July 22, 2005

More Mental Health Plans

In the old era when Gordon Campbell commanded 77 of 79 seats in the legislature, the typical response when a minister was asked a question was to attack the former government and ignore the question. In no area was that truer than in mental health. The Minister of State for Mental Health claimed that the former government introduced a mental health plan but did not fund it. That comment was unfair since funding would have taken place over several years as new budgets were introduced, but that is ancient history; now there is a new government to be held to account. When the legislature meets in September, for the beginning of BC's 38th Parliament, the former government will be the Campbell government of 2001-2005. Blaming one's predecessors will have worn itself out as an excuse. There no longer is a Minister of State for Mental Health; the incumbent was defeated and the position was eliminated in the cabinet shuffle, but there is an opposition critic devoted exclusively to mental health.

In 2001 and prior years it was possible to find a line item in the budget for the Ministry of Health which stated the amount budgeted for mental health. In the 2001-02 budget introduced prior to that year's election the adult mental health budget was $404 million. That budget was part of the budget for regional health services; 2001-02 was the last year any details were provided other than the total grant to the health authorities (over $7 billion in 2005-06). In the last year any detail was provided, a note in the budget document said: "Adult mental health provides for the management and delivery of mental health service to adults, on both an outpatient and inpatient basis and in tertiary psychiatric care, as well as adult forensic psychiatric services."

While there is no published financial information and no consistency between the health authorities on how they report on mental health, some information can be extracted. Under the objective of providing high quality patient care, the 2005 service plan for the Ministry of Health includes the strategies to: "Provide a full continuum of mental health and addiction services within each health authority" and "Provide integrated youth addictions programs". Under the objective of better integration of health services, the plan states that:

Performance measures are a key part of service plans. They reveal how the government plans to measure whether it is meeting its objectives. The plan states: "We will measure the continuity of care in mental health services by tracking the percentage of persons hospitalized for a mental health diagnosis who receive community or physician follow-up within 30 days of discharge. A high rate of community or physician follow-up reduces the chances that a mental health client will suffer a relapse and have to be readmitted to hospital." In particular, the plan states that 74.3% of those hospitalized for mental health or addictions received community or physician follow-up in 2003-04; that is to increase to 76.0% this year and to 80%, the long term goal, in 2007-08. No other performance measure specifically for mental health and addictions is included in the ministry's service plan.

Mental health services are delivered through the health authorities which have signed "performance contracts" with the ministry. Clauses in the contracts with the five regional health authorities add three performance measurements to the 30 day follow-up measure in the ministry's service plan. All authorities are expected to decrease the percentage of alternate level of care days (ALCs) spent by mental health and alcohol and drug clients (aged 15-64) in hospitals once the primary need for inpatient care has completed. ALCs are like bed-blockers when seniors are discussed; they are stays in hospital when there should be a discharge to community care. The authorities are also expected to develop Riverview replacement units in 2005-06: 160 for Fraser Health, 35 for Northern Health, 143 for Vancouver Coastal Health, and 117 for Vancouver Island Health. The performance contract also specifies that authorities are expected to "increase towards benchmarks the proportion of mental health services received by clients (aged 15-64) in their own health authority" for acute care: 98% Vancouver Coastal and Vancouver Island, 95% Interior and North, and 85% Fraser. The contracts provide 3 pages of definitions in the appendices so as to remove any uncertainty with respect to terms used in the expected performances.

A cynic might observe that more effort could go into developing performance measurements or expectations that have to do with patient care and quality of life rather than with cost of service delivery; however, there are instances when the two coincide. Working towards more 30 day follow up after hospital discharge is in the interest of the patient as well as in the interest of reducing the hospital costs caused by readmission. The four measures all point to more community-based care and less institutional care of all types. The ministry published a report on the 2002-03 health authority performance agreements. It provides the clearest statement as to the ministry's intent with the statement that:

Few would argue with those goals. They should probably be incorporated in the ministry's service plan; measures of disability and resiliency would be a welcome addition to measures that focus on the use of resources.

Ideally it should be possible to look at the service plans or their equivalent for each health authority, to determine how they intend to achieve their performance expectations. Better yet, annual reports for each authority should report on their progress. In the 94 page "operating plan" for Fraser Health, one page is devoted to mental health and addictions. It begins with the statement that there are $4.4 million in investments for mental health and addictions which will grow to $5.3 million in 2006-07. Key performance indicators are stated only in general terms as being relative to baseline and benchmarks but those aren't specified in the published document. In response to a question on mental health funding, communications staff for Vancouver Coastal Health provided a table showing that $121.5 million would be spent this year. Comparing that to the Fraser Health figure suggests that Fraser Health's plan reports its new spending but does not report its total spending on mental health.

Vancouver Coastal Health's 89 page "Service Redesign Plan" provides 12 pages on its intentions for mental health and addictions. It provides a level of detail that should serve as a model for the other health authorities. Perhaps others are reluctant to follow VCH's lead because information produces questions. The VCH plan refers to various "business cases" in support of different aspects of its plan. The business cases are not available on the health authority's website, and their communications staff have not responded to my request for further information. StrategicThoughts has submitted a freedom of information request for those documents. All of the health authorities need to realize that together they spend over $7 billion of public funds, and they hold the lives and welfare of many people in their hands. Their plans, including business cases, should be public documents posted on their website. Good published plans, which demonstrate benefits for patients (clients), can help diminish concerns over changes to our health system. Flawed plans can benefit from public input. The health authority that has been the most specific with its published redesign plan should take the next step and publish the requested documents to its website; the others should follow and, if the authorities aren't willing, the Minister should direct that they be more open.