THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, sCIENCE AND tECHNOLOGY
OTTAWA, Friday, September 22, 2006
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 10 a.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
We have talked many times in this committee about the importance in public policy of defining the terms of the debate. One of the unresolved issues in their report was how to quantify the term "undue financial hardship." Colleagues will get a chuckle out of that because this committee's report said that the whole purpose of a catastrophic drug plan should be to figure out how to avoid individuals suffering undue financial hardship as a result of having to pay drug costs. That is the last piece of the report that continues.
This meeting is an exercise in picking the collective brains of the people around the table. The committee's proposal for a Canadian mental health commission would have three specific areas of work, one of which was a national anti-stigma campaign. Mr. Phil Upshall is running a two-day conference in October in Ottawa on such a campaign. The second area proposed was a knowledge exchange centre. We thought it would be useful to have this discussion today so that we can prepare a background paper for the incoming commission, assuming it will be created, and we will prepare one for the stigma issues as well after Mr. Upshall's conference. We do not know whether the commission will be created but all the provinces and territories are still on side. It is an issue of the federal government making that decision as part of the budget process, and I am optimistic.
When the commission is formed, I thought it would be useful and effective for commission members to have at the outset a background report on what some thoughtful people would do in respect of an anti-stigma campaign and a knowledge exchange centre.
Therefore, the purpose of this committee is to prepare a paper for the proposed commission on recommendations for the building of a national knowledge exchange centre that would cover the entire field of mental health. Today, the purpose is to glean as much information as possible for that purpose. I would ask everyone to introduce themselves, please.
Senator Keon: I am Senator Wilbert Keon, deputy chairman of the committee.
Ross Hetherington, Director, About Kids Health, Hospital for Sick Children: I am Ross Hetherington.
Bonnie Pape, As an individual: I am Bonnie Pape, formerly with the National Office of the Canadian Mental Health Association. I am still affiliated with them as a special adviser, but I am here today as an individual.
Ray Block, CEO, Alberta Mental Health Board: I am Ray Block.
Senator Cordy: I am Jane Cordy, a senator from Nova Scotia. I have been on this committee since we started studying health care.
Dr. Alain Lesage, Past President, The Canadian Academy of Psychiatric Epidemiology: I am Alain Lesage. I represent the Canadian Academy of Psychiatric Epidemiology. I am also a professor in the Department of Psychiatry at the University of Montreal and am affiliated with the research centre at Fernand-Séguin in the east end of Montreal.
Barbara Beckett, Associate Director, Canadian Institutes of Health Research: I am Barbara Beckett, from the Institute of Neurosciences, Mental Health and Addiction, at the Canadian Institutes of Health Research.
Irving Gold, Director of Knowledge Transfer & Exchange, Canadian Health Services - Research Foundation: I am Irving Gold.
Paula Goering, Director, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health: I am Paula Goering, director of a research unit at the Centre for Addiction and Mental Health. I also hold a chair, funded by CHSRF and CIHR, that focuses on knowledge translation.
Phil Upshall, National Executive Director, Canadian Alliance on Mental Illness and Mental Health: I am Phil Upshall. The Canadian Alliance on Mental Illness and Mental Health is the largest mental health coalition in Canada at the national level. We are proud to be here today. I am also Executive Director of the Mood Disorders Society of Canada, which is hosting the National Stigma Research Project in Ottawa from October 2 to 4, 2006, and I would invite everyone to take a look at the material on their website. It is very good.
Constance McKnight, National Executive Director, National Network for Mental Health: I am Constance McKnight, I am also here today representing the Canadian Coalition of Alternative Mental Health Resources. We are all consumer driven.
Dan Reist, University of Victoria: I am Dan Reist. I direct the Communication and Resource Unit for knowledge exchange activities at the Centre for Addictions Research of B.C. at the University of Victoria.
Karren Kidder, The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO: I am Karren Kidder. I am the manager of knowledge exchange at the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO.
Dr. Ian Manion, Psychologist, The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO: I am Ian Manion. I am the Executive Director of operations for the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO. I am also a researcher at the University of Ottawa and at the research institute for the children's hospital.
Senator Di Nino: Good morning. My name is Consiglio Di Nino. I apologize for my throat problem this morning. I am not a member of this committee regularly. I am here out of interest and pinch hitting for a colleague, but I wanted to give my colleagues on this committee a little plug publicly.
This is a critical issue for our country, and this committee has probably one of the best reports that has been produced by the Senate in a long time. To the regular members of the committee, I would like to add my applause and congratulations.
Patrick Smith, B.C. Mental Health & Addiction Services - Centre for Research & Knowledge Exchange: I am Patrick Smith from the B.C. Mental Health & Addiction Services, Provincial Health Services Authority in British Columbia, and head of addictions psychiatry at UBC.
Peter Coleridge, B.C. Mental Health & Addiction Services - Centre for Research & Knowledge Exchange: I am Peter Coleridge and I work in the same place as Mr. Smith. I am also special adviser to the Global Business and Economic Roundtable on Addiction and Mental Health. Certainly, workplaces are a primary place for knowledge exchange. I am also a founding member of the Canadian Executive Council on Addictions.
The Chairman: I would like to go around the table in the reverse direction this time. I would like each person to tell us the advice you would give to a group of people at the Mental Health Commission who were charged with building a knowledge exchange centre. What are the three or four things that would be the most important for them to do? I asked some of you to bring written material to make it a little easier for us and if you have those notes, you can give them to our chief researcher or our clerk afterward.
Mr. Coleridge: This is something that both Mr. Smith and I worked on together, so I will touch on some of this and then turn it over to him.
Our advice would be that in thinking about knowledge exchange, we need to look at three categories of change: first, changing practice among professionals; second, influencing policy in terms of policy decision makers; and third, the public and all the many subpopulations and multicultural communities, as well as clients and families who want to access and go through services.
Those would be the three categories for knowledge exchange; and in each of those, it is important to look at a comprehensive strategy for how you would change practice, influence policy and attitudes and behaviours among the public.
There has been a tendency to do these one-shot deals of a campaign for the public or a conference for health professionals or a paper for policy-makers. We know that those things — one shot in isolation from a variety of other strategies — will not change practice, policy or attitudes and behaviour. We come at this from a comprehensive, longer term process. We also feel it is important to understand the context for change. I will stop there and turn it over to Mr. Smith.
Mr. Smith: In moving through our collective understanding of knowledge exchange and translation, we look at the history where researchers publish their information in journals. We hope that someone would have read it and changed their practice and attitudes accordingly. We have moved from that to a better practice of compiling the information in ways that can be more accessible to various populations.
Mostly what we see and hear is frustration that those best practice guidelines, all that information is uncoordinated but it also is not making a change. Even when it is available and people are aware of the information, it does not translate to meaningful change in attitudes or behaviours.
At the B.C. Centre for Research and Knowledge Exchange, this is our day job. As the Provincial Health Services Authority of B.C., we are charged with looking at ways to support the five regional health authorities and to support change in mental health practices, change in attitudes across the province and how to support those changes. We are taking a changed management perspective, looking at targeted attitudes or behaviours that need to be changed based on research findings, and looking at a comprehensive system change model. That is our recommendation for a national framework.
The other recommendation, which we have touched on in B.C. when Senator Kirby came to visit, is that it would make the most sense to have a community of practice, a network, so that the national knowledge exchange centre is a virtual centre that builds on regional nodes of expertise to maintain the standards and on-the-ground activity in each of the regions and provinces. In this way, we can really have active support for meaningful change in practice and attitudes in the three areas that were mentioned.
Dr. Manion: In our centre, we are involved in funding and undertaking research, educational training and forming partnerships and networks. We realized early on that knowledge exchange touched everything we do — not as an add-on but as a critical component of everything we do. When you are forming a partnership, you are establishing the readiness for change for that information to have a proper uptake. By forming relationships with others, you are also promoting knowledge exchange.
I will let Ms. Kidder talk about the details. Probably one-third of our personnel is engaged in knowledge exchange at our centre; it has been resourced to the hilt. The importance of having processes in place is ongoing and incorporated into everything we do. Assuming others already know how to do knowledge exchange is bit of a misleading idea. To assume that scientists who are creating knowledge know how to mobilize it is not necessarily right. To assume that service providers who need to use the knowledge know how to understand it, where the researchers are, again, is not something you can assume. We are throwing many of the assumptions out and talking to all the different kinds of stakeholders so they can have a proper appreciation of what their active role is in knowledge exchange — not just as a recipient but also as a producer of knowledge.
The other recommendation concerns the work we do with children and youth. We have to be careful not to assume that knowledge exchange with children and youth, and the stakeholders involved in child and youth mental health, will be identical across the age span. There are some similarities, but some of the issues are very different. One, for example, is looking at youth themselves as recipients of information and as agents for the exchange of information.
Ms. Kidder: It is difficult following Mr. Manion. He knows so much about knowledge exchange that he always steals some of my planned comments. I will try not to repeat anything he has said. The comments of Mr. Smith and Mr. Coleridge are very much in line with what the centre is doing. I will not repeat their words either.
I would like to emphasize the important relationship between critically assessing the evidence and the knowledge exchange activities that you develop. One of the lessons that we learned when we started the centre was that you could not jump directly into mobilization. We wanted to; I was all geared up to get the information out there, but we had to pull back. We had to ask what do we know is the most credible information? What do we know for sure is at least credible information before we began that mobilization process?
Now we are balancing those two. One is the process for critical assessment where we do systematic reviews of the literature to identify the most credible interventions and information on conditions. The other is the study of critical practice guidelines where we decide, amongst all these diverse recommendations, which ones we can tell people to do, with confidence — all the challenges and all the costs in relation to change and practice — because we know these recommendations will make a difference for children.
At the same time, we are trying to take a scientific approach to knowledge exchange as well. What actually works in knowledge exchange? I want to applaud the idea of having a knowledge exchange centre as separate and discreet from other activities because this idea needs individual attention. We need to look at it with the same kind of scrutiny that we look at other kinds of research. Do we know, for example, that putting information on our website will lead to any kind of practice change? Let us apply that same rigor to the knowledge exchange activities we use.
We have that scrutiny going on and the assessment of the evidence, but at the same time, because the need is so great, we are saying that you cannot wait. You cannot wait for these two processes so you need preliminary steps to get started. We are moving on issues around stigma, for example, because we have confidence, based on a systematic review that we have completed, that we can make legitimate contributions around that; some ways to create change to be positive for children and youth. I suggest that you seriously look at balancing those three different things.
Mr. Reist: I want to echo what I have heard already; they are the kinds of things we recommend. I would add, and maybe emphasize, two pieces to the discussion. One is that we need to abandon the notion that knowledge is generated at one place and needs to be delivered to another. Knowledge is generated at many places and needs to be exchanged between those places. Knowledge does not flow in academic-based research to communities; it flows back and forth. We need a way to honour and capture that knowledge that is developed in the community, and exchange that knowledge with the other players within the system as well. We need to emphasize a multidimensional, multidirectional flow of information.
Second, there is a danger in trying to build huge infrastructures that are natural processes in community. Communities have mechanisms to move information around and we need to learn from that and how we can enhance those mechanisms relative to the issues we are trying to address, as opposed to creating something foreign. The whole theory around communities of practice is an interesting one and offers ways of moving forward in a sustainable way, but I think we need to look at what is pragmatic, what is sustainable and what are natural ways as opposed to something that is foreign.
Ms. McKnight: This is timely. Last week we had consumer leaders from across the country come together and talk specifically about this.
We have a number of recommendations. Instead thinking from institution to institution — of course we do not think that way because we are grassroots — we understood that the knowledge exchange centre would likely be housed in a institution; that is fine. We wholeheartedly support everything the Senate has recommended. We have always worked well with institutions, but institutions have not always worked well with consumer organizations. That issue needs to be addressed at some point.
We also feel that consumers need to be hired as part of the team to develop the knowledge exchange centre, so that we can — I do not know what a politically appropriate word is — put it into basic layman language for folks. We feel it would be great to have the consumers there but they should not be researchers who call themselves consumers; they should be consumers interested in research.
Also, the website should be visual and interactive and have the capacity to attract all learning styles. It should be easy to navigate, dynamic and user friendly by including questions and answers in plain language. It should be tested and compatible at the lowest common access because a lot of our folks are marginalized already and do not have access to the best technology. Links should be made available to consumer-survivor sites, and a site map needs to be developed and accessible for all disabilities, not just for us. It must be multilingual, must mirror the multicultural makeup of Canada and it must be marketed and publicized.
We already have a website that is user friendly and has a number of research pieces on it. To push that website into something bigger would be great because the more information we can get out there, the better. We need to look at the model of the Substance Abuse and Mental Health Services Administration, SAMHSA, in the States. I do not know if anyone is familiar with that, but it would be something to think about.
The Chairman: Is that site run by the U.S. Department of Health and Social Services, HHS, the addiction and mental health branch?
Ms. McKnight: Yes: we feel that model would be something to look at as a guide.
Mr. Upshall: It is a treat to be here with this august group. Having heard everything that has been said so far, there is not much more to say, but I will anyway.
To get back to reality, you have to look at the vision for the knowledge exchange centre. It is nice to talk about the concepts, but what do you want? I assume you want a consumer centre, consumer-focused in the broadest sense, and an accessible and practically used website. There are myriad numbers of websites out there designed or oriented to consumers: consumers in research, consumers and family members. The websites are poorly developed, not well used and a waste of money. It would be useful to look at what works. Lots of people have wonderful websites and pat themselves on the back, but the reality is, there are not a whole lot of visits.
We had an activity called the Canadian Collaborative Mental Health Initiative, CCMHI, now over but the website is still active. There was tremendous activity, which we tracked in terms of downloads and visits. We also tracked satisfaction levels. That is something that you have to consider here. Are the users happy with the work? What is coming down? What kind of demands are they making? Then respond and satisfy that demand.
