Winter 1998 - Regional Report: Report from Canada

xxAACP Newsletter, Volume 12, Number 1, Winter 1998

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Regional Report: Report from Canada

Canada's national system of government financed health insurance is called Medicare, the principles of which are: universality, comprehensiveness, portability (between all parts of the country), public administration and accessibility. These principles were enacted in Federal Legislation in 1957. The roots of Medicare are embedded in much history, including the devastating effect on many Canadians of the Depression years and World War II. In 1966, the Medical Care Act guaranteed 50:50 Federal-Provincial sharing of all "medically necessary" physicians services - in the community or in hospital, as long as the terms of Medicare were met. Such cost sharing contributed to rising health care costs and in 1977 the Federal Government replaced this strategy with more predictable "block" transfer payments based on GNP and population growth. However, since 1986 these Federal transfers have been progressively decreasing in proportionate size to the provincial share of funding. As a result, provincial governments have attempted to control rising costs in the health sector through efforts which at times seem perilously close to destroying the principles of Medicare. What is politely called "the free market approach" appeals to some, but polls of ordinary Canadians consistently show that Medicare is sacrosanct - for now. Whether this reflects a determination to protect principles, or a fear of a slippery ride to a multi-tiered system is less clear. For not though, it seems that politicians in government and in professional associations still have the tendency to heed what their constituents are saying.

Nonetheless, a lot is changing, and we aren't immune in Canada to giving difficult issues nice and efficient sounding names such as "health care restructuring". These are variations on the theme in different provinces, but hospital closures and mergers, reductions in hospital beds and budgets, pressure to reduce length of stay and slow decreases in specialty training positions are familiar notes. All of this ostensibly to shift more resources to community based care, but such shifts in funding seem not to be occurring as rapidly as are cuts at one level and the increases in responsiblity for care at community level.

Family doctors have always had a pivotal role in the Canadian health care system. Now, they are doing more and can expect their clinical and managerial responsibilities to grow. Shared mental health care is a concept of community consultation between the family doctor and psychiatrist. The interesting and significant thing about this is that the collaboration between family physicians and psychiatrists implied in "shared mental health care" has been extended to a formal collaboration between the College of Family Physicians of Canada (CFPC) and the Canadian Psychiatric Association (CPA). This has a number of important implications of which I can identify three principle ones now: an acknowledged value to and reason for a greater degree of individual and group commitment to making the ideas of "shared care" work; in continuing medical education for practicing family physicians and psychiatrists and; in training objectives and approaches for medical students and residents.

The formalization of the concept of "shared care" comes fron a decision, several years ago, of the College of Family Physicians of Canada (CFPC) and the Canadian Psychiatric Association (CPA) to set up a joint working group. The group was asked to prepare a report on the advantages of greater collaboration between family physicians and psychiatrists and to describe a range of startegies which could contribute to collaborative mental health care. The position paper they drafted was approved by the Canadian Psychiatric Association and the College of Family Physicians of Canada Boards of Directors in 1996.

The Working Group's report limits its comments to shared care betwen psychiatrists and family physicians, while acknowledging that many of the issues it raises are likely to apply to all mental health and primary care providers. The Working Group solicited input from psychiatrists and family physicians, their professional associations and departmetns of family medicine and psychiatry across Canada. It also drew on planning documents already prepared by provincial and national organizations and built on different models of collaboartion already being used in various parts of the country.

The Report outlines three broad strategies for collaborative work in mental health care: 1) improving communication; 2) building new linkages between family physicians and psychiatrist and psychiatric services; and 3) integrating psychiatrists and psychiatric services within primary care settings. It notes that such strategies can be adapted to any community, especially more isolated, underserved communities. The concept of shared mental health care is not an alternate style of practice but rather a component of care that can become an extension of the current clinical practices of the family physician and psychiatrist and thereby broadening and enriching the care that each offers. Clearly, the audience fo this report is frontline practitioners and policy makers and planners. To quote the Report, this is "a concept whose time has arrived".

Sharon Levine, MD

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