STANDING COMMITTEE ON PUBLIC ACCOUNTS

COMITÉ PERMANENT DES COMPTES PUBLICS

Wednesday 29 April 2009 Mercredi 29 avril 2009

APPOINTMENT OF SUBCOMMITTEE

2008 ANNUAL REPORT,
AUDITOR GENERAL
MINISTRY OF CHILDREN
AND YOUTH SERVICES


 

   

The committee met at 1230 in committee room 1, following a closed session.

The Acting Chair (Mr. Ernie Hardeman): We'll call this meeting of the public accounts committee to order. I'm Ernie Hardeman, and I'm sitting in for the Chair, Norm Sterling, who was called away for a funeral this afternoon, so he couldn't be here. We will try and get this done in an orderly fashion so I won't have to go on the carpet for too long when Norm returns. But we do want to thank everyone who's here for coming in this afternoon.

APPOINTMENT OF SUBCOMMITTEE

The Acting Chair (Mr. Ernie Hardeman): We do have one item of business that we need to clear up for the committee. I believe, Mr. Zimmer, you have a motion to put on the floor.

Mr. David Zimmer: Yes, thank you, Mr. Chair. I move that a subcommittee on committee business be appointed to meet from time to time at the call of the Chair, or at the request of any member thereof, to consider and report to the committee on the business of the committee;

That the presence of all members of the subcommittee is necessary to constitute a meeting;

That the subcommittee be composed of the following members: the Chair as Chair, Mrs. Sandals, Mr. Hardeman and Madame Gélinas; and that substitution be permitted on the subcommittee.

The Acting Chair (Mr. Ernie Hardeman): Thank you very much. For the members of the committee, this motion is required because we've had a change in the membership of the committee, so the former committee no longer exists here.

Is there any debate on the motion? If not, all those in favour? All those opposed? The motion's carried. That concludes that part of the meeting.

2008 ANNUAL REPORT,
AUDITOR GENERAL
MINISTRY OF CHILDREN
AND YOUTH SERVICES

Consideration of section 3.04, child and youth mental health agencies.

The Acting Chair (Mr. Ernie Hardeman): We are here this afternoon for consideration of section 3.04 of the 2008 annual report of the Auditor General, child and youth mental health agencies. We have the Auditor General and his staff here to hear the presentation, but what we really want to hear is the presentation from the people who have joined us. We have Judith Wright, the deputy minister for the ministry. We also have five providers of the services: from the Hincks-Dellcrest Centre, John Spekkens; from Kinark Child and Family Services, Peter Moore; from the Associated Youth Services of Peel, Kelly Henderson; and we have Children's Mental Health Ontario, Gordon Floyd. We welcome you all.

I do believe, Deputy, thatâ€"

Interjection.

The Acting Chair (Mr. Ernie Hardeman): Did I miss one? Oh, my gosh. My apologies. The Youth Services Bureau of Ottawaâ€"Alex Munter. Welcome, Alex. I have a habit of never saying "Last but not least," because there's always the question, "If that person isn't least, then who is?" So we won't do that, but we do thank you all for being here.

There are a number of other people here, I believe, that the deputy, as required, will call forward, and hopefully at that point will introduce them for the Hansard services.

With that, we'll start the meeting. Madam Deputy, if you would like to make a presentation.

Ms. Judith Wright: Thank you, Chair and members of the committee. I am pleased to be here on behalf of the Minister of Children and Youth Services. I want to thank the committee for providing us with this opportunity to talk about services for children and youth who have mental health issues. I am particularly pleased to be here with the representatives of the agencies that do work so hard to actually provide these services for children and youth.

I'd also like to, once again, thank the auditor for his report. We consistently welcome his advice on how all of the programs at children and youth can be improved, but in particular, his advice on child and youth mental health services.

Today, what I'd like to do very briefly, because I recognize you want an opportunity to speak to all of the members, is to update you on a number of the issues which have been highlighted by the Auditor General in his report. To contribute to today's discussion, I have with me three senior members of the ministry whom I would like to introduce. To my immediate right is Alex Bezzina, who is the assistant deputy minister for the program management division, which is the division accountable for the transfer payment to the agencies. Beside him is Aryeh Gitterman, who is the assistant deputy minister for the policy development and program design division, which is responsible for the policy framework for child and youth mental health. And sitting behind me is Jeff Wright, whom I think you know from previous visits to this committee, and who is the director of the outcome and measures branch. He is responsible for performance measurements.

To begin my presentation, I'd like to discuss the ministry's activities related to the child and youth mental health framework. As you are aware, in November 2006, the minister released A Shared Responsibility: Ontario's Policy Framework for Child and Youth Mental Health. As we have discussed previously at this committee, the creation of the framework recognized the need by all partners for a consistent, province-wide approach for defining and measuring mental health services for children and youth in the province.

It was recognized at that time that the child and youth mental health sector had evolved over time in response to each community's own needs. While this local community response has strengths, the result was a service system characterized by differential growth across the province. As such, the system had evolved to the point where an opportunity existed for a collaborative, strategic approach, one that would allow community agencies to benefit from shared expertise and resources. It was within this context that the framework was developed.

As you are aware, the framework has four core goals: a collaborative child and youth mental health sector, timely access to a flexible continuum of programs, provision of quality and effective services for all levels of need, and a sector that is accountable and well managed.

At our previous appearance before the committee, we indicated that the next step in implementing the framework would be for the ministry and the sector to conduct a large-scale mapping exercise which would examine current services against this policy framework. The mapping exercise was undertaken so that both the ministry and the service agencies would have a clear and comprehensive picture as to what types of programs and services are available, who's receiving them and where they are available.

This exercise, which was begun in the summer of 2008, has been a significant undertaking. I would like, first and foremost, to thank all of the over 370 agencies who participated in this exercise and who really took time away from their very busy schedules to enable us to successfully complete it.

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The exercise involved a point-in-time mapping of a continuum of services and supports based on the policy framework, against 12 mental health functions, for over 370 agencies across the province. Over 1,500 survey tools were received. Over time, this information, which we're beginning to analyze, will allow the sector and the ministry to demonstrate that investments are used effectively, to match service delivery to outcomes and to build an evidence base that will support strategic investments.

In addition to the work that the agencies have completed for the mapping exercise, both the Ministry of Education and the Ministry of Health and Long-Term Care have provided data on child and youth mental health services that they deliver.

As I said, we're currently analyzing the information and will, over the next couple of months, be engaging with service providers, regionally and locally, on what the information is that's been collected. The purpose of these sessions will be to develop a shared understanding of what the data can and cannot tell us about the children and youth mental health sector as it has evolved over the last 30 years.

Mapping of programs and services is one key component of a larger set of activities the ministry is undertaking to develop better data and information. Parallel to the mapping exercise, we're implementing a child and youth mental health data and information strategy that will guide the collection, analysis and use of a variety of information. The purpose of developing this strategy is to support effective and coherent policy, program and resource decisions for all of us in the sector. The strategy includes, for example, collaboration with the Mental Health Commission of Canada to conduct an updated prevalence study on mental health issues experienced by children and youth in Ontario.

We are also undertaking a review of intake and assessment tools used by other jurisdictions to assess whether the ones we use in Ontario, BCFPI and CAFAS, can be improved. As you are aware from previous conversations, the ministry currently funds and supports the use of these two evidence-based intake and assessment tools; that is, the brief child and family phone interview, known as BCFPI, and the child and youth functional assessment scale, or CAFAS.

BCFPI is an intake tool used by licensed agencies to collect data on current wait times, clients and presenting problems. This information is aggregated at the agency, regional and provincial level to support planning decisions. CAFAS, on the other hand, is an assessment tool used by clinicians to assess the degree of an individual's functional impairment, and therefore assists in the development of a treatment plan and the monitoring of the client's progress during treatment. CAFAS data is also aggregated at the agency, regional and provincial level.

Agencies licensed to use BCFPI and CAFAS are able to compare their own service data and outcomes with other service providers in their region. The ability of agencies to compare their client and outcome data locally or across the province is a key factor in support of informed practice.

While both tools are supported by research and are considered evidence-based themselves, we are undertaking this review with the goal of improving data quality, usefulness and timeliness for both agencies and the ministries. The outcome of this review will include developing options for increase in use and usability of evidence-based tools and standardized processes across the province.

In addition, the ministry is working with other ministries through the Institute for Clinical Evaluative Sciencesâ€"or ICES, as it's more colloquially knownâ€"to bring together anonymized data from a number of health and social service databases. Bringing these databases together will enable us to do better research and trends analysis and to identify policy issues.

In this context, I'd like to also talk about wait time information, which the Auditor General has highlighted in his report. I think it's fair to say everyone is committed to identifying opportunities to reduce wait times and to providing appropriate services for children and youth. In line with the auditor's recommendations, service agencies do work with the ministry and collect wait time information through BCFPI, as I mentioned. As previously mentioned as well, this information is used by agencies and local communities to inform service planning with the shared goal of reducing wait times and improving service coordination for children and youth who are waiting for services.

The review that we're undertaking of BCFPI and CAFAS will provide further direction on how we can continue to improve and use this wait time data. In addition, the information acquired through mapping will play a key role as we develop a better understanding of regionally specific wait times.

Finally, as committee members know, collaboration across service sectors is a key to better-coordinated services for children and youth experiencing mental health problems. We work collaboratively with the Ministry of Health and Long-Term Care and the Ministry of Community and Social Services, among others.

Today, I'd like to speak to one example of collaboration, and that's with the Ministry of Education. We know that success in school is the number one indicator of success later in life. Because of this, the Ministry of Children and Youth Services has made the goal of every young person graduating from secondary school as one of our five strategic goals. In light of this, we've also begun a number of initiatives.

The one example I'd like to highlight today is the student support leadership project, a collaborative project between schools, school boards and child and youth mental health providers. This is a joint Ministry of Children and Youth Services and Ministry of Education initiative. It was developed in recognition of the fact that service providers were establishing working relationships with principals and teachers on an individual school basis, but there were often challenges in scaling those up to a board level or a system-wide approach.

Through the student support leadership initiative, the ministries are supporting designated clusters of school boards and child and youth mental health agencies to work together. For each cluster, a mental health agency lead has been identified to facilitate the coordination of service delivery. Enhanced partnerships and service delivery linkages will better meet the needs of students and families through increased collaboration, coordination and referrals.

While contributing to the ministry's strategic goals, this initiative also aligns with our mental health policy framework, A Shared Responsibility, in its aim to foster collaboration among all child- and youth-serving sectors.

I would like to conclude this presentation by once again recognizing the many, many dedicated individuals who work hard every day in not only the four agencies present today, but across the province. Their hard work to support children and youth with mental health needs is resulting in a stronger and more integrated system of child and youth mental health services. We'll continue to work with our many partners to build an Ontario in which child and youth mental health is recognized as a key determinant of overall health and well-being. Thank you.

The Acting Chair (Mr. Ernie Hardeman): Thank you very much for the presentation. I understand that the executive directors of each one of the organizations would like to make an opening statement?

Mr. Gordon Floyd: We had not planned to make any significant opening statement. In our response to the Auditor General's report, we did note that we were very pleased with the report and with the approach that the Auditor General and his staff took in looking at the operations of these agencies.

As you may have noted in his report, this audit happened in part because we asked for it, which is a little bit unusual. Not many people invite the Auditor General in, but in our sectorâ€"

The Acting Chair (Mr. Ernie Hardeman): I can understand that.

Interjection: I said this morning I thought it was a first, actually.