The Canadian Alliance of Mental Illness and Mental Health is concerned that the knowledge exchange centre reinvents the wheel. There are tons of databases out there and some are very good. Stats Canada, the Public Health Agency of Canada, PHAC, and others are valuable and need to be linked in an appropriate way. We talk about consumer friendliness: it has to be consumer friendly so it will satisfy the initial needs and continue to satisfy needs as it grows. You have to start somewhere and use the KISS principle; keep it simple at the start.
In terms of a gap analysis, it might be useful to determine what is not available at the moment and what should be done as of the first instance in terms of structuring it. A number of dialogues are going on now, as I am sure you know. Five dialogues are underway in the mental illness and surveillance activities of the Public Health Agency of Canada and private industry to access private databases. I think you should determine what is going on in the community and how to link in with those activities, particularly with the activities of the public health agencies and surveillance activities. Our sense again is that the KEC will only be effective if it has an effective voice at the management level of the commission.
The person who operates it should be a knowledgeable, senior person. There should be an advisory committee of some sort, made up not just of experts but also of consumer family people who understand and who can develop links with the community.
Our final point is that KEC should only develop information that fills gaps that are identified as the development of the database linkages continues. One of our initial points, if KEC is to be particularly useful in the new realities, is that it should cover all mental illnesses, brain and neurological disorders, and generally any subject having to do with the brain and its malfunction. In other words, the breadth of the data collected within that database is very important as we start to look at the brain as not just a collection of illnesses or functions.
The Chairman: Follow the CIHR model, which is an institute for mental illness and neurological sciences; in other words, cover both.
Mr. Upshall: You want to pick up the cancer, heart and stroke issues that relate to co-morbidity and concurrent disorders. Please, whatever you do, do not follow the CIHR model of website building. It is, without a doubt, the worst website; it does absolutely nothing for millions of dollars. Take a look at that. The other site you might want to look at is the Canadian Health Network. Millions of dollars have been spent on CHN. More people visit the mood disorders website than they do CHN, and that is not very good.
Ms. Goering: I am glad to be here and I am very excited about the idea of a national knowledge exchange network. I am worried, however, about the emphasis on the website. Knowledge is a lot more than information and it really requires the exchange component. We have to be careful not to set up another place where one can get information, another library function. If we do a mapping exercise and find out what is out there in terms of information, we will find that is not what is missing. What is missing is the opportunity to bring knowledge to action, and that could be what the exchange is about.
There is a lot of action that the commission has recommended. I think that whatever the knowledge exchange centre is doing should be very closely tied to what the commission wants to accomplish because it is a vehicle for addressing particular issues, and the content, the mechanisms and the audiences should be tied to whatever it is the commission wants to focus on.
To me, it is not a separate entity. It is very much an extension of knowledge and a way of achieving action. Knowledge oftentimes is in the people and in the exchanges. One can use websites for that. There are webinars, podcasts, chat rooms, and so on, but the emphasis is not on the information but on which communities are connected and for what purposes. It is a different way of thinking about what it is. Again, it makes me nervous to think that we might invest a lot in setting up something that will not necessarily help us bridge the gap between what we know and what we do, which you have heard so much about.
The Chairman: I agree with the notion that this would be an integral part of the commission. That is why the committee put it the way it is. That is fine. We in this committee know of many neat things that are happening with regard to helping people living with mental illness around this country. We are the only people who know it, because we are the only people who have travelled from one end of the country to the other, talking to various groups. We know there is a neat thing in St. John's Newfoundland and in Northern Manitoba. One of the things that we had hoped would come out of a knowledge exchange centre, however it is structured — and I agree with you that it is not and should not be just a website — is enabling policy-makers and service deliverers in other parts of the country to know what is working. A lesser example is how to get that information out to people. It is silly for someone to try to reinvent the wheel if there is good example going on in some part of the country.
Ms. Goering: You should start a conversation and an interaction; you do not just tell them that it is there.
The Chairman: That is correct.
Mr. Gold: You asked for three or four questions; I came up with six. I will be as brief as I can. My reflections are based on the dubious honour I have of having been involved in many failed attempts such as this. I come bearing some scars and my recommendations come from worst practice as opposed to best practice. However, I do believe that we do not spend enough time on worst practices, because replicating someone's error is more expensive and problematic than not necessarily coming up with the best practice.
First, I would echo Ms. Goering; knowledge mobilization is not the same as knowledge transfer and exchange. We need to be clear about what it is we are trying to achieve with this initiative. These words are all sexy right now, but we need to be clear about what we are trying to encourage and what we are trying to do. A lot of what I read about and hear about sounds like a platform for disseminating information. That is not the same as knowledge exchange. Dissemination can be one way, and there is nothing wrong with that and we ought not to apologize for doing that. However, if it is knowledge exchange that we want to accomplish, we need mechanisms built in at the outset that encourage exchange. That is complicated, particularly in this community. We are talking about a wide range of stakeholders with a wide range of scientific, experiential knowledge and understanding. There is a whole range of issues. That is different than creating the world's best dissemination platform for the topic, which is also a laudable goal, but we need to be clear. It is not just semantics, because those of us working in the community get confused by what people want to do when they use these labels differently. It sounds like it is splitting hairs, but it is not.
Second, there needs to be some discussion around what counts as evidence and what you would include in this, whatever it is. Those criteria need to be fairly explicit. I have been on so many of these steering committees for platforms like this, and credibility is the key. If communities do not see this as a credible entity, or thing, they will not use it, but they will only find it credible if they understand how decisions are made about what gets on this thing. That is a complicated issue that I have only seen addressed after a lot of money is spent, so I would urge you to have some of those discussions now. Will there be expert panels created in various areas to adjudicate? Who will make the decision? At CHSRF we have discussions about what links get put on our website, and it is a much smaller scope than what you are talking about. Make it not an afterthought.
Third, make it evidence-based. People in the knowledge community often say that we have no evidence about what works. It is actually not true. There are a lot of people doing research on knowledge exchange and transfer. There is evidence out there. People who say we do not have evidence are usually just not interested in finding it. I would urge you to make this an evidence-based endeavour.
Fourth, think about evaluation at the outset. We do too much in this country in the area of knowledge transfer and exchange without thinking about evaluation at the beginning. Sooner or later, this will catch up to us in a huge way and people will no longer be willing to spend money on this important activity. Let us think at the beginning about what we want to accomplish, about the baseline measures we will use and how will we prove, after a given amount of time, that this has made a difference in the community. I think it will make a difference, but if we do not think about it in advance, we miss the opportunity to come up with a solid evaluation framework.
Fifth, governance is critical. I will not belabour this point, but coming up with a governance structure for something of this nature is absolutely critical to the credibility and to the decision-making process.
The last point is sustainability. We often underestimate the cost of maintaining these things. Building them we cost out fairly well; however, we do not think about the fact that use actually becomes more expensive. The more successful we are, the more we need to continue to invest. I have seen the plug pulled on a lot of these just before they reach their full potential, so sustainability is critical.
Ms. Beckett: I am not an expert on knowledge translation, mobilization, exchange or dissemination, whatever label you choose to put to it. I want to bring to you some information about what the Institute of Neurosciences, Mental Health and Addiction is doing in this area and some general advice I received from our knowledge translation branch. Unfortunately, we were unable to have a direct representation here this morning.
Everything that people have said here today about knowledge exchange was echoed by our knowledge translation branch. In particular, careful thought needs to go into defining the purpose and the target audiences for the knowledge exchange centre. Our branch wants to ensure that the overall quality of the web content and design focused on key messages, focusing on push and user poll activities, which are very different. Special attention should go to assessing the barriers to access and use of the knowledge exchange centre information. The issue of evaluation, which Mr. Gold just mentioned, came up also, to ensure that evaluation is done at the beginning and that it is done on an ongoing and regular basis. Also, there are sustainability issues, as Mr. Gold just mentioned.
In terms of what the Institute of Neurosciences, Mental Health and Addiction has done and the approaches we have taken, our initiatives all involve an initial consultation phase. In this phase, we talk to stakeholders from wide varieties of backgrounds to determine what the questions should be and to try to assess the knowledge base on all fronts before we proceed with framing of questions that then go out for calls for research proposals.
Some of the areas that we have identified that relate to mental health involve stigma, and we are working closely with Mr. Upshall and the Canadian Alliance on Mental Illness and Mental Health in developing the workshop. We have every intention of following up at a later stage when the information has been consolidated and putting out a call for applications for research in this area.
Another area that we have identified is mental health in the workplace. We had a call that went out last year. We went through a letter of intent phase and received 15 full applications, which have just been evaluated, and we are going through the process of finalizing the outcome of that evaluation.
Another area that we put forward this spring was intervention-type research on knowledge translation in mental health. We do not have the applications for that yet but I believe we will have at least a handful of high quality applications. We look forward to the outcome of that research.
In all these initiatives, we have focused on partnership involvement from the very earliest stages of the research. We have a consultation phase, and a development of the RFA. We have a requirement that researchers work with partner organizations in order to ensure that the questions that are answered are relevant to the real world and that there will be a willingness to do something with the research once the information is available. There is also the credibility issue. We want to ensure that whatever research is put out there is not perceived just as ivory tower information, but that it has credibility within the user community as something of real value.
Dr. Lesage: It may be useful to bring to you some of our work in developing a proposal for a Canadian mental health services knowledge translation network.
You have the handout that I prepared before you. It is the proposal for a Canada mental health services knowledge translation network. With our colleagues, we were commissioned by the Institute of Neuroscience, Mental Health and Addiction and the Institute of Health Services and Policy Research of the Canadian Institutes of Health Research to develop this proposal to submit to the Senate committee. In doing so, we first looked at the challenge, that is, what we would like to achieve in terms of mental health and addictions services research. We indicated that we need a dedicated national resource to facilitate dissemination and foster utilization of knowledge. We need to synthesize objective, evidence-based information available across Canada and other jurisdictions and enhance access, sharing and utilization of a comprehensive knowledge base regarding mental health system improvements. We need to establish active working relationships, because networks are built on relations, between mental health services knowledge producers and users. Finally, we need expertise at facilitating on-the-ground translation of mental health services research into policy, practices, planning and management by providers, policy-makers and other decision-makers.
This network of mental health services research would be one aspect of a multi-pronged approach that is needed to ensure that knowledge is transferred and acted upon. There are three pillars to that. First is a national advocacy group — and we almost wrote that maybe the commission would be that national advocacy group, but it needs to be there as sort of a national intelligence. The second pillar is increasing internal capacity of governments at the federal, territorial, provincial and regional levels to be evidence-informed. The third pillar is a mental health services knowledge transfer and translation network for federal, territorial, provincial and regional planners, managers, decision-makers, service providers and consumer organizations.
The network we propose would be what we already heard here, the classic push research, how to use it, but with some activities like the translation of high-quality, relevant mental health services research or new best practices reports on mental health services. The proposed functions of the network include facilitating user pull to provide, for example, a database of existing knowledge syntheses, as well as mental health services knowledge needs assessment, and capacity development through training and education of knowledge users. Again, you need to think about who you target because, according to the resources that you have, that may be difficult because the country is large.
Further proposed functions of the network include facilitating exchange between pushers and pullers; that is, to provide, for example, the rapid response to policy-makers and decision-makers on priority areas based on the best available knowledge. Again, that can be achieved but it depends on the resources and your target public. You have two or three researchers who answer to each local planner. Quebec has 100 local authorities, for whom they develop a mental health plan, they want to have evidence, they call, and by the end of the day, it is impossible for your two researchers to function. You must think of who you will reach and how.
What was excluded is not because it should not be done but is something that the network could not do. Again, that will bring you to think about what we will and will not do. For example, the organization will not fund and undertake specific research projects. It will not recreate existing knowledge, data and information that is available with CIHI, Statistics Canada or through the Public Health Agency of Canada, for example. It will not recreate existing knowledge translation tools and resources, or a 1-800 service for consumers to access mental health services. That is needed in the everywhere in the country, but who will do it and how will it be done? Finally, to implement knowledge is also not the aim of the research knowledge exchange network.
I will close with some of the lessons we learned. The slide shows you different sectors of the public that must be reached with the services. There is the general public, nongovernmental organizations, clinicians, health professionals, planners, decision-makers, elected governments, industry, the researchers from the four pillars of biomedical, clinical services and health and population dimensions, and the media. We do not have media experts around the table. Maybe with their expertise they will help with a knowledge exchange centre.
The next slide is about what I call the "geography of services" decision-making. Again, think of increasing the number of people nationally, provincially, regionally and locally that would benefit from being informed by mental health and addiction services research, not only from dissemination but also from having the sort of relationship we are talking about that is essential to obtain knowledge. When there is a resource at the national level, maybe you can reach the provincial level. Can you reach the regional or local level? With respect to reaching regional or local levels, there is the researcher who, for example, has to cover the 100 local authorities in Quebec.
This slide is about types of information. I have talked a lot about services, but, obviously, people want to know about the dimensions of mental health and addiction. They want to know about the nature and amplitude of mental health, and interventions that are different from these services. The interventions include promotion, prevention, treatment, rehabilitation and recovery. Services include providers, service settings, programs and policies.
Since I have been on the advisory board of the Institute of Neurosciences, Mental Health and Addiction, we are proud of one of the websites called "The brain, Le cerveau en tête." When you go to Google and type in "le cerveau," it is the first hit. It is a remarkable thing, and it may help in thinking about a website. It has three levels of complexity: beginner, intermediate and advanced. Researchers or their students may learn something there. You can go for the beginner level and learn about the brain. There are also different levels of organization. It is not only about the neurological aspects but also about the social determinants, consequences and manifestations and the psychological aspects. It goes from cellular to molecular. It might help in organizing whatever websites are already available.
Mr. Block: When we develop the website, all of us can look at it through a different lens. I have chosen this morning to look through the communications lens in terms of developing a website. When we look through that lens, I have outlined some critical areas if we want a strong, strategic website. Others have said this in different ways, and perhaps the labels I am giving are somewhat different.
