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Restructuring mental health policy in Ontario: Deconstructing the evolving welfare state.

Introduction

Although the intent of health system restructuring in Ontario was to reshape the hospital sector, it had sweeping implications for one of its weakest links--mental health care--which affects twenty per cent of the population and is the second highest contributor to hospital costs. (1) Understanding the dynamics of reform in the health sector requires a recognition that it is based on the politics of rationalization--in which governments attempt to solve problems in existing programs--as distinguished from "breakthrough" politics, which entail efforts to involve government in a new activity or to expand its commitment. (2) Mental health sector restructuring has involved both, guided in recent years by a neo-liberal agenda of welfare state restructuring. But despite a consensus among successive provincial governments (since 1989) and the mental health policy community to reduce the institutional sector and adopt models of community-based care, disagreements about how to proceed intensified. (3) Restructuring thus introduced a political dimension from which Conservative governments distanced themselves, by delegating decisions concerning hospital closures and community reinvestment to successive arm's-length bodies. (4)

Restructuring Ontario's mental health sector has involved the divestment, reconfiguration or closure of six psychiatric hospitals (an additional two were slated for divestment), amalgamation of four facilities, closure of fifty per cent of psychiatric beds, and transfer of a portion of the remaining beds to general hospitals. (5) While premised on a shift from institutional to community-based care, such reforms proceeded largely in the absence of enhanced community supports, except for the addition of Assertive Community Treatment (ACT) teams. (6) The Canadian Mental Health Association (CMHA) reported its programs are operating above capacity, with long waiting lists. For example, 200 people were waiting for case-management services in Ottawa; without further investment they may wait for up to five years. (7) Base funding for community mental health services has been frozen over the ten years in which restructuring has occurred, "creating an unsustainable cycle of service and support reductions, workforce recruitment and retention problems, and significant ripple effects throughout the broader health, education, social services and justice systems." (8) The consequences of shortfalls in community services are costly, as they place pressure on emergency departments, hospitals, police and correctional services. Indeed, community case management has been found to reduce hospitalizations by up to eighty-six per cent. (9) At the same time, patients transferred to the community often become invisible to the system, making accountability for their care more diffuse. The trend to shift patients to the community without needed supports has been referred to as "passive privatization," and suggests a redefinition of the role of the state in the health care sector. (10) While the Romanow Commission and the National Forum on Health recommended funding follow patients rather than be tied to institutions, the community infrastructure on which such a shift relies is underdeveloped. (11) District Health Council System Designs recommended that a continuum of community mental health services be coordinated through such strategies as assessment tools, lead agencies, joint protocols and joint networks. (12)
 The commission's advice to divest, reconfigure and close
 psychiatric hospitals via health system restructuring
 thus created a window of opportunity for several goals to
 converge


Although health policy lies within provincial jurisdiction, the design of health programs is guided by a national framework of public health insurance reinforced by federal funding that was initially limited to hospital and physician services. Since mental health care was delivered by provincial psychiatric hospitals before the inception of public health insurance, and legislators had not envisioned the shift to community care, it remained of peripheral concern. Indeed, the federal Hospital Insurance and Diagnostic Services Act (1957) specified general hospitals could have no more than ten per cent of their beds assigned to psychiatric care to be eligible for federal cost-shared funding. (13) Although federal transfers became block grants in 1977, making a reorientation to community care possible, such a transition has only recently begun to occur. And while a tenet of the Canada Health Act specifies comprehensiveness in the provision of medically necessary services, such services are limited to those provided by hospitals and physicians. Since mental health care includes allied health professionals in community settings, it often extends beyond the services specified in the Canada Health Act, leading to variable coverage among provinces, undermining the comprehensiveness of a health care system in transition.

We analyse the obstacles preventing the development of a community-based approach to mental health care by adopting a neo-institutionalist perspective. Our premise is that the processes used to develop policy establish the strategic context in which decisions are made: by including or excluding the perspectives of various groups in defining issues, institutions determine where the balance lies between interest-group demands and programmatic goals of government decision-makers. (14) As formal policy processes can be vested with varying degrees of authority to advance their decisions, those granted such authority can facilitate strategic courses of action, while those whose work proceeds without it provide governments with a means for delay via "death by committee." In both cases, policy may be influenced through informal channels of engagement with select members of the policy community.

In analysing the process of mental health-policy development and implementation, we focus on successive arm's-length and internal government frameworks that formulated restructuring policy, the level of authority with which each was vested, and the nature and influence of policy community involvement within them. Formal processes are distinguished from the informal channels and policy networks that establish links between government agencies and concentrated interest groups. (15) Our analysis reveals several obstacles, including successive arm's-length and internal government processes of policy formation with varying degrees of authority; inconsistent engagement of the policy community responsible for policy implementation; and the complexity of inter-sectoral coordination--among such sectors as health, housing, social assistance and disability supplements, employment, justice and addictions--on which delivery of the constellation of community services relies. However, a lack of political will to reallocate funds to the community, and to delegate control for them on a regional basis, serve as the most significant barriers to reform, entrenched within the policy process itself: while those bodies assigned with rationalizing services were given the power to implement their directives, those asked to devise plans for community re-investment served in only an advisory capacity, the commitment to which remains to be seen.

