Psychological Services and the Future of Health Care in Canada

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Psychological Services and the Future of Health Care
in Canada

ROY J. ROMANOW                                                    ceived lack of adequate funding. These issues had
Former Premier of Saskatchewan, Former Chair                      already precipitated a number of arms-length govern-
of the Commission on the Future of Health Care                    ment studies. In April 2001, when the CFHCC was
in Canada, and Senior Policy Fellow                               established, the governments of Québec (2000) and
University of Saskatchewan and University of Regina               Saskatchewan (2001) had already been provided with
                                                                  their own Commission reports. Moreover, the Alberta
GREGORY P. MARCHILDON                                             government (2001) was about to receive its report.
Former Executive Director of the Commission on the                Given the provincial context of these studies, however,
Future of Health Care in Canada and Canada                        the reports barely touched upon the national dimen-
Research Chair in Public Policy and Economic History
                                                                  sions of health care.
University of Regina
                                                                      As for the federal government, it had already decid-
                                                                  ed to reduce its social (including health) transfers to
Abstract                                                          the provinces before receiving the recommendations
The implications of the Commission on the Future of               of an earlier commissioned study. As a consequence,
Health Care in Canada’s (CFHCC) recommendations                   the recommendations of the National Forum on
extend beyond the necessarily limited scope of its report.        Health (1997) were initially sidelined as the federal
This article explores the potential role of psychologists in a    and provincial governments began to debate their
restructured public health care system that goes beyond           respective roles and responsibilities in the funding,
hospital and physician care to home care and a revamped           administration, and delivery of public health care. By
primary care system. Public plans would also benefit from         1999, the Senate Standing Committee on Social
the use of psychological alternatives to prescription drug        Affairs, Science and Technology had begun to study
therapies. Such evidence-based extensions to the existing         the federal role in health care, but it was not perceived
Canadian model would improve both health and medical              as acting on behalf of the federal government, nor was
outcomes. They could also introduce new cost-savings to           its mandate considered, at least initially, to be directly
provincial health plans that are presently under immense          relevant to the provinces.
financial strain.                                                     Unlike previous Royal Commissions that had three
                                                                  to five years to complete their work, the CFHCC was
                                                                  given a mere 18 months. The debate concerning the
                                                                  sustainability of public health care was then reaching a
    The Commission on the Future of Health Care in                crescendo. Federal-provincial conflict in particular
Canada (CFHCC) was created to address some very spe-              had escalated to the point of destabilizing the health
cific problems facing Canada’s public health care sys-            care system itself. The sources of this conflict were
tem. These included escalating costs, timely access to            varied, but the main fault lines were constitutional,
certain services and procedures, and shortages of                 institutional, financial, and ideological in nature. The
some types of providers. Questions had also been                  debate that this conflict triggered was confusing, and
raised concerning the quality of health care as well as           it was unclear as to whether the fundamental values of
the range of services that should be offered by the               the system were in question. Moreover, it was unclear
public sector and the role of the private sector in the           whether governments agreed or disagreed as to the
delivery of those services. Beyond these specific chal-           general framework within which change and reform
lenges was the question of whether the governance of              could take place over the coming years. As a conse-
the health system was failing. There was also a grow-             quence, it was believed that any report released
ing dysfunction within the federal system as each                 beyond the 18-month time period might be too late to
order of government attempted to blame the other for              provide answers directed to these basic questions and
the shortcomings of the public system and its per-                provide the recommendations that would help shape
                                                                  the policy outcome in the country.
                                                                      In addition, the CFHCC was required by its original
Canadian Psychology/Psychologie canadienne, 44:4 2003             order-in-council to deliver an interim report, which
284 Romanow and Marchildon

was released in February 2002 (Canada, 2002a). This                      The Canadian Medicare Model
left nine months to conduct one of the most extensive          Canadian medicare is, first and foremost, a histori-
and intensive public consultation processes ever            cal construct. The first pillar of our contemporary
engaged by a Royal Commission in Canada and to              public health care system was initiated by
write a final report with a broad range of recommen-        Saskatchewan in 1947, followed by other variants of
dations on the future of health care. This report was       hospitalization in Alberta and British Columbia. With
delivered in November 2002, amidst saturation-level         the passage of the Hospital Insurance and Diagnostic
media attention and at the peak of federal-provincial       Services Act by the federal Parliament in 1957, and the
conflict over the future of public health care (Canada,     offer of federal cost-sharing transfers, the
2002b). Although the recommendations went beyond            Saskatchewan model of universal public hospital
at least some of the immediate issues that were of con-     insurance was adopted in all the provinces and territo-
cern when the CFHCC was created, the extremely              ries by 1961 (Boychuk, 1999; Taylor, 1987, 1990).
short time frame meant that the recommendations             Psychiatric health services were, however, excluded
could not cover the entire waterfront of longer-term        from the definition of hospital services, and federal
issues, including the role of psychology in the health      government inspectors actually counted the number
of Canadians (Allon & Service, 1999). Instead, the          of psychiatric beds in general hospitals to exclude
report delivered a limited package of fiscally and polit-   them from the federal share of provincial hospital
ically feasible recommendations, many of which would        expenditures. This encouraged the pre-existing ten-
be capable of implementation within a short period of       dency to keep long-term mental health facilities such
time. Particular emphasis was placed on lancing the         as psychiatric hospitals separate from the “regular” sys-
federal-provincial boils because of the difficulty of       tem. Nonetheless, some emergency mental health
achieving positive health care change on the ground         services were covered under hospitalization, and this
without addressing the malfunctions at the highest          meant that psychiatrists and psychologists could pro-
governance level. Moreover, contrary to most recent         vide critical care mental health services under the
health care reports in Canada, much time was spent          rubric of hospitalization. These services would
on how to achieve change, most significantly on how         expand over time but even by the mid-1980s, no
to create new intergovernmental structures and              Canadian hospital offered admitting privileges to psy-
processes, such as the establishment of a Health            chologists, nor would most hospital patients be
Council of Canada, to replace existing intergovern-         assessed and/or treated by psychologists except after
mental processes and institutions (see CFHCC imple-         physician referral (Arnett, Martin, Streiner, &
mentation plan, Canada 2002b, 255-256).                     Goodman, 1987).
