STANDING COMMITTEE ON PUBLIC ACCOUNTS
COMITÉ PERMANENT DES COMPTES PUBLICS
Thursday 16 February 2006 Jeudi 16 février 2006
2005 ANNUAL
REPORT,
AUDITOR GENERAL
MINISTRY OF CHILDREN
AND YOUTH SERVICES
The committee met at 0943 in room 1, following a closed session.
2005
ANNUAL REPORT,
AUDITOR GENERAL
MINISTRY OF CHILDREN
AND YOUTH SERVICES
Consideration of section 4.02, children's mental health services.
The Chair (Mr. Norman W. Sterling): Is everybody settled? Welcome, Ms. Wright, to the public accounts committee. I see you have an opening statement, which we'll give you the opportunity to present. Perhaps you would also introduce the people sitting with you at the table, and if you require the assistance of any of the other staff sitting behind you, would you introduce them as they come forward. You may proceed.
Ms. Judith Wright: Thank you, Chair, members of the committee, auditor and staff. I am pleased to be here today to respond on behalf of the Ministry of Children and Youth Services to the Auditor General's and the committee's recommendations on children's mental health. Joining me today is Trinela Cane, assistant deputy minister of the policy development and program design division within the ministry, which is responsible for policy development for the key areas of children's mental health. I also have joining me at the table Terry McCarthy, assistant deputy minister for the program management division, which supports the ministry through the nine regional offices that are responsible for the transfer payment funding for children and youth services. Each of them has responsibilities for areas in the recommendations from the audit report, and they're pleased to be here to participate in the discussion.
I have shortened my opening remarks a bit, because I know the benefit of this is actually from the discussion. I just wanted to flag that for you.
I would like to begin by recognizing that the Auditor General's and the committee's recommendations have provided valuable input and direction as we move forward on improvements in mental health services for children and youth in the province. I will speak today about the progress we've made in addressing the issues raised by the Auditor Genera and this committee. I will also touch on some of the challenges we have faced in moving forward on implementation. I know that the children's mental health system is diverse and complex; we all know that. That makes finding ways to standardize and measure the system more challenging. We are moving forward, but at the same time, we recognize that this is a process of continual improvement.
Since my appointment as deputy this past October, I have had the opportunity to visit the 13 regional offices of the ministry. I have met with staff, service agencies and community partners, as well as families, and children and youth. I've met many very dedicated and hard-working people committed to improving children's mental health and children's services in this province.
In that context, I just wanted to remind members of the committee that the ministry was created two years ago with the overall objective of supporting the healthy growth and development of children and youth from birth to age 18 so that they can get the best start in life, achieve success in school and grow up to be productive and contributing adults. Within the area of children's mental health, the ministry is accountable for funding more than 250 agencies, including approximately 90 dedicated child and youth mental health centres, hospital-based outpatient programs and a telepsychiatry service through the Hospital for Sick Kids. The ministry also directly operates two child and youth mental health facilities: the Thistletown Regional Centre in Etobicoke and the Child and Parent Resource Institute in London. In 2004-05, the ministry funded programs that provided mental health services to approximately 153,000 children and youth across the province.
Before I talk in detail about our progress on addressing the audit recommendations, I would like to note a couple of areas that the ministry also supports that are linked to children's mental health, in particular in the areas of prevention and early intervention.
The first is the Best Start program: Its commitment to early healthy development and child care helps support each child's mental health and well-being by identifying young children who need extra support early. Through initiatives such as the preschool speech and language program and the standardized baby checkup at 18 months, children can get the help that they need sooner. This ministry also supports the aboriginal Healthy Babies, Healthy Children program, a voluntary early intervention and prevention initiative with a focus on home visiting the parents of newborns. This program is intended to improve the well-being and long-term prospects of aboriginal children in Ontario.
In response to the unique needs of aboriginal children and youth, the ministry provides funding for the Akwe:go program, operated by the Ontario Federation of Indian Friendship Centres. This new program provides urban aboriginal children age seven to 12 with the support, tools and healthy activities which will build and foster their inherent ability to make positive choices.
Mental health issues cover a broad spectrum. They can range from the stress a child might feel because of parents having disagreements at home, to bullying or showing aggression towards other students at school, to experiencing anxiety or severe clinical depression and other serious illnesses
As you are aware, the 2004 Ontario budget allocated $25 million in new funds for child and youth mental health services, which grew to $38 million in this fiscal year. The investment has helped create more than 100 new programs and expand 96 existing programs across the province, as well as providing a 3% increase in funding for staff salaries at community agencies. This brings the 2005-06 investment in mental health services for children and youth to $461.6 million.
We are working closely with the sector to increase efficiencies, for better coordination, better use of information and to provide children, youth and their families with the support they need.
I would now like to outline what the ministry and the service providers have done to continue to respond to the Auditor General's and this committee's many recommendations. We are confident that these initiatives will lead to improved accessibility, accountability and responsiveness in the delivery of child and youth mental health services.
The first set of recommendations identified the need to properly monitor the quality of mental health services provided, to establish standards of service and to work with partner agencies to take corrective actions where necessary. In previous discussions with this committee, the ministry representatives have addressed the steps we are taking to put in place the tools to collect the data and to measure outcomes in order to address the auditor's and the committee's concerns about service standards and access. In implementing these steps, what we found, and what the sector told us, was that we need an overall policy framework for children's mental health if we are going to have good data collection, comparable measures of outcomes and identification of service needs across the province.
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The ministry is now in the final stages of developing this policy framework for children and youth mental health. Last summer, the ministry distributed a background document on issues related to the policy framework to service providers and key stakeholders. This past fall, in partnership with Children's Mental Health Ontario, we received extensive community input from a range of stakeholders and service providers on the development of the framework. I would like to recognize Children's Mental Health Ontario, which has been our indispensable partner in developing this framework and has assisted the ministry in undertaking extensive discussions to help guide its direction.
The framework will outline guiding principles for the system, goals and a framework for a continuum of services and levels of care. We believe this framework will provide the foundation for the further development of provincial standards and guidelines to support evidence-based services. We'll be releasing the policy framework later this spring, and we will continue to work with the sector as we implement the policy framework
In addition, in order to both support the policy development process for the framework and to meet the recommendations of this committee to better measure outcomes in this sector, the ministry has developed an evaluation process for the programs funded by the new investments announced in the 2004 budget.
The provincial centre of excellence at the Children's Hospital of Eastern Ontario in Ottawa is leading the evaluation, implementation and design process. Secondly, the ministry is establishing baseline data for client progress and wait times based on the information obtained from the brief child and family phone interview -- or BCFPI -- and the child and adolescent functional assessment scale -- or CAFAS. These tools allow the ministry and the sector to identify baseline data against which performance outcomes can be measured. Use of these two tools by agencies will be required under the transfer payment service contract agreements for this year.
The auditor's recommendations related to wait times and waiting lists focused on establishing reasonable wait-time standards and the development of strategies to monitor and remedy situations where waiting times for services are too long. The standing committee's recommendations also spoke of the need to have a consolidated ministry wait list. We recognize, of course, the importance of good wait time data and monitoring wait times as a key indicator of service needs.
As we proceed with collecting the necessary data on wait times from BCFPI, we need to work in a thoughtful way that has meaning for the sector. We understand the importance of this information to parents and the importance of getting the information right. As we have been implementing the data collection process with BCFPI, we have addressed a number of challenges in moving forward.
The first is that the mental health services that we fund respond to a complex range of mental health concerns, disorders and conditions, ranging from anxiety disorders to substance abuse, attention deficit, to just mention a few.
Second, children, youth and their families may require a variety of services and interventions to address this need. We do not have a single or unique identifier, which makes it challenging to track whether clients are, appropriately so, on multiple waiting lists.
The third challenge is the need for greater standardization of terminology for the various stages of service. The provincial child and youth mental health policy framework, which I spoke about earlier and which is currently being finalized, will provide a foundation for addressing these challenges. However, in the immediate term, we continue to work with Children's Mental Health Ontario to develop baseline data for current waiting times.
The BCFPI tool I spoke of earlier has the capacity to provide critical data on wait times for child and youth mental health services. The tool also permits individual agencies to assess the needs of those seeking service and triage to provide support to those assessed as being most in need.
Children's Mental Health Ontario, working closely with the ministry, began collecting data using the BCFPI tool in 2004. The first provincial report on baseline data shows that in 2004, the average wait time for clients who were admitted to service province-wide was 36 days. As I mentioned previously, the ministry is working with CMHO to make sure data collected by agencies is done in a consistent manner and with consistent definition.
The 2004 budget investment of $38 million by 2005-06 in the sector was undertaken directly in recognition of the need for increased service capacity across the province. The new service funding was allocated through community planning tables in order to identify and respond to local service gaps.
In terms of performance measures, we recognize that they provide important information to support funding and program decisions. For the past two years, the ministry has taken steps to improve performance measures for services provided by transfer payment agencies.
In the short term, the ministry is establishing outcome measures for the new funding for child and youth mental health programs. The policy framework I mentioned previously will lay the foundation for the development of evidence-based standards and guidelines upon which outcome measures can be established across the sector. We are doing this work in partnership with the Provincial Centre of Excellence at the Children's Hospital of Eastern Ontario.
Key to supporting the development of good outcome measures and measuring quality services is applied research and evaluation. As you are aware, the ministry funds the provincial centre of excellence at CHEO to support relevant research and evaluation. To date, funding has been provided to seven major evaluation projects, and a further 22 such proposals are soon to be adjudicated.
Additionally, the provincial centre of excellence has built research capacity by funding protected time for practitioners to conduct research, undergraduate, graduate and post-doctoral fellowships, and youth awards tailored to combatting stigma.
The ministry has also taken steps to address the key recommendations from the auditor and from this committee related to strengthening of financial accountability. In the 2005-06 budget package for agencies, we made a series of technical revisions. These were communicated to agencies last July and have laid the foundation for more significant changes in the 2006-07 transfer payment budget. These changes will result in improvements to the accuracy, reliability and usability of service management information data. This will help us to better monitor transfer payment expenditures and to better assess whether agency funding is equitable and based on meeting the needs of children and youth in their communities.
As well, the ministry established a working group to update and provide consistent service description schedules for the majority of child and youth services across the province. This includes revised service description schedules for child and youth mental health services in the 2006-07 budget package. The revised schedules will be distributed to service providers this month.
Service and financial reports received by the ministry from the agencies have been improved, and corporate and regional staff have been trained so that we are better able to identify ineligible and inappropriate expenditures. We have also added expenditure and revenue worksheets to the 2006-07 transfer payment budget package to support additional year-end reporting requirements. We are continuing to provide training on transfer payment business process and accrual accounting to regional staff, and this includes emphasizing that surpluses identified through year-end reconciliation must be recovered.
Finally, the ministry has taken several steps to ensure that the management information systems provided sufficiently detailed, relevant and accurate information to allow monitoring of the cost-effectiveness of service delivery.
The fact that we are discussing these issues at this committee is evidence of how vitally important they are, and we thank you very much for your interest and for spending time to raise your concerns. All of your contributions add value. We work with our service providers and agencies to make improvements for delivering crucial programs to children and youth.
To conclude, steps have been taken and investments made to address the issues raised in the reports by the Auditor General and by the committee. I would like to take this opportunity to recognize the many dedicated individuals who work hard every day to support children and youth with mental health issues. We will continue to work across all regions with our many dedicated partners to build a strong, integrated system of child and youth mental health services. The goal is to provide vulnerable children and youth with the appropriate support when the need it, so they can achieve the best possible outcome.