The research involved document review and semi-structured interviews with nineteen key informants from the Ontario Ministry of Health and Long-Term Care (referred to as the Ministry of Health), district health councils (DHCS), the Canadian Mental Health Association (CMHA), the Ontario Federation of Community Mental Health and Addiction Programs (OFCM-HAP), the Ontario Medical Association (OMA), the Association of General Hospital Psychiatry Services (AGHPS), mental health service managers and general and psychiatric hospitals, from April 2000 to November 2004. The perspectives of persons with mental illness and their families were incorporated through two colloquia on psychiatric de-institutionalization. (16) The following sections analyse the obstacles to policy reform, including the implications of successive governance and advisory processes, and the challenges of inter-sectoral collaboration on which the shift to community care relies.

Policy processes on the road to reform

While government-sponsored reports from the 1930s proposed developing community-based mental health care, the Ministry of Health addressed immediate problems with short-term measures without ever developing a comprehensive plan. (17) A more systematic approach emerged at the turn of the century through a series of stages. The Heseltine and Graham reports (18) of the mid-1980s set the stage by emphasizing the need for consumer involvement, and integration of the silos represented by the institutional and community sectors. The Ministry of Health under the New Democratic Party outlined its response in The Road to Reform, (19) guided by the theme of transforming an institutionally based into a community-oriented system. It specified the factors needed for reform in greater detail in Putting People First, a more client-oriented report that focused on case management, housing, crisis care and consumer-led initiatives. (20) The Ministry of Health did not, however, consult the policy community, and only did so after the report's release. Consumer and community service groups raised the concern that employment initiatives needed to support and sustain clients in the community were lacking. (21)

Putting People First also set the ambitious ten-year goal of shifting the proportion of funds allocated to the institutional and community sectors from eighty and twenty per cent respectively in 1993, to forty and sixty per cent respectively, by 2003. The 1990s thus commenced with select program initiatives, and ended with the turbulent reforms associated with health system restructuring, intended to reshape the sector from a "systems" perspective.

District health councils

Recognizing the magnitude of the reforms envisioned in the Graham report, the Ministry of Health under the NDP called on district health councils (DHCS) (regional advisory and planning agencies without fiscal authority) to develop plans on a regional basis. Specifically, they were asked to realign organizational roles and reconfigure the mental health system by defining population needs and develop system designs and implementation plans. (22) As DHCS had no authority over government ministries across the sectors on which such planning relied, they experienced difficulty. (23) When the Conservatives entered office in 1995, the ministry asked DHCS to include ACT teams in their system designs, despite the late stage of planning. (24) District health councils balanced the Ministry of Health's and the policy community's perspectives in their service configuration recommendations. (25) The Toronto DHC advised the creation of regional mental health authorities to facilitate coordination among institutional and community organizations. (26) Given the DHC'S role as an advisory body, it lacked the power to act on its plans.

The ministry resisted devolving power to regional health authorities despite the trend in other Canadian provinces. (27) Instead, it initiated the Community Investment Fund (CIF), using financial incentives to initiate a "systems" approach. In order to receive program funding, community service agencies and general hospitals had to agree to coordinate their services (client assessment, intake and referral). (28) Despite the completion of DHC system designs in 1997, the community service networks envisioned developed sporadically, given the indirect and ad hoc support.

Health Services Restructuring Commission

The Conservatives made several strategic decisions to advance health sector restructuring, relying on a series of arm's-length bodies to develop blueprints for hospital closures and advise on community planning. The Health Services Restructuring Commission (HSRC), made up of members of the business and health sectors (excluding mental health), was given the mandate of reconfiguring hospital services in twenty-two cities. As psychiatric hospitals were owned and operated by the Ministry of Health, the commission was asked only to advise on their restructuring.

Given past public resistance to hospital closures, (29) the government enacted the omnibus Ontario Savings and Restructuring Act (Bill 26), giving HSRC the authority to close, amalgamate and transfer programs among general hospitals. The commission was therefore granted authority to develop and implement reforms without legislative debate. The Tories thus deflected criticism by distancing themselves from the political ramifications of unpopular decisions concerning hospital closures, while retaining the right to intervene in their implementation. (30) An amendment to the Mental Health Act (31) gave the minister of health the ability to change the conditions under which psychiatric hospitals were paid, foreshadowing their subsequent divestment.

The commission considered DHC reports and general and psychiatric hospital operating plans in devising its directives for each region. Although HSRC held regional public hearings, their formality made them an intimidating forum for community groups, and they became a venue for hospital executives to present their case. Only the best informed, resourced and organized groups submitted comment, while the remainder were excluded. (32) The commission's consultations were thus largely confined to select members of the policy community: hospital executives, union representatives, and the former director of the Institute for Clinical and Evaluative Sciences. (33) Following HSRC'S Notice of Intention to Issue Directions, a thirty-day appeal period was granted before final directives were issued. Few public submissions were received, however, thus largely excluding the concerns of community groups. (34) While the commission granted news interviews, and contributed to newspaper editorials, its communications were intended to inform the public of decisions made, whereas the community was most interested in contributing to them. (35)
 The commission's decisions created a domino effect with
 implications for the community sector and the patients
 who relied on it


The commission issued more than 1,200 legally binding directives to 119 of 203 public hospitals, including the amalgamation of 45 hospitals into 13, and the closure of 29 hospital sites. It also recommended a transformation of the mental health sector through the divestment, closure or amalgamation of ten provincial psychiatric hospitals, closure of psychiatric beds (thirty-nine per cent), and transfer of most of the remaining beds to general hospital psychiatric units. In operating without a board of trustees, provincial psychiatric hospitals were considered unwieldy and unresponsive to their community (provincial management of psychiatric hospitals dates back to the time of asylums). The restructuring commission recommended their divestment, congruent with the transfer of care to general hospitals, and the maintenance of patients in their communities.