    There was a price to be paid for this focus in the         The second phase of medicare was the implementa-
CFHCC’s final report. Professional psychologists were       tion of universal public health insurance for primary
not alone, for example, in wishing that the CFHCC had       medical care services outside hospitals by
gone further into the issues of greatest interest to        Saskatchewan in 1962. Despite the existence of other
them (Canadian Psychological Association, 2002). As         models, including a targeted subsidy approach in
a consequence, the purpose of this article is to            Alberta, it was the Saskatchewan model that was rec-
explore at greater length the implications of key rec-      ommended for national implementation to the federal
ommendations in the report for the future of psycho-        government by the Royal Commission on Health
logical services. We begin by summarizing the princi-       Services – the Hall Commission – two years later
ple features of the Canadian model of medicare as it        (Canada, 1964). It took another 50:50 cost-sharing
has evolved over time in order to understand why psy-       offer by Ottawa, plus years of negotiation, but all the
chological services are largely outside the core of pub-    provinces and territories had implemented universal
lic health care. We then review the major systemic          medicare by 1972 (Naylor, 1986; Taylor, 1987, 1990).
changes recommended by the report – home care and           There were two significant factors in this phase. First,
primary health care – and the role that psychological       the family/general physician was seen as the centre of
services could potentially play in their organization       the primary care universe. Second, the fee-for-service
and delivery in the future. This is followed by an          (FFS) methods of physician remuneration that predat-
examination of prescription drugs, the most signifi-        ed medicare were continued, except that the govern-
cant cost-driver in health care today, and the alterna-     ment rather than individuals or private insurers paid
tives to physician-directed drug therapies. Finally, we     the physicians’ bills. In the beginning, therefore,
look at some of the more immediate challenges in            other professions, including professional psychologists,
Canadian health, in particular, rural, remote, and abo-     were largely excluded from the FFS medicare system.
riginal health and health care.                                This changed little over time, in large part because
Psychological Services and the Future of Health Care in Canada 285

of the desire by governments to limit their expendi-          their respective health plans, it has meant that both
tures of public funds on new services and new                 hospital services and primary care physician services
providers. A few other professions such as chiroprac-         are historically privileged. Moreover, given the focus
tors were occasionally, and temporarily, let into the         of general/family physicians on physical ailments, this
FFS public system by particular provincial govern-            has resulted in a lack of emphasis on mental health
ments, but professional psychologists provided prima-         services, other than mental disorders that can be easi-
ry care services in the private sector. This was despite      ly identified and referred to a psychiatrist by other
the replacement of shared-cost funding schemes for            physicians. The result is that almost 80% of consulta-
both medicare and hospitalization with a block fund-          tions with psychologists – the majority of which likely
ing transfer known as Established Programs Financing          involve mental health issues – occur within the private
(EPF) in 1977. One of the reasons behind the change           rather than the public system (Canadian Psychological
was the provinces’ desire for greater flexibility in their    Association, 2001). Of this 80%, a portion is covered
use of federal health transfer funds, which was trig-         through private insurance (largely employment
gered in part by an interest in new organizational            based) and the remainder is paid out-of-pocket.
models of primary care delivery (Canada, 1972) and                The enormous burden of mental disorders in
population health through the Lalonde Report                  Canada is one of the more unfortunate legacies of the
(Canada, 1974).                                               Canadian medicare model. Without a doubt, mental
   By the end of the 1970s, provincial health care            disability has a major impact on the health status of
plans were covering or subsidizing health services well       the population. Despite this, our public system invests
beyond hospitals and primary care physicians, includ-         disproportionately on addressing physical diseases,
ing prescription drugs, as well as home/community             particularly those associated with death (Bland, 1998).
care and long-term care. At the same time, advances           One estimate of the economic cost of mental disor-
in drug therapy and changes in mental health treat-           ders in Canada was $14.4 billion in 1998, a little more
ment modalities had resulted in the “de-institutional-        than 25% of the total invested in public health care
ization” of many patients previously resident in              that year. This is a consequence of the fact that
provincial psychiatric hospitals. Despite these               approximately 3% of the Canadian population suffers
changes, the medical model of treatment, with the             from serious mental disorders in any given year, while
physician at the centre, remained the norm. Most pri-         about 1 in 5 Canadians suffer a less serious, but
mary care continued to flow through general/family            nonetheless potentially disabling, mental condition
practitioners who referred patients with serious men-         (Canada Mental Health Association, 2001). Canada is
tal disorders or difficulties to psychiatrists while          not alone in terms of this burden and the fact that it is
attempting to cope with less serious cases on their own       inadequately addressed. As the World Health
or, very occasionally, by sending them to a psychiatric       Organization (2001) recently pointed out, mental
nurse or psychologist.                                        health remains one of the most neglected areas of
   In 1984, the federal Parliament passed the Canada          public health care throughout the world.
Health Act (CHA, 1985). The motives for passing the               In Canada, there is a gradiant of services. Within
Act were varied, although the chief preoccupation of          the core medicare system, most serious mental disor-
the federal Minister of Health at the time was to cur-        ders are treated by psychiatrists. Unfortunately, less
tail the practices of extra billing by physicians and         serious mental conditions are often not being diag-
user fees by hospitals in parts of the country. These         nosed much less treated within the existing system.
were contrary to the operating principles of the origi-       Finally, the systematic pursuit of mental health, as
nal federal legislation underpinning the federal trans-       opposed to the treatment of mental disorders, is poor-
fers but made almost unenforceable through the EPF            ly resourced and rarely done in Canada. Each of these
changes (Bégin, 1987). On this count, the CHA was a           categories will be examined in turn.