Thank you. I look forward to the discussion.
The Chair: Thank you very much. I saw Mr. Zimmer's hand up first.
Ms. Shelley Martel (Nickel Belt): Are we going around in rotation?
The Chair: Yes, we'll go around. Go ahead, Ms. Martel; that's fine.
Ms. Martel: All right. Deputy, staff, thanks for being here this morning. I'm going to focus my first round of questions on the autism program. Where I want to start is actually in the allocation of funding for the preschool program last year, fiscal 2004-05, because, from an FOI that we got from the ministry -- we were of course looking for information about what the allocation was for IBI and what was spent -- we were very dismayed to discover that last year, the budget was underspent by $2.7 million and that instead of putting that money into IBI, especially when there was a waiting list, $2.7 million was directed instead to child welfare.
I'd like to know the rationale for this, because if I can just give you the numbers, somewhere around the time that the decision was made, there seemed to be 287 kids who were waiting for an assessment to determine if they would qualify for IBI. Another 399 children had already qualified and were on the waiting list for treatment. I don't understand why the ministry would have made a decision to redirect $2.7 million to child welfare in the face of that waiting list.
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Mr. David Zimmer (Willowdale): Sorry, I didn't hear.
Ms. Martel: I said I don't understand why the ministry would have made a decision to divert $2.7 million to child welfare, which was done, when there were those kinds of numbers of kids (a) on a waiting list ready for treatment, and (b) just waiting to be assessed.
Ms Wright: Thank you for your question, Ms. Martel. I'm going to actually ask Terry to speak to it in terms of managing that budget. I do want to acknowledge that we are tracking the expenditures this year extremely closely. We've recognized the importance of spending this money on service delivery for kids. We're tracking it carefully, and I believe we're on target for expenditures this year. But I will have Terry speak to last year's numbers.
Mr. Terry McCarthy: I'd like to further acknowledge that we share your interest in ensuring that all the money that's available for intensive behavioural intervention is in fact spent for the intended purpose. I will say, as I'm sure you're aware, that we've had capacity issues in that program. We've worked very hard with our service-provider community to recruit, retain and train suitable professionals who are able to provide services to autistic children. We've made choices available to parents in order to tap whatever available resources are in the community beyond those that reside in the nine regional service providers. What I'm speaking to in particular, of course, is the direct funding option, whereby some parents -- approximately one third -- make the decision to go out and hire trained professionals independently in the marketplace. This has allowed even more children to receive service.
This year, as the deputy has noted, we've tracked expenditures in the IBI program very carefully and I'm pleased to report that we're on track to spend virtually all the allocation for its intended purpose, providing intensive behavioural intervention for those identified children. As you know, last year, lacking the capacity to actually expand the program at year-end, we had to make difficult choices.
Ms. Martel: Can I interrupt? If you're saying to me that the problem was that there weren't enough people to provide IBI, I don't buy that argument. That was the same argument that the ministry -- former staff, okay? -- came and gave us when the committee looked at this report and when we found that the Conservatives had underspent in this program every year that the program was under way. That is exactly the rationale we got over 15 months ago, that there wasn't enough capacity in the system, there weren't enough therapists, so the services couldn't be provided. I don't buy that argument any more. We are 15 months later. We know that training has gone on.
I can tell you that I don't know a parent who has been offered direct funding who can't find therapists. The problem that parents have with direct funding is paying for the additional costs they have to pay out of their own pocket if they go that route versus direct service. The other problem you've got is that many regional providers won't even make an offer of direct funding to parents. So with all due respect, I don't buy that argument.
I'm happy to hear that you're on track for this year. I'm really angry to hear that last year, $2.7 million was diverted to child welfare at a time when 400 kids were sitting on a list waiting for treatment. I cannot believe that there weren't one or two or three or four parents there who couldn't have been offered the direct funding route and couldn't have found IBI therapists. I don't believe that. I don't accept that rationale.
Ms. Wright: You are correct: We have invested in the capacity side and trained 110 new therapists. And you are absolutely correct. We are in a much better position to offer IBI therapy now than we were a year or so ago. I think it's why we're confident in saying we're on track in terms of the allocation of that budget to what it should have been allocated to this year.
Ms. Martel: But Deputy, even last year, we were in -- what? -- year 5 or 6 of this program. So it's not as if we're talking about a new program. In year 2 or 3, I would have agreed that there was a problem ramping up, that there was a problem finding people. What I do know is that when parents are given a direct funding option, they have no problem finding therapists. We've got $2.7 million. What effort, if any, was made to make an offer to parents in any of the regions to go the direct funding route to ensure that those funds could have been spent? Why didn't that happen?
Mr. McCarthy: With respect, I think it's fair to acknowledge that while the program has reached capacity now, where we have the capacity to produce on the money we have, this program has increased in expenditures, year over year, since year 1, when it began with a mere $5-million allocation. Today it's in excess of $50 million. So while it's true that the program has been in existence for five years, it's also true that each year has presented capacity issues to us as we've expanded it.
The Chair: Could I just get a clarification from Ms. Martel's question? She indicated that not all regional agencies were offering the direct funding model. Is that correct, and why is it so?
Mr. McCarthy: I don't think it's entirely correct. I'll try to reply clearly here. We certainly have one regional office, the northern regional office, where there either isn't any uptake or any possibility of uptake because we don't have service providers available in the community to offer that service. There simply isn't the critical mass.
My understanding, absolutely, is that the direct funding option is available in every other region of the province and is offered to parents. Where the difficulty occurs, and I think where Ms. Martel may be commenting here, is that as parents on the wait list come to the first place in the wait list, they are offered a choice between direct service and direct funding. However, in all cases, one or the other of those options may not be immediately available. So while it's true that in some regions direct funding may not be immediately available as they achieve first place on the wait list, it's equally true that in some regions direct service isn't available as the first choice.
So it really does depend on how much money is allocated to direct funding versus direct service and at what point that particular parent achieves first place in the list. They are always offered the choice, but unfortunately in some cases, if their preferred option is one or the other, there may be an additional wait.
The Chair: Wouldn't the regional office be given X amount of dollars for IBI service?
Mr. McCarthy: Yes.
The Chair: If the first-in-line child for that service doesn't want to take the option that's available, do you not go to number two and say, "We have money for direct service"?
Mr. McCarthy: I'll try to be a bit clearer here. If we had allocated, for argument's sake, $100,000 in region A to deliver IBI, and $50,000 was allocated to direct funding and $50,000 to direct service, all those options are completely subscribed because of the demand. When one of those options becomes available, a place becomes available, for example, on the direct service side, the first in line is offered that option. If that parent chooses direct funding and it remains fully subscribed, there will be an additional wait for the direct funding option to become available.
The Chair: Why do you put it in two envelopes? That doesn't make sense. All we want to do is get the kids --
Mr. McCarthy: If I can explain, the direct service option really involves base funding of transfer-payment organizations. These organizations, of course, hire people into positions. They provide space for IBI. They do training. They do recruitment. They provide the infrastructure to the system. The direct funding option, of course, is much more flexible; it has no responsibility for providing any of those details. The direct funding option is, in effect, a piecework option. So, Mr. Sterling, there really isn't the kind of flexibility to take the money out of the direct service option at will. Those organizations have base budgets and simply don't have the flexibility to give up money on short notice.
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Ms. Martel: Except, if the direct service wait list is full and the next parent on the list comes up, one of the only reasons a parent wouldn't accept direct funding is because there are additional costs that are not covered that they have to pay out of their own pocket. This was an issue we raised 15 months ago. I ask at this point what the ministry has done to deal with that, because there wouldn't be any parent who is next on the list who would turn down a space in direct funding if it were offered, if they could be assured that the psychological assessments would be covered -- the costs for the psychologists and any of the resources that are already covered. So you could make those spaces available and every parent coming up next would grab a spot, provided some of those costs were covered. Right now you've got a two-tier system because parents have to be able to pay out of their own pockets in order to make the choice about direct funding. That was an issue the auditor raised, and that's an issue we raised 15 months ago. What has the ministry done to deal with the ongoing discrepancy between those two options for parents?
Ms. Wright: Let me talk a little bit, generally, about that, Ms. Martel. I think, as Terry touched on, the direct service option provides additional core kinds of services, and I think those are really important. In moving forward on policies related to autism, one of the aspects of it that I think is really important to discuss is -- two parts, I guess. One is that we are increasingly aware, as the research develops on ASD, that this is a lifelong disability, that this is a disability that's about a full-age spectrum. One of the aspects that's important to look at is what the full continuum of services is that individuals with ASD are actually going to need over their lifetime. So I think the discussions on the funding model are equally important to link to the fact that we need to increasingly look at what a full continuum of services is for all individuals, youth and children who experience this particular disability. The context within the discussion on DSO and DFO -- and I'll have Terry speak a bit more about that -- has to be placed within the fact that we are increasingly needing to take a broader look in that sense on this particular program area.
Ms. Martel: Okay. That may be, but right now we're talking about a very specific program that has specific options for IBI. I'm not talking about any other service here. Even with respect to the provision of IBI, the reality is that last year there were 400 kids who qualified for IBI and were on a wait list, and $2.7 million was not spent to respond. I cannot get that, okay? I cannot understand that. And it's not as if it was the first time it happened; it had happened every single year leading up to that. It was a focal point in the last report. The ministry can do what it wants on the full spectrum -- great. I'm just trying to deal with a reality of $2.7 million being rdiverted to child welfare at a time when 400 kids qualified and another 200 and some are waiting to be assessed. I can't understand this. I'll stop now, because I know the others want a rotation. Can I just get an answer to that, if there is an answer?
The Chair: Sure.
Mr. McCarthy: The only answer I'd offer, Ms Martel, is that I guarantee it won't happen this year.
Ms. Wright: We appreciate your point deeply, and we have put in place the steps we need to to make sure it doesn't happen again.
The Chair: Mr. Zimmer.
Mr. Zimmer: To move to some general questions about administrative challenges, in your remarks on the penultimate page, "The ministry has taken several steps to ensure that management information systems provide sufficiently detailed," and then there's a paragraph or so about management information systems and IT issues.
It seems to me, or I have the sense, that as you're trying to work through these challenges, there must be huge information technology challenges and management information challenges. In the almost two years I've been on this committee, time and time again we hear from ministries -- I suppose of the folks that we're dealing with, FRO was the most notorious in its challenges and difficulties -- that the best planned initiatives and concepts got wrecked on the management information challenges and so on. I was particularly struck by an answer to one of the questions of Ms. Martel from Mr. McCarthy, where he used the expression "We don't have the flexibility to respond" to turning something around quickly. The nature of the question escapes me, but your answer was, "I'm sorry, but we don't have the flexibility to respond in a timely way."
Can you tell me what the general management information challenges are, number one? Number two, give me some specific examples of IT challenges that probably go a long way to address some of the concerns Ms. Martel raises. Thirdly, I'd like some information about your budget for IT management information systems and whether you have enough in the budget, whether you have enough technical advice in that area to make it all happen.
Ms Wright: Let me take this question from two perspectives. I'll talk a bit about the challenges we faced in putting in place with the service agencies BCFPI and CAFAS, two instruments that we think are just extremely important to be able to move forward on the auditor's recommendations. Then more specifically, I'll ask Terry to speak about the kinds of information systems we've put in place in terms of accountability with transfer payment agencies when we fund them.
I touched on this in my remarks. BCFPI is a terrific instrument for looking at intake and wait times, and CAFAS is an instrument that looks at assessment. We have been working over the last two years with Children's Mental Health Ontario and the Hospital for Sick Children to work with agencies to embed these instruments and collect the data from them.