Including the earlier bed reductions, the decade ending in 2003 witnessed the closure of fifty per cent of psychiatric beds. (36) As HSRC'S mandate did not include community care--an omission reminiscent of previous initiatives in de-institutionalization--its approach was unbalanced. Although divestment of psychiatric facilities was proposed as early as 1963, to enhance accountability, the government resisted earlier proposals that might have made their subsequent closure more difficult. (37) The commission's advice to divest, reconfigure and close psychiatric hospitals via health system restructuring thus created a window of opportunity for several goals to converge.

Closing psychiatric hospitals, however, takes political will and seed money to develop an infrastructure of community services on which such closures rely. A circular argument lies at its core: while the funds needed to develop community services are tied up in hospitals, hospitals cannot close in the absence of community programs. Transitional funds must thus be allocated to develop a community infrastructure. Given the employee terminations involved, resistance from unions also had to be overcome. The Ministry of Health also wanted to be sure clients' needs would be met in community settings. Given the "hospital-without-walls" approach adopted by several American states, evidence of the effectiveness of community care was growing. Community mental health programs have indeed been shown to reduce emergency department visits by sixty per cent and hospitalizations by eighty-six per cent. (38) The ministry thus supported HSRC'S recommendations to divest and close six psychiatric hospitals (the divestment of two additional facilities was planned for a later date), disperse a portion of their beds among renovated general hospitals, and amalgamate four facilities. It nevertheless failed to heed the commission's advice for community reinvestment, which extended beyond HSRC'S mandate. (39)

The commission's directives were met with varying degrees of resistance. While a handful of hospitals tried to discredit HSRC through the local media, others launched legal challenges. In response, the ministry assigned facilitators to hospitals being amalgamated to resolve governance issues, and revised several of its resource allocation decisions. As HSRC's directives neared implementation and communities found themselves unprepared for the magnitude of the reform, bed closures were delayed. Indeed, as the North Bay community vociferously disagreed with the closure of Lakehead Psychiatric Hospital, it was assigned a new facility. Because divestments led the receiving general hospitals to incur massive debt arising from renovations and employment terminations, the transfer of funds to support community programs was postponed.

Since the restructuring commission lacked confidence in the ministry's ability to address local circumstances, it reiterated the Toronto DHC'S advice to establish regional mental health authorities to guide the development of community infrastructure and protect the mental health envelope. "The lack of a local structure with clear responsibility and accountability to effect and monitor the shift from in-patient to community-based services, and coordinate reinvestments continues to be a major barrier to reform." (40) Since community services comprise thirty per cent of the mental health budget, while hospital and physician services make up the remainder, the ministry would face serious opposition from the Ontario Hospital Association, as regionalization could lead to further hospital integration, under which individual boards and management would be forced to relinquish control. Nor would the OMA be interested in having the Ontario Health Insurance Plan (OHIP) budget allocated to regional authorities.

The Ministry of Health thus had no appetite to mandate authorities; instead its approach would appear to be driven by internal funding priorities and resistance from key groups. (41) As a lack of community leadership was a barrier to reform, the restructuring commission advised establishing mental health implementation task forces (MHITFS) to guide regional reforms. The ministry deflected pressure for regionalization by announcing nine MHITFS and seven regional ministry offices, perceiving the community to be more manageable and less politically charged than the hospital sector. Instead of devolving authority to regional boards, the ministry delegated responsibility associated with its Health Services Management Division to regional offices. Regional offices were to work with task forces, DHCS and health service agencies to ensure local issues and opportunities were aligned with provincial priorities, thereby consolidating rather than devolving the ministry's authority.

Although HSRC set the parameters for transforming the mental health sector, its mandate of hospital closures left each region to grapple with the fallout in the absence of the community supports they required. Development of community programs was thus limited by a lack of financial support and leadership; legal constraints also prevented organizations from sharing client information, which hampered the formation of coordinated service networks. (42) While HSRC emphasized institutional reconfigurations were incomplete without additional community funding, its directives were adopted in an effort to rationalize the hospital sector, without fully enhancing the community supports on which such closures relied.

The commission's decisions created a domino effect with implications for the community sector and the patients who relied on it. Recognizing the limitations of this "non-system" of mental health care, the Ministry of Health engaged in consultations with the policy community to develop a vision of care on which de-institutionalization could rely.

Ministry of Health and long-term care

Public concern raised by the divestment of psychiatric facilities led to community consultations focusing on the review of the Mental Health Act (MHA), which foreshadowed legislative amendments concerning Community Treatment Orders (CTOS). Bill 68, referred to as "Brian's Law," amended the MHA and Health Care Consent Act to facilitate CTOS. The word "imminent" in the phrase "... imminent harm to self or others" was removed from the involuntary examination, assessment and civil commitment provisions, thus expanding the committal criteria to include persons with chronic mental illness. The amendments allow health professionals to initiate the committal process at an earlier stage, and broaden the powers of the police. They also redefine the commitment process to a brief hospital stay, followed by treatment in the community. Consumer groups opposed the bill, referring to it as a "leash law." Public hearings and legislative review, however, occurred mainly to consult on how and not whether to implement Bill 68.

