Best Practices in Mental Health Reform: Discussion Paper

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1. Introduction

The past 30 years have seen dramatic changes in the treatment of mental disorders and the organization of mental health care systems. Between 1960 and 1976 the number of beds in Canadian mental hospitals decreased from 47,633 to 15,011 while bed capacity in general hospital psychiatric units rose from 844 to 5,836. This deinstitutionalisation process resulted in a dispersion of clients into the community without the necessary services and supports to allow them to function successfully (Wasylenki, Goering and Macnaughton, 1992). In recent decades, jurisdictions have made an effort to develop a mental health care system that can better support individuals with mental illnesses and maximize their community tenure, independence and quality of life.

Since the mid 1980s provinces have pursued various courses of action to improve their mental health care systems. The primary focus has been on the subgroup of individuals with severe mental illnesses. This group, which represents approximately 2% of the population, has been poorly served by past policy initiatives and, as a result, has consumed a disproportionate share of expensive inpatient and treatment services, with little benefit to themselves and their families. Mental health reform does not intend to ignore the needs of those with less serious mental health problems - approximately 18% of the population. Rather it is felt that with better systems of care in place for those with severe mental illness and a better interface between the primary and mental health specialty sectors (Canadian Psychiatric Association, 1996), all members of the community who need assistance for mental health problems will be better served.

1.1 Cornerstones of Mental Health Reform

In his summary of provincial reform activity across Canada, Nasir (1994) noted a remarkable consistency among the provinces in embracing three common goals for mental health reform. These include:

• correcting the historical imbalance between institutional and community-based care
• offering a comprehensive range of services - treatment, rehabilitative, preventive and promotional
• devolving governance of health/mental health services at the regional/local level to make the system responsive to local needs

Two other critical cornerstones of mental health reform being pursued include:

• recognition that mental health care should not be limited to formal mental health supports
• acknowledgement of consumers and families as critical partners in planning, delivering and evaluating mental health care delivery.

The Canadian Mental Health Association (CMHA) Framework for Support (Trainor et al., 1993), a policy orientation which is reviewed in depth in Phase II of this project, has achieved considerable success in changing thinking about the capacities and roles of consumers; in encouraging provinces to direct resources and develop structures that support consumer participation; and in encouraging involvement of a broader array of human and social services in the lives of citizens with mental illness.

In pursuing program and system reform, the ultimate goal is to improve the lives of those with mental illness. William Anthony (1993) reinforced this perspective when he noted that recovery is what people with mental illness do, while services such as case management and treatment are what helps to facilitate recovery. In this context, best practices must be implemented within a clearly articulated value base that puts the consumer in the centre and focuses on consumer empowerment and recovery. The values established at the outset of reform will influence many aspects of reform implementation such as desired individual, program and system outcomes, human resource strategies, training programs, and views on the capacities of consumers and their roles in the system. Over the last decade many consumers have given voice to the concept of recovery, offering eloquent and insightful chronicles of their recovery experiences (Deegan, 1988; Long, 1994). It is important to realize that in this context recovery is not equivalent to cure. There may be ongoing symptoms and need for treatment and support. It is the level of adjustment and meaning of illness that are modified for those who "recover".

Fortunately many provinces have spent considerable time developing a vision and value base to guide the reform process. One consumer consultant reminds us that any reform approach which does not include these aspects as key elements will not lead us to the future.

1.2 Context for Implementing Reform

In pursuing mental health reform, provinces have used various legislative and policy tools, and have revised methods of resource allocation and system organization. Activities have been pursued within the broader context of substantial reconfiguration of all health care delivery, especially as regards hospital downsizing, regionalisation and integrated care delivery. In the midst of these many changes, reform proponents have strived to protect mental health dollars within shrinking health care budgets and to make certain that community supports are put in place prior to hospital closures and downsizing. They also have focussed on developing governance and funding structures that can better respond to regional/local needs, and can integrate services/supports across community and institution, across mental health and primary care, and across mental health and social services sectors. (See Literature Review, ANMH, for discussion of governance and funding strategies related to implementing reform.)

The mental health system in Canada has a number of unique characteristics that have facilitated implementation of reform or are encouraging with regard to future progress (Goering et al., 1996).

• At a time when accountability is paramount, we have a growing body of evidence on the effectiveness of models of service delivery to inform decision-making and influence funders (see Literature Review, ANMH).
• There are numerous examples of horizontal and vertical linkages that have been developed across both agency and sector boundaries (see Situational Analysis, ANMH).
• In comparison to primary care and long-term care, mental health services for the severely ill are a smaller, more manageable piece of a much larger configuration of providers and organizations.
• We are operating within a single payer health care system, a major advantage in comparison with the complex administrative and funding environments in the United States.
• Finally, and perhaps most importantly, many of the leaders and players within mental health share a common core of beliefs about the value of collaboration and the need to overcome vested interests in order to work effectively as a group.