The challenges we've run into, and to some extent they're the challenges that will be the same in the information systems Terry will talk about, are first and foremost that children's mental health is such a diverse field. It's diverse not only in the diagnosis, but the agencies vary in size and sophistication in terms of their ability to use those sorts of instruments and their ability to use technology, so it's not a monolithic system. That has led to certain challenges on how the instruments get used.
Secondly, as I mentioned, the lack of a unique identifier in this field, as is true for many other fields where we try to do outcome measures, is a problem in terms of just knowing what the data really mean when we collect it.
Thirdly, what we've found as we implemented it was that there was not a consistent use of definitions. For example, what is a "discharge"? It seems pretty simple, but when you're working with this many agencies, it turns out to be quite complex.
So this year -- primarily, I'll deal with BCFPI -- in working with CMHO, we've identified those challenges by putting in place better training for the staff who actually have to use the instruments. We've also simplified, if I can use my non-geeky term, the software so that it's more user-friendly, and we've put in place community of practices, which enables the agencies to come together. We believe that has addressed some of the challenges, but we also know that there are many more we have to address. We will address them as we move forward with the policy frameworks. We believe that the 2004 report provided baseline data, but we're not totally confident it's really good data. We are confident that the data will be better in the 2005 report that we bring in.
Those are the challenges we've tried to address as we move forward on the auditor's recommendations from the perspective of data collection on the program side and the outcome side. Perhaps I could ask Terry to speak specifically on more of the ministry's IT challenges with the sector in terms of collecting information on holding agencies accountable.
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Mr. McCarthy: The deputy has referred to the diversity of the sector, and I have to comment that the diversity couldn't be greater. We have very small organizations, sometimes with as few as two or three employees, and large organizations employing hundreds of staff doing very complicated clinical work. The difference in sophistication among those agencies is immense.
The main information system we work with is called SMIS. We depend on a somewhat old-fashioned reporting relationship to the ministry. Unfortunately, information that currently comes in from the field must be transposed in regional offices and that does account for a number of transposition errors, so we do have some challenges. We have plans in place to look forward to a day when we have automatic uploading to the SMIS database from our agency system, and that should take care of the transposition errors.
The deputy has mentioned that we've embarked on a rigorous training activity, particularly with our contract management and financial services staff in the regional office to ensure they have a clear understanding of the expectations and requirements respecting data from the field.
We've also done a fair bit of work to define data elements. The deputy mentioned that simply defining "discharge" is sometimes a bit of a challenge. We've provided clear definitions. We're now reasonably assured that we will have a consistent information base upon which to make management decisions and help formulate policy.
We've also revised the service description standards, and I know the auditor had some concerns. Many of those service descriptions hadn't been revised in 10 or 15 years. Beginning in 2006, this budget year, we will have refined those service descriptions and standardized them across the various programs so that we all understand what programs we're working with.
Mr. Zimmer: Two follow-up questions: What portion of your overall budget would you estimate is going to get spent on IT management systems? The second question is that there's a certain optimism here that things are going to get better. Could I have some specific time frames on when you expect a number of these systems to be up and running in the sense that they're useful and are dealing with the challenges you're facing? Is that a year down the road, three years, four years or whatever? So money spent and some time frame for meeting these challenges.
Ms. Wright: I don't actually have those figures with me, but will get them for you, in terms of the percentage of the budget that the ministry currently spends on IT. I do know that we are aware of the need to increase our investment on the IT side, particularly in the program management division. Terry indicated that we had a somewhat, I think the phrase was, "old-fashioned" relationship. We are fully aware that we need to upgrade those systems, and we have been in discussions with finance on ways that we can do that. That will lead to not only better accountability but, I think, greater efficiency on our part with the agencies that we have and better use of looking at the data. So I will get you the information on the IT budget, and those are the contextual comments.
In terms of the systems that I spoke about, CAFAS and BCFPI, they are in place now, and as of next year, they will be required to be used by all of the agencies that we fund, that we have licensed agreements with. My own view on this is that the use of those instruments is truly -- it's a bit of cliché, but I'm going to use it -- a continuous improvement process, that when you are looking at using those sorts of instruments, you need to both continually improve the instrument and improve the process of what the data is and the analysis of the data you're getting. There probably isn't a drop-dead deadline as to when they'll be perfect. They will be implemented next year, and then we will continue to work with CMHO and the Hospital for Sick Kids to make sure that that data is as solid and valid as we can make it. Just to repeat myself a bit, the policy framework that we're working on will enable us to take that information and use it much more effectively in terms of determining outcomes and standard program assessment tools.
Mr. Zimmer: Just one last question: Is it a big challenge? You've got your province of Ontario IT management systems and so on. What's the plan for linking in or hooking up with all of the other stakeholders not, in the close sense of the word, a part of the provincial system? How are you going to hook up with their management information systems, IT stuff and all of that?
Ms. Wright: Are you referring to the agencies that we fund, or are you referring broader than that?
Mr. Zimmer: The agencies that you fund and broader than that. All of these stakeholders have got to be using the same script, if you will, the same computer script, to make the system work.
Mr. McCarthy: I'd like to be definitive; unfortunately, I can't be definitive. What I can do is give you a good example of some of the work that we're doing. In the north, for example, we've realized for quite some time that we've had a very good service system model that includes an IT infrastructure in the ISNC program, and we've made a decision to use that as a template to move that system into the urban areas of the north. One of the pieces of that will be to devise a centralized information management system together with a software package that will allow us, in the regional offices and corporately, to link in directly. We have to realize that while at one point in time we may be able to expect transfer payment organizations through which we deliver the vast majority of our services to be on the same database as we are, that doesn't exist right now. But the opportunity is nonetheless there if we can get our systems talking to one another. I think we have, largely speaking, agreement in the field that we need to move there.
The Chair: Mrs. Sandals, about five minutes, and then we'll rotate.
Mrs. Liz Sandals (Guelph-Wellington): Actually, David's introduction is good for where I want to go, because you're looking at consistent information technology and I'm interested in the policy framework and the actual service. How are we progressing with coming up with consistent expectations around actual service delivery and also the services that are available in different communities? My sense, anecdotally, is that as you move from community to community, the menu of services that's available in different communities is quite dependent on which agencies somebody happened to set up, so that you can go to one agency and there's a group of people that is focused on delivering one service. You go to another community and somebody delivers a different service. In fact, the menu of services available around the province has no consistency. We don't seem to have a handle on which services have which waiting lists, who does a good job and who does a lesser job. How are you proceeding with that whole area of getting a handle on who's waiting for what, what's actually available and does it work? I'm not sure we can handle all that in five minutes. That's actually the whole work of the --
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Ms. Wright: Actually I'll talk in more detail about the policy framework, because I think it's an important part of the answer to your question. There is absolutely no doubt that in the consultation, while we did the policy framework, we heard this issue raised again and again. As well as hearing again and again from the sector, we really want to have more collaboration and integration at the local level. You recognize, as you said, that we have such a diverse set of stakeholders and agencies here, that that's a complex conversation to have, but it was a very important part of that.
In terms of the policy framework itself, one of the objectives we've set for it is -- and Trinela can talk about this in more detail -- we want to begin to identify across the full spectrum what an appropriate continuum of service for mental health services would be and to begin to group them, for lack of a better word, in levels of care from the prevention side to the acute side, so that we can start to pull the services together in a levels-of-care manner. That will then enable us to engage in a conversation with the sector specifically about the question you've put on the table: What is a reasonable range of services for your community? That's an extraordinarily important conversation to have on the very question of how we monitor what the program services are and how we evaluate those.
The evaluation on the new funding that CHEO is doing for us, which I referenced in my opening remarks, is an evaluation just on the new program funding, but still I think it's a very significant step. Part of the first phase of that evaluation will be for them to take a look at what services are being funded, who's being served by them and what's the profile being served by them. The second phase will actually be to attempt to push that evaluation to some kind of effectiveness outcome evaluation. But I think that first step will form a model for how we can do this in other areas as well.
Trinela, I don't know if there's anything you want to add.
Ms. Trinela Cane: Perhaps I could just comment to your multi-faceted question. I'd like to take a little bit of a step back. The policy framework is going to play a very important role for us.
To your point around the complexity, the multiplicity of services, the differences in services across the province, I would like to comment that as part of our 2004 budget exercise, one of the pieces that Judith mentioned was the development of community planning tables for children and youth mental health. The reason I raise that is because it was at those tables where we brought people from different sectors and different disciplines together for the first time in a very long time to talk about children's mental health as a group.
Part of the focus of the actual fund was to bring people to a local consensus on the service gaps that they were facing, the service demands with respect to their various waiting lists and demands for specific types of services. In the plans, which were developed in very short order, within about a month's time, what we had across the province was both a local sense of what the issues were, what services were available and how groups could come together in a much more integrated way to decide on the types of services needed and how best to provide them. I have to signal that, because it's been a very different approach in the province. But it does signal the gaps in service. The fund has gone some considerable distance to address them. There is much distance to go, but I think, in terms of the framework that was laid with the planning tables, the local plans that began to identify the inventory of services available and not available, we'd like to use that as we move forward.
The other signal we got very clearly at the planning tables was the absence of a provincial policy framework. Certainly one of the first things I heard in my portfolio was about the need for a framework, a set of core principles and values, but for much more than that. I think the deputy alluded to some of the other elements we're going to have to put forward in our policy framework which really deal with not just establishing a set of core services, because people have asked for a set of core services -- but our extensive consultations throughout the fall related to the framework have in fact shown that that will not be sufficient. We need to identify a different structure and approach to the way we provide mental health services, the way we identify the key functions that need to be performed, from the prevention side, as the deputy mentioned, through to intake and assessment, right through to various interventions that are both acute interventions, episodic interventions and ongoing support for children who are going to be in need for the majority of their lives.
It's quite a complex issue. We hope that the policy framework, with a delineation of levels of care, will actually provide us the opportunity not only to design a service system that is able to deal with the complexity of need, but will also allow us to begin to develop service standards in each of those levels of care as we move forward. I apologize for a long-winded answer, but it is a complex issue.
Mrs. Sandals: It's a very complex issue, and thank you. It sounds to me like we are beginning to make progress. Maybe one of my colleagues, when they get a chance, can follow up with some information about how that ties into the new funding that has gone into the sector in terms of programming. Thank you.
The Chair: Mrs. Munro.
Mrs. Julia Munro (York North): I appreciate you coming here today, because children's mental health is certainly an issue that I think all MPPs have occasion to deal with in their ridings. It's something that all of us share in that regard.
As it happens, I'd like to continue the conversation on the policy framework, because clearly, from what you have provided us with as a committee and in the auditor's findings, this seems to be the centrepiece upon which planning will be done.
There are a number of questions that fall out from this that you have described. First of all is the fact that in your information you've set yourselves a deadline of spring 2006. So I guess my first question would be, are you on time?
Ms. Wright: For release of the policy framework? Yes, we are on time. That is a next step. With the release of the policy framework, we will then have to engage and want to engage with the sector on how we move forward with that policy framework, how we go about implementing some of the broad strokes that we've outlined here. But we are on track for releasing the policy framework in the spring.
Mrs. Munro: I can imagine that there's significant anticipation within the sector to see some of the details, and I'm not different in that I would like to have from you today sort of a peek at the direction in which you're going. I would like to come at it from the perspective of the hypothetical agency that exists. What can they expect to see coming from the development of this policy framework?