As the implications of the restructuring process to shift treatment to the community were evident, the Ministry of Health commenced the next stage of planning through consultations with the policy community (see Appendix 1). An informal channel of communication subsequently evolved into a policy network: when former minister of health Jim Wilson announced new mental health services in Stratford, a regional CMHA director asserted that "no framework exists on which to hang new services." (43) After acknowledging the assertion, Wilson asked the CMHA to assist in developing a "systems approach" to mental health care, and submit its advice in a report. Twelve CMHA regional directors worked collaboratively to develop ACCESS: A Framework for a Community Based Mental Health Service System. And while the Conservatives' public employee layoffs created a vacuum of knowledgeable ministry staff, subsequent hiring from the CMHA enhanced its influence. The ministry drew on ACCESS, along with a federally commissioned Best Practices report (44) to develop its strategy for mental health reform.

While past program developments occurred on a piecemeal basis, the Ministry's strategy outlined in Making It Happen stressed that future investments would be strategic, community services would meet a range of client needs (first line, intensive and specialized), and access to services would occur through a common assessment tool, and a triage protocol based on referral relationships. Regionally centralized information and referral functions would create fewer points of entry, and facilitate access to psychiatric consultation. Services would be coordinated through agreements among hospitals and community agencies, and be linked to family physicians. Policies on access to housing, and an accountability framework, would be developed. Regional ministry offices would allocate funds, and organize and monitor services. However, the government's modest funding and limited operational plans to support its policies challenged its commitment and credibility.

The Ministry of Health's policy and operations divisions were separated when it was re-organized in 1999. Members of the policy community, however, suggest a disjuncture between its policy and operations branches, and a lack of leadership orients it toward maintenance rather than reform. Although policies are pronounced, they are often not well operationalized and financed, limiting their capacity for implementation. Employee turnover within the ministry also created a loss of collective memory of policy initiatives. (45)

Mental Health Implementation Task Forces were to recommend plans for system design; the operations branch was to support the task forces' recommendations, pending ministry approval. (46)

Mental health implementation task forces

The Ministry of Health appointed nine MHITFS in 2001, to address its policy objectives articulated in Making It Happen, and to develop recommendations for the allocation of transitional funds. A five-year delay (two years to strike the task forces, two years for the task forces to develop their plans, a year before the ministry released their recommendations), however, meant some of the most challenging work of developing agreements among hospitals and community agencies to coordinate services occurred before release of the task forces' final reports. (47) However, many regions made little progress, though in developing a coordinated approach to community care. And while diverse members of the policy community contributed to the task forces, the new Liberal government essentially set their reports aside.

Despite the goals Making It Happen emphasized, operational planning occurred in a disjointed manner through the nine task forces, seven regional offices, DHCS and local service networks whose jurisdictions did not correspond. The ministry thus disentangled itself from implementation by allowing individual approaches rather than offering a framework of support. Thus, communities that experienced difficulty in addressing the policies struggled.
 Local networks of community and institutional agencies
 initiated coordinated planning, resulting in uneven
 policy implementation across the province


Although the MHITFS submitted their final reports in December 2002, they were released only a year later, following the election of the Liberal government. The task force reports embodied several themes: increase the profile and funding of mental health care, focus on recovery, ensure a range of community-based supports that encompass the broader determinants of health (affordable housing, employment opportunities, income supports, peer and self-help supports), and eliminate stigma and discrimination. They also emphasized enhanced coordination among government ministries and agencies in local service networks. (48) Finally, the provincial forum of task force chairs reiterated DHCS' and HSRC'S advice to devolve the funding and authority for mental health service reconfiguration to regional mental health boards. (49)

Although task forces were to provide leadership, the ministry's delay in striking and in reviewing their advice contributed to its disentangled approach, resulting in uneven progress in the interim. Indeed, a survey of chiefs of psychiatry of general hospitals revealed remarkable similarities in the issues they faced, emphasizing the benefits to be derived from a coordinated approach with central support. (50) The government's reticence may have been due to its inexperience in developing models of community care, and a lack of political will to reallocate funds to the community. Again, policy development was delegated to an arm's-length body, which was asked to submit its recommendations as advice, and dissolved after twenty-four months. Instead of directly addressing the task forces' advice, the McGuinty Liberal government announced an initiative to transform the health sector through local health integration networks (LHINS), without specifying how mental health services would be incorporated within them.

Contributions of the policy community: "Speaking truth to power" (51)

Health policies are often shaped by relations of conflict and accommodation between the Ministry of Health and organized interests within established policy networks. In the health arena, provincial policy has evolved in the context of a pivotal relationship between the Ontario Medical Association (OMA) and the Ministry of Health. As health policy has expanded to encompass areas such as midwifery, so have the array of groups within the policy network. (52) The nature and frequency of policy-community consultation, however, depends on the government's agenda, leading groups to experience variable access to such channels. The contributions of interest groups to the policy process include consultation, coordination, and cooperation in policy formation and implementation. (53) Although the public sector is generally resistant to shared decision-making, contemporary governments wish to be seen as responsive and engaging their communities. R.A. Young views opportunities for consultation as tectonic shifts ,that alter the political playing field and its rules, thereby reshaping groups resources and influence. (54) Such concepts of new public management as "agency" also influence government behaviour, and have led to the state's withdrawal from areas the non-profit or private sector are seen as capable of addressing. Critics, however, identify declining service quality in sectors in which such agency relationships--those based on competitive contracts--exist (home care and long-term care). Contracting out to the non-profit and private sector may also diminish such groups' role in the policy process, as they restrain their advocacy stance in an attempt to mitigate loss of future contracts. (55)

