Local Health System Integration Act, 2005 - PPAO Submission to Standing Committee on Social Policy

Bill 36 - Local Health System Integration Act, 2005

Submission of the Psychiatric Patient Advocate Office
to the Standing Committee on Social Policy

February, 2006

Table of Contents
Covering Letter to Mario Racco M.P.P.
Summary of Recommendations
Introduction and Background
Transformation Agenda
     Services in Your Own Community
     A Process for Reimbursing Expenses
     Protecting Against the Erosion of Mental Health and Addiction Services
     A Process for Engaging Vulnerable Populations
     A Cautionary Note About Single Point of Access Approach
     Defined "Basket of Services"
     Oversight Responsibility
     Qualifications of Board of Directors and Business Matters
Clear, Concise and Comprehensive Definitions
     Defining Broad Concepts
     Defining the Role of the Ministry
     Community Engagement Process Needs Further Definition
Enhanced Rights Protection Mechanisms
     Independent Health Systems Advocate
     Patients' Rights
     Bill of Rights
     Education
     Accountability and Complaints Process
Provincial Co-ordination
     Continued Ministry Co-ordination Required
Commitment to Consumer Involvement
     Consumer-Survivor Participation
     Consumer and Family Councils
     Peer Supports
     Advisory Council
     Advisory Committee to the LHIN
Transforming the Orientation of the Health Care System
     Transforming How Service is Provided
     Developing A Client-Directed System
Privacy and Confidentiality
     An Expectation of Confidentiality
Conclusion

February 8, 2006

Mr. Mario Racco M.P.P.
Chair
Standing Committee on Social Policy
Room 1405, Whitney Block
Queen's Park
Toronto, Ontario M7A 1A2

Dear Mr. Racco:

RE: Bill 36 - Local Health System Integration Act, 2005

Thank you for the opportunity to participate in the consultation process relating to Bill 36 and for the opportunity to present to the Standing Committee. We are supportive of the fundamental intent and purpose of this legislation but feel it could be strengthened via specific amendments, for the benefit of all parties, including those with serious mental illness and addictions who will receive direct services under the proposed new structure. The amendments would strengthen the law and provide increased public protection, transparency and accountability.

The Psychiatric Patient Advocate Office (PPAO) was established in 1983 to protect the legal and civil rights of inpatients in the ten current and divested Ontario provincial psychiatric hospitals. Since 2000 we have also been providing rights advice in the majority of the general hospitals in Ontario that have mental health units and to clients who are being considered for placement on a Community Treatment Order, as well as their Substitute Decision Makers, if any. We now provide approximately 21,000 first rights advice visits, work to resolve more than 3,500 individual advocacy issues and have approximately 70 local and provincial systemic advocacy initiatives that we are addressing at any one time.

The PPAO is participating in this consultation process in an attempt to ensure that the special and unique needs of individuals with mental illness and addictions are not lost in the devolution of services and responsibility from the provincial government to the Local Health Integration Networks. We also want to ensure that fundamental rights and entitlements are not undermined or eroded during the process. Rather, there should be a renewed commitment to protecting the rights of vulnerable individuals and in supporting them in their quest for wellness and recovery. Such a commitment will heighten accountability, transparency and public confidence in the new system.

It is our hope that the full range of mental health and addiction services will be viewed as a priority by the Local Health Integration Networks. This will demand an investment in community and hospital based mental health programs, the provision of and access to a broad range of services and supports, in addition to a comprehensive range of treatment modalities, while examining the social determinants of health to guide decision making in this sector. Anything less will result in a failure of confidence and trust by the clients and families who rely on these services and supports.

Should you have any questions or if we can provide additional assistance, please contact me at (416) 327-7004.