great success, rolling back almost $247 million in                Serious mental disorders are now mainly addressed
extra billing and user fees within three years.               through drug therapies under the supervision of psy-
However, the CHA also entrenched the hospital and             chiatrists. Drugless therapies are much less common
physician-centred model of medicare by limiting               for two reasons. The first relates to the major
insured health services covered by the five governing         advances in psychotropic drugs over the past 30 years
principles of the Act – public administration, univer-        and the fact that drug therapy has become the treat-
sality, accessibility, portability, and comprehensiveness –   ment of choice among psychiatrists. The second is
to medically necessary hospital and physician services.       that clinical psychologists, who are not permitted to
   Although the CHA has never blocked the provinces           prescribe medication, are rarely consulted in such
from providing a broader range of services under              cases, in part because they are not part of the
286 Romanow and Marchildon

Canadian medicare model, unless hired by hospitals          extremely difficult to overcome institutional rigidities
or community mental health clinics. Both psycholo-          that are, to a considerable extent, the historical legacy
gists and psychiatrists can provide psychotherapy but       of the Canadian medicare model.
in most provinces, psychotherapy is only funded pub-           In practice, it is much more feasible to target those
licly if provided by physicians, a consequence of a tra-    parts of the model that governments have now agreed
ditional FFS system, discussed earlier, in which physi-     can, and should, be changed as part of an agreed-
cian services are automatically covered but psycholo-       upon plan of health system reform. Some of this con-
gists’ services are not. This is despite the fact that      sensus was reflected in the common recommenda-
PhD-level clinical psychologists receive far more           tions of recent health commission reports in Canada.
extensive training and education in psychotherapy           The CFHCC went a step further in attempting to deter-
than physician-trained psychiatrists (Ontario               mine what the general public desired and supported
Psychological Association, 2001). Although Canada is        in terms of directional change through an innovative
similar to many Organization for Economic                   “citizen’s dialogue” involving a representative sample
Cooperation and Development (OECD) countries in             of Canadians in 12 day-long deliberative sessions
this respect, there are exceptions. In Germany, for         (Maxwell, Rosell, & Forest, 2003). To better under-
example, psychoanalytical services provided by either       stand what would be within the realm of politically
psychologists or psychiatrists are covered in the public    possible, the CFHCC kept in touch with all provincial
system (Canadian Psychoanalytic Society, 2001).             and territorial governments as well as aboriginal orga-
     If diagnosed, less serious, but nonetheless debili-    nizations through a formal intergovernmental liaison
tating, mental disorders are addressed both inside and      as well as informal but high-level contacts with first
outside the public system. For such ailments, drugless      ministers. The CFHCC final report reflected a judg-
therapies provided by psychologists play a correspond-      ment on not only the changes that needed to occur
ingly larger role. Although the economic benefit of         but the reforms that had the most chance of success
psychological services has not been fully studied, the      given the level of public support in the context of
initial results are very encouraging (Hunsley, 2002,        what was politically and fiscally feasible. The next step
2003). Indeed, treating depression and various addic-       was for governments to act on the basis of the existing
tions, as well as anxiety, conduct, mood, and personal-     consensus, and a little more than two months follow-
ity disorders through cognitive behaviour therapies         ing the report, federal, provincial, and territorial first
(CBT) and other empirically supported psychological         ministers agreed to a basic package of reforms
interventions holds considerable promise for the            through the Health Accord of February 5, 2003
future (Hunsley, Dobson, Johnston, & Mikail, 1999).         (Canadian Intergovernmental Conference Secretariat,
In addition, psychologists have been central in treat-      2003). We now turn to the key areas of health system
ing stress-exacerbated physical conditions such as          reform (relevant to the future of psychological ser-
hypertension and ulcerative colitis. Psychologists also     vices) that were an integral part of the 47 recommen-
play a recognized role in treating the psychological        dations made in the CFHCC final report.
dimension of physical diseases such as cancer, through
group and individual therapies. In addition to their                               Home Care
clinical effectiveness, some of these therapies are also       Home care has never been part of the basket of
proving to be cost-effective. In a recent study of          “insured health services” under the Canada Health Act.
female breast cancer patients in Calgary, for example,      In many instances, however, health care provided in
the availability of group therapy lowered health care       the home can be less expensive and more appropriate
costs by 24% (Ontario Psychological Association,            for an individual than hospital or institutional treat-
2001).                                                      ment. In fact, since the 1970s, provinces have been
    Each of the treatment modalities for mental disor-      adding home care services to their respective health
ders and the psychological dimensions of physical ill-      plans in an effort to improve the continuum of public
ness or disability, including drugs, psychotherapy, CBT,    health care services and to contain acute care and
as well as family and group therapies, have their inher-    long-term institutional care costs. The provinces were
ent advantages and disadvantages. Moreover, treat-          encouraged to continue down this track by the relax-
ment effectiveness will also depend on the unique           ing of federal transfer conditions with the introduc-
needs of the individual being treated. Nonetheless,         tion of EPF in 1977. This was more formally recog-
for both financial and quality-of-outcome reasons,          nized when Ottawa expressly permitted federal trans-
there should be, in theory, a far greater availability of   fer funding to flow to “noninsured health services”
psychological therapies within the public system in the     such as home care and long term care as defined
future. It needs to be emphasized, however, that it is      under the Canada Health Act (1985).
Psychological Services and the Future of Health Care in Canada 287

    Today, every province has its own unique set of          was becoming clear, as described by the Canadian
home care services in place. Unlike hospital and pri-        Mental Health Association (2001, p. 8) in its written
mary physician care services, the absence of federal         submission to the CFHCC:
funding tied to legislated conditions or principles per-
mits enormous variability in the quality and quantity        For many former hospital residents, the new system meant
of home care programming, as well as the conditions          either abandonment, demonstrated by the increasing
of access, across the provinces and territories.             numbers of homeless mentally ill people; ‘trans-institu-
Moreover, most jurisdictions have little in place to sup-    tionalization’: living in grim institution-like conditions
port home and community care for individuals with            such as those found in the large psychiatric boarding
mental disabilities. This stands in stark contrast to the    homes; or a return to family who suddenly had to cope
provincial infrastructure for institutionalized patients     with an enormous burden of care with very little support.