The number of public interest groups in the mental health policy community expanded in the 1980s, challenging the hegemony of the medical profession and contributing to a decline in the authority of psychiatry. (56) In considering groups" financial resources, in 1990 psychiatric hospitals received the highest proportion of the mental health budget, followed by general hospitals, family physicians, psychiatrists, community service providers and consumer groups. Community mental health services were offered by eighty general hospitals (thirty-three per cent), free-standing community boards (thirty-two per cent) and the CMHA (twenty-two per cent). (57) The diversity of groups and their conflicting perspectives reflect the silos and competing interests within the policy community (see Appendix 1). An ongoing tension is apparent between professionals offering medical and community services, as each possesses different views of what constitutes mental illness and how to alleviate it, arguing that increased resources in their envelope is essential to patient care. The Ontario Medical Association perceives community groups advocating in a polished manner through their policy reports, and suggests the congruity between the Ministry of Health's Making It Happen and the CMHA'S ACCESS reports reflects its influence; the OMA would like to see policy reoriented toward treatment issues. (58) As such, physicians see themselves as preoccupied with caring for the most seriously ill, and have less time for advocacy. Medical associations' resources and established links to government would, however, suggest otherwise. The rise in community groups' influence may reflect a recognition that social supports are as important as treatment, suggesting a swing in the policy pendulum. And while consumers have legitimate concerns, if not presented in a manner the government can incorporate into its policy agenda, they are unlikely to be addressed. (59) As policy proposals must be approved by cabinet, they must be designed to meet the government's broader imperatives. Groups who shape their advocacy accordingly are more likely to succeed.
 Planning community care in the mental health sector
 involves reconceptualizing services as extending beyond
 acute care to a system of social supports


The mental health policy network of the 1980s was, however, too fragmented to influence the development of a comprehensive plan for mental health. As a result, the government "was successful in ignoring the advice of every mental health policy report since 1930." (60) An evolution, however, occurred at the end of the 1990s. A Mental Health Alliance, made up of medical and community groups: the Ontario Psychiatric Association, Ontario Medical Association, Association of General Hospital Psychiatric Services, Canadaian Mental Health Association and Ontario Federation of Community Mental Health and Addiction Program was formed, which sought to advance common positions with a unified voice that would carry more weight. As the OMA is seldom in agreement with the CMHA, however, issues must be brought back to their membership. An alliance was formed in lieu of the past approach, in which fifteen groups presented potentially divergent opinions. Instead, the ministry receives input from three or four coalitions with broad bases of support. (61) Such coalitions are fragile, though, as groups are competitive where funding is concerned, and become adversarial when perceived under threat. The influence of this evolving landscape of pressure groups has varied across policy episodes of the 1990s, as successive governments engaged the policy community to different extents.

While the restructuring commission offered the appearance of consultation, it was dominated by narrow channels of communication with experts and hospital executives that were not as accessible to community groups. As much of the traditional policy community was excluded from HSRC'S deliberations, the scope of the debate was narrowed, which led to uncertainties as to whether the premise on which restructuring decisions were based represented community values. While groups representing persons with mental illness are weaker actors, their voices led to the unravelling of policy directives and the inability to sustain those that did not address their concerns, reflected by the reversed decision to close Lakehead Psychiatric Hospital.

Those who supported the restructuring commission emphasized that consultation had to be curtailed to realize the magnitude of the reforms sought, as consensus would never have been achieved. This raises two concerns. First, the limited scope of community consultation meant regional issues were not fully addressed, which led to a partial unravelling of the directives as implementation became imminent. Second, although the commission set the parameters for downsizing psychiatric facilities, the level and timing of support for community programs was unknown. As enhancements to community infrastructure depended on the government's acceptance of the task forces' recommendations, each region addressed the fallout in an environment of organizational flux and financial uncertainty. The incremental support regions received in the interim also appeared more responsive to political imperative than to systematic planning. For example, when it was evident that de-institutionalization would lead to homelessness among former patients, housing initiatives were announced. Operating grants ($50 million) in 1999 and 2000 allowed non-profit agencies to lease housing units and provide support services, while capital grants ($37.9 million) were targeted for the purchase of units. Non-profit agencies developed innovative housing projects and services based on local needs. Such programs preempted a federal-provincial summit on housing proposed by the Toronto mayor, as housing was deemed a national crisis. (62)

After the ministry curtailed one of its main consultation forums, the Provincial Advisory Committee, formal consultation occurred through task force subcommittees. (63) The task forces incorporated considerable representation from the policy community, reflected in their final recommendations. (64) The delay in striking and acting on the task forces' advice, however, made it difficult for community agencies to address clients' needs without the financial and organizational support they required. Local networks of community and institutional agencies initiated coordinated planning, resulting in uneven policy implementation across the province.

The development of community services was delayed for five years following the release of Making It Happen, as transitional funds were contingent on the ministry's review and acceptance of MHITF recommendations. The pace of reform was also slowed down by operational issues related to the development of information systems, organizational strategies to coordinate hospital and community care, and absence of an accountability framework with indicators of appropriate care. Inter-sectoral collaboration has nevertheless progressed to varying extents.

Inter-sectoral coordination

The concept of a system of care implies not only a range of services, but the policies and incentives required to design and deliver programs and to ensure they function as a cohesive system. (65) Planning community care in the mental health sector involves reconceptualizing services as extending beyond acute care to a system of social supports. Coordination across sectors is one of the challenges in realizing effective community care, as it is necessary at three levels (Figure 1). At the macro level, inter-ministerial coordination is required to facilitate policy and operational plans among such sectors as health, housing, employment, addictions, justice, corrections and social services. At the meso or local service network level, coordination must occur among clinical, rehabilitation, housing and other service agencies to design coordinated programs and facilitate access to needed supports. At the micro or client level, coordination is required among the constellation of service providers to ensure continuity of care.

