In Canada and other countries, such as the United Kingdom,1 we seem to be permanently in an era of budgetary restrictions. A balanced mental health system has been difficult to achieve during the last few decades because funding associated with downsizing and closure of psychiatric hospital beds has been moved to other health care and social services.2 The justice system has taken over some of the functions of the mental health system, with the police in many areas being the only 24/7 service, and the jail system housing people with schizophrenia, who frequently receive inadequate mental health care.3 Not to mention the system failure indicator that homeless people with severe mental illness (SMI) represent in Canadian cities, or the excess mortality of psychiatric patients.4 Moreover, even if medication is generally well provided for people with SMI, evidence-based psychosocial interventions are only implemented piecemeal in our resources-rich systems of care (see the 2 In Review papers by Mr Matthew Menear and Dr Catherine Briand5,6 in this issue of The Canadian Journal of Psychiatry [The CJP]).
However, with proper leadership by clinicians and managers at the regional and provincial levels, regional psychiatric rehabilitation centres and authorities, properly funded, could offer better tertiary psychiatric services and evidence-based rehabilitation interventions to all patients requiring it in their region or province.
We will briefly describe the system issues, such as reform of mental health services in Canada, under the 4 headings suggested by Health Canada7 (governance, funding, training, and evaluation), supported by the In Review papers in this issue on evidence-based rehabilitation interventions (see Dr Tania Lecomte, Dr Marc Corbière, and Dr Claude Leclerc8) and effective implementation strategies in programs and systems (see Menear and Briand5 and Briand and Menear6). For training of the future generation of Canadian psychiatrists in the rehabilitation of SMI (see Freeland et al9 in the Canadian Psychiatric Association’s book Approaches to Postgraduate Education in Psychiatry in Canada).
Funding
The system costs for the array of required services in the treatment and rehabilitation of SMI, estimated at 1.5% of the population, are illustrated as a simulation in Table 1. The table excludes other direct system costs, such as medical services, medication, disabilities, and income supplement, or other sectors, such as the judiciary system; it represents what most provincial ministries of health and social services consider as their mental health program expenditures. The items, proposed ratios, and costs could be modulated and are further explained in Lesage.10 It is of interest that the simulated average per capita of $134 is only 20% higher than Quebec’s mental health program when it launched its action plan in 2005: a balanced mental health care system for SMI need not be much more expensive, but must be better organized. In Table 1, it can be seen that hospital and supervised residential settings will represent at least 65% of this total simulated mental health budget. A similar funding distribution has been reported by the United Kingdom11 and in a best practice area of Italy, which has been a leader in mental health care reform.12
Table 1.
Simulation of the number of places and people in need of specialist care in a balanced mental health care system for people with SMI (catchment area size of 100 000 inhabitants)
| Variable | People or places n | Per person per year Cost, $ | Total per year Cost, $ |
|---|---|---|---|
| Long-term hospitalization | 15 | 89 078 | 1 336 170 |
| Acute care beds | 25 | 109 438 | 2 735 950 |
| Day hospital places | 60 | 17 229 | 1 033 740 |
| Nursing homes | 22 | 65 521 | 1 441 462 |
| Hostels | 14 | 35 616 | 498 624 |
| Foster families | 26 | 7746 | 201 396 |
| Supervised group homes | 28 | 49 793 | 1 394 204 |
| Supervised apartments | 48 | 19 348 | 928 704 |
| PACT | 70 | 7410 | 578 700 |
| Intensive home care | 120 | 4711 | 565 320 |
| Supplement to renta | 200 | 5000 | 1 000 000 |
| CMHT outpatients not above | 1072 | 1638 | 1 755 936 |
| Total costs | 13 410 206 | ||
| Per capita | 134 |
Supplement to rent for most PACT, intensive home care, and some CMHT patients, as described in the At Home/Chez soi demonstration project.15
Governance
In the United Kingdom, it has been suggested that in each local area, psychiatric services, along with social services and health services, develop specialist psychiatric rehabilitation services working with all the other relevant mental health and social programs. The latter include the Community Mental Health Teams (CMHTs), mental retardation teams, and specialist substance dependence teams. Interestingly, in Quebec, mental retardation and specialist addiction services are under the authority of regionalized mental retardation or addiction rehabilitation centres. These local or regional psychiatric rehabilitation services cover the patients in the array of services described in Table 1, from long-term hospitalization to supplement to rent. They encompass the tertiary psychiatric services described by Wasylenki et al.13
The reviews of Menaar and Briand stress the importance, at the system level (such as provinces or states), of leadership, adequate financing, and technical assistance for implementing, supporting, and monitoring quality of tertiary psychiatric services and rehabilitation interventions and (or) programs provided. Israel’s experience, reported in Briand and Menear’s review,6 suggests adding a key role to patients and families as part of a national rehabilitation council responsible for planning rehabilitation services, improving quality and accessibility of services, and advising the government on rehabilitation policy.
