is the ministry also tracking waiting lists out of institutions?
Mr Ballantyne: We don't supply that information to the ministry. It could be.
Ms Martel: The reason I'm asking is that I was wondering if you're really talking waiting list and to understand what the nature of the list is, of the people who are waiting, and for what services. It would surely be helpful to the ministry in planning for other services, be they community-based services or additions to institutional care. I'm just curious as to why there's no link there or connection.
Ms Hill: I think one of the aspects that needs to be understood is that without an information system, waiting lists are an indicator, they are not a science. Often we find for instance that people are on more than one waiting list. They may be on a waiting list for a period of time, but actually find another service.
The most important factor that we encourage both the hospitals and ourselves to look at is readmission rates as well as new admission rates, because in essence what you're trying to do is track a population to see that they are getting the appropriate service. It can inform your program planning. If you have a very high readmission rate, maybe you need to make some changes in how you deliver the service. If you have a significant increase in new admissions or new people on your waiting list, you then need to determine whether they are there because they've been referred from another service or they are waiting at a number of other services and the nature of what they need.
The level at which I think it's most valuable is the program planning level and the service planning level. There are many activities at a local level that Mr Ballantyne could describe that are in a sense service planning activities with other providers which address these issues.
Mr Ballantyne: The important thing is not just arbitrarily to leave someone on a waiting list but to try to work with other partners in the support system generally to provide whatever support there can be until such time as the person accesses the programs. We may very well call on an community mental health agency that provides case management services or one that provides crisis intervention if the person is in a community program. But if they're in a general hospital environment, we will try to work on a regular basis with that facility and communicate regularly to ensure that we're trying to have them access our program in a timely fashion, because it serves nobody's interests to have long waiting lists for many of the reasons that Ms Hill described.
Ms Martel: You have set a system in place that is monitoring that. Has the ministry taken a look at the other facilities to determine whether or not there is a similar problem around waiting lists and a similar lack of mechanism to monitor that and made recommendations to either pattern at Whitby, or put in place in a different institution elsewhere some kind of system that would indeed track the same thing?
Ms Hill: I think that's a very good question. We would expect that the same kind of service planning took place at a local level with all our psychiatric hospitals. What we certainly do is share the auditor's report with all of our psychiatric hospitals and bring to their attention the same kinds of systems improvements that we would be expecting them to make also. You can learn a lot from each other, as a group of administrators and hospitals, about how to improve practice.
Ms Martel: Can I ask about the consent-to-treatment legislation and how that is being monitored? You said, Mr Ballantyne, in your response, that you'd taken some very major steps to deal with both medical staff and other health care professionals about the legislation. Can you describe to the committee how a process would work whereby a patient was advised of his or her rights, how that is documented and how you would now be in a better position than you were at the time the auditor went in, which clearly everyone can see shows very high levels of people who felt they had not been appropriately advised or had not granted their consent before treatment was actually provided.
Mr Ballantyne: This, as I said earlier, is a critical issue for any mental health facility. Maybe it would help the committee here if I just cited our policy on consent to treatment. This is our hospital policy, consistent with the legislation that applies, the Mental Health Act, the Health Care Consent Act and so on.
We want to respect the dignity and the rights of the individual, at the same time ensuring that the person does access appropriate treatment and that they're properly informed on consent to treatment where that's possible, and where it's not possible, to follow the procedures that are necessarily there.
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Just very quickly citing the initial statements in our policy:
"No treatment shall be initiated at Whitby Mental Health Centre without the consent of a capable patient or substitute decision-maker in accordance with the Health Care Consent Act and Mental Health Act. The policy applies to inpatients, outpatients and assessed and not admitted patients. It is the responsibility of the health care practitioner who proposes the treatment to follow the procedures outlined. If a patient has been found incapable to consent to treatment, the consent of a substitute decision-maker, in accordance with the hierarchy of the Health Care Consent Act, must be obtained in writing. A separate consent for an incapable patient must be signed by the substitute decision-maker for testing such as HIV, electroconvulsive therapy or clozapine treatment."
