Advocacy for Mental Health

On March 8, 2006, Transportation Minister Kevin Falcon announced the appointment of a three person panel to review the "governance" of TransLink. There are many reasons to do that which is probably why there hasn't been much by way of objection to the possible shakeup. TransLink, currently governed by appointees from the Greater Vancouver Regional District, has a 2006 budget of $844 million: $235 million from property taxes, $257 million from fuel taxes, $303 million from transit fees and the remaining $49 million from other sources, including the controversial parking tax. At least directors of TransLink are elected as mayors or members of councils. The six regional health authorities have no members that are even indirectly elected and they are responsible for $7.5 billion - 65% of the health budget, 27% of the total provincial budget, and that doesn't count what they raise from other sources like user fees. The Vancouver Coastal Health Authority has a budget of $2.2 billion, $2 billion from the province, and the rest from other sources. If we have reason to worry about the governance of TransLink, we have reason to panic over the governance and accountability of the health authorities.

In July 2005 I began to examine how accountable the health authorities are to the public, something the Auditor General should do. My analysis focused on expenditures for mental health by the Vancouver Coastal Health Authority (VCH). Their publication, "Health Service Redesign Plan 2005/06", deserves credit for being more detailed than anything that is available from the other health authorities. Unfortunately, it took eight months through freedom of information to obtain documents that were referenced in the mental health (Section 2.6) part of that report. The overall document, "Business Case: Implementation plan for Investment in Mental Health and Addictions" (February 15, 2005) (3 meg pdf), while incomplete, demonstrates an admirable effort by VCH staff to advocate for increased supported housing for a population with unmet mental health needs. In early 2005, VCH had 32,045 clients receiving services from mental health and addictions, including 4,966 acute psychiatry cases. VCH estimates that it has a population of 74,984 with self-rated mental health of fair to poor, and 47,637 with unmet mental health needs. The VCH report reviewed "evidence based practices to enhance acute and emergency access" and quoted a study by DP Culhane and others (2001) which found that residents of supportive housing experienced fewer and shorter hospitalizations "with the average individual's hospital use declining 49% for every housing unit constructed".

Unfortunately, the VCH report does not appear to assess strategies for mental health patients who are not suffering from "concurrent disorders", both mental health and addiction issues. The literature review cites Mellman and others (2001), Psychiatric Services, 52 as reporting that "while antipsychotic medicates for persons diagnosed with schizophrenia were prescribed for 89% of inpatients and 92% of outpatients, prescriptions conformed to dosage recommendations for only 62% of inpatients and only 29% of outpatients." The VCH report did not cite the extent of ineffective prescribing practice for other mental disorders such as severe depression, but some advocates, including Rafe Mair, have long called for mandatory mental health training for general practitioners or family physicians. The VCH report is silent on that issue.

Students of public policy and administration may find the third draft VCH report an interesting document to study in order to understand how policy is developed and how internal advocacy occurs for program spending. Others may study the report and react in horror over how little is understood about their needs and how lack of details in "business cases" can result in programs, such as the $2 million primary care program or the $1 million regional prevention program, falling off the agenda (see March 2, 2005 email, 3 meg pdf page 35).

The Campbell government is understandably critical of TransLink, yet the health authorities spend almost 10 times as much with virtually no transparency and little or no accountability. Their published operating statements consist of four lines: compensation, supplies, contracted services and depreciation. The public deserves to know many more specific details. How can the government pour $7.5 billion into the health authorities without so much as a mention of how much is spent on mental health compared to how much is spent on hip replacements? Those who think it is a mistake not to provide needed supported housing, or to turn a blind eye to ineffective, perhaps incompetent, prescribing habits need access to information in order to contribute to change within the health system. The Campbell government needs to lift its veil of secrecy. By publishing documents such as their "business cases" on government websites, knowledgeable consumers and practitioners can work with the government to find better solutions. Secrecy helps no one.