Mr. Gordon Floyd: There you are. But in our sector we truly are very committed to showing value for money. We really do appreciate the findings in the report that show where there are opportunities to tighten up in some policy areas and in some administrative areas. We've been working not only within these four agencies, but across the bulk of the children's mental health community-based sector to ensure that those recommendations are being implemented and taken seriously.

We were pleased that the Auditor General provided some good advice and somewhat relieved that there weren't any burning houses found in the audit process. The findings, I think, spoke very well to the way in which agencies are being managed. Although there were a number of significant and important findings, there was nothing that was seriously embarrassing or seriously offside.

What we were most struck about and perhaps happiest to see was the Auditor General's conclusions and findings in terms of the constraints on capacity in this sector. In the summary to the report, the Auditor General refers to the reality that agencies in this sector have been so constrained in their funding over the last several yearsâ€"the last decade or moreâ€"that they truly have had, to use his phrase, "to rob Peter to pay Paul" in order to ensure that children who need mental health services are able to get them as fast as possible.

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We know that there are unacceptably long wait times and unacceptably long wait lists in this sector. That's a reality that these agencies have been dealing with for 12 to 15 years, during a period when the funding increases have simply not been keeping up with growth in demand; they've not been keeping up with the growth in inflation and in costs.

What agencies have been doing during this period is really quite radical surgery in many parts of the province. There's one agency before you that is the result of a merger. There are other agencies here who have led the way in developing collaborative services to support the work of their partners and their neighbours in the children's mental health field. Across the board, agencies have been changing the way in which they deliver service; as an example, moving from individual counselling to group counselling as a way to shorten and manage wait lists.

In this sector, I think it's fair to say that agencies are, as the Auditor General put it, really working in a very, very difficult environment. They're stretching their resources to try not only to meet today's needs but to work with the ministry on some of the goals that the deputy described a few minutes ago. There's a real commitment in this sector to move much more to a system that uses evidence-based practices, for instance, but we recognize that the introduction of evidence-based practices is a complicated and intensive process that requires staff time that simply isn't available at the moment.

When the Auditor General, in his report, refers to the desirability or the best practice of analyzing some of the CAFAS and the BCFPI data on an agency basis, we agree entirely, but we know that the resources don't exist in the system currently to make that happen.

In his report, the Auditor General spoke a few times about the reality that children's mental health services, unlike, for instance, child welfare services or youth justice services, are not mandated, and there is no legislated mandate for these services. The practical effect of that is that these services are funded according to the amount of money that's available, rather than to the level of need. I think the ministry acknowledges that. We know that the ministry has been working hard internally to try to increase the resources that are available for children's mental health. We've certainly been working hard from the outside to do that, but bottom line, this is a system that is falling far, far short of meeting the growing demand for services in today's Ontario, and every year things are falling farther and farther behind.

One way we measure that is we see, in our agencies, that each year the cut-off point for getting admitted to service is higher than it was the year before. In other words, our agencies are dealing on a year-to-year basis with kids who are further and further into the deep end, and there are essentially no resources in the system that are available to be dedicated to the prevention work or the early intervention work that would allow us to get ahead of some of the crisis work that really occupies most of the activity in children's mental health centres.

These are things that the Auditor General wrote about in his report. As I say, we were very happy to see them there and are delighted to have this opportunity to discuss those with members of the committee, and other things that you want us to discuss, so thank you.

The Acting Chair (Mr. Ernie Hardeman): Thank you very much. We haveâ€"

Mr. Gordon Floyd: Do people know who is which agency here? Is this clear? We haveâ€"

Interjection.

Mr. Gordon Floyd: Okay. Do you want to describe your agencies?

Mr. John Spekkens: My name is John Spekkens. I'm the president and CEO at the Hincks-Dellcrest Centre. I have with me as well Dr. Carole Sinclair, who is sitting right behind me. Carole is the head of our treatment services. I'll probably take one minute or soâ€"that's what we're all planning to doâ€"just to position our agency and give you an idea of size and the scope of our services.

Our budget at the Hincks-Dellcrest Centre is a total of $16.5 million, of which approximately $11.5 million comes from the children's mental health services. We also have funding from Youth Justice Ontario, United Way, the federal government, and the city, and many of those are grants and projects.

Our staffing numbers approximately 240. Our catchment area isâ€"really, we don't define catchment areas very strictly. Basically, we serve Metro Toronto, and in the programs where transportation to the program is essential, we typically will serve the downtown area and what used to be known as the North York area. So that's where we have our two major offices.

As Gordon referred to, we are an amalgamated agency, but nine years ago two of us, Hincks and Dellcrest, joined, took the hyphenated name, and we've been able to coordinate our services much better. We also saved a fair bit of money on overhead from when we were two separate agencies.

We provide treatment services. We provide prevention services, and the treatment services come in the outpatient service and in our residential programs. Again, any of this we can elaborate on if needed.

We also have something that we're very proud of. We have an affiliation with the University of Toronto. We are one of their main community-based training settings for both psychiatryâ€"we have about five psychiatry residents coming through. We have interns in psychology. We have about eight or 10 social work placements at the masters level.

The reason I say we're proud of thatâ€"in our sector, like so many other sectors, there's a wave of retirements coming in the next five years, and somebody has to train the next generation of professionals. This is done mostly in our outpatient department because most of the professionals will be working in outpatient-type departments in community settings.

One of our biggest difficulties is the threat that our outpatient department is shrinking every year because of the cutbacks that we have to make in our staff because of the funding issue. That's why, by the way, as an aside, I'm very happy, as Gordon mentioned, that the auditor spoke both of the specifics in the centres but also the big-picture issues of funding for the system.

What we're most pleased about is that we're able to provide service in prevention for approximately 3,000 families per year and in treatment services of all the typesâ€"about 1,500 per year, and we do the training. What causes us the biggest distress is both the waiting lists and the cutbacks in service that happen gradually every year.

I'll end my comments at that. Thank you.

The Acting Chair (Mr. Ernie Hardeman): Thank you very much.

Mr. Alex Munter: Thank you very much, Mr. Chair. My name is Alex Munter. I'm the executive director of the Youth Services Bureau of Ottawa, which is a multiservice agency that's existed in our community since 1960. It operates at 20 sites across the city of Ottawa and serves at-risk youth ages 12 and over.

We have four service areas: our youth justice program, our mental health program, housing and community services, and employment. So for us, mental health is a program that fits on the org chart, but it is also the lived reality of our clients across all of our programs. Whether it is the youth we see in our emergency housing shelters or the custody facilities for young offenders that we operate in our youth engagement program, for us, addressing mental health issues and giving young people the tools to succeed in dealing with their obstacles is core to the mandate and mission of the organization.

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In terms of the mental health services, specifically, that were the subject of this report, we have 10 distinct programs in our mental health service, the majority of whichâ€"and certainly the largest and most significant onesâ€"are funded by the Ministry of Children and Youth Services' program division, in particular our long-term youth and family counselling program; our crisis intervention and support, which is actually three connected programs; a 24-hour crisis line that's backed up by a mobile teamâ€"it's not 24 hours, but it's most of the hours of the day; and a short-stay crisis residence. We also offer intensive counselling support and a number of school-based programs.

The MCYS program division also supports some of the programming in our emergency shelters. We have a 30-bed emergency shelter for young men and a 30-bed emergency shelter for young women, and the funding that is provided by MCYS allows us to make sure that that's not just a dorm, that's not just a safe place to sleep, but that it is also a place where there is counselling support and there are services available to help young people get back on track.

Further to John's commentâ€"and I think we all here share that in commonâ€"the core ethic of all of our programs is prevention, even our programs in the justice system. What we work to do is to prevent street-involved youth from becoming homeless adults, prevent young offenders from becoming adult offenders, and prevent entire lives being shaped by a struggle with mental illness through identification, intervention and support.

We are proud of the impact that we make. I'm newâ€"I'm the rookie here; I've been doing this less than two years in this organizationâ€"and for me, it is always inspiring to go into our programs and see the work that is being done. I think what we all share in common is the desire to have a greater impact, learn more, do more, have better tools and have more resources to be able to support the young people in our community.

The Acting Chair (Mr. Ernie Hardeman): Thank you.

Mr. Peter Moore: Good afternoon. My name is Peter Moore. I'm the executive director of Kinark Child and Family Services. We're a multi-service agency that serves Simcoe county, York region, Durham region and the Four County area to the east. Our budget is about $65 million and we have 800 staff. Of that, $25 million is for children's mental health, with about 300 staff providing service.

As Alex and John have mentioned, we have multiple services, ranging from early intervention to dealing with the most difficult to serve children and youth. I should mention I've brought Dr. Dick Meen with me. He's our clinical director. He's a psychiatrist who joined us about 10 years ago.

We operate the secure treatment setting in Syl Apps Youth Centre, which deals with the, I think, most significantly disturbed youth in Ontario, and we also provide a range of prevention programs. A couple of weeks ago, we co-hosted the international Triple P convention, which is an evidence-based program, a population-based program, for effective parenting. We were happy that the founder of Triple P, Dr. Matt Sanders, visited the ministry policy people and talked to them about the benefits of a population-based approach to positive parenting in terms of the impact it would have on children's mental health.

I share the issues that my colleagues have mentioned in terms of struggling with waiting lists and collaborating with other sectors to find solutions. We have embarked on a clinical transformation process, implementing evidence-based programs which have had some impact in terms of clear evidence of effectiveness, and it has also helped us reduce waiting lists, but it's an ongoing struggle. Thank you.

Ms. Kelly Henderson: Good afternoon. I'm Kelly Henderson, the executive director of Associated Youth Services of Peel.

Associated Youth Services was incorporated in 1986, and we began as an organization funded to support the youth justice system. Our services grew to support young people involved in child welfare, and since the mid-1990s we've been delivering children's mental health services in the homes of our clients and in the community. Our services range from early intervention to intensive support for our most needy clients.

We receive funding from the Ministry of Children and Youth Services, children's services and youth justice branch; the Ministry of the Attorney General; the Ministry of Community Safety and Correctional Services; the United Way; Trillium and the local children's aid society. Currently, our operating budget is $6.4 million, with $3.9 million funded through MCYS for children's mental health services. Our staff numbers 93, with approximately 46 being related to the children's mental health services. Our volunteers number approximately 150.

In 2008-09, AYSP supported over 5,900 clients, young people and their families. A total of approximately 800 were supported through children's mental health programs directly funded by the ministry.

Since the Auditor General's visit, we've been working to incorporate the recommendations and further refine our operating practices. To that end, AYSP has now joined Children's Mental Health Ontario. We see this as a further opportunity to increase our agency's accountability and also, as my colleagues have noted, contribute to the work of the provincial association.

The Acting Chair (Mr. Ernie Hardeman): Thank you very much. We want to thank you all for the presentations and particularly for being the first in history to ask the auditor to come in because he was getting to feel like he wasn't wanted. I notice today that he's feeling much better.

I do want to point out that the audit, of course, is a value-for-money audit, and the committee is very interested in dealing with the items in the report where the auditor talks about what can be done better to provide a higher quality or more a efficient service to what's presently being provided. The number one goal of the audit is notâ€"though the auditor did mention the lack of total funding in his report, that is not the main focus of the public accounts committee. It's to make sure that the public is getting full value for the money that's being presented. That's why I much appreciated the comments from the individual organizations to point out how their money is being spent, even though there's not enough of it.

I also want to suggest that, as we discuss writing the report, the fact that more needs to be done can very well be a part of that discussion, but the report will not be a total report to say that everything is working fine in children's mental health except they need more money. At least, if past example is an experience, that will not be what the public accounts report says, but we do appreciate the issues brought forward by the auditor and what the presenters have presented to us this morning.

