STANDING COMMITTEE ON PUBLIC ACCOUNTS
COMITÉ PERMANENT DES COMPTES PUBLICS
Tuesday 10 February 2004 Mardi 10 février 2004
The Chair (Mr Norman W. Sterling): Good morning. I look forward to hearing from the new ministry. I'm not unfamiliar with the new deputy, whose retirement party I attended not too long ago. I was saying to the committee in the closed session that I'm going to demand back my portion of the retirement gift that you received, Deputy. I understand that you can only be here for a period of time and then you will be leaving, but the committee thought it was important you come and present your views, even though you've only been in this post for a very short period of time. So, Ms Lang, if you would like to make your introductory remarks and introduce the people you have with you.
Ms Sandra Lang: Thank you, Mr Chair. I am delighted to be back. It's a very exciting opportunity to be part of a brand new ministry. What I would like to do this morning is take a few minutes and bring the committee up to speed on what's happening with the new ministry, do a bit of a contextual piece for you, and then I will turn it over to Peter Rzadki, who is our ADM for integrated services, who will talk to you specifically about the actions taken to date in response to the auditor's report for children's mental health. I also have at the table Heather Martin, who is our director of policy, and Dan Lafranier, who is our current regional director in northern Ontario, but at the time the audit was being done he was the director of the program management unit in the ministry.
I would just like to give you a bit of a context with what's happening with the new children's ministry and bring you up to speed on the developments to date. Before I do that, though, I should also say that we are very pleased to have the benefit of the auditor's report. We always welcome the kind of input and value that the auditor brings to an examination of our service system. I'm confident that we will respond in a way that will deal with the concerns that have been raised, and I understand they've been raised a couple of times. I'm hopeful the new ministry will take this one on as a significant opportunity to deal with the kind of change we believe is necessary for the service system in the province.
Let me just first of all talk about the new ministry. As you're aware, it was set up back in late October. The ministry is intended to provide a focus inside government and outside government for all children between the ages of zero and 18. It is dealing with a wide range of issues and concerns for our children, but we are also taking a strong look at how we provide the framework that allows the government to provide a direction for children in the province that allows them to succeed.
The tack that we're taking at the moment is to take a look at the developmental stages of children's lives and determine what kinds of services can be provided to help parents and families move through those various developmental stages for children as they move through the transitions. We're dealing with the transitions from birth through to the early years through to being ready to learn in the education sector, supporting them as they succeed in school and the transition to high school and then the transition to independence, whatever that may be, whether that's post-secondary education, apprenticeship or moving into the world of work. We see ourselves putting together a policy framework and a set of directions that allow the system out there to respond to those directions, and making sure that our young people have successes and move through those transitions.
We're also going to be focusing a significant amount of time and energy on outcomes. We want to be able to determine what it is that will allow young people to succeed, what the outcomes are that need to be measured. We want to put in place a system to be able to evaluate in an ongoing way whether our services and the response to children's success are in fact in keeping with the outcomes that we've set for ourselves, and report to a public process in a regular, ongoing way, because we believe that we need to learn about what works out there. We need to use the benefit of research to tell us what is making a difference in the lives of children, and in order for them to succeed, we need to use that research to target our resources and our policies and our priorities.
Where we are at the moment is very developmental. We're in the early stages of setting up a new ministry. We have put in place some special resources to take a look at the kind of organizational design we need to carry out the mandate of the new ministry, and focus on a strategic plan. We are spending a fair amount of time taking a look at the strategic directions for the new ministry, trying to shape a long-term vision and set up priorities for the new ministry. The intent would be to think about the things that need to be altered in the way in which services are provided out there now to make it much more seamless for parents.
I think many of you are probably aware that parents in this province have a hard time working their way through the service system. The service system is made up of a lot of different sectors: health, education, social service, recreation, just to name a few. It can be a bit of a maze if we don't find a way to work through, in a much more integrated fashion, the approach to service delivery. So I think a key mandate for this new ministry will be to take a look at those service systems out there and try to find the structural changes necessary to help parents work their way through the various service sectors.
We're also in the throes of working on the transfer of a number of programs and services into the new ministry at the moment. We have completed the transfer, at least in the legal sense, for the social service components of the children's ministry. So we are now dealing with child welfare, children's mental health, daycare, children's treatment services.
We are actively engaged in discussions with our colleagues over at the ministry of corrections for the transfer of services for youth justice, and that will be coming very soon to the new ministry for young people between the ages of 12 and 17.
We're engaged in a very detailed dialogue with our colleagues at the Ministry of Health at the moment to move a number of programs and services dealing with children in the health sector so that we will then have the basis of a foundation of significant programs and services that give us the opportunity to start taking a look at how we begin the process of integration and looking at bringing those various services and components together in a way that makes sense for parents and families, in a way that allows us to ensure that there are sufficient strategies available to help get the outcomes that we want for our children in the province.
We're also in the throes of doing a series of discussions. The minister and I and others are spending a lot of time meeting with people across the province, talking with stakeholders, talking with parents, talking with people who have an interest in children -- which, in our view, is everybody. We think that everybody should have a stake in how our children do. So we're spending a lot of time and energy at the moment getting input, trying to hear from parents, trying to hear from service providers, trying to hear from the other sectors about what needs to be tackled as we think about the long-term directions for shaping the way in which services are provided to our children and to our families. That will be going on for the next two or three months, and then we hope to be able to complete a longer-term strategic plan sometime in the late spring, early summer.
In addition to all of that, as we think about the framework that will guide the policy directions and the priorities for the new ministry, we're also going to be spending a fair amount of time and energy thinking through all of the infrastructure pieces that deal with accountabilities, funding frameworks and ways in which we monitor services. I think for the purposes of this committee, it's fair to say that the ministry is mindful of the need to take a look at the longer-term underpinnings of how services are funded, how services are accounted for and how we measure the outcomes for the way in which services are provided in the province. We have not missed the need to take a look at that in a very thorough and comprehensive way.
We're excited about the possibilities of a new ministry. I think it's fair to say that it's early days, and there is a fair amount of work yet to do to get the ministry fully in swing, to get the directions finalized and the policies and perhaps legislative change, if that's part of the requirements, well in hand as we shape the directions.
I'd like to now just turn it over quickly to Peter Rzadki and ask him to bring the committee up to speed on what we've done in terms of the actions, following the auditor, as it relates to children's mental health.
I am pleased to be here to report on the progress we have made to improve the administrative systems and processes that support our accountability relationship with the transfer payment agencies that deliver children's mental health services.
We have indeed taken some steps toward improvement. We've implemented several initiatives since the 1997 audit to change and improve accessibility, flexibility and responsiveness in the delivery of children's mental health services.
With respect to the quality of services we provide and the issues that the auditor has raised in his report in 2003, our new ministry, as the deputy has indicated, is focussing its efforts on outcomes and evidenced-based clinical practice. The auditor's findings support our decision to undertake a more detailed review to assess the effectiveness and efficiency of children's mental health services.
The ministry will also be developing key strategic policy directions -- new ones -- within a broader policy context for children's services, as the deputy has outlined. Our review of children's mental health services will confirm the outcomes of services, as recommended to us by the auditor; will verify the nature and scope of children's mental health services in a much more clear way, as recommended by the auditor; and will assess the overall effectiveness and efficiency of the delivery of those services as it relates to the roles and responsibilities of our transfer payment agencies.
We plan to develop key strategic policy directions in the context of the overall broader policy for children's services. These policy directions will confirm the government's expectations of children's mental health service providers, identify core children's mental health services and establish a common policy platform for all children's mental health services currently being provided by different ministries.
We have implemented standard intake and assessment tools for children with social, emotional and behavioural problems. These, we believe, have made a significant contribution to the quality of services being provided by our agencies. These tools provide agencies with the ability to track outcomes for individual children and to use the aggregate data to support planning and service delivery.
A new centre of excellence for child and youth mental health at the Children's Hospital of Eastern Ontario is being established. The centre of excellence will be a leading resource for program innovation, research, teaching and knowledge transfer. It will act as a clearing house for the dissemination of best practice information across the province and beyond. By undertaking a lead role in evidence-based clinical research and knowledge transfer, training and the evaluation of innovative approaches in treatment and intervention, the centre of excellence will help to build provincial capacity in the children's mental health sector that does not now exist in a coordinated fashion.
In 1997, an initiative undertaken by the Ministry of Community and Social Services entitled Making Services Work for People was released to agencies. This process and framework were developed in consultation with agencies across the social services field. This framework outlined several specific steps to improve services for children and resulted in locally based approaches designed to address communities' specific needs -- the needs, in particular, with respect to the clients and children that community agencies were serving.
As well, we have implemented standardized intake and assessment tools like the brief child and family phone interview and the child and adolescent functional assessment scale. These were implemented in the year 2000 to help agencies identify children whose needs were most complex and who needed services promptly.
As part of our policy work, the ministry will begin to develop policies that provide better direction to agencies about access to services. This is an important issue raised by the auditor in his most recent audit and had been raised in previous audits as well. We will also continue to work with all service providers to improve and better coordinate services for children with social, emotional or behavioural problems to improve access so that community services can be prioritized for children who need them most.
We believe that the integration of children's services across all sectors will improve access for families and children in need. Our review of children's mental health services and the development of strategic policy directions for service providers will help to better identify core services and provide agencies with direction on prioritizing service needs.
With respect to performance measurement, the ministry fully agrees that performance measures are essential to support good decision-making, both at the government level and in terms of decision-making at the agency level.
To that end, the ministry has begun to introduce a ministry-wide strategy to focus on outcomes for children and indicators that reflect the effectiveness of our programs. The deputy spoke briefly about that initiative now underway.
Our review of children's mental health services will also allow the ministry to better define outcomes for children in the mental health field and assess the overall effectiveness of our system. The ministry will continue to develop outcome-based performance measures and use these to guide and direct our agencies in the provision of services.
With respect to agency funding requests and approvals, the auditor's report indicates the work and recommendations he and staff have undertaken in this past audit. We agree that detailed information is necessary for program budget submissions and that we require further detail in the submissions made to us by our agencies.
Through the annual transfer payment budget package, the ministry will reconfirm its requirements for agency funding requests and approvals. There are already a number of ongoing improvements to the transfer payment budget package that include a continued emphasis on contract management, yearly training for regional office staff on the use of the budget package, accrual accounting training and financial management.
Implementation of strategic policy directions for children's mental health services will help to strengthen our ability to monitor our expectations associated with the funding we provide to our agencies.
To improve the APER review and approval process, the ministry has revised the APER form, provided regional and corporate office staff with training on how to use the APER form more effectively. The ministry continues to monitor the APER process by collecting data three times a year. The government's recent change to accrual accounting will also positively impact on the APER process.
With respect to surplus recovery, the Provincial Auditor has recommended that the ministry not enter into service agreements that span two fiscal years. The ministry acknowledges this policy requirement and has reconfirmed that agreements spanning two fiscal years require the identification and recovery of annual funding surpluses.
With respect to our information systems, the Provincial Auditor recommended that the ministry confirm that its management information systems provide better and more sufficiently the detailed, relevant and accurate information that can help the ministry determine whether services are provided by transfer payment agencies and whether these services are effective and represent value for money spent.
The ministry is committed to having information systems that determine the effectiveness and value of services provided by our agencies. As the deputy alluded to earlier in her remarks, the need to look at investments in information and information technology is critical if the amount of change and potential restructuring of the children's services system is to be undertaken in a way that we can monitor, assess and evaluate.
The ministry is implementing improvements to our management information system to allow for the development of data quality assurance tools and methodologies, and refinement to the transfer payment budget package to ensure clarity and consistency of the data elements and definitions.
-- Develop data quality assurance tools and methodologies to ensure the data inputted into our service management information system is of a degree of quality that does not require additional time-consuming validation;
-- Continue to refine the transfer payment budget package to enhance the clarity and consistency of data elements and definitions so that agencies across the province are providing us information with an agreed-upon set of definitions, and so that the data we collect can be used to assess the impact of our services, not just locally or by agencies in particular, but at the level of the province;
-- Make improvements and additions of new functionality to ensure that, as I indicated earlier, our IT systems have the capacity to provide us, as policy developers, and those of my colleagues in the region, as program managers, the information we require to understand the quality of services that are being provided, to understand where there may be gaps and to able to work with the government to develop and seek out improvements to those services.
