In 1998, the British Columbia government attempted to reform mental health care. Why does this still matter? First, mental illness remains a significant global problem, an invisible disability affecting millions. According to the United Nations,
An estimated one in four people globally will experience a mental health condition in their lifetime … Suicide is the third leading cause of death among young people. Depression is the leading cause of years lost due to disability … and ranked third in the global burden of disease … Mental health is one of the most neglected yet essential development issues in achieving internationally agreed development goals.¹
Recent publicity about mental health effects of the pandemic underscores the impact.
The second reason this story is still relevant is the timeless theme that the making and implementation of any public policy can be sidetracked by the governmental and social context. Administrative incompetence explains more than malign strategy, but political considerations often amplify the problem. Roadblocks emerge that are invisible to most of the public; the civil service cannot defend itself. Senior civil servants geared to please and to be in “solution mode” are not always willing to give their political masters bad news, such as conflicts with stakeholders. “The Emperor’s New Clothes” is not just a fairy tale.
This essay is an abbreviated account of the initiative that ate my career as a health care executive. In a nutshell: British Columbia’s NDP government released a mental health strategy in early 1998. Soon after, I was appointed to run B.C.’s provincial psychiatric hospital. In February 1999, I was additionally appointed Acting Executive Director of the Mental Health Branch tasked with implementing the strategy. I left both jobs in the autumn of 2000.²
Space does not permit me to explore parallels to policymaking in this field today, such as the opioid crisis and mental illness among homeless people, although I refer to the influence of deinstitutionalization on both. I focus on one conclusion: context rules; strategic progress depends on circumstances; change-makers need to know the evidence but apply it opportunistically.
Enter the “Plan”
Like all complex public policy problems, management of mental illness continues to be a Gordian knot of wickedly interwoven threads: individual factors such as brain injury due to trauma or substance use; family background or genetic and biological factors; social effects including poverty and stigma; practical issues such as housing, education and employment; accessibility, quality and affordability of the care system and so on. These threads are components of a complex adaptive system that is evolving even as we try to shape it. Policymakers may set priorities such as intervening earlier when mental health problems first arise; unfortunately, isolated solutions such as training school teachers to recognize early signs may be ineffective in a complex adaptive system. Obviously, this complexity differs from place to place and over time – hence my emphasis on understanding context. One “best practice” does not fit all situations, in this or many other public policy fields.
Titled Revitalizing and Rebalancing British Columbia’s Mental Health System, the B.C. government’s 1998 Mental Health Plan (the “Plan”), followed large-scale changes in the general hospital system all over B.C.³ The central strategy, “Closer to Home,” was popular in rural areas. Another strategy was to focus on serious and persistent mental illness (SPMI), such as schizophrenia and major depression, rather than less disabling conditions. The emphasis was on evidence-based community care that leveraged new, powerful medications. Other Plan activities were based on a national survey of “Best Practices” for mental health care,⁴ from which working groups of providers, “consumers” and family members developed local applications.⁵ The Best Practices report did not advocate closing the large psychiatric institutions and was largely silent on the resource implications of delivering the new models of care.
Of several important elements, the Plan’s most prominent feature was transferring resources from Riverview Hospital (RVH), the provincially run 800-bed referral institute, to decentralized programs in each of the new regional health authorities (RHAs).⁶ “Deinstitutionalizing” the big asylums was a global trend and the greatest downsizing across Canada occurred in the 1970s and 1980s.⁷ Now, under the Plan, there was a fresh commitment backed with promises of significant funding to pay for transition costs, such as labour settlements and construction of replacement facilities in each region. The RHAs would run in-patient and out-patient programs staffed by former government employees such as community nurses and RVH staff.
Enter a commissioner
The task that I initially accepted in early 1998 was to develop a transition strategy for closing RVH and improving “throughput.” I had some experience in mental health as a nurse and as a senior manager for acute care psychiatry programs. However, this new assignment was in different territory. RVH had evolved from unique influences such as its sanctuary-like isolation, the civil service status of employees and the low status of psychiatry among medical specialties. Until about five years earlier, RVH had been a troubled institution. A 1992 report detailed complaints of patients and their family members; government personnel policies had led to recruitment problems; regional providers complained of difficulties in transferring patients who needed specialized care to RVH.
