B.C.’s Ministry of Mental Health and Addictions said in an announcement it is working to cut emergency room wait times using a change to the Mental Health Act - a change nurse practitioners say will actually have more of an impact in community settings.
The 2011 amendment to the Mental Health Act gave nurse practitioners the ability to assess patients for involuntary assessment, a right that was previously exclusive to physicians.
Though the change was made to the act over 10 years ago, the ministry said in a statement that training with NP’s and consultation with physicians, health authorities and Indigenous groups was needed before it could be put into action.
The announcement, which was released Feb. 23, stated “more people in a hospital emergency rooms will be able to respond to people presenting mental-health crises.”
Though there are approximately 900 nurse practitioners working in B.C., the ministry said Victoria General Hospital and Royal Jubilee don’t have one on their ER staff and Karen Simms, who works with Nurses and Nurse Practitioners of BC said the impact of the expansion is more likely to happen in community settings rather than emergency rooms.
“Is it going to make a big impact in the emergency department? Not a huge one,” Simms said. “I see it as less being about the emergency department and more about changes in scope that allows NP’s to provide that full support to the patients that we are already seeing in primary care. If I had to think about the benefit to the system, it is that now the scope for NP’s has expanded to allow them to do something that they’re quite capable of doing with the patients that they are following longitudinally throughout their life.”
The announcement states there is “work underway to implement this service” and it is expected to serve patients in the fall of this year.
Patient rights advocates raise concerns
While this expansion may not have an impact on ER wait times, patient rights advocates are using this moment as a renewed opportunity to discuss the fall-backs of the Mental Health Care Act and ask for changes they believe will be more impactful.
Laura Johnston, who works with Health Justice - a Vancouver-based, non-profit which advocates for patient rights - said this change expands power without assessing oversight, accountability or transparency.
According to the ministry, to be involuntarily admitted for treatment due to a mental disorder, a patient must meet four requirements: their mental disorder must seriously impact their ability to react to their environment and others appropriately; psychiatric care in or through a facility is needed; supervision and control is necessary to “prevent the person’s substantial mental or physical deterioration or for the person’s own protection or the protection of others” and the patient is not suitable to be voluntary.
Along with these four basic requirements, physicians and now nurse practitioners, are required to fill out paperwork and inform patients of their rights, but a 2019 Ombudsperson report found compliance with these regulations is lacking.
“The Ombudsperson report did a compliance check and unfortunately found widespread, systemic violation of the human rights of people who were being detained, with people not being informed of their rights and not being told why they were being detained,” Johnston said.
Simms said the change in scope might present a partial solution to the lack of forms compliance the report found.
“The statistic that stuck out to me was the high percentage of forms that either weren’t filled out or were filled out incorrectly, and I think that does speak to the time and volume and pressure on emergency staff,” Simms said. “I think that having NP’s be able to fill out these forms on their own patients, who they know, will improve the care and attention and detail in that assessment.”
While over one million people in B.C. don’t have a family doctor who has been following their health, Simms said there are times when patients present to urgent care or walk-in clinics needing a mental health assessment. It is here that she said NP’s can fill that need, reducing the burden on emergency staff.
Victoria Police Department Co-Response Team (CRT) officer Const. Tristan Williams said the CRT sees individuals certified for involuntary admission by general practitioners “somewhat often,” but if someone is detained by officers under the Mental Health Act, they are still taken to the hospital for assessment before being transferred to the appropriate unit.
Still, advocates are concerned about the increase in number of people being involuntarily admitted, and worry this expansion of power will only exacerbate that.
According to research on trends in British Columbia, involuntary admissions increased 71 per cent from 2006 to 2017 and the Ombudsperson report found there were 20,483 patients detained under the Mental Health Act in the 2016/2017 fiscal year.
“If we’ve now expanded the types of health-care providers who have the power to examine and detain, this would have been an opportunity to expand safeguards and we haven’t done that,” Johnston said.
A 2022 Mental Health Act amendment does require providers to give patients the option of an independent rights advisor to help them navigate how to go through processes such as a case review, but Johnston said more is needed.
Johnston said increasing the amount of cases that are reviewed by an independent group is far more important than the question of who is completing the assessment.
Currently, patients themselves must seek to obtain an independent review of their involuntary admission. Johnston said patients are often unaware they even have that right, or are pressured, threatened or persuaded not to use it.
“Approximately three per cent of detentions actually get reviewed by the independent tribunal,” she said. “A much more productive safeguard would be to have automatic hearings so the law could just take that burden off of detained people.”
Advocates have also called for a review of a provision in the Mental Health Act which allows direction and discipline by facility staff. Johnston said the power that provision provides can create trauma and alienate people from the health-care system.
“Eliminating discipline powers in our Act is something that people have been calling for for decades and is long over due,” Johnston said. “This permits unlimited, no criteria, no definition, unreviewed use of restraints - mechanical, physical and chemical, solitary confining people in seclusion rooms, withholding of fresh air, grounds privileges, access to telephone and visitors. We’re way behind accepted science and human right principles on that front.”
While there are many ways the Mental Health Act can be reformed, Johnston said any changes need to take into consideration experiences from impacted communities in order to be meaningful.
Expanding the powers to involuntarily admit patients doesn’t make the mark, she said.
“There are lots of different ways we can design safeguards,” she said. “It’s important that they include independent oversight of how the powers are being exercised and that there is meaningful accountability when people’s human rights are being violated.”