These are elements of the policy that we've adopted. It's actually a five-page policy which outlines very clearly for all the professionals in the facility what the requirements are, legislative and otherwise, and what the standards are for our facility.
We have had many discussions. We established a task force. As you know, there were several variations in legislation over the last six or seven years. We had a task force established to serve two purposes: (1) to ensure that we were current across the facility as to what the legislation was and changes in legislation; and (2) to more effectively educate our staff and our patients, and by extension family members of patients, as to what the legislation is, because it's complicated legislation.
It's difficult for someone who comes to the facility to understand what their rights are, what they can and can't agree to. There's a great onus on us as a facility and the practitioners, the professionals, to ensure that they follow the legislation here. We've made it a high priority in the facility to ensure that appropriate procedures are followed, that medical staff and other practitioners effectively document when treatment is being proposed, what the possible implications of that are, whether the person was properly informed and whether they did or didn't agree, and of course as I outlined in the situation where someone is not capable, the procedure for a substitute decision-maker and the hierarchy for that.
Ms Martel: The hospital policy document which you just referred to, was that developed then as a consequence of the auditor's recommendations?
Mr Ballantyne: We did have a policy in place, but it certainly spurred us to review and make the policy more comprehensive, stressing elements of the policy, the philosophy behind that, and it proved to be very helpful.
Ms Martel: I'm not sure if the task force is still in place, but as a consequence of that change and as a consequence of trying to respond to the auditor's report, do you have some kind of mechanism now in place to monitor how well that hospital policy is being implemented? Do you review cases on a quarterly basis, monthly?
Mr Ballantyne: Yes, we have a thorough audit process, a multidisciplinary audit procedure, plus in our health records area there's an audit for documentation. We have instituted what we believe to be a fail-safe method where we cannot complete a chart unless all the elements consistent with the policy have been addressed at various stages along the treatment path. We're confident that we're in a much better position to pilot the legislation.
Mr Marcel Beaubien (Lambton): I have a very short question. Ms Hill, first of all, thank you very much for coming. You pointed out in your opening statement with regard to the Whitby Mental Health Centre that a strong community system improves the quality of life of the patient. Mr Ballantyne, I think you also described the facility as an environment which is a century ahead of its time which meets the needs of the current population in the area. Am I pretty close in saying that?
Mr Ballantyne: I don't think I said it was a century ahead of its time. The new facility is state of the art, which replaced a facility which last year at this time was a century behind the times.
Mr Beaubien: So then it's a modern facility we have.
There has been some controversy in the past few days with regard to facilities that are proposed to close in Ontario. My question to you is: Are the facilities the Health Services Restructuring Commission is proposing to close the same types of facilities that we're looking at in Whitby?
Ms Hill: I'm not sure. I don't have the dates when each of these hospitals was built. I believe Brockville is quite old, St Thomas is quite old, and I believe London is a newer facility. I don't have the exact dates, which is why I'm hesitating.
Mr Beaubien: Would those facilities meet the needs of patients in 1997?
Ms Hill: The hospitals are doing their best to meet the needs of the patients. They have considerably fewer inpatients than existed, say, 80 years ago. You have to remember the context in which these facilities were built. They were built for a much larger inpatient population and completely different methods of treatment 100 years ago. We had virtually no drug therapies 100 years ago. The philosophy of care was radically different 100 years ago, so often I believe many of these facilities like Ron's were ending up only using a very small part of their facility.
Mr Beaubien: In other words, it would be fair to say that the quality of life of patients in those facilities may not be the same as the one the patients in Whitby might experience.
Ms Hill: I think this is a question of how much weight you're going to be putting on the building and how much weight you're going to be putting on the clinical care. Clearly from our perspective the care given, the quality of the programs and the clinical staff are more significant elements than environment. Ideally you can marry the two.
Mrs Brenda Elliott (Guelph) : Thank you for coming today. I have a question relating to the copayments. I come from Guelph and we have a terrific facility there called Homewood, which is primarily a private institution, although it takes some patients under an arrangement with the province.