Sincerely,

Original signed by
_______________________
David Simpson
Director (Acting)

Summary of Recommendations

Transformation Agenda

The LHIN provide access to a full range of mental health care and addiction services, supports and treatment modalities within the local LHIN so that individuals can access care and treatment in their own community.
The LHIN have a legislated responsibility to connect people to the appropriate health care services that they require, either within or outside their local LHIN.
The LHIN not ask clients to pay for services which should be available from a publicly funded health care system.
The LHIN have a legislated responsibility to pay for and reimburse expenses, similar to the Northern Health Travel Grant program, when an individual is required to travel outside of the LHIN to access health care services.
The Ministry of Health and Long-Term Care continuously monitor each LHIN to ensure that specific health care services are not neglected, underfunded or simply abandoned in favour of services that are more desirous to provide at the local level.
The Minister of Health and Long-Term Care establish an advisory committee on mental health, mental illness and addictions to provide advice to both the Minister and the local LHINs.
The proposed legislation and regulations specifically articulate the process whereby community or citizen engagement is undertaken and how such consultations should be conducted.
The Ministry of Health and Long-Term Care not move towards a "single point of access approach" for the provision of mental health care and addictions services.
Patients must continue to be able to have a choice and options as to who provides them with health care services as provider of choice is an important component of a comprehensive health care system.
The Ministry of Health and Long-Term Care define the "basket of services" which must be provided by each LHIN.
The Ministry of Health and Long-Term Care create greater accountability and transparency by appointing an individual or independent office to have an oversight function, as well as mechanisms for compliance and enforcement.
The Ministry of Health and Long-Term Care appoint an independent advocate to assist all Ontarians when they have difficulty accessing health care services.
The Ministry of Health and Long-Term Care define the qualifications required to be a member of a LHIN Board of Directors as well as the process for the removal of a director who is not fulfilling their duties and responsibilities.
The legislation provide a mechanism for members of the public to request a special meeting to deal with a specific issue.
The legislation require that annual audits not only be conducted but that these audits be available to the public.

Clear, Concise and Comprehensive Definitions

The legislation provide clear, concise and comprehensive definitions for terms such as "health services", "integrate" and "public interest". Definitions that are too broad and open to vast interpretations may be problematic from an operational and legal point of view.
The legislation specifically define the role and function of the Ministry of Health and Long-Term Care and "how" they will support the LHINs.
The legislation include more specific information regarding accountability agreements including but not limited to: purpose, structure, content, outcome measures, evaluation and appeal processes. Such amendments will provide for standardized measures and outcomes to be established.
The legislation provide a clear definition of community engagement and enshrine in the legislation a "reporting back to the community" obligation to heighten accountability and transparency.

Enhanced Rights Protection Mechanisms

The Ministry of Health and Long-Term Care appoint an independent health systems advocate as part of the transformation of the health care system in Ontario.
The government of Ontario use the proposed legislation as an opportunity to make a renewed commitment to patients' rights, to protecting vulnerable populations and providing penalty provisions for those who violate those rights.
The government of Ontario should enshrine in the proposed legislation a health care Bill of Rights. The Bill could become a catalyst for change, supporting individuals in their pursuit of individualized care and treatment based on best practices and timely access to care.
The Ministry of Health and Long-Term Care and the Ministry of Health Promotion retain responsibility for conducting broad-based public education campaigns that focus on mental health, addictions and stigma and discrimination.
The Ministry of Health and Long-Term Care design, deliver and evaluate public education campaigns in collaboration with stakeholders, including those with mental illness.
The Ministry of Health and Long-Term Care include a complaints process in the legislation that is timely, fair and transparent with corresponding timelines, possible outcomes for resolution and reasons for decision along with an independent appeal process.
The legislation specifically state that a complainant can have a third party support them through the above complaints process.

Provincial Co-ordination

The Ministry of Health and Long-Term Care immediately advise the public of the programs that it will continue to either operate or provincially co-ordinate.
The legislation enshrine the role, function and authority of independent rights advisers and patient advocates in the legislation.

