We Have the Mental Health System We Designed

Minister of Mental Health and Addictions Sheila Malcolmson sounds very proud of our new mental health system:

We inherited a broken system that had been long neglected, and over the past four years we have made historic investments to patch the holes in this fragmented system. But now we are now moving beyond filling gaps, to make true system-level change.

Our government invested a historic $500 million in Budget 2021 to build a comprehensive system of mental health and addictions care that people in British Columbia deserve. (emphasis added)

Excerpt from an opinion piece that ran in Black Press Media’s community newspapers Nov 29th

What we deserve?

I don’t know about you, but I’d be offended to think we deserve what we have, given most people believe what we have now is pretty horrible.

People often want to know why the system works this poorly or why someone doesn’t fix it.

Actually, it’s working exactly as it’s supposed to.

People may be surprised (or a bit pissed off) to hear that, but it’s true. It’s working very well to achieve its goals. Unfortunately, those goals don’t have a lot to do with providing effective mental health care.

We may not have the system we deserve, but we have the one we designed.

It doesn’t work? Prove it!

For such a large, frighteningly complex, and enormously expensive operation, there’s very little data saying how well it actually works. You know, at providing people with mental health care.

I’ve talked about this before. Nobody publishes useful measurements or metrics about what seem to be obvious things like how long it takes to see a psychiatrist or counsellor.

What we have instead are periodic funding announcements. “We’ve invested XXX million for…. opened XXX new beds for…”

And you think there’s any kind of measure for any given person that says how they are when they first encounter the system, or at any time after that? Don’t be ridiculous!

Would you tell me, please, which way I ought to go from here?

So, if there’s no data about how the system operates, how do you know how well it works or where the problems are? Where should effort be focused?

Let me answer that by talking about navigation (in two senses).

First, there is navigation in terms of people finding the right services in the system. It’s not easy. So people want to fix that. A lot of people.

I’ve lost track of the number of databases, directories, websites, referral services, processes, and other overlapping efforts spawned by a wide range of individuals, organizations, and committees. An incredible amount of time, energy, and manpower has been devoted to this.

“Imagine, if only everyone could use the same referral system, we’d be able to effortlessly track all referrals and know about wait times everywhere in the system…!”

And how much better would things be if this problem was fully solved?

Think about the benefit of replacing smoke detectors in a building… as it’s burning to the ground. That much better.

It’s more likely planning stakeholder meetings about visioning for replacing smoke detectors…

The best navigation and referral system in the world doesn’t help if there aren’t enough resources to refer to in the first place.

But it’s hard to appreciate the scope of the resources problem without data. You can’t assess the full impact of a potential project. So we devote countless efforts to projects that can’t work or will have minimal impact.

Planning and prioritizing can’t be effective when we’re all in the dark about how the system functions.

To be fair, many people deeply involved in the system generally appreciate, albeit imperfectly, how it functions. That’s why they’re desperate to do what they can to try to improve things. While they may not be able to create accessible treatment resources, carving off a piece of the problem within their circle of influence is a natural and human response.

The unacceptable alternative is sitting there and doing nothing. They likely know the odds of their navigation system being meaningfully different from others. Or the odds that the largest organizations—with the worst wait times, with zero incentive to give up control or want to see their wait times published—would participate in their universal referral system.

Optimize for minimum negativity

If providing the best mental health care possible isn’t the system’s primary goal, what is it? This may sound cynical, but minimizing embarrassment for the government seems to be the overriding principle.

Health care (including mental health care) is ultimately the government’s responsibility. If things aren’t going well, the government is ultimately blamed.

Yes, other things being equal, better care is preferred to worse care. The people working in government, health authorities, and health care settings aren’t monsters, and they don’t enjoy seeing suffering.

