Demand Ownership and Accountability

Access to outpatient treatment is one of several intertwined mental health crises in Victoria. We can fix it if we make it a priority. Ownership must be assigned. Gaps between silos called out and eliminated. It demands public metrics and accountability. Better access to therapists and psychiatrists won’t happen otherwise.

I’ve previously described the impact that woeful access to mental health care in Victoria is having. Patients can’t access essential care, and family doctors on the front lines are stuck. The impact is spilling over to the emergency room.

There are concrete, incremental, and realistic steps we can take to improve access. We can make progress without relying only on pie-in-the-sky “let’s remake the system in one fell swoop” or “cover all therapy through MSP” long shots. But these cannot succeed without clear ownership and accountability.

Access is Nobody’s Problem

Access to essential mental health treatment in Victoria is a problem. And nobody owns that problem. We can’t fix it until that changes.

To the best of my knowledge, nobody has clear responsibility for ensuring an adequate number of psychiatrists and other mental health resources are available in Victoria. Or at least, that’s not an essential component of anyone’s job performance. I don’t mean just in VIHA or a particular service like USTAT or mood disorders, but overall. I hope I’m wrong; please correct me if so!

I don’t mean accountability or responsibility in a punitive or backward-looking sense. Criticism and identifying flaws have their place. And witch hunts may be cathartic, but they can’t be the entire answer. Assigning ownership should be a positive step towards solving problems.

As a specific example, nobody is responsible for ensuring we have enough psychiatrists in community practices, which generally fall outside health authority concerns. It becomes a system-wide issue when health authorities choose to exclude large classes of patients and expect “the community” (i.e., maybe a dozen psychiatrists) to pick up the slack, as happened at VMHC a few years ago.

Such decisions aren’t malicious. Someone decides “we’ll prioritize X.” Implicitly, that means “we won’t prioritize Y,” or less charitably, “Y is not our problem.” The latter statement is often unsaid (at least in public) or not kicked back up the ladder to properly review. We celebrate “X.” We don’t ask: “What are the consequences of not doing Y? Should Y be prioritized higher? If you’re not doing Y, who is?” It’s not visible, so it slips through the cracks. (In this case, “Y” has become “patients who need psychiatric care but haven’t required extended inpatient hospitalization.”)

Expectations and Disclosure

Expecting a 100% solution any time soon is not realistic. Just pinning failure on someone or creating a scapegoat isn’t helpful.

Real ownership requires responsibility and resources. Accountability means reporting on efforts and progress. Equally, it requires reporting on why things have fallen short. What stands in the way of solutions? Are there alternatives? What needed resources aren’t available? Where could we find them?

Honesty and a solution-focused orientation must take priority over providing political cover for those higher up the food chain.

Measure and Report

Let’s start by recognizing the management truism that you can’t improve what you don’t measure. Metrics need to be frequently updated, reviewed, and public. Think report cards.

Some possible metrics to start with:

  • number of psychiatrists (or FTE’s) and where they work
  • psychiatry referral statistics (e.g., how many received, accepted/rejected, wait times for each service)
  • level of care provided (e.g., single consult vs. ongoing care, frequency seen)
  • affordable counselling and therapy groups (e.g., number of referrals, number served, wait times)
  • outcomes (e.g., re-referrals, crisis line usage, PES presentations, hospital admissions, other service utilization)

Some of these may need substantial effort and new resources to collect. They need to encompass all services, not just within VIHA.

We generally do a poor job of measuring and reporting on health care performance in Canada. Wait times are a good example; ridiculously few are published. The overall culture leans towards not wanting to highlight news that might reflect poorly. For change to happen, that’s not good enough.

A Starting Point

In future posts, I’ll be suggesting several concrete steps we can take to improve access. Ownership, accountability, and good metrics are necessary for any such efforts to succeed.

I also believe that ownership, accountability, and metrics for both access and quality are necessary to address PES concerns. Without baking these into the system, the temptation is to treat the current situation as a short-term PR crisis. Without structural improvements, any fixes will be temporary. While it’s beyond the scope of what I can usefully comment on, I hope others will take up this call.

Related: see all Victoria posts here