Ms. Wright: It would be a pleasure to talk about that. Thank you very much for the question. Just in terms of the question of peeking into this, I want to reiterate that this is a policy we have worked very closely on with Children's Mental Health Ontario and in conversation with the sector. So much of what we have here we put together with them. It reflects a lengthy, year-long conversation which culminated in a summit in the fall with representatives from children's mental health agencies to work through some of the aspects of this.
In terms of more details about what is being proposed, I will just ask Trinela to speak to that, if that's okay with you.
Ms. Cane: Thank you very much for the question. Perhaps I could give you a little bit of a sneak peek also at the results of the consultations, which are actually going to inform our policy framework. I should also comment that we are in the process of drafting the policy framework as we speak. It's still in fairly early stages. We will be engaging the expertise of clinical experts, sector experts and our broader stakeholder group as we move forward -- much more of an engagement.
The comment I will make about the policy framework development -- there are some who may say, "Why has that taken so long?" We actually developed a very intensive approach to engagement. It's one thing to develop a policy framework in the dark; it's quite another to actually engage in discussions, as we did, with over 300 individuals. We've received over 30 submissions related to our policy framework in all parts of the province, so it's actually been quite an intensive exercise.
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From a sneak-peak point of view, I'd like to highlight a few of themes, if I may, that came up in our consultations. All of them in some way need to find their way either into the policy framework or into the strategies that will support the implementation of the framework. Some of them will not be a surprise to you. We heard in great detail about the need for adequate funding in our sector and the need for resources to be available in a timely way for children. We heard a considerable amount about wait lists and wait times for services, about the need for more prevention at the front end of the system, as well as a much more intensive focus on the very specialized services that children most in need also require.
At the same time, we heard a great deal about human resources in the children and youth mental health sector -- the issue around recruitment and retention of staff, around salaries, which will not come as a surprise to you -- not only moving a sector toward a new policy framework but beginning to address some of these very foundational issues.
One thing that came out very loud and clear is that there isn't really common knowledge of evidence-based practices across the sector. By saying this, I don't mean that individual programs aren't working, with a research base and working on what they know will work with various children, but that across the province there's actually quite a bit of an inconsistent approach. In part, the centre of excellence at CHEO will help us with some of this, but I think as we begin to articulate the policy framework -- and let me get to what it might mean in terms of that -- we need to describe what our vision is for children and youth mental health. I assure you it can't be a status quo vision, because I think we heard loud and clear that the status quo does not go far enough or fast enough.
On the other hand, what we also heard is that there isn't a clear enough delineation of what people should be doing, what types of evidence-based programs they should be providing, what specialized supports and interventions should be provided for various types of issues that children are facing. One of the most widespread comments relates to the fact that we're not dealing with one mental health disorder per child; we are dealing with multiple and often concurrent mental health problems that transcend not just the children's mental health system but also Ministry of Health and other programs.
What came out of the consultations, as you will hear from what I'm saying, is a tremendous amount of complexity. As we begin to look at our framework and what we need to do, it's not enough, as other jurisdictions have done, to lay out the key areas of priority and focus. We are going to have to not only describe where we're headed as a system and how we're going to get there, but also delineate very clearly what we mean by levels of care, what types of functions are going to be provided in each level of care and how we mobilize the community system from an agency perspective to not only understand where they fit into that framework but what role they'll be playing for the future.
Mrs. Munro: Thank you. You touched on something that I would like to hear more about in terms of what you see as future steps, and that is the fact that because we all recognize the complexity of the spectrum of children's mental health, there are obviously, as has been referenced, the areas from prevention to significant acuity. How do you envision being able to provide what I believe this framework should do, i.e., support agencies? How are you going to look at even the differences in size of agencies? And by size, that implicates, obviously, staffing, levels of expertise and things like that. I think it's important for us to feel that those kinds of issues are being addressed in developing something as ambitious as this framework appears to be.
Ms. Wright: I think you've raised a really important issue in terms of how we proceed on the implementation of this framework. Part of the guiding principle in this is that it has a base assumption that's been developed, or a consensus, if I could use that word, amongst the stakeholders that there are a number of guiding principles that will be important as we move forward.
One of them is what you're touching on, which is that we will have a continuum of services in communities. That's not the same as having one agency in a community; that's actually recognizing that communities have different needs and agencies have different roles. But in having a continuum of services, it's really important that we have a collaborative, community-based planning process so that those services are in place.
Secondly, I think a guiding principle is that these services should meet the needs of children and youth, and part of the work that I've talked about before in terms of measuring outcomes and looking at service gaps is actually to also address that issue.
Thirdly, we need to move forward on evidence-based practices. So just to answer your question, when we look at what it means to an agency, we hope that a policy framework will help agencies develop their own expertise on evidence-based practices, and we hope that, as a community of mental health agencies, that will happen as well. I believe Trinela spoke to the importance of having a collaborative approach.
Those have been a set of guiding principles in the discussions with the agencies and the sector, and I think it will get reflected in the vision and the principles that the framework will put forward.
Mrs. Munro: When you mention the continuum, does that mean you envisage more agencies, fewer agencies or the same?
Ms. Wright: I think it's premature to answer a quantitative question. There's no doubt that everybody agrees there needs to be more collaboration and more coordination. So I think it's important to say that what we are talking about here is the system coming together in a reasonable way that meets the needs of children and youth.
The mental health system, you know as well as I, has grown up in a certain way and has lots of strengths from having the large number of agencies that it has. It also has some weaknesses, which are the questions of coordination and how you access the system. We've met with many parents, and I'm sure everybody at this table has as well, who are frustrated at times at trying to find the right entry point into the system. We believe that a combination of the initiatives we have started as a result of your reports, as well as the policy framework, will help resolve those issues as we move forward.
Mrs. Munro: I had another question that relates to that in terms of what kind of -- and I realize this is beyond writing the framework; this is really in the area of implementation. Obviously, when you write the policy framework, you know the next step is implementation.
The question of staff training and the kinds of expertise, particularly going back to your issue around a continuum -- I think no one would disagree that a continuum is an ideal, but obviously there are some challenges, and it seems to me that one of those would be around the issue of staff and potential staff training. Even the question of the standardized terminology that you've referred to obviously implies that. So I would like you to give us a sense of where you think the responsibility lies. To what extent is a regional office going to play a role, and to what extent would individual agencies do that?
Ms. Wright: I'll ask Trinela to speak in more detail about what came out of this in the consultation, because it was a really significant part of the consultation and certainly one that the service providers raised.
The specifics of who is responsible -- I think this is very much a joint responsibility. I think it is up to agencies to know what training they need to deliver their services best. It's equally up to the ministry to provide some global training and some global standards on what we think appropriate human resource needs are. So I would say this is one we definitely share in terms of responsibility. But I'll ask Trinela to talk about what came out of the consultation, because it was quite rich, actually.
Ms. Cane: Also, Mrs. Munro, to your question related to implementation, I want to be clear: In terms of the policy framework, by itself it doesn't answer every question related to children and youth mental health, as you can appreciate. I think when we're dealing with a set of organizations -- 250 various agencies -- pertaining to your earlier question about whether there will be a shrinking footprint, etc., I think I just want to be on the record as having said that we're trying to build on the strengths of the existing system. I think people engaged with us as part of the consultation process in good faith, that we are actually wanting to set a bolder vision for Ontario and that, in fact, there is a significant understanding that, to some extent, the sector has some entrenchment and that there is a need to move forward. We're trying to build at least on the positive spirit that comes from that, and part and parcel with the implementation will actually be a very significant staging that will need to take place over time. Once the policy framework provides the guideposts, essentially we'll actually have a very significant multi-year plan related to it that we'll have to roll out over time.
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In terms of the actual human resources aspect of this and the training component, the deputy is absolutely right that there are a variety of roles and responsibilities. I think it's up to us as a ministry to play a leadership role in both setting the frame, through the policy framework, but also understanding that based on a continuum of services and key functions that need to be performed and levels of care that will be inherent in that is really to identify what competencies are required for the people performing a number of services. Based on the evidence that we know best, what works and what training is required for folks to deliver the types of services that work are going to be very key components. What I will say is that the centre of excellence at CHEO has already undertaken quite a number of consultation sessions, both professional and clinical consultation, with key staff across the province in the various agencies, but also as part of best practices sharing.
I think we're starting, not from a position of understanding completely what standardization in competencies and training we require, but what the best practices are that are emerging. I think there will be a varied role to be played. The centre of excellence, over the period of years, will play an important role in supporting, training and competency development. We have a big piece of work, I would tell you, to do with colleges and universities, both in terms of the curricula that are being proposed and currently in place, which may not go far enough for what we need to deliver in terms of children and youth mental health for the future, and also a very strong piece of work with staff on the ground.
Staff played a major role in our consultations and have also indicated the need to be trained by their agencies in the context of what they should be doing. I think regional offices will be monitoring that and providing the actual centralized training per region where they feel it's necessary. Coming out of the planning tables, people locally expressed a need to have multi-disciplinary sessions and training so that they can begin to think beyond their own individual bailiwick, so to speak, to the broader children's mental health sector. That's a little bit of a variety of responses, but I think it is something that will have to be addressed.
Mrs. Munro: Do I have any more time?
The Chair: You've used up 17 to 18 minutes or so. I think we'll go to Ms. Martel.
Mrs. Munro: Okay, I'll save it.
Ms. Martel: I wanted focus on the information that you gave us dated January 2006, the ministry's response to the auditor's report on the special audit. I just have a couple of questions: The auditor -- I'll wait until you find your copies.
Ms. Wright: That's all right. Thank you.
Ms. Martel: Deputy, if you've got one copy there, I'll start. You're going to have to share. Let me go to number 5 first. This is not in any order of priority; just let me state that at the outset. The auditor, in point number 5, recommended that the ministry "Formally assess the relative advantages and disadvantages of the direct service and direct funding options and determine whether the current mix of selected options provided facilitates the delivery of services to the largest number of children." This certainly went back to the concerns about the different levels of funding and how many kids could be serviced because it was so much more expensive, from the information that we had, to provide a direct service option. I'd like to know where the ministry is on that. I'm not asking about a centre-based service delivery model; I see the answer to that. I didn't see any answer, though, with respect to that recommendation by the auditor.
Ms. Cane: Perhaps I can comment on a couple of aspects. As part of our commitment in response to the Auditor General, we indicated that we were undertaking what I will call the costing project, because one of the questions that was raised, as you will recall, in the last audit was related to the differential costs of DFO and DSO. This is something that was clearly brought to our attention, not only as part of our report but in conversations with both our service providers and parents that we have discussions with, and that will be of no surprise to anyone.
This is our first effort in examining the key differences between DFO and DSO. I should stress that this will inform what decisions we make in the future as to how we move forward. We actually undertook what we call an activity-based costing exercise, which has been a very laborious process. I'll talk briefly about the process and what we expect to come out of it.
We started with the three service providers that the Auditor General's report covered, in part because they had the best available data and they had it at the ready. What we undertook to do, working with our service providers, was take the individual functions provided by the service providers completely apart. Currently, the service provider budgets are really bundled in a fairly global way. What we identified for each of DFO and DSO was the key service components that are performed. They're things like intake, assessment, IBI as an entity itself, parent supports etc. What we did was identify all those key components, and then we attempted to map. Using the Canadian Institute of Chartered Accountants' approach to this type of methodology for this type of approach, we actually tried to do unit-based costing for each of these activities. We identified, with respect to DFO and DSO, the base costs for providing that discrete service in the absence of program administration and other things.