We will now go around and give everyone in the committee an opportunity to ask questions and to get straight in their mind the relationship between the presentations and the auditor's report and hopefully to assist us all in coming up with recommendations to make the system work better for the people of the province. We'll start the questions with Mr. Hampton from the New Democratic Party.

Mr. Howard Hampton: How much time do I have, Chair?

The Acting Chair (Mr. Ernie Hardeman): We usually have 15 or 20 minutes in the rotation, and we keep going until the questions are done or until 3 o'clock, whichever arrives first.

Mr. Howard Hampton: First of all, I want to thank everyone who's here today. I'm going to ask that you give me some latitude, Chair, in terms of some of the questions I want to ask because there's a lot of information that's been presented here, and I'd like to delve into some of it.

I guess I want to ask the deputy minister, first of all, about Jordan's Principle; you're aware of Jordan's Principle?

Ms. Judith Wright: Yes.

Mr. Howard Hampton: Could you tell us what it means?

Ms. Judith Wright: Perhaps I could ask Aryeh, who is working closer with health on this than I am in terms of the effect it's going to have on aboriginal communities. If you don't mind, I'll hand that question to him. I am aware of it, but he's been actually working with MOHLTC on it.

Mr. Aryeh Gitterman: Essentially Jordan's Principle arose out of a tragic circumstance in Manitoba where a child with very specialized health needs was not able to return to his home because of some differences of opinion between the federal and provincial governments as to who was accountable for the costs associated with that. Subsequent to that event, there was an effort across Canada, including in Ontario, to agree that such circumstances wouldn't ever again prevent a child from getting services that he or she needs, regardless of who in the end should be providing or paying for those services. I believe all governments across Canada, and certainly Ontario, have agreed to Jordan's Principle, and I think just recently there was a public commitment from the government.

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Mr. Howard Hampton: One of the things I find revealing is the auditor has given us a list of the number of transfer agencies that receive funding from the Ministry of Children and Youth Services. It's included as sort of an appendage to this document.

Mr. Jim McCarter: It's actually provided by legislative research.

Mr. Howard Hampton: Okay, legislative research. I recognize that a family and children's service organizationâ€"so you could have a family and children's service organization that doesn't do children's mental health; it does child protection, apprehension and child welfare. What I'm struck by here isâ€"I'll use my own part of the province as an example. Two things jump out: If I look at the Kenora-Patricia Child and Family Services, they get a budget of about $12.7 million.

Ms. Judith Wright: What page is that, sir?

Mr. Howard Hampton: That's page 62, $12.78 million a year in transfer. Now, as I understand it, that is a child welfare agency. If I flip over the page, and correct me if I'm wrong on something, and I look at the Patricia Centre for Children and Youth, which, as I understand it, is the corresponding children's mental health agencyâ€"am I correct in that?â€"the same geographic area, more or less, it's $1.4 million.

I'm having a hard time understanding how we could put so much money into child welfare and in the same geographic area, not much money, relatively speaking, into children's mental health. Am I missing something?

Ms. Judith Wright: Two points I think would be important to raise on this: One is to recognize that those two agencies would likely, in some cases, share similar clients and actually coordinate their services together. In some cases, there may be a familyâ€"I'll use this as an exampleâ€"who is in need of assistance who would be helped by both a child welfare agency that would help with the family in those circumstances, and also may refer that family to service. That's one point.

The second point, actually, is relevant to the point that Gordon Floyd made at the beginning, which is that child welfare is a mandated service and children's mental health is not a mandated service. As you're aware, we work around the envelope that we've been given. I would imagine as wellâ€"Alex can correct me on thisâ€"that the geographical area and the scope of the child welfare agency is probably larger than the children's mental health agency, but I don't know this level of detail on these agencies.

I don't know, Alex, if you would like to add anything.

Mr. Alex Bezzina: I'll just say a few things, and thank you for the opportunity. I can't speak off the top of my head, but I would be happy to bring information back to the committee as to whether or not the mental health agency to which you refer is the only agency that receives children and youth mental health funding in your specific community.

The other thing I will say is that it is a little bit difficult to compare the child welfare budgets to the children and youth mental health budget. When a child is apprehended and brought into service, that agency is responsible for the total care of a child. Many of these children in child welfare don't only have care, boarding and supervision needs, but they have multiple service needs. The costs of caring for kids are quite high in the child welfare system, so it's a little bit of comparing different types of service interventions and it's difficult to draw conclusions, as a result.

Mr. Howard Hampton: Okay. That's part of the reason why we ask questions.

I want to draw your attention to page 67, Tikinagan Child and Family Services. So Tikinagan is the child and family service agency. It has the mandate, I believe, to work with children in the northern First Nations. Basically those First Nationsâ€"

Ms. Judith Wright: In the fly-in communities.

Mr. Howard Hampton: That's right. Those communities, for the most part, are members of the Nishnawbe Aski Nation. I know that some of the child and family service agencies are integrated. They do child welfare; they also do children's mental health. Is this an integrated agency? They do both? Okay. How is their funding allocated?

Mr. Alex Bezzina: We've allocated it in two different ways. For the child welfare mandate there is a specific funding formula that is used to apportion the child welfare dollars and it is volume-sensitive. With Tikinagan, though, even on the child welfare side, they have been able to demonstrate historically that they have larger base costs, mostly because of the costs of attracting professionals up to the north and secondly with respect to theâ€"

Mr. Howard Hampton: Travel.

Mr. Alex Bezzina: Travel. There are also higher costs associated with caring for children when they're brought into careâ€"costs of groceries etc. So Tikinagan, as well as a number of other child welfare agencies in Ontario, has been able to demonstrate to us that their unit costsâ€"not just their volume, but their unit costsâ€"are different. So the child welfareâ€"

Mr. Howard Hampton: Let me be more specific. Of that $39.7 million, can you break down how much would go towards child welfare or how much is, by a formula, allocated for child welfare and how much is allocated for children's mental health?

Mr. Alex Bezzina: Off the top of my head, I can't do that. I apologize.

Ms. Judith Wright: We can get back to you with those numbers. We'd need to look at the budgets. We weren't prepared to talk about that.

Mr. Howard Hampton: And I appreciate your help on this because this is a number I'd like very much to know.

I also know that there are a number of First Nations that are in that First Nations grouping that receive individual funding. For example, if I can draw your attention to Kasabonika Lake First Nation. Kasabonika Lake is on page 62, about a third of the way up the page. It doesn't get a lot of money: $157,000. I realize these are raw transfer numbers. Why would an individual First Nation be funded? Would that be for a child care centre or something like that?

Mr. Alex Bezzina: In part, it has to do with the funding that is provided directly to First Nations for a prevention worker. So most First Nations in Ontario either have a prevention worker funded directlyâ€"

Mr. Howard Hampton: How do you define a prevention worker?

Mr. Alex Bezzina: The child is not in need of protection, but they work with families that are struggling with various types of issues and either connect them to the types of services they require or, using traditional methods, work with the community toâ€"

Mr. Howard Hampton: So is this child welfare money or children's mental health money?

Mr. Alex Bezzina: Native services on-reserve is a line under children's mental health money.

Ms. Judith Wright: And some of this money, sir, would be historical, if I can put it that way. They would have been relations that we would have entered into, probably before the ministry was created, with some of these First Nations. The most current project that we're working on with 10 of the NAN First Nations actually is in negotiations with NAN as a representative of those First Nations. I don't know if that's where you're going, butâ€"

Mr. Howard Hampton: This is helpful because I think what you're saying is thatâ€"correct me, I don't want to put words in your mouthâ€"some of this funding is historical. It may not necessarily be according to a needs-based formula. It's just the service was thereâ€"

Ms. Judith Wright: And we will continue to fund it because we believe the need is still there. As you know from those communities, they're very high-need communities.

Mr. Howard Hampton: Which raises the next question: Are you familiar with Pikangikum First Nation?

Ms. Judith Wright: Yes. I've actually visited Pikangikum.

Mr. Howard Hampton: And you probably know that it's not unusual that you might see three, four, five, six youth suicides a month in Pikangikum.

Ms. Judith Wright: Correct.

Mr. Howard Hampton: It's probably one of the highest-needs communities in Ontario.

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Ms. Judith Wright: Absolutely.

Mr. Howard Hampton: And I've searched throughout this to see if Pikangikum has any of this funding.

Ms. Judith Wright: If I may speak to that, and actually Alex may speak to it in more detail, we are just finalizing a set of negotiations with the chiefs and elders of Pikangikum, with support of NAN, to provide them with around $700,000 in funding to help put in place programs for their youth, specifically around enhancing resilience and preventing suicides. We haven't got to signatures yet but we're almost there.

Mr. Alex Bezzina: We were in fact ready to sign last summer, but as you may know, there was a changeover in chiefs. We've been working with the community and with NAN. We work very closely with NAN on some of these issues because we also need their support to make sure that we're not doing something that either duplicates what NAN is already doing or is counterproductive.

Mr. Howard Hampton: Which raises the next question. NAN is essentially a political organization. NAN is not a service organization. It's essentially a political organization.

Mr. Alex Bezzina: NAN has a service arm. We work closely with Deputy Grand Chief Roseanne Archibald, who has been working with us on a number of different fronts around the issues of youth resiliency.

Mr. Howard Hampton: How do you decide when an organization is a service organization or when it's a political organization? What are the criteria?

Ms. Judith Wright: We are working with an organization usually to fund a specific service. In the case of NAN and First Nations there is a commitment on their part to be involved in those sorts of conversations, as you would know. Alex, please.

Mr. Alex Bezzina: When it comes to working with aboriginal communities, First Nations in particular, it is very difficult, you're correct, to separate out what's a political entity from what's a service entity, because frankly speaking, all First Nations are political entities. Neverthelessâ€"

Mr. Howard Hampton: But Tikinagan is a service organization.

Mr. Alex Bezzina: Tikinagan is different. It is not a First Nation. It is an organizationâ€"

Mr. Howard Hampton: And Weechi-it-te-win is a service. They're very clear about that.

I recognize that the funding for children's mental healthâ€"we all recognize this; you can go to any community in Ontario and find this. I guess what I'm wondering is, if the money is scarce, why is some money going to some First Nations on a historical basis where other First Nations that unfortunately too often make the headlines in North America have not been funded, and on the other hand, organizations that are primarily political organizations and not service organizations are funded? How do we make sense of this?

Mr. Alex Bezzina: First of all, just with respect to the historical nature of funding, we don't provide funding blindly. There is a requirement to meet certain service targets. There is financial accountability associated with it. If the dollars aren't used for the purposes for which the ministry contracts, the money has to be reconciled back and brought back to the ministry.

If we are, for example, contracting with Pikangikum or with any other of the First Nations, it's based on a very specific service contract that says this is what you're going to do with the money. It has to be based on the program that we fund. We can't just give money for the purposes of giving money. It has to fit in, in this particular case, to the children and youth mental health program.

With respect to NAN, one of the things that they've been working on is the whole issue of youth resiliency. That's what we're funding with NAN, a research program with respect to youth resiliency. It's a very specific program. We're not funding their political arm. We're funding this work that they're doing on behalf of a number of First Nations in the north to raise the profile of youth resiliency.

Mr. Howard Hampton: So why wouldn't you fund Weechi-it-te-win, the organization which struggles with these issues all the time and probably has more expertise than any of us in this room in wrestling with these issues, with limited budget, huge travel, and which also knows the uniqueness of different communities? Why wouldn't there simply be better funding of an organization like Weechi-it-te-win? That's its mandate.