I needed to learn a lot in a hurry. My frequent hospital walkarounds revealed sincere efforts to address the report’s recommendations, with many dedicated staff trying to respond to the government’s direction to improve care quality and throughput. Touring regional hospitals, community care homes and the impoverished neighbourhoods that disabled people can afford, I met hundreds of frontline staff, patients, relatives and advocates. There was no shortage of published evidence. In addition to reading dozens of studies and reports, I visited impressive care systems elsewhere in Canada, meeting with progressive leaders in large and small institutional sites that applied “better practices.”
I quickly learned that B.C.’s mental health services were not only complicated as a result of many siloed parts but were complex because all those parts were constantly and independently changing in response to internal and larger-society factors. I also learned that no government can fix such problems alone. Politicians can only lead where constituents will follow. Unfortunately, at that time the context included important fallacies that undermined public support and affected the policy directions of the Plan itself.
Some of the fallacies were mere prejudice: scepticism about psychiatry among other medical specialists and administrators (“ten cardiologists, one opinion; ten psychiatrists, twelve opinions”); media clichés (“The Cuckoo’s Nest”); alternative facts from pseudo-experts (“antipsychiatry”); and stigma and public ignorance, especially in some immigrant communities.
Another fallacy was “one size fits all”: a particular form or location of treatment would help everyone. Certainly, those with mild and moderate problems can live independently or with minimal support in their own community. But I had also encountered a sizable group with severe mental illness and related problems such as addiction or neurological impairment who were so disabled or unstable that they needed intensive, continuous support.
A related misconception was that “care in the community” would be cheaper than institutional care: like people with developmental delays, people with SPMI could be served in family-style settings, resulting in savings from noncare overheads like maintenance, housekeeping and “administration.” This was fundamental to the Plan strategy. However, compared to the benefits of scale and specialization of RVH, small group settings have significant drawbacks, including quality and safety issues for both clients and staff; NIMBY problems; diversion of resources from specialized programs like vocational rehabilitation; and sometimes higher costs (increased ratios of care staff with minimal overhead savings).
Another fallacy, “Snow White’s prince will arrive,” is that a cure for every mental illness is just around the corner. Modern pharmaceutical and behavioural therapies make an enormous difference for many people with mental illness of all kinds. But sadly, as we now realize, we do not have complete cures. As with many physical illnesses, such as diabetes, heart failure or multiple sclerosis, some people with SPMI will never fully recover, despite treatment. And as with people suffering from those physical illnesses, we owe them continuous care to meet their needs.
One of my most important lessons came from a mental health team on the Downtown Eastside in Vancouver. “What do you need me to do?” I asked. They replied,
Keep Riverview open. It is the only safe place for some people who are too disabled to protect themselves. When they are discharged from Riverview, they drift to Skid Row because it is the only place they can afford, where there are services, where they are sort of accepted. Unfortunately, people with mental illness are bottom of the street pecking order. For many released from Riverview, the only way to cope is to join the addicts and soon a potentially treatable mental illness is complicated with incurable hepatitis or HIV. Riverview is a sanctuary where they can be rehabilitated away from the predators who victimize people with mental illness.
Unpacking the context
According to John C. Glidewell and Erwin C. Hargrove, the editors of Impossible Jobs in Public Management, a primary cause of impossibility is conflict among stakeholders.⁸ My political masters had handed me a hornet’s nest. The NDP government made a cult of “consultation.” There were numerous administrative committees with different combinations of RHA staff. The unions and physician representatives required constant appeasement and often used the consultation process to stall changes. I spent much time listening to pressure groups who often differed among themselves – as did the regional family advisory councils, professional associations, local politicians and self-appointed advocates.