As I'm reading the notes here, I guess under the Mental Health Act, financially capable patients admitted were responsible for their maintenance. Then the Insurance Act was changed in 1994 to permit a copayment, which was never enacted in regulation. When you were asked earlier about it, your answer was that particularly psychogeriatric patients are there a long time. The inference from that was that there was a problem with payment, I guess. But then you also went on to say that many of them have been downsized to other facilities; I'm assuming they're long-term-care facilities. I'm still not clear on the reasoning within the ministry about the philosophy of copayments, not only in your area of expertise, the psychiatric institutions, but also as it would pertain for instance to another hospital setting. Can you elaborate more on that for me?
Ms Hill: I'm not in a position to be able to elaborate on the copayment policy in general in the ministry. The rationale for psychiatric hospitals has been that probably our focus has been primarily to ensure that people are in the right facility by careful planning on an individual basis. The size of many of the psychogeriatric programs is quite small at this point. It has been, with all the other planning, to shift resources to the community and work closely with the long-term-care area, that the decision has been made at this point not to implement copayment in psychiatric hospitals.
I don't think we've eliminated it completely as a possibility because we recognize that the inconsistency in policy can be problematic and can create incentives to be on either side of the House. With the other initiatives the psychiatric hospitals have been implementing, this was one we weren't implementing at this time.
The Chair: Mr Shea.
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Mr Derwyn Shea (High Park-Swansea): I have a couple of quick questions. In terms of this particular facility, is there in place what I would refer to as, in layman's terms, a ombudsman system?
Mr Ballantyne: As a provincial psychiatric hospital, there is a patient advocate and a part-time rights adviser on site.
Mr Shea: Explain a little bit about the patient's rights role.
Mr Ballantyne: The role of the rights adviser is to inform newly admitted individuals what their particular legal rights are under the existing legislation and in an informal way certainly provide information to them about the facility and about what they might expect with respect to certain treatment.
Mr Shea: What would be the volume of admissions on a weekly basis?
Mr Ballantyne: On a weekly basis?
Mr Shea: Yes.
Mr Ballantyne: Last year we had 707 admissions. That was reduced because of the OPSEU strike about a year ago at this point.
Mr Shea: You're talking about an average of about 15 a week.
Mr Ballantyne: Yes.
Mr Shea: You used the words "part-time" when you talked about that position.
Mr Ballantyne: The rights adviser.
Mr Shea: "Part-time" meaning how much time?
Mr Ballantyne: I believe she's half-time. There is a full-time patient advocate, who, in the absence of a rights adviser, can provide that function.
Mr Shea: I see. What are the qualifications of the patient advocate?
Mr Ballantyne: The patient advocate program is independent of our management structure and is set up on that basis.
Mr Shea: Provided by whom?
Mr Ballantyne: I'm not privy to the selection process or the qualifications for it.
Mr Shea: Fair enough. Who does the patient advocate report to?
Ms Hill: Perhaps I can describe the program.
Mr Shea: Please.
Ms Hill: The patient advocate program was created over 10 years ago as a program that is, in a sense, semiautonomous. The actual provincial program does report to me, so they are government employees, but they are given greater independence by virtue of their role in the psychiatric hospitals of monitoring both clinical practice and ensuring that patients are not being abused or mistreated. They're given a little bit more independence.
Mr Shea: But they report to you.
Ms Hill: The director of the program reports to me.
Mr Shea: What are the qualifications of the advocates?
Ms Hill: They range from social work degrees; some of them have been trained -- I'm not sure if any advocates are lawyers, but in the past they have been.
Mr Shea: Some are lawyers?
Ms Hill: Yes.
Mr Shea: They are full-time advocates?
Ms Hill: Yes, most of the hospitals have a full-time advocate. They focus on a variety of levels of issues, whether it is actual incidents that take place or what we call systemic issues, where programs, in the way that they're run, are considered to be not sufficiently appropriate; to broader-level issues to do with the policies and procedures of the hospital or the mental health system.
Mr Shea: Would they sit at the medical --
The Chair: I'm sorry, Mr Shea, but your colleague Mrs Elliott --
Mrs Elliott: Don't interrupt him.