with chronic physical and mental disabilities.               In addition, fears and prejudices about mental illness, in
    Indeed, mental asylums, psychiatric hospitals, and       part responsible for the long history of segregation in
similar institutions were a familiar part of the health      institutions, compounded the problems in the community.
care landscape in most of Canada long before hospi-
talization and medicare. In many cases, these served             The current system has some perverse features
to “warehouse” a small group of individuals with seri-       associated with it. In a recent study of Ontario, for
ous mental conditions but did little or nothing for the      example, the Canada Mental Health Association
many more with less serious conditions. Moreover, in         (2001) discovered that people with serious mental dis-
terms of the institutionalized patients, the existing sys-   orders are generally not eligible for home care in the
tem fell short of acute care hospitals in having cura-       province unless they have previously been admitted to
tive objectives. This led the Hall Commission to state:      a hospital: this, despite the fact that effective home
“Of all the problems presented before the                    supports for such individuals may be able to prevent a
Commission, that which reflects the greatest public          hospital admission in the first place. Moreover, even
concern, apart from the financing of health services         serious mental disorders are not the chronic, incur-
generally, is mental illness” (Canada, 1964, p. 21). In      able, conditions once believed, and our knowledge
a bid to put mental disorders on the same level as           base concerning appropriate and effective interven-
physical illness in terms of the organization and provi-     tions is growing rapidly (Trainor, Pomeroy, & Pape,
sion of services, Hall recommended that mental               1997).
health care be integrated into the hospital system by            For a broad range of mental disorders, professional
adding psychiatric wards and wings to hospitals and          home care is much more than simply an alternative to
replacing the larger, segregated mental asylums. His         institutionalization. It is often an essential element in
commission also recommended that the majority of             ensuring that a treatment regime (drug or nondrug)
children with mental disorders should be treated at          is strictly adhered to in order to avoid periodic relaps-
home or in the community rather than placed in               es and destructive behaviours as well as repeated read-
long-term institutional care (Canada, 1964, p. 24).          missions to hospital. According to Hollander and
However, these recommendations were bypassed to              Chappell (2002), very large savings to the public
some extent by a major societal shift that would have        health care system can be realized by focusing home
been difficult to predict by the Hall Commission.            mental health services on individuals who generally
    In the 1960s and 1970s, the deinstitutionalization       live well in their communities, but who may have occa-
movement took hold in Canada and other advanced              sional problems. This is particularly true for individu-
industrial countries (Trainor, Pape, & Pomeroy, 1997).       als who only rarely exhibit violent behaviour during
New psychotropic drug therapies and a new vision of          these problem periods but, when they do, are then
community psychiatry, along with the cost advantages         hospitalized or institutionalized to protect the care-
of treatment outside expensive long-term mental insti-       givers around them. Currently, intervention, general-
tutions, led to the release of many patients back to         ly by the police and emergency response units, only
home and community environments. But while                   takes place after the situation boils over and causes
provinces invested heavily in paying for the drug ther-      damage to both patients and caregivers. This form of
apies for these individuals, little was done to improve      emergency intervention is costly to society while doing
the home and community care infrastructure for indi-         little or nothing to improve the quality of lives of
viduals with mental disorders in most provinces              those most directly affected.
despite the fact that this should have also been part of         To address this situation, the CFHCC recommended
deinstitutionalization (Gatz & Smyer, 1992). By the          that two types of home mental health care services be
mid-1970s, the negative side of deinstitutionalization       the planks in a new national floor. The first was case
288 Romanow and Marchildon

management and the second was behavioural inter-            atrists in Canada despite the growing demand for
vention. In the former, a case manager would work           such services. Even in Ontario, which has more than
directly with the patient and a range of health care        the national average of psychiatrists, there are 7,000
providers and community agencies to monitor the             children waiting an average of 6 months for psychi-
individual’s health and ensure continuity and coordi-       atric services (Canadian Mental Health Association,
nation of care with the appropriate supports in place.      2001). This waiting list could be reduced or eliminat-
The latter category would involve more systematic           ed over time if clinical child psychologists could
intervention services to assist and support clients and     become an integral part of the public system.
their caregivers during periods of disruptive behav-           Whether home care will trigger major changes in
iour that pose a threat to themselves or their care-        the public utilization of psychological services ulti-
givers. Clearly, the two services are directly connected    mately depends on the precise range of specialized
in the sense that it would be almost impossible to have     services that provincial governments and (where dele-
timely and effective intervention without the case          gated) regional health authorities (RHAs) will pay for
management infrastructure in place, an infrastructure       with public funds. If provinces automatically privilege
which is largely absent in most provinces. As a conse-      psychiatrists, psychiatric nurses, and nurse practition-
quence, of the estimated $568 million annualized cost       ers for home-based mental health care, this will leave
for mental health home care, almost all ($528 mil-          only limited space for specialized clinical psychology
lion) would be needed to create a case management           services. If, on the other hand, provinces or RHAs fun-
infrastructure in Canada (Canada, 2002b).                   damentally reassess the membership of the home care
    This reform involves more than a timely crisis          team, or allow case managers a significant amount of
response, diverting individuals from inpatient hospi-       discretion in selecting the professional services most
talization. It involves comprehensive monitoring and        appropriate to an individual home mental health
evaluation by skilled health professionals, at least one    client, then much more space for psychological ser-
of whom has built up a trusting relationship with the       vices will be created.
mental health patient and this individual’s caregivers.        Part of the solution may lie in determining who the
It is a methodology that strives to improve clinical sta-   home mental health case managers of the future will
tus by preserving, promoting, and restoring mental          be and how much they will be paid. There are a num-
health. It also involves the active participation of both   ber of possibilities that range from nurse and nurse
clients and caregivers in treatment and care.               practitioners to social workers and psychologists.