Ms. Judith Wright: I think the proposal from NAN is not the same as the services being currently provided by Weechi-it-te-win, so it's not that we gave money to NAN or are giving money to NANâ€"we haven't finished those negotiationsâ€"to do exactly what Weechi-it-te-win is doing. It's a different proposal to look at very specifically what needs to be done to enhance, across the fly-in communities/north NAN First Nations, youth resilience. What factors do we need to look at?

Mr. Howard Hampton: But this then raises the issue, if you've got multiple service agencies, how do you sort this out? I could give you the example in North Spirit Lake. North Spirit Lake made national headlines last summer as another community where youth suicides, child suicides, happened on an almost weekly basis. They're not here. They're nowhere mentioned here either.

I'm having trouble figuring out, why would you fund this organization, which is fundamentally a political organizationâ€"not to criticize NAN; they do a very effective job politically. Why would you fund them to do something in the area of children's mental health? You have another special program over here with Pikangikum, and you've got Tikinagan, which was the service agency specifically created to wrestle with these issues, always short of cash. I don't get the rationale, why you'd be a little bit into politics, a little bit into serving individual communities, and yet the service agency that is specifically created with the mandate to do this work chronically says to me, "We don't have the money to do our job."

The Acting Chair (Mr. Phil McNeely): I'm sorry; time is up. Can we go back to that later, Mr. Hampton? Ms. Sandals.

Mrs. Liz Sandals: Thank you very much. I'll help Hansard by turning this up where it's supposed to be.

I've been involved with this, I guess, in some ways as a service consumer/partner from the school board perpective for lots of years. In talking to people all around the province, certainly the perception, which I think the auditor has also commented on, is that when you look at children's mental health, because, as Mr. Hampton has alluded to, you're often dealing with programs being funded historically based on "They're funded because they're funded," you get a significant variability in the services that are provided from community to community, the level, quantity and quality of services that are provided as you move from community to community.

I wonder if we could start with talking about the mapping that the ministry has been working on. My sense is that the purpose of the mapping is that it should give you some information about what services are being provided by different agencies as a starting point in terms of figuring out some of these service distribution issues. I wonder if the ministry could give us a bit more detailed update on the data that has been collected so far. Specifically, what data have you been able to collect? And then, what plans do you have in terms of how you can take that data and start to address the service distribution issues that we see?

I think it's fascinating that when we're looking at the services that are here today, we've got Metro, we've got a GTA-plus service, we've got Peel, we've got Ottawa, and then there are those of us in the rest of the province. If you could talk about those of us in the rest of the province, how do we address some of those issues, and is the mapping data going to be helpful there?

Ms. Judith Wright: I'll ask Aryeh to speak to this because he did the leadership work around establishing mapping, and I would also encourage the agencies who would have been involved in this to actually give their perspective on it as well.

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Mr. Aryeh Gitterman: Thank you. Let me first start by going backwards a little bit from the mapping. It might provide some context for the previous discussion as well.

Until 2006, when there was a release of our policy framework for children and youth mental health, there was really no statement, framework or guidance as to what we mean by "children and youth mental health." So the long-term distribution of that policy framework started a very different exercise that hadn't been accomplished in the province previously. What the policy framework did was describe and define the range of services that we would from then on describe as mental health programs and services, including quite detailed descriptions as to how those programs could be delivered. It also describes the range of children and youth needs, so we have committed, in that framework, to a statement related to a range starting from prevention all the way to very intensive intervention for severely exceptional children and youth with severe mental health difficulties.

Given the statement as to what mental health should look like in the province, we then undertook the mapping exercise, which is basically an exercise of determining, with the screen of the framework, exactly what is happening in the province. As the deputy mentioned previously, we began that exercise last summer. Essentially, what the exercise does is give us a way to describe the distribution and availability of children and youth mental health programs and services, how densely they're offeredâ€"that is, across the province as a whole, relatively speaking, are there more services here than there?â€"and how all of that is associated with the funding that the province provides for those services. So that necessarily is quite an intensive undertaking. We, of course, always did have information about funding and number of children served, but we never really did have information that described the programs and services at this level of detail, down to the program definition and the distribution across the types of students, children and youth, and individuals being served.

That undertaking started last summer. We distributed tools to all of our agencies that could have been receiving and therefore offering programs and services that could be called mental health, as defined by the framework.

You have all that information in. I can give a little bit of information as to what we have so far.

Mrs. Liz Sandals: That would be very helpful.

Mr. Aryeh Gitterman: It's not totally analyzed yet; we're still digging into the data.

Let me start first by the number of agencies. We have very detailed information now on over 370 agencies across the province. These are agencies that are offering mental health programs and services. Of course, it doesn't mean they're all doing the same thing, and we had a very good description from the four agencies here as to the range of programs that could be offered.

Those 370 agencies describe for us over 1,500 programs and services. So of course, many agencies are doing more than one thing. For each one of those programs we have a definition of the kind of child or youth being served; what the level of need is; how long the children and youth are waiting for service, or the families as it may be; how much money is associated with that program; and a detailed description of the programs themselves.

For example, we know that of the 12 large categories of programs, the most commonly offered programs are around assessment services and what we call intervention or treatment services. There's a whole variety, 10 other program categories, for example crisis intervention, emergency intervention, family support etc., but the two most commonly offered are the two I mentioned.

Just by way of theâ€"

Mrs. Liz Sandals: Could I interrupt you there for a minute, Aryeh? Intervention/treatment as a common category doesn't surprise me, but that sounds to me very, very broad. Would I be correct in assuming, then, that if this child presents with this very specific problem, within the mapping data you wouldn't yet be able to sort out who has the most appropriate treatment for this particular child's particular problem?

Mr. Aryeh Gitterman: I can tell you what we can do, which sometimes helps define what we can't doâ€"

Mrs. Liz Sandals: Okay, that's a good start.

Mr. Aryeh Gitterman: â€"but not always. What we can do, for example, for a particular agency that has described the services they're offering as an intervention program is determine, because of the information provided by the agencies, what proportion of the children being served by that program would be at a high level of need, a moderate level of need or, in fact, have no demonstrated problem but are there more for an early prevention service. So one of the things we haveâ€"

Mrs. Liz Sandals: So the BCâ€"whatever it is?

Mr. Aryeh Gitterman: BCFPI.

Mrs. Liz Sandals: If I can get all the right letters. In that initial intake screen there, you've got children who actually aren't coming up very high on that screen at all?

Mr. Aryeh Gitterman: That's one of the ways that is determined; that's correct. We do know, for example, that there are many programs, and for very good reasons, that are offered to children at several levels of need, if I could describe it that way. Because of the need for service, often agencies will take in children from a wide variety of need levels because they want to provide services. We now have a better understanding of the mix of types of need and how well or poorly that is matched to the services in a community. We didn't have that level of understanding before.

The Acting Chair (Mr. Phil McNeely): Could I suggest that we let the executive directors make comments, if they wish, as well? Is there any input you wish to make?

Mr. Alex Munter: I guess everybody has suddenly been struck by shyness. I would say the mapping exercise was certainly, first of all, very useful. It will be a very useful tool for system planning, and we are all engaged with the ministry in our regional areas in system planning exercises. In our agency's case, we involved staff teams in it, so it was a good opportunity for us around reflection in terms of what the strengths of our programs are and the clientele that we serve.

I would say, as a word of warning, that I think it is always wise to scrutinize resources. It is always wise to see how we could more optimally use those resources and serve more kids, and serve more kids better. But at the end of the day, there is a law of diminishing returns, and there's only so far you can go with the resources that you do have. I think that is an omnipresent reality for us.

The other piece that we're hopeful about is the big focus on evidence-based practices and big focus on learning, program evaluation. I think there's a great ambition in our staff team to learn more and to have better tools but, funded as a service delivery organization, there's a limit to how much of that we can do. We've recently signed a partnership agreement with the University of Ottawa to develop a research partnership. We've got truckloads of data, and they've got truckloads of researchers. We think it's a match made in heaven, so we're going to try to figure out how we can leverage the combined brain power of the two organizations to help with some of this work as well.

Mrs. Liz Sandals: Anyone else? I've got a follow-up question, if I may. Gordon?

Mr. Gordon Floyd: Can I just add a little bit, Mr. Chairman? As Alex has said and as we all feel, this mapping exercise is clearly going to be useful, and it's clearly needed. We don't have as strong a sense as we need about what services are available where in the province and how those match to the needs.

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Part of this confusion has arisen from, actually, some of the issues that Mr. Hampton was getting at around the wide variety of different kinds of organizations that are getting bits and pieces of the children's mental health budget.

The community-based children's mental health system that we have in Ontario is one that was created in 1970 by the Davis government. They created about 100 community-based agencies, covering the entire province, to be the backbone of a child and youth mental health system. Most of those agencies still exist, some of them amalgamated, but they're out there and they still cover the entire province, and they are the locus in each community of clinical expertise and research expertise around the delivery of child and youth mental health services.

We have been very surprised to see the numbers of transfer payment agencies that are being funded out of this budget. The notion that there are 440 agenciesâ€"we can't even identify about 300â€"is a real concern for those of us involved with Children's Mental Health Ontario, where we have some very clear standards around accreditation, where all of those agenciesâ€"only 125 agencies in the province actually use the BCFPI tool, and a similar number are using the CAFAS tool.

The situation we have is that vast parts of the child and youth mental health budget are being dispersed to agencies that aren't collecting any of the standardized data across the province. They aren't using the standardized intake tool, they aren't using the standardized outcomes measurement tool and they aren't accredited. We have some very, very serious questions and concerns about what's going on in those agencies, because we know so little.

Mrs. Liz Sandals: Thank you. That's very helpful. One of the things that the auditor mentioned, which caught my attention, was an example of a situation where an agency was funded for, I think, eight beds, and staffed at eight beds, and a number of those beds were vacant. I don't know whether I canâ€"first of all, I'd like to clarify that those were mental health beds and not youth justice beds. Does anybody know what I'm talking about? Jim, can you help me out here?

Mr. Jim McCarter: I think that might have been one of the residential programs.

Mrs. Liz Sandals: Yes, it was a residential program.

Mr. Jim McCarter: We had a look at the residential programs, and we were just looking to see where there were beds. If there were beds, were they being filled? And if they weren't full, was the staffing adjusted for it? I think that was the issue.

What I said this morning was, probably what we found overall is, on the residential side of the services, for a large part, the needs were largely being met. I think we felt that it was maybe more the non-residential side that was a bigger part of the problem. I think that was our perspective.

Mrs. Liz Sandals: Okay. Can you speak to that, Alex?

Mr. Alex Munter: I'll speak to that, because I believe the residence in question is the residential crisis unit, which is one partâ€"if you recall, earlier, I talked about the 24-hour crisis line, which is backed up by a mobile team, which is backed up by a residence. That's the residence in question.

Mrs. Liz Sandals: What funding stream would that be?

Mr. Alex Munter: That is out of the funding stream we're talking about. That is a mental health service.

Mrs. Liz Sandals: Okay. It's not youth justice. I understand that's a differentâ€"

Mr. Alex Munter: No. And just to be clear on just a couple of points that are relevant here: First of all, staffing is adjusted. In fact, we do adjust for volume of occupancy. What is relevant here is that the period that the audit was looking at was the first year of the operation of that program. What we've seen steadily over the course of the three years that it has been in operation, not surprisingly, is that the occupancy has progressively gone up, as have the number of calls for service to the crisis line, as have the visits by the mobile team.