I can assure members of this committee that we will continue to improve our processes and systems to support effective, value-for-money programs and services at the community level as our new ministry evolves.
First of all, I think we detected the enthusiasm and energy from the remarks of Deputy Lang, but with your permission, I would like to -- it reminds me of a particular quotation or saying, and that is, what's past is prologue. What I mean by that is I'd like to give the members of the ministerial staff here a little bit of opportunity to expand on what I think is a very historic commitment and initiative that's been made by the government of this day, and that is, to create for the first time in the history of Ontario, in the history of this province, this new Ministry of Children's Services. I was wondering if Assistant Deputy Minister Rzadki -- and the staff here -- would be able to perhaps share with us some of his thoughts on what has gone on previously and what he envisions going forward.
In particular, I was always struck in the many briefings I had the privilege to attend in the past that, for example, things seemed to be not integrated, not fully directed, not accorded the highest priority, perhaps underserviced, not capitalizing on the full synergies and frankly the considerable talent and experience that is displayed by the public service.
In particular, I'd like to quote for the members of this committee and for you, Mr Chair, what I and the government consider, and certainly the ministry considers, to be one of the master reports that was filed, and that is, of course, the McCain-Mustard report, Early Years Study: Reversing the Real Brain Drain. One of the recommendations in the final chapter was, "To ensure there is a strong voice around the cabinet table for early child development issues, and to ensure there is a provincial minister with the responsibility for leading the development of the early child development and parenting program across Ontario, we urge the Premier to" create a minister responsible for children.
I think there are certainly elements to be hopeful about, and the enthusiasm and energy that I spoke about. I'd like to ask very specifically, Mr Rzadki, how do you feel that this is an event of empowerment to help you execute a more coherent vision, integrate your policy framework, better the stakeholder relations and ultimately better serve the 2.9 million children in Ontario between the ages of zero and 18, those at risk and those not?
The Chair: Just before you answer, I think it's important for those who might be listening to understand that Dr Qaadri's enthusiasm results not only from his being a member of the Legislature but he is also the parliamentary assistant to this particular ministry and therefore he is, no doubt and naturally, an advocate for this particular ministry.
Mr Rzadki: In response to your question, I'd like to just echo and perhaps expand on some of the comments made by Deputy Minister Lang. The creation of the children's ministry, the first ever in this province and the first new ministry in many decades, is indeed an exciting prospect for children, who depend on the province of Ontario for services to assist in their development, in their readiness to learn, in their ability to learn through school and to develop as youth and young adults.
The reason there are opportunities created by the creation of a new ministry is that for some time it's been understood that ministries at Queen's Park -- at headquarters and in the regions -- need to work better to direct our children's services system, which crosses the responsibility lines of many ministries. We need to work better to direct our agencies and providers to work better in the community, to support the very complex needs of some children and the universal needs of all children. So the opportunity to bring into one organization services that relate very much together in the community is certainly one we are looking forward to and, as the deputy indicated, working hard to achieve.
An example of where there needs to be greater policy and planning synergy at the ministerial level is the example of children's services with respect to youth who are in conflict with the law. Many of those children require children's mental health services, many of those children may have an experience within the child welfare system, and in order to understand the complex interdependencies of those three children's services systems, bringing together those services and the funding that relates to them into one ministry creates a positive opportunity.
Another important benefit of bringing together services that interact or relate to children in the community is the prospect of examining how government funding, broadly, for children's services is now aligned by ministry, by agencies and by sector, and to take a look at whether or not there are alternative ways to allocate that funding through new or improved delivery systems so that parents don't experience the children's services system to be one of disintegration but experience a system of services that is easy to access and that provides continuous services to their children; that do not, as is the case today, provide for children periods of service and periods of waiting time.
Those are the things that we believe have been raised by experts, analysts and critics of governments in the past. There have been issues with respect to integration that have been around for quite some time. I think while we're in the early stages of the creation of the ministry, the opportunity to work more closely with staff in our regions, and corporately, who also serve children, the opportunity that that might mean we'll all do a much better job of ensuring our agencies serve those children much better is a very positive thing. As we understand it, because we are taking a look at the experience in other jurisdictions, it is a step that has been taken by other jurisdictions to the benefit of children and to the benefit of a more efficient and effective children's services system.
Mrs Julia Munro (York North): Thank you very much for bringing us up to date on some of these initiatives. I think all of us share the interest, obviously, in the well-being of children across the province. I don't think we'd be here if we didn't.
I have a couple of questions that relate to some of the issues that are in the auditor's report that speak to dilemmas we face. This has to do with the question of understanding the need for accountability measures, as has been suggested, but where the balance lies between creating the appropriate accountability measures and the diversion of money from front-line service to administration. In a number of the comments you've made, you've talked about the need for accessibility, formalizing intake mechanisms and things like that. So I thought you might have a sense of what kind of balance you are looking for when you start looking at an agency in regard to that increased accountability mechanism and the kind of administrative burden which translates into dollars in terms of front-line services.
Mr Rzadki: Thank you for the question, Ms Munro. I will make a few remarks in response to this. I might ask my colleague, Dan Lafranier, also to provide some perspective from his experience, working much more directly with children's mental health agencies.
One of the many key themes in this most recent auditor's report certainly points us to the need to bring a much more outcomes-focused orientation to the services we provide. We intend to do that with vigour across all of children's services and we intend to do that, with respect to children's mental health services, as part of a broader review of children's services. We do intend to undertake this year a review of the children's mental health system so that we can better understand the accountability balance that is out there; so we can better understand what we need to do from a policy and funding perspective to help our agencies who are primarily tasked with the responsibility to manage services, make clinical decisions, manage the resources they have to meet the needs in their community; so we can better understand what we can do to help them do that better.
It has been some time since the ministry has had a serious look at exactly what services are being provided agency by agency and rolling those up to paint a picture for ourselves of the services provided provincially. It's difficult for us at this time to, for example, know where every gap in service is and understand the reasons why in any particular community there are waiting times. So we need to deliberately, in short order, arm ourselves, prepare ourselves with that kind of information. That's the side of accountability that I think is on the ministry's side: to understand much better, as the auditor has pointed out, what is happening in terms of capacity and to lay out for agencies in a much more clear way what our expectations are.
On the side of the agencies, beyond the contractual obligations and processes we have in place to fund agencies -- their primary responsibilities, as I've said, are to manage the funding and resources they have the best they can to meet the service demands in their community. This places a critical responsibility on them to ensure that wait times for children most in need are minimized. We as a ministry have provided community processes and intake and assessment tools that can help agencies perform those functions better, and we look to further discussions with our system to understand what more we can do. But the role, in terms of a balance, is on the agencies to make those clinical decisions, to use the tools they have and we have to make those decisions more promptly, with a view to ensuring that the resources that are being provided to children's mental health are being provided to the children most in need.
Mr Dan Lafranier: Thank you again for the question. Just to add to what Peter was saying, I think the ministry wants to be satisfied that the resources we have available go into services for children and families, and that only where it's required do we support infrastructure and administration in agencies. I think there are a number of strategies we've used in the past and will continue to use to try to achieve, as you say, that compromise.
One of them is ensuring that we're clear on what it is the ministry really needs to know, so we're only asking what is really necessary to avoid duplication of effort and work at the agency. That speaks to the auditor's report in being clear about what our expectations are, that the agencies understand, and are they trained in providing that type and level of service? Have we provided the agency with clarity around the use technology can have within agencies in providing information and reducing effort so that those resources can be devoted to service for children and families?
Particularly with smaller agencies, which are more of an extreme dilemma, they have a critical mass and you need to make the decision around how small an agency can be and still provide an effective service across the province. In those situations we're looking at providing agencies with opportunities to partner with other agencies so that smaller agencies can work together around administration and use of opportunities like that.
These are the types of conversations we have year after year with agencies when we settle their service contract: Are we satisfied that we're asking for the absolute required information to minimize duplication of effort? Are we providing good training and support to agencies around what it is we're looking for? Are we satisfied the agency has sufficient infrastructure to meet the expectations we have in giving us the information we need so we're satisfied we're getting the services we're looking for? Are we satisfied the agency is taking advantage of local opportunities to partner with agencies where they have similar problems and issues? It speaks to the earlier comment around the community as a system of partnerships. Those relationships are important and they need to be healthy in order for smaller agencies to survive.
Let me make some comments and then I have a question. I preface my remarks by saying I appreciate that it was a different government in place at the time of the audit, but let me make a couple of comments.
First of all, thanks for being here. Peter, I heard you say many times, "We will, we will." Except if you look at the auditor's report, he was really clear. He said, "Our conclusions and findings were of particular concern because many dealt with issues we had previously raised in our 1997 audit.... Although the ministry agreed with the recommendations in that audit and agreed to implement the necessary corrective action, its progress has been less than satisfactory."
There is a chart on that page with seven recommendations made by the auditor, three of which were not implemented at all, three that were noting some progress, and one improvement. That was it. Then you talked about some of the actions you had taken to respond, but I note that the actions you talked about -- Making Services Work for People or the assessment tools -- were changes that were already in place before the auditor did his most recent audit. So even though those things were in place, I don't think he was very supportive, or let me say that the report was still fairly critical of the ministry in terms of its responses and its understanding of the issues.
The second problem I have is you mentioned, on a couple of occasions, that you were giving policy direction, tools and procedures to the transfer payment agencies so they could prioritize children in need and make sure those children who had the most needs got the services first. In defence of the transfer payment agencies, I'd have to argue that I don't think they need any more direction about how to prioritize children. They have been juggling, trying to meet the needs of children for way too long. Their argument would be they need some increase to their base funding, and they need a budget that's actually based on needs in order to not only serve the children who have the most needs but get rid of the waiting lists entirely.
In that regard, what I'd like to know is, what specific actions has the ministry taken since the conclusion of the auditor's report, which would have been in March 2003, to now, which is almost a year later? What are the specific actions that the ministry has taken to respond to the most recent finding in this report?
Mr Rzadki: Thank you for the question. With respect to, first of all, the improvements that the ministry had undertaken following the 1997 audit, I think it's fair to say that the Making Services Work for People process was only just rolling out at the time of the audit and has really represented a significant change in the way children's services are planned, coordinated and delivered in communities.
We believe that is a significant improvement to have undertaken with our communities and our agencies. Many of the benefits of that framework are evident in your observations, Ms Martel, that agencies now know well how to prioritize, plan and work better with their colleagues and colleague agencies in their community.
We also believe that the introduction of singular screening and assessment tools, in an area of children's services that for a long time was characterized by wide use of varied screening and assessment tools, is a significant accomplishment. While it was referenced and reflected in the auditor's report, perhaps we feel that the accomplishment in bringing the research and assessment clinical community together to agree on a tool that really does significantly, in a consistent way across the province allow our agencies to approach the critical needs of children in their community and make determinations in a timely way as to how those needs can be met -- we think those are fairly significant accomplishments.
I agree and acknowledge, as we have in our comments, that recommendations of the auditor in the 1997 report have not all been addressed and it is our commitment, on a going-forward basis with the creation of the new ministry, to use those findings and recommendations as bearing points for a broader children's system change. It's important for us to acknowledge that these are findings and observations that have value regardless of the type of children's service being provided. To primarily be more clear about outcomes and to primarily seek out clinical and support and service practices based in evidence is a significant change and that we are committing on a going-forward basis, I'll admit, to use those as guiding principles is significant. We believe as our plans to bring an outcomes-focused and an evidence-based practice -- as our plans to bring those approaches to the ground develop, we think they'll have significant benefits on how existing services, existing resources in the children's services system are being provided.
With respect to the question of capacity and the alignment of resources to need, we are aware as a ministry of submissions made by agencies every day, every week, every month, and those made on a more annual regularized basis by Children's Mental Health Ontario, an association that represents many of our service providers, that speak to the question of the pressures that agencies providing children's mental health services are facing with respect to budgets and their capacity. We're aware that agencies in an ongoing way are making determinations about their capacity to serve their populations, and they do that by realigning continually the kinds of programs they have to offer so that they can reach the most in need and the broadest possible number of those children.
With respect to future funding, I cannot provide any indication of the government's ongoing deliberations about its budget. I know that the minister, as she meets with key stakeholders and service providers in this sector across the province, will have an open ear to the issues raised with respect to waiting times and waiting lists and funding, and that as she embarks on that discussion and as the government invites all Ontarians to have a role in shaping the upcoming budget, considerations such as those brought forward in the past by children's mental health service providers and associations will form part of what the government considers in the development of its budget.
