Ontario moved its psychiatric hospitals into the community system. Was the community care in place?

In the 1990s, Ontario set out to change where people with serious mental illness get care: fewer beds in big provincial psychiatric hospitals, more support in the community. The plans were clear about the order: the community help was supposed to come first.

The province's own Auditor General later checked how that went.

The promise

It started with Putting People First in 1993, a 10-year reform strategy with measurable targets. According to the 2002 audit, the reasoning was that if community services worked, hospitalization should drop, and beds would be reduced only after appropriate community-based services were in place.

The Auditor General's 2002 audit records the two goals. Spending should tilt 60:40 toward community care over institutional care. Psychiatric beds should ultimately fall to 30 per 100,000 people, with an interim target of 35 after advice from the Health Services Restructuring Commission (HSRC) in the late 1990s.

Making It Happen in 1999 restated 60/40 and adopted 35 beds per 100,000 by 2003. It was blunt about sequence: "significant investment in community mental health services is required before bed transfers and reductions can effectively take place." Reinvestment was to reach communities targeted for cuts before those cuts happened. The planned uses were community treatment teams, case management and crisis response.

What happened to the hospitals

From 1998, the Ministry of Health (later Health and Long-Term Care) divested or transferred nine of 10 provincial psychiatric hospitals to public hospitals and community providers.

The words matter here, because they don't all mean "closed." Under the HSRC advice, some sites closed and their programs were transferred. Whitby and Kingston were to remain open, with operations divested to public hospital boards. Toronto was described as an amalgamation into a new public hospital corporation.

What the audits found

The 2002 audit, using Ministry figures, put psychiatric beds at 43 per 100,000 in 1997 and 41 by March 31, 2002, against the interim target of 35. Its spending table showed 32:68 in 1997 and 46:54 at March 31, 2002.

The 2008 audit picked up the thread. Beds fell from 40 per 100,000 in 2002/03 to 36 in 2006/07, close to the interim 35. Its own spending series starts at 28:72 in 2002/03 and rises to 39:61 in 2006/07: about $39 on community services for every $61 on institutional care, still short of 60:40.

A note on the numbers: both audits cite Ministry data, but the 2008 audit's table puts 2002/03 at 28:72, while the 2002 audit reported 46:54 for March 31, 2002; neither report explains the gap, so we use the 2008 series for the trend rather than comparing across audits.

So by the mid-2000s, beds almost met the target; the community spending ratio did not. The Ministry blamed rising hospital costs. The Auditor General wrote that the gap "suggests that adequate community-based supports may not be available for people being discharged from psychiatric hospitals as a result of bed closures."

The echo in 2016

A 2016 audit found specialty psychiatric hospitals still holding patients who were ready for discharge but had nowhere suitable to go, for lack of supportive housing or long-term care: about one in 10 specialty beds over five years. A companion audit counted over 12,300 mental-health supportive housing units subsidized by the Ministry. Housing is where the next piece picks up.

What we know, and what we don't

Established: the 60:40 and bed-ratio targets (Making It Happen; Putting People First via AGO 2002); the AGO 2002 and 2008 figures above; nine of 10 provincial psychiatric hospitals divested or transferred since 1998; AGO 2016's one-in-10 discharge bottleneck and 12,300+ subsidized units.

Claimed: the Ministry's account that rising hospital costs kept the funding ratio off target (AGO 2008).

Unknown: a full ledger of which sites closed, were divested or merged; how many community places were promised compared with built; and any claim that bed cuts alone caused today's homelessness or ER volumes.

Spin check

Omission / loaded word: Bed cuts get told as reform success without the unmatched community funding ratio. "Divestment" or "transfer" is often heard as "closure," even when programs moved to another hospital board rather than ending.

Bottom line

Beds neared the interim target. The community spending ratio did not. The province's own auditor said that gap suggests community supports may not have been ready for people leaving those beds.

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