    In the 2003 First Ministers’ Accord on Health Care      Although the nursing professions have much training
Renewal, the Prime Minister and the Premiers all            in health care, social workers are experienced in case
agreed to provide full public coverage for “short-term      management and the business of co-ordinating a
acute home care,” including “acute community men-           diverse range of services. Psychologists, in particular
tal health” services and case management within the         those clinical psychologists with a broad knowledge of
next three years (Canadian Intergovernmental                the health system, should also be considered. At the
Conference Secretariat, 2003). Although the word            same time, it must be admitted that there is no perfect
“acute” may end up limiting what governments do or          professional background for such a role and that no
provide, this commitment by all governments likely          one provider group has all the skills necessary for a
marks the first major step in addressing mental health      home mental health care case manager. In this new
services since the introduction of medicare decades         home care landscape, we require case managers, irre-
ago. The question remains, however: What role will          spective of label, who are aware of the full breadth of
psychological services play in this reform?                 psychological services, including the advantages and
    The simplest response by provinces may be to layer      disadvantages of alternative therapies (Service, Allon,
onto the existing physician-centred approach by allow-      & Mikail, 2001).
ing the provision of professionally accredited psycho-         That said, clinical psychologists may be in the best
logical services that are already well recognized by the    position to work on a regular basis with such clients if
medical professions in the U.S. and Canada. In this         they can gain expertise in the nonmental health care
regard, Dobson (2001) identifies three specializations:     aspects of case management and service co-ordina-
clinical psychology, including clinical child psycholo-     tion. Moreover, this may be a very cost-effective
gy; clinical neuropsychology; and clinical health psy-      approach from a provincial government’s (or RHAs)
chology. Such an approach could fill in some obvious        perspective as well, given the already demonstrated
gaps in the current system. It could also be a substi-      savings gained through psychological treatment of
tute for specialized physician services that are in short   anxiety disorders, depression, and borderline person-
supply. There are, for example, very few child psychi-      ality disorder (Hunsley, 2003). There should be
Psychological Services and the Future of Health Care in Canada 289

ample opportunity for large-scale pilot projects in          home care policies and programs are in place that will
home care that can be used as a comparative bench-           forestall hospital and institutional care, including psy-
mark for both cost-effectiveness and quality in home         chological assistance for caregivers (Grunfeld,
mental health case management.                               Glossop, McDowell, & Danbrook, 1997). Providing
   In reality, the amount the public system is willing to    care for older individuals suffering mental disabilities
pay home care case managers will determine the               can exact an enormous psychological toll on family
range of possibilities. If case managers are perceived       and loved ones. Much of the support for home care
to be at the very low end of the skilled professional        can actually become support for the caregivers to facil-
continuum (as they are now), they will be paid accord-       itate their ability to continue to provide high-quality
ingly. In such a situation, they are not likely to attract   care to loved ones. Moreover, it must be recognized
more highly educated professionals such as psycholo-         that, at some point, because of the severity of the dis-
gists. If, however, such positions are reconfigured as       abilities and the difficulty and high cost of continuing
high-skill occupations, new possibilities will open up       to provide care in the home, the individual may need
not only for psychologists but also for other well-edu-      to be transferred to an institutional setting.
cated professionals. The question is whether we, as a            The CFHCC recommendations on home care went
society, are willing and/or able to make the public          beyond mental health services to include post-acute
investment necessary for this to occur.                      home care and palliative, or end-of-life, care (Canada,
   The aging of the Canadian population will increase        2002b). These services are also part of the 2003 First
the demand for home care for the simple reason that          Ministers’ Accord on Health Care Renewal, slated for
the incidence of brain disorders – dementia and delir-       implementation by 2006 (Canadian Intergovernmen-
ium – increases with age. Alzheimer’s alone now              tal Conference Secretariat, 2003). In the case of post-
accounts for over 50% of dementia cases. The finan-          acute home care, the CFHCC recommended that the
cial burden imposed by this disease is already sizeable      14 days covered following release from hospital be
in advanced industrial societies (Heston & White,            extended to 28 days if rehabilitation is involved.
1991; LaRue, Dessonville, & Jarvik, 1985). One               Psychologists who specialize in rehabilitation work
Canadian study estimated the cost to be $3.9 billion in      with patients to speed up recovery, prevent relapse,
1991, slightly over half of which was for long-term          and help with the adjustments necessary in the case of
institutional care (Ostbye & Crosse, 1994). A recent         chronic disability could be critical in the delivery of
study using 1994 Canadian data, found that the aver-         this service if the recommendation is adopted by the
age annual cost of care for an individual suffering          provinces (Canadian Mental Health Association,
from Alzheimer’s ranges from $9,451 for a mild case,         2001). Services that improve the quality of care while
$25,724 for a moderate case, and $36,794 for the             saving the public system money will be the most
severe type (Hux, O’Brien, Iskedjian, Goeree,                immediate impetus for change.
Gagnon, & Gauthier, 1998). Another Canadian study                In the case of palliative home care, end-of-life
found that delirium was associated with 51% of older         patients and their loved ones may benefit from psy-
patients who had been admitted to hospital, and that         chological counseling. This is often the time when
patients suffering from both delirium and dementia           unresolved issues come to the fore and may cause
were at much higher risk of being moved into expen-          more suffering if not addressed constructively. More
sive long-term institutional care (McCusker, Cole,           importantly, as in the case of mental disorders, the
Dendukur, Belzile, & Primeau, 2001) than older               emotional toll on palliative caregivers is often enor-
patients suffering neither condition.                        mous, in many cases heavier than that faced by a
   At present, this age group, and those that support        dying patient. As Grunfeld, Glossop, McDowell, and
their care in the home, do not receive the public ser-       Danbrook (1997) point out, the percentage of care-
vices they require (Gatz, Karel, & Wolkenstein, 1991).       givers suffering anxiety and depression is often
For years now, brain disorders of the type described         greater than the percentage of terminally ill patients
above account for more admissions and hospital inpa-         suffering the same difficulties. Thus, for palliative
tient days for older individuals than any other condi-       home care to be a viable option in the future, the psy-
tion in advanced industrial countries (Christie, 1982).      chological burden of caregivers must be addressed.
Although only a small percentage of people under the         Given their education and experience, clinical psy-
age of 60 suffer from dementia, approximately 30% of         chologists may be in the best position to provide this
individuals over 80 years of age do (Heston & White,         type of support.