The first step is clear goal setting. We need to know why we are creating a website and how it will fit in with the mental health commission's overall goals and the opportunities it will provide for the organization. If we try to please everybody, we may end up pleasing no one.
The second area to look at is the website strategy itself. The specific target audiences need to be identified to allow the commission to target communications. "The public" or "all Canadians" are not specific enough to define a website target audience. Once audiences have been identified clearly, the subjects and the databases required for the website will become apparent.
The target audiences have been identified when the type of content, the degree of user friendliness required of the website and how much infrastructure content the knowledge exchange centre must build itself will become apparent through different audience research methodology, focus groups, online discussions and so on.
The entire focus of the website development is to target the expectations and the needs of its audience. An industry review or survey of other similar organizations and their websites will help identify good and bad trends in meeting audience needs and expectations. Benchmarks provide an ongoing analysis of how the website is doing, relative to competitors' websites.
The third area is website purpose. Once the target audience is identified, the next step is to determine what the website will do for those audiences. Will it give them information? Will it offer them unique services? How will the website be a valuable resource tool to the target audiences? What makes the website a more valuable resource than, or just as valuable resource as, the website of similar organizations?
A fourth area is differentiating the website. What will differentiate the KEC website from websites of similar organizations? Why will users go to that site instead of others? Why will target audiences return to that site? What is lacking with websites of similar organizations that the site can address?
Techniques to encourage visitor loyalty include offering subscription services to news feeds or e-newsletters, updating site content on a regular basis and providing real-time inquiry response mechanisms.
The final and most important area is the power of partnerships. We have seen this power in the development of this report by the Senate as bringing the power of the partnerships together. As we come together as partners, we will develop a more responsive website that will meet the needs and expectations of the users.
Ms. Pape: I came at this thinking about knowledge. What is knowledge? Where does knowledge reside? A lot of my thinking was based on a model that the Canadian Mental Health Association developed many years ago as part of our framework-for-support model, which some of you may have heard of. We have a model about knowledge called the "Knowledge Resource Base." It explores where knowledge resides and identifies four key areas in the area of mental health knowledge. One is medical clinical knowledge; we talked about that around the table, the brain. Other areas of knowledge about mental health include social science. Dr. Lesage mentioned determinants of health. That knowledge will fit into social science knowledge. There is experiential knowledge, as Ms. McKnight and others brought up: the knowledge of living with the mental illness as a consumer or family member. Finally, there is what we call "customary" and "traditional" that Ms. McKnight also mentioned: that is, different cultures and different traditions of their own knowledge of mental and mental illness. My comments are based on that, but they are consistent with what many of you have said.
If you look at knowledge as residing in many different areas, then when you look at a knowledge exchange, it will not be a thing: It will not be a website or a product but a process, as many of you talked about. Of course, it would not be a one-way process. Mr. Manion said it will not be from here to there. It will not be bilateral but multilateral because the users of knowledge are also the producers of knowledge, and the producers are also the users. It is complex. We need to think about these things when we think about how we exchange knowledge.
We also need to define "research" broadly. Research is not just be medical clinical research but also the community-based, consumer-driven and qualitative research that looks at issues not just of illness but also of self-help and determinants of health, et cetera.
What outcomes are we looking for if we look at knowledge this way? We would look for lots of opportunities for robust dialogue amongst all the providers, users or recipients of knowledge. This exchange centre, whatever it is, would provide a forum and legitimacy for the voices of stakeholder groups that we often do not hear, not just those ones that we are used to hearing.
There would be more increased sharing of knowledge and information across these various perspectives. As a result, there would be enhanced understanding amongst all of us, the providers and users of knowledge, about what mental illness and mental health are, and practical applications — as Ms. Goering mentioned, the "action piece" —of this knowledge in research planning and practice.
Mr. Hetherington: A few months ago, I had the privilege of preparing a document for Senator Kirby, thinking about how to build a website or knowledge exchange centre. Senator Kirby asked me to do that because of my experience at the Hospital for Sick Children with our About Kids health group, which is essentially a consumer health informatics group.
Over the last three or four years we have been building a rather ambitious website with a goal of trying to influence child and youth health outcomes, not only in the area of complex conditions but also for typically developing families. We felt that we had as a differentiator to raise language to a strong brand. We recognize that people from third party research require credibility. The way we approached it was by going out into the field to try to understand what we could do to offer value to our potential users.
First was the audience analysis, and that has come up around this table a number of times. Who are they? What are their needs? Then you can use hypotheses in the field and rigorously test things with qualitative research, performing proof of concept and also growing an understanding of what they need so you are able to best serve them with the information in a form that is accessible and usable to them. This does not only involve information, but also the use of tools and the interactive techniques they use. That is only the beginning.
When you are out there working in the field, you will recruit a national core group of users with whom you can work from the different constituencies identified. They will work with you through prototype development, wire framing and the structure. Whether that structure is conceived as an online or offline structure of continuing education and other techniques of networking that can be developed over the course of this initial stage that culminates in a strategic plan for building of the KEC. That plan would include a competitive or gap analysis where you look at what is out there. You try to understand how what you are offering differs, adds to, does not cannibalize and utilizes what is out there. For example, if one wants to find out about depression, there is a plethora of information out there on the Internet, much of it Canadian. Some of the sites are active, some are moribund and all of them have something from the DSM-IV.
What could a group like this do? It could be the single credible source to standardizing a lot of information and to take valuable information from CAMH and other organizations, work together to standardize this in an information architecture and design accessible across a number of domains.
The issue of comprehensiveness arose as well. This project should be comprehensive to deal with the mental health issues that arise with chronic health conditions. It can be a single source.
I focused on consumers, meaning both the public and the users. At this stage it is encouraging when we think about providing service to those individuals that online health information with interactive components makes a difference. We had a Cochrane review published last year that demonstrated that for a number of ages, youth to adults, if you provide accessible information along with either peer support or an ask the expert feature, you can influence not only quality of life but, in some cases, disease end points. That research needs to continue.
This idea of evaluation is an important idea. Evaluation of the main project should absolutely be built in from the very beginning. However, you can also have evaluation going on in parallel of small projects that could merge into the main projects. For example, in our experience we have three CIHR RCTs, randomized control trials, occurring now, which is looking at things that will eventually be folded into our site. We have just closed one, and that data are online and available for community-based professionals and teachers.
The idea of evaluation and having evidence-based critical ideas needs to be thought out to have a multifaceted plan of attack. That also builds collaboration with scientists across the country in order to develop these kinds of things. It helps one understand regional needs. This idea that came out of a national with regional is also very important.
There are ways you can cross-cut, whether through research or through understanding different audiences or through simply going out into the field and finding out what it is they need and ensuring what is built is what is wanted and works. Just building it and knowing it works is not enough. There must be uptake. There was a point made about traffic.
You want Canadians who are concerned about depression to type the word into Google and have this website come up high in the rankings. That requires an understanding of how search engine optimization operates. We know from third party research that when people are concerned about a condition, they punch words in, look at five different websites and look for consensus. We want to capture these individuals because we want to believe we have a differentiated offering that has the depth, breadth, tools and information that will make a difference to our constituents. We have to get them there and give them what they need once they are there.
The other issue concerns professionals. We could build a sophisticated tool that would allow, for example, remote administration of a standardized protocol for assessment of something or other. Here it is. It is elegant, we have the usability testing, it is fabulous, everything is great but no one is using it.
You must have people on the ground with the organizations, wherever it will be utilized, helping them understand how to use it and if there is something wrong, provide feedback and change it. At that level, the changes will be precipitated through development and provision of these kinds of mechanisms. That must be built into the budget at the beginning. That is not an inexpensive component. That is a whole other division.
Presumably, there will be interactive mechanisms to reach the various audiences of employers and of users. There will be mechanisms for feedback and interaction. We might be able to learn that way, but we must also build in mechanisms for interacting with them directly. Is this working? What is not working? What do you need? How do we provide you with more?
Someone talked about the CIHR website as being the worst. User experience is the key. This website targeting the public must be as sophisticated as anything else out there in terms of interactivity, design, layout and values, yet this goes deep and is not cheap to actualize. You need high-level talent to understand information architecture and good design principles to build this website and if it is not very slick, it will not be used. Interestingly enough, there is data to show it does not matter if the website looks good; it is more credible to a large body of consumers than if it said Government of Canada across the top. We must consider those things. It is not just a name; it is how we present it and how we communicate to users the credibility in visible language and that sort of thing.
I think this is a fantastically exciting project. The potential is dramatic on both the public and professional side for building collaboration and making a difference. I wish it every success.
The Chairman: Thank you. This first hour has been extraordinarily useful in terms of producing the document I want to produce. You have done a couple of things. You utilize a number of consistent items, and we will come back to those. Most importantly, you have told us what does not work. Reinventing a wheel that does not work is difficult and something we would like to avoid.
Senator Keon: Thank you very much, everybody. Those were tremendously useful comments. It was our intention from the beginning to have an exchange centre, not a dissemination centre.
All the speakers have put a great deal of information forward. Some interesting concepts have been mentioned. My own feeling about mental health, and about any health discipline for that matter, is we have to get beyond the fix-the-problem stage and move to health promotion and the prevent-the-problem stage. How do we get there? This is not just about mental health but about everything.
We will only get there when we have an adequate system for the ongoing measurement and evaluation of population health. This system has to link into global resources. I will have a very busy fall in this area. Just this morning, I accepted the first invitation to one of these think-tanks — which is really quite intimidating for me. I will be rubbing shoulders with real experts, Nobel laureates and so forth, and I will have to grope for something intelligent to say.
As we revisit this around the table, I should like you to think about the following. If the knowledge exchange centre is to make a real contribution to the evolution of a mental health system that will promote good mental health in Canada, then it has to move out away from the concept of health care delivery systems.
Can you enlighten us as to how we can design a system that must be plugged into population health? I do not think you can get the feedback loops if it is not. If I am wrong about that, then please tell me.
How can we come up with a structural framework, as Mr. Gold and others have mentioned, that will not lose sight of the fact that the reason for its existence is the promotion of good mental health and not just garbage in and garbage out, which is a huge problem in most of our databases now?
I will stop there. On the next round, I should like to hear where you can go with this.
Mr. Upshall: A couple of things Mr. Hetherington said caught me off guard. Thus, I apologize for this interjection.
I disagree entirely with the idea of identifying other good websites as competitors. If we start saying, "Your website is competitive to ours," we will lose the willingness of the NGOs and other communities to develop something that is above the fray. Competitiveness is not a word we should be using. If you type the phrase "mood disorders" into the Google search engine, Mood Disorders Society of Canada comes up. I want it to stay that way. I need that to fund the society. I need that recognition. The people we work with need that recognition. If people do not come to the site, that is fine, we will go.
To have the Government of Canada say, "We will compete with you," loses me right off the bat. I will be gone. If you want to get chat lines going, then I am sure the national network will be gone.
Whatever comes up has to be filling a gap, not taking over the world. I am very uncomfortable with that theory, Mr. Hetherington.
Mr. Hetherington: Competitive analysis is a business term.
Mr. Upshall: I am fully aware of that.
Mr. Hetherington: It was in no way meant to look at other sites such as yours and ask, "How can we put him out of business?" which might be the case if you were Exxon, say. Equally useful terms would be survey or gap analysis. What you want to know is what is out there. If you have something that is terrific, what would come out of that analysis is that we would know you did, for example, or the project would know that you did. We would be able to figure out how to work with you.
Mr. Upshall: A simple link would work fine.
The point you made was that when you Google "depression," our knowledge exchange centre comes up. That is not my idea of what this knowledge exchange centre needs to be.
Mr. Hetherington: Why is that?
Mr. Upshall: There is much information already on the web that deals with depression. We do not want to reinvent that wheel. We may want to link with it. We want to come above that fray. We need to be able to work together and share information and links.
If the knowledge exchange centre becomes a pivotal point in the public use and acquisition of general information, then by virtue of where the public will start to go you will lose the support of significant people in the community, significant NGOs.
Concerning links to depression, KEC says, type the word "depression" into the KEC website and what follows are websites you can link to about depression. To me, that is knowledge exchange.
Mr. Hetherington: You mentioned the Canadian Health Network. I understand that is the strategy the Canadian Health Network uses; in other words, they provide the links. Nevertheless, the traffic to that site has dropped precipitously over the last year. Perhaps that is not such an effective strategy.
Mr. Upshall: It is an effective strategy, if the website works. The point is that that website does not work. That is something we have talked about before. It is important that the website work properly; if it becomes a bureaucratic nightmare, it will not work.
Mr. Hetherington: Links are fine. We must recognize all the work that has been done. However, linking holus-bolus out of the middle of a page might not be the best user experience. Certainly, having resources with all credible links that are annotated is a good idea. However, one site might attack depression in a grade-7 language while another website might organize it completely differently. One site might detail the history of the disease.
As well, we know that there are individuals who are concerned with co-morbidity. In child and youth, there are many of these issues. A person may want to learn about ADHD because he or she may have been their child is co-morbid with anxiety and has learning disabilities. If a person clicks over to the LDAO, which is an excellent resource for learning disabilities, he or she can perhaps learn something there. If the child is learning disabled, the parent might be, too. There is a strong genetic component in that. A person may then go to an ADHD resource that is organized completely differently. Thus, they are not able to get the information they need to synthesize.
I advocate standardizing this information in a somewhat templated format, so that, yes, this site could have information about depression, even though good depression information exists. However, it would be put forward in such a way that it would satisfy the overall architecture of the site. A user can say, "I need to know this about the treatment for depression. How does that map on to treatment for anxiety? Let's see. It goes over here to ‘treatment to anxiety’." Rather than going off to a site from New Brunswick or B.C., both of which have excellent material but which are not organized in the same way, we have to think about our users. We have to think about giving them the information they need in a way that is accessible, understanding that they likely have complex needs.