Ms Laurel C. Broten (Etobicoke-Lakeshore): I think, as we've sat and listened to the ministry speak, we're faced with a clear indication of the massive challenge you face as you move to outcomes-based analysis when we can really focus on what children need to succeed. I commend you for that and I wish you good luck on that massive project.
For those of us who have a chance to speak to folks in our constituencies on a regular basis, the challenge we'll face over the short term is both juggling immediate needs -- folks who come into my office and their children need mental health services; folks who come into my office and their children need support through various therapies available for autistic children. In a long-term plan we can move forward to a greater examination, and we absolutely must, and we must be brave to do that and look at how we can do that in the long run. I guess from the perspective of our analysis, we also want to look in the short term at how we are we going to move forward with some of these issues right now and combine that as part of a long-term plan. I guess I raise with you, what is your plan specifically to deal with the immediate needs in communities and juggling that as part of a greater analysis?
Mr Rzadki: Thank you for the question. In terms of the immediate needs of children, in-year with the budgets we currently have, the primary responsibility through the contracts we have with our agencies is with the agencies to ensure that in a world of fixed or limited resources, the children who are most in need are getting the services they require. We have found that that isn't always the case, for reasons not particularly related to funding, but related to relationships in the communities between various programs and lack of integration between, for example, hospital-provided children's mental health services and those provided by our community agencies. The disintegration or lack of coordination is often a barrier to ensuring that services get to the kids in a prompt and immediate way. Certainly, as we begin to develop our going-forward plan -- and there will be long-term elements to that plan and there will also be short-term goals for those plans -- the experience we now have in providing services to kids will certainly inform how we move forward. This will be true with respect to the range of children's mental health programs and services that we support, and those would include those with respect to children with autism.
Ms Broten: Just one follow-up question: I wonder if you see a role that the ministry can bring in terms of the transfer agencies being assisted in innovation, in terms of new ways to provide the services, and if you see at all a role that the ministry can bring to bear in that regard.
Mr Rzadki: Certainly the ministry has in the past worked with our delivery system to bring about innovation. Investments in recent years in the field of tele-psychiatry have brought significant benefits, we think, to children with mental illness and mental health needs in rural and remote communities through very innovative approaches; approaches that involve the psychiatric counselling over video and telephone technology. Those are innovations that require investments.
I think there are also innovations that happen more out of the need to break down silos, not thicken them but actually break them down. There is some work underway, for example, in the southwestern part of the province involving our regional office, but led by and large by providers of children's mental health services in hospitals and schools and community agencies to innovatively look at their population, the needs of their population and to work out community by community in that region roles and responsibilities in terms of responding to the various gradients of need. That's innovative. It's innovative in part, the ministry will admit, because there hasn't been a clear outcomes-based policy direction from the government and there has been a need for that community -- and this would be a need across all communities in the province -- a need in particular for that community to better coordinate its resources so that there is an ongoing innovative look at children who are in crisis who are not now getting services and supports and can stand a better chance of doing that.
Mr Ted Arnott (Waterloo-Wellington): Thank you very much, Mr Rzadki, for your presentation. On behalf of the Conservative caucus, I want to express the appreciation of our members for the work you're doing as you set up this new Ministry of Children's Services. I was impressed by the deputy minister's presentation today. I realize that there are probably considerable challenges that members of the Legislature aren't aware of when you're trying to build a ministry from scratch, but we do appreciate the work you're doing.
We're here today because, of course, the Provincial Auditor identified some areas with respect to service delivery and accountability for service delivery of the previous Ministry of Community, Family and Children's Services. I know you're taking that advice and you're endeavouring to respond to it, and we appreciate the information you've provided.
One of the government members, Dr Qaadri, talked about the fact that this is the first Ministry of Children's Services, and I would point out to committee members who may have forgotten that the former government appointed the Honourable Margaret Marland to be the minister responsible for children, consistent with the recommendation of the Mustard-McCain report, the Early Years. Mrs Marland did good work in this respect during her tenure of some two years as an advocate for children's services within the government. I think that has to be pointed out. I believe this is the first full-line ministry that has been created for children's services, but certainly Mrs Marland had not a full-scale ministry but a secretariat that was engaged in the same kind of work that you're doing today. I would expect and hope that your work can be guided to some degree by the work that has already been accomplished in that regard.
One idea that has come to mind, just as I've been sitting here listening to the discussion today, is in terms of accountability for the money that's spent and the services that are provided. Most of these community agencies, if not all of them, the 250 that we fund, have boards of directors, I would assume. Peter, is that correct?
Mr Arnott: To what degree are we working with the boards to make sure that their effectiveness is enhanced going forward in terms of accountability? Do we have any training for prospective board members who are coming on as directors of these community agencies? They have an important responsibility, I know, to maintain these agencies and to ensure that the agencies are as effective as they possibly can be, to ensure that services are being delivered in a timely way, to ensure that money is being well-spent. These agencies are not just accountable to the province, they're accountable to their boards of directors. What are we doing in that respect to ensure that there is more local accountability?
Mr Rzadki: I appreciate the question. Thank you very much. Indeed, if I might just reflect on the period of time during which Minister Marland was heading up initiatives for children, she undertook an intensive review of children's mental health services, I believe in the summer of 2000, 1999-2000, which ultimately guided and underpinned the government of the day's decision to invest in four key areas, which we can speak a little bit about perhaps later. But these were enhancements to intensive children and family services, investments in tele-psychiatry, investments in mobile crisis units and important investments, as we've talked about, in intake and assessment tools.
With respect to board accountability and the support the ministry provides, I will ask Dan Lafranier to provide some comments there. I do know that associations of children's services providers also invest in programs that support their boards of directors, their members, and I think that's a reflection of the importance that agencies and their associations place on the quality of decision-making that boards of directors need to be prepared to make, particularly with respect to the provision of critical and important mandatory children's services. I think it's an ongoing part of the relationship between the ministry and its regional offices and the boards of our agencies to be monitoring board capacity and assessing, through the services that are being provided and the decisions that are being made, the needs of each board and agency to ensure that the capacity is there to actually deliver the services and meet the needs of the population.
Mr Lafranier: The ministry's regional office, while its day-to-day working relationship with the agencies is primarily through its executive director, does maintain regular contact with the board of directors. We have a presence at their board meetings, in terms of support there. We have visited all the boards and shared with the boards the accountability framework for the ministry, outlining what the ministry expects in terms of its service contract, its membership, how they operate, that type of thing. That has been consistently delivered across the province, just in terms of showing the ministry's consistent practice. Whether you're a small board or a large board, we have similar expectations.
The annual service contract is another mechanism that the ministry uses to formally sit down with the board and go through contract expectations so the board is familiar with what the agency is being contracted for, actually formally signs off as part of that service contract that it's aware of its responsibilities and accountabilities. We have built mechanisms in place that give signals to the ministry that the board is a "healthy" board.
Throughout the year, there are often opportunities for the ministry staff to attend board meetings just to stay close to the board conversations and give them whatever support they require. But it is up to a board, in terms of their own orientation. The support that we provide is tools, processes. As Peter was saying, some of the associations have board orientation sessions. It's our expectation that they would have that in place.
Mrs Liz Sandals (Guelph-Wellington): I'm delighted that we have a Ministry of Children's Services and that we're able to talk about children's mental health issues today, because certainly in my experience that has been a big issue in my community, and certainly an issue that has been underserviced.
One of the things I've noticed as people come in to talk to me in my constituency office is concerns about a lack of consistency. I know that that's an area the auditor has talked about -- a lack of consistency in two ways: (1) a lack of consistency in terms of what programs are available as you move from community to community; and (2) a lack of consistency in terms of what programs are available as you move from one mental health issue to another mental health issue, that, depending on what the child's particular issue is, you may or may not be able to get services in the community.
In my community, I would hear from people who are having to go to Peel or Toronto or Hamilton, even for initial assessment. I would hear from parents who are quite aware that the same agency, if they lived in Kitchener-Waterloo, would be able to give service, but they live in Guelph, and if you live in Guelph you can't receive service. So even within agencies, there's a lack of consistency in the service that's provided.
I hear from my family in children's services that they're running into more and more instances of parents who, out of the frustration of not being able to deal with the children, are essentially handing the children over to family and children's services. I certainly know that the school board locally has worked with family and children's services on a number of cases to expel quite young children from school because it's the only way to legally put the pressure on to get children into residential treatment programs. So there's a whole range of issues around consistency, and they're geographic as you move from issue to issue.
We've talked a lot about standard intake and assessment tools. We've talked a lot about standard performance measures. We've talked about the auditor noting whether these things are seen as mandatory or optional when you move out into the agencies. How do you see this all fitting together in tackling what I know is not just a consistency issue in my jurisdiction, but is a consistency issue throughout the whole province? How do you see this puzzle all fitting together? I quite admit it's a huge, complicated problem.
Mr Rzadki: Thank you for the question. I think the first step the ministry plans to take is to ensure that it has all the pieces of the puzzle in front of it, and to understand the pieces of the puzzle that it does now have in front of it. This is why we're putting a significant emphasis, in our responses today, on our steps to review the system.
That there is inconsistency geographically and that there is inconsistency with respect to the kinds of services that children with one type of illness or need have over another in part comes from the fact that it has been quite some time, if ever, snce the government has been clear about what core children's mental health services it's willing to fund. In order to get us to a point where we can work with the government and recommend what those core services will be, we need to engage with experts and clinicians in the research community to help us understand the current thinking and the current evidence that suggests which services are absolutely vital to have in every community.
I think the examples you've provided are very much the portrayal of the stories that parents tell us as well, that we read about in letters they write, that agencies bring forward to us and that we have here from parents as we discuss with them. These are stories about what are perceived to be gaps. Beyond perception, there are truthfully gaps. As the minister indicated in her recent comments when she was in Ottawa, there are truly gaps in the system that need to be filled.
It creates the feeling of discontinuity and it creates the feeling of too many doors and too many assessment processes to go through and very much the feeling of frustration that you have expressed and the deputy has expressed earlier. Our need to embark on a review is really driven by the stories you have shared and will get us to a point where, through discussion, through analysis, through a better understanding of what the capacity of the system is now that we fund and what the true need is, we understand much better, as the auditor has indicated, the question of waiting lists and waiting times based on reliable information from our agencies. Piecing those pieces of the puzzle together will, we believe, paint a picture of the kinds of high-level and more operational policy directions that we need to provide to our agencies, directions that we hope at a local services system level will correct gaps in service created by arbitrary geographic boundaries, will encourage agencies to work together, so that whether it's a city boundary or county boundary, the child in that broad community can be served by a more co-operative, integrated effort by the agencies there.
I've spoken a little bit about this. With respect to responding to the specific needs of children -- and this is with respect to clinical needs and the type of illness -- our work on core services and our work with the research community we hope will guide us toward a better understanding of what the role of government can be to support stronger agencies staffed with more and higher-quality children's mental health workers to make those determinations about services and the specific needs of kids, with an ongoing view that children most in need, children in crisis, families in crisis, are where we need to put our resources as soon as we can.
Mrs Sandals: Can I just follow up? I just want to do one little boast and brag bit. I suspect I'm in the unique position -- you're talking about inter-agency co-operation -- of having the children's mental health agency and the family and children services jointly make a presentation to Dr Rozanski when he was looking at education funding. We actually have a good community co-operation model that's trying to get the services in there. Thank you.
Mr David Zimmer (Willowdale): I just want to pick up on something that Ms Martel raised. Again, I'm quoting from the same section of the auditor's report, the opening comments. It seems to me that the auditor's overview, if you will, is that he had real problems with the assessing and monitoring abilities or functions of the ministry. The auditor went on to say, as Ms Martel pointed out, that although the ministry pointed out these deficiencies in 1997 and "the ministry agreed with the recommendations in that audit and agreed to implement the necessary corrective action," progress had been "less than satisfactory." That's as of 2002-03.
Could you tell me, in your view, where the two or three major systemic barriers or institutional barriers or difficulties were in the ministry achieving a paradigm shift so that it could correct those areas? That's a very general question and it has to do with institutional culture, if you will. What would you say were the two or three major institutional cultural barriers that prevented you from reacting more quickly to the auditor's 1997 concerns, and how do you plan going about breaking down those institutional blocks or barriers?