That's a new service, that integrated crisis response serviceâ€"it's basically three years old at this point. It continues to be used more and more effectively. Remember, it is also really a preventative service. Part of the business case why the ministry is investing in these services is that that short-stay residence, because it's a stay of only up to five days, is designed to prevent those young people and those families from being involved in the child protection system or, worse yet, the youth justice system, which, as you know, is far more intrusive and far more expensive.

Mrs. Liz Sandals: Just a question then: Given that it is short stay, and you've therefore, by definition, got high turnover, where I was going with this is, if you've got spaceâ€"we know coordination of service is an issue; we know distribution of service is an issue. If you do have nights where you don't have kids there that week, or very many, from the immediate Ottawa area, do you have the capacity to reach out to the people to the south or the west of you to allow their kids to access your service?

Mr. Alex Munter: They do have access to the service, actually, because that integrated program is a regional program, so that's a good example of what you're talking about. The phone line is a 24-hour line, backed up by a database that we share with nine agencies ranging from Renfrew county to Akwesasne reserve through that band in Champlain. Those agencies don't have capacity for 24 hours, so we're their emergency backup. They give out the hotline number to their clients, and then we push the information through the database from our operation to them, right into their database, so their workers the next morning have the information on the intervention.

The residence is available to them. It is far, and it is short stay, so if you're in Pembroke, going all the way into Ottawa for a two-day stay can be more daunting than it is if you live in Orléans. But it is there. It is used. As we see the occupancy numbers go up, it will continue to be used more and more.

Mrs. Liz Sandals: Nevertheless, it isâ€"

The Acting Chair (Mr. Phil McNeely): That's the time we have.

Mrs. Liz Sandals: Yes, could I just finish a comment? Nevertheless, it is a service that you'll never be able to afford in Pembroke, so having it available in Ottawa is really, really valuable.

Mr. Alex Munter: We work with them to deliver the service. There are nine agencies that work together on the delivery aspects of that service.

Mrs. Liz Sandals: Okay. That's good news.

The Acting Chair (Mr. Phil McNeely): Thank you. Mr. Hardeman.

Mr. Ernie Hardeman: Thank you all very much again for the presentation. I'm going to start off with the ministry. It seems that the audit was fairly supportive of or benign about the services that are being provided by the different agencies. The concern I have uppermost in my mind is, do we, as a ministry, know what we're getting for the money we're spending? In fact, is that being spent in an equitable way for the citizens of the province, not geographically in the province, but for the individuals who need the service? How do we decide where the money goes?

To help with the answer or to explain the question more, it seems to me, because of the historic way this sector has been put in place, that we fund it based on where the initiative was taken originally to set up an organization to help children and youth, but places where they didn't have that initiative at that time cannot get any money now to get one started. The funding is based on historic spending as opposed to historic or present service needs. I wonder if the deputy could help me with that.

Ms. Judith Wright: I think it is fair to say, just to repeat what others have said at this table, that this sector is, relatively speaking, a very young sector. Child welfare has been around 100 years; I think it was Gordon who said that this was started in 1970. It is fair to say that the sector itself has grown up on a community-by-community basis and that our funding has been allocated on a regional basis to encourage and have flexibility of services on a regional basis. I think what we're trying to say is with the development we did with the sector of the framework, we, for the first time, started to say, "Where are the strengths in that community-based approach?" There is, in this sector, time to do a number of things, one of which is to find: What do we think children's mental health services are and what's a common definition of that? What are consistent levels of services? So the framework sets out the four levels of needsâ€"sorry, not services. Finally, what are we currently funding now that fits into the framework, which is the purpose of the mapping exercise?

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The mapping exercise, which Aryeh was starting to explain, will provide and has provided us with information on, "Here's your frame; what are you actually ministry-funding now?" Some of itâ€"I don't disagree with youâ€"is historical, but that doesn't mean, as we were having the discussion with Mr. Hampton, that it isn't a useful service. But it may be that it now has to be looked at within the new framework that we're talking about.

The mapping will give us enough evidence to start to have that discussion at the local level with the local planning tables and with the agencies as to, "Here's what children and youth mental health services are like in your community; here's the framework; where are the gaps? Where are the duplications? Where do we want to go forward on it?" Over time, that will enable us, I think, to have a more disciplined approach to what services are delivered and in the same way to what we fund.

Mr. Ernie Hardeman: I know this is going to sound like I'm going to be critical, and I'm notâ€"

Ms. Judith Wright: It's okay. I'm not perfect.

Mr. Ernie Hardeman: I'm not that type of person.

Somebody moves into my communityâ€"and this is not from the provision of services, but from the political sideâ€"and calls my office and says, "We just moved from downtown Ottawa"â€"and I've visited some of those residential places that Alex spoke aboutâ€""and these were the services available for my child. How come that service is not available in Oxford?" Obviously, it's a government-paid-for service, so it must be my responsibility to make sure that my people whom I represent have fair and equitable service. Who do I go to to get that service in Oxford county?

Ms. Judith Wright: This does go back to the point that these services not only grew up at a community level, but there isn't what we would call a core set of mandated services. There isn't, with children and mental health, a mandated service to have a doctor in your community. Because of that and because of the fact it isn't mandated, we work within the resources that the government has given us within its fiscal framework. Under those circumstances, I think the agencies on the ground do their best to attempt to meet the broad level of needs that exist for all children and youth that have mental health problems in this province. But in some cases, there are gaps, and we've seen some already from the mapping that we've done. As I said, based on that information and the framework, we'll be able to discuss what, at a community level, needs to be done on that.

Mr. Ernie Hardeman: I'm starting to think like I'm in question period now.

Ms. Judith Wright: Uh-oh; that's a problem for me, sir.

Mr. Ernie Hardeman: Exactly, because the question was, where would I go, as the MPP for Oxford, to deal with the challenge of a service that is available elsewhere but not available to my people? Who would I call and how would you go about getting that service?

Ms. Judith Wright: Sorry, I misunderstood your question.

Mr. Alex Bezzina: The first thing to note is that it may simply not be available in your specific community. Can it be made available in a surrounding community for that particular family or are there other ways of getting that service met? If you're wondering who to call, I think that most MPP offices know to call the regional office of the ministry. The program supervisor or one of the managers in the office can assist the family with finding the service that they might require. This is particularly true when families are in crisis, as they sometimes are. The ministry does work very diligently to find the services that families need.

Mr. Ernie Hardeman: I'm going to try it a third time. I don't have an individual who is lacking the service today, okay? I have the responsibility, as the elected official for my community, to see that my people have the same level of service as anyone else in the province. I'm told by a third party that, in my community, I haven't done my job because there are services available in every geographic area around me but not in my riding. Where do I go, who do I talk to in government, to say, "I want to start up that service. I want that service available to my people, the same as everyone else gets"? Where do I go to do that?

Ms. Judith Wright: Technically you would approach the Ministry of Children and Youth Servicesâ€"you know thisâ€"and approach our regional office. Within that context and within the context of the allocation of the resources that we make, we would likely have to do a number of things. One is to ascertain what the need in your community really is for that service. Are there any other current services that exist in your community that provide that service but are not named that, perhaps, or where we can actually link you in with a service that's not in your community that's provided?

One of the expansions that we've made most recently is in telepsychiatry. It may not be the exact example of the constituent you're talking about, but our increased investment in telepsychiatry has enabled us to address some of the service gaps in terms of access to professional services in rural and northern areas.

The first stop would probably be not just the regional office, but the regional office would then engage with the other service providers in that community to see where we could address that gap.

Mr. Ernie Hardeman: One further question on that, and then I'll change this, but I went through this process. We do have the services available in part of my jurisdiction. I wanted that service expanded to the other part of the same area I represent, because they don't have any of those services there. When we went to the ministry, they said that the money coming to my area was fair and equitable compared to everyone else's. When I looked at the people providing the service, that wasn't the case. We did a lot of chasing. It turns out that there was another organization getting funding for children's mental health and not necessarily spending it on that. Meanwhile, children's mental health in my riding was not getting the service it was entitled to, and nobody seemed to be able to do anything about it.

The challenge I see: What do we need to do, as a recommendation from the committee, to make sure that the money for children's mental health is all being spent on children's mental health? Is there a way that the ministry actually follows that up to make sure that that's happening?

Mr. Alex Bezzina: I think the point that you're making is that if there are funds being allocated to children's mental health, this committee wants assurance that it's being used for that particular purpose.

I'm not entirely sure if everybody would be in full agreement with what the definition of a mental health service is, to begin with. In fact, that is one of the things that we're finding as we're doing the mapping exercise: There's a broad range of ways of intervening with families, with kids, with youth, from a very early intervention/prevention kind of perspective to some fairly intensive interventions that are required. So what might be a mental health service to one agency may not be considered to be as important by another agency. That's the reason why, at this particular point in time, our main way of keeping organizations accountable is through our service contracts. If we're contracting for a particular service, they must be accountable for that.

The most systemic issue that you're raising is what we're trying to get at through mapping: to determine what range of services need to be available or should be available in any given community. How do we ensure that the resources that we allocated are being used to fulfill the mandate of the policy framework?

Mr. Ernie Hardeman: Thank you very much. I do want to say, I'm going to be biased in my next question, but in Oxford county we do have the best child and youth services anywhere in the province. They're good folks. I meet with them on a regular basis, and the biggest challenge is, of course, as was mentioned, the lack of funding in the big picture. What that causes is a waiting list. We have to work hard, of course, in deciding what creates the waiting list or what we do with the waiting list. What happens to those people if they're on the bottom of the list for service? What are the chances of them getting service? The time that they are eligible moves faster than the list moves up, so they never get to the service. Recognizing that we're only going to serve the number of people we are presently, because everybody is working as hard as they can and there's no more service available, is there a way that you can set the eligibility at a level that there would be no waiting list? We're going to miss doing some. I want to be sure that we're missing the ones who least need it.

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Ms. Judith Wright: Actually, the agencies would probably be better to talk about this. I think the question you're asking is what happens around the triaging of someone who is in need of a service. Because not all of the mental health requirements are on the same level of urgency, agencies triage those who are most urgent and manage, I think, their wait times accordingly.

So I would actually ask the agencies, if they don't mindâ€"I'm sorry to put you on the spotâ€"to just talk about the challenges of actually doing that. I personally can't imagine a time where we would never have wait times/wait lists. It's just kind of part of life, but the agencies may have a different view.

Mr. Peter Moore: I can talk about our experience. It's the art and science of managing this. So we look at the BCFPI data, you look at the type of problem and you look at the array of services and you match. I can say that we don't have anybody who doesn't get service, but they will have less intensive services if their problems are less severeâ€"so those who are early intervention and prevention. It's always a challenge. I'm not minimizing that, but I think we pretty well match what the intensity of need is with the kinds of problems there are.

We would do a large group program, a parenting program in an auditorium, for those less severe problems, and we would do intensive individual work with those with more severe problems. But we track the wait time for all of our clients so we can tell you to the day how many days every client has been waiting and match that against their profiles.

The Acting Chair (Mr. Phil McNeely): Mr. Spekkens wanted to add.

Mr. John Spekkens: I'll just add a comment. In our agencyâ€"and I think it's a common practice in a number of agenciesâ€"we may talk about a waiting list of, say, 100, but it's not like lining up for tickets somewhere, where it always goes numerically one at a time. The triage that we perform is, if somebody comes in with an extremely urgent need, they may get service much faster than somebody where things are sort of held together not too badly. Now, of course, the flaw there is that you've got to have a crisis to get service, it seems.