The Chair: Good. Is there an understanding between you two? Mr Shea, carry on, one short question.
Mr Shea: There are going to be a lot of commas in this one, then. Would those advocates sit at the medical council table at the facility to be permitted to make comments in terms of the medical-psychiatric intervention -- dash -- what is the link between your facility and general hospitals in terms of feeder mechanisms -- dash -- what is happening to the community advisory boards? My understanding is that they are being eliminated, and I want to know why. That was just a brief question, Mr Chairman.
The Chair: Dash.
Ms Hill: Perhaps I could have Mr Ballantyne answer the first dash and then I'll answer the second two dashes.
Mr Ballantyne: Basically, the patient advocates have rights to access records and to query any aspect of the operations of the facility in many respects. They take an approach which is constructive and consultative. If an issue has been identified by a patient, they follow instructions from that patient. They then query with the treatment team. If it's a physician or a member of a multidisciplinary team, their first approach would be to sit down and discuss the concern there. Ultimately it can be brought to my attention if there isn't clarification or resolution of the issue that's addressed.
The Chair: That's one dash; good enough. Your time has expired, Mr Shea. We'll go on to Mr Patten, and we'll alternate.
Mr Patten: I gather throughout the province there are waiting lists in different capacities, and I appreciate your description somewhat of the waiting lists, but it's still not adequate.
The referral from general hospitals -- people are usually referred to the psychiatric hospital if it's an extreme case, of course. Are you at maximum capacity now?
Mr Ballantyne: The new facility was built with a capacity of 325 inpatient beds, but we are currently at 285. The difference is the 40-bed, medium-secure forensic unit, which is under development. We're at capacity.
Mr Patten: You're at capacity now in a growing environment, so you're going to be presumably receiving more and more pressure. I think the act doesn't provide the flexibility for general hospitals which may have adequate psychiatrists or what have you to perform assessments because it only refers to those without consent who are committed for assessment. They must go to a psych hospital, right? That's my understanding. For involuntary assessments, they must go to a psych hospital.
Mr Ballantyne: No.
Mr Patten: That's what the act says.
Mr Ballantyne: The Mental Health Act basically says that when a physician or medical practitioner -- and there are of course other avenues through the courts -- identifies someone to be in need of assessment, he or she can direct that the person is taken to the nearest psychiatric facility. That doesn't necessarily mean a provincial psychiatric hospital. That may mean, and should mean in most cases, if there is an acute state, the general hospital that has a psychiatric unit.
Mr Patten: Yes, the interpretation is not usually being followed along those lines, though, is it? My reading is that the general hospitals have tended to resist responding except -- certainly not in terms of the more severely ill cases.
Mr Ballantyne: I don't know exactly, but my experience in our catchment area, and we have 11 general hospitals with psychiatric units, is that there is an effective partnership between the facilities, and there's a will not to compete or divert someone who may not be preferred to be part of their program to another facility. We've established a mechanism in our particular service area to ensure that doesn't happen; that the interests of the person who needs the help are met as best as possible with whatever the resources are.
We know that the resources aren't perfect, but there are ways to provide quality services in the current environment for people who are most seriously mentally ill. Our mandate, as a mental health centre, is to serve the most seriously mentally ill. We believe we are trying to do the best we can for that needy group, supplemented by the work of general hospitals and, again, the important role the community mental health sector contributes and other practitioners: general practitioners, psychiatrists, private practice, GPs and the like. There's a will and there's a need to ensure that we have a collective, consistent and coordinated approach to this population. It's a difficult area. You know it has special needs. There's great diversity in the populations. That's all the more reason why those who are providing mental health services have to be in sync to make it happen in whatever area we're talking about, whether it's eastern Ontario, the 905 area or the GTA area that we're part of. That's absolutely critical now and will become even more so in the years ahead.
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Ms Martel: The auditor made a specific recommendation around the tracking of chemical and mechanical restraints, and you said to this committee that there is a monitoring system that you now have in place. I'm assuming that includes the pharmacy as well in tracking of information around chemical restraints that wasn't in place beforehand.
Mr Ballantyne: That's correct, yes.