What we found, I think as we reported in the estimates process previously, was that the cost per hour for DSO is in the range of about $36 per hour -- these are preliminary types of analyses that have been done -- and DFO is in the range of $33 an hour -- fairly close hour by hour. But as you can appreciate, as we move forward across the province, these are just three key areas, largely in the GTA. We want to not only update the figures we used, which were from 2003-04 and may not represent the accurate truth as we stand today, but we want to extend it to our other six agencies that are also providing the service by way of creating not only an activity-based costing approach, but a way of actually fairly comparing apples and apples, not only the costs of the programs but as we overlay our evaluation results on the benefits of the program.
We're in fairly preliminary stages there. We have made a decision that for the foreseeable future, of course, we'll continue to offer DFO and DSO, but I think as we move forward with building the continuum and determining next steps, there will have to be some decisions about how to standardize the approach to DFO and DSO to ensure that the best possible services are available for children.
Ms. Martel: As part of that analysis, is the ministry considering that it may have to top up or would consider topping up those parents who choose the DFO option so that they are on a par with those people who accept a DSO?
Ms. Cane: I think that will have to be a consideration, Ms. Martel.
Ms. Martel: Do you have an idea of the costing of that differential?
Ms. Cane: I don't at this time, and I wouldn't want to hazard a guess.
Ms. Martel: But you've undertaken a commitment that this will be looked at, because clearly those parents have a disadvantage, and that can be significant if they're paying two, three and four years -- very significant.
Ms. Cane: Absolutely, and we understand that.
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Ms. Martel: The second question has to do with the recommendation that was made by the auditor, again in section 5, and this is on page 5 of 8: "Regularly receive and assess the extent of lost service hours for each service provider, take the minimum necessary corrective action to minimize lost hours, and reassess its practice of allowing service providers to retain funding for undelivered service hours under the direct service model."
My questions here are, what regular data/information is the ministry now receiving, I hope from each of the providers, about lost service hours? I see what you've written down in terms of the discussions you've had with providers about how to minimize that. What I'm more interested in is, are you getting the data, what are they showing you? Because the auditor's report, at least in a snapshot of one month, showed 33 or 38 kids lost about 4.4 hours of service a week. That's huge if we expand that over a service period.
In view of the numbers, and I hope you have them, is the ministry considering moving to a very formal policy that says hours will be made up? You fund the agencies through direct service. They have the money to pay for that being provided. If it is not being provided, especially in the case where it's the agency's fault, then I really think the ministry should be moving to a policy that says, "That has to be made up. You got paid for it. Now you have to provide the service." I don't think that has been happening.
Ms. Cane: Perhaps I'll start, and if my colleague cares to provide any additional information -- as we noted in our response, we've actually had very considerable discussions with our service providers about this issue. We've had a number of different meetings where we actually developed a series of strategies, as you will note from the response, that should be employed as part of good management practice across Ontario in our nine service providers. I know Ms. Martel's question is not related to centre-based care, but I think what some service providers are identifying in the plan of care is that for individual children in their care, there is an opportunity in some instances to move to much more of a centre-based approach.
This brings a number of advantages from a lost hours point of view, one of which is that there are a number of staff who will actually know the child and who have worked with the child on a daily basis. This is a very important issue, because change can be extremely disruptive. So if there is staff absenteeism, which there often is, this actually serves to mitigate it somewhat.
In the case of one-on-one IBI often taking place in the child's home, the agencies have looked at a number of strategies, beyond what I'd consider a normal management practice of employee wellness programs and those types of things, to actually look at having floaters available who can come in and perhaps know the child. That is difficult at the best of times.
I think the fundamental question raised by the member really relates to whether people are allowed to bank lost hours. We have not changed our policy in that regard at this time. As we are looking at moving ahead and a more standardized approach across nine regions, this may be something we will be looking at. Particularly, our principle would be that where it is through no fault of the parent or child that service hours are lost, we would do our level best to ensure that if it's possible, time can be made up.
The other comment I would make related to lost service hours is that each agency has been asked to track their lost service hours. At this time, I don't have a provincial report available, but I understand our program supervisors work with the agencies to discuss these issues.
Ms. Martel: So the agencies have been asked to track that. Is the ministry getting that information, just to be clear? Are you regularly receiving that information?
Mr. McCarthy: We're not regularly receiving it, but we could get it.
Ms. Martel: Okay, because the auditor's recommendation was that you do regularly receive it, so I'm wondering when that's going to happen.
The second thing -- I've got to be honest -- that I'm really concerned and unhappy about is that this was raised in the special audit. It was raised in the public hearing we had. At the time, I gave two really concrete examples of parents who had written to me to talk about their lost service hours. In one case, a family from London, the Bouffords: By the time their son got arbitrarily cut off at age six, he had lost over 560 hours of service that was never made up and never accounted for, even though the agency got paid, because it was a direct service contract. There was a second case of a father who was estimating that -- I don't remember all the details, so I apologize for this one -- significant hours were lost in the case of his son.
These were raised very specifically. Deputy, I appreciate that you weren't here at the time. These were raised as really significant issues that I had really hoped the ministry would get their head around, partly because of the numbers involved, what it would have meant for those kids to actually have the numbers, and more importantly because the agencies got paid to provide these hours -- and they didn't deliver. You don't claw that money back, and I understand the reason for that, because there's a structure. But for goodness' sake, the ministry and the public are getting ripped off royally with these numbers of hours of service that are lost, not to mention what has happened to the kids who need those hours.
I have got to tell you, I'm really distressed to hear today that 15 months later the ministry is still considering this, when I think you should have moved very clearly to have a policy that said to service providers -- not the parents; that's another issue -- "When the fault is yours because your staff weren't there, you make up the hours. They're banked. You make them up. We've paid for that." I don't understand why you haven't moved to that process. I'm worried to hear you say, "As we develop policy, we may get there," because that sounds like another 15 months before we get a decision in this regard.
Ms. Wright: Thank you, Ms. Martel, for raising this. As Terry said, we will look at getting that information. I think this is a particularly important issue, given the lifting of the age parameters. I think it does make the issue even more important, that we look at getting a definition on what the lost hours would be that doesn't, as you yourself said, penalize parents and puts in place some reasonable guidelines for the agencies. Thank you for your point. We will move on it.
Ms. Martel: So you've committed to --
Ms. Wright: We'll get back to this. I think Terry's point is that we'll look at what the hours look like. We will look at how, as we work with the service providers, we can move forward on defining lost hours in a way that is reasonable for them and is a reasonably accountable process. As you yourself say, sometimes these things aren't totally manageable, but where they are, you are correct, we should be looking at how we can make that well managed.
Ms. Martel: I wanted to ask a question on page 1. This went back to a recommendation by the auditor that the ministry "should consider having a direct contractual agreement with each agency that provides services" under IEIP. Your status was that you had had discussions and, based on those discussions, you're going to continue to use subcontracting and consider other things. I'd like to know what specific financial analysis the ministry did to make an assessment about the effectiveness to arrive at a decision where you were going to continue with subcontracting.
Ms. Wright: I'll ask Terry if he could address this.
Mr. McCarthy: I can't speak specifically to the exact financial analysis. I can speak a little bit more generally to why we made the decision to continue with subcontracting. We've tried to be sensitive to the need for local delivery agents. As you know, the regional provider is in a situation of providing the overall direction for the program and the training and the administrative link with the ministry's regional office.
Subcontractors are largely located out of county. They are trained and equally able to provide the service. What we've tried to do is ensure that the accountability relationship between the primary service provider and the subcontractors is clarified so there is a clearer line of accountability. We hold the regional service provider ultimately accountable for the quality and quantity of service, and they have clear obligations with respect to the subcontractors to deliver on those local delivery options.
Ms. Martel: In terms of that accountability, part of what led to this was that it appeared that some of the lead agencies had no clue what was being offered in terms of service etc. I'd like some reassurance that those issues that the auditor identified, where the main providers had no clue what was going on, have now been addressed in terms of service hours, what's being provided, costing etc.
Mr. McCarthy: There is a clear expectation that there is a reporting relationship between the subcontractors and the main service provider, so we should be able to get all that information through the regional service providers now.
Ms. Martel: Are you asking for that kind of information just as a check, as a monitor on any kind of basis?
Mr. McCarthy: Our program supervisors are looking at it, yes.
Ms. Martel: Can I ask what they're looking at, what they're requesting from time to time as a check?
Mr. McCarthy: I could get back to you specifically with that.
Ms. Martel: Yes, I'd appreciate that information.
This goes back to your costing analysis project. It was point number 4: "Where the costs of similar services vary significantly over time within or between individual service providers, the ministry ... should determine the reasons for such variances." I appreciate that you're trying to arrive at a costing model. There were variances, if I recall, within a provider in terms of really significant changes in costing both for DFO and DSO within a region from one year to the next and between regions from one year to the next. You've partially answered where you're trying to go on the costing model but in terms of that particular problem, what is it in the costing analysis that's going to get at those real variances?
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Ms. Cane: I think our hope, as part of the costing analysis -- and once it's extrapolated across all of the nine service providers, we'll get a very good sense from an apples-to-apples point of view just what the costs are, and it allows us some analytical opportunity for identifying where the variances are and why. We do know that across regions and even sometimes within regions there are cost variances in terms of supply and demand in terms of the service providers. Even the individual service providers in the nine locations, for example, have different salary grids that really speak more about their own local situation. So there are a number of variables that I think come into play.
At this point in time, what we've found across the agencies that we've looked at is that there is variability. We're just beginning the analysis related to that, but we do need further information across the province to understand just how different the costs are for each type and unit of service provided and to do some analysis in that regard. So we're at a very preliminary stage.
Ms. Martel: Do you have a sense of when that's going to be further along and you'll be able to make some of the decisions about what the program looks like?
Ms. Cane: As I mentioned, we've developed and tested the costing model and actually administered what I'd call the costing templates to come up with the unit cost for services in the three providers that I mentioned. We're fine-tuning the tool, because it did need some amendments based on the feedback we got and we're beginning to roll it out in the next month or so, in very short order. The service providers have already been notified that we will be moving forward, and I expect that within the next four to six months we will have some very definitive responses.
Ms. Martel: One of the commitments you made during the course of the public hearings around this, the day that we had the public hearing, was that there was an overall evaluation of the program being done. I see that you've engaged the services of Dr. Perry "to conduct an analysis of the historical information." I'd like a clearer idea of what she's been asked to do, and I'd like to know how parents are going to be involved in that process.
Ms. Cane: As you indicate, Dr. Perry has been contracted by the ministry to undertake what we're calling a retrospective review. This is actually similar to work that was done for Surrey Place Centre, which identified 89 children for whom we had entry data, clinical data on an ongoing basis and discharge-related data pertaining to those cases. Surrey Place Centre, with Dr. Perry's help, did a very extensive evaluation of the outcomes of the program from a child and clinical perspective, and that included discussions with parents.
In the case of the remainder of our nine service providers, Dr. Perry is currently sampling about 400 cases across the province. The data collection has already begun, and we're identifying cases for whom we have the relevant data; in other words, the intake information, the clinical reports on an ongoing basis and, where it's appropriate, the discharge or transition data in cases where that has happened. I'm not clear, though, on how parents are being involved, but I'd be happy to find that out.
Ms. Martel: I'd appreciate that because if it's an evaluation of the program and how effective it is, it's effective from two points: your clinical outcomes and from the parents' perspective and what they got out of it or didn't get out of it.
Ms. Cane: I'm not sure what approach is being taken with parents, but I do know that from an outcome point of view, we're looking at both the improvement made and what the factors related to that improvement may have been, as well as the impact on parents and families in terms of stress and burdens. Those are things that are being looked at. I'm just not clear on the details with respect to how she will approach parents, but I'd be happy to get that.