That period in provincial politics was also tricky. The economy was in the doldrums and several members of cabinet faced recall campaigns. Premier Glen Clark resigned later that year, but not before replacing the Minister of Health who had announced the Plan and its $125 million budget. The new minister was less attached to the Plan and the third, a year later, was even more distant. Some union leaders were allied with particular cabinet members. University-appointed psychiatrists protected a hoard of pharmaceutical research contracts based on their access to “subjects.” The RHA managers held mixed views: some believed they could do a better job with Riverview’s resources; others believed they could slice the mental health salami thinner to fund other programs; a few realized they lacked local capacity and worked with me to develop other solutions.
Writing in 2022, it seems trite to observe the impact of all this stakeholder strife on people suffering from SPMI. Anyone can see the increased homelessness, a toxic drug epidemic and jails-as-substitute. Even in the late 1990s, at the time of the Plan, there was clear evidence from the U.K. and the U.S. that deinstitutionalization was not a panacea.
Like any large-scale change initiative, the Plan needed not only significant new resources but also collaborative effort and – even more challenging – new ways of working. It needed a human resources strategy focused on building capacity to deliver new care approaches.
Unfortunately, mental health programs in B.C. at that time suffered from a legacy of insufficient professional development. Hospital-based caregivers did not understand community mental health services and vice versa. Ignorance about modern mental health services among nonspecialist officials, administrators and analysts was made worse by a lack of meaningful, up-to-date information for human resource planning. Management theorist Peter Drucker wrote, “Culture eats strategy for breakfast.” I would add, “Context sets the table.”
Managing the context: A plan for RVH
As a planner, I alternate divergent thinking – all issues considered – with convergent thinking, focusing on findings and action steps. So, with my initial analysis complete, I drafted a list of “Critical Success Factors”:
- Work with the ministry policy team to tackle B.C.’s skills shortage, using the RVH trainers.
- Stabilize RVH after years of uncertainty and help staff prepare for the transition.
- Recognize the capabilities of RVH frontline staff and focus on “Better Practice” as a motivator.
- Channel family and consumer involvement, particularly to neutralize the antipsychiatry faction.
- Address regional disparities in resources, population risk and staff capability.
Improving the RVH admission process was my first concern because of the pressure on emergency rooms in metropolitan and regional hospitals. The goal was to increase throughput of the most severely ill individuals.
I started by focusing on upper management at RVH. Following a review, I replaced a few managers, promoted respected insiders and introduced a few seasoned outsiders. I spent a lot of time meeting medical staff to raise expectations for greater accountability. These were important signals that inspired managers and staff already trying to make improvements. Staff recruitment and turnover were huge problems because RVH’s collective agreements contained lesser wages and benefits than those of the RHAs. We gave managers more flexibility to hire part-timers and pay overtime rates. We also increased resources for better discharge planning to regional care. Surprisingly quickly, we were able to expand access, focusing on hard-to-serve patients from the downtown hospitals.
Next, I began to tackle the transfer of RVH resources to the RHAs. This had been underway informally for decades. RVH had shrunk from more than 5,000 beds in the 1950s to just over 800 beds in the 1990s. Most RVH patients were already “closer to home,” with over 80 per cent from the Vancouver area; unfortunately, the Plan would reduce the Vancouver share of RVH resources to 60 per cent.
Another problem was that breaking up RVH compromised highly specialized provincial referral services that could not be replicated with smaller catchments. Many managers in outlying regions acknowledged that they lacked skilled staff and so were not ready to care for the types of patients currently sent to RVH – even with more funding. Looking at all the contextual factors, I realized that RVH should not be liquidated until the impact was better understood. It should continue providing services for at least five more years, and at a significantly enhanced level.
And another thing
In February 1999, almost a year into my tenure at RVH, I was asked to become Executive Director of B.C.’s Mental Health Branch, leading the policy staff with Plan implementation. As Director, I finally had access to the overall Plan budget – and got a nasty surprise. The $125 million Plan was a bit short of cash, actually $115 million short: there was only $10 million available. A friendly senior civil servant suggested I look for cheaper options to escalate action on the Plan: “Get an alternate plan built in some way.” In other words, find a volunteer mouse to bell the cat.