Mr Rzadki: Thank you for the question. I can't speak fully to the culture of the ministry or cultural institutional barriers that might have existed in the years following the 1997 audit. I know that as a priority the ministry did put its efforts to what was probably the most intensive and most significant contribution it could make to improving the world of children's mental health services and social services more broadly, which was to embark with the service system on the Making Services Work for People framework. That was very much about locking in the accomplishments of each community in terms of where they had worked together and building on that to have, as a requirement in every community, a certain capacity to respond more quickly to resolve complex cases, to ensure that access to the residential system of services was achieved through a single window and to increase significantly the information sharing among agencies about the cases of children and adults that were before them at the time to be resolved and served.
That the fuller program of recommendations was not accomplished is something we've clearly recognized. At this time, what I can say on a going-forward basis is that it's clear to us the auditor is making recommendations that can inform our work on a broad range of children's services. It's clear to us that it's going to take a considerable amount of work. And it's clear to us that it will take, in some respects, some investment in our capacity as a ministry to manage the significant change ahead as well as to invest in improvements in the way we're expected, and appropriately expected, to manage public funding to services.
I would say an important aspect that really underpins why, going forward, our ability to respond fully to these recommendations stands an improved chance is because we've created a ministry around the needs of kids. There's a greater focus than there has been before on the need to look at, first, research and what research tells us kids need and what services governments can fund to meet those needs.
We're looking much more in a focused way now than ever before at our information systems and the information we collect so we can be better equipped managers of the relationships we have with our transfer payment agencies. These are investments in information technology that I think need to be significant, not only improving our existing databases and asking better questions of those databases and our agencies, but making it far less labour-intensive for agencies to provide us with the information that we need so they can be off spending their time serving children and not our important needs as managers.
Rather than reflect on the past -- and I can't provide a full answer to you -- I think there are some organizational and cultural changes upon us that give us the best chance of moving forward on the agenda of work that the auditor has recommended to us.
Mr Rzadki: There would be a huge emphasis on working co-operatively across ministries. We're doing that in two ways. First, by bringing into our new ministry the services for children that best belong where there is a need for policy integration as there is a need for service integration. That's the first way.
The second way is to build stronger relationships across ministries that will continue to serve children in their ways -- that will be the Ministry of Education, predominantly, and the Ministry of Health and Long-Term Care -- so their work and our work can be accomplished together.
I think there is a certain amount of cultural change that is brought by political leadership around an organization. This has been the case in every effort by governments now and in the past to bring focus to children. So whether it's a secretariat or a much larger step toward a ministry, those kinds of initiatives do bring people together with a particular focus. I think that's important, and senior leadership at the bureaucratic level also. The return of Deputy Minister Lang has certainly brought some focus and commitment of people who have worked with her in the past to bear down on this agenda and find solutions in an early way. So it's a combination of things.
I'm certain that three months from now, six months from now and a year from now we'll have a better handle on what it was that we meant by it and what it was that made it happen at the pace we hope it will happen at.
Ms Martel: I have questions regarding waiting lists and capacity. I wanted to start with a point the auditor made, which was that with the exception of the autism program, information about waiting lists and times was not normally provided to the ministry. I'm wondering why it's not a requirement of the transfer payment agencies to give the ministry information about waiting lists, because that's pretty critical in terms of determining how you allocate resources from there; and if it hasn't been a requirement, is it going to be a requirement, and by when?
Mr Rzadki: Thank you for the question. It has not been a requirement for us to be asking our transfer payment agencies about the waiting lists that they face. We believe, going forward, we need definitely to understand what services children are waiting for. It would be very difficult for the ministry and the government to be able to develop a plan for allocating resources better or investing resources more effectively without a better handle on where the gaps in service are. It's clear to us, even among the community of people who have a sense of the size of the waiting lists province-wide, that we all need a more reliable or accurate gauge of in fact what the difference between the capacity and the wait-list is. So I would say up until now we haven't collected that information. I think we're going to need to.
It's also important, though, for us to indicate one of the significant responsibilities of our agencies, and this touches on the question earlier with respect to the capacity of boards and the need to have agency boards that understand their roles and responsibilities. It's the main responsibility of agencies not only to provide service but to manage their caseload or potential caseload to ensure that children in critical need are getting the services as early as they can and to fashion and create programs that best use those resources to serve the maximum number of children. So in terms of wait-list management and reducing those wait-lists region by region, community by community, agency by agency, we have traditionally looked, and will in the future look, to the role of our agencies to be the lead in making decisions about what is urgent, what's clinically necessary and which children in their potential population are in need of resources sooner rather than later.
Ms Martel: I'm not suggesting you do that. I don't want to see that happen, because it is the people at the local level who have a better understanding of that. My concern is, though, that ideas about waiting lists are running up to about 12,000. I'm going to ask you next, even without those data, what your best guess is. That's certainly a number that Susan Hess and other people in the community would use and feel quite comfortable about using. But my concern is, as a ministry you can't make intelligent decisions about allocation of resources if you do not have that information. You could do it as part of a service contract and have it reported on an annual basis. You could do it on a quarterly basis. But you really do need to have -- and this probably requires some technology upgrades -- a system whereby that can be much better managed and you have an understanding of what those waiting lists are. I'm not suggesting you should be telling the agencies how to manage their lists. We need to know how big those lists are to make appropriate determinations about funding.
My second question is, based on the fact that it's not a requirement, what is the ministry's best understanding now of what the waiting lists are? I'm interested both for residential placement and for non-residential placement or placement in the community. Do you have a sense of that from the regional offices?
I will say generally, though, that we're aware of the wait-list estimates that Susan Hess has been explaining and articulating quite well and effectively to parents and others across the province, and that number reaches 12,000. We know that Children's Mental Health Ontario has a number that's in the range of, I believe, 8,000. What we don't know, and this is not to diminish at all the advice that we need to get our hands on it and a handle on it -- what we'll need to do as we embark on this is to find a way to discern, among what's reported to us by agencies, who are children truly waiting for service at that agency who may already, at any point in time, be receiving supports or services from another agency. Given the complexity of the system and the many players who are funded to provide services, it's often true that parents may be waiting at one agency and receiving services from another. That is not at all to say that the waiting list is non-existent or much smaller than what people are purporting to say. We take the size of the potential waiting list quite seriously and need to endeavour to get a better handle on it.
Permit me to ask staff if we've got at our fingertips here the detailed answers to the questions you have asked and, if not, we will certainly endeavour to provide those. Staff indicate that we don't have wait-list information at all, either for day programs in our community services or, as well, for residential services.
Mr Rzadki: The ministry doesn't collect it. We would be able to compile it through a process, no doubt, of surveying agencies, but we do not do that on a regular basis and therefore don't have the information.
Ms Martel: OK. Peter, do you mind if I just ask the auditor's staff something? On page 58, when you talk about waiting lists, bullet point number two says, "In one region that we visited, 224 children who had been approved as requiring residential-based care were on a waiting list" averaging eight months. The next bullet point below talks about another region that "had a consolidated waiting list for non-residential services." Where did you get that information from, then?
Mr Jim McCarter: It could be that when we went out to visit the regions, some of the regions had some waiting list information, but all the regions weren't collecting it consistently and it wasn't being consolidated at the head office level.
Ms Martel: Can I ask the ministry -- it sounds like some regions have something. I would appreciate it, when you go back from here, if you could go through the regions and see how many of those you can provide us with. I'm looking for both residential and non-residential waiting lists. If you can do that, that would be really helpful.
The other suggestion I have is, since one region appeared to have a consolidated waiting list -- that might be another approach when you make it a requirement to provide information, which I hope you do -- you also suggest to the transfer payment agencies that they try and develop consolidated waiting lists so that you don't run into the problem of parents or children being on three or four different lists for services. I don't know which region that is, and maybe it's a smaller region so it's easier, but it might be a model that you could look at.
Ms Martel: Thanks for that clarification. I think what it did point out, though, which was interesting, is that they had 138 children waiting but only 28 being served. So I had some real questions about who those agencies were, if that was the small number being served.
Mr Rzadki: I'll just ask Dan Lafranier to add some perspective on where in the children's mental health system waiting list information may be collected. In part, this has to do with capacity, the framework we've created under making services work for people, where we've asked communities to create a single window for access to residential care and an access mechanism and a case resolution mechanism for more complex cases. It is likely that in that part of the system a keener eye on the waiting list issues might be kept. Dan, perhaps you could provide some insight there.
Mr Lafranier: Yes; two things I think I'll share. One is that the ministry expects agencies to measure demand for service year over year in terms of how it aligns its funds for service. So there's an expectation around waiting lists that the agency understands the demand for service within the territory. The ministry doesn't collect that information because this is agency information they need to use to allocate their resources. The ministry does not allocate funds according to waiting lists. We have a funding base with agencies within the resources we have available. We contract year over year with those agencies, defining what the service priorities are, what services they have available given the population they serve, and we enter into a service contract. So I wanted to clarify that there is an expectation that demand for services, often expressed through waiting lists, is part of that expectation of agencies.
What Peter is talking about on central access -- part of the "making services work for people" policy that was referenced earlier was the underpinning for the creation of a central access mechanism within communities so that individual families had a single place to go to access services for children. It's those mechanisms that may have the list you're talking about around residential and non-residential. Whether it's inclusive of all services depends on the access mechanism. Whether it's for children's mental health only depends on the access mechanism. So you need to be careful that when you get a waiting list number, you have to look within the number: What are we talking about? What are we waiting for? How large is it? Although a waiting list can be an expression of demand, we need to understand demand for what, what type of services and how large. So it's not as simple as a number, although sometimes -- numbers certainly indicate demand, but we have to look inside of that. That's why we ask agencies, which understand their business, their territory, their geography, let's hope, what kind of demand they are experiencing.
Ms Martel: I understand that, and I'm not saying agencies shouldn't do that work. I'm getting back to a point I think the auditor identified. You are essentially funding agencies based on what they got last year and perhaps an inflationary increase. My argument to you would be that that may have nothing to do with the reality of the number of clients, the number of children you're trying to cope with. The only way you're going to start to reallocate resources in a legitimate fashion, in a reasonable fashion, is if you can actually receive the information from the transfer payment agencies about who their clients are and what their needs are, both residential and non-residential. I'm not for one moment arguing that the ministry should be running the waiting list; I'm saying, until you start getting that information, you're not going to be able to respond to a concern that I think we all have about how money is being allocated or making decisions about whether you allocate money based on waiting lists versus special projects.
This is the second area I just wanted to touch on. The auditor made it clear in terms of the waiting lists that we couldn't really see how the ministry could respond to significant problems on a timely basis. The ministry's response, on page 59, was that you had implemented standardized intake and assessment tools to try and improve services. That would improve prioritizing services. Then you go on to say, "The children's mental health sector is currently experiencing capacity issues." I understand that, but the point the auditor makes is that the ministry, although increasing funding since 1999, has been putting money into special projects and not dealing with the capacity issue, and if the ministry started to do that, you might start to make an impact on the waiting lists.
My question is, over and above whether you are going to start getting information in, are you then going to make some decisions that you have to get at that capacity issue, at the recruitment and the retention of staff in those programs to make sure that the TPAs are able to provide a high-quality service? It seems what has happened since 1999 -- and there has been a very significant increase in funding -- hasn't done anything to deal with many of the kids who are sitting and waiting for service.
Mr Rzadki: You are right, and the auditor is correct, that investments in recent years have been very focused. We spoke a little earlier about the benefits of the investments in mobile crisis response, tele-psychiatry, intensive child services and zero-to-6 investments. We believe those are all bearing out. As the auditor indicated, we had set in a clear way some of the outcomes we were expecting from those investments. So indeed for those four initiatives or projects, they were, as you indicate, very focused.
The other large area of increase in government investments in the children's mental health field has been in the area of autism. To the point of whether those investments have had a broad positive impact on agencies, the answer would be that they have worked to benefit those who are serving children with autism in a very focused and specific way.
There is no question that the approach to begin to take a look at the capacity of agencies with respect to their salary and wage pressures has to begin with a very serious look at the outcomes we want out of investments in children's mental health services and to look at research, as we've indicated, to help guide us in what practices and approaches work best for children.