Ms. Martel: I would appreciate getting that information. That would be very useful.
The Chair: I'll go now to Mr. Patten.
Mr. Richard Patten (Ottawa Centre): Welcome to you all. Congratulations, Deputy Wright. That is an ominous responsibility with the title -- that name.
Ms. Wright: No name jokes, please.
Mr. Patten: I have two areas I would like to ask, and two of my colleagues also have other questions, so I'll try and be as quick as I can.
One area is research. The first thing I want to do, though, is ask a quick question and get a quick response. The services seem to be split up between some different ministries. For example, there are services for counselling and services for treatment within the educational system, within the hospital system. That's separate from the budget we're talking about here in terms of what you have, but there must be some interrelationship, it seems to me, because part of the ministry's -- and I recognize it's a new ministry. As an advocacy ministry, you must be looking at how that interrelates. A lot of parents will say that they're having to knock on too many doors in order to find or discover some of the services. Is my assessment on that positioning correct?
Ms. Wright: It is correct. I think for the first time -- I could be incorrect on this -- when we did the community planning tables for allocation of the new $25 million growing to $38 million, we involved representatives from education and health at those tables, so there was a full, broad spectrum of those.
I will say, in terms of the creation of the ministry, that the strengthening of relationships with education and health from a ministry perspective is one of my priorities since I've arrived. We do need to put some organizational locus in place to make that happen more effectively. As we've been putting the ministry together, it's one of the things we have to strengthen.
Mr. Patten: Given your role as an advocacy ministry, let me posit a general assumption. You may have the data already, but my recollection is that there's been a dramatic increase in requirements for children's mental health services in a variety of areas, some that require far more clinical attention than others, some that are permanent, some that are not. I notice much of the research you have and connections you have with other institutions such as the Ontario mental health organizations, CHEO and Sick Kids is on policy frameworks, best delivery systems and those kinds of things; the means by which we, after the fact -- I believe I'm correct in saying part of your role is looking at prevention. But I have to ask you the question: Do you have any good statistics on, first of all, the growth in the area of mental health requirements for children and a breakdown in some of the areas?
I know autism is just going out of sight. It's kind of scary, which leads me to believe that somebody has got to be taking a look at what is the root of all this. Our systems, as you well know, medically and otherwise, tend to be after-the-fact and treatment-oriented rather than, "Let's take a look at those kinds of trends." What's your position related to that?
Ms. Wright: We do have good data in varying places and areas, so we don't have a good overview data collection of all children's mental health prevalence data or necessarily case-specific data either. It is an area that we think is really important. We have established a new branch within the ministry, the focus of which will be to put some concerted energy and resources into a better statistical and data analysis of the children's mental health system, but we have a ways to go on that.
In terms of measuring the prevention side, it's a bit of a challenge. It's measuring something that doesn't happen. We do have an understanding of some of the key factors that are really important to preventing kids from getting lost, falling between the cracks. In research on youth at risk and students at risk, we have some really good understanding of what kinds of programs and services those kids need to be successful. We have put in place, through the Best Start program -- I think I referenced it in my opening remarks -- some early speech and language programs, as well as a proposal to have an 18-month well baby checkup, which will enable family physicians and parents to do a standard assessment of the developmental stage of a child and whether or not the child is at the appropriate stage. We're in the process of looking at something called the Nipissing scale, which was developed in North Bay, to help parents and family physicians do that. When that gets fully implemented, along with Healthy Babies, Healthy Children, which is newborn screening, I think it will go a long way to addressing some of the early intervention component of it.
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Mr. Patten: That begs the question that there should be some relationship, it seems to me, with the Ministry of Health Promotion. I don't see research on the fundamental basis of why it is -- there seem to be some indicators, even at childbirth, that suggest things like contamination of food, air, pesticides and all kinds of things. I don't know why we're all afraid to look at it, but I don't see it being looked at and incorporated on the preventive side of things. Be that as it may, I would encourage the ministry to promote that area of exploration.
Ms. Wright: If I could just speak very specifically to autism, we have, with the Ministry of Training, Colleges and Universities, endowed a chair of autism at the University of Western Ontario. Part of it is to be able to start investing in some of the important research work that is being done on ASD. ASD is a very emerging and volatile area in terms of research, and some of the questions you have raised are extremely important in terms of the growth we have seen in children experiencing ASD.
Mr. Patten: I have another question, but I'll defer to one of my colleagues. If there's more time, I'll come back to it.
Mr. Bill Mauro (Thunder Bay-Atikokan): Before I begin my questions, I just want to mention that procedurally we need to deal with a member being appointed to the subcommittee before we adjourn today.
Thank you for being here today. I want to get a clear indication that, on the $2.7 million that was transferred to other child welfare work, it's the position of your ministry that that occurred because there were not enough health care professionals to deliver the service. Is that what you said?
Ms. Cane: No. Just to clarify a point made by my colleague, the $2.7 million that remained as an under-expenditure last year was in part related to the ability to ramp up appropriate programs and services -- I know Ms. Martel has raised the question of DFO and whether that would have been a possibility. I should reference that this under-expenditure came in the context of an additional $10 million that had been put into our programs last year and was left on the table at the end of the year. But as you know, in a ministry with many competing priorities, which we've talked about, child welfare is a mandated program dealing, as we know, with our vulnerable children, and the ministry was in a position to have to make a decision around using the available funds from the autism budget to offset the legislated program.
Mr. Mauro: So it would be more accurate for me to say that you were given $10 million extra and you didn't have an opportunity to create the capacity to spend it all. Is that a more accurate characterization?
Ms. Cane: We made our best efforts in that area, but we were unable to, and there are a number of reasons that relate to that.
Mr. Mauro: So the $2.7 million that was left unspent actually indicates that $7.3 million more was spent.
Ms. Cane: Yes.
Mr. Mauro: Okay. I want to talk a little bit about the direct funding model. The suggestion is that parents who choose that method of service provision would be responsible for the assessment or some costs that are not funded through the direct service provision, right? That's what you've been saying?
Ms. Cane: Yes.
Mr. Mauro: Can you explain to me why that's the case?
Ms Wright: Terry, could I ask you to speak to the direct funding model?
Mr. Mauro: Just on the pieces of it that are not funded. Why would a parent have to pay for some costs that are otherwise paid for under the direct service piece?
Mr. McCarthy: In principle, and probably in an ideal world, that wouldn't happen. I don't believe the policy intent was to disincent parents from choosing the direct funding model. I believe Trinela has talked to us a little bit about the costing analysis to try to get a better understanding of the relationship between the pure costs of care delivered through the direct funding model versus the direct service option.
There was a belief -- I think a fairly broadly held belief -- that the direct service option was extremely expensive by comparison. I think the initial reports coming back, after detailed study of the three service providers that were involved in the last audit, tell us that the differential, when a direct comparison is made, is less than what might otherwise have been the case. Trinela referenced $33 per hour for the direct funding option versus $36 an hour for the direct service option, comparing an hour of comparable service for an hour of comparable service. We've also indicated here today that we will go back, given the information we have today and pending a further look at the remaining six regional providers, to try to determine a course of action that will correct that problem.
Mr. Mauro: So at the end of the day, I have to pay more if I choose direct funding, as it presently sits. Correct?
Mr. McCarthy: I believe that's true.
Mr. Mauro: Okay. I didn't hear in your answer why that is the case.
Mr. McCarthy: I can't give you a direct reason, other than to say that I don't believe there was a policy intent to disincent choosing direct funding option.
Mr. Mauro: I guess it raises another question for me, too, and that would be that if we would then be providing financing to parents to choose their own service provider, who would be doing the assessment on a child who might -- are they being assessed by the same criteria that somebody would be through the direct service piece? So whoever the direct funding provider was would have to do the assessment on the same basis as somebody who is a direct service --
Mr. McCarthy: Yes.
Mr. Mauro: Okay. So we don't have to worry about that part of it, then.
Ms. Cane: Perhaps I should just clarify, if I may, that the assessments are undertaken by the direct service providers in all instances, and then a decision is taken --
Mr. Mauro: Oh, I see. Then the costs would flow.
Ms. Cane: Yes.
Mr. Mauro: Okay. Why did we end up with two: direct service and direct funding? Was there an initiative from parent groups? Were parent groups interested in being able to choose their own service provider?
Mr. McCarthy: I'll try to answer a little bit and ask Trinela to finish up, if necessary. As you are undoubtedly aware, the province has funded autism services -- IBI -- for about five years -- Shelley will correct me if I'm wrong. Prior to that, many parents did independent research and looked at models of service delivery, mostly in the States. The method, as it was called then, was the Lovaas method. Parents independently contracted with psychologists and therapists to deliver that service. When the province introduced the program, many of those parents had intimate relationships with their therapists or psychologists. They trusted them, they believed in the quality of the work and they wanted to continue that service, but they wanted to be subsidized as well. At that point, I think it's fair to say, there was an historical imperative to continue that.
Mr. Mauro: So that would be a yes; the push was from parent groups. There's a characterization that there's possibly a bit of a two-tier system existing in terms of service provision and that those who can afford the costs that aren't covered through the direct service model can access this other piece. But the history of it is that this was in response to an initiative from the parent groups themselves, not a process initiated by the government of the day or by a ministry. Is that a pretty fair characterization?
Mr. McCarthy: Said quickly, I think that's true, but I do think there's a nuance there.
Mr. Mauro: Well, there always is. Thank you for that.
My last question is, from the 2003 audit to where we are today, there's approximately $100 million more being spent on children's mental health within your ministry, aside from the money, which my colleague Mr. Patten has referenced, that's spent in other ministries on these same issues. Can you just give me a quick sense of the new programs that have been added? The documents tell us there are new programs being funded and also that we've expanded services in what were some of the existing programs.
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Ms. Wright: I can tell you that of the new money that went into children's mental health -- the $25 million that is going to $38 million -- $12 million has gone to the 3% base funding for salaries for workers in children's mental health services. The additional money -- the $13 million that will go to $26 million, which will be ongoing -- has been to expand 113 new programs and enhance the 96 additional programs. Those programs have ranged in a variety of services. The actual services that were funded, as I think we indicated, were determined on a community basis by planning tables that said we need this service more than that service. Terry McCarthy is willing to give you some examples of the kinds of agencies that were funded, but the planning process was to bring, as I said, the agencies together with representatives from health and from the education system to say, "If we were to strengthen those parts of the children's mental health system in your community that need to be strengthened, where would we put those resources?" Does that answer your question?
Mr. Mauro: It does.
Mr. John Milloy (Kitchener Centre): Do we have time?
The Chair: Sure. You have a few moments.
Mr. Milloy: Thank you very much. I wanted to go back a little to some of the comments emanating from the policy framework discussion. Of course, so much of what is talked about and has been talked about by everyone around the table has been the silos within children's mental health. When you take a step back, you can take a look at the Best Start program and also at some of the work you are doing in terms of youth crime prevention. All those tie in to mental health issues.
Although I'm curious about how you are working to try to dovetail these different policies, I also had a more practical question, and that's about capacity. You spoke a bit about some of the organizations. As you said, a lot of them are very small organizations, with a few individuals running them, a lot of them have long waiting lists, a lot of them are mired in budgeting issues. In a sense, they're living right on the edge. When you talk about trying to break down silos, how do you deal with some of these capacity issues, to go to these small organizations and say, "Look, you folks all have to work together," when the fact of the matter is that they're having a hard enough time just dealing with their waiting lists and trying to live within their budget. I guess it's a two-part question, but more importantly, how do you deal with these capacity issues?