Commitment to Consumer Involvement

The legislation contain a purpose statement that specifically addresses the unique and special needs of individuals with mental illness and addictions and the importance of involving them at all levels of decision making.
The legislation specifically require that Consumer and Family Councils be available in all inpatient mental health programs with full funding and autonomy.
Recognition and inclusion of peer support workers and peer support specialists in the legislation, with defined roles, responsibilities and authority, would send a clear message about their importance in a transformed health care system and the governments commitment to consumer-survivor participation.
The legislation require a consumer-survivor advisory committee with duties and responsibilities similar to that of the health professionals advisory committee. The parallel advisory committees could work collaboratively and their efforts could supplement each other's activities.

Transforming the Orientation of the Health Care System

The transformation and devolution of decision making to the LHINs also be supported by a transformation of "how" mental health and addiction services are provided.
The legislation require the adoption of a recovery orientation and not purely a medical model approach to care provision.
Service provision be client-centred and client directed with a client-first perspective. Such a transformation will heighten accountability to the people to whom the service is provided.

Privacy and Confidentiality

The legislation specifically address the issues of privacy and confidentiality, the rights of individuals if there is a breach, in addition to the sanctions and recourses available to resolve the issue.

Background and Introduction

For the past two decades the Psychiatric Patient Advocate Office (PPAO) has provided independent advocacy and rights advice services to patients in the ten current and divested provincial psychiatric hospitals in an effort to protect and promote their legal and civil rights. With over two decades of experience, we believe that we are uniquely qualified to comment on the Local Health Integration Network (LHIN) legislation, rights protection mechanisms and transparent complaint processes, transforming the health care system to better meet the needs of patients, and the potential impact that it may have on our clients. As a rights protection organization, we have developed expertise in resolving issues, identifying systemic issues, protecting patients' rights and in working to improve the quality of life and care of our clients. We believe our submissions provide a means to strengthen the proposed legislation and its regulations, from a patient rights' and quality of care perspective.

Although our experience within the health care system is specific to mental health and addictions, we believe that many of our recommendations are equally applicable to the broader health care sector and will lead to both enhanced system accountability and adoption of a "client-centred, client-first and client-directed" perspective.

Transformation Agenda

Services in Your Own Community
The PPAO is supportive of the intent and vision of the transformation agenda and development of the LHINs provided that a full range of mental health and addiction services, support and treatment modalities continue to be available and accessible to patients, including both hospital and community-based programs. This includes timely access to services available in the home community of the person, and where those services are not available, the LHIN must have a legislated responsibility to connect the person to the appropriate services they require. Moreover, clients must not be asked to pay for such services, as they should continue to be provided by a publicly funded system.

A Process for Reimbursing Expenses
In cases where client are required to travel to other LHINs to access services, a system for the reimbursement of expenses, similar to the Northern Health Travel Grant, must be put in place. Many individuals with mental illness may not have the necessary funds to travel outside their community to access services and any hint of financial hardship may prevent them from accessing the services that they may want and need. Funding must also be available to individuals who choose to access mental health and addiction services outside of their own community due to concerns regarding conflict with a service provider, confidentiality, privacy or the quality of care they would receive in their own community. The legislation must specifically support and confirm these principles, for the benefit of all Ontarians.

Protecting Against the Erosion of Mental Health and Addiction Services
Mental health has been described as the "orphan child" of the health care system and, for this reason, care must be taken to ensure that mental health services are neither eroded nor inaccessible to patients. It is hoped that each LHIN will have a "champion" for mental health, mental illness and addictions to ensure that the needs of this sector are not lost in a highly complex and resource competitive environment. All health providers will be attempting to obtain funding from their relevant LHIN, potentially resulting in the loss of financial support to other mental health and addiction services. The provincial government must continuously monitor each LHIN to ensure that individual service delivery areas and specific services are not neglected, underfunded or simply abandoned in favour of services that are more desirous to provide at the local level.

It would be advisable for the Minister of Health and Long-Term Care to form an advisory committee on mental health, mental illness and addictions. Such an advisory committee could provide advice and consultation to both the Minister and the fourteen LHINs on issues related to this sector, from both a provincial and systemic perspective.