What we're also doing is, people on the waiting listâ€"again, depending on the need and the intensity of their problem, the treatment staff will also carry five or six or 10 people on a waiting list that they will have some contact with, minimal contact. It's not an intensive treatment contact, but it is a contact to monitor that the situation does not deteriorate dangerously or to respond to a need where maybe a half hour may settle something so they can wait another month before they get into the full service.

Still, it has the feeling that it's sort of churning a list and the list is still a problem, but the most in need will typically get the service faster than those in much less need.

Mr. Alex Munter: And that is, in fact, a reframing effectively of the eligibility criteria. Our agency does the same thing. We do a risk assessment at intake. We try to divert clients where possible, where it's appropriate, into parenting groups, single-session therapy. We have the crisis support there. We check in with everybody on the waiting list. So there's that kind of a dynamic management of it.

When I talk to folks in our agency who have been, for example, in our youth and family counselling program for 15 or 20 years, their observation about the impact of that is that the cases are more complex, the needs are far more severe and the program then evolves on that basis, which gets us away from our capacity to be doing some of the early intervention/prevention pieces as we become more and more about responding to crisis.

Mr. Ernie Hardeman: If I was to make the comparison between the medical system and children's mental health, we have waiting lists for things in the health care system. If I want to get a hip replacement, I may have to wait eight months, I may have to wait 10 months. That's all predicated on that if I get sick and I need immediate medical attention, I go to the emergency room and they look after me. Is that also true for children's mental health, that everybody who needs immediate service is going to get it?

Mr. Gordon Floyd: I think it depends on the level of need. Anybody who approaches a children's mental health centre in crisis will go to the head of the line. So if we have a child who has attempted suicideâ€"let's take that exampleâ€"that child is going to get immediate service.

There are a couple of areas, though, where there's a real divergence between what happens in the children's mental health system and what happens in other parts of the health care system. We don't have any kind of wait time strategy around the children's mental health system as the government has created in a number of other areas. There are no targets that have been set for the system to aim at and to strive to meet, although we do knowâ€"there's been a fair bit of academic work done on thisâ€"that the average wait time that does exist in the system far exceeds what clinicians would set as targets, had they been asked to do so formally. That's one big difference: There's no formal monitoring of wait times in that way.

I guess another difference that's very important to bear in mind is who it is that we're dealing with here. When somebody comes looking for children's mental health services, usually it's the parent bringing the child and usually, by the time they have gotten to the point of asking for help, they're at the end of their rope. They've gone through a long period of denial, stigma being such a huge issue and the shame around these conditions being so large. They've tried to manage the problem at home through better parenting techniques and bringing in the grandmothers, or however that's done. They've probably worked with the school. They've quite possibly been to their family physician. None of that has yielded a solution, and so they end up at the door of a children's mental health centre. Then if their child is not in crisis, we say to them, "You're on a wait list now that's going to be probably between five and six months," which is an eternity.

I think the analogy that I would use with the health system is, what happens when somebody approaches their physician with a bad cold and nothing happens, that cold becomes bronchitis and still nothing happens, and then that bronchitis becomes pneumonia? By the time it's become pneumonia or its equivalent, then they get into the children's mental health system.

Certainly we can set a threshold so that there will be no waiting lists, but I think that the consequences of setting the threshold that high would be horrendous for the children of this province.

The Acting Chair (Mr. Phil McNeely): Thank you. That's the end of that round.

Ms. Judith Wright: I'd like to add one thing to what Gordon saidâ€"

The Acting Chair (Mr. Phil McNeely): One minute.

Ms. Judith Wright: â€"as I think that's a very eloquent statement that he's made. It's true we haven't thought about it and we're not proposing to set wait time targets, partially because I think we have a round of research and evidence to do to make sure that we actually understand and have good data on wait times. One of the things we're going to do on mapping is look at what the regional variation in wait times is. The other thing we're going to do under mapping is look at the potential of benchmarking those wait times, because if we can benchmark them, we can begin to go in the direction that Gordon's recommending around targets. The third thing we're doing is, we're going to do a review of best practicesâ€"

Interjection.

Ms. Judith Wright: â€"I'm talking quicklyâ€"on wait times so that it's not only on how you measure wait times, but how you monitor them and actually how you can reduce wait times. We believe those steps to be important before we would move to something like the targets that Gordon's recommending.

The Acting Chair (Mr. Phil McNeely): Thank you. This next round will be 15 minutes, and that'll take us till the bells sound. Ms. Gélinas.

Mme France Gélinas: Thank you, Mr. McNeely. Sorry I missed your introductory comments. I'm truly sorry.

Interjection.

Mme France Gélinas: I'm pleased to meet you, too. Children's mental health is something that is very important to me. I tried really hard to be here, but I just couldn't.

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The first question I had had to do with the mapping exercise. I understand some of it, but not truly. But the part that I'm most interested in is, we have done the mapping, and we have a pretty good idea of what's on the ground. Has the work already started to seeâ€"okay, now, here's the set of mandated services we want. We have our map. Do we also have a goal as to how we would want to use that information to inform change in the children's mental health system?

Mr. Aryeh Gitterman: We do have a goal in the broadest sense of the word "goal." The policy framework does set out the description of a coordinated system with timely access to a range of services or a range of needs. It's not concrete about quantity of service or program.

One of our more immediate next steps, which I think is a step toward what you're describingâ€"one of our immediate next steps is to take the information from mapping and put it in a sort of profile of the province, and by region and by community, so that we can then go back to those communities with that information and have a discussion with the agencies and with other representatives of the community as to whether or not the picture of that community, contrasted to the framework's goal, is adequate; and if not, what can be done, both from our perspective, the agency perspective, and that of other representatives in the community, in the short term or perhaps the long term, given whatever restrictions we have with current resources.

It's not quite as specific as you've mentioned, because it doesn't include the entitlement aspect, or the mandated aspect, because children and youth mental health is not a program with entitlements. It goes somewhat toward what you've described, but not all the way.

Ms. Judith Wright: I'd just like to add to that. Because this is a new exercise for children and youth mental healthâ€"on the community-based side, anyway; on the health-based side, this is a fairly well trodden territoryâ€"the conversation with the agencies and back in the local communities is probably as important as having done the exercise. People have to understand and believe that this data is real data. We all have to agree that it has real meaning. We're going to take a thoughtful rollout process in doing that, and engage in a good, solid discussion on what this data means for all of us.

Mme France Gélinas: Okay. I think that the end goal that you've stated is very good, but I'm still a little bit surprised that there is no work being done to go from these high-level goals, province-wide, to what it will really look like. I have in mind things like what is the percentage of resources that will be in promotion and primary prevention, in actual casework, in treatment etc. Who is working on that kind of issue? Or am I dreaming here?

Mr. Aryeh Gitterman: Let me describe a little bit more some of the other things that we are undertaking, which I think may be helpful.

Mme France Gélinas: Sure.

Mr. Aryeh Gitterman: We do understand, and it goes to some of the other evidence we've already collected, that I had started earlierâ€"we do know from mapping what percentage of programs and services are being directed currently to children at different levels of need across that continuum. And just by way of example, at a very high level, about 20% of our programs and services are directed toward children at the lowest level of risk and about 18%, 19% at the highest level of risk; there are four levels. So we know the current. We don't know, howeverâ€"and this is some of the work we're undertakingâ€"what is an appropriate distribution.

That goes back to some of the comments the deputy made about benchmarking ourselves. It's not just benchmarking ourselves on issues like wait time; it's also benchmarking ourselves on distribution across those levels and it's also benchmarking ourselves on the success rates for our interventions. We collect information through one of our other tools, CAFAS, on the improvement level associated with different programs. Until we do this benchmarking exercise, we don't know what is a reasonable goal for improvement. Of course, the other level we want to benchmark ourselves on is the quality of the program and service being delivered. Is it based adequately andâ€"several agencies commented on this as wellâ€"is the evidence attached to the program which is attached to the outcome? We are undertaking that work, which isn't quite as specific as you mentioned but is on the road to that.

Mme France Gélinas: Do you see at some point having mandated services in children's mental health province-wide?

Ms. Judith Wright: I think the decision to mandate it would be a government decision.

Mme France Gélinas: Which is all right.

Ms. Judith Wright: Yes, it is that.

Mme France Gélinas: We'll leave it at that.

Of the 448 agencies that receive funding, how many of them are under the LHINs?

Ms. Judith Wright: Do you mean under the LHINs in the sense of funded by the LHINs at the same time?

Mme France Gélinas: That's right.

Ms. Judith Wright: I don't have that data with me. Do you, Alex?

Mr. Alex Bezzina: We don't have that data.

Ms. Judith Wright: Gordon?

Mr. Gordon Floyd: I know there's at least 27 hospitals that I believeâ€"

Ms. Judith Wright: We do fund outpatient programs in hospitals.

Mr. Aryeh Gitterman: Again through mapping a point in timeâ€"

Mr. Gordon Floyd: Sorry, it's 17.

Mr. Aryeh Gitterman: There are 17 outpatient programs we fund which are housed in hospitals. There's also a very, very small percentage that may also be receiving money through LHINs. Of the agencies that we've been talking about, well over 90% of their funding is from MCYS. There may be a small number. We could uncover that, but it's a very small number.

Mr. Alex Munter: It's an interesting issue, because what it means is that since the vast bulk of adult mental health services are funded through the LHINs, when the LHINs talk about mental health, they mean adults. That's what they see. That's what they understand. I know in our LHIN we've been having discussion around how we establish a community of practice around child and youth mental health that fits in with the rest of the health care system so that this piece is not invisible.

Mr. Aryeh Gitterman: Just to continue, that is absolutely correct; it's primarily adult mental health. The Ministry of Health does have responsibility for addiction services for children and youth, so there's some activity there. There are a number of in-patient beds for children and youth in the mental health area as well. Those are related. I should addâ€"I didn't mention this beforeâ€"that the mapping exercise we have undertaken will include all of those services as well. We'll have a better understanding of it when we have that information.

Mme France Gélinas: Okay. One of the recommendations from the auditor, recommendation 10, had to do with governance and accountability. Of the 440 that were submitted withâ€"do they have that? You do have the report?

Ms. Judith Wright: Yes, we do.

Mme France Gélinas: How many of them have a board of directors?

Mr. Alex Bezzina: All of them have a board of directors. The transfer payment accountability directive of the government, which the ministry follows, requires a board of directors to be in place when we fund an agency. There's a number of requirements; that's one of them.

Mme France Gélinas: They're all not-for-profit boards?

Mr. Alex Bezzina: The organizations that we fund directly are not-for-profit.

Mme France Gélinas: I see that you fund quite a few First Nations communities. How do you reconcile the structure of the First Nations, which isn't really conducive to having not-for-profit boards operate within First Nations communities?

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Mr. Alex Bezzina: We have to ensure that there is some capacity for oversight for the program dollars that are being provided. Whether it's the band council or other oversight bodies, we need to make sure that there is a point of accountability for the oversight of the use of the dollars.

Mme France Gélinas: When you said that all 440 had a board of directors, some of them, especially the First Nations, may not have a board of directors; they have an accountability mechanism through their First Nations band council?

Ms. Judith Wright: That's correct. They'd have an elected body. It would be similar if we gave funding to a municipality.

Mme France Gélinas: The recommendation from the auditor was to include child advocates. I was wondering what is being done right now to make sure that we put forward children's mental health advocates on all 440 of those not-for-profit boards or band councils?