1991). This is a concern given the ever-growing per-             For some patients dying from cancer or other dis-
centage of the population exceeding that age. We can         eases, pain management is a major concern.
prepare for Canada’s graying population by ensuring          Although drug therapy assists greatly in alleviating
290 Romanow and Marchildon

pain, patients might also benefit from some evidence-         care team provides a range of broadly defined treat-
based psychological therapies aimed at managing               ments as well as disease prevention and health educa-
chronic pain. These may also prove to be cost effec-          tion services. As the first point of contact with the
tive. Jacobs (1987, 1988), for example, found that            health system, such services would ideally be available
treatment of chronic pain conditions produced a sav-          24 hours a day, 7 days a week, with the expertise and
ing of $5 for every dollar invested in psychological          co-ordinating capacity to refer individuals quickly and
treatment. Here again, psychologists have researched          effectively for acute and other care when necessary.
the impact of chronic pain and have pioneered some            As the first line of contact, primary care units, rather
of the most important treatment methodologies to              than acute care hospitals, should be the central focus
cope with such pain.                                          of the health care system (Mikail, McGrath, & Service,
   Home care is an important illustration of how to           2000).
build on the existing medicare model while redefin-              As Hutchison, Abelson, and Lavis (2001) note,
ing public health care beyond hospitals and primary           however, this is easier said than done in a public
care physicians. By targeting public resources towards        health care system that was historically built upon
three very specific aspects of home care – mental             publicly insuring an existing pattern of physician-cen-
health, post-acute health care, and palliative care –         tred primary care. As the current primary health
the result can be a catalyst for even more profound           gatekeepers to the public system, physicians currently
and long-term change in the future. In other words,           deal with a host of psychological conditions.
this change is a financially and politically feasible first   According to one estimate, 60% of the “conditions
step that is built upon a public consensus. What              presented to primary care physicians are psychologi-
remains missing, however, is for such change to be            cal, have a psychological component,” or are “highly
“locked-in.” The CFHCC recommended that the                   influenced” by psychological factors. In addition,
Canada Health Act be amended to include these partic-         although about 40% of high-end primary care users
ular home care services so that they become perma-            suffer from some form of depression, well over one-
nently protected under the principles and conditions          half of these individuals receive no treatment for their
of the Act (Canada, 2002b). If the federal govern-            condition (Ontario Psychological Association, 2001).
ment takes this step, medicare will forever have to be        Stress and other conditions that substantially increase
defined beyond hospitals and primary care physicians.         medical costs often go untreated (Saskatchewan
Until then, any progress on the home care front is            Psychological Association, 2001). This focus on physi-
more easily reversed. In this sense, the CFHCC judged         cian care in the Canadian model reduces quality for
that the risk of opening the CHA was less than the            patients and may be costly for provincial health plans.
opportunity of using the legislation to reshape the              Aside from the Canadian system’s focus on hospital
Canadian model of medicare.                                   and physician care, other barriers to primary care
                                                              change include: increasing professional specialization
             Primary Health Care Reform                       and protection of turf; fragmented health care deliv-
   Changes in the organization and delivery of prima-         ery; marginalized health promotion activities and ill-
ry health care services are pivotal to the future sustain-    ness prevention services; limited patient empower-
ability and quality of the public system in Canada.           ment; and a lack of health information (Canada 2002,
The concept is simple. As a society, we should invest         p. 119). Consistent with recent provincial and federal
more in front-end health services aimed at reducing           reports (Alberta, 2001; Québec, 2000; National Forum
the demand for illness care services at the back end.         on Health, 1997; Saskatchewan, 2001; Senate, 2002),
As well as early detection of illness, these services         the CFHCC recommended a less fragmented approach
involve health promotion and disease prevention,              to primary health care. Given the vast and diverse
which, in turn, should include managing stress, anger,        nature of the country, as well as the very different
and chronic disease, improving parenting and caregiv-         needs, organizations, and providers available in differ-
er skills, and ending addictions such as smoking              ent communities, the CFHCC did not propose a single
(Ontario Psychological Association, 2001).                    model or approach as the final solution to achieving a
   Although there has long been agreement among               reformed primary care system. Instead, it proposed,
health policy experts on this proposition, most gov-          in order of priority, four essential building blocks that
ernment efforts over the last three decades to change         must be put in place for any given approach to suc-
the nature of primary delivery have had limited               ceed: 1) continuity and co-ordination of care; 2) early
impact. The purpose of most of the reforms was to             detection (including prevention) and action; 3) better
move from a physician-centred, fee-for-service, deliv-        information flow concerning needs and outcomes for
ery model to one in which a multidisciplinary health          both providers and patients; and 4) new and stronger
Psychological Services and the Future of Health Care in Canada 291

incentives so that providers are encouraged to provide      priate to the individual. In this sense, the current
more comprehensive and integrated care. These four          trend towards increasing professional specialization
building blocks were also accepted as the “key” to an       within psychology may actually work against the feasi-
“effective primary health care system” in the 2003 First    bility of providing primary care through such a
Ministers’ Accord on Health Care Renewal (Canadian          methodology. In addition, the tendency to jealously
Intergovernmental Conference Secretariat, 2003).            guard the “scope of practice” within any old (e.g., psy-
    The first building block would, as in home care,        chiatry) or new (e.g., clinical psychology) specializa-
likely require case managers to guide individuals           tion can be a formidable barrier to change. To create
through the health care system and co-ordinate their        the primary health care teams of the future, it will be
care services. Although a truncated version of this         essential to draw on the broadest possible range of
role is currently occupied by primary care physicians,      health-provider skills and knowledge.
