General Articles

Nobody's Seeing the Big Picture in Mental Health

By Pauline Anderson
The Medical Post, Feb. 13, 1996

TORONTO - A strong mental health network that links services at general hospitals with community mental health programs should be considered under any plan for hospital restructuring, a doctor here says.

Currently, these services often operate in isolation with no single person or group having a global picture of everything that's available, said Dr. Frederick Lowy, who was the lone physician on a committee which studied restructuring of hospitals in Metropolitan Toronto.

"On any given night, there's a scramble to find beds," Dr. Lowy told delegates to the Ontario Psychiatric Association (OPA) meeting here. "If the Holiday Inn can tell you right now how many beds they have in Fiji, why can't we tell you how many beds we have in Toronto?"

Like Dr. Lowy, many psychiatrists are concerned about the impact that hospital restructuring -- a phenomenon that's spreading across Ontario and in other jurisdictions -- will have on mental health services. During the OPA meeting, a large crowd turned up for a discussion of the topic that featured a panel of experts involved in the restructuring process in Toronto, Ottawa, London/St. Thomas and Thunder Bay, as well as the deputy minister of health, Jessica Hill.

According to Dr. Lowy, the former director of the centre for bioethics at the University of Toronto, who recently became rector at Montreal's Concordia University, the Toronto restructuring committee concluded that mental health services in the area were "variable but on the whole inadequate," and that co-ordination of the services that do exist was also "inadequate."

The committee's report, which was delivered to the District Health Council (DHC) last September, suggested the focus of care should be shifted to community care but that there should be no reduction in institutional services until community services are available "to take up the slack," said Dr. Lowy.

The report recommended that the catchment area for the Queen Street Mental Health Centre (QSMHC), which now is restricted to only part of Metro Toronto, be expanded. It also suggested examining shifting the QSMHC to a public-hospital status. It' s an institution Dr. Lowy called a "marvelous resource." (QSMHC is one of the province's 10 psychiatric hospitals.)

The report also recommended the Clarke Institute of Psychiatry remain in its present form and that the Addiction Research Foundation offer ambulatory rather than inpatient services.

Under the restructuring plan, the Hospital for Sick Children would be responsible for co-ordinating regional mental health services for children, said Dr. Lowy, who added children and adolescents are "the least well served" so service for these populations should be enhanced.

Another major acute care centre should be identified as a resource for central geriatric psychiatric services, said Dr. Lowy.

Individual psychiatrists can help improve the poor distribution of services in the system by "moving out of our offices," he said. "Ideally every one of us should take time to provide services in a consultative way ... This is not always the practise in Toronto."

Hospital services doomed

Hospital restructuring discussions often involve reducing services at general hospitals. Psychiatric services would be "particularly vulnerable" if such plans proceed, said Dr. Lowy. As it stands now these programs are already underserviced.

"The funding envelope for mental health has to be preserved."

Hill reassured delegates the health ministry is committed to protecting psychiatric services in general hospitals and that any changes to these programs must meet ministry approval.

Hill said her ministry is "extremely supportive" of mental health reform and is concerned about the impact that restructuring will have on mental health services.

Hospital restructuring, she said, should be done in co-operation with community services, with consultation and input from DHCs and with consideration of how shifting of resources will impact on the region and on outpatient and crisis intervention services.

Hill talked about looking "beyond the walls" at service integration -- at programs that can be offered partially by hospitals and partially by community agencies. She also dispelled rumors that Brockville Psychiatric Hospital will close.

Another panelist, Ottawa psychiatrist Dr. Keith Anderson, agreed with Dr. Lowy that better links are essential to improving services. He also agreed it's necessary "to get community psychiatrists involved in the whole system." He said alternative funding mechanisms may facilitate the process.

The problems of mental health service delivery in Thunder Bay don't involve private practice psychiatrists since there aren't many of these in this northern community. But the Thunder Bay experience is similar to that of other jurisdictions in that its aim is to reduce administrative costs, divert these savings into patient care, and decrease duplication of services, said another speaker, Dr. Lois Hutchinson, a psychiatrist at Lakehead Psychiatric Hospital.

Dr. Hutchinson said provision of mental health services "was not given sufficient thought" during the recent restructuring process in her area. But the recommendation in the consultant's report to close Lakehead Psychiatric Hospital did make some sense because the site had become uneconomical. Something had to be done to the hospital," she said.

Another panelist, Barb Tiessen, described the process involved in restructuring the provincial psychiatric hospitals in London and St.Thomas. The two facilities are only 35 km apart but cover eight counties.

That area's restructuring committee concluded it would be feasible to offer the necessary tertiary care programs on one site and that the London site should be the preferred location.

Like virtually all its counterparts the London/St. Thomas restructuring committee looked at which services could be better provided in the community. But according to Barbara Everett, who represented the Ontario Federation of Community Mental Health and Addiction Services on the OPA panel, the current network of community services is "seriously underfunded."

The percentage of the mental health care budget that goes to community services is only 16.5%, although current recommendations are for this to be tripled, said Everett, a social worker at Homeward, a Toronto organization offering services for homeless kids and others.

The current provincial system includes over 300 community-based mental health programs that employ some 3,000 people and treat about 34,000 patients every day.

The average organization has fewer than 10 employees. Half of these agencies have a waiting list of at least six months, said Everett.

Everett said she's concerned about the "veritable hemorrhage of workers" into the community that will result from hospital restructuring.

She emphasized that working in the community is often very different from working in a hospital. Different skills are required, and community workers aren't normally unionized like many of their hospital counterparts and their wages are usually lower.

Those employed in the community health care sector want to be included in plans for hospital restructuring, said Everett.

The community sector is also wondering who has access to the whole picture when it comes to planning for future mental health services. "Who's taking the long view -- not in the year 2003, but in 2013 and in 2023."

Copyright 1996 Maclean Hunter Publishing Limited
Reprinted with permission.

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