Macro-level: Intra- and inter-ministerial coordination

As the Ministry of Health is the largest ministry in Ontario, intra- and interministerial collaboration is required. In the late 1990s, the ministries of Health, Community and Social Services (MCSS), Housing and Municipal Affairs, and municipal social services met regularly to discuss and resolve mental health issues at the regional level. The Ministry of Health and MCSS developed guidelines for collaboration among divisions responsible for different service components. Once a framework is established, inter-sectoral collaboration is believed to function most effectively at the local level, with greater opportunity to discuss and resolve concerns at the local level. (66) Intersectoral cooperation with health has occurred in several program areas: addictions, supportive housing, children's mental health services, social assistance and supplemental disability benefits, court diversion programs and employment. An area reflecting a lack of intra-ministerial coordination concerns patients' access to medications. While those on social assistance access medications through the Ontario Drug Benefit program, user fees introduced in 1997 led to a nine per cent decline in the use of anti-psychotic medications. (67) Treatment non-compliance is, however, such a serious issue as to have warranted community treatment orders. User fees, which serve as a disincentive to compliance, thus reflect an inconsistent policy stance within the Ministry of Health.

Meso-level: organizational coordination

Coordinating mental health and social services is a complex undertaking as it involves translating policy into client-related activities guided by processes mediated by the activity of dozens of organizations as shown at the meso-level (Figure 1). Operationally, it involves fostering inter-organizational relationships among medical, rehabilitation, housing and other agencies to create a network of services that address clients' varying needs. The activities of these agencies can, however, create an integration outcome very different from the one intended. Coordination involves facilitating relationships and resource flows (information, services, clients, staff) between independent organizations in order to strengthen inter-organizational linkages. It has been defined as a process of combining or relating different services across agencies and program lines. Integration involves formally linking organizational administrations into a cohesive network through a single management structure, and by centralizing, strengthening and rationalizing administrative authority. (68)

[FIGURE 1 OMITTED]

In aggregating services, new forms of vertical and horizontal coordination are required among institutional, community, health and social service agencies to create fewer points of contact for clients. Vertical coordination refers to service agreements among hospital and community-based mental health providers, and mental health and social service providers. From the client's perspective, inadequate service coordination may create a lack of clarity in the services available and how to access them. At the same time, an environment of consolidation poses a threat to organizations seeking to ensure their role in the system design.

Developing integrated systems is thus a complex process as it involves confronting such issues as organizational survival, autonomy and conflicting philosophical perspectives. (69) And while many organizations share common values, translating these values into common service patterns can be a challenge. Organizations must negotiate who will provide which services and how potential gaps will be alleviated, taking into account the strengths of each agency. In 2004, the Ministry of Health announced the introduction of fourteen government-operated local health integration networks (LHINS) across the province: community-based organizations with a mandate to plan, coordinate, integrate, manage and fund care at the local level within their defined geographic areas. Although the LHINS are to include 353 mental health agencies, it is not clear how their services will be coordinated.

Micro-level: service-delivery coordination

While ACT teams coordinate needed services, only a fraction of persons with the most serious illness have access to them, while others may or may not be supported by a case manager. Whether case management provides sufficient links to clinical services is unknown. District health councils reviewed service agencies' operating plans, and assessed their fit with the service framework. However, with the emergence of LHINS, DHCS will cease to exist. A systems approach to service coordination has thus started to develop, but not to the same extent in all communities. Although most organizations cooperate, about twenty per cent are recalcitrant. (70) While the ministry has chosen not to coordinate services through regional agencies, the emergence of LHINS may offer an opportunity to do so. And while some family doctors see case management as an extension of themselves, coordination of family practice with the broader array of mental health services remains a challenge. Models of shared care involving psychiatric clinics in family practices are another means of coordinating services. (71) However, community services are often not available to meet current demand.

Community infrastructure: supports and information systems

Community services

Although limited community reinvestment has occurred through ACT teams, (72) expenditures on community services have not been comparable to those for institutions, and demand still exceeds supply. (73) While ACT teams offer effective support, access to them is limited. Despite the Ministry of Health's goal to develop an integrated system of treatment, rehabilitation and support, programs addressing early psychosis, court diversion, affordable housing and employment are only beginning to be addressed; additional funding and inter-ministerial coordination are required. Although the ministry envisions clients flowing through the system with initial access via primary care, family doctors are not linked to the community services on which their clients rely. In integrating primary care with the broader array of mental health services, client confidentiality and the stigma associated with mental illness limit the degree of client follow-up possible. As community service base budgets were not increased for ten years, wait lists for case management and related community services have grown. Given the paucity of community supports, clients' condition may deteriorate, leading to re-hospitalization; suicides have in some cases been reported for clients on wait lists. (74) Such limited access can also prevent persons in costly in-patient care from being discharged.

Although further investment is planned, releasing funds to the community tied up in institutions is difficult. Transitional funding to support community care is required. The budget for community services has increased twenty-eight per cent from 1995 to 2000, compared to the nine per cent increase in hospital expenditures over the same period. The community component thus increased from twenty-one to twenty-seven per cent of mental health expenditures from 1993 to 2000 (excluding physician services). Despite the Ministry of Health's goal to shift sixty per cent of spending to the community sector by 2003, its objective has not been attained. (75) The restructuring commission estimated $63 to $87 million in community investment was required before reconfiguring psychiatric hospitals, excluding supportive housing. Community groups estimated $400 million was required "to make Making It Happen, happen." (76) The Ministry of Health announced an additional $65 million for community mental health services in 2004.