one recent Health Transition Fund project in primary
care demonstrated that the case manager of the                 Prescription Drug Therapies and Future Options
future need not be a physician or nurse as long as             As in other OECD countries, prescription drug ther-
access to those providers can be assured (Durand,           apies have become a major part of the Canadian
Tourigny, Bonin, Paradis, Lemay, & Bergeron, 2001).         health care system. As is the case with home care, pre-
Whether some psychologists could ever work as case          scription drug therapy is not an insured health service
managers in a reconfigured primary care setting             under the CHA. Nonetheless, because of the growing
would depend on factors similar to those discussed          importance of drugs in medical treatment, every
above in relation to home care. This would certainly        province and territory has created its own drug plan
require knowledge and experience beyond a narrow            to provide public coverage for defined prescription
specialization. Unlike home care, however, remunera-        drugs to certain classes of individuals. For the most
tion for case managers should be less of an issue given     part, these plans supplement existing private insur-
that primary care physicians currently act as de facto      ance plans, which are primarily employer-based in
case managers in the current system, and most receive       Canada. As is the case with home care, provincial and
incomes that exceed those of the majority of practic-       territorial drug plans vary considerably by jurisdiction.
ing psychologists.                                             Scientific breakthroughs, combined with intensive
    The more plausible scenario is for psychologists to     research and development activities by pharmaceuti-
become full-fledged members of the multidisciplinary        cal companies, have produced a wealth of prescrip-
primary health care teams of the future. In this            tion and over-the-counter ( OTC ) drugs that now
regard, the Prime Minister and the Premiers have            accompany medical treatments, as well as substitute
committed their governments to provide all                  for older treatments and interventions, including
Canadians with access to 24-hour a day, 7 days a week,      surgery. Based on Québec data, the following six cate-
care from “multidisciplinary health care organizations      gories of pharmaceuticals now account for over 50%
or teams,” with one-half of their respective popula-        of total spending in provincial drug plans: lipid reduc-
tions to have access to this reconfigured type of prima-    tion, antihypertensives, antiinflammatories (anal-
ry health care within 8 years (Canadian Inter-              gesics), gastrointestinal, antiinfectives, and psy-
governmental Conference Secretariat, 2003, p. 3). In        chotropic (Québec, 2001).
this respect, psychologists already enjoy a comparative        These pharmaceutical categories are largely
advantage due to their “specific training in interper-      responsible for the surge in public and private drug
sonal, group and workgroup dynamics that help them          spending in Canada, the fastest growing sector of
work collaboratively with colleagues as team mem-           health expenditures for the last two decades. In 1980,
bers” (Canadian Psychological Association, 2001, p.         prescription drug expenditures represented 5.8% of
2).                                                         total (public and private) health expenditures in
    Going beyond the referral system, which lies at the     Canada. By 2001, this prescription drug share had
heart of the curative medical model, the future prima-      risen to 12% (Canadian Institute for Health
ry health care team will not only diagnose, treat, and      Information, 2001, 2002). Combined spending on
rehabilitate a given roster of patients, but will take      prescription and OTC drugs now surpasses total
proactive steps to prevent illness or disease, provide      spending on physician services in Canada. Inferring
public health services, and promote health through          again from Québec data, prescription drug costs have
education. Although team members gain entry into            grown by almost 60% from 1997 to 2000. By far, the
such teams by virtue of their specialized education         fastest growing pharmaceuticals are psychotropic
and training, they work as general health care practi-      drugs, which grew by an astounding 115.4% during
tioners providing the advice and services most appro-       the same period (Québec, 2001).
292 Romanow and Marchildon

    Many would argue that such rates of growth are          physical illnesses and disabilities (Canadian
unsustainable for the provincial drug plans that have       Psychological Association, 2001).
been underwriting 44% of total prescription drug               The profession of psychology seems to be divided
costs based on a national average of 1999 data              on a related issue. Some would like to see clinical psy-
(Canadian Institute for Health Information, 2002).          chologists receive prescription privileges in Canada.
They may also be unsustainable in the long run for          They point to the efforts in certain American territo-
private insurance plans, which cover approximately          ries and states that have resulted in some psychologists
34% of total prescription drug outlays, as well as for      being permitted to write prescriptions for their
individual Canadians, who pay out-of-pocket for 22%         patients or clients. Others oppose the idea of the pro-
of these drugs. Concerns have also been raised about        fession having prescription privileges, emphasizing
inaccurate prescribing and inappropriate utilization        the efficacy of drugless treatment modalities (Dozois
behaviours that are detrimental to the health of            & Dobson, 1995). Given the cost pressure of current
Canadians.                                                  drug plans, however, it is almost inconceivable that
    The more fundamental question is whether the            any provincial government would allow another pro-
existing health care system is, as a general rule, overly   fession to write prescriptions for fear that this would
weighted toward drug therapies as opposed to drug-          drive up consumption and costs. The stronger argu-
less alternatives. There is some evidence to support        ment in an environment of scarce resources is that the
the proposition that some nondrug psychological             drugless therapies provided by psychologists are both
therapies may be just as effective as drug therapies. In    less costly and more effective than the prescription
one study of severely depressed outpatients, nondrug        drug alternatives. Research in this area should take
cognitive behaviour therapy (CBT) was directly com-         on greater importance. As a society, we allocate enor-
pared to antidepressant medication, the most com-           mous resources to pharmaceutical research, mainly
mon therapy recommended by psychiatrists. The out-          through the private sector. This could be offset by a
comes associated with the use of CBT for very severely      combination of increasing public and private funding
depressed individuals were as positive as antidepres-       for research into drugless therapies. Moreover, this
sant drug therapy (DeRubeis, Gelfard, Tang, &               research must include cost effectiveness as well as clin-
Simons, 1999). This points out the need for more            ical effectiveness.