My new minister was sympathetic and in the following months squeezed another $3 million from Treasury Board. None of this was public knowledge, of course, and I could not talk about the shortfall with the RHA teams, which were fixated on their share of $125 million. Working with only 10 per cent of the original “commitment,” the Branch staff cobbled together a reasonable patchwork of appeasement, accountability and targeted investments. We contracted university-based experts to train RHA care providers in evidence-based best practices for psychiatric care.9 We funded early intervention programs for youth in every RHA. This included a heavily staffed in-patient program at a Vancouver hospital for hard-to-treat young adults. For patients ready to live semi-independently, we funded provincewide programs with rent subsidies and intensive case worker support.
None of this much impressed the RHAs, which believed they should have complete autonomy with their share of RVH resources. They suspected me of protecting the teaching hospitals. Meanwhile a Ministry executive feared that RHA executives would use RVH resources for their general budget problems. To tackle the finger-pointing about unfairness, I set up a unit to scrutinize staffing allocations, services offered and numbers of patients served in every mental health program in B.C. This comprehensive and transparent accounting of resources used in each region helped reduce friction in distributing new funding, which we also tracked carefully.
In addition to the lack of money, the Plan itself was flawed. Trying to satisfy multiple stakeholders, it was simply too much at one time for the capacity of officials and care providers. Many of the objectives came from “the evidence” of other jurisdictions with different circumstances. There was almost no computerized evidence to establish baseline service levels, validate local conditions, identify barriers and constraints or measure progress. Everyone recognized that some kind of computerized data collection was essential, but these were early days for patient-based information systems in Canada. At the time, even basic definitions such as “tertiary level care” varied widely. As one of my staff remarked, “Hearing stories from people is the Minimum Data Set right now.”¹⁰
Meanwhile, I was finding my footing with the larger advocacy organizations. Government was extremely nervous about these groups, erroneously believing that they were widely supported. I began stakeholder meetings by saying I felt a strong obligation to listen carefully to everyone, but it was not possible to do everything I was asked to do. In turn, I tried to be as transparent as possible in sharing some of the challenges in implementing the Plan. Usually, I found people had highly specific interests and knew a lot about the challenges, and we both benefited from in-depth exploration of workarounds. Later, the trust I developed with the advocates gave me useful leverage in dealing with much more powerful groups – the care providers.
I had worked closely with the UBC Faculty of Medicine department heads during a decade at Vancouver General Hospital. I was unprepared, however, for the self-serving tactics and empire-building strategies of some academic psychiatrists. Admittedly, the Plan proposed transfer of beds from the metropolitan area and its high needs, which was reasonably predicted to be disastrous. But the Plan also created positive opportunities for change that were thwarted because key psychiatrists were protecting their career interests.
To build capacity for new ways of working, we invested in a university-based research and education centre that organized conferences and training sessions. We also provided primary-care doctors with specialized training in managing people with chronic SPMI within their practice and “buddied” them with psychiatrists who agreed to be available on short notice. We raised the profile of the underutilized psychiatric clinical nurse specialists and psychologists.
By the spring of 2000, I was juggling progress on both RVH and the largely unfunded Plan for a transition that I expected could take five to ten years. Unfortunately, RVH staff were already leaving for better-paid jobs in the RHAs, so we needed to match those wages or risk losing the specialized staff. The Deputy Minister persuaded Treasury Board to fund the levelling-up, a significant amount. I called the president of one of the many unions at RVH to share the good news.
Enter Paradox, the policymaker’s confounder. “Big deal,” said the union boss, “We could have got that through negotiations. It’s more important that you implement the Plan and start laying off our members.” Insiders had warned me that long-serving RVH staff wanted to be terminated with severance payouts from RVH, then take new jobs with the RHAs and continue working to full pensionable age. Instead, my efforts meant that not only would they continue at RVH, but their work would intensify with sicker patients.
With the NDP government reeling from the Premier’s abrupt resignation and the member for the RVH riding appointed as the latest Health Minister, the union leaders had a strong hand. As I drove into RVH one morning the radio newscaster announced, “Minister appoints labour troubleshooter at Riverview.” Having no advance notice, I was angry. Although the unions’ fear of the NDP’s imminent collapse ultimately motivated them to accept my deal, this was my turning point.