Ms. Judith Wright: We have actually, over the last couple of years, encouraged agencies to have a youth voice, as we call it, on their board. In fact, the Youth Services Bureau of Ottawa has a very fine model for incorporating advice from clients and from youth. We haven't made it a mandatory requirement. I think it's something that we would need to look at and talk to the sector very clearly about. As part of our strategic plan, we have as one of our goals that there will be enhanced participation and a place for the clients and for children and youth in the decision-making process around their services. I don't know if Alex wants to talk about his model or not; he may not want to.

Mr. Alex Munter: I always want to talk about our model. Very briefly, and we can send you some of the information, we have a youth engagement program in our agency that operates out of our downtown services. To see the transformation of these young people, who were some of the most at-risk people in the community, at the end of their involvement with the program is quite inspirational. So we've developed a mechanism for them to have direct input with our board of directors, to be able to provide input, to meet with the board, to attend the board retreats, to report to the board on a regular basis and to engage the board in their activities.

The Acting Chair (Mr. Phil McNeely): That's the end of the time. For the Liberals, there are three of you who wish to speak. You have 15 minutes, so we'll start with Mr. Zimmer.

Mr. David Zimmer: My question is about accountability. The Auditor General refers to $502 million for the children and mental health program; 40 agencies get $250 million, and 390 agencies get $250 million. I was struck by Mr. Bezzina's comment about the oversight mechanisms that are in place for program dollars that you referred to, but then I contrast that with the statement of Mr. Floyd earlier, who said some of these things: "We don't have a good idea of what services are available in different parts of the provinces. We can't identify about 300 of the agencies." Presumably that's 300 of the 440 agencies. "We know so very little about what's going on in those agencies." The two points of view don't fit. On the one hand, you're talking about dollar program accountability. Mr. Floyd says we don't even know what's going on in 300 of those agencies, and yet 390 of those agencies are getting $250 million. How can that be? How do you resolve those two points of view?

Ms. Judith Wright: I beg to differ with my colleague at the end of the table. The ministry does know what it's funding in those agencies. We have transfer payment accountability agreements with every one of them. I think Gordon is probably speaking more from an association perspective, and that's fair. From an accountability perspective, we do know what we're funding.

The question that we're now grappling with is, are we funding exactly what we should be funding? That's actually where the mapping exercise will take us. We do know and we can tell you what's being funded in the various places. Gordon is free to elaborate if he wishes.

Mr. David Zimmer: Fair enough. And so, Mr. Floyd, could you justâ€"

Mr. Gordon Floyd: My commentâ€"

Mr. David Zimmer: I just have to resolve those two statements in my mind.

Mr. Gordon Floyd: Absolutely and quite fairly. Certainly, as the deputy has said, the ministry contracts for specific services and specific numbers of children to receive particular types of service. They know that, and there are lots of those coming in. Lots of those contracts are very smallâ€"so small that they don't even get reported in public accounts. They don't meet the threshold to be reported individually, which is why we don't know the names of a lot of the agencies. We can't find that from outside. I'm sure the ministry knows who they're cutting cheques to.

My comments about not knowing what's going on in about 300 agencies actually were tied to my observation that the two mandated toolsâ€"the BCFPI, the intake tool, and CAFAS, the outcomes measurement toolâ€"are only being used in 125 agencies. For the other agencies, we're not using the consistent screening tool to do the kind of triage that we were talking about earlier to assess what needs are and we're not measuring outcomes in any consistent way that can be compared to what's happening in other parts of the system.

Mr. David Zimmer: I saw that Mr. Bezzina wanted to respond to that.

Mr. Alex Bezzina: To get a point of accountability from the ministry's perspective, I just wanted to indicate that not a single dollar can flow to any agency outside of government unless there's a service contract in place.

Mr. David Zimmer: All right. Thank you.

Mr. Alex Bezzina: I'm sure the agencies would agree, service contracts are somewhat onerous in their reporting requirements.

Mr. David Zimmer: Back to Mr. Floyd, then, to do with your statement that you know so very little about what's going on in the agencies and you can't identify about 300 of them. How could an answer or a solution be provided to your concerns?

Mr. Gordon Floyd: I suppose that if we're truly going to haveâ€"in fairness, I think the ministry is definitely trying to move in this direction. But if we are going to have what we want to refer to as a "system" of children's mental health services, then there are going to have to be some consistent pieces that exist across that system that are going to allow us all to see who is accessing what kinds of services and what kinds of outcomes are being delivered by the system.

Again, as the Auditor General noted in his report, we don't have in the children's mental health system the same kind of standards for service delivery, for the way in which services are actually put out there, as exists in a much more highly regulated system like the child welfare system. As service providers, we've collectively tried to address that by developing and managing an accreditation program that does establish some consistency in the way services are delivered, and it does hold agencies to account to those accreditation standards. As with the BCFPI and the CAFAS tools, the accreditation program is actually only being used in fewer than 100 agencies.

Mr. David Zimmer: Just a last point: How closely does the ministry work with agencies, for instance, like Mr. Floyd's agency, Children's Mental Health Ontario?

Ms. Judith Wright: We work extremely closely with the agencies that are his members because those are the agencies with which we have a contractual relationship. Our regional offices work with them, and most communities have a planning table for mental health where those agencies and other related services fit in.

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Mr. David Zimmer: So he could get his information that he needs about the 300 agencies through that relationship?

Ms. Judith Wright: He could get it that way, but if Mr. Floyd would like a copy of all the agencies we fund, I'd be pleased to give it to him.

Mr. David Zimmer: Thank you, Mr. Chair.

The Acting Chair (Mr. Phil McNeely): Mrs. Van Bommel.

Mrs. Maria Van Bommel: Thank you for being here today. I just want to go a little bit further because we've talked quite a bit about who's funded, can we list them and all this sort of thing, but I think at the end of the day the really critical piece is the outcomes of that. We heard that not all the organizations use CAFAS. So how do we measure the outcomes? How do we know that the dollars that we're sending into the agencies and the service delivery people are getting the kinds of outcomes that we need to have? Do we measure that? What happens if they don't meet the measure?

Ms. Judith Wright: I understand the point that CAFAS and BCFPI are only used by 120 agencies, but they're 120 agencies that represent a fairly large percentage of the service delivery in the province. From that data we do get effectiveness data, particularly from CAFAS, in terms of how well we're doing in assessing and serving children and youth.

In addition, as part of the contracting process, and Alex can speak more to it, we require agencies under this onerous process that we have to report to us on service data, and we fund them according to service data. So we can measure through that the number of units of service that we're funding and what type of service we're funding.

Once again, we are now drilling down, as we've talked about at this committee, on what more specifically that means by level of need in terms of service.

Mr. Alex Bezzina: I will indicate that up until nowâ€"it's really only been in the last couple of years since the release of the policy framework that we've begun to have a robust discussion about outcomes. So now, from an accountability perspective, for those agencies that are not using CAFAS it really is about looking at inputs and outputs from a service data perspective. We expect agencies, and perhaps some of the agencies can speak to this, to be looking at their own service quality and that boards be working with their senior staff with respect to continuous quality improvement. But as yet, we haven't systematized that for all of our contract agencies.

Mrs. Maria Van Bommel: Okay. I take it you would like to say something?

Mr. Gordon Floyd: If I may. Yes, it's true that agencies report quarterly on their output, but as the Auditor General has noted on page 136, everyone's counted the same way regardless of the extent and type of service that he or she received. For example, a person would be counted as one whether he or she attended a single, one-on-one session in the year or many sessions over the course of the year.

So the kind of data that the deputy has referred to that's included in those quarterly reports is pretty primitive output data. It's certainly not outcomes data, and we are a long way from having that consistently across the system.

Mrs. Maria Van Bommel: Do you want to respond to that?

Ms. Judith Wright: I think Gordon's touching on a good point about the difference between output and outcomes. I think there is some measure of outcomes through CAFAS. I think it would be misleading to say that there's none. Measuring outcomes in mental health has a lot of challenges, not the least of which is the diversity of the presenting symptom and the diversity of the intervention. I think through our funding for CHEO, we have actually tried to investâ€"sorry, that's the Children's Hospital of Eastern Ontario and the Centre of Excellence in Mental Health. We have started to invest in providing expertise on what interventions and clinical practices our best evidence tells us work and don't work and, therefore, should lead to outcomes. I don't disagree with Mr. Floyd that we're a long way away from having good, robust outcome data, but we're all committed to getting there. It's just extraordinarily complex in this field.

Mrs. Maria Van Bommel: When you talk about complexities, how do you handle them? Very often mental health isn't just one nice little diagnosis. It's ADHD, and there are often other things that kind of complicate, and it could be any number of things. Again, the measure of that sort of thingâ€"how would you assess a situation in that case where, I would suggest, probably most often children who present have complex situations as opposed to a very simple, nice "We treat that and we're good to go"?

Ms. Judith Wright: Yes, I think that's actually very true. We have always encouraged and tried to fund a multi-disciplinary approach. I think the agencies have embedded a multi-disciplinary approach. Your question would probably best be answered by somebody delivering the service.

Mr. Peter Moore: I can speak to that. All of the agencies have multi-disciplinary teams, so usually it's an approach of doing an intake screening by the telephone interviewâ€"BCFPIâ€"collecting data and then looking at the complexity. Then it moves to whether it's going to be just a social worker who does the intervention or whether they get psychiatrists or psychologists involved. It really unfolds depending on the complexity. Rick, do you wantâ€"

Dr. Richard Meen: No, I would agree. In this day and age it is an interdisciplinary team.

Mrs. Maria Van Bommel: Just one other thingâ€"Mr. Bezzina mentioned it earlier, and it was something I wanted to get back toâ€"and that is the policy framework that was established called the shared responsibility. I just want to quote from the auditor's report on this, where he talks about the fact that of course this is something that is intended to be implemented over 10 years, but he says, "It is not yet clear whoâ€"the ministry or the agenciesâ€"will take the initiative and be accountable for ensuring that the proposed changes occur on a timely basis." Has that been addressed? Where are we with the framework? Have we seen any benefits coming out of having established a framework? What kind of progress have we made?

Ms. Judith Wright: I think we had seen some very clear benefits out of the framework, many of which we've touched on today in terms of being able to have a definition of what is a mental health service under children and youth mental health services and enabling us to dig into what is actually happening at the community level.

In terms of the question of whose accountability it is to move forward on the framework, it's very much a shared accountability between ourselves and the agencies that deliver the services for the children and youth who need them. We developed the framework very much in consultation with the agencies, and CMHO had a terrific leadership position in terms of developing this framework. We would see continuing that kind of collaborative relationship going forward. That is why I said earlier to Madame Gélinas that we see taking the data we have from the mapping back to the community and having a really good conversation with the agencies and the communities, because it has been very much a joint process, both in terms of developing the framework and the mapping exercise.

Mrs. Maria Van Bommel: Thank you.

The Acting Chair (Mr. Phil McNeely): Thank you. The time has expired. We'll go to Mr. Hardeman.

Mr. Ernie Hardeman: I just quickly want to go back to the wait times. I found a disturbing comment that had to do with Peel region. It was a school trustee who said, "20% of our kidsâ€"that's 50,000 kids in the Toronto school boardâ€"have a mental illness and only one in six of them are getting help...." Is that an accurate statement as it relates to the problem? That means that 8,000 of 50,000 children with mental health problems are going to get some type of service.

Ms. Kelly Henderson: I'm not sure that's an accurate statement because I don't have those numbers in my mind. What I do know is one of the opportunities that was spoken of earlier in reference to the shared responsibility in the development of the student support leadership initiative.