research in light of the fact that Canada may be on an
unsustainable prescription drug trajectory if current                Rural, Remote, and Aboriginal Health
prescription and utilization patterns persist. In terms                         and Health Care
of cost, virtually every provincial drug plan is under          The CFHCC also proposed major change in terms
immense strain due to growing demand and the rapid          of rural, remote, and Aboriginal populations that
introduction of new and costly prescription drugs.          could have some bearing on the future deployment of
Some provinces have responded by reducing public            psychological services. Canada has an immense geog-
coverage. In terms of patient safety and health quality     raphy with a rural and remote population dispersion
outcomes, serious concerns have been raised about           that is more extreme than any OECD country by a con-
the knowledge base of some primary care physicians          siderable margin. Not only is it expensive and diffi-
as well as the medical profession’s overall emphasis on     cult to provide health and health care services within
drug treatment versus drugless alternatives.                reach of these populations, but many types of health
Psychological services may provide one part of the          providers are in chronic short supply. In addition, the
solution to the future sustainability of prescription       needs of Canada’s rural and remote populations are
drug plans – both public and employment-based plans         greater than their urban counterparts. Both physical
– as well as providing treatment modalities that actual-    illness and mental disorders are more prevalent in the
ly improve patient safety and health outcomes.              rural, remote, and northern parts of Canada, an
    At a minimum, patients should be made aware of          unsurprising result given the high correlation
alternative treatments in such cases. These will gener-     between the two (McIlwraith & Dyck, 2002).
ally come down to three options: first, drug therapy            Despite the prevalence of mental health problems
alone; second, psychological (including cognitive           in rural and remote regions, there are very few psychi-
behaviour therapy and other psychotherapies) treat-         atrists practicing outside urban areas. Of the 3,600
ment combined with drug therapy; and third, psycho-         psychiatrists in Canada, for example, not one resides
logical treatment alone. There is supporting evidence       in the Yukon, according to the Canadian Mental
concerning the effectiveness of psychological treat-        Health Association (2001). Drawing from a larger
ment for anxiety, depression, panic disorder, anger,        pool of psychologists to provide mental health services
and stress, as well as for coping with cancer and major     in rural and remote communities could potentially
Psychological Services and the Future of Health Care in Canada 293

address the chronic shortage of psychiatrists.               tion, often by location (e.g., hospital) or the profes-
However, psychologists are also concentrated in urban        sion delivering the services (e.g., primary-care physi-
areas, generally in close proximity to university and        cians). Reconstructing health care for the 21st centu-
health-related research infrastructures. As is the case      ry requires moving away from this simple categoriza-
with all health provider professions, the ability to         tion approach to a more complex assessment of alter-
attract individuals who have grown up in such rural          native treatments based upon proven evidence of
and remote communities into the psychological pro-           quality and cost outcomes, the ground work for which
fession may be the determinative factor. One example         has now begun (McEwan & Goldner, 2001).
of such a successful program for recruitment and                One potential area to begin with is for one or more
retention is provided by the Rural Psychology and            jurisdictions to experiment with limiting public fund-
Post-Doctoral Residency Program at the Health                ing to empirically supported treatments. For psychol-
Science Centre in Winnipeg (Saskatchewan                     ogists to be “in the running,” as Hunsley, Dobson,
Psychological Association, 2001).                            Johnston, and Mikail (1999) point out, this would
   Sixty-five per cent of aboriginal people live in areas    require psychologists to develop treatment lists and
defined as rural by Statistics Canada. More signifi-         practice guidelines for a host of mental health ser-
cantly, the rate of suicide among Aboriginal peoples is      vices. Without doubt, there are public health care ser-
eight times the national average (Canada, 1994).             vices offered by psychologists that are substitutes for
Clearly, there is a need for services that could be pro-     the services offered by other professions. But there
vided by psychologists with some broader cultural            are many more unique services offered by psycholo-
understanding and sensitivity. More importantly, this        gists, some of which can play a critical role in improv-
should indicate the need for psychologists of                ing the quality of the system and ensuring its sustain-
Aboriginal ancestry and the great opportunity to be          ability into the future.
obtained by university psychology departments to
attract Aboriginal students in a very proactive way.            Correspondence concerning this manuscript should be
Funding here should not be an issue given ongoing            addressed to Gregory P. Marchildon, Faculty of Admi-
federal funding that is available to universities, col-      nistration, University of Regina, Regina, Saskatchewan,
leges, and other organizations that establish programs       Canada S4S 0A2 (E-mail:
and processes to increase the participation of
Aboriginal students in courses leading to professional
health careers (Canada, 2002b).
   In the CFHCC consultations, many Aboriginal peo-          Résumé
ple expressed their belief in a more traditional, spiri-     Les répercussions découlant des recommandations issues
tually based and holistic approach to health and             de la Commission sur l'avenir des soins de santé au
health care. The approaches suggested – from heal-           Canada (CASSC) vont bien au-delà de la portée, par
ing circles to the use of native herbal therapies – are      nécessité limitée, du rapport qui en a émané. Le présent
worth careful examination by psychologists. Through          article explore le rôle possible que pourraient jouer les
such research, many non-Aboriginal Canadians might           psychologues dans un système de soins de santé public
benefit from this Aboriginal knowledge.                      restructuré, qui déborderait les soins hospitaliers et médi-
                                                             caux pour gagner les soins à domicile et un système de
                      Conclusion                             soins primaires remanié. Les régimes publics de soins de
   The future sustainability of public health care in        santé pourraient également bénéficier du recours aux
Canada depends on the effective marshalling and allo-        approches psychologiques comme solutions de rechange à
cation of scarce public resources. Costs must be man-        la pharmacothérapie. Un tel élargissement du modèle
aged while constantly working to improve outcomes in         canadien existant, fondé sur l’expérience clinique, pour-
both population health and health care. To avoid a           rait améliorer à la fois les résultats cliniques et les résultats
fate similar to many managed care organizations in           médicaux. Ces résultats pourraient à leur tour permettre
the United States, it is not enough to simply contain        aux régimes de soins médicaux provinciaux, qui sont
costs without regard to outcomes. Instead, provincial        soumis à des pressions financières énormes, de réaliser de
health plans should be focused “cost-efficient inter-        nouvelles économies.
ventions with demonstrable outcomes” (Hunsley,
Dobson, Johnston, & Mikail, 1999). Certain psycho-                                    References
logical services meet this criterion but the decisions       Alberta (2001). A framework for reform. Report of the premier’s
concerning public coverage, and the priorities within           advisory council on health. Edmonton, AB: Premier’s
public coverage, remain based on service categoriza-            Advisory Council on Health
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