The state of mental health in Quebec is a real scandal. The citizen who is psychologically vulnerable and financially weakened by the pandemic is torn between a pole of public services, to which he has less and less access, and a pole of private services, which he struggles to afford. Two diametrically opposed logics of care (either the all-out free market versus rigid state regulation) lead to the same impasse, or a premature saturation of services.
In fact, vulnerable people are captive to a real carousel. They often arrive in public services after having received private services that they can no longer afford. They are sometimes directed towards the private services themselves, after a rigid framework of encounters in the public services. It is not uncommon for them to have even wandered between a few EAP (employee assistance program) meetings, a few meeting pursuits through their insurance, and a few general service meetings of all types (GMF, college or university, etc.). Some people even return to private services after having received specialized services in a hospital setting, or follow both paths at the same time.
Waiting lists are no longer representative of population reality. Everyone shoots (and shoots each other!) everywhere at once. The lists are doubled, even tripled and perhaps even quadrupled. Some are silent, in private services, for example. Others are systematically revised by busy professionals, in good mandarins.
The access counters are bogged down endemically. These are new “revolving doors” of the network.
The eternal question of the “front line” is at the heart of this scandal. It finds no viable solution in the current political horizon.
Three myths
Three myths surrounding governance lead to the impasse. However, these myths have obtained less than convincing management results since the modernization of psychiatry in the 1960s.
The first myth concerns the arrangement of services according to a hierarchical logic (first, second and third lines). This hierarchy never materialized. Promulgated by the Castonguay-Nepveu reform (in the 1970s), this virtuous ideal is in fact the fruit of structural stubbornness. The carousel that people requesting services come up against proves it. The integration of mental health services is an unfortunate failure. In mental health, we must step back and abandon the Barette reform.
The second myth comes from the all-powerful technocracy. Mental health action plans (1989 policy, PASM [Perspective autonomie en santé mentale] 1998, 2005; AISM [Plan d’action interministériel en santé mentale] 2022; and PQPTM [Programme québécois pour les troubles mentaux]) had very little real impact. While they provide laudable broad guidelines, they do not by themselves initiate any viable structural change.
For the “front line”, the PAISM 2022 is of rare eloquence. It offers no direction. It refers to the PQPTM. However, this one is yet another layer of structures telegraphed on a failing model of care. (Another small health myth in Quebec: the solutions come from elsewhere!) Directly imported from England, the PQPTM describes a care trajectory, but does not correct the cracked infrastructure of the network. Can we then really hope that the map, which does not correspond to its territory, will lead us to the right port?
The third myth claims that the solution will come through funding. Since the beginning of the welfare state (almost 70 years ago already!), we have observed a pendulum movement: the network is financed, then definanced, then refinanced and refinanced, and so on. On the left as on the right, the financial aspect is presented as the ideal solution. Some will say that there are not enough resources, others will answer that there are too many, but that they are not efficient enough. Despite investments and purchases of services in the midst of a pandemic, this solution does not solve any problems.
The heart of the problem is obvious. Health and mental health are prisoners of the political and ideological orientations of the parties in power. The reforms follow each other, contradict each other, but fundamentally resemble each other. No reform has had real population accountability. No reform was decided by itself by the population concerned! Leaving the management of health orientations to political parties, through, among other things, appointments without any accountability on the part of high authorities in terms of governance, has been the fundamental error that has fueled the repeated impasses in health.
Let’s be clear: the patients are again crying out for help. To answer their call, and if we want sustainable collective health care, we will have to be bold and rethink the democratization of health and mental health.