Mr. Upshall: Perhaps we could have a dialogue after this session, because I disagree.
Senator Cordy: This morning has been amazing. Every time I think I have a handle on the issue of mental health and mental illness I attend something like this and realize how little I actually know.
The teacher in me loved hearing things such as the need for clear goal setting, gap analysis, looking at what works, continuous evaluation and how important it is to communicate to the users, because if we do not do the groundwork before setting something up, it will not work.
Whatever we do must be user friendly. We heard that repeatedly this morning. I believe it was Ms. Goering who said that dissemination is not the same as knowledge exchange. Interaction is so important. If we do not have interaction, if we go only to the site for information, that is not exchange.
As Senator Kirby mentioned earlier, as we traveled across the country we saw some wonderful things happening. In St. John's, Newfoundland, they are doing wonderful things with housing and work programs. In Collingwood, Ontario they have broken down silos, and provincial departments of community services and education are working together. Good things are happening, but whatever we set up has to be easy to access and easy to exchange so that you can get information as well as give information.
In any non-government agencies, grassroots agencies in particular, there is always a shortage of money and personnel. In Newfoundland they talked to us about accessing government money for housing. They said that sometimes what comes through from the government is so complicated that they do not have the time to access the funding. It is not worth it. They can get funding for care workers and social workers, but not for a finance person or for a person to fill out the documents.
Non-governmental and non-profit agencies are dealing with those realities. If it is not easy to access and takes a lot of time to exchange information, it will not happen.
I was on the board of Phoenix House in Nova Scotia, which provides housing for homeless young people. It was a wonderful organization. We constantly received requests from other provinces and even other countries that wanted to visit or to have our executive director speak to them. However, every time our executive director travelled or prepared a speech, that was time away from what she was paid to do. You are all familiar with that.
The bottom line is finding a way to ensure that your great plans do not become mired in bureaucracy.
Senator Di Nino: If Senator Cordy feels inadequate, just imagine how I feel here this morning.
I agree that incredible ideas have come out this morning. Sustainability is a key area. It is no use working on something for three years and then trying to find the money to implement it.
Another thing I heard that I thought was wise is that knowledge is not exclusive to some. We must understand that many people contribute to this knowledge.
I want to challenge you folks on one issue. The reality of Canada today is that we have many languages and many cultures. If this initiative is not able to reach those many cultures with many languages, of which there will probably be even more in the future, I do not think it will succeed. It may not fail, but I do not think it will succeed.
In addition to the need to address that issue, we must address the senior population of our country. We often forget that area. Without being critical, and in an attempt to be constructive, no one mentioned that area this morning. Seniors are not wired. A website may not be useful to them.
When talking about a knowledge exchange centre, those two issues must be at the top of mind: otherwise it will not succeed.
Mr. Coleridge: I want to respond to some of the comments and to pick up on a number of the themes expressed around the table this morning.
There is a concept of multiple knowledge generators, and that information and knowledge needs to be exchanged in many places. Many people spoke to that. I heard loudly and clearly that knowledge exchange is a process and much beyond a website. A website may be an important component, but only one component of a much broader comprehensive strategy. I worry when we focus our discussions about information on a website, because we must think much more broadly than that.
There are multiple audiences, and some of us touched on that. One point for discussion today should be around focus. Do we want this knowledge exchange centre to deal with a number of those audiences or do we want it to focus on the public, consumers, clients and families, or should it deal with health professionals and change of practice?
Discussion about focus and scope of the knowledge exchange centre might help you in developing your paper. As part of that, we need to focus on the objective of the centre. For example, if we focus on information on a website, what is the objective of that information? If it is to change public attitudes and behaviours, and support clients and families, reams of research show that information in isolation of other strategies has no impact. It does not lead to sustained attitude and behaviour change, so let us not go down that path again. There are many websites, many campaigns and many posters. In isolation they do not have a sustained impact.
I want to touch on Senator Keon's point on population health and health promotion, which is a topic near and dear to my heart, even though I am not as expert on it as other people in Canada are. One challenge has been, as Senator Keon mentioned, that we tend to focus on addressing health care — sickness care versus a health system. The problem with population health and health promotion is that they have not been adequately resourced, and therefore not evaluated adequately, and that they tend to be one-shot deals that focus on campaigns. Health promotion and population health is a broad integrated strategy sustained over a period of time, and that is what has an impact on population health. We need to begin thinking about it that way, and resourcing and evaluating it.
Senator Cochrane: I am so pleased that you are here because I know that you have encountered many of these situations.
Mr. Gold began by apologizing for being unsuccessful in many of his projects. The important thing about unsuccessful projects is the learning, which is as important as anything else. I hope the ideas that were not successful are made known. Please, let us not try to reinvent the wheel. We have to know the unsuccessful projects, in setting up an organization.
Someone said that institutions have not always worked well, and I know that is true. We have heard that a lot of people with mental health disorders are put in prisons, for the sake of finding a place for them.
In setting up this knowledge centre, it is important not to overlook the prisons; it is important to try to find a way to insert your knowledge and abilities there, to make sure that everybody is looked after. Those institutions are a concern of mine. You are probably talking about institutions like the mental health institutions, but do not forget that there is a sector of the population that is in prison centres as well, and quite a few of them are probably only there for want of a better place to put them.
Another thing many of you have talked about is not reinventing the wheel, and I totally agree with that.
As well, do not settle for bureaucracy. Ensure that what is done will result in solutions that the public will gain many advantages from, and help those who are ill.
Dr. Manion: Near the beginning, Ms. Goering was talking about how she was worried about the talk of a website. I was not too worried until the conversation kept continuing. There is a concern about creating a clearing house and not a knowledge-exchange centre. All of the questions that are being asked we have struggled with in our centre.
At the end of it, we are not trying to do things for people; we are trying to do things with people. It is about relationships and building those relationships. That is key to how this is organized. At the beginning, understanding the dynamic process that is involved and investing the dynamic process, which may have some tools and technology attached to it, is important; however, unless that is very much to facilitate those relationships we will not have the long-term change we are looking for. That is one point.
The other point is in response to the comment from Senator Keon around prevention. I agree that we have insufficient evidence. There is evidence, but it is insufficient. Any time we can share that information, obviously, we try to do what is evidence-based. There is some evidence-based information there. It also speaks to the scope of the knowledge exchange centre but, more specifically, of the commission. I do not think it will be the leadership from the knowledge exchange centre that will push the prevention-promotion agenda; it will be the commission's agenda to do that.
In relation to Ms. Goering's comments earlier, if the activities of the knowledge exchange centre are not completely linked to the commission and what it is trying to accomplish, then you have missed the boat. It should be an arm of the commission in that respect. They must go hand in hand. That will help to identify what some of the focus will be for the knowledge exchange centre once the commission determines some of its focus. Otherwise, there is a danger of two things spinning off in different directions, with one not being as useful to the other as it should be in both directions.
The Chairman: Thank you for that.
Let me make a couple of comments. First, Senator Keon's comments on population health are dead on. Personally, I had always seen that as being built into the anti-stigma program. If you look at some of the successful things that have been done in Australia, New Zealand, Scotland, and so on, at the same time as you try to remove the stigma, part of the same communications program also promotes good mental health because that helps to make people realize that the stigma does not need to be there or that you can get rid of the stigma.
In terms of the focus issue that Mr. Diakopoulos raised, there is no sense doing this if it will not be useful. That is why you must evaluate it. Therefore, giving people information, if they do not follow up on it, does not help very much.
I want to give you two examples, because I find it easier to start with an illustrative example. An Ontario school district, the Bluewater School District, has done a great job of identifying, at the school level, students with a mental illness. They have a testing tool, among other things. Bluewater School District has said that it would be happy to have other school boards from across the country visit them, and we have recommended to other school boards that they visit the Bluewater School District. There are a couple of things happening at the Vancouver School Board that no one outside of Vancouver knows about. Hence, it is important not only to tell people that these things exist, but to tell people how they work.
You can begin to have an impact on what this is all about, which is making life better for people who are living with a mental illness, if you can find a way of taking very practical things and telling service-providers, policy-makers and others how to do that. All of you have said that there must be a dialogue, not just a one-way exchange. You can tell someone to check out the Bluewater School District, but that is an extended discussion before some other school board decides to take that up.
As you make your comments, think about the following: How do you facilitate an ongoing exchange? It is not just a passive website. I do not know where that goes.
Ms. Goering: That exchange of best-practice information has been already very valuable in terms of what you have done in your reporting and in your discussions. We want to continue that dialogue, but I agree that we must focus it.
Instead of focusing on an audience, I would focus on actions and proceed from there. There are 114 recommendations, all of which require some action. The commission must determine its focus. When we know the focus — and perhaps the focus will be prevention, and we know quite a bit about preventing conduct disorder in kids. When we do our needs assessment, which we must do, we must look at the resources that already exist that might help with that. We must talk to policy people, to providers and to consumers about what they need in order to act on that issue.
The website is designed with that in mind, but so is the technical assistance and the dialogue, et cetera. You may want a website to help you decide what are you interested in acting on. If you are interested in acting on this and you are a consumer, here is where you go. Here is the tool kit, here is the knowledge from research and here are some examples that have gone across Canada, and so on. I get very nervous about comprehensive, all diseases, all audiences and all purposes.
The Chairman: Your focus on action is exactly my focus when I say that if it is not useful and it does not make life better for people living with a mental illness we should not do it.
Senator Keon: I wanted to focus my question again, if I could.
One of the problems with talking about prevention is that when you make a strong statement about it, as I just did, people think that this is the only thing you are thinking about. Of course, that is not true. We must fix the problems of the day along the road also.
In mentioning population health, I am not suggesting that we design a population health system but, hopefully, with what time I have left in the Senate, I will force the government to design one. I will participate in forcing the government to design one that is at least as good ones in Third World countries, if we cannot be in line with the developed countries. Once that is designed, it is simply a matter of our being plugged into it. It is not up to us to design it.
Nevertheless, we should never lose sight of the fact that 90 per cent of the disease treated in the health care system in Canada is of environmental origin; only 10 per cent is of genetic origin. Until we start looking at diseases from the agri-industry, from the construction industry, et cetera, and look at what city planners are doing, we will be wasting our time. The problem just grows and grows and grows.
Mr. Gold: I will come back to the first thing I said. Much of what I know about knowledge transfer, translation and exchange came from my mother, who had absolutely no formal education. Before I would do anything, I would call my mother and her whether it made sense to her. If she said, yes, I get it, I would know that I had brought it to a level that an intelligent person could understand, that it did not need an expert to understand. I talked to her about the difference between knowledge transfer and knowledge exchange. After a long conversation, she said it sounded to her like knowledge exchange presumes that all of the players have something to contribute. I thought, absolutely, that is exactly the defining difference. Knowledge transfer is about experts communicating out what they know to those who need it, but knowledge exchange is much more about bringing people together. It is that "marketplace of ideas," a cliché but true. Essentially, it is to create a space where all kinds of people with bits of answers come together to create a much better picture of what the collective solution could be and what the problems are. We do not even know all the problems, let alone all the solutions.
There are two risks: The first is creating nothing more than a website that provides a hyperlink to everything ever written about anything to do with mental health disorders. The second is doing nothing because we think that the scope is so big that we cannot do anything. I say that now because there will be a small sense from some here today that we cannot do it because we are not looking at it the right way, but something has to happen.
The Bluewater example was fantastic for me. At CHSRF, we put best practices, which we call "promising practices" — on our website. We believe that some of the important stuff to share has not been evaluated. It could be that the regional health authority is doing something fun and CHSRF might make that information available on our website to other organizations struggling with similar problems. However, that is not where the impact is. Rather, the impact comes from the phone call I might receive from the regional health authority in Moose Jaw, for example, who tells me that he just read the promising practice information happening in Newfoundland. He might ask, because there is no money from the ministries of health across the country for travel outside the provinces or even the regions, whether the CHSRF would cover his costs to travel for a face-to face meeting with the folks in Moose Jaw so that his group might apply that solution to their own context. The foundation agrees to that because no one else funds that kind of activity. You cannot go to the CIHR and ask for a ticket. The CHSRF tries to do what no one else is doing.
This initiative should try to do what no one else is doing. We need to identify the audiences and what no one else is doing — and let us just do it. Perhaps it is risky but it has the potential for the best impact. Everyone has said, "Information overload — let us not contribute yet another link on everyone's bookmark page that we do not go to." What the public often needs is digested information. Who can I trust? Type in any number of disorders and 7,000 websites will pop up, including websites on MySpace.com. That is not the same as something coming from the Centre for Addiction and Mental Health, CAMH. People need help to understand how to navigate all the information available, and the needs are different for clinicians, managers and policy-makers in the area. Let us determine what no one else is doing and the needs of the community groups and then take a shot at doing something.
Senator Cochrane: Perhaps you could do something more than that, Mr. Gold , by having regional people, from Newfoundland, say, travel to you for a face-to-face sharing of information with even greater volume.
Mr. Gold: We have an initiative that does such a thing. There are so many opportunities and models that show what could be done. They are about knowledge exchange, not only about dissemination or transfer, that could have a huge impact, I believe.
Ms. Kidder: Mr. Gold led beautifully to my comment. I want to revisit the idea of promising practices and sharing promising practices. Certainly, we have heard from our stakeholders that people are extraordinarily interested in. They want to learn from each other. In trying to determine how the Centre for Excellence at CHEO can participate in the process, it is becoming apparent to us that it is important to find a way to support the people who use these practices in the community to participate in our evidence framework. We need to know where they fit into that evidence framework.
I will go back to something Mr. Gold said about having criteria for the evidence that fits in our knowledge exchange centre. We need to ensure that the community organizations active in innovative ideas can understand how their work fits into an evidence framework and how it can move up to the levels of credibility, as well.