From that base of research and improved understanding -- much more improved than where we are today -- we need to take a look at the demands out there through a good, thorough look at the waiting lists and the capacity of the system to provide existing or new approaches. Then we need to look at how we've aligned our resources geographically to serve growing populations in some areas and diminishing populations in others and, as Dan indicated, examine where the demand for more intensive critical services is and how we need to reallocate across our existing agencies to better serve children and to work with them around service frameworks and policy frameworks that get at issues raised by Ms Sandals earlier as to artificial or arbitrary geographic barriers that limit access to services at the very local level.
I think the first step is a broader approach at realignment. I think also, though, the agencies continue to make very compelling cases about their wage and service pressures and, we know, struggle each day with decisions about their programming: which programs they can afford to keep funded and operating in the community, and which ones, because of encroaching salary pressures, they cannot. These are issues we manage day to day through our regional offices, through the contracting we have, to ensure at least, at this point in time, that services are as stable as they can be in meeting the needs of their population.
The Chair: Ms Martel, you've had about 20 minutes at this point. I understand you probably want to go into some more questioning, but I'm going to give some other members a chance now, and I'll come back to you.
Mr Ernie Hardeman (Oxford): The auditor's report deals a lot with accountability and equity in service and making sure we're getting value for money, as the ministry is putting it in. I have a couple of questions on it.
First of all, all the money is funnelled through funding partners; other agencies provide the service, and the ministry just funds them. I want to know how we go about making sure we have an equitable distribution of those agencies throughout the province. It would seem to me that we fund agencies when they apply and put something together in our communities to provide services for our young people. But if no one in the community initiates it, that community doesn't have that service. How do we make sure we have the provision of services equitably distributed, not dollar-wise but service-wise, throughout the province?
Mr Rzadki: Thank you for the question. In part, my answer is the response provided to Ms Martel. We need to take a step back from the way we've historically funded children's mental health, which very much has been historical allotments or allocations to existing agencies, without a significant opportunity in the recent past to invest new dollars or aggressively reallocate as populations shift and change and as the needs of children become more apparent to us. So taking a more equitable approach is certainly one of the objectives we need to have in mind.
Part of the benefit we see ahead, in the near term of the approach we're taking in creating a children's ministry, is the opportunity to potentially bring into our sphere of influence funding for mental health services that exists and is provided through the school system, but perhaps more importantly through the health care system in terms of hospital funding.
It's true that equity at a very local level can sometimes be created when different types of agencies funded by different ministries work much more collaboratively to take a look at the children before them and serve them in a much more well-planned, coordinated fashion. It would hold true, then, that local inequity can sometimes come from the fact that hospitals may not be planning their services and programs, whether inside or outside the hospital setting, in collaboration with local agencies that the social services side of government might fund. And there may not be the connection with the school system, where it's often the case that a child's mental illness becomes an issue of an urgent nature. There may not be well-coordinated partnerships with the education system. So the feeling of inequity and the feeling that the resources we have in the community aren't working well for parents can very much come as a result of a lack of co-operation or coordination, despite the fact there may be resources there that can assist the child.
Mr Hardeman: I just want to talk a little further on the issue of accountability and whom we're accountable for. Obviously the auditor's report deals with the accountability of the providers to the ministry to make sure we have value for money and that it's going to serve the purpose the ministry's directives suggest it should go to.
In my community, the concern is from the other side, from the consumers. Are we accountable to the people we're going to provide the service for? Are we helping the families who have children with mental health needs to be able to access those services and know where to go to get them? That's how we're accountable to the end user.
In my community, it was brought to my attention that this wasn't the case. Parents couldn't find services, and where they could find them, they weren't available. The list was so long that the child would graduate from high school long before he got the mental health services he needed. They said it was because our area was not fairly funded, based on our neighbouring communities or the rest of the province. Others in our area were getting more than we were.
We spent months trying to figure out whether that was true. If I can't figure it out with the staff we have and so forth, how can I expect the poor lady who is looking for services for her child to find those services? As you mentioned in your earlier response, it turned out, when we got through, when we put all these sources together, there seemed to be some relationship between the funding for children's mental health in my community and in our neighbouring communities, but when you actually looked at the services as they're outlined in children's mental health, there was absolutely no fairness in it whatsoever.
The question really is, with the new mandate and a new ministry -- we're going to take all children's services into that ministry -- can I tell my community this is going to help the availability of services, the accessibility of services and the understanding of where the services are to be found? Is there going to be a one-window approach that when we need services, everyone is made aware of it, and that when mental health services are being provided at the hospital, the people who need the services will know they can go to the hospital and get them, rather than the only ones who go there are the ones who happen to be there for other reasons? Are we going to get more accountability than we presently have?
Mr Rzadki: I think very much so. An important part of communicating to parents what improvements may lie ahead, really, centres on parents and service providers knowing what to expect will exist in their community. The work we want to do in the near term around establishing which core services need to be available locally or regionally -- or in terms of specialized services, provincially -- we think is very important work. It is important for parents to know what set of services to meet what set of particular needs would exist locally, and to have their expectations and understanding quite clear that wherever they go at a local level there will be a certain base of services provided. It's also important for them to know what would be provided regionally and by whom -- services of a more complex or specialized nature, and lastly, which services we can afford as a province to provide to children with mental illness but on a province-wide basis, where we know we have the capacity, we know we perhaps can't locate it in every town and city, but which we need to be committed to ensuring exist, and exist in a way that can be accessed more broadly by children.
We've never taken this approach to ordering the services in the community and in the regions and the province this way. We think it will contribute immensely to what is understood locally by parents and by service providers should be available and, more importantly, who among hospitals, community service providers, the education system and others will be providing those local core services.
Mr Hardeman: Lastly, again I want to go to the waiting list that Ms Martel was talking about. In my community, Oxford Child and Youth can only provide so many services. There is need for another one or two organizations just like that to meet the waiting list and the demands of our population. But since they don't exist, does the ministry ever look at actually funding the existing ones more, based on their need? And if that was a possibility, how can you make that judgment without the ministry having some idea of what the waiting lists are?
When my community tells me we have twice as many clients as we can service, if another agency came forward and said, "We would like to provide that service," we would provide funding for that, because that's how we set up our front-line services. But that agency can't get more money, regardless of how many children they have waiting. How do you justify not looking at the waiting list and not collecting the waiting list, and still provide good service?
Mr Rzadki: Well, we haven't provided a justification yet for not having a better grasp of the waiting list, and indeed we've committed here to endeavour to do that. It's the only way. It's one of the starting points or pieces of the puzzle that were referred to earlier that we need to have in our hands before we can, first, understand whether or not existing resources and funding and services are working best for children, let alone what new investments, if those opportunities come, need to be put where to ensure the maximum positive new benefit for serving children with mental illness. So I would agree it's certainly a key starting point for us.
The Chair: Just before Dr Qaadri comes up, perhaps the committee would allow me to ask something about these waiting lists. I'm always very wary about waiting lists that are produced by various different groups.
I know in the long-term-care area in the city of Ottawa, for instance, at one time we had waiting lists of 1,200 or 1,300 people. Actually, when people were phoned to bring their parent, or the person was phoned, only one third would take it up, so that you essentially had to divide your waiting list by three in order to get what the real shortage was in long-term-care beds in the city of Ottawa. Consequently, the Ministry of Health goes out and provides for more long-term-care beds, and now we have an overcapacity, in essence, in terms of long-term-care beds.
So my question is this: In terms of waiting lists, are you doing any work to establish how you would structure what is a valid name on a waiting list? I think in terms of long-term-care, children of elderly people would put their mom or their dad on the list in order to protect them in the future. Even though they thought they weren't ready for a long-term-care bed, they would say, "I know there's a waiting list. Therefore, I'll put mom and dad on the list just in case they need it in two years," and when two years comes up, they are still able to stay in their own home. Therefore, the waiting list is not a real measure of what the need is.
I guess in terms of waiting lists, I'm very skeptical of them because they are driven by a whole number of purposes, sometimes by the providers of the services rather than the clients of the services, and those kinds of things. Therefore, a waiting list in Oxford, or the waiting list in Lanark or in Ottawa or anywhere else, has to be consistent in terms of where you go from one part of the province to another. Have you thought about how you would go about creating the tool so that you could measure equitably what the services were vis-à-vis Oxford against any other part of the province?
Mr Rzadki: We are in the process of thinking through how we're going to tackle this issue. I think it's been -- and, Heather, you might want to help out here -- since the 1980s that the methodology was developed and rolled out to provide for the government and others a sense of the disconnect between the capacity and the demand for these services in communities. So we need to take a look at those methodologies and others that will ensure that when we ask, we are, as Dan indicated, not double or triple counting, and that when we ask, it's understood in one region what we're asking for as consistently as it is understood in another region.
I think this kind of survey is important. In terms of all the work that we're doing in the new Ministry of Children's Services, the inquiries that we make, we need to make in a very deliberately scientific, accurate way so that the base of information that we use to embark on new change is sound.
As the auditor has pointed out, even we have less than full confidence in our information systems at this point in terms of accuracy, and we need to spend sometimes additional time validating our own inputting. I think in addition to that, other obstacles stand in the way of our taking a really clear, good, accurate, deliberate, scientific approach to these big questions. But indeed, as I said, these are the ingredients that we need to have in place before we can embark on any discussion of realignment of services, of the creation of more integration, or indeed, if future opportunities come, of how we might invest further funds in this system as well as other parts of the children's services system.
Mr Qaadri: My question is really about the assessment of children with potential mental health problems. In civilian life, as a physician dealing with both adults and children, it's a somewhat nebulous area sometimes to get a handle on. For example, we're dealing with individuals who have difficulty, say, with their sleep cycle, their ability to focus, their readiness to learn, or unlearn, as the case may be. Malnutrition, unfortunately, continues to remain a problem, particularly in some of our younger Ontarians, and of course the official saying is that when you're hungry, you can't learn. There are problems with violence and acting out and abuse of various forms, and suicide.
My question is about these various schools and mental health assessment tools: the scales, intake forms, assessment modules and so on. How are they developed, how do they help to determine need, and what exactly is the implementation process? For example, do you have to be trained for a week before you can actually assess a child? And how has the monitoring been regarding the impact on allocation of resources, triage, and standardization across the province?
Mr Rzadki: Thank you for the question and its many elements. I'm going to ask Heather Martin to provide some further detail in terms of the development of the BCFPI and the child and family assessment tool. But at this point I'd just like to say that these were significant endeavours by the government to bring some clarity to the world of assessment and intake to address some of the issues we're still hearing about today through members of this committee and elsewhere. It's important for parents to have confidence that when they go through the process of an assessment with their child, as much as possible it's a one-time thing, and that as they travel from an agency to a psychiatrist or to a hospital, that kind of assessment has a base, a determination, of what challenges the child faces and what potential services can be brought to improve the child's development. That's a sound assessment and trusted by all who will be asked to deliberate on a plan of care for the child. It hasn't been the case, up until recently, we believe, that parents have experienced a system of service providers who all agree on what the best determination of a child's need is and, therefore, what the best plan of care should be.
We think work in the children's mental health field has brought some benefits. We think, more broadly, as children travel -- particularly children with special and complex needs -- to seek out services or have services provided by a varied number of disciplines, that the more we can minimize the differences of opinion about how to assess and what the needs are, by bringing the community of providers together and using research, the better off this service system will look and perform for children and their parents.
As long as we have, though, at the very local level, differences of opinion, approaches around what a child needs and that those approaches or opinions are based on differing views or debates about assessment tools, we're going to be supporting a system that creates confusion and expends time -- unnecessarily perhaps, but certainly time that stands in the way of identification of a child's need and when care and service can get to them.
Ms Heather Martin: To answer the question about how it was developed, it was developed with a group of stakeholders and with a consultant who considered a variety of tools in the previous government and came up with the model of tools that they thought would be best for children's mental health. That was the brief child and family phone interview, which is a half-hour interview conducted with the assistance of a computer whereby a family and a child's needs and strengths are assessed. It's a method that is used to triage, to determine what the appropriate service would be and, also, to assess priority of need. From there, if the child is not in need of children's mental health services, the tool is quite adept at picking that out as well, and the family can be referred to another service.
The child and adolescent functional assessment scale is used to really measure the effectiveness of the interventions and see how the child progresses. The intent always was that this material would be available on a stand-alone information system to prevent families from having to tell their stories over and over again. So if they are shopping around for service, one service provider in, say, Woodstock and another service provider in, say, London could talk so that the child and family wouldn't have to tell the story all over again. The intent also was to provide an information system that would enable us to track child outcomes as a result of services provided, but without the technological supports, that hasn't occurred.