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In Peel, our cluster is working collaboratively with the school boards there, as well as the children's mental health organizations and, in fact, we're joining with a broader planning table initiative to ensure that we're trying to move our work forward, both at the school level and in the community, to address the needs of young people and their families. I think that broader perspective of coming together as a community, touching upon mental health and other less formal support, is key in making sure that we are addressing the needs of young people on that spectrum of lower need into more intensive need.

I would say, although I can't comment specifically on those numbers, there is certainly initiative in moving forward to address the needs of the students.

Mr. Ernie Hardeman: Thank you. That number, I find somewhat disturbing.

Mr. Gordon Floyd: I can actually comment, and I know the deputy can do this too. That number is derived from the Ontario Child Health Study, which was conducted out of McMaster University about 20 years ago. I believe it is the most comprehensive study that has ever been done around children's mental health issues, but it's pretty dated. Unfortunately, we don't have anything that's more current than that.

That one-in-six figure, whether it's precise or not, is one that is used quite widely around the country. I think, whether it's exact or not, it's certainly in the ballpark. There are three big reasons behind that figure. The first is that there are an awful lot of kids who have mental health problems who are not coming forward and identifying themselves, or their families are not identifying them. The biggest issue that we all have to deal with in this field is the stigma that's associated with it, so many children just slip under the radar. We don't address that reality effectively here in Ontario because we don't have any universal screening programs to identify kids who do need help.

We know that most of the kids who are slipping under the radar are not the ones who are acting out and who have serious behaviour problems, but the kids who have quieter, emotional problems, anxiety disorders, depressive disorders and mood disorders. They're the ones who sit quietly at the back of the classroom, and the teacher is happy that they're not disrupting the class, so they never get identified.

We have not taken the steps here in Ontario that they have taken, for instance, in British Columbia, where there is now a routine screening program at the grade 4 level and again at the grade 7 level to try to identify which children need help.

While we, at Children's Mental Health Ontario, are very strongly supportive of the policy framework that has been developedâ€"as the deputy said, we worked closely with the ministry in the development of that policy frameworkâ€"we are also very strongly supportive of the mapping work that's being done. But we are very concerned that action, on almost all fronts, is being held up while we go through this process of building the business case. We look at other parts of the country, like British Columbia, where they have taken some steps to say, "Listen; we don't know exactly how much money should be spent on prevention"â€"to go to your question, Madame Gélinasâ€""but for starters we're saying you've got to spend 10% of your budget on prevention programs and we'll continue working on the data and hopefully the business case will catch up with reality as we go."

Similarly, we don't know what's perfect in the way of a screening process but we know that we've got to start screening for these kinds of problems and, again, the business case can catch up to that.

This is a partial response to some of the things that we have heard from the officials. Again, we're very strongly supportive of the direction they're going in, but we're very concerned that things are moving extremely slowly, and that, really, when the deputy talks aboutâ€"

Mr. Ernie Hardeman: The answer, though, is the numbers are, to the best of our ability, right?

Mr. Gordon Floyd: To the best we know.

Mr. Ernie Hardeman: The reason that my questions are the way they are is that I understand that there will be areas, and I think this was an example, where the ministry and all the service providers are happy with the direction we're going, but I have to be sure, as the people's representative, that the people are being served, that they're happy with the direction we're going in. Everybody can be happy, but unless we're getting a positive result for the people we're trying to serve, we might as well forget the value-for-money audit and get out of the business, because we have to deal with the people we're serving, not the people who are serving. Much as I appreciate that we're doing the best we can, I think that's a very important thing that we have to keep focused on.

The other thing has more to do with the actual audit: There are a number of areas where the auditor points out that as organizations, the providers of the service are not doing things in maybe the most accountable and cost-effective way, such as the use of credit cards by the agencies and getting accountability at the end of the day for the money that was spent. There were some mentions in the report about some expenditures that the auditor thought were not legitimate expenditures, but there was no mechanism in the average organization to do that.

Another one was, do we actually tender? Do we get the best price for services purchased, both clinical and non-clinical, within the agencies? On those generallyâ€"I don't want to go through each one and ask what you have done about those. What have we done since the auditor's report came out to address those real value-for-money audits and how we deliver the service?

Mr. Gordon Floyd: Certainly, the four agencies that were audited have addressed every one of those issues within their own agencies, but we have done more than that. We found that the auditor's recommendations in those areas were really useful, and we have disseminated those to the hundred or so agencies, the larger agencies that are members of Children's Mental Health Ontario, and have been working with them to ensure that those recommendations are implemented right across the system.

The Acting Chair (Mr. Phil McNeely): I think the deputy minister wanted to respond to some of those issues, too.

Ms. Judith Wright: We have also provided a set of best practice guidelines on procurement, contracting and use of credit cards to all of our agencies, not just the children's mental health agencies, and it is our expectation that those best practices would be put in place.

Mr. Ernie Hardeman: In the relationship between the ministry and the service providers, is child and youth mental health any different from the association between the province and the children's aid society?

Ms. Judith Wright: From the perspective of an accountability agreement, you mean?

Mr. Ernie Hardeman: Yes.

Ms. Judith Wright: No, it's pretty much the same. We follow, actually, government-wide transfer payment directives.

Why do I feel you're setting a trap for me? What was it about that claim?

Mr. Ernie Hardeman: That's what I'm getting to. We did this same exercise with the children's aid society a year or so ago, and there were a lot of large vehicles that were purchased for the good purpose of looking after our children, but they weren't busing the children to school. I guess there was very little accountability. None of those present, of course, would be involved, but I was sure, from the ministry perspective, that we have enough oversight that that's not what's happening in those that are not represented here today in the provision of services.

Mr. Alex Bezzina: What the auditor commented on in the audit with respect to child welfare and again in this audit is that the standards that are in place within the public service should be looked at as a benchmark for standards of practice in the broader public service. The ministry has, in fact, taken the internal OPS policies with respect to the reimbursement of travel meals and hospitality costs and fleet management and the use of other road transportation. In the area of procurement of goods and services, including the use of credit cards and purchasing cards, we've taken our internal policies and we've adapted them for use externally. The internal ones make reference to things like deputy ministers etc., which don't exist outside of government, but we've adapted them. We've sent them out as best practice to all of our agencies, with the expectation, as the deputy indicated, that they be adopted into practice. Basically what we've said is, "Here are the elements of a good policy. This is what you should have in your policy. Compare your current policies to what we suggest are good practice and make adjustments accordingly."

Mr. Ernie Hardeman: I mentioned the children's aid society for a reason. When you sent in the directive to the children's mental health agencies, was that because of the problem or the issues that the Auditor General found at children's aid societies or was that subsequent to these audits?

Ms. Judith Wright: We sent out to the CASsâ€"actually, we require them to use these guidelines, because we actually have more legislative authority over the child welfare agencies than we have over children's mental health. At that point, we did make a public commitment that we would take those and translate them into these best practices and send them out to the full number of agencies that the ministry funds. We did make a commitment to do that at the time of the child welfare audit.

Mr. Ernie Hardeman: Of children's aid.

Ms. Judith Wright: Children's aid, yes. It took us a while to translate them and get it done, but yes, that's what we did.

Mr. Ernie Hardeman: So the challenges that the auditor found hereâ€"were they because they had not yet received the direction or because they were not following the direction?

Ms. Judith Wright: I think they had not received them at that point. I'm pretty sure of that. I'd have to get theâ€"

Mr. Ernie Hardeman: Oh, okay. I want to make sure that they all are working in that direction.

Ms. Judith Wright: No, I'm pretty sure. We made the commitment to do it when we prescribed it for the children's aid societies, and then by the time we got them translated into something less prescriptiveâ€"because we didn't have the authorityâ€"and sent them out, I think your audit had been finished. Walter would know this better than I would.

Mr. Ernie Hardeman: The other issue was the issue of oversight for the individual organizations, the board of directors and the community people to run them. The auditor suggested that maybe there be a different makeupâ€"different skill sets for different people on the board were recommended, and bringing consumers involved in the other side of it on the board of directors. Has there been much initiative taken on that in the four that were audited? Do you have a different makeup on the board now?

Mr. Gordon Floyd: This was one of the few recommendations from the auditor that we didn't wholly agree with. The reality on every board that I'm familiar with in the children's mental health field is that a good number of the board members are parents of children who have received service from those agencies, and there has long been and continues to be a very significant consumer voice on the boards of agencies.

What has not been present in very many agencies until very recently is what the deputy was referring to earlier, and that's the youth voice. Any child over the age of 16 can receive services without their parents' involvement, and certainly they are important players in ensuring that we have an effective and responsive system of services.

So what has been happening over the course of the last yearâ€"this actually predated the release of the auditor's reportâ€"is that more and more agencies have been following the example of the Youth Services Bureau and a few others to engage young people in the governance of their organizations and to engage them in a number of ways in the life of their organizations, because they're clearly one of the most important voices to have at the table.

The Acting Chair (Mr. Phil McNeely): Thank you. The time has expired.

I just ask the committee, do we want to go into a closed session? Is there any other business for today?

Seeing no further business, thank you, Deputy Minister Wright, your staff, and John Spekkens, Peter Moore, Kelly Henderson and Gordon Floyd. And I'm glad to see Alex Munter here. I served on his committee when he was chair of community and social services in the city of Ottawa. Thank you for your leadership in Ottawa.

If there's nothing else, then the committee is adjourned.

The committee adjourned at 1452.

CONTENTS

Wednesday 29 April 2009

Appointment of subcommittee P-337

2008 Annual Report, Auditor General: Section 3.04, child and youth
mental health agencies
P-337

Ms. Judith Wright, deputy minister, Ministry of Children and Youth Services
Mr. Aryeh Gitterman, assistant deputy minister, policy development and program design,
Ministry of Children and Youth Services
Mr. Alex Bezzina, assistant deputy minister, program management,
Ministry of Children and Youth Services
Mr. Gordon Floyd, executive director, Children's Mental Health Ontario
Mr. John Spekkens, chief executive officer, Hincks-Dellcrest Centre
Mr. Alex Munter, executive director, Youth Services Bureau of Ottawa
Mr. Peter Moore, executive director, Kinark Child and Family Services
Ms. Kelly Henderson, executive director, Associated Youth Services of Peel
Dr. Richard Meen, clinical director, Kinark Child and Family Services

STANDING COMMITTEE ON PUBLIC ACCOUNTS

Chair / Président

Mr. Norman W. Sterling (Carletonâ€"Mississippi Mills PC)

Vice-Chair / Vice-Président

Mr. Jerry J. Ouellette (Oshawa PC)

Mrs. Laura Albanese (York Southâ€"Weston / York-Sudâ€"Weston L)

Mme France Gélinas (Nickel Belt ND)

Mr. Ernie Hardeman (Oxford PC)

Mr. Phil McNeely (Ottawaâ€"Orléans L)

Mr. Jerry J. Ouellette (Oshawa PC)

Mrs. Liz Sandals (Guelph L)

Mr. Norman W. Sterling (Carletonâ€"Mississippi Mills PC)

Mrs. Maria Van Bommel (Lambtonâ€"Kentâ€"Middlesex L)

Mr. David Zimmer (Willowdale L)

Also taking part / Autres participants et participantes

Mr. Howard Hampton (Kenoraâ€"Rainy River ND)

Mr. Jim McCarter, Auditor General

Clerk / Greffier

Mr. Katch Koch

Staff / Personnel

Ms. Susan Viets, research officer,

Research and Information Services