That brings me to another point — that is, funding for program evaluation and research in the communities. The Centre of Excellence takes that seriously and provides funding to support organizations to bring their programs up to a level of evidence that can be acted upon and bear credibility. The purpose is to help people see where they fit. People often question where their work fits in to evidence dissemination that happens. Hence, ensure that there is a fit, that you are not changing your standards for what constitutes good evidence and that you are creating a framework for people to take their work and increase its credibility. Forging links between organizations is taken seriously by the Centre of Excellence.
Mr. Gold, you mentioned Bluewater. The Centre of Excellence helped to create that experience by bringing the right people together in the room.
On a much smaller note, the people at the knowledge exchange centre of the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO have created a knowledge exchange framework that is divided into two concepts: One is passive and one is active. It is not the kind of framework that catches us in gridlock but rather it forces us to think. When we look at the activities designed for specific topics, we ask ourselves whether we are relying on passive exchange models for some and what the opportunities are for active models for others. Certainly, "bringing people together" is an excellent example of an active strategy, and it is not expensive. Other activities include bringing together, having town hall meetings, establishing programs in schools and in boys and girls clubs, utilizing the YMCA facilities, perhaps, or other organizations to create an active exchange of information. You do not need to reinvent the wheel to accomplish that.
I will go back to Mr. Reist who said "use the natural networks." There are many existing natural networks that we can utilize and support. We can offer some great evidence for them to activate in their groups. We can ask what they have been doing in their groups and whether they will share it with other groups.
Ms. Pape: I will take us back to mental health promotion and Senator Keon's comments. Ms. Goering, you sparked an idea when you suggested a site where we could ask people what they want to take action on. What if a community group wanted to take action, having identified a community issue that they wanted to do something about? That is mental health promotion. Through a knowledge exchange process, we could promote mental health in ways that go beyond stopping or trying to stop stigma. I do think stigma campaigns, as Peter Coleridge said, can risk becoming one way. As you said yourself, Senator Keon, you can have the knowledge but do not necessarily act on it. There are many more active ways to deal with this.
What Mr. Manion said made me think of another thing, that the commission does have to take control of this and take responsibility for it. As well, if they can continue the linkages that Health Canada has started with other departments whose policies impact people's mental health — Justice, Housing, Employment — if they can keep those linkages vibrant, that is another way we can take the population health approach in promoting mental health.
Mr. Block: In your report, you quoted Roy Romanow's report, where you said that the mental health system was the orphan of the health system. You went on to say that the children were the orphans of the orphans. When you look at the statistics of those children, their mental illness will emerge for 50 per cent of the kids by age 14; by age 24, it will have emerged for 75 per cent of those kids.
We know by the statistics and the literature that early detection and treatment will greatly enhance their mental wellness. We also know that kids are very technically literate. I would make the appeal that one of the audiences and targets we would look at is the children. I think they are neglected and I would encourage us to look at that as one target audience.
The Chairman: Absolutely. I wish to pursue that and link it in with what Senator Keon said. Given those data, from a population health standpoint, at the very least the commission ought to focus on educating parents and kids about what they can do to prevent them becoming mentally ill.
In various experiments that have been done with high school and middle school-age kids, there is evidence to show that you can have a significant impact. I should like to know from those around the table the following: If we were to support the idea that the first target audience from the whole population would be the under-20s, going all the way down to the young kids, how do we do that? How do we give the commission — whether it is through the knowledge exchange centre or whatever — some hard-nosed, practical advice on how to attack the problem? In the long run, that will have a much larger impact. I leave that with you as a question.
Mr. Upshall: As I have been listening around the table, we talk about websites and trying to avoid focusing too much on that. In terms of consumer friendliness, one of the great things for knowledge exchange is a call centre. I know it is simple — it uses the telephone and people — but quite frequently, it is one of the best ways to exchange knowledge and effect change, certainly at the grassroots level.
The Chairman: By a "call centre," do you mean what is typically called a 1-800 number?
Mr. Upshall: Yes, something like that. You access it however we choose to make it accessible. It is the same as the website. It may be a 1-800 number or whatever. It requires warm bodies. It requires people who are well trained, with the kind of manuals that call centres have. It would facilitate making information available to places that are remote and do not have computer access, or to people who do not use computers, whose language skills are not English or French and who need someone to talk to — not in a medical or therapy way but just to say, "Help me out. I am here." It may be a guidance counsellor in Iron Bridge who needs information about something. I am just throwing out the concept of a call centre as something that would be an adjunct to the website.
If a national call centre worked as a knowledge exchange site — if you evaluated that process and brought people together and knew that change occurred — then maybe you could do regional centres and get the provinces involved. I think we need to get provinces involved in knowledge exchange. They demand their pound of flesh when it comes to engagement in health care.
Mr. Reist: I find these kinds of discussions stimulating but I always struggle with focus. I hear lots of good ideas, and I think this or that is a great idea, but what is the purpose of this thing?
I thought a couple of things were really interesting. We have talked about focus several times and have looked at different ways of focusing it. I like Ms. Goering's idea of focusing on actions as opposed to populations, largely because when we focus on populations, it is often easy to lose perspective.
For example, in British Columbia, when we reorganized government around a population concern for children, we created a ministry that was to draw all of the pieces together and focus it on children, and developed a "child-centred" war cry. I do not disagree with that notion, but we lost perspective that one of the key ways to address the needs of children was to address the needs of their mothers, in particular, and their parents more generally.
It is easy to lose that kind of perspective when you focus on a population; whereas when you focus on an action — What is it we are trying to achieve? — it sometimes helps us to be more holistic in our response relative to a population of interest. That is one thing I would like to put back on the table again as being a key thing.
The other thing, which we have not picked up again, was Dr. Lesage's comment relative to the network. It was to ask the geographical question, what are we trying to do here? If we go micro, we might be able to do a couple of interesting micro things — that is, mechanisms that reach the wide, universal population in some way, whether that universal population be a population of the public, consumer users of the system, service providers or whoever.
However, is that the job of a national group? Rather, is it to go back to the systems level and ask the following: How do we create a system that will nurture networks that operate effectively at the micro level? I think we need to go back to that higher systems level of what we can do that would nurture that kind of network of knowledge exchange that will achieve those micro things that need to happen at the local, regional and provincial levels.
Ms. McKnight: I have a couple of comments. One is that promotion is very important — it is important for today, but it is most important for our kids. We try to promote good mental health with everything that we do.
However, the reality is that I am tired of getting handwritten letters from mothers whose children have killed themselves and I am tired of hearing about suicide — three in the last week and a half. That is one letter and two people that are very close to the people that I work with. This happens all the time.
It is very disheartening to me to think just about knowledge transfer. We need to have a place, be it on the Internet or through a toll-free number, where people can feel less isolated. Providing hope through the transfer of knowledge is important to folks, but having access to a reduced isolation is very big.
I agree with what everyone is saying, but there must be a way in which to not only create a mechanism to harness the intelligence and enthusiasm in all of the programs and promising practices around the country and translate it so that everyone understands what is going on and to disseminate the information to the general public — be it family members, consumers or just folks that are interested — to promote good mental health for our children, but also to save lives today. That is what is important to me.
Dr. Manion: Just picking up on what Senator Kirby said in terms of focus on youth and also hearing what you just said, if you really want to target children and youth, and you want to decrease isolation, part of the outcome is actually going to be the process. If you dedicate part of what you are doing to youth engagement, for example, engage youth in generating knowledge and sharing knowledge, you actually engage youth in how to ask and answer the questions so they have skills and can be in the field.
Not only do you create different kinds of knowledge and facilitate grassroots uptake of information, but through that process you are actually doing something that is health-promoting. When youth are engaged, they are healthier physically and mentally and the risk of suicide decreases. By engaging in a process, you actually have provoked an outcome.
Ms. Beckett: I should like to comment on the user side of the equation. I am not a professional in this area, but my impression is that that is the area where there is a lack of organizations with a mandate and lack of funding. There are a lot of organizations that would like to improve their practices but are not willing to commit the manpower and the money to educate themselves to be able to be proper receptors for the information and to take it up properly. To me, this is a huge gap. I see knowledge translation — that is the wrong term, though, I apologize. CIHR is not able to do anything to help in that equation. I am not sure that anyone really is able to and perhaps that is a niche the commission, if it comes to pass, could fill to some extent.
CIHR does have a large pool of highly qualified personnel trained in academia with a tremendous amount of knowledge and in many cases no where to go. It is very difficult to get jobs in universities and not all of these people find themselves in academic-type positions in industry. It has always struck me that we should have another track of career path that we are encouraging and that is the knowledge broker path. Why not involve some of these people during their training, promote this as a legitimate career option, and when they graduate, if someone is willing to put time and money into this kind of thing, involve them in the push activities and try to encourage the uptake, the action part of the equation.
Mr. Smith: That is a nice segue to what I was going to say. This experience comes from an activity that we were not as successful as we would have liked, the Concurrent Disorders Best Practice Guidelines for Health Canada. We compiled the information of the best and promising practices in the area of concurrent disorders. It came together and was disseminated widely. We did some presentations across the country and then we started to get requests for concurrent disorders training for addictions and mental health practitioners. This was exciting. There was an information deficit and skills development deficit and we could fill that gap.
I was more enlightened and a little bit perplexed that most of the people and the audiences that I went to had the information. There was some frustration in that they had the information and most of the skill and they still did not change practice. That is when we started to focus on the user push and to look at what the barriers were.
When we started to do basic screening for addictions and mental health basic treatment, they spent most of their time focusing on having the information, having interest in getting more skill development, but being perplexed by the attitudinal barriers in their organizations. Here, I am specifically talking about knowledge exchange and change of practice for practitioners for formal and informal care providers — I am focusing on that knowledge exchange arm. I was amazed that it was not a skill development deficit or information deficit; it was mostly attitudinal and interventions that were needed to deal with the barriers.
Then we looked to corporate Canada and to what they do when they want to make a sustained change or want to put in some kind of action. They certainly do focus on ensuring they have the right, accurate, available information so that everyone understands it, but they do not just put it out and hope people do something with it. They have a clear strategy, a strategic vision, and they articulate the action or the change that needs to occur. They focus on that change, and then they have a comprehensive strategy, which include policies that support and sustain the change and the infrastructure, the user push. They do not leave it to chance.
There is a lot of research in the knowledge translation area that suggests that, when you actually focus in this comprehensive way, it works; however, it is not done and it is not resourced. That is the exciting thing that this action-focused knowledge exchange national centre can do. It is not a new website or a super journal; it is actioning and focusing on resourcing the change.
Senator Wilbert J. Keon (Deputy Chairman) in the chair.
The Deputy Chairman: In my previous life with medicine, health care and administration research, when we talked about systems, I used to frequently interrupt and say that the greatest information system ever built was the human brain, that we cannot even come close. It has an efferent loop and afferent loop — the afferent loop is the action — but the beauty of the repository is that it gets updated every minute so it is always current.
My previous remarks this morning were in an effort to get more emphasis on the afferent loop because this system has to be a dynamic system or it will not be useful.
The young people in my institution would come in all gung-ho saying they had to have money to do this right now. I would ask them whether they had enough information, whether they really knew what they were doing, whether this system work next year? They used to get kind of annoyed, but I found it made them think.
This is a terribly important thing that we are talking about today. I think the commission will fly and I think this knowledge exchange centre will fly. It cannot be all things to all people, but it can build on the ideas that come out from all of you; there is no question about that. It is very important that we maximize its chances of success and see what we can do about it over the rest of the day.
For the next session, perhaps we could talk about the structure and function of the knowledge exchange centre. That will focus the discussion a bit. Perhaps you would like to discuss that in reverse order, namely, the function first and then the structure. That is another way of looking at it.
Mr. Upshall: We have spoken this morning about the kind of function that we would like to see, and I am not sure how much more discussion about function, as opposed to functionality, we need to engage in.
In terms of structure, there must be some dialogue about this being the essence of the commission's engagement. This will overlap with the issues of anti-stigma activities and the development of a national action plan, which is the third leg that we have not yet talked about but need to do so eventually in term of the commission's mandate.
In terms of the structure, we must recognize that, if this is to be a user-friendly, consumer-friendly, people-friendly activity, whether it is web-based or web and call-centre based, however it is structured, it must have its guidance and direction from the highest level of the commission. Immediately below the executive director there needs to be an assistant director in charge of the knowledge exchange activity. The principal activity would be the KEC, but there may be other knowledge exchange activities that need to be controlled, managed and synchronized. The knowledge exchange centre would be a major aspect, but not the only aspect, of knowledge exchange for the commission.
I foresee an assistant executive director and an advisory committee that would be comprised of a significant number of consumer and family folks. I also foresee a staff person who would be a researcher, someone familiar with the structure of knowledge exchange and what knowledge exchange is, who could facilitate the initial engagement, which I think is a gap analysis. Prior to that time, there might need to be a discussion about the focus and the mandate of the KEC. It must be managed at the commission level and at the senior levels of the commission. Something must happen within days of the establishment of the commission.
I do not know if that gives the discussion a kick-off, but that is where I think we need to start looking at it.
Mr. Gold: I will begin with an exact opposite approach. There is absolutely no clarity, in my mind, about what the "it" is, based on this morning's conversation. In fact, I have counted no less than eight functions that have been identified for this "it." I have heard advocacy, intervention and telephone-type intervention — and support is a type of intervention. I have heard dissemination, a clearing house of resources across the country, and an organization or entity that creates or supports networks. I have heard user-group capacity development for the use of resources that exist in the area.
Before we talk about how many bodies man the desks and what the organizational structure is — that should be perhaps following or supporting whatever the "it" is and the IT component of the "it" — clearly, there needs to be a dialog about what, if any, of these eight items I have found, and others which I may have missed, are the priority in terms of what this actually does. If it is about dissemination, then we need to be talking about synthesis, that is, what information needs to be synthesized and for whom. That is clearly the big vacuum out there for certain user groups.