Information systems

Information systems assist health care professions in linking clients to the services they require and in following their care from institutional to community settings, thereby enhancing accountability. When a client is referred for a psychiatric consult, for example, the psychiatrist is often not aware of the medications he or she is taking; without such knowledge, additional prescribing could potentially lead to adverse effects. While Making It Happen emphasized the adoption of centralized information and referral systems, a comprehensive information system has not been supported. Instead, case-management databases that link various organizations operate in a few communities, but are not compatible in software or the types of services included.
 Despite the risks inherent in de-institutionalization in
 the absence of community reinvestment, Ontario is witnessing
 this reality


Client confidentiality remains an issue in information systems. As clients may not wish to inform their family doctor of a hospital admission, they may decline their consent, which limits the usefulness of information systems. At the same time, a large proportion of clients never receive follow-up services after hospital discharge, due to lengthy waiting lists.

Discussion

Despite a series of Ministry of Health consultation forums in the 1990s, the restructuring commission excluded much of the policy community from the effective axis of authority concerning rationalization decisions. The CMHA nevertheless played a decisive role in influencing the policies articulated in Making It Happen through its ACCESS report. It was, however, unable to influence the allocation of funds on which its vision relied. By gathering the CMHA'S insights through a policy network, the ministry created a tectonic shift followed by retrenchment to the familiar pattern where implementation was concerned. Indeed, it was not until the government established yet another arm's-length body--Mental Health Implementation Task Forces--that a venue was created for members of the policy community who would ultimately oversee implementation of regional plans to contribute their insights.

And while the task forces created a means for the policy community to shape the emerging vision of community care, the extent to which their recommendations will be accepted is uncertain. For despite a sympathetic response from the Ministry of Health, the policy community found government bureaucrats have little influence over implementation. (77) As Harvey Simmons suggests,

in the case of mental health policy, civil servants cannot make major policy changes on their own. Certainly bureaucrats can formulate policies, and they may even formulate radical and innovative policies, but they cannot implement them without support from their political masters or without outside pressure. (78)

The efforts of the groups seeking to influence policy are constrained by their limited access to the government's policy- and budget-setting processes. And while powerful allies within the political structure, medical associations and the public advocate for expansions in acute care services, such outside pressure has been absent for the mental health sector. (79)

Although the divestment and reconfiguration of psychiatric facilities were to generate savings to be redistributed to the community, the cost of employment terminations, capital investments, and operating renovated facilities was greater than anticipated, leading to cost over-runs. Despite a vision of community care, the resources and infrastructure to support it did not materialize in the five years following HSRC'S recommendations. It remains to be seen whether the government accepts the task forces' advice for enhanced community care, public education campaigns and new models of governance.

Despite the ministry's disentangled approach following the release of Making It Happen, coordinated mechanisms would have been beneficial in the early stages to support the development of a province-wide information system and strategies to facilitate coordinated service delivery. Although the ministry encouraged regional solutions, Ontario eluded any true form of "regionalization." Neither the DHCS, ministry regional offices, nor the MHITFS had the fiscal authority to alter patterns of service delivery. As devolution fundamentally alters who makes decisions and oversees control of funds, it entails a bargaining process, and is not simply a juridical act. (80) Without such devolution, regions lack the instruments of authority needed to develop models of coordinated care among the organizations that provide mental health services. Sequential shifts in the locus of planning to the nine task forces, and seven regional ministry offices made program development a moving target.

Establishing a "systems" approach to community care has thus relied on voluntary consensus-based agreements among hospitals and community service agencies through local models of cooperation at the board of directors and management levels. As such reform involves political bargaining and struggles over control of scarce resources, cooperation among hospitals and community agencies to create coordinated service delivery systems has developed unevenly across Ontario. An absence of regional authority with a mandate to promote or create incentives for such reform has thus hindered policy advances. Despite the risks inherent in de-institutionalization in the absence of community reinvestment, Ontario is witnessing this reality.

Conclusion

While the de-institutionalization of the 1970s occurred in a policy vacuum, the policy processes associated with the twenty-first century's de-institutionalization sought to prevent the devastating effects by developing an infrastructure of community support--an infrastructure that remains to be realized.
 The sustainability and credibility of current policies thus
 remain uncertain, suggesting the mental health sector
 will remain a vivid example of welfare state restructuring
 into the twenty-first century


Although divestment of psychiatric facilities was considered as early as the 1960s, the restructuring commission served as a catalyst for reform. As the commission's mandate excluded the community sector, its approach was, however, unbalanced. While the government's reliance on arm's-length bodies was initially used to deflect criticism concerning rationalizations, such processes later served as instruments of delay. While the limited tenure of democratic governments from one administration to another can prevent long-term plans from being realized, the Ontario case demonstrates the profound effect of strategically varying arm's-length bodies' authority for policy development. Indeed, those bodies assigned with rationalizing services (Health Services Restructuring Commission) were granted the power to implement their decisions. Such authority, however, eluded those assigned with devising plans for community reinvestment (DHCS, Ministry of Health, and MHITFS), whose role was to advise. Without the ability to act on their plans, these latter bodies instead supported delay. The unbalanced sequence of policy processes that unfolded is not surprising, given the diminished incentives governments have to invest in areas that affect constituencies with weak political representation.