Ms. Wright: Thank you for that question. I think this is a really important topic for us to pursue. As I mentioned, in the consultation we did hear a lot about the need to bring agencies together and to collaborate. We also heard -- at least I did from a number of agencies when I went to the regional offices -- "We're planning too much. We're putting too many resources into this. We want to be there, we want to plan but we are awfully tight for resources." There's absolutely no doubt, when you talk to agencies, that they recognize they want to be there and they want to be collaborative, but it is taking time. I think we believe, and they believe, that the more we can systemize this and the more we can reinforce the importance of collaboration, the more we can find some efficiencies, and those efficiencies will actually help some of the smaller agencies, as well as some of the larger agencies, to work better together and use their resources better. That's the most direct answer to the capacity question.
The capacity question and collaboration lead into the question of how you actually coordinate services so that, as well, they look efficient and organized from the perspective of the parent and the child. So much of our discussion around the policy framework does deal with how you coordinate access. I think that if you can coordinate access, you can also help some of the smaller agencies in terms of their capacity. Before the Ministry of Children and Youth Services was created, the Ministry of Community and Social Services did a major piece of work called Making Services Work for People, which really was an opportunity to promote some kinds of models, coordination and efficiencies at the local level. It has worked to varying degrees in various communities, but we do believe we have learned a lot of good lessons from that, which we can use to go forward with.
Mr. Milloy: Taking something like Best Start, how do you then add that other piece? When you take a look at Best Start, at the range of programs there and trying to have them dovetail and address some of the children's mental health needs, that obviously must be a big challenge to the more, if I can call them, mainstream programs that are available to every child. How do you dovetail the two together?
Ms. Wright: On a very specific basis, we put out planning guidelines for Best Start which actually require them to consult with, for example, CTCs, and to ensure, as they are working on planning, particularly in the demos but in all of Best Start, that we have an opportunity to have the agencies that need to work with Best Start at the table with them talking about what the service requirements would be as we push the early learning and child care proposals forward and look at early intervention.
The Chair: I think the auditor had some questions with regard to the $33 and the $36.
Mr. Jim McCarter: A couple of years ago, when we did the audit -- I would agree with Mr. McCarthy's observation. With the data we had -- it was difficult getting good costing data, and I'm certainly happy to hear that you are actually getting better costing data -- we actually found that the direct service option was more expensive than direct funding.
My question is, in calculating the $36, are you backing out any associated administrative overhead? You're really just comparing therapy hours to therapy hours?
Mr. McCarthy: Yes.
Mr. McCarter: I see.
The Chair: Are you eliminating empty hours? In other words, if a therapist who's on staff has been paid, and is sick, are you including that as a hour of service?
Mr. McCarthy: We did not discount for that, if that's your question.
The Chair: So the empty hours are still at $36 an hour.
Mr. McCarthy: Yes.
The Chair: Do you know how many empty hours of service there are?
Mr. McCarthy: I don't know, but we've committed to Ms. Martel to try to determine that.
The Chair: How much overhead is there, on top of the $36 an hour, with the direct service?
Mr. McCarthy: I don't have that at my fingertips, but we can get that for you as well, bearing in mind that that overhead, just to be clear, pays for assessments, recruitment, outreach to parents on the waiting list and a variety of other services. I suppose the way I like to think about this service -- maybe it makes some sense and maybe it doesn't -- is that we have an obligation to ensure that there is that service capacity in every community in Ontario. The way we do that is the same way we do it with public education, the same way we do it with hospitals and the same way we do it with other public services. We do have an obligation to provide that public infrastructure, and stable funding, with all its inflexibilities, is part of that equation.
The direct funding option offers an alternative for parents. It's much more flexible. When viewed from one lens, it's much more accountable, but it also isn't responsible for being there all the time. It doesn't take on the role of assessment. It doesn't take on the obligation of training. It is an option, one that parents appreciate, but we believe we have the obligation to provide the direct service option as a part of ensuring that there is stability and predictability in this area of service.
The Chair: But as a parent, I'm more likely, or in fact guaranteed, that I'm actually going to get more hours of service with my child with a therapist under the direct funding model than under the other model. As a parent, I might say, "Even though I'm not going to get these side things, my kid is going to get more hours by taking this `lesser service.'" Is that correct?
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Mr. McCarthy: It's likely true in many circumstances. I gave you the example earlier on that it certainly wouldn't be true in the north, and I don't believe it would be true everywhere for always if we didn't offer both options. I think both options are indicated as a part of our responsibility.
Mrs. Sandals: Could I just comment on that as well?
The Chair: Sure.
Mrs. Sandals: My sense would be that in a lot of rural southern Ontario, you would have a similar issue as in the north, that if there were not an infrastructure service available, there would be no private service available. So I agree with your equity of service observation, but for those people who are doing the direct funding model, would it not also be true that, at least initially to get in to that model, they're taking advantage of the assessment services and the waiting list management services and the coordination, pointing them to other interim services available through the direct service model?
Mr. McCarthy: That's absolutely true, in addition to other services.
Mrs. Sandals: So everybody, in fact.
Mr. McCarthy: Yes.
Mrs. Sandals: Although future assessment may not be provided, the intake part of it and the coordination of other services are enjoyed by everyone.
Mr. McCarthy: That's true.
Mrs. Sandals: Thank you.
The Chair: We have about 45 minutes left before lunch. So we'll go around once more, starting with Julia. Let's keep it to about 15 minutes apiece.
Mrs. Sandals: I think Julia's got another turn, because we started with Shelley.
The Chair: That's fine. I think Julia doesn't want any more than 15 minutes anyway.
Mrs. Munro: Oh, no. I didn't realize we had that much time.
There are a couple of points that I want to come back to. The policy framework issue: I think one of the dilemmas that faces government in setting out policies is the question of providing incentives and ultimate compliance. You've indicated that this document will come out this spring, and obviously there are some processes that you've alluded to that would follow from that. So I guess my question, then, is on the issue of incentives and compliance and things like that. What kind of timetable have you set for yourself in terms of the development of this framework and, ultimately, agencies following this?
I recognize that earlier in your comments you said, and I understand, that to some degree this is a work in progress, but obviously you need to set timelines and be able to say to agencies, "Okay, these are our expectations." So what kind of expectations have you set forward in developing this framework?
Ms. Wright: Upon release of the framework, we will begin to work very directly with the sector on the implementation and on more detailed work planning and steps that we need to put in place with them to actually proceed to implementation. I think it's fair to say that doing a provincial policy framework, which has been attempted a number of times before, is an ambitious and, as Trinela said, visionary step. So we will be looking at doing it in a measured and reasonable manner, if that's part of the sub-question to your question.
I think that we really strongly believe that we need to get this policy framework in place if we are to get to issues of incentives, as you call them, or get to a system where we are able to know that our funding is actually good value-for-money funding, as our auditors have asked us again and again. We also need to have this policy framework in place if we are to be able to show parents that the system works. If we can get to evidence-based practices, we need the policy framework, but we want to take it in a reasoned manner. I guess we believe it's an important step, but it is one that has to be done very much in partnership with the sector.
Mrs. Munro: Are we privy to any kind of time frame?
Ms. Wright: In terms of when it will be done?
Mrs. Munro: Yes.
Ms. Cane: At this point in time, we don't have a complete time frame. As you can appreciate, we're still in the drafting stages of the framework, which still has a considerable amount of work attached. What I can tell you is that coming out of the framework, I think we are going to have to fairly quickly establish some priorities for immediate action. Not speaking specifically to the issue of incentives, because with that comes the question of sanctions, which you may have alluded to a little bit, I think our intention would be to identify those immediate priorities, those areas that we need to move the sector toward immediately in order to establish the right foundation for the next steps. I can't tell you today what they are. I think the sector is quite variable ,and some of it is for good reasons, but I think we're going to need to identify the areas where we need standardization and what that needs to look like, and then I think as part of our service management and our priority setting, we will establish targets to move towards. It will be very much target-focused in terms of moving agencies in that direction.
The other thing that is going to be important is this: When we talked about the evaluation that we're doing of our new funding, there could be some very tough decisions when we may find out, as part of the evaluations, that even though we've tried to choose evidence-based approaches, and we've done that from the get-go, there may be programs and projects that aren't working effectively. With that comes a responsibility for some decision-making, that we either won't be going ahead or we will go ahead in a different way. I think we have a different set of opportunities, both around the evaluation framework we're putting in place, and what we're going to do about that and what it tells us around articulating the standards as part of the policy framework, identifying which priorities we're moving on at what pace -- and I don't know that as of today -- and then attaching expectations from a service and perhaps a community planning table focus that are going to be required.
Ms. Wright: The framework will address aspects of things such as guiding principles, what are the system goals and what is a continuum of service in broad-level terms. I don't want to mislead you that we're releasing a detailed plan in the spring. We believe this is an incredibly significant step to working with the sector, to begin to bring a framework onto the ground that we can move forward with in terms of service outcomes and service measures. But the first document we release will really deal with vision, guiding principles, systems goals and a broad description of a continuum of service. Then we will work and move and engage with the sector on what that looks like as we start to work with each of the agencies and the communities. I just didn't want to mislead you that I had perhaps promised more than I am able to deliver.
Mrs. Munro: I guess my question comes from the fact that, as I expressed when I made my first comments this morning, we, as MPPs, are all aware of the great need that sits in our communities and the question, then, of anticipation of dealing with issues. We've talked a great deal about the autism side of things and that parents understandably feel extremely pressured and so for everyone this has a timeliness. People age out. This is why I'm sure that from your perspective it's something that you recognize: Yes, you've talked about the broad goals and perspectives, but there's an element of not only anticipation but, quite frankly, need for people to feel comfort in the progress that's made in this regard.
That leads me to my second area, where I want to stress what I feel is very important in this process, and that is transparency, particularly for parents, because the object of all of this is obviously our children. The kind of emotional investment that every parent has in his own children then becomes focused on the frustrations of a system. I think that we are all cognizant of the many, many examples -- too many examples, I would argue -- of that kind of frustration. I would ask you to comment on the steps that you intend to pursue that will provide that kind of transparency, not only for parents but also for the public at large.
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Ms. Wright: I would like to also say that we really are seized with the urgency of this; I don't mean to imply that we're not. We recognize and we talk to parents as well who are frustrated with their inability to get the services that they need. I think that we can appreciate that frustration a great deal.
The new resources that we have put into children's mental health, the $38 million, were put there in recognition of the need to provide those additional services. As I indicated, there are both new services and an expansion of existing services that will help to address them.
The issue of accountability and transparency is an extremely important one as well. I will speak to the wait time a little bit, because that is one of the areas of great frustration to parents. The steps that we have taken in terms of the agencies using a standard instrument now, the BCFPI, to do a standard intake and to be able to standardize the way in which they manage their wait times is a significant step towards increased transparency for parents, for the agencies and for us.
I've spoken a little bit about the challenges we face, but the fact that Children's Mental Health Ontario is collecting that data on a quarterly basis and talking to regions about it through planning tables and community-of-practice tables not only helps the data, but also helps with the transparency.
Mrs. Munro: I think it's extremely important to keep that focus. My next question actually dealts with the waiting list, obviously following on the same logic you used in creating an answer. I wondered if you would comment on some of the dilemmas with regard to managing wait lists. Where is the thinking on making what are sometimes very tough decisions for people managing wait lists? Quite frankly, the frustration also in that "management," whether you're using specific criteria -- I've known of situations where people have made the decision not to have a long wait list. That doesn't mean that there aren't people out there in the community who in fact need service.