A Process for Engaging Vulnerable Populations
Mental health and addiction clients are largely disenfranchised, vulnerable and without a voice in the political process, making it easy for their needs to be ignored and their voices forgotten in the consultation process. The LHINs must make a special effort to engage these vulnerable populations in an effort to maximize their voices to gain input into the issues that impact them directly. It may be helpful for the legislation and corresponding regulations to specifically articulate the process whereby community or citizen engagement is undertaken and how such consultations should be conducted. For example, vulnerable populations may require consultation processes to be flexible in order to accommodate special needs or unique circumstances. Formal processes that require patients to respond in writing should be avoided as these may become a barrier to access and participation.

A Cautionary Note About Single Point of Access Approach
The PPAO would also like to raise a cautionary note about any move to create a single point of access in each community for the delivery of mental health and addiction services. All too often, when mental health clients attend general hospital emergency settings (as the single point of access and admission for mental health care in a community) trying to access health services, they appear invisible amongst the patients requiring more immediate attention because of medical emergencies. This may result in a delay in receiving emergency mental health care and treatment.

As a patients' rights organization, we believe that patients must continue to be able to have a choice and options as to who provides them with service. The ability to have a provider of choice is an important component of a comprehensive health care system that is client-directed and client-focused. To take this away by forcing a "single point of access" model would be a mistake. It is foreseeable that such an approach would result in a system akin to a monopoly, causing complacency and a decreased quality of services and choices for the client. Additionally, the client may have had difficulty in the past with the "single point" of access provider thus being reluctant to approach them again for service. For instance, the client may have been advised by the provider to have "no further contact" with the agency or they may have been denied service outright

Defined "Basket of Services"
Bill 36 should define in law the basic basket of services required to be provided by each LHIN, as well as the reasons why these services should be available in each local community. This will generate public discussion regarding health services and the expectations of the community to be able to receive care and treatment close to home. The Ministry must take a leadership role in defining these services and then working with the LHINs to ensure that the services are available and accessible.

Oversight Responsibility
The evolution of the LHINs system in Ontario would be greatly advanced with increased accountability and transparency if there was one individual or office charged with an oversight function, as well as mechanisms for compliance and enforcement. All Ontarians must have equal access to health care services whether they live in an urban or rural neighbourhood, in the southern or northern part of the province or in a large or small community. Health care must be accessible to all.

The PPAO would also encourage the government to articulate a provision in the legislation regarding the accountability of service providers to the people that they serve.

LHINs legislation could be further strengthened if it required an independent advocate to assist all Ontarians when they are having difficulty accessing services from their local LHIN, or the health care system in general. Inclusion of independent advocacy services would strengthen the system by heightening the public accountability of both service providers and the LHINs through a transparent rights protection process.

Qualifications of Board of Directors and Business Matters
The legislation must also address issues such as the qualifications required to be a member of the Board of Directors of the local LHIN pursuant to section 7 or the process for the removal of a director who is not fulfilling their duties and responsibilities. Currently, the legislation is silent on both issues.

While it is positive that meetings pursuant to section 9 are required to be open to the public, the Lieutenant Governor in Council has the authority to prescribe otherwise. Moreover, there is no mechanism for members of the public to request a special meeting to deal with a specific issue. Such a mechanism would increase public accountability and allow for the LHIN to be responsive to the needs of the community.

Although subsection 12(2) of the proposed legislation requires annual audits to be conducted, it does not state if the results will be made available to the public and the other LHINs across the province. If there is to be public accountability and transparency, then information related to the financial health of the local LHIN must be made available to the public for scrutiny.

The PPAO recommends that:

The LHIN provide access to a full range of mental health care and addiction services, supports and treatment modalities within the local LHIN so that individuals can access care and treatment in their own community.
The LHIN have a legislated responsibility to connect people to the appropriate health care services that they require, either within or outside their local LHIN.
The LHIN not ask clients to pay for services which should be available from a publicly funded health care system.
The LHIN have a legislated responsibility to pay for and reimburse expenses, similar to the Northern Health Travel Grant program, when an individual is required to travel outside of the LHIN to access health care services.
The Ministry of Health and Long-Term Care continuously monitor each LHIN to ensure that specific health care services are not neglected, underfunded or simply abandoned in favour of services that are more desirous to provide at the local level.
The Minister of Health and Long-Term Care establish an advisory committee on mental health, mental illness and addictions to provide advice to both the Minister and the local LHINs.
The proposed legislation and regulations specifically articulate the process whereby community or citizen engagement is undertaken and how such consultations should be conducted.
The Ministry of Health and Long-Term Care not move towards a "single point of access approach" for the provision of mental health care and addictions services.
Patients must continue to be able to have a choice and options as to who provides them with health care services as provider of choice is an important component of a comprehensive health care system.
The Ministry of Health and Long-Term Care define the "basket of services" which must be provided by each LHIN.
The Ministry of Health and Long-Term Care create greater accountability and transparency by appointing an individual or independent office to have an oversight function, as well as mechanisms for compliance and enforcement.
The Ministry of Health and Long-Term Care appoint an independent advocate to assist all Ontarians when they have difficulty accessing health care services.
The Ministry of Health and Long-Term Care define the qualifications required to be a member of a LHIN Board of Directors as well as the process for the removal of a director who is not fulfilling their duties and responsibilities.
The legislation provide a mechanism for members of the public to request a special meeting to deal with a specific issue.
The legislation require that annual audits not only be conducted but that these audits be available to the public.

Clear, Concise and Comprehensive Definitions

Defining Broad Concepts
The PPAO believes that the proposed legislation has not gone far enough in articulating definitions or in delineating the roles and responsibilities of all parts of the system. Unless there is a clear understanding by all parties, the vision for an integrated health care system will be lost. It is for this reason that we would suggest that the government amend the proposed legislation to include a comprehensive and clear definition of the terms "health services," "integrate" and "public interest." These terms may mean different things to different stakeholders and thus the development and application of consistent definitions is essential. Definitions that are too broad and open to vast interpretations may also be problematic from an operational and legal point of view.

Defining the Role of the Ministry
The legislation must also specifically define the role of the Ministry of Health and Long-Term Care and specify "how" they will support the LHINs and what services they will continue to provide from a corporate, performance and accountability level. Additionally, the purpose, structure, content, outcome measures and evaluation processes of the accountability agreements that the Ministry will enter into with the LHINs should be included in the legislation. This will allow for not only standardization of the agreements but also to take into account unique, specific and local needs. It does not appear that these functions have been specified which may lead to confusion or duplication of functions between the LHINs and the Ministry. Accountability and outcome measures must be defined and set in consultation with stakeholders. Additionally, provincial and local roles must be defined so that everyone in the health care system and the community is aware of what their respective roles will be and who will maintain responsibility for certain functions and programs.

Community Engagement Process Needs Further Definition
The process for community engagement must be developed in consultation with a broad range of stakeholders and the proposed legislation must specifically define what this means. Further, the legislation must clearly define the community engagement process and include a mechanism for "reporting back" to the community the results of the engagement process. This will heighten accountability and further the public interest by having a real and meaningful process defined in law, not a process which is viewed with skepticism or seen as a "rubber stamp".

Ideally, the proposed legislation and its regulations would also address the issue of stakeholder involvement from all sectors and create a process for maximizing the voice of those who will access services from the local LHIN. Stakeholder involvement will be key to getting to "buy in" and in making the transformed health system a success. Thus, more importance needs to be placed on defining and developing a process for real and meaningful stakeholder involvement in the system, at all levels.

The PPAO recommends that:

The legislation provide clear, concise and comprehensive definitions for terms such as "health services", "integrate" and "public interest". Definitions that are too broad and open to vast interpretations may be problematic from an operational and legal point of view.
The legislation specifically define the role and function of the Ministry of Health and Long-Term Care and "how" they will support the LHINs.
The legislation include more specific information regarding accountability agreements including but not limited to: purpose, structure, content, outcome measures, evaluation and appeal processes. Such amendments will provide for standardized measures and outcomes to be established.
The legislation provide a clear definition of community engagement and enshrine in the legislation a "reporting back to the community" obligation to heighten accountability and transparency.

