Bill Tholl, President and CEO of HealthCareCAN
Sunny Ways” to Levelling the Playing Field for Mental Health:
Overcoming the “Canadian Condition”
Canadian Psychological Association, Policy Advocacy and Engagement Workshop
Ottawa, January 15, 2016
Thank you for the invitation to be with you this afternoon. I am looking forward to the exchange with Rick and Karen and with all of you to find sunny ways to advance the mental health agenda across Canada.
It is “E+90”…just shy of 90 days since an historic federal election. One that delivered a surprising Liberal majority after 10 years of Mr. Harper and a government that had little interest in health and healthcare.
In the Prime Minister designate’s election night speech, he invoked Wilfrid Laurier, who 120 years ago, talked about the “sunny ways” approach to governing Canada by looking for compromise and collaboration.
Mr. Trudeau then went on to talk about sunny ways to advancing the Canadian agenda. He committed to taking a more collaborative approach to governing, working with the provinces and territories as well as more meaningful engagement with stakeholders. He committed to a Conference of First Ministers in his first 90 days and to engaging stakeholders in the process of building a better Canada.
One of the key campaign commitments was to negotiate a new Health Accord and to start the process within 90 days. This process is well underway as we look forward to Ministers getting together next week in Vancouver to discuss the new accord.
In the next 10 minutes or so I want to share one way to conceptualize the change agenda that is before us…Kingdon’s three streams.
I will then take stock of the government’s health platform commitments and the opportunities that will be presenting themselves to shape the policy agenda, especially in relation to levelling the playing field for mental health.
Finally, I will share with you the tentative top ten tips on effective policy advocacy and engagement coming out of soon to be released guidebook entitled “Getting to Yes, Minister”. Something that Sean and I, along with several other co-authors, have been working on for over a year.
With Canada about to celebrate its 150th birthday, I believe that the new government and Canada’s 29th Prime Minister present an unprecedented opportunity to begin to level the playing field for mental health. I’ll tell you why.
To begin, I want to share with you one way to think about the policy window that the election of this federal government presents. John W. Kingdon’s seminal 1984 book entitled “Agendas, Alternatives and Public Policies” suggests that shaping policy agenda is akin to launching a rocket ship. When planning the launch of a rocket from say Cape Canaveral, Kingdon reminds us that there are limited windows of opportunity in terms of rotation of the earth, time of year, other launches in other parts of the world and, of course, weather…the unexpected.
Kingdon goes on to identify three streams that need to converge to successfully launch new policies or programs. They are: the political stream, then the problem stream and finally the policy stream. Let’s look briefly at how the three streams line up to present an opportunity to advance the mental health agenda.
The first stream is the “political stream”…
The Political Stream:
Because it’s 2016!
As you all know, it was the second longest elections in Canadian history…78 days. Three times the normal writ period. This allowed for a broad range of policy issues to be debated, discussed and distilled…the economy, foreign policy, tax policy, child care policy, environment etc.
Once again, however, health and healthcare did not receive a lot of air time in the campaign. This is not unusual. As Jeffrey Simpson points out in his book “Condition Critical”, Medicare is now seen as the “third rail of Canadian politics”…touch it and you die. Or, as former premier Smallwood was reported to have famously remarked: “I haven’t had a conversation on healthcare that didn’t lose me votes!”
That said, health and homecare did find their way into the Liberal platform. There is a firm commitment to work with the provinces and territories to negotiate a new Health Accord. Indeed, Deputy Ministers met last month and Ministers are scheduled to meet next week in Vancouver to initiate these discussions.
The marching orders for Minister Philpott, at least in terms of basic building blocks for a new Health Accord are pretty clearly laid out in her mandate letter. I believe both the two pages “Real Change” healthcare and homecare policy statement along with the Minister’s Mandate letter have been pre-circulated.
The first three building blocks are: (1) expanded homecare programs with a particular focus on helping provinces address the growing challenges around palliative care; (2) expanding access or coverage to out-of-hospital pharmaceuticals and (3) scaling up and spreading innovations more quickly. What I call the “Naylor lite” agenda both in terms of machinery and money. Happy to come back to this in the Q and A.
The fourth building block and the one that will be of most interest to this gathering is the new government’s commitment to move the policy yardstick on mental health, to wit:
In terms of Kingdon’s three streams, the political stream in terms of this government’s commitment to mental health seems to be a go. We also have an ally in court in PMO: the PM himself.
Levelling the playing field for mental health.
The next task then is to define, in operational terms, the nature and the extent of the policy problem.
I know I’m preaching to the choir with this group when it comes to describing the large and growing challenges of mental health.
Mental health, as we all know, affects everyone. We all know the stats by heart…at least 1 in 5 Canadians have experienced a mental health health or illness; 1 in 3 will, over the course of their lifetime, experience a serious mental health problem; mental health costs well over $50 billion dollars to our economy. Yet only 7 cents of every healthcare dollar is spent on mental health. And on it goes.
Despite the incredible progress that has been and is being made to destigmatize mental health issues (Bell’s Let’s talk, DIFD, etc.), we clearly still have a long way to go and a number of political, legal, financial and structural barriers to overcome if we are to level the playing field for mental health.
The inconvenient truth, for example, is that out-of-hospital mental health services, including psychological therapy are not defined as insured medical services under the Canada Health Act and that free-standing mental healthcare facilities are explicitly excluded from the CHA. Is it any wonder that many Canadians and their loved ones either don’t seek or can’t get the services and supports they need?
After 32 years it is long overdue to remedy this legislative anachronism.
Here’s where what Kingdon calls the “policy entrepreneurs” get their chance to make a very real difference by coming forward with clear, concrete and compelling ways of defining the dimensions of the problem.
