This is the first instalment in a three-part series examining the state of mental-health care in Ontario. Watch for Part 2 on Wednesday.
There is a time that comes without fail at some point in the process of drafting every article I’ve ever written. It’s when I realize that there is really great stuff I should have mentioned but that I don’t think I have enough words left to squeeze in. This kicks off a period of frantic indecision. Should I go back and cut out stuff to make room? Should I leave out the good stuff entirely and circle back to it on a later date? Should I at least mention the good thing so that I don’t look like an idiot who forgot a key part of the story?
I’m not sure there’s a perfect answer to this. You do your best every time given the circumstances. Readers of mine here at TVO.org were witness to this dilemma several months ago without realizing it. I had written a three-part series about capacity issues in our health-care system — specifically, about how our difficulty in putting patients in appropriate beds due to overcrowding causes a ripple effect of delays throughout the entire system. When a patient is ready to leave the emergency room and spend a few days recovering in a hospital bed, for instance, they often find themselves languishing in that emergency room, and creating delays there, because no bed is available. Once they finally get that bed and improve, instead of moving swiftly to a rehabilitation hospital, they face another delay because the rehab ward is full. The rehab beds are full because patients awaiting transfer to a long-term-care facility are stuck until beds become available there. And so on and so forth. Our entire health-care system operates either at or slightly beyond capacity. It is a logistical nightmare.
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That was the story I told back in August. As I worked on it, I was painfully aware that there was a big part of this story that I had not touched at all. In that case, I decided to semi-apologetically mention it, so that the reader would at least understand that the issue existed. I promised myself I’d return to this important part of the topic later. It took me a bit longer than I expected, but here we are: the start of a three-part series examining the status of mental-health care in the province of Ontario.
The plan to write these essays got a firm kick in the rear after a friend of mine mentioned that she would soon be losing access to the therapist she has been seeing for some time. The problem for my friend is simple. Her therapy sessions are fully covered by the province, but her psychiatrist recently retired. Her physician immediately put in a referral for a new one, but there is a long backlog for care in her part of the province, a medium-size city in southern Ontario. Her doctor currently estimates that she may be without provincially funded therapy for approximately 12 months. During this time, she can either go without, relying on her friends and family to act as her support network, or she can dig into her own pocket and look into private options, which theoretically may be partially covered by workplace insurance plans.
My friend’s story was not originally going to fit within the scope of this project. My earlier intention, dating back to my August articles on overcrowding in the hospitals, was to focus specifically on that issue. Every day, approximately 2,300 Ontarians are occupying a hospital bed even though they would be better treated in a different bed or at a different facility. This is known as “alternate level of care,” or ALC. Approximately half of the ALC patients in Ontario are awaiting transfer to a long-term-care home. But a sizable group of patients caught up in this gridlock are awaiting transfer from primary-care hospitals to so-called assisted-living centres, which are for patients who are not primarily suffering from a physical ailment but are living with either a mental-health issue or an addiction or, in some instances, both.
To be clear, some of these individuals may also require medical care, either for acute problems or chronic conditions; these issues may occasionally require hospitalization. In this way, such individuals are the same as any Ontarian. But they are living, for short or long periods, in medical facilities simply because they are not capable of living independently, and there is nowhere appropriate to send them. Eventually, a bed will become available, and they will transfer into it. In the meantime, they wait in a facility that is not optimized for their needs, delaying their own recovery and contributing to the delays elsewhere in the health-care system. The next time you show up at an emergency room for a busted bone or a nasty cut and find yourself sitting there half a day later, the explanation for the problem could well be the lack of appropriate mental-health-care resources hundreds of kilometres away from the emergency room you’re waiting inside.
This is a small contributor to the overall problem of overcrowded hospitals: approximately 9 per cent of ALC patients are awaiting transfer to assisted living — a daily average of perhaps some 200 souls. But that metric, though useful, understates the problem. The ALC figures capture those Ontarians most in need of specialized in-patient care, but not the scale of the broader mental-health-care challenges faced by Ontarians. For every Ontarian waiting for a bed in assisted living, there are literally 10,000 like my friend just trying to get the out-patient therapy they need to live the best life they can.
A 2015 report by Health Quality Ontario reported that 2 million Ontarians live with some degree of mental-health challenge or addiction. Many of these challenges are moderate and temporary, or only intermittent. But some are severe and enduring, even constant. Family physicians are often the first point of contact with the mental-health-care system. Individuals with the means to seek private therapy can typically access it (but not always — more on that to come). Workplace insurance programs can also cover some or all of the costs of therapy and whatever medications, if any, may be deemed helpful. But a third of Ontarians went without care.
The reasons, and definitions, are complicated, and need to be stated carefully. The figures come from a 2012 Statistics Canada report, which found that, of the 2 million Ontarians who needed mental-health care, 700,000 did not access it or had their need only partially met. The first thing to note is that those 2 million Ontarians had self-identified as needing mental-health care; they did not necessarily have a diagnosis of any mental-health-care challenge or addiction. Further, of the 700,000 who felt they needed care and did not receive it, some did not seek care at all, due to personal circumstances, including those related to the stigma that surrounds all issues relating to mental-health-care and addiction. StatsCan data suggests that that could in fact be the majority of cases — of those Canadians who sought care and did not receive it, problems with the system itself were generally cited only approximately 20 per cent of the time.
But many Ontarians did seek care and didn’t receive it, or at least not enough of it. Thousands of Ontarians either could not access or could not afford mental-health care. Many thousands of these people, in a crisis, end up in our hospital emergency rooms. Most of them will be discharged without admission and will then experience major problems receiving follow-up care outside the hospital. Some will be admitted to hospital and then find themselves stuck in the same backlogged system as every other Ontarian.
How can we do better? How can we keep those people from going to the hospital in the first place or ensure that, once they’ve been to an emergency room, they don’t need to return, as thousands do? That must start with effective, and accessible, mental-health care in communities — and that’s where we’ll pick up in Part 2.