In my work, what I hear most often is that there is so much information that we cannot breathe. Do not give us more sources of information; give us distilled information with key messages. Tell us what the evidence says, as of right now, that we should be doing about X, Y or Z. That is one slice, which is completely different from being a clearing house, which says we will not synthesize anything. We will just tell you that if you are interested in X, here is the landscape of where you can go, with some kind of rating scheme perhaps, some kind of quality assurance matter. That is a whole differently structured organization that would require subcommittees and groups that would work on different theme areas. What it is that "it" does will become very important.
Theme areas are another big question. There is a tension in the room between covering all of the potential different topic areas within mental health and saying we need to focus on specific themes, for instance, children and youth, or rural remote, or the Aboriginal community. There are many different options. That is where we should be focusing our tangible discussions.
Dr. Manion: I totally agree with Mr. Gold. The synthesis piece will be a critical decision-making process by which you identify what will be the first topic for the synthesis. There are models out there. We have been developing some models for our own activities. You cannot do a shotgun approach, because then you will have a little bit of information about a lot of things, none of which will be useful.
We come back to Ms. Goering's cry to action. If you marry it to the action of the commission, it will tell you what is your first topic area or population, and then within that area you apply a template for gathering, synthesizing and evaluating information before you then look at the exchange of information. That will be a given. Through that, the partners with whom you must engage to do that will be identified. Some will be funding partners; some will be those who already have the information synthesized and organized in a different way; some may have the best uptake within a particular topic area.
Mr. Upshall spoke about a number of different advisory groups that could be useful. We have found that very useful but not directly for the KEC. Again, I am thinking of the commission. If the commission has a number of advisory groups that will support its activities, then I would use that vehicle, where knowledge exchange would be imbedded as part of that. Do not create an additional structure; rather, make it part of the parlance of all those groups to think about knowledge exchange. That way, a link has been created between the two, the idea of different stakeholder groups has been respected, and one structure has been created that works well.
Mr. Gold: How are you structuring the KEC within the commission?
Dr. Manion: I was speaking more specifically to the advisory piece.
For example, in our organization we have an overarching advisory group, but we also have a consumer advocates’ reference group, a service-provider reference group and a research group, all of which sit on our overarching advisory group. Our knowledge exchange staff interacts with all those exchange groups. They discuss what we do. There are a lot of people who do this already, so you will not be reinventing the wheel. Maybe you could look into your first scan and gap analysis and determine which of the existing structures work and which do not work, rather than sitting around a table and inventing a new structure, approaching the question in an empirical way. Yes, you will have to have a structure for the KEC itself, but its links and how to feed information or give advice to that entity may be something that is more closely linked with the commission's activity.
Ms. Goering: I found a paper when I was preparing for today. It was a paper from Peru, an interesting international knowledge exchange. Try to think about the functions of networks. It dealt in particular about policy research networks. I think that, whatever the audience, some of the thinking there was useful. They said that when you look at networks there is a superordinate question that has to do with change. You have to decide whether the network will be an agency of change, which would be to be an advocacy group itself, or it will support other groups that were the agencies of change. That may be one distinction we need to have. In my mind, this knowledge exchange is to support the commission, and the commission is the agency of change. The knowledge exchange function is not advocacy per se; it is a resource on which the advocacy effort of the commission could draw. There may be other groups trying to be agencies of change and advocates that also will draw on those resources, but tying it closely to the commission makes sense to me.
Once that is figured out, they list in the paper the functions to think about that could be done by the knowledge exchange. In terms of language, in Canada we are used to "user push and pull and exchange," and maybe that is sufficient. I do not think we have to choose there. You can have a platform that does all of those things as long as it is focused on what it is trying to achieve and has some way of evaluating whether or not it will achieve it.
In the paper I looked at, they use other terminology, such as being filters of knowledge. They talk about amplifying, which probably is "push." However, there is one function that we need to think about and that is the investor function. Part of the function could be to identify groups that are already in the business but need some seed resources or additional capacity in order to help the commission achieve its goals. Instead of thinking of it all happening at the centre, the centre might invest strategically in resources out there doing that function that will help achieve the goal.
Again, the detail of that must wait until we know what it is we are trying to change. We cannot decide that. It will have to be the provinces that are very involved in setting that agenda. In the end, the action on many of these issues is at that level. If they can come up with something they collectively want to act on and can decide on those kinds of things, then for me the knowledge exchange function is tailored to assist in whatever that agenda is and then it does all those functions.
Senator Michael Kirby (Chairman) in the chair.
The Chairman: Let me make one comment on your last point.
We make a mistake if we ask what it is that the provinces collectively want to do. We have an agreement on the commission, but it was not easy, and it is also rare.
In addition, the areas where action needs to be taken vary significantly from province to province, and they vary even within a province. The regional health authorities across the provinces are quite different. The commission would make a huge mistake if it set out to try to get a set of collective agreements. It needs to recognize that the goal is very simple, to do two things: first, to make life better for people living with a mental illness; and second, to do everything to prevent people who do not now have a mental illness from getting one.
What is the objective? It is crystal clear. That is the whole purpose of the commission.
Why do you worry about stigma? The only reason you worry about stigma is because people with mental illness tell you it is the worst part of their illness. I am not out to get rid of stigma because I think it is a morally reprehensible thing. I think that, but that is not the issue. It is a simple issue. People with a mental illness tell me it is the worst thing about their illness. If you are to make life better for them, you might as well attack that.
I am totally locked in on our issue that the word "action" is the operative word here, but the action is both action to prevent the problem and action to solve the existing problem. There are two sides to that.
The question then becomes: How do you do that most efficiently without duplicating what is out there? We do not use the word "consumer" in our report. You must have strong input from people living with a mental illness because you cannot help make their lives better unless you understand precisely what it is that needs to be done to make their lives better.
Ms. Goering: May I ask a question? I may be naive about the political process, so you will have to help me understand. If you were imagining a scenario that picked up on the comments made earlier about suicide, would it not be possible that perhaps the provinces together would decide on a national campaign to reduce suicide, which would have many different elements to it, including targeting youth, where the action in each province might look a bit different but where there was a collective buy-in to the outcome?
The Chairman: Yes, they might, but why waste all the effort in doing that? If the issue is to reduce suicide, I am 100 per behind that. However, there are many ways to do that. The way one province does it need not be the same as another province. Forget about the collectivity.
Our committee did the unthinkable. We went around selling the concept of the commission without ever talking to anyone in Ottawa about it. In fact, we reappeared in Ottawa with a sold deal, which increases the chances it would happen. We did it by talking to individuals in every provincial and territorial capital — which is why I am now a super-elite on Air Canada. We went to every province and territory and talked to every minister and every deputy minister of health. If we had brought everyone into one room and tried to make a collective decision, I do not think we would have got one. We got there in the end because when Senator Keon and I went to talk to the ministers, we already had the deal. I do not think we could have done the deal without doing it individually, one person at a time.
However the knowledge exchange centre works, it must reflect not just provincial interests but also sub-provincial interests. What works on the Vancouver Island Health Authority may not be the same thing that the Vancouver Coastal Health Authority wants, because there are different problems. Vancouver Coastal must deal with the downtown eastside, which no one else does. That is all I am saying.
This is very much not a one-size-fits-all situation. That, to me, is one of the toughest single things about a national organization trying to provide help across the country. It would be so much easier if it were one-size-fits-all, but that will never work.
Mr. Gold: With my simple brain, I need to wrap my head around several things you have already said, because it sounds like it is not as complicated as I thought it was.
There are two major mandates from all of this: to make life easier for those suffering with mental illness, and to help reduce, if at all possible, the number of people who will become mentally ill. We have moved from that to having a discussion about the knowledge exchange centre. That means we believe that in order to reach those two goals there is knowledge or information and wisdom in multiple communities that must be brought together to find a solution. If that is the case, the real question is how the knowledge exchange centre provides spaces for all of those voices to work towards those solutions. A super website with links to everything that exists will not do any of that, so we do not have to talk about that anymore. We can talk about how it might support this, but the overarching primary goal is to create spaces for the all of the different pockets of wisdom that can lead to these solutions to come to bear on the problems. If we keep that first and foremost in our minds, many of the side discussions are not relevant because we are talking about the means, not the ends.
The Chairman: The two overarching objectives that I gave were set by the committee for the commission.
Mr. Gold: Clearly, the KEC must support those. We are not taking about creating another form of voice for the research community or for any one group. We are looking at creating a space, and I am oversimplifying it linguistically to create a discussion, for the pockets of wisdom that exist within all the multiple communities to speak together to create that solution we believe we are missing, because we are not bringing those altogether. If that is the case, we can have a different discussion about how to move forward.
Dr. Manion: I agree with you. We have gone through that kind of thing as well, and our language has now changed. We have stopped talking about our knowledge exchange centre, which is the label we had used, and now we are talking about knowledge exchange at our centre. In the same vein, it would be knowledge exchange at the commission. Therefore, with respect to the commission's overarching goals, what are the knowledge exchange activities and the relationships that bring people together with one common voice to serve those goals? How can that happen? Then you start with the structures to make that happen. We do not want to create two entities that have conflicting goals and objectives at times. Knowledge exchange is an activity associated with the goals of the commission.
The Chairman: Absolutely.
Mr. Gold: If those are the goals, we need to identify the voices we want to hear from and the tools and investments that need to be made in those communities to make them able to express what they have to exchange. That is the fundamental challenge.
The Chairman: Except that some of the people will be largely takers, in the sense that there will be people with mental illness or their families or caregivers who are more taking information than putting it in. I love the phrase "promising practices." I will never use "best practices" again. On the promising practices side, that is a give and take.
Mr. Smith: With that is the use of the evidence-based strategies that work for the different targeted populations or targeted actions at which you are looking. In addition to creating the space to bring people together, what do we do with that? Let us not recreate the wheel; instead, let us look at the evidence-based practices and strategies that do work for different populations.
The Chairman: I agree.
Dr. Lesage: To go back to the issue of the aim of the commission, another way to phrase it would be that it has to do with improving the mental health of Canadians. In a way, we will not be picking one group or another or one disease or another. It will be the overall. That was the thrust, and it identified areas where it seemed to be going slower or there were greater gaps, but nowhere did you find a satisfactory situation. Therefore, the aim has to do with making the mental health of Canadians better — contributing to it. The commission will be judged by whether the state of mental health in Canada is improving. That is the outcome that should be looked at.
The Chairman: Absolutely.
Dr. Lesage: That is the outcome that should be looked at, and also there should be some piece of information that the commission can gather to evaluate itself to say this is the state of mental health in Canada in 2006-07, 2008, et cetera.
The Chairman: To echo that point, on the anti-stigma program you do what every other country has done, which is track on an annual basis how public attitudes have changed. If you run the program for three years and public attitudes have not changed, forget it, you are not doing anything.
The interesting thing to me is that Australia has been doing it for 13 years, and every year the numbers are better. The stigma has gone down, and the reality is you can do it. However, your point is dead on. You have to be able to evaluate what you are doing to know whether it is having an impact. There is no sense in doing it if you do not know whether it is working.
Dr. Lesage: On the other hand, nationally, I think they are drinking more in Australia than we are in Canada. They may have more substance problems than we have. That is also part of the mental health picture nationally.
The Chairman: I was talking about attitudes on stigma. What they have done is to show that their program has moved attitudes on stigma in the same way that attitudes on HIV have changed in this country in the last decade, for example. The drinking issue is different. I am not sure they consume more alcohol; they consume more beer.
Ms. Beckett: Another perspective is the quick-win perspective and evaluating the levels of evidence that are already there. If there are things that are incontrovertibly true and, if implemented, would have an immediate impact on the mental health of Canadians, why not focus initially on those before undertaking longer-term strategies?
The Chairman: Absolutely, the trick in any new organization is to get a couple of quick wins, and then you buy time to do the longer-term stuff. That is standard.
I wish to go to the issue of what Senator Keon called a population health approach targeted specifically at the subpopulation of children. That does not mean that it is not targeted as well at their parents, but does anyone have any thoughts on what one does if the objective is to reduce the incidence of mental illness amongst children by giving them tools that help to make the problem not materialize in the way that it normally would?
By the way, we had one piece of evidence where one school board gave information to students on how to reduce stress with the hope that it would alleviate some of the problems. Half the class got the lectures and advice, and the other half did not. The interesting thing was that not only did it teach them a lot about stress management techniques, but also everyone who had the stress management techniques had their grades improve. When they asked students why that was the case, a student said that when he started to panic about a test, he applied the stress techniques. When they did the exercise, they were doing it as a pure mental health exercise, not as a method of improving their grades. However, believe it or not, it worked.
Who has thoughts on what we do vis-à-vis population health approach targeted at having an impact on school-age children, even if means some of the people you have to target are their parents?
Senator Cordy: Some good programs have been developed. I used to be an elementary school teacher, and I know in Nova Scotia there was a wonderful program called the peaceful schools program. Student mediators were out in the schoolyard. If kids were having a problem, they could go to a peer on the school grounds to help them out. It was not always the teachers getting involved in a punitive way, but kids were helping one another. The program started at kindergarten or primary and worked its way up. Each year, there was a specific focus on teaching kids problem solving and those kinds of things.
In my 30 years teaching experience, the difficulty is that there seems to be a flavour of the year with school boards. Teachers get in-serviced and money to buy aids for teaching in a particular program. Everyone is gung-ho on it. The following year, there is a new focus, and unless someone in the school takes an interest and is keen on continuing to push forward, then it is pretty good the second year and okay the third year. By the seventh and eighth years, there will be staff members in the school who have never even heard of the program.
My concern about the longevity of programs was mentioned this morning. There are good programs out there, but how do we keep them focused and in the public eye? I do remember a program about inappropriate touching that was great. Kids were disclosing to teachers, and teachers were phoning to get help from the health authorities. It was going well and we were glad the kids began disclosing. In six months, we can give the child an appointment. There is only one thing worse than a child not disclosing, and that is a child disclosing but not getting help.