Enhanced Rights Protection Mechanisms

Independent Health Systems Advocate
The introduction of an independent health systems advocate would be an important step forward in transforming the health care system in Ontario. An independent advocate could address not only individual complaints but systemic complaints. This environmental scanning would allow for the identification of emerging issues and trends, with recommendations for the allocation of health care resources.

The health systems advocate could report annually on the state of health care in Ontario and make recommendations to both the LHINs and the government on how to improve the system at large. The advocate would be available to the public for advice, consultation, support and assistance in resolving complaints. Such a role is imperative as the changes to health care in Ontario may lead to a lack of standardization across the system, and a lack of knowledge about how to access services. At present, there is no defined process for the dissemination of best practices across the system. The advocate could also report on the overall "health" of the system itself.

Patients' Rights
The proposed legislation is an opportunity for the government of Ontario to make a renewed commitment to patients' rights providing protection and corresponding penalty provisions for those who violate patient rights. Rights protection mechanisms are perhaps the best and most efficient way to change the health care system in Ontario. The PPAO has fulfilled this role in the mental health sector for more than two decades and it is because of this role that many of the advances in the mental health sector have been made.

Bill of Rights
Ontario should consider adopting and implementing a Bill of Rights for the health care sector. Such a Bill could heighten accountability and public awareness with respect to quality care, service delivery and outcome expectations while providing guaranteed access to services. The Bill could become a catalyst for change, supporting individuals in their pursuit of individualized care and treatment based on best practices and timely access to care. The Bill of Rights would be enshrined in the current legislation as an additional level of protection to address concerns by the public that their interests may be affected by the new structure for health care delivery in Ontario.

Education
The local LHINs will be focused on the operational aspects of the health care system and may not have adequate time or resources to conduct public education. In particular, the LHINs might not be able to provide education with respect to stigma and discrimination or its impact on individuals with mental illness and their ability to participate fully in the community. The provincial government should retain responsibility for conducting broad-based public education campaigns that focus on the above issue and other public health issues. This will ensure that there is a consistent message given in all parts of the province and that the message will be linked to government initiatives, priorities and public health policy.

The Ministry could design public education campaigns in collaboration with stakeholders and partner with them in the delivery and evaluation of the campaign. However, responsibility for public education and awareness campaigns should be retained by the Ministry.

Accountability and Complaints Process
It is imperative that any complaint process be timely, fair and transparent with clear timelines and possible outcomes for resolution defined in the legislation. A process that allows for an escalation of a complaint and an appeal process beyond the local level is important as it will increase the public's confidence in the complaints process and the decisions rendered. Complaints may be about the LHINs themselves, about a particular health provider or about a staff member of the LHINs. The body charged with the resolution of complaints must also be given the power of reconsideration, the ability to conduct own motion investigations and receive complaints from third parties. The public will need to be educated about the complaints process and information must be readily available in various languages. People can only exercise their right of complaint if they know that they have a right to complain.

It would also be helpful if the legislation specifically stated that a complainant has the right to have a third party of their choice present to support them through the complaint process. This will recognize that some vulnerable populations may choose to have a friend, independent advocate or a family member help and support them through the process. Otherwise, complainants may be intimidated by the complexity of the process or may not have the resources to pursue a legitimate complaint.

Subsection 25(7) of the proposed legislation states that the Statutory Powers Procedure Act does not apply to an integration decision. This would lead one to believe that the process excludes procedural fairness requirements, leaving judicial review as the only alternative. Further, the planned legislation has limited rights of appeal and affords broad powers to the Minister. These provisions are concerning and leaves the impression that the process is not fair, thereby undermining public confidence in the decision making process.