There was actually training provided to each of the children's mental health staff that are funded under community and social services and under health and long-term care so that they could learn to use the tools effectively. The contract managers for both of those tools -- one being McMaster for the brief child and family phone interview, and the Hospital for Sick Children for the child and family assessment scale -- actually provide ongoing training to agencies as required, to make sure that, as there is staff turnover, staff have the appropriate knowledge in order to implement those tools.
Mrs Sandals: It occurred to me, as Mr Hardeman was talking and asking the question about, "What if no agency in the community applies; can the service exist?" -- maybe we even need to back up a step and talk about the capacity of the community to assess, because certainly assessment is going to drive demand, in the sense that if the child hasn't been assessed, they're not going to be on anybody's waiting list.
Have we looked at, then, the capacity to assess within various communities, in terms of looking at equitable services? That would be the first question. Going beyond that, the deputy talked about a maze of services. We've talked about overlapping waiting lists, and trying to sort that out. In many cases, it will be a case management team that will be helping people to sort out (a) where to find the assessments and (b) where to find the services. But in a lot of cases, the case manager has a backup too, so that there's a waiting list even for case management services.
When we went right back to the beginning of the deputy's presentation, she spoke about seamless service delivery. So (a) if you could talk about capacity of communities to assess and (b) this whole case management, integrated service delivery -- where are you going in terms of future planning with that?
Mr Rzadki: Thank you for the question. I'm going to ask probably Dan and Heather also to contribute to this question, with respect to whether or not we've deliberately gone out to measure the assessment capacity of our communities.
I know the assessment function is one that we contract with our agencies to provide, largely against what they have contracted with us to provide in the past. We have not undertaken deliberately, though, to look at whether or not the assessment capacity in each of our agencies, regions or province meets the demand for assessment. You're right: If children aren't being assessed, then they aren't showing up yet at all on anybody's list for service. So assessment, and the role and the function of that and who provides it in the community, is certainly part of the equation of core services that we need to be looking at and need to be determining how these are distributed and delivered locally, regionally and provincially.
Mr Lafranier: There are a couple of parts to the question, and I'm going to back up a wee bit. The point was made around what happens if communities don't step forward. I think, if you take a look at the development of our relationship with transfer payment agencies across the province, the foundation of our transfer payment system is around the community's ability to respond to community need. That has always been there. The ministry has never been in a position of having to say, "The community is not responding. We need to do something here." It's usually the other way around. They've been very responsive. I think our support there is in developing them, supporting them, giving them the kind of direction and information they need to form an organization to deliver a service. So I wanted to give you some feedback on that part of the question that came earlier.
In terms of communities' ability to assess, I think it's an interesting question. You're quite right: In smaller communities they really do have a lack of resources of being able to really fundamentally deal with the assessment question. The answer's a bit complex, but it rests within the ministry's overall responsibility in managing a system of services across a territory. The regional office contracts with a number of service delivery agencies. Our expectation is that there is a relationship across those agencies, so that in smaller communities and remote locations, or where there's a limited capacity and the ministry recognizes that, we're able to bring to the table expertise from other parts of the geography to supplement the assessment capacity: training, best practices, perhaps providing the services at outreach, so that each community doesn't need to develop its own; it can look to a partnership with larger communities to support it. That's part of the response.
The other part of it is in training, support, service development and those types of things, which is more medium- and longer term. But in the immediate term, we do have relationships across the service system that enable us to at least get a broad view of where the issues and where the needs are. That's what Deputy Lang was referring to earlier when she talked about the maze of services. Part of what she was referring to was the intent of the Ministry of Children's Services to begin to unbundle the maze and begin to make it coordinated and cohesive so that the system functions better.
Ms Martin: I think the other thing I'd take note of in terms of assessment capacity -- one of the things we frequently hear about families is that they're over-assessed, and that there's an assessment tool for a variety of doors they may go to. I think the intent of the brief child and family phone interview was to get away from that, to really speak to parents about what their child was experiencing.
In the context of lack of capacity to assess, that was one of the reasons why the tele-psychiatry initiative was begun. We recognized that across the province of Ontario there was a real lack of child psychiatrists. Originally there were eight to 10 tele-psychiatry sites, and it has grown in the last two to three years to be 26 specific sites in remote and rural communities that are accessing psychiatrists through the Hospital for Sick Children. So it has been highly successful for those parts of the province where they don't have the capacity.
Mr Zimmer: Setting up a new ministry from scratch is a huge project, I suspect. There is a lot in the auditor's report and you've heard a lot today. We've heard a lot from you on the difficulty in usefully gathering relevant information and then using it to manage all the issues you have to. Information technology is a huge administrative nightmare that large organizations have to come to grips with. How are you grappling with the IT systems that your new ministry is going to have to put in place so it can manage the information that we're all talking about today that we're not getting or getting in part?
Mr Rzadki: Thank you for the question. First, we're really spending our time coming to terms with the number of information systems that we have working for us in this plan to better understand how the system's operating and what we might do to improve things. Governments in the past have made significant investments in some places in information technology, largely to improve the ability of our agencies to track the services they're providing and track some of the outcomes of the services they're providing. We've moved, in part, away from just collecting input/output data and are moving a little bit more toward tracking service outcomes, which is a positive step that has been taken recently by recent governments.
We do need to map much better -- this will be the first step we take -- which IT assets we have that are generating what kind of information for us and to determine from that map what might be the two types of investments we might consider making.
The first type would be incremental improvements around existing systems so we can get more from them for small investments and so we can move toward having the kind of information we need much more readily.
The second type of investment would be of a more strategic nature. It would really involve us looking at which parts of the children's services system aren't well supported by information technology and gauging where new investments in those parts of the children's system might give us the best return for our money.
One of the most difficult issues that we expect to have clearly portrayed for us as we develop this map is the lack of inter-operability between what our agencies are using to track their service and financial information, what we're using, and what service providers are using in other parts of the children's services system; for example, hospitals, children's treatment centres, school boards.
It's a frightening prospect to think of the last several decades of investment in IT and that these investments have created a system that quite likely doesn't talk to itself well. Despite the fact that there are always issues of privacy and of sharing of information, which has to be done with great care and caution, there is a need for the many disciplines that circle around the child to provide services to share information in many ways in an electronic format. That's a grand vision and it's one that's been articulated by previous governments around a smart system for health. The principles that underlie that initiative would very much underlie where we'd like to go someday in providing and supporting services to children. But we've got a long way to go before we get there, and I think our initial steps to map it will point to some early, immediate investments that we would propose to the government that would be worthwhile investments and would certainly help not just governments make decisions, but service providers provide services in a much more timely and effective way.
Mr Rzadki: We have spent some time in recent years developing an IT system that we call ISCIS, which stands for the integrated services for children information system. It is a system that we have rolled out through the public health units that are delivering the Healthy Babies, Healthy Children program. It's a program that has developed somewhat in programs for children that we refer to as infant hearing programs and preschool speech and language programs. We have an early version of ISCIS supporting our providers of services for children with autism, and we really do need to take stock of whether that investment is providing us with the kind of information we need. We think there could be certainly some improvement, some further investments that we could make to join the providers of service who are now based on an ISCIS platform to provide some opportunity for information to be shared within privacy rules and regulations, but to be shared at a broad level so that wait-lists can be understood and well managed locally.
It's often true that a child and family who have been assessed and supported through the early intervention program of Healthy Babies, Healthy Children, where there is an identified need, would be referred to an infant hearing program or a preschool speech and language program. The ability for the public health unit and those service providers to be working off the same information technology platform would, we think, be one of the areas where we might want to make some early investments. It would certainly facilitate case planning and coordination, if not expedite the provision of services to those children.
Mr Rzadki: At this time, we are in the process of examining the current programs and services for children with autism. I think investment in IT at this time would be down a few notches in terms of what might be the next steps the government takes to improve those services or complement or supplement them. We have what we believe to be a pretty good investment in IT. What we need to do is, I think, a lot more definitional work and training of regional program providers so that they understand what the data elements are that we want to collect, and to provide them with the opportunity and the resources to actually collect them and input them into the system.
I'll add that the intent early on in investment in IT for these programs was really to be able to track very accurately and in a timely way how services were being provided, how quickly they were being provided to the emerging number of children with autism who need to be served. We would say at this point that, as in the creation and start-up of any new program, there are difficulties in applying all the training and staff time to all of the functions that we expect of our agencies, including the one to provide timely and accurate data on the services they were providing. So we believe agencies chose to focus on staffing up and providing therapy and other supports to children over spending the time on inputting data. I think, in retrospect, that might have been a choice they had to make. We wish that we would have had some effort on the IT side too, so we could have a more regular sense of how those programs are growing and expanding and serving children.
So we'll need to, through the efforts of our colleagues in our regional offices and through much fuller planning, really take a look at what is needed in the agencies providing these services in terms of training and what can be done to help them input data and provide us with information in a way that takes the least amount of resources, particularly staffing time.
The Chair: I have on my list Ms Martel, Ms Broten, Mrs Munro, Dr Qaadri and Mr Arnott. We were aiming at 3 o'clock. We may be a few minutes after that, if necessary, but I just wanted to let everybody know that that's sort of the timeframe we're trying to work within. Of course, after the delegation has left, we will have a closed session to try to instruct our researcher as to our general tendencies at this point in time.
Ms Martel: My question's about autism and I want to start with the information system because the auditor in his remarks says that the system only provides consolidated province-wide information and as a result the ministry cannot relate specific data such as lengthy waiting lists and long waiting times to specific agencies. Is that a function, then, of the agencies not taking the time to input it, or the software doesn't allow them to input that on a regional basis?
Ms Martin: The software actually allows them to input the information on a regional basis but the information is available at an aggregate provincial level only. So they don't have the capacity locally.
Ms Martel: So are you going to make some changes to that? This is just further to the need to -- especially with autism, because this is growing, not declining. If you're going to make some serious assessment of regions' waiting lists, you're going to need to have that information in a different format. What is the cost to do that? Does the ministry have a sense of that and is that where you're heading?
Ms Martin: I don't think we have a sense of the cost of it. We do think that it is important. In fact, we did engage a consultant over the summer who prepared a report on ISCIS and indicated that in fact the regional programs were putting the information into the system for the most part. The concern is that in addition to inputting information into ISCIS, which does pose some confidentiality and ethical concerns for psychologists, as an example, who, according to their code of ethics, cannot allow others to see the actual assessment tool scores -- but that being aside, the information is being put in. Agencies have existing systems that they are already putting the information in, but it goes to the comment of Mr Rzadki earlier that these systems don't talk to one another, so there's no capacity to upload or download.
In addition to that, the other issue related to those information systems is that the regional offices, which are responsible for monitoring and accountability, don't have access to ISCIS at all. So the intent was always that that information would be rolled up corporately. From the vantage point of the policy branch not actually monitoring what's going on in the community -- that's a regional office function -- that's also something we need to consider.
Ms Martel: Is that why the auditor pointed out that ministry staff stated they were uncertain about the accuracy and completeness of the information in the system? Is it because they can't actually access it themselves?
Ms Martin: That may have been part of it. I think part of it is based on conversations that we also had with the auditor around the accuracy of the information. There have been huge training issues related to ISCIS with the regional autism programs. In fairness to them, as Mr Rzadki noted earlier, their primary concern was service. While the definitions are clear, I would say it's not been their forte that they are techno-wizards. That's been the issue.
Ms Martel: For what it's worth, it's actually one of your technology systems that is gathering relevant information, and while I understand it might not be a priority because there are other demands on the government with respect to IBI, if it's not a huge expenditure to fix so it works better, it would be my suggestion that you do that. These are important databases, and I think the information you're gathering is going to become even more important, given the incidence of autism as that continues to grow.
Ms Martel: The former government made an announcement on November 18, 2002, about investments in autism. There was a significant investment that was announced but that won't actually fully flow until 2006-07. That was to double IBI -- at the time, it was about $39 million. I see there has been some increase over last year to move toward that commitment.
Two other announcements that were made by the government at the time: $3 million to help support families and their children with autism as the children enter school or other community services. This was transition funding or money to hire transition coordinators. Has any of that money been spent?