Ms Martel: Have you had enough time to look at that data and to observe any kind of particular trends that you've had to respond to or has the system not been in place long enough to really make an evaluation?
Mr Ballantyne: No. We haven't had sufficient time. Actually, the system was only developed very recently, so it's too early.
Ms Martel: I'm going to assume, as per a previous question I raised around another issue as to whether or not other institutions are being made aware of the changes as a consequence of the audit, that this particular issue is also one that other facilities have been made aware of, because I think it's an important issue.
Ms Hill: Absolutely.
Mrs Elliott: Just to go back to the payment issue, prior to 1994, a financially capable patient admitted to a psychiatric hospital was responsible for their maintenance; is that correct?
Ms Hill: Was responsible for -- I'm sorry?
Mrs Elliott: For their maintenance; they paid for part or all of their accommodation, treatment?
Ms Hill: No.
Mr Patten: No. That was the policy.
The Chair: What is the answer?
Ms Hill: No, it was not.
Mrs Elliott: A patient did not pay for any of this?
Ms Hill: No.
Mrs Elliott: In 1994, then, the act was amended to permit a copayment charge?
Ms Hill: The Health Insurance Act was changed to allow for it, but a regulation was not brought in.
Mrs Elliott: So a patient could contribute?
Ms Hill: A regulation would have to be passed to implement it. In other words, the provision was made in the statute that this could be pursued through regulatory means.
Mrs Elliott: The decision on the ministry's behalf, then, not to do this was because it felt perhaps that the type of patients were financially incapable or that if this policy was implemented in this section of the ministry, it would have to be applied across the ministry or in other ministries?
Ms Hill: It already did exist in long-term care. At that period of time, it did exist in long-term care and chronic care. I believe at that time -- I'd have to check my information -- they were different copayments. Part of the process has been to look at both of those and ensure that there's consistency. We're a third piece of the equation that will have to continue to be examined.
Mrs Elliott: Why aren't we looking at that now?
Ms Hill: We haven't looked at it currently because of the other changes taking place in the psychiatric hospitals.
Mrs Elliott: I'm sorry, I couldn't hear you.
Ms Hill: Because of the other changes that have been taking place in the psychiatric hospitals. The actual impact would be that people who are long-stay or psychogeriatric would have a copayment apply to them. Given that it is not a very rapidly changing environment, you could obviously implement it so that it's new people and not necessarily the people who are in the service. But potentially, in terms of people who have been there for a considerable amount of time, you could have people having to face a copayment for the first time for their family member. Given the other changes we've been pursuing with mental health reform, the community investment fund and a variety of other strategic initiatives that the psychiatric hospitals have been involved in, we decided not to implement it at this time.
The Chair: Maybe we can have another quick round, Mr Patten, M. Lalonde.
Mr Patten: I want to give Ms Hill a chance to respond. I think she wanted to respond to my last question.
Ms Hill: Now I have to remember it.
Mr Patten: The information I have is that while someone may be able to go to a general hospital -- and this may be unique in this area, but in other areas the psych hospitals are telling me that the general hospitals are not assuming their rightful responsibility as perceived by the ministry or as the intent of the act was, that they're passing it over and putting tremendous pressure on the psych hospitals because they don't want to have anything to do with it, because they feel that they don't have the capacity to deal with the more severely ill patients.
Ms Hill: Perhaps I can clarify two pieces of information. Under the Mental Health Act, schedule 1 units in particular do take involuntary patients. The ministry actually collects information on the involuntary admissions. From a legislative point of view, they can do it and do do it.
The piece of information I'd like to put as a context piece is that we have the mental health survey that says essentially that 20% of the adult population has a mental disorder. We know that a huge part of that population -- not huge, but I think it's 25% -- has no contact with the mental health system; a great number of people who do, probably rely on a psychiatrist or another practitioner as well as use of a schedule 1 unit or other inpatient units in public hospitals on a short-term basis. The schedule 1 units have reported to us that they are definitely seeing populations that are perhaps more acute, which is appropriate to their role, and, through a variety of efforts to become more effective and efficient, a shorter length of stay. So they're in fact seeing a larger volume of patients.