The PPAO recommends that:

The Ministry of Health and Long-Term Care appoint an independent health systems advocate as part of the transformation of the health care system in Ontario.
The government of Ontario use the proposed legislation as an opportunity to make a renewed commitment to patients' rights, to protecting vulnerable populations and providing penalty provisions for those who violate those rights.
The government of Ontario should enshrine in the proposed legislation a health care Bill of Rights. The Bill could become a catalyst for change, supporting individuals in their pursuit of individualized care and treatment based on best practices and timely access to care.
The Ministry of Health and Long-Term Care and the Ministry of Health Promotion retain responsibility for conducting broad-based public education campaigns that focus on mental health, addictions and stigma and discrimination.
The Ministry of Health and Long-Term Care design, deliver and evaluate public education campaigns in collaboration with stakeholders, including those with mental illness.
The Ministry of Health and Long-Term Care include a complaints process in the legislation that is timely, fair and transparent with corresponding timelines, possible outcomes for resolution and reasons for decision along with an independent appeal process.
The legislation specifically state that a complainant can have a third party support them through the above complaints process.

Provincial Co-ordination

Continued Ministry Co-ordination Required
There are several services and programs which, in our opinion, must continue to be provincially co-ordinated and managed centrally by the Ministry. These programs, because of the nature of the services they provide are not good candidates for devolution to the LHINs.

The Ministry must very early in the process advise the public of the programs that it will continue to either operate or provincially co-ordinate. A clear statement by the Ministry will quell any discussions about the provision of these services. The Ministry must provide strong leadership, championing the transformation process and supporting the development of local communities in shouldering the responsibility for health care delivery.

The PPAO would like the LHIN legislation to specifically enshrine the role, function and authority of independent rights advisers and patient advocates in the new legislation. Such a move would not only recognize the importance of these services from a rights perspective but it would also provide the legislative authority necessary to provide the service without interference from any part of the health care system.

The PPAO recommends that:

The Ministry of Health and Long-Term Care immediately advise the public of the programs that it will continue to either operate or provincially co-ordinate.
The legislation enshrine the role, function and authority of independent rights advisers and patient advocates in the legislation.

Commitment to Consumer Involvement

Consumer-Survivor Participation
Although the legislation addresses the issue of planning and community engagement (Part III), it does not go far enough in defining the process or who will be involved in the engagement process. In order to be meaningful, the legislation must specifically define the processes to be utilized and address issues such as consultation with special and vulnerable populations, development of a strategy to engage these clients through education and outreach and clarification of the term "on an ongoing basis" (subsection 16(1)). The legislation must provide additional detail to ensure that the community engagement process is consistent across the province while being flexible and taking into account regional or local disparities.

Consumer and Family Councils
Bill 36 should also contain a purpose statement that specifically addresses the unique and special needs of individuals with mental illness and addictions. The rationale of the purpose statement would then be reflected in the legislation with the role of consumer-survivors being clearly articulated and the importance of involving them at all levels of decision making. For example, the legislation should require that all mental health and addiction service providers have a patient or consumer council, as well as a family council, that is fully funded and autonomous. This would heighten accountability and ensure that consumers and families would become an essential and integral component of the transformed health care system as they would be involved at all levels of the system. Consumers and families could be actively involved in the community engagement process, sitting on advisory committees and providing expertise about the mental health and addiction system. Consumers and families have a more extensive role to play and much more to offer than is currently acknowledged or recognized in Bill 36.

Peer Supports
Recognition and inclusion of peer support workers and peer support specialists in the legislation would also send a clear message about their importance in a transformed health care system. It would recognize the "value added" contribution that they could make to the mental health and addictions programs and lead to peer support for all medical conditions being seen as important and endorsed by the Ministry and the government. To date, the contribution of peer support workers and specialists has largely gone unnoticed by the professional and provider communities.

Advisory Council
The Minister could expand the role of consumers and families by defining them in the legislation. Further, the Minister could develop an advisory committee on mental health, mental illness and addictions to assist in setting policy and direction and for the purpose of providing support and advice to the LHINs.

Advisory Committee to the LHIN
Subsection 16(2) of Bill 36 specifies that a health professionals advisory committee must be struck by each LHIN. The Ministry could further demonstrate its commitment to mental health, mental illness and addiction issues by amending the legislation to require that a similar advisory committee of consumer-survivors be formed by each LHIN for the same purposes as the health professionals advisory committee. The parallel advisory committees could work collaboratively and their efforts could supplement each other's activities.