Mr Rzadki: I'll ask Heather to help out here too. Yes, some of that money has been flowed to our regions, who in turn have flowed it to service providers, who have hired transition coordinators to very much assist children and parents in the transition from the services they are receiving from regional programs and other services they might be receiving in the community to the school setting in a way that ensures there's awareness at the school level of the child's needs and that any ongoing services, beyond those of a specific therapy that might be provided by the community, continue to be provided in a way that is supportive of the child's education.
The other announcement was $16 million for an out-of-class program for elementary school age children with autism. If I'm correct, that probably was the announcement around the Bridges program, which hasn't gone forward.
Let me ask you about waiting lists for autism. In the auditor's report -- the most recent statistics were December 2002 -- 1,105 children were on the province-wide waiting list. Do you have a more recent figure with respect to how many kids are now waiting for IBI?
Ms Martel: December 2002, page 58 of the auditor's report: The figure was 1,105 children on the provincial waiting list, compared to 453 children who were receiving service. I'd actually like both figures, if you have them.
Ms Martin: What I can do is tell you that between September 2000 and September 30, 2003, 1,910 children were assessed, and 53 children were in the assessment process; 1,430 of these children were assessed as eligible, and 452 were assessed as ineligible; 1,326 children have been discharged from the program, including 531 children who graduated from the program at age six. The number of children discharged may also include some children who were removed from the waiting list without receiving IBI services. As of that date, there were 952 children waiting for eligibility assessments.
Ms Martel: Can you get us a more specific breakdown? It may be a very small group of kids who were ineligible, or it may be quite a large one. You don't know that, and that would make a difference in terms of how many actually were eligible for service and never got it because they turned six before that happened.
Ms Martel: So the bulk of the kids just never got service in time, essentially, before they reached age six. You know where I stand on that issue, so I'm not going to make a political rant about that.
Let me raise something that I found was rather extraordinary, and I'd like to know what the ministry did about this. If you look on page 63, the auditor pointed out that at one regional office there were four agencies that were to provide IBI and received $1.9 million for that very purpose: "They spent all of this funding without providing the contracted-for services. The ministry did not have the necessary detailed information to explain what services had been provided with this funding."
Ms Martin: The money actually went for training staff who were going to provide the service through the regional program. The service was confirmed to begin in the fall of 2000. In fact the regional programs had not hired the requisite number of staff and/or trained them to deliver the service. So the ministry provided direction to those agencies to spend that money to get the staff trained, because they have to go through two weeks of extensive training in how to deliver IBI. Staff had to be trained in that before they could actually provide the service, and that's what that money was used for.
Ms Martel: I'd appreciate that, and I'll tell you why. Conservatively -- sorry for using that word -- at a minimum, $1.9 million would have provided probably 40 kids with IBI for 30 hours a week for a full year. I'm using $50,000; that's probably a rounded-off figure in terms of how much it costs for children who have severe autism to get 30 hours a week. That's a fair number of kids -- it's a lot of money, but it's very expensive for this treatment -- who didn't receive the service.
My next question would be, if it went to training -- and I'd like to know the number of people who got trained with that money -- why was money not then provided to actually supplement that to provide the actual service to the clients and the families?
Ms Martin: The reality is that service couldn't be provided until the children had been assessed. If there were not the staff to do the assessment and develop the plan of service, we couldn't give them the money.
Ms Martel: I understand that. But there was an initial allocation of $1.9 million that was supposed to be for kids to get service, right? So the $1.9 million went to train people. What happens to the decision about putting $1.9 million back in, so you can start to deal with more kids who are on the waiting list? You've got the kids waiting there; there's no doubt you've got kids who could be served.
Ms Martin: As you know, there is a capacity problem with this program. That means that even though there are more children on the waiting list than are being served, before those children can actually be given money to go and purchase the service directly, they still all have to go through the same assessment process at the regional program. The assessments take a considerable length of time, and there's just no way children can be moved through quicker at this point in time.
Ms Martel: Let me just go back to your assessments. I'm sure you gave this to me in the figures you released, but tell me again: How many kids do you have waiting to be assessed right now to determine if they're eligible?
Let me ask you some questions about direct service. I raise this in the context of some cases we've had raised with us where families said, "We were guaranteed a certain number of hours of service by the provider," and I won't name the provider. I have one mom who contacted me yesterday to say that in her estimation right now, because the child started IBI in 2000 and is due to finish at the end of February, they have lost over 800 hours that should have been provided through direct service from this particular agency.
This is not the first time I've heard this complaint or concern. What is the ministry doing to investigate what is happening in this regard? Parents sign a contract, they are told they are going to get so many hours, I am assuming the agency is paid for the number of hours listed in the contract, yet the child doesn't get it. Where is the money going if it's not being provided in terms of direct service to these kids?
Ms Martel: Direct service. This was a direct service contract. This was a provider, and it was the staff from the direct service provider that was providing the IBI. It was not a case where the family received compensation after, because they hired an IBI therapist themselves. It was a direct service contract.
Ms Martin: The ministry and the regional service providers don't have any involvement in those programs unless the child actually goes through an assessment at the regional program. The only way money would be flowing to a family through provincially allocated funds for direct funding is if they actually went through an assessment process at the regional program.
Ms Martel: Yes. And the dilemma appears to be that, for a whole number of reasons I won't list but are in the letter -- services didn't get started on time, there was a conflict with one of the providers who had to be replaced -- at the end of the day, the child didn't receive the number of hours he should have received as per the contract. I still assume the regional provider is getting the money, but the child's not getting the service.
My question is, how is that happening and what can we do to ensure, when the contract is signed, that the child is going to receive the service? This is a child who is going to be cut off the program at the end of February, whose mother believes he is entitled to 800 hours of service that he didn't get over the last four years. Maybe 800 hours is wrong. Even if it's 400 hours, that's a lot of hours of service for a child who still needs IBI.
Ms Martin: Without having the details of the specific circumstance, I don't feel I can comment further. However, one of the things that is clearly explained to families when they are getting service through a regional program is that there is no banking of service hours. So if a child is sick, if a service provider is sick, if an issue arises that a child can't participate for any reason, it's not like they can get the 400 hours they didn't receive at a later time. That's the policy as it currently exists.
The Vice-Chair: I think the Chair did indicate the list of speakers who are still here. In the last two days we have been going on a rotation among members. I would just ask you to draw your comments to a conclusion so we may move on.
Ms Martel: If I might, I would make a really strong suggestion to the ministry as you move forward with this program, because it is an important program; you know that. There are really serious issues around the direct funding model versus the direct service model.
The direct service model is preferable for parents because all of their costs are paid, so obviously there's a preference. If they can get into that stream, they're going to look for that. But then you get the problems I've just outlined to you, where a contract is signed and a child, through no fault of their own -- because it's not a question of the child being sick for many of those hours, but conflicts and problems with the agency -- then doesn't get the hours they are entitled to.
The problem with the direct funding method is that all of those parents end up paying a significant portion of the costs out of their own pockets, because the money you provide to them that they provide to the provider is capped. So many of those parents are paying thousands of dollars out of their own pockets, and that's not a preferred route for them either. As a result, you have any number of people sitting on waiting lists, many of those parents paying out of their own pockets, or alternatively, parents getting the service but then actually not getting the service, not because their child is sick or can't participate but because of problems through the agency.
Those are issues, I think, that you really need to resolve as you move forward. I'm hoping there are going to be additional investments in this program; they certainly are needed. Some of that inequity between the funding and these families seriously has to be dealt with. There's no reason why so many families should pay so many thousands of dollars out of their own pockets when other families are receiving a service and it's fully paid for.
Ms Broten: We've talked a lot today about waiting lists. Waiting lists are important, whatever the accuracy of them, because they indicate to us at some level that children are waiting for services. We've talked about the need for measurable outcomes, because obviously we're not in the business of providing service for no end outcome. We are in the business of making sure that we really, truly help children to an outcome that is beneficial to them.
I guess it's easy to talk about that we know, and the ministry has acknowledged now for many years, that we need to get our waiting lists in check and we need to make those measurable outcomes come in place. I'm wondering if you can articulate for us the beginnings of an action plan of some measurable steps that will be taken to move in that direction. I haven't been in this milieu for long but I have been a community activist for many years. Sometimes breaking things down into concrete, step-by-step analysis of looking at whether it's a particular facility or how we would make sure that we're not all sitting around this table again a number of years from now, saying exactly the same thing -- we know we have to get the waiting lists down. We know we have to have measurable outcomes.
I'm wondering if in that response you could indicate to us whether or not there are some innovative strategies and concepts that we can take from other jurisdictions that may be doing a better job than we are, who participate on this committee, so that we can help make sure that we remedy these things. But for all of us walking out of the room today, I think there is probably still a common concern. We know you want to get there, we're not sure how we're going to get there, and we want to make sure we can assist in what way we can to keep you on track.
Mr Rzadki: Indeed, I think the only way you get to a certain place in time is with a good plan and an ability to measure whether or not you are achieving the smaller, achievable steps toward that long-term goal. I think the deputy had outlined earlier this morning some of the really critical, complex and important early steps we've been taking to tackle this question of outcomes and capacity and making determinations about where new investments need to be made.
The first steps really are to bring under a single roof the programs and services that make sense to be underneath one ministry and to ensure that what remains in other ministries -- that we have important and effective working relationships so that the policies and programs that are developed in those other ministries and what we do are coordinated and in sync. The plans are to have a really good sense of the transfers into our new ministry over the next few months. I can't provide any more detail there but there is, as you can appreciate, some significant work that needs to be done to sort out what resources belong in the existing ministry and which resources come to ours. That's an important first step.
In terms of the more strategic planning and policy work that we need to do, work is broadly already underway, undertaken by a colleague of mine, to begin to look at what other jurisdictions have done to improve services for children prior to school and to enhance and improve services for children as they go through their phases of development and, in particular, journey through the important transitions in life, entry into school and that transition between elementary school and secondary school being two that we are learning quite a bit about. There are other jurisdictions that are alongside us or ahead of us in some respects in supporting children through those important transitions. So interjurisdictional work is certainly a phase that we need to undertake.
A third element, and these all need to occur concurrently, so I know that you appreciate the management of all this is quite complex: There is an important amount of work that the minister wishes to do to engage parents, service providers and experts in helping us chart a course toward a more integrated, more effective and responsive system with respect to wait-lists, as you mentioned. So the minister is holding a series of round tables across the province. She spent some time in a round table setting a few weeks ago in the Ottawa area. She'll be heading, I believe, to Peterborough a little later this week. There's an effort underway to develop a series of other opportunities for her so that she and we can engage in a dialogue about best practice, about outcomes and about what the research is telling us.
Alongside these regional round tables which were meant to engage children, parents, youth and service providers, we are also hoping to engage experts in expert panels. One certain important one to have would be to bring the great wealth of research expertise that we have in this province together around a table and really talk about what we mean when we say we need to do better for children. We need to be able to measure that with a view to certain outcomes. We know other jurisdictions have journeyed this path and have made determinations about what our key outcomes will be. Will it be readiness to learn? Will it be a certain level of cognitive development? Will it be a certain level of social development? How do we actually want to measure the impact of our services, and what are we capable of measuring? These are very significant, very tricky issues that we like to seek out a lot of advice on, and have been advised by other jurisdictions here that have travelled this path -- perhaps not in a fashion as we are about to -- that you need to take the time to engage the people who know about this. So we certainly plan to do that.
In terms of the children's mental health system and how we hope to move along with this broader strategy to look at the broader children's services system, we made some commitments when we had the opportunity to respond to the auditor's report. They are published in his report and are public. Since that report has been released, we have worked with the current government to fine-tune and refine our approach so that it is consistent with this tremendous amount of work that we're doing on the children's services system more broadly. So what we'd like to do is undertake, as we've said, a review of the children's mental health system to verify the nature and scope of the services being delivered currently and to assess the overall effectiveness and efficiency of these services: Are they being delivered now in a way that meets at least our contractual obligations or expectations of agencies to identify areas of improvement, but most importantly, identify where the government needs to consider a new or expanded or clearer policy direction?
So the review will help us get to the work we need to get done and have committed to doing around wait-lists. It will get us to a point of understanding how assessments are being provided, where the gaps in the service system are, how our resources are being used now and what steps we need to take to reallocate not on the basis of traditional or historical funding per se but in a way that best meets the needs of communities.