It is a matter of everybody working together. The silo has broken down, which is working in Bluewater. It is also a matter of longevity and focus being directed on things so they are not dying out. If you have an anti-stigma program or one in which to teach kids how to deal with stress or problem-solving situations, they should not die out as the personalities involved are no longer available.
Ms. Goering: There is good evidence out there about how to complete the prevention work. Some of it is targeted and some is more widespread.
Charlotte Waddell has done a recent summary of evidence as published in the Canadian Journal of Psychiatry. That might be the kind of action strategy that one can approach in various different ways. Some of the action must be with mothers — single mothers on welfare and mothers who are depressed. There are different ways of approaching it, but we need to be careful about the evidence base. There are many interventions that sound good and feel good but for which there is absolutely no evidence that they actually accomplish what we want them to. That is my one concern about going in that direction.
Dr. Manion: In your report, you talk about the critical role of school systems. We are preaching to the converted in that respect.
As you mentioned, it cannot just be a flavour of the month. Sometimes that requires a corporate culture change in terms of imbedding the best practice available based on the evidence as a requirement — in the same way there may be a requirement for physical education up to a certain age as part of the core curriculum. Similarly, there should be requirements around mental health and mental health promotion.
Although the program may change because it is better, the requirement remains. They must transcend government as well. If the government comes in and says a school is only going to focus on reading, writing and arithmetic, you have a problem. The first thing to go will be the programs that need help promoting.
It must transcend the political climate and viewed as almost a mandated requirement of education. You cannot learn if you are mentally ill. You cannot learn properly if your problem is concentrating, you are anxious or depressed all the time or you cannot sit still. Therefore, if you look at it as a right — to be able to learn you must be mentally healthy as well as physically healthy — then you imbed that thought into the culture.
Mr. Block: I will speak of a few programs we are attempting in Alberta. We are hopeful they will be successful.
One of them is the mental health first aid program that we are implementing in 36 schools across the province where we intend to train at least one person on staff in the school who is prepared to recognize and obtain help for kids who may be suffering from a mental illness.
Another thing we have recently established is Grip magazine written by kids for kids. For example, we had an issue in Edmonton where a big kid sexually —
The Chairman: What is Grip magazine? Is that the name of the magazine?
Mr. Block: Yes. It is on our website if you would like more information — www.amhb.ab.ca.
We were astounded. We just completed it in May, and I was nervous about trying it. We printed 60,000 copies of the magazine, and it is going for a second print. The uptake has been unbelievable, and it seems to be reaching the kids.
Another thing we are trying is a chat line for kids on the Internet. It seems to be a place where they talk. We were so overwhelmed by the response that we had to shut it down initially because the kids were coming with problems that blew us away in terms of the issues they were facing. We are attempting it again, but we have involved psychologists and other professionals because it was more than we had imagined.
Another area of great concern is Aboriginal youth. We all know the statistics are horrible. The work Lieutenant-Governor Bartleman has done on literacy has been groundbreaking and is also a very important area.
Mr. Upshall: I think this discussion is great one, but I cannot see how you can bring this into the knowledge exchange centre. I see this as a very dramatic activity for the commission and the commissioner as part of a national action strategy on mental health. By trying to cram this into a knowledge exchange centre would not —
The Chairman: Do you agree it is critical?
Mr. Upshall: Absolutely.
The Chairman: What category does it fit into?
Mr. Upshall: This is a commissioner's job. This is at a very high level, and it requires tremendous engagement with the community.
Mr. Reist: Following up on that, it is a question of what we mean by a knowledge exchange centre. Maybe the language of that is problematic.
Going back to addressing the knowledge exchange issues the commission will be facing in trying to move forward, I think there is a level at which we need access to evidence of effective practice. There is a wealth of that out there, but it is about finding the right channels in order to flow it to the right places.
There is something we do not focus as much attention towards, however. You can have the best evidence of effective practice, yet it will not be acceptable policy. Therefore, the question is this: How could a knowledge exchange function capacity help the commission gain knowledge about how to translate evidence of effective practice into saleable blocks for policy change?
As an example, right now we are producing a learning resource for schools in British Columbia focused on substance use, but the first stream out in particular is an emphasis on methamphetamine because of the attention in the media and public around that drug.
We have produced a resource based on the evidence of health education best or promising practice, yet now it is at the stage of figuring out how to get the policy-makers to accept the onus of selling to politicians that in fact this is — even though if it may seem counterintuitive to some people — good practice on achieving the current objective.
It is on that level that we need to focus attention, and the commission will constantly be facing that as they try to address issues of change in public perception and political will.
The Chairman: The 19-person board of the commission and the four or five senior positions should not be there if, as a collectivity, they do not have a lot of information on how to make things happen. That is something you cannot teach. It is something that requires a lot of experience.
I agree with you that it is a problem. I am surprised you say there are things for which there is evidence that it is good practice but people will not do it.
Mr. Smith: Mr. Chairman, you were out of the room when I gave the concurrent disorders best practice example. My Bluewater experience was thinking that we would be able to fill this big information gap with best practices. Most of the people we were training had the information but spent their time talking about their frustration, which was that they were not able to apply the information in the best practices. They were met with attitudinal and policy barriers. Having the information more accessible fixes the problem caused by the information gap. In most cases, it is not an information gap; it is like a changed management perspective.
Senator Cordy gave an example concerning the education system. Like the health system, it was the flavour of the month. Every year there is a new training in the next flavour of the month. How do we have an effective sustainable workforce development in education as well as in the practitioner population?
The Chairman: That is a very depressing comment. Everybody nodded heads when you said it.
Senator Keon: It is a good point and a worrisome one as it relates to mental health, particularly as it relates to the interface between mental health and education, which is key to progress. Nonetheless, as it relates to best practices, it depends on how hard the evidence is. If the evidence is really hard, there is not much difficulty in implementing best practices. It is where the evidence is a bit soft, a bit foggy or in the process of evolution that it becomes a difficult exercise. This again comes back to the enormous importance of the knowledge exchange centre in mental health. Unfortunately, mental health is at the stage where it has to crawl before it can walk. It will not be an overwhelming success the first day or the first year. However, you have to start somewhere, which is why I think it is important that there be this balance between information going into the system and action coming out of the system.
Mr. Gold: I know I am speaking with two voices now. You could hear my breathing, as well as Paul's breathing, stop when you said you were surprised to hear that there are mountains of evidence not being implemented. There is no-brainer evidence that is not being implemented on a day-to-day basis.
The Chairman: I knew the system was bad; it is just worse than I thought it was. I did not think it could be worse than I thought it was.
Mr. Gold: It is almost always worse than you think it is. Some areas are better than others. Clearly, when there is incontrovertible evidence in the clinical arena, it is probably easier to move evidence into practice. In health services, however, that is not the case. A lot of these decisions are highly political and economic in nature. They involve trade-offs. Evidence is but one factor. There are many other factors that go into making those decisions. It is the struggle of my organization. It is very telling that two of the most popular documents available on our website are a document called Evidence Boost and another one called Mythbusters.
Mythbusters is a document we create by taking a myth in the system — we analyze the research and debunk the myth. That document is downloaded tens of thousands of times a month. It has been translated into five or six other languages. We see it entered into Hansards and into parliamentary debates all over the world. We know this because we get frequent requests from people asking us if they can use it. Professors use it all the time in their course materials.
Evidence Boost is more depressing. With that document, we take situations with a clear evidence-based path that is not being followed by governments or decision makers. We create this document that is a slap in the face to the system. We say, "Look, folks, this is a no-brainer." A recent example involves the use of midwives in rural and remote communities. There is a whole bunch of others.
The challenge is rarely a lack of evidence. The challenge is putting the evidence in a context where decision makers are willing to implement it for a variety of reasons.
A huge role for the centre is to identify promising practices across the country and do what no one else is doing, which is to share them. No one is willing to do that right now. We are replicating interventions across the country in a wide range of areas of mental illness. We talk about sharing only those things that have been proven. Unless there is a systematic review, we are not willing to share it. The reason we are having problems is because we are talking about best practices instead of promising practices. Let us identify promising practices and do what no one else is doing. Let us assist in the sharing of those and evaluate them. That is what no one is doing. Individual organizations do not have the resources to do these evaluations.
Imagine a situation where the centre said, "We will take this promising practice, help it be implemented in five or six other jurisdictions and evaluate whether or not it works. You can be responsible for moving it from a promising practice to a best practice."
Dr. Manion: We are going to get Mr. Gold to stop saying that no one is doing it because some people are doing exactly that.
Mr. Gold: On a national scale?
Dr. Manion: No, not on a national scale.
Mr. Gold: It is happening provincially. The problem is that it is not happening nationally. Why should British Columbia not benefit from your work, for example?
The Chairman: By the way, that deals with my Bluewater question, which is an illustrative example of a typical problem.
Mr. Upshall: I remind this august group that not too long ago there was a lot of evidence to show that community mental health was the way to go and we closed an awful lot of hospital beds and said, "We are going to do that." The sad fact is that once the advocacy funds were freed from the institutions, the institutions regrabbed them and misspent that money. That left us without hospital beds or community treatment, in the face of best practices, promising practices and knowing that community mental health was the way to go.
The problem I see is one of advocacy and the unwillingness of the Ontario Hospital Association, as well as the national groups, to recognize that they have to give up something in terms of power and allow the movement of it into the community of mental health services and mental health promotion. They have to do that.
To my way of thinking, the commission is the saviour for us, if we can get it done. There are bureaucrats who know the promising and best practices. They know they are doing the exact wrong thing. They close their offices at 4:30 and go up to their cottages in Muskoka and leave people hanging in the street without supports, knowing they could do something.
I agree with everything you said about availability, senator. However, there is a lack of willingness to do the uptake. Frankly, what worries me most is that money will be made available for mental health issues but hospitals will take it and say, "Let us build some bricks and mortar," where we do not need it. We know very well what has to be done.
The Chairman: The arguments that have been made by several of you in the last few minutes have really made the argument for the commission more powerful than I ever made it. Simply put, you need an aggressive focal point to push the system and to be prepared to take on entrenched interests and all that kind of stuff. In contrast to that, the committee has always been asking, "How do you avoid going back into the shadows again?" That is the genesis of the thought that led to the commission. This is very much a people issue and it is now clear that the people involved must be prepared to be aggressive, although not obnoxious, in terms of not letting the entrenched interests stop them, in much the same way as the committee did not let the entrenched interests stop us from saying that there is nothing wrong with privately delivered services and that we must change scope of practice rules, for which Senator Keon has been pilloried from by every doctors' organization in the country.
That is what you must do. The reason it will happen ultimately is that, once they finish attacking you, the government starts to say that maybe we ought to do that. Someone has to get shot first, that is all. It goes with the territory.
Ms. Pape: I am a little confused; let me take us back to our discussion this morning. What the chair said made me think that what we are talking about is not so much a dissemination strategy or even an exchange strategy but, as Patrick Smith said, a change strategy. Part of the change strategy is that the commission will have some clout and part is that the people who will receive the knowledge will have a say, will have some power and control about what the knowledge is and will be able to contribute to the discussion. That is a way for people to change their behaviour as well.
I am sure that in your example of a stigma campaign that is what you are thinking, not just that we will give information but that it will be a strategy.
The Chairman: Absolutely.
Ms. Pape: We know this is the process to take, and I think we have established that this morning. To take it back to the knowledge exchange process, perhaps that is our way to get at the gap between knowledge and practice.
The Chairman: Is anyone doing the change strategy well anywhere in the country? Is anyone doing it at all?
Mr. Smith: We are doing it and that is what our presentation is about. We are looking at everything we are doing from an organizational change perspective, but it is in the very early stage. We are evaluating the primary care transition fund where we are trying to change GP activity in the areas of addictions and mental health in the Yukon and two regions in British Columbia.
The Chairman: Which two?
Mr. Smith: Kelowna and North Shore. The key issue there is that the evidence is very clear about screening and intervention for addictions and for tobacco use, but GPs do not change their practice. We are trying to look at what the facilitators are to that change. We are at the stage of data collection and writing that up.
Again, it is looking at it from the perspective that big businesses use our research around change management. When they want to change something, they have a comprehensive change strategy. It goes back to looking at the action and the targeted goal and building your strategy accordingly. This is not new. There is a lot of knowledge translation and knowledge exchange research that supports it as a change perspective. That is just through our trials and tribulations and not getting there with the information. Part of it is that it is still necessary to share that accurate information; it is just not sufficient, so we are looking so see what is next.
The Chairman: As has been said, we have repeatedly used the word "action" today. Action, by its very nature, involves change. Therefore, the question is: How will you get the action if you cannot persuade the people to make the change? As you have said, even though they know it is the right thing to do, they may well not do it.
Mr. Smith: The strategies are different to create the action if you are looking at the public and client-based information of families for practitioners. A big part of my role is changing practice. Even when we have evidence, why is it mostly not being taken up? Even when we get the information out there in glossy best practice guidelines and have great conferences, when you go back and evaluate what is happening on the ground, there is no change. We ask: What would corporate Canada do? They would use our research and organizational change to have a comprehensive change strategy targeted toward the goal and work backwards.
We do a lot of training in isolation on concurrent disorders. How many people have not had concurrent disorders training? Everyone has it, but people are saying it is not changing their practice.
Sometimes it is policy barriers. For example, we found that in one region physicians could only bill four sessions per patient for screening or identification of anything to do with addictions and mental health. The barrier there to making a change was more policy based. An intervention there would be very different than if their attitude were that this is not the right place to deal with addiction and mental health issues; that is a totally different strategy.
You look at identifying the barriers to the change you are trying to achieve and then work backwards with that. There is a lot of good evidence about how to address each individual specified barrier.
The Chairman: The corporate analogy only goes so far because ultimately in the corporate world management has the ability to force things. As I have discovered, regrettably, in the health care system, like the academic system, no one has the ability to force anything. You have to get it by persuasion; brute force will not work.
