Best Practices in Mental Health Reform: Discussion Paper

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4. Applying Best Practices

The best practices identified in the literature review define what one would expect to find in a reformed mental health system in terms of the types of services and supports and the infrastructure in which they are located. Best practices can be used as guidelines for systems planning and as general criteria for the assessment of performance but they are not detailed blueprints which can be immediately mapped onto a region or province, specifying the quantities and interrelationships of the various components. The best practices provide a more general program of action that requires further specification to fit the particular circumstances in which the system of care is being implemented.

4.1 Implementing Model Programs

A number of reasons account for the lack of an exact correspondence between elements of best practice derived primarily from research and applied examples as described in the situational analysis. As Leona Bachrach has often reminded us, there are many differences between the world of model programs (1980) and synthesized community support systems (1982) developed and tested for demonstration purposes, and the realities of service delivery in normal conditions. This means that there is always a process of adaptation rather than simple adoption when a program with demonstrated efficacy is transplanted to another circumstance. The planning principle is one of cultural relevance (Bachrach, 1984), i.e. tailoring to local conditions. A supported housing approach in British Columbia may look different in many respects from a supported housing approach in Vermont. The same is true with system-wide strategies. We can learn that regional authorities are a promising approach based on studies and experience in other jurisdictions, but it is not appropriate for an administrative and funding arrangement to be exactly replicated in a different political and environmental context. The Mental Health Commission in New Brunswick was designed for a province with a population of about 738,000 and a mental health budget of $50.6 million 1 in 1995/96 (Black, 1997). The concepts have wide relevance, but the particulars will have to be rethought in Ontario with a population of about 10,750,000 and a mental health budget of $1,555.7 million in 1993/94 (Ontario Ministry of Health, 1996). It is important to distill from the best practice descriptions the essential components that define the approach, as we have tried to do in Phase I. This inevitably means that the best practices are at a level of generality that falls short of being immediately operational.

There are also important differences between descriptions of ideal community support systems and those that are actually functioning. Systems of care in natural conditions are far more complex and dynamic than are the representations that are used to describe them. For heuristic purposes, it is common to subdivide into categories the types of services and supports that are essential components within a system, so that we talk about promising approaches to treatment, vocational rehabilitation and housing etc., as if they are separate entities. But, as anyone knows who has tried to develop an inventory of programs, these categories are not mutually exclusive or clear-cut. Programs, like patients and psychiatric diagnoses, often do not fit neatly into the classifications that have been devised. Bachrach's (1984) principles of functional equivalence and potential trade-offs remind us to focus on function, not form, when developing programs. This admonition is relevant to the widespread tendency to equate community care with a particular type of sponsoring organization. There is no reason to assume that hospitals cannot provide excellent community services. In fact both the literature and the situational analysis clearly demonstrate this point. "The central issue in reforming services, therefore, is not so much geographic - hospital versus community - as it is functional. It centres around the ability to provide the right kinds of services to the right people" (Trainor et al., 1993, p 10).

4.2 Forming Best Practice Checklists

Although there is a gap between a description of best practices and a detailed blueprint of how to build a system of care, this does not mean that there is latitude to pick and choose only those aspects which are easiest or most convenient. Just as engineers are given the specifications for a bridge (location, weight bearing, weather resistance) that will condition and shape its design and construction, best practices should guide the planning, implementation and evaluation of mental health reform. They can be used as a checklist to assess whether a system is attending to critical issues and processes. A valuable resource in this regard is the discussion guide on Mental Health Reform prepared by the Canadian Mental Health Association (1995a) under the direction of the National Mental Health Services Work Group.

The discussion guide is intended to help advance the reform agenda for the seriously mentally ill population in a period of economic challenges. A series of questions are posed to identify both what has been accomplished within a region or province, and the areas of greatest need. Sections of the guide focus on the overall context and on three critical outcomes of mental health reform i.e., a balanced and effective service system, a range of consumer and family initiatives, and promotion of community integration. These questions came from many years of consultation with various stakeholders, including three national policy forums. The coverage and emphasis are somewhat different than what would be in a discussion guide derived purely from a best practice orientation, but still there is remarkable overlap in the issues and approaches to be monitored.

Borrowing on the concept of the discussion guide, we have incorporated the findings from Phase I into a checklist of best practice programs and strategies that provinces can use to examine their progress in mental health reform (see Tables 1A and 1B).

Recommendation 1

Best practices should be used as guidelines for systems planning and as criteria for the assessment of performance.