Training
Issues of training and developing competences in psychiatric rehabilitation during the formative years of mental health professionals, including psychiatric residents, as experts, as multidisciplinary collaborators, and in managerial dimensions, is well developed by Freeland et al.9 The continuing training of professionals across the regions of a province in evidence-based rehabilitation interventions, and in complex programs such as the Program of Assertive Community Treatment (PACT), should be an integral part of their implementation and sustainability. One key strategy is a clear responsibility at the system level (provincial) for systematic training, consultation, and fidelity monitoring activities, and assumed by state or provincial technical assistance centres (see Briand and Menear’s paper6).
Evaluation
Continuous evaluation and quality monitoring of evidence-based interventions and programs6 is a key strategy to ensure maintenance of program fidelity and expected positive outcomes by the professionals of the multidisciplinary rehabilitation teams and programs across the regions of a province. New information technologies, with standard questionnaires and informative results feedback, at the clinical, program, and system levels, should be seen as supportive of such continuous evaluation, providing information on input (for example, number of patients, services, and budget), processes (for example, array of services and interventions provided), and outcomes (for example, suicide, premature deaths, homelessness and judiciary transinstitutionalization, and employment).
A Proposal for Regional Psychiatric Rehabilitation Centres and (or) Authorities for Patients With SMI
In my opinion, the best proposal is for psychiatric rehabilitation centres and services authorities to be set up in each region with clinical and managerial leadership, and to cover most of the tertiary services: long-term inpatient and residential care, intensive treatment and rehabilitation home care, and occupational–educational rehabilitation and continuing care for patients with severe and persistent mental disorders in collaboration with the CMHT, mental retardation and addiction rehabilitation centres and authorities, and teams. It would represent about 500 patients per 100 000 inhabitants (with a range of 250 to 750 per 100 000 inhabitants, considering the greater need in underprivileged and urban areas11). These centres and authorities should control access to their services, be properly funded, and ensure that CMHT maintain clinical responsibility for the patients they referred to these tertiary care services, as they may require less intensive care but still need continuing care in the community. It should be supported at the provincial level by rehabilitation technical assistance centres, with the functions of implementing, training, and evaluating the quality of evidence-based rehabilitation interventions and programs under the governance of the mental health directorate or equivalent in the applicable province, that would ensure proper funding. Such centres have been successfully operating in Ontario for the development and implementation of assertive community treatment (ACT) teams; and a prototype of it has been set up for training at least PACT and intensive home care teams in Quebec—its Centre national d’excellence en santé mentale. The latter was unfortunately not associated with funding, and Quebec has been slow to ensure that its 2005–2010 mental health action plan ACT teams’ population-based deployment targets were met. Adding a governance role for families’ and patients’ representatives in regional authorities and in provincial rehabilitation authorities’ accompanying mental health directorate and its rehabilitation assistance technical centres, as in Israel, and as suggested by Briand and Menear,6 is recommended. The proper governance in each region and funding, as well as the training and continuous quality monitoring of mental health services, remain the stumbling blocks to ensuring quality mental health systems across Canada, if they are to offer people with SMI disorders and their families effective care and rehabilitation services across the country on their road to recovery and the opportunity to fully participate in citizenship.14
Acknowledgments
Dr Lesage has received a research grant from the Canadian Institutes of Health Research. He is a public health system employee and researcher with a planning and evaluation mandate and activities.
The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
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