Sadly, I realized that my hopes for meaningful progress had been diluted with multiple handoffs. In two years, I had reported to three ministers, three deputy ministers and four assistant deputies. The Plan’s brief awakening of “mental health reform” subsided. The political furore waxed and waned. The civil service churned through minister’s letters, budget briefing notes, responses to the crisis of the day. With occasional collaboration from entrepreneurial NGOs or RHA managers, we harvested a few low-hanging fruit. I continued lighting fires and moving deck chairs but I had run out of metaphors.
In the autumn of 2000, I took a job as Head of Hospital Policy for England in the U.K. Department of Health. The civil servant who replaced me in Victoria told me, “I’m not interested in serious and persistent mental illness. Anxiety and depression are my priority.” Shortly afterward, the B.C. Liberals routed the NDP government. The Liberals moved swiftly to transfer RVH resources to the RHAs. Five years later, Liberal Premier Gordon Campbell told municipal leaders, “We’re going to listen to what we’ve heard from you … Deinstitutionalization is a failed experiment.”
Rueful lessons learned
The end of the last century was a time of dramatic change in Canadian health care delivery. The word reform was used a lot in the 1990s, often accompanied by the words failure and uproar. I experienced modest successes and recognized that these were not just about evidence-based strategy, diligent implementation, authentic communication and managerial capability. Success must be grounded in context – factors such as organizational readiness for change; adequate resources for “transition”; a consistent, unwavering political leadership; proper data and measurement capacity; and ability to combat ignorance and misconceptions.
In addition to these foundational contextual factors, success is vitally dependent on the magic sauce of politicians and civil servants collaborating to build trust within the public service, with political leaders of different jurisdictions, with groups outside the administration whose support is needed to move the plan along and with the current government’s stakeholders who may at best never be more than neutral. Without those factors, any progress requires an incremental approach: what I call “strategic opportunism.”
There will always be limits. Leadership is about making choices and, often, finding the “corridors of comparative indifference.”¹¹ Sometimes one must exploit crises to achieve what rational planning cannot. More often, the choices are about taking difficult routes, maybe previously recognized but ignored.
More than just money, human resources are a significant constraint, so change efforts must engage staff. Serving people with mental illness is inherently hard, often fruitless, not much respected and sometimes unpleasant or dangerous. Health care providers are knowledge workers: they usually know their own jobs better than their boss does, and always better than the senior bosses. Among professionals, a command-and-control approach does not work. Their resistance to change is usually based on the conviction that they are already doing what’s best for their patients; other parts of the system should do things differently. My ten-word lesson: study change management and spend a decade applying the evidence.
The Plan was full of good ideas – too many good ideas and not enough hard choices. In such an environment, leadership cannot be based on position power alone: in order to direct change, I needed to connect with the goals and values of care providers, patients and families, and communities. How to convince them that they should support the overall change path? Trust was essential, trust that my objectives were based on fairness, on putting today’s patients first, on caring for providers, on thinking about future patients.
“Evidence matters, must always be the foundation, but context rules.” So much of success in the public sphere depends on circumstance – the shifting environment of media interest, competing demands, political leadership, influential individuals at opportune moments, random incidents. Communication is fraught, because of public mistrust, confidentiality, protection of privacy, misinformation, disinformation, misconceptions, outright ignorance, lack of relevant reliable data, and handover gaps among ministers, officials and new regimes. Almost daily, I travelled between the Plan’s big picture ideals and the as-found operational realities – as Harold Macmillan once said, “Events, dear boy, events.”¹²
Spare a thought for people like me. Guess what: management grip is as scarce as every other resource in the health sector. More important, shower many thoughts – and much, much more – on those citizens affected by our policy failures: the vulnerable people suffering severe and persistent mental illness, the family and friends who suffer with them, those who provide care under difficult circumstances. We owe it to all these people to ensure that evidence counteracts disruptive context whenever possible.