The problem definition needs to reflect the available evidence. But it also needs to be packaged and presented in a clear and compelling way. “While the plural of anecdote is not evidence, never dismiss the power of the anecdote”.
Kingdon suggests that we have to be clear about the scope or dimensions of the policy problem and set clear priorities in a way that gives policy makers a chance to successfully address them.
I don’t believe the mental health community has reached consensus on the top priorities or how best to present the mental health “ask”
The “Agility Quotient”
So let’s move on to the third and final stream…the policy stream.
The current political and economic environment is unprecedented. British Prime Minister Harold McMillan when describing the greatest challenge to a statesman, reportedly said “events, my boy, events”.
On the political side the events of Oct 19th were unexpected and might best be framed in terms of “what does the dog do when he actually catches the car”? Did the Liberals really expect to see a majority government that would see them held account for delivering on what some have suggested as high as 130 campaign commitments? I dare say that no-one saw this coming…including the current PM.
To lead is to make choices… to set priorities. You already see the government attempting to manage expectation by reminding us that it is a four year mandate. Minister Morneau publicly said earlier this week in pre-budget consultations in Toronto…tongue in cheek…that we should see economic policy as spreading over the 16 year mandate of this government!
On the economic side, could anyone have imagined the looney dropping as far or as fast as it has in the last 90 days….or that the price of oil according to some might drop to as low as $15 a barrel…or that Alberta would slip as quickly as it appears to be doing into “have not” status?
These are dramatic, unforeseen developments and as policy advocates, you need to be agile in reframing or reprofiling your asks. So, for example, moving from 7% to 9% of total healthcare spending going to mental health sounds modest. It certainly is desirable. But it would mean an increase in annual spending of some $ 5 billion dollars. Given the current fiscal circumstance, it may be more responsible to see this as a multi-year goal: reprofiling the “ask”.
While some new investments are required (we’ve recommended a doubling of the MHCC annual budget, for example), we will have to be more imaginative in allocating existing resources both within and across jurisdictions.
We will have to address, for example, what I call the Canadian Condition. What is the Canadian condition? The irrepressible urge to repeatedly reinvent the wheel across jurisdictions.
One of my former bosses…Madame Bégin famously described the Canadian healthcare systems as the land of many pilot projects. More recently, one of my colleagues, tongue in cheek, added: “Yeah, in fact Canada has more health pilot projects than Air Canada has pilots!
The Naylor panel provides some great advice on how to overcome the Canadian condition.
Top Ten Tips:
Getting to Yes, Minister.
So, to conclude, what have we learned…so far from the the “Getting to Yes, Minister” project about how best to bring Kingdon’s three streams together. With the caveat that these are simply illustrative at this point, here are my top ten:
1. Think like the animal you hunt…I put this first because it is Sean’s favourite. You need to put yourself in the Ministers’ shoes. You need to understand the nature of Cabinet decision making. Strive to get to know and better understand the players, selling your strengths, and buying your weaknesses!
2. Don’t fight political gravity: This federal government has a majority mandate and is committed to delivering on its promises, including mental health agenda. Start by offering to help deliver on the Liberal “real change” agenda, the Health Accord by leveraging up your knowledge, expertise and influence.
3. Put all your begs in one “ask it”…working together as a community, whether under the banner of CAMHMI or some other coalition is often the best way to get your priority to the top of the policy agenda…but you will tend to sacrifice two things: control and time. So know when to draw the line and go it alone.
4. Patience is a virtue…As Bill Ury pointed out in “Getting to Yes”: in order to get to yes; you often times have to “get past no”. Or, as Sir Humphrey in Yes Prime Minister pointed out to Sir Desmond, who asked: “Surely once a Minister has made his decision, that’s it, isn’t it?”…Sir Humphrey: “What on earth gave you that idea?” Sir Desmond: “Surely a decision is a decision”. Sir Humphrey: “Only if it is the decision you want. If not it’s just a temporary setback”.
5. Keeping the “Brief” brief…it’s key to know and influence the senior official that has responsibility for writing the ministerial brief. Again, as Minister Hacker asks Sir Humphrey: “Why can’t ministers go anywhere without briefs?” the answer is: “It’s in case they get caught with their trousers down”!
6. Credit is infinitely divisible…In 1961, responding to a question by a journalist about the Bay of Pigs, JFK put it: “…victory has 100 fathers and defeat is an orphan.” It’s important to share the credit but also important to “fail forward”…learning collectively from our collective failures as we go forward”.
7. Ask, Listen, Talk…all too often we assume we know what the politicians want or need. This is hazardous to everyone’s health…somatic and non-somatic!
8. The bigger the concept, the greater the need for simplicity…Kissinger was once asked what he thought of the most recent proposed peace agreement between Israel and Palestine. His answer: “It all depends”. On what asked the reporter: “It all depends on whether it advances the cause of world peace”.
9. You never get a second chance to make a good first impression…be relevant be specific be responsible and, above all, be prepared!
10. Advocacy is never ending…it is important to think longer term, always guided by the public interest and remembering that whether you are on the receiving end or delivery end of advocacy…it is indeed an honourable pursuit!
The election of a majority Liberal government, with a leader that has a very real appreciation for the challenges of mental health, there is a unique window of opportunity to level the playing field for mental health.
This will require bringing Kingdon’s three policy streams together. Not easy, but not beyond the grasp of the mental health community, which has a history of working together.
Getting to yes will require looking for short term wins around mutual interests, continuing to engage a broader community of interests, including the business community.
Many thanks for the opportunity to participate in today’s panel discussion. HealthcareCAN will continue to do its part to work with the MHCC and looks forward to working with CPA to help take advantage of this opportunity to launch a rocket ship that takes mental health truly out of the shadows.