Perhaps where it becomes more difficult is that if a person presents in an emergency room -- many of the schedule 1 units do most of their admissions through emergency -- they may encounter patients who have more acute or chronic mental illness, and that's where the partnership between the provincial psychiatric hospital as well as effective community programs is critical. This really is the intent of our whole mental health policy: to have the various providers work more effectively together.
Another piece of the equation is that there are services that we know from the literature are very effective at helping people stabilize in the community. Probably the three critical ones are case management, for the severe and persistently mentally ill; crisis response, and that could be for someone who might have an acute episode but only be admitted twice a year for short lengths of stay, and you can in fact intervene more effectively if you stabilize a person early on before they come to emergency and before they are either quite psychotic, acting out or suicidal; and the third being community treatment teams, which is something we've been implementing slowly in Ontario and hope to do more of.
These teams are really intensive community treatment for the severely and persistently mentally ill, involving daily monitoring of care, daily provision of care. It is something we see as being a fundamental piece of the service system that will help people stabilize in the community but also prevent the pressure on the door to a hospital and also the pressure on the court system, since you're actually reaching people and maintaining people in a continuous way in their communities. We have several of these: one in Ottawa, one in Windsor, a couple in London and a couple here, and they really are tremendously effective.
The Chair: One short question, Mr Martel.
Ms Martel: I'll defer to Mr Shea so he can ask about community advisory boards.
Mr Shea: I really do want to make sure we get that answer. There have been a series of community advisory boards established. I note that there is some question that the one in Whitby is disappearing. I'd like some confirmation of that, if it hasn't already disappeared. Can you give me some background on that and whether this intends to be a systemic decision on the part of the ministry, and then, if you can, just perhaps finish off with my colleague's comments about the copayment and why in fact the legislation was changed but regulations not effected.
Ms Hill: The community advisory boards have been a very important piece of the psychiatric hospital system for perhaps two or three reasons; one is that these are regional facilities. That's one of the important aspects of these hospitals, that they have truly worked towards being regional services, and the community advisory boards have had regional representation. They've acted as a very important voice in their communities locally as well as a voice back to the hospital.
The Woods committee, when they reviewed the community advisory boards, recommended that as the government pursues alternative delivery for psychiatric hospitals and if the hospitals become established as public hospitals or specialty hospitals and have a full governing board, the community advisory boards be eliminated in that context. In other words, we have no plans to eliminate community advisory boards unless a full governing board is created.
Mr Shea: A full governing board meaning that people from the local community might well be on that board?
Ms Hill: And running it, yes, like any other public hospital board. That's what I mean by a governing board.
Mr Shea: So I'm clear what I'm taking from this: Residents of the community would in fact be running the hospital?
Ms Hill: That's right. The challenge again will be to ensure regional representation on that governing board.
Mr Shea: The final part to that question was, in 1994 the legislation was changed to permit copayments, but you didn't get around to making any changes to regulations. Can you explain why?
Ms Hill: I think I've answered this in previous questions, perhaps not to the satisfaction of the committee. Essentially the reason for not pursuing regulations at that time was the other activities we've been involved in, in changing and integrating the psychiatric hospitals with the full mental health system.
Mr Shea: Yes, you did say that. You can understand the curiosity that I have. Why would a government move in the direction of in fact amending legislation and bring it in but not do the regulations? Isn't that a curious step to take if you didn't have intentions to do it?
Ms Hill: I think we probably did have intentions and revisited the intentions.
Mr Shea: After you had done the legislation?
Ms Hill: Yes, and I think that we are, again, not eliminating it as a possibility, because we continue to look for cross-system linkages and integration, and we do recognize that by not making these changes in the psychiatric hospitals it can create an imbalance. I know the ministry is concerned first about ensuring consistency between chronic care and long-term care, and I think in time this piece will be examined again.
The Chair: Thank you. It being after 12 o'clock, I'd like to thank our three witnesses this morning. This committee is adjourned until next Thursday, March 6.
The committee adjourned at 1204.