But at what cost? People may bitch and moan, but the situation isn’t bad enough that it’s gained enough traction in the public eye to influence voting patterns. Other issues are more pressing. The downsides (higher taxes, etc.) could have more impact, e.g., providing leverage for the BC Liberals to attack the NDP. Plus, nobody is (credibly) seen as doing anything better; the Liberals aren’t about to invest more.

Conversely, an excellent mental health system isn’t seen as enough to swing voting patterns in the positive. It’s not just a matter of it being too expensive. We’ve repeatedly seen that when money is truly seen as needed, it’s available (COVID, bailouts, etc.). The political backlash that would have resulted from ignoring those situations justified the costs.

Drawing more attention to the problem would be a political liability.

In this view, transparency in the system is a negative. Concrete data on how poorly it functions is ammunition for opponents.

If there’s no data, you can claim anything you want.

If we don’t measure, we don’t look as bad.

As I said, the system is doing exactly what it’s designed to do.

Ministry of Mental Health and Addictions

There’s no clearer example than this recently created ministry responsible for mental health and addictions.

Does it manage the system? Does it actually provide treatment? Of course not.

I have yet to be convinced that spinning it off into its own ministry was about anything other than creating a glorified public relations factory.

Drip, drip, drip. Bits of funding here. Bits there. Announcements and announcements. Sprinklings of good news.

Nothing about how well the system works or what’s still needed.

The public doesn’t need to know that. There’d be no benefit.

You may have missed the Minister of Health rallying against a proposed federal mental health transfer. While the federal effort may well be as cynical a public relations effort as the provincial one, it would involve the province reporting actual data on access to mental health care in BC. That disclosure is not in the BC government’s best interests, no matter if the extra investment could improve care.

Instead, we see the usual political playbook trotted out, as reflected in the quote at the start of this piece. To paraphrase:

After discovering the (shocking!) horror left to us by the previous (evil) government, we’ve gone to heroic lengths to dig ourselves out from the disaster we inherited. We are now selflessly going above and beyond to build an even shinier future. And everyone gets a pony! This radiant future (and the pony) will immediately burst into flames if anyone else were elected.

Could we build a better system?

At finer-grained levels, we know that some things would help the system deliver better mental health care.

And that while there are definite costs, in the long run, it’s usually cheaper to fix problems early on when they’re small than wait until they’re bigger and cost more to fix. Which is how our crisis-driven system functions today. That doesn’t even factor in the indirect costs of not providing timely and effective care.

For the sake of argument, let’s say that our idealized system measures people’s needs and routes them to the right place for treatment with the appropriate professionals. It continually measures their progress, publishes and manages wait times and outcomes against some set of standards, ensuring sufficient resources to meet those standards. These types of systems are generally classified as stepped care.

Could we build this?

Given the broad scope of such a system, encompassing so many professions and organizations, it would require tremendous leadership at the highest levels.

For all the reasons already given, this would be a disaster politically.

In our short-term, next-election-focused system, no politician in their right mind would be okay with this. The price to pay is way too high.

Until the price of suffering is perceived as too high…

Until mental health affects the electoral calculus…

Until the perverse incentives at the root of the system change…

The system will keep doing exactly what it was designed to do.

No single raindrop believes it is to blame for the flood

Until then, we continue on, and we all continue to suffer. Without a clear picture or adequate data, everyone runs around doing what they think is right, with no feedback to the contrary. The blind leading the blind. Or, if you prefer, the inmates running the asylum.

Next time, I’ll provide another example of the consequences of this approach on patient care. I’ll explore the promises and pitfalls of shared care in a landscape devoid of shared information.

Related: see all Victoria posts here

One thought on “We Have the Mental Health System We Designed

  • Information is key but, as you say, expensive. A “let’s get this done” attitude is less common than it ought to be (“Oh, you need access to a psychiatrist asap? Okay, let’s see what we can do here …”) Resources to collect useful data are expensive–but it provides what one needs to direct RESOURCES; resources to fund the doctoring is expensive–but, like you say, How else are you going to know what’s needed, when, and where!?

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