The PPAO recommends that:

The legislation contain a purpose statement that specifically addresses the unique and special needs of individuals with mental illness and addictions and the importance of involving them at all levels of decision making.
The legislation specifically require that Consumer and Family Councils be available in all inpatient mental health programs with full funding and autonomy.
Recognition and inclusion of peer support workers and peer support specialists in the legislation, with defined roles, responsibilities and authority, would send a clear message about their importance in a transformed health care system and the governments commitment to consumer-survivor participation.
The legislation require a consumer-survivor advisory committee with duties and responsibilities similar to that of the health professionals advisory committee. The parallel advisory committees could work collaboratively and their efforts could supplement each other's activities.

Transforming the Orientation of the Health Care System

Transforming How Service is Provided
Transformation and devolution of decision making to local LHINs must also be supported by a transformation of how mental health and addiction services are provided and how clients and patients are viewed by the system. It must have a recovery orientation and move away from a purely medical model of care provision. Once integrated, the health care system in Ontario must have a wellness and recovery focus with a defined and shared philosophy of care. This "made in Ontario" model of care will result in astounding transformation.The new system must emerge with a greater sense of care and compassion, with a new found respect for the dignity and autonomy of all individuals and their rights and be able to recognize, support and respect the decisions of those to whom care is provided.

This will mean a move away from a paternalistic and best interests approach of providing care to one which is client driven and client directed. This change may be threatening or daunting to some but the system will emerge better and stronger if Ontario is able to make this philosophical shift and truly transform health care. However, it will take strong leadership at the local and provincial level to articulate this vision, to change attitudes, to become a catalyst for change and to support a period of transition where health care providers learn new and better ways of delivering care in a transformed and client directed health care system. The task will not be simple nor without challenges but the benefits and rewards will be priceless.

Developing A Client-Directed System
The new system must be client centred with a client-first perspective where all individuals in the health care system will be able to recognize quality care, where services will be individualized and where their physical and mental health needs will be met in their local community. This shift in care provision will not only empower the individual but also the health care system and those who work within it - to the benefit of all. The legislation should require that health service providers conduct client satisfaction surveys at regular intervals and make this information available to the public, similar to the newly introduced public reporting system in the long-term care sector.

The PPAO recommends that:

The transformation and devolution of decision making to the LHINs also be supported by a transformation of "how" mental health and addiction services are provided.
The legislation require the adoption of a recovery orientation and not purely a medical model approach to care provision.
Service provision be client-centred and client directed with a client-first perspective. Such a transformation will heighten accountability to the people to whom the service is provided.

Privacy and Confidentiality

An Expectation of Confidentiality
Given that health care decisions will be made at the local level once Bill 36 is fully implemented, the legislation must address the issues of privacy and confidentiality. For instance, the sharing of confidential information within the LHIN, with service providers and with systems planners and evaluators must be considered. The public has an expectation that their personal health information will be kept confidential and disclosed only in keeping with provincial privacy legislation. However, there is concern that some personal information may be shared across the LHIN and with those who will be planning and evaluating services. Bill 36 must address this issue so that the public will have confidence in knowing that their information and confidentiality is protected at all times.

The PPAO recommends that:

The legislation specifically address the issues of privacy and confidentiality, the rights of individuals if there is a breach, in addition to the sanctions and recourses available to resolve the issue.

Conclusion

In conclusion, the PPAO is supportive of the fundamental intent and purpose of this legislation but recommends additional changes to strengthen the law and provide increased public protection, transparency and accountability. As a rights protection agency, we believe that the government has the opportunity through this legislation to make a firm and lasting commitment to patients' rights, transforming how the system provides service while making it client directed, through the adoption of a wellness and recovery focus.

The PPAO would be pleased to assist in any way possible in making the health care system in Ontario one that is responsive to individual need, in becoming a world leader in the provision of publicly funded health care and in developing a rights based and client perspective.