I am a Psychologist who, for the last 14 years, has been working both in the Canadian public health care system as well as the private fee-for-service sector. My roles within these very different systems have given me some perspective to better understand a subject that is important but confusing to many Canadians: What are the limitations of mental health care within Canada’s public, “universal” health care system? In answering this question, the companion question about the benefits of the private sector services will also be addressed.
In Canada, most medical care is typically accessed via the universal, socialized public health care system. Dental care among other services, on the other hand, is accessed in the private, fee-for-service sector. With limited exceptions, these services may all be described as conforming to a single-tier model of service distribution.
Psychological service, however, is quite different to the extent that it is widely available both within the public medical system, as well as outside it in the private sector. Because the same services offered within the public system are also available in the private sector, this effectively establishes a two-tier system.
We Canadians love and hate our universal healthcare, but from my experience, mostly we love it. When encountering difficulties associated with public system limitations, we remind ourselves of our good fortune with tales about problems in other countries, such as the U.S., where the costs of needed medical services can be financially devastating or worse–unaffordable and, consequently, unattainable with dire consequences. In a two-tier system, patients have a choice between publicly provided and privately purchased services.
Because mental health care (and particularly psychological service) is distributed across two-tiers, the emphasis here is to clear up confusion by presenting the main benefits and limitations of the public system in order to illuminate the advantages, in many instances, of private sector alternatives. Prospective consumers of psychological services, it is hoped, may then better appreciate the circumstances under which they would be better served by the private sector.
I began private practice work over a dozen years ago with some uneasiness, knowing, as I did, that there were good psychologists working in the local hospital system where tax dollars, not out-of-pocket fees, “pay the bill.” It seemed unethical, if not dishonest, not to ensure clients knew where and how to obtain similar services “free.” I soon learned that most clients come to me out of deliberate choice to avoid the public system rather than ignorance of its availability.
The public health care system has a single advantage over private sector services: it is free! And were it public system adequate in what it provides, it is certain that psychologists could not earn a dollar in private practice. No one will pay out of pocket if they can obtain the same service at no cost. The reality is, the services available are not really the same. There are important limitations in the public system, and many people are confused and frustrated in their efforts to obtain needed help. They are uncertain where they should turn, and unaware what considerations should inform their choices.
To highlight the differences with an analogy, public mental healthcare can be likened to public transit. The public transit system was designed as a solution for the masses, and when evaluated at that level of service–to the masses–it can be seen to perform very well. By design, however, the public system is very different than personal transportation. It is completely insensitive and unresponsive to the needs and preferences of the individual. The individual must accommodate to what is offered, tolerating the limitations of (among many things) availability, access, convenience, flexibility and quality of service in the hopes that at least their most basic goals will eventually be, more or less, acceptably addressed.
Point of Access
Public outpatient mental health services are accessed by referral from a physician. Private services do not require a referral. While informal referrals or recommendations are commonly offered by other professionals, clients typically seek psychological services directly.
Community psychiatric and public system-based psychological services typically involve waiting lists rarely less than several months in duration and wait times well over a year are common. Wait times for private sector psychologists, in my experience, rarely exceed one week.
Restricted Range of Services
Within the public sector there are many areas where there are gaps in the services provided. Furthermore, for any given issue, there are typically multiple treatment options. If one is not satisfied with the treatment model offered, there is no option but to look to the private sector where a diverse range of options is to be expected.
Many service programs have arbitrary limitations (e.g., 6-session therapy) having nothing to do with actual clinical needs, and everything to do with institutional constraints.
Public system services that are technically available usually have restrictive (often undocumented) selection criteria that are convenient for the program providing the service. I have often heard complaints by physicians about the bewildering refusal of programs to accept patients who met a service program’s explicit selection criteria.
Choice of Care Provider
In a system where services truly are in short supply and very much rationed, patients have limited opportunities to request other providers, should those initially assigned prove unsatisfactory. Requests for a “second opinion,” while not at all unusual in the private sector, are viewed in the public sector as reflecting an attitude of entitlement, and often taken as an insult to the care provider.
All practitioners were once students, and by contrast with other areas of healthcare, in mental health there is simply nothing useful to be learned from plastic models, fetal pigs and cadavers. There is no other way to gain practical experience than trial-by-fire with real patients, and almost all such training happens in public system facilities. One always has the right to refuse care from a student provider, but the practical reality is that so doing frequently means longer wait times for service.
Quality of Care and the Economics of Accountability
While much could be said here, it boils down to the simple reality that employees must satisfy the requirements of those who pay them. In the private sector, where the professional is paid directly by the client, let it suffice to say the incentives for performance are very different than in the public system.
While needing to meet certain (usually fairly high) training standards in order to be hired into public systems, there is little formal incentive to actually be effective, clinically, or even to make an effort. In the private sector, those who are skilled and work hard tend to be rewarded directly by clients who stay with them, and recommend others. In the public system, success is usually defined in terms of conformity with administrative needs, such as timely submission of (invariably arduous) paperwork.
Public Health Records and Confidentiality
Health care professionals are ethically required to maintain records of their professional contact. Those working in public institutions also must also meet their employers’ specific requirements for record keeping. Once treatment is concluded, patient files are usually transferred to a central records department where they are stored for years. While these records are considered “confidential,” they are not “privileged,” and can be legally accessed by other professionals involved in the patient’s care. This is sometimes, but not often, a concern to patients. More cause for concern is seen in cases where patients on long-term disability are coerced to “consent” to their records being disclosed to their insurance provider as a condition of continuing to receive benefits. I know of many clients who were concerned their records might be subpoenaed as part of a legal action (e.g., a contentious divorce, or ongoing insurance litigation). A recent Alberta Appeals Court decision made an important ruling upholding a psychologist’s right not to keep records at the insistence of a patient who was concerned about her records being subpoenaed. It is unlikely that a public system would permit a psychologist in its employ to exercise this option.
Despite the number of drawbacks to the public system, it remains an important resource in certain circumstances. Here are a few guidelines to help inform your decisions.
You should use the public, universal system:
1. If your life is in immediate jeopardy from the irresistible urge to commit suicide, you seek immediate care from your family doctor. If he or she cannot see you the same day, then a walk-in clinic or hospital emergency department should be your next destination.
2. If you suffer from a condition so severe and debilitating that you are unable to attend to basics of self-care needs, this suggest you may require hospitalization and psychiatric attention.
3. If you have other mental health care issues, but due to financial limitations, simply cannot access private sector services, you should seek out what (if any) public system services may be available by referral from your family doctor.
4. If you have other mental health care related issues, but don’t mind limitations of access, timeliness, quality of service, and choice of service and service provider, then you may be satisfied with public services that may be available through referral.
If the above four points do not compel you to use the public system, then you should consider the private sector for the therapy services you seek. Within the private sector, you may expect a broader range service types and options, with choice among practitioners with varying training and experience backgrounds to suit your individual needs and preferences. Private sector services are typically available with minimal delay, from psychologists who, in my experience, are ready to explain their services and methods, and also to recommend other professionals when their offerings are not a good fit to your needs. In my own practice, I typically field several calls a week from individuals needing guidance in determining the type of services that would be most helpful. Frequently these fall outside my practice areas, where I am glad to provide recommendations to colleagues who I believe would be more helpful.