That review I think is going to be informative. It will help us move to the important work we need to do around core services. We spoke a little bit about that today: What can, and should, parents expect locally in their community to be provided for children with mental illness; what can we support more regionally; and what, in terms of very specialized services, are we up to the task of providing on a provincial level? With that alignment of services and a better understanding of what those are, we can then work to clarify rules and responsibilities better in the community among community service agencies, among hospitals and other agencies we're providing children's mental health services to.
There are many steps I've listed. The most important for this particular system are really the fact-finding under our review and then the work we need to do to align our resources to ensure that we've got local, regional and province-wide core services very clearly defined.
We expect to have this work done within the next year. We would hope to be in a position as the broader strategic planning around children's services -- and I know you can appreciate that that's very complex work and portends some enormous change for the way we deliver services, but most importantly, improvements to services for children. Our expectation is that as this evolves over the coming months and year, we'll be able to work within that broader framework to have within a year a clearer sense of what the core services for the children's mental health system should be in Ontario.
Mrs Munro: I have three quick questions. We talked earlier about the problems of gaps, where in a community there hasn't been an agency that has seen a need and come forward, and inconsistencies that might create in terms of service delivery. You have talked certainly in your fact-finding about the approach that you plan to ensure that there aren't gaps.
As someone who represents part of the fastest-growing area in the province, I believe, obviously this is of concern to me and perhaps from a different perspective. I wondered if you could comment on how you plan to address, in the thinking and in the planning that you've just described, the issues around demographic changes. Clearly, there are communities such as mine -- 40,000 people move annually to York region -- but we also know that there are communities in the province which have either a static population or in fact out-migration. What is your concept at this point in terms of addressing issues such as that?
Mr Rzadki: Our approach in principle would be to strive for allocation of funding to best meet children's needs regardless of where they are. What we have done in the past is structure our funding around our regions and, in turn, they have structured funding allocations to agencies, on a mix of both an historical basis as well as on the basis of changes in demographics and population growth. So we have currently a mix of approaches that we use to fund children's services. Our main objective would be to look at all the ways that we fund all of our children's systems and determine what approaches we can bring to bear on that series of funding formulas and approaches that will more accurately put money into the communities where the need is the greatest. I think that's a principle that any community would expect us to be striving toward.
That means, though, a process of ensuring that we really, truly understand the connection between population growth and need. There is literature, for example, that suggests that need may be defined more on the basis of income level as opposed to population growth. So we need to look at funding approaches that consider a range of variables, including the socio-economic status of the population in communities, including historical needs, including resources that exist or do not exist in other parts of the system in that community -- for example, the health care system and the education system. There is a broad range of variables and we need to do a lot of work to understand what is the best approach. But the principle of getting dollars to where the need is is the one that is right in front of us, clearly, and we do understand from our experience that historical allotments or allocations aren't keeping pace with demographic as well as socio-economic changes in our communities.
Mrs Munro: The second part of my question has to do with following along on that. I'm quite sure you're familiar with the work that has been done in York region, where there has been an historic underfunding and obviously a great sensitivity to the situations which we heard of earlier, that so much of the funding had been done on an historic basis, with agencies receiving monies they've received before and looking at inflation and things like that.
I wonder whether or not you have considered the model that has been provided to you, as a ministry, with regard to a method where you would be looking at much of the same logic that Rozanski used in looking at updating the funding formula in education. Obviously, at the end of the day we all recognize that a child in need is a child in need, regardless of where that child is in the province. I wonder if you had considered a funding formula following along the same kinds of principles as were established in that exercise.
Mr Rzadki: We haven't yet completed or defined fully the project before us to examine the way we fund, but the principle would be that we'd be looking far and wide at approaches that would bring about some of the improvement we've talked about in how we fund. At this time, all I can say is that as we take a serious look at funding models and approaches, we're going to take a wide look at what's available and what has been the recent experience in Ontario in human services funding, as well as recent experiences in other jurisdictions.
Mrs Munro: My third and final question: In those discussions, are you considering -- I understand there is a significant difference in salaries between people who work in children's mental health and people who work in adult mental health. Correct me if I'm wrong, but if not, are you looking at some of those discrepancies as well?
Mr Rzadki: We certainly have benefited from the work that agencies have forwarded to us about their own situations, the work that Children's Mental Health Ontario has done to examine the wage and salary differences across their agencies, to come up with average levels of differences. We know that for some agencies, as we talked about earlier today, their salary pressures are certainly challenges that they are finding very difficult to manage. We know there is quite a variability across agencies in the children's mental health system with respect to salaries and wages.
To the extent that human resource capacity is an issue in some agencies, we know there are high turnover rates. It's very difficult to keep staff, let alone recruit them. We know there is anecdotal evidence that folks who are working with children, either in children's mental health settings or other developmental services settings, child welfare settings, are multi-disciplined in tasks and highly qualified and move often within the system and across systems to find work that is perhaps more rewarding financially.
I think what we need to do as part of our review is to understand much better what these pressures are, to continue to rely on the work that agencies and the association have done to help us understand that better and to articulate much more clearly for ourselves the true human resource demand, which we're finding exceeds the supply of qualified, experienced individuals, very much like the pressures we face in the health care system, which has enjoined a national and provincial effort to study and come to terms with that.
The pressures we are foreseeing and are already experiencing in terms of attracting youth to seek out jobs and vocations in social work, in supporting and providing children's services, are seemingly insurmountable. We need to be looking at ways we can understand what the true demand for qualified, professional human resources is in the provision of children's services and determine what steps government can take, not just at an agency level where there are salary, recruitment and retention pressures, but more systematically what we can do to encourage more Ontarians to seek careers here or indeed to attract others from outside our jurisdiction to come here and bring their expertise so that our children can be served.
Mr Qaadri: My question first of all is about mental health as it intersects with the youth criminal justice system. I understand that the Minister of Children's Services, newly endowed, will actually be inheriting that particular portfolio from the Ministry of Community Safety and Correctional Services. Obviously we need to continue the custodial function, but it seems to me that a lot of the individuals who are, to use your phrase, youth in conflict with the law are actually, in reality, suffering from various mental health disorders. What I'm asking particularly is, in inheriting youth criminal justice, will the Ministry of Children's Services be able to offer them services they may not otherwise have received, with a view to reclamation, rehabilitation and reintegration into society?
Mr Rzadki: Yes, I believe so. I think the advantages and benefits of the integration of youth justice services into our ministry will best be felt at the policy and program planning level. It is true -- and it is something we haven't spoken much about today but could well have -- that the children's mental health system is absolutely integral as a supporting early intervention system for the education system, but also to prevent children from needing the services of our child welfare agencies and certainly to help children before they find themselves in conflict with the law. So, many would say that if only we could have a stronger children's mental health system that intervenes early, ahead of the need for services elsewhere, our children would certainly be better off. I think that, ideally in the long term, earlier interventions around mental illness or social or emotional behavioural challenges that children and youth have are critical investments for a government to make.
In the youth criminal justice area, as we go through the integration of the young offender's capacity for 12- to 15-year-olds and that of 16- and 17-year-olds, and as we embark to follow some of the principles under the Youth Criminal Justice Act which really do ensure that youth in conflict are steered toward community and community supports early on, as a response to their offending or their conflict, I think we need to ensure there are services in the community to support some of the underlying mental health issues those children have. So bringing the program and the policy responsibility under the same roof where children's mental health policy and programming are developed and where child welfare policy and programming are developed is a tremendous first step to ensuring that these systems are planned with the interdependencies in mind.
The Chair: Just before I turn to Mr Arnott, I hope you will be seeking a significant amount of compensation from the federal government for these programs, as they were unilaterally thrust upon the provinces in a lot of ways over the last 20 to 25 years, because the requirements of the justice system are significantly more now, after the new Youth Criminal Justice Act, compared to before. The options of incarceration as a penalty are probably four or five times what the provinces have to provide in services. I would hope we get significant compensation, which was originally promised at 50% but has been far below that kind of compensation way back in 1982.
Mr Arnott: We're now probably 15 or 20 minutes away from concluding this discussion. I want to thank you for your thoughtful answers to the questions today. I think the information you have provided has been very helpful for all of us. I just want to say that at the outset.
I want to return to the issue of waiting lists for children with autism. As was pointed out in the auditor's report, there was a significant waiting list issue for these children, and you indicated, in response to another question this afternoon, that there still is a waiting list issue. Perhaps some progress has been made, but in other areas there are more challenges. We're aware that the former government committed to spending almost $100 million on children with autism by the year 2006-07, including establishing a new program, about $19 million, to assist children over six years old. We're aware that there was a commitment made during the election campaign, or perhaps before, by the now Premier of the province that assistance for children with autism would be expanded to children beyond age six, and we're also aware that in a number of court cases the government is currently taking a different position, arguing against the interests of some of the parents who have brought this issue forward. I'm also told that the Minister of Children's Services has committed to putting in place a plan of some sort on how she will deal with autism issues and she's expected to conclude that in about two months. You mentioned there is an ongoing consultation and planning exercise that will conclude in about a year. Is this the same plan we're talking about or a different one?
Mr Rzadki: Indeed, the minister indicated a few weeks ago that she would ask the ministry to develop some solutions for some of the issues that children with autism are facing, with respect to the capacity of our program and with respect to services for a wider range of children with autism. That is work we are doing and are going to be doing in co-operation with others in government, in the education and health care systems, who have a need to be working with us, and is a process that, as the minister has outlined, will involve some discussions with parents and experts, so that her review of the programs that are in place and have yet to be put in place can be guided by good advice and with the widest possible opportunities and options that are available now. It's work that's happening on a different timeline, and certainly one that's much sooner than a year.
Mr Arnott: Of course, the larger consultation that's going on, which the government has initiated, is the pre-budget discussion; I know there are town hall meetings taking place. The standing committee on finance and economic affairs has its consultation, which is an annual process, and the Minister of Finance is engaging people in other private, public and semi-private consultations. If the minister were able to put all this together by March 21, in theory one would hope that information would be made available to the Minister of Finance and there would be some significant announcement in the budget this year that would go some length to following through on the Premier's commitment.
When we talk about waiting lists and the aggregate nature of the problem across the province and deal in the statistics, we sometimes unfortunately overlook that with each individual statistic there is a family. I was speaking to the grandparents of a child with autism today before I came into this meeting, constituents of mine who live in Wilmot township. Their grandson, who is 10 years old and whose name is Kieran, has autism. For the last almost nine or 10 years, his parents have been paying for private therapy, because they were unable to access the kinds of services they felt they needed. They've spent tens of thousands of dollars over this period of time. They're a family of average means, from what I can understand, so they've sacrificed a great deal to ensure that Kieran has the best possible start in life that he can have.
Speaking to his grandparents, who spend a lot of time with him, obviously they're very concerned about this issue. They were telling me that most recently, when he turned eight years old, one of the behaviours he exhibited was running away from home. Of course any of us who are parents can imagine what it must be like when your child is away and you can't find them. It was an extremely stressful situation when Kieran was visiting his grandparents and this happened when they were looking after him. We can only imagine what this must be like, and I think there's an obligation on the part of the government to make this a priority.
Certainly being in government is a challenging situation to find yourself in, but it gives you the opportunity to make positive change in society. Certainly there are financial constraints that the government faces, and we all know that. At the same time, I think we all recognize that being in government involves making decisions on priorities. I would hope this particular need is given a very high priority in the months and years ahead.
Mr Rzadki: Thank you for the comment. While I can't respond to any particular situation or case -- it would be inappropriate for me to do that -- I think it's a difficult time for government to be examining and undertaking new policy work and program work while there are other issues of a different nature, a legal nature, being determined and examined in other forums, but we are bound and determined to do that. I think the minister is very keen to take a wide look at what might be an improved response from government to families who have children with autism and to those children. As I said, the timeline is tight and soon. We're working hard with the minister and the government to examine the opportunities.
The Chair: I guess we're finished for the day. I'd like to thank you for your presentation and your help to the committee. As I said to the Deputy Attorney General yesterday, there is an opportunity for you to respond to any questions you feel may need to be filled out; you can forward that to our researcher. I ask you to do that within a month or so, before we get down to writing reports and those kinds of things.
Ministry of Children's Services P-37
Ms Sandra Lang, deputy minister
Mr Peter Rzadki, assistant deputy minister, integrated services for children division
Mr Dan Lafranier, regional director, northern region
Ms Heather Martin, director, children with special needs branch