Mr. Smith: We are using the forensic system, which you said in your report was one of the best in Canada. It is one of the biggest in Canada, but the gaps between what we know we should be doing and what we are doing are still pretty significant.
A good example is again concurrent disorders. For the last two years, we have had a concurrent disorders initiative. Many people got training and there is a very nice plan. When I first looked at the plan when I moved to B.C., I thought it needed to be disseminated, because it was perfect. However, people came back from training frustrated because the policies do not support a change of practice. There may not be alignment in the hospital or in the leadership for making that change. There may be confusion about what they are to do differently after the training.
We have taken a new strategy, and that is where this enhanced conceptual model of knowledge exchange comes from. It comes from our lived experience.
This is an area in which we manage these beds and the six provincial clinics. If we are going to try to do this externally, let us demonstrate that we can have a comprehensive change strategy that supports this, and every step of the way we find barriers. Sometimes there are attitudinal barriers, so we go in with attitudinal interventions. Sometimes it is alignment of management, so we deal with that. We are looking to see whether, if you address all the specific areas, you can have a change of practice.
Brian Golden's work in terms of strategic alignment shows that, if any of those are missing, there will be failure for different reasons. If you have all the information, but you do not have resources, you have frustration. If you have everything in place but you have no strategic direction, you have confusion. We have articulation of all the different pathways to failure, but if you get all these pieces in place, can you make a difference? That is what we are looking at.
The Chairman: Mr. Coleridge, would you comment on the population health side of this?
Mr. Coleridge: It is very similar to what Mr. Smith is saying. We are trying to change attitudes and behaviours in the public, targeted separately at youth, seniors and a variety of populations in multicultural communities. You have to create the environments for attitude and behaviour change. You cannot just educate people and give them information and expect that that change will happen.
In schools, for example, you look at what policies in a school may be a barrier or a facilitator to changing a behaviour related to nutrition, tobacco or other issues. You must look at those kinds of barriers and facilitators and build your comprehensive strategy around, which usually includes education and information, changes in policy and other types of activities like peer groups among students and training the trainers.
There is a variety of things, but in order to determine what those activities, tactics or vehicles are, you must understand the context within which those young people are operating, living and playing. It is very similar, just in different contexts.
Ms. Pape: I am thinking of groups or individuals who want to change and do not know how.
That brings me back to Ms. Goering's idea of a place in a knowledge-exchange process where people can say, "Here is what we want to do." I can see an exciting process where they get taken to a certain point, but this is not exactly it, they want to do something in this line. It can be very complex and people can learn and grow, and they, or groups, have initiated it themselves. Does that fit, too?
Mr. Smith: If I could add to that. We find there are all kinds of categories. For some people, just having the information, because they are ready, was enough. It was similar to what we know from our addictions work. There are different stages of change. Some people just need the new information and how their behaviour relates to the norm, and that is enough. Others need much more support through the process. It is very similar to changing practice on knowledge-exchange activities with clinicians and practitioners. You do find that different people and different groups need different things based on the Bridges model of change. If you have early adopters, you need to turn those into our champions.
It is looking at knowledge exchange from a changed management perspective. The great thing about it is that there is much literature to support how to do that in a systematic way.
Mr. Coleridge: I thought of a couple of other points around population health. There are some promising practices or lessons we can learn from other health areas, like cardiovascular disease prevention, and even in the tobacco area and a number of other areas, where policy and engaging and creating the environments to support attitude and behaviour change has had a population health impact.
Tobacco is a great example of where the research is in on best practice. We know that tobacco kills, and yet we still live and work in an environment where there are problems with that. Yes, policy change and educational programs have made a huge impact, but it is a great example of where research is clear and it is still happening. The biggest lever around the change we have seen, in terms of tobacco patterns, has to do with policy and not about educational and informational messages.
Ms. Goering: I do not want you to be too depressed.
The Chairman: I guess you are not supposed to get depressed at a mental health conference.
Ms. Goering: We do have many examples where people are implementing and changing things and doing best practices. We do tend to concentrate more on the failures than the successes. They are out there. We have learned a lot about how to do this.
SAMHSA has a whole program in the U.S. about how to implement best practices for the severely mentally ill. They have done a lot of research and they have a program of developing the tools that people need if they want a change. They have tool kits. The tool kits are around the following: What do the policy people need? What can consumers do? What does the provider need to know and do? They include educational things, summaries of the evidence; they include actual things that would help people make changes.
You could see how the knowledge-exchange function of the commission could be in the business of developing tools so that people who want to make a change in a particular area could actually go there, get the tools and have something to use. It could be more than tool kits.
There is also this concept of a rapid-response service, so that if people are looking for answers to questions, they actually call and talk to people who say to them, "If you are interested in that you should look at this New Brunswick program. You might want to check out this or do that." They craft a solution to the question in a quick and timely fashion and get it back to people.
I do not think we are at a loss for mechanisms. I still think it will be hard unless we decide in what areas or on what content it needs to be focused, because it would be anywhere and everywhere. There is a lot that we know that could make this work in terms of the functions.
The Chairman: I am taken by your notion that someone phones up. That is my Bluewater example, where someone phones up and says, "Do you know anywhere in the country that is doing good stuff with schools?" That is a useful function.
Your first point, though, seemed to suggest that you saw the commission actually developing tools as opposed to just putting out information about existing tools.
Ms. Goering: Yes.
The Chairman: I wanted to be clear. I had not thought about that function until now.
Dr. Lesage: Also on a more optimistic tone about change, we learned that change takes time. We need to have a long perspective. One example, again, is about smoking. Forty years ago, 50 per cent of the population was smoking; today the percentage of the population that smokes is 20 per cent. It takes time. You could say that there is a lot of evidence at all levels. We have repeated it over and over, but it is never ending. That is one point.
The second point is that it will have to be up to the commission, and whatever efforts in knowledge transfer, to make change happen more rapidly than it does, but it does happen in mental health.
You may remember that about 40 or 50 years ago we had a system of care for the mentally ill where the fixed point of responsibility was psychiatric hospitals. We have moved into a fixed point of responsibility being a form of community psychiatric care. More people were treated in the community than in the hospital.
We are now talking about moving the fixed point of responsibility to primary care. That is a big challenge. Many people fear that some people will fall between the cracks. That is likely to happen if not enough resources are made available.
At the same time, there is a situation where we have trains that arrive on time. That is, there are people in specialized services, for example, that do a marvellous job. There are model programs for young people with first-onset episodes of schizophrenia, for example. If my son were suffering from schizophrenia first onset, I would like him to go through that program, but I know it is not available everywhere. My colleagues running those programs say, yes, that is true. I would like this program to be available everywhere in the country. However, we are also in a situation where we are talking about taking away some resources from these programs to go to other important needs, for example, to support child care, et cetera. They ask, what will happen to those programs, the trains that arrive on time, at this point?
The Chairman: That is a big problem.
Senator Keon: I wish to intervene here. If our report can make an impact and we can develop a mental health system in Canada, that problem will be overcome.
When I started in cardiac care 30 years ago, we were doing a number of things at the Ottawa Heart Institute that were not being done anywhere else in Canada — 10 or 12 procedures. People had to come in from British Columbia, Newfoundland or wherever. I can tell you today that there is not a single thing that is not done across the country.
As well, with the integration of services, everybody knew where these quaternary services were available. There was national access, and with a very small intervention at the federal government level. As a matter of fact, they employ two people. They arrange the interprovincial transfer of funds so that no one is deprived of quaternary treatment in that discipline.
If you have an expert centre for the management of schizophrenia in one location, it may have to be enlarged or it may have to be duplicated or whatever, but with the appropriate integration of information through the very entity that we are talking about, this should be available to everybody in the country.
Ms. Pape: I wanted to add a specific example to the couple of examples Ms. Goering gave, the tool kit and telephone.
Ms. Goering: It is called rapid response.
Ms. Pape: The Hincks-Dellcrest Institute is involved in a project — I am now associated with it — developing a web-based resource for elementary teachers whereby they could identify a behaviour they see in the classroom that is troubling them. They might see a child that seems isolated or is crying all the time. The institute will put up bits of information from experts on the site so that people providing a simple description of the behaviour can have access to sites that can provide some answers. The access is designed to ask questions to take someone through the hoops and hurdles associated with finding the answers. Those answers might not be specific, but they can help to direct toward appropriate action. That is another way the web can respond to the need.
I am not saying that we should do this for the knowledge exchange centre, but a website can respond to questions generated by individuals or groups.
Mr. Block: When we talk about changed behaviour, one great influence is opinion leaders in their field. I can look around this table and see Ms. Goering, among other, who would have great influence over their peers across the country. If we could establish chairs in this area of knowledge exchange and then tightly align the program with this knowledge exchange centre, it would go a long way in influencing folks in changing their practices.
The Chairman: Are there other comments?
Dr. Lesage: I will speak to Senator Keon's comment that perhaps the geographical focus of the commission would be at both the federal and the provincial levels and to look for all the stakeholders at that level. That would include the decision makers, national or provincial organizations of providers of community and voluntary organizations. I would suggest that it include the media, research chairs and provincial and university research grant agencies. That would remain at the provincial level and would not necessarily move to the regional level because there would be so many people, although you talked about the media reaching all Canadians across the country. That would best be done with groups of Canadians rather than individuals. Other levels could have that role.
The Chairman: The idea of the commission was never that it would be a federal organization. In fact, it has been deliberately structured such that no single, special interest group, including government, would control it. The extent to which it goes down to the local community level will depend in part on where the demand originates. I would not rule that out. This is not a jurisdictional issue. It is interesting that every government of every political stripe across the country has not seen this as either a federal-provincial issue or as a jurisdictional issue. That simply speaks to the fact that they recognize that, first, they have a problem and, second, they would be willing to say that they should not have allowed it to become so bad. I am happy to pray for that.
Are there other issues to be discussed today?
Dr. Manion: Regardless of where it finally lands, the issue of proper resourcing for the activity and sustaining resourcing for the activity is critical. As the commission comes to be, because I believe, Mr. Chair, that you will not let it be otherwise, this must be imbedded in its core budget from the outset.
The Chairman: Agreed.
Dr. Manion: There is a lot of wisdom around the table from those who have done things that have both worked and not worked and know what some of those real costs might be.
The Chairman: I agree. Are there comments?
Mr. Upshall: I keep coming back to the same thing: None of this will be of any use unless we get the commission up and running. Is there some utility in engaging in a modest discussion about what we can do to move it forward? Are the wheels moving in a way that we can anticipate it being up and running by the end of the year, with appropriate funding?
The Chairman: I can say only, although Senator Keon might have a different view, that the pressure is being applied at the only places where the pressure matters. My experience thus far has been that I cannot find anyone who is against it. I can find many people who are in favour of it, both bureaucratically and at the ministerial level. This kind of process must run its course through October and November. My gut tells me that if there were much opposition to it building somewhere one of the two of us would have picked up that sense. Is that a fair summary?
Senator Keon: We must remember that this is a government commitment. The Prime Minister and the Minister of Health have committed to it, but there is big money involved. Senator Kirby can tell you about that better than I can because he was in the trenches for a number of years, so this requires a massage to get it through finance. However, in principle, I do not think there is any doubt about it.
The Chairman: We have recruited the necessary people and I think it comes down to the process; however, we will keep pushing until we get a formal decision.
Mr. Upshall: I have been following the Canadian Strategy for Cancer Control, the bill for which is $276 million, and, as you know, the cheque is almost written. I have received some indications that once the strategy is through and the vehicle is identified, it will move forward. The next step will be to model the commission on the cancer strategy vehicle.
The Chairman: I do not know what the cancer strategy vehicle is.
Mr. Upshall: Basically, it is similar to the mental health commission but larger and with a whole lot more money. It is an independent body managed by the cancer community. The $276 million is a little more than the $50 million we need to get things going.
My other frequent comment is this: Let us get the commission going and the research funding set aside, $50 million per year, and then let us have a debate on the basket of services.
The Chairman: On the transition, yes.
Senator Keon: Again, I do not think there is any secret. The commission is a $75-million deal. If someone had $25 million sitting in their desk drawer, the commission would be up and running.
The Chairman: Are there other issues?
Ms. Kidder: I had hoped to hear more about the anti-stigma campaign. The chair mentioned at the beginning that he would talk about the anti-stigma campaign as well as the knowledge-based campaign.
The Chairman: No, I said something slightly different. The committee wanted to have a round table meeting and then prepare a good background document. Then, we would have a similar event built around understanding and developing a background document that we could give on the anti-stigma campaign. Mr. Upshall is running a conference in the first week of October. An outcome of that will be a similar document for the anti-stigma campaign. That is part of mental health week, and other parts include the mental health champions lunch that those organizations do annually.
Mr. Upshall: We also have the launch of the new report on the face of mental illness in Canada.
The Chairman: There is a great deal happening during mental health week. Does anyone wish to add something?
Ms. Goering: We have talked a lot about the fact that, as soon as the focus is decided, there needs to be some sort of inventory or gap analysis. The people at this table probably know where the key websites and resources are that you should start with. It might be worthwhile for each to put down the top five and send them to you.
The Chairman: That is a perfect lead-in, because one of the things I was going to say at the end was that, as all of you go back on planes to various places, there will be things that will suddenly cross your mind that you wish you had said or that you want to amplify, so please just send them to us.
Apropos of that specific point, many of you talked about a lot of websites and a lot of pieces of information. To the extent you can direct us to those, please send them to us as well. They would be really helpful, and it saves us having to go out and find them on our own. You have already done the search, so we might as well save ourselves the time and effort of doing it again.
On behalf of my colleagues, let me thank all of you for attending here. I know some of you came a long way. This has been really helpful, in that if the commission is done, we will be able to give a much better road map to them, including a much better indication of the pitfalls to avoid and the people to contact.
The one mistake you did make in coming today is that we have a tendency to seek free help all the time from people who we think are smart and who know something. Do not think this will be your one and only contribution; the odds are that we will be back at you again in the next little while.
The committee adjourned.