I'm a bit nervous about this wait list issue, because I think it can be manipulated. We need to understand, and the parents need to understand, particularly, as you point out, on the transparency side of things, what the tools are and how those decisions are made. More importantly, from your perspective as being responsible for creating a policy framework, what advice are you going to provide on the issue of wait lists?
Ms. Wright: We really believe strongly that the instrument we've put in place, BCFPI, will help with determining wait times on an agency basis. We are not happy that that data is as strong as it should be now, so we are working with agencies to improve the data and the data collection, and, as I mentioned, are confident that the data we get in 2005 will be better.
I'll answer your question on what the key components are of appropriate wait time management, and then I'll talk about wait lists. On wait times, I can't say it too often: It is having a common set of definitions, having a rigour around the use of those and having an ability to collect that data in a way that's comparable and is about outcomes, because it is outcomes that parents care about. I don't mean to sound like this is too much like a systems process; it does lead to something that matters to parents.
Those are the challenges of collecting the wait times. We have put in place a number of strategies to address some of the limitations of the data, and we are confident we can move forward with that. As I said earlier, as we move forward and become more adept at this, both as a ministry and as a system, we'll continue to refine it and improve it.
The issue of collecting appropriate data for outcomes is something that's going to be with us forever and ever and we just have to get better at it, and appropriately so. That's my first point on this.
In terms of actually managing wait lists, it's probably a more complicated question. I know the committee made a recommendation on ministry managing of wait lists. I think at this point wait lists are still being managed at the agency level and the regional level. We believe that continues to be appropriate for three reasons. One is that we don't have the database yet to do it, if we did want to do it. But the more salient point as to why managing wait lists is a local issue is that it enables the local community to have their own priorities. They know their communities better than I do, sitting in -- where do I live? -- 56 Wellesley. So it's really important for the local communities to be able to manage wait lists.
Secondly -- and I think this goes to Mr. Patten's point -- increasingly these are questions of clinical judgment. The minister certainly doesn't have the capacity to deal with, second-guess or even comment on clinical judgment at this point. When you put those two together you have a case, at least in the immediate term, for wait lists to be managed at the local level.
The Chair: We may have a division in the House, and some members might want to leave to vote. So whenever that division takes place, we'll break off and then continue after that until 12:30, when we're going to have lunch upstairs.
So, Ms. Martel, would you like to go ahead at this time and take at least part of your time.
Ms. Martel: There are two things I want to raise, and I have some other questions. The first still has to go back to the $2.7 million, because we've got some different answers about what the reasons were, and I appreciate all of that. What I'd say is this: If it became clear that regional providers or their subcontractors were having capacity issues in terms of delivering the direct service option and that they were going to be in a position where they could not offer any more spots for whatever reason, then I really think a directive should have gone out to those agencies to say, "Then put your money into the direct funding option." If the reason was that on the direct service side there was just no capacity for any other children to be given service, because of human resources or whatever, then clearly in each of those agencies, or any agency, there should have been a directive to say, "Move to the DFO model," because that wouldn't have been a burden on any of the resources of the direct service provider. You wouldn't have been calling on their therapists, because you would have been contracting their own. You wouldn't have been having a requirement to have wait-list management, because you would have been off the wait list. There wouldn't have been a requirement for somebody to be looking for other resources for you, because you would have been getting the resource you really wanted and needed in the first place, which is the IBI.
Secondly, I think I have to provide some additional information and maybe get some clarification about the DFO model, because I appreciate the questions that Mr. Mauro was raising. Parents who are on a DFO model pay for all of the resources of the program for their child, whatever those resources may be. Under the direct service model, those are covered by the agency or the subcontractor. So whatever resources they have for their children to participate in the program, they pay it out of their own pocket.
What is happening and what has been happening in a number of areas, as far as I'm aware, is that the cost of the therapists has increased and parents are paying for an additional portion of that cost of the therapist. I don't want to say there's a cap, but there is a limiting factor here in terms of what is paid for therapists, and I know there are parents who are covering an additional cost, because the hourly cost of their therapist is more than what they're getting to pay for that. Under the direct service model, that's covered.
Thirdly, if I'm correct, there is a cost around the psychological supervision of the program because, rightly so, a psychologist should be supervising a direct funding program as well. But my understanding also is that the cost is related to a percentage. If you were having 30 hours a week, 10% of that is supposed to be a psychologist's supervision or a lead therapist's supervision. So that's three hours a week, and the parent on DFO is responsible for paying that cost, which would be covered under direct service.
Those are three areas that I think I'm pretty confident to say are areas where parents pay out of their own pocket if they are using the direct funding option. Those are costs that would not have to be covered under direct service. Why it leads to two tiers is because some parents can afford to pay for that and some parents can't. Over the course of a year, that can be a pretty significant cost, especially if they're picking up additional hourly costs of a therapist. If you've got a 30-hour-a-week program going on, that could be really significant.
The ministry can clarify that or get back to us with some additional information, but that's certainly my understanding of some of the out-of-pocket costs for parents on DFO.
The Chair: I'm going to ask you to hold your response until after the members return from voting. We'll reconvene right after the vote has been taken.
The committee recessed from 1201 to 1211.
The Chair: I believe Mr Patten has a few more questions. There's a response to yours, or do you want to --
Ms. Martel: I didn't get a response.
The Chair: Do you want the response now?
Ms. Martel: Yes, and I had one very short question after that.
The Chair: Okay.
Ms. Wright: Terry McCarthy is going to pursue the conversation with you, Ms. Martel.
Mr. McCarthy: I'd just say that we're appreciative of the recess so we could provide you with a better response.
We take your points, Ms. Martel. I just want to reiterate a bit. There is no policy intent to disadvantage the direct-funding-option parents. In discussions with my colleagues at the recess, it's somewhat clear to us that the funding that is currently allocated by way of unit allocation for IBI to DFO parents is based on a point in time, and I think we're all in agreement that we need to bring that analysis up to date. If the costs of delivering these services exceed the capability of parents, then we need to take that into account. So we'll commit to do that today.
The other piece, I guess more broadly, is that we need to look at the proportionality, I suppose, between our funding allocation for DFO and DSO, keeping in mind two pieces. One is parental demand, because I certainly heard Mr. Sterling speak of that, and we understand completely why parents would gravitate to this option, but at the same time balancing that against the need to maintain a basic infrastructure in each and every community across the province. I'll commit to you here today on behalf of all of us that we'll look at that as well, so that we can deliver a stable program but one that's fair to everyone.
Ms. Martel: I appreciate that commitment. I just wanted to ask one final question about the autism wait list. I'd like to know if you can get the numbers for the committee -- I don't know if you have them today, or you can get back to us -- on two elements as most up to date as you have: The wait list that's now in place for children who have qualified for IBI and are waiting for service and, secondly, those children who are still waiting to be assessed.
I recognize the complexities as a result of Deskin-Weinberg and what that has meant in terms of kids over 16 on the wait list. I won't make any comment about that. I would just like to know what the most recent numbers are around wait lists in this program.
Ms. Wright: We can get that information to you and to all the committee members.
The Chair: Mr. Patten.
Mr. Patten: It's in the same area as the last question Shelley asked -- three comments and then a response.
One, the function of the LHINs that are now being established is to provide some integrity and presumably co-operation and coordination. One of the biggest challenges it's going to have is waiting lists from a variety of areas. My question is, do you have available or have you taken advantage of other ministries that are looking at waiting lists, acknowledging that indeed each manager of a waiting list probably has some unique features that others don't have?
Number two -- and this is for the Auditor General -- there are generalities throughout the whole government system, and this is one of them. When you begin to see a pattern of things developing, are the IT offices on their own? Are they part of a larger government-wide system? Is there an ability of the government across the board to gather its collective wisdom to be supportive of a new ministry in looking at trying to develop its database for waiting lists and manage that for the purposes of its programs?
Ms. Wright: I'll answer the first question, or would you like to answer the first question too?
Mr. McCarter: No, it gives me time to think.
Ms. Wright: Oh. After you, Alphonse.
Yes, we have actually benefited primarily from the experience in health with having managed wait lists, how they define them. You've probably followed, as well as I have, the national debate on trying to come up with a standard for a reasonable wait time for whatever it is, four or five procedures. I think that actually reflects the complexities you've acknowledged. We have been actively engaged with health and learning from health in terms of how they go about doing wait-time management. It's been primarily health, and we will start to engage more with the health promotion ministry at this point.
Mr. McCarter: With respect to the IT issue, I think what you're getting at is that a lot of the agencies have good data in their databases. Unfortunately, their databases can't communicate or link up to the ministry's central databases. So what happens is, if the minister wants information, they basically send down either an Excel spreadsheet or a template, and somebody's got to re-enter it, pull the information off. It goes to the regional office and they have to re-enter it yet another time.
Ideally, if you could have middleware that would basically link up two databases and allow them to communicate, you could actually go in and extract the data, the analysis, right from their database. It's more difficult to do that than you might expect. It's a fairly difficult issue and you may decide, "You know what, we only want to do it for the 10 or 15 very large agencies, and for the other 235 agencies, maybe we'd do it the old way."
Ms. Wright: When I was speaking to Mr. Zimmer's question about IT, I was alluding to the fact that we are aware that we need to invest in our IT function around collecting agency data and that we were in discussions on how to do that. It was an oblique explanation for that.
The Chair: Thank you very much, Ms. Wright, Ms. Cane and Mr. McCarthy. We appreciate very much your frankness and openness with us.
We usually meet in camera in order to give our researcher a few directions with regard to writing our report or not. I'd ask you, because we are in a time bind here, to vacate as soon as possible. While you're vacating, I believe Mr. Mauro has a motion.
ELECTION OF SUBCOMMITTEE
Mr. Mauro: I move that a subcommittee on committee business be appointed to meet from time to time at the call of the Chair, or on the request of any member thereof, to consider and report to the committee on the business of the committee;
That the subcommittee be composed of the following members: the Chair as chair, Ms. Munro, Ms. Martel and Ms. Sandals;
That the presence of all members of the subcommittee is necessary to constitute a meeting; and
That substitutions be permitted on the subcommittee.
The Chair: Any discussion? Carried. Thank you very much.
The committee continued in closed session at 1220.
CONTENTS
Thursday 16 February 2006
2005 Annual Report, Auditor
General:
Section 4.02, children's mental health services P-7
Ministry of Children and Youth Services
P-7
Ms. Judith Wright, deputy minister
Mr. Terry McCarthy, assistant deputy minister, program management
Ms. Trinela Cane, assistant deputy minister, policy development and program
design
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Chair / Président
Mr. Norman W. Sterling (Lanark-Carleton PC)
Vice-Chair / Vice-Présidente
Mrs. Julia Munro (York North / York-Nord PC)
Ms. Shelley Martel (Nickel Belt ND)
Mr. Bill Mauro (Thunder Bay-Atikokan L)
Mr. John Milloy (Kitchener Centre / Kitchener-Centre L)
Mrs. Julia Munro (York North / York-Nord PC)
Mr. Richard Patten (Ottawa Centre / Ottawa-Centre L)
Mrs. Liz Sandals (Guelph-Wellington L)
Mr. Norman W. Sterling (Lanark-Carleton PC)
Mr. David Zimmer (Willowdale L)
Also taking part / Autres participants et participantes
Mr. Jim McCarter, Auditor General
Clerk / Greffière
Ms. Susan Sourial
Staff / Personnel
Elaine Campbell, research officer
Research and Information Services