Although relations between the government and the policy community were formerly antagonistic, they became moderated in the twenty-first century and some unpopular policy decisions were reversed. Coalitions within medical, institutional and community service associations formed, as did an alliance among them that sought to exert greater influence. Although a model of community care involving networks of service agencies emerged, insufficient community resources make the approach to care envisioned unsustainable, given the service inadequacies in early intervention, case management, addictions, justice, housing, disability benefits and employment, and in coordinating the constellation of health and social services on which community care relies. The $65 million in new community mental health service funding announced in July 2004 falls short of the $400 million needed for community supports. Considerable distance thus remains along the road to reform.

Whether the Liberal government possesses the political will to act on the MHITFS' recommendations remains to be seen. Despite the Ministry of Health's announcement of fourteen LHINS, how the task forces' advice will be incorporated to create local systems of care is unclear. Inheriting a several billion dollar deficit on entering office does not bode well for program expansion. The sustainability and credibility of current policies thus remain uncertain, suggesting the mental health sector will remain a vivid example of welfare state restructuring into the twenty-first century.

Appendix 1

Associations representing the medical profession in the mental health policy community are based in the institutional and community sectors. The Association of General Hospital Psychiatry Services (AGHPS) represents the chiefs of staff of psychiatry of the sixty-five general hospitals, and is an important subgroup of the Ontario Hospital Association, given the scarcity of psychiatrists. Following the recent reforms, general hospitals find themselves "sandwiched" as the only facilities offering in-patient care 24/7. As the AGHPS is the primary means through which the Ministry of Health gains access to general hospital units, its influence increased in the 1990s.

The Coalition of Ontario Psychiatrists represents community-based psychiatrists, made up of the Ontario Medical Association (OMA) Section on Psychiatry and the Ontario Psychiatric Association. While members of the OMA participate in Ministry of Health reference committees, they do not necessarily speak for it. Nor did the OMA contribute to the development of the ministry's pivotal report Making It Happen. The OMA Section on Family Physicians was involved in the Physician Services Committee Workgroup on Mental Health that addressed building linkages between family physicians and community mental health services. A mental health task force made up of the OMA, OPA and AGHPS seeks to establish a common provider voice. The AGHPS is instrumental in linking coalition members, and advocates for hospital-based providers.

The OMA, however, considers the CMHA as dominating the current policy dialogue and would like to see psychiatry gain more influence in order to protect resources for treatment. Although the OMA suggests its influence has declined, physicians bring different expertise, and access the Ministry of Health through such alternate channels as the health services division, while other groups do so through the mental health division. The medical profession is thus one of a handful of groups, though not the dominant one in the policy community.

In the community sector, the Ontario Federation of Community Mental Health and Addiction Programs (OFCMHAP) is the largest umbrella organization representing 230 community mental health service agencies. Alternatively, the CMHA is the largest single organization providing mental health services, with thirty-two branches in Ontario and over 100 nationally. Operating through its national, provincial and regional branches, the CMHA leverages its infrastructure to enhance its advocacy and service, and is considered the more influential group. The CMHA and the OFCMHAP also work cooperatively to develop position papers and advocate for common policies.

The author is associate professor, School of Health Policy and Management, York University. She would like to thank the many key informants who shared their insights, as well as the anonymous reviewers of this journal, and Stephen State, Raisa Deber, Allan Tupper and Barbara Wake Carroll for their suggestions on an earlier version of this paper. She would also like to thank the Canadian Health Services Research Foundation, the Ontario Ministry of Health and Long-Term Care and the Alberta Heritage Foundation for Medical Research for their support.

Notes

(1) Twenty per cent of the Canadian population sought mental health care in 2001, and three per cent are affected by serious disability. Mental illness ranks second highest in hospitalization costs, surpassed only by cardiovascular illness; twenty-five per cent of hospital days, and twenty per cent of hospital admissions are due to a psychiatric condition. Ontario, Ministry of Health and Long-Term Care, Mental Health, Finance and Information Management Branch (Toronto: Queen's Printer, 2001); D.T. Wigle, Y. Mao, T. Wong and R. Lane, "Economic burden of illness in Canada," in L.J. Anderson and K. Wilkins, eds., Chronic Diseases in Canada: Supplement 12, no. 3 (1986), pp. 1-37.

(2) See Lawrence Brown, New Policies, New Politics: Government's Response to Government's Growth (Washington, D.C.: The Brookings Institution, 1983).

(3) Interview with a regional director of the CMHA, 26 May 2000. See Ontario, Community Mental Health Committee, Building Community Support for People: A Plan for Mental Health in Ontario chaired by R. Graham (Toronto: Queen's Printer, 1988); Ontario, Ministry of Health, Implementation Strategy Sub-Committee, The Road to Reform. Final Report (Toronto: Queen's Printer, 1991).

(4) See, for example, Peggy Leatt and George Pink, "The use of 'arm's-length' organizations for health system change in Ontario, Canada: Some observations by insiders," Health Policy 63, no. 1 (2002), pp. 1-15.

(5) See Ontario, Ministry of Health, Health Services Restructuring Commission, Advice to the Ministry of Health on Building a Community Mental Health System in Ontario (Toronto: Queen's Printer, 1999).

(6) The ACT involves a multidisciplinary team of professionals who provide twenty-four-hour case-management support in the community, including medication management, crisis care, life skills attainment, and access to community housing, employment and recreational support.

(7) See Ontario, Office of the Auditor General, Report 2002, Ministry of Health and Long-Term Care, Section 3.03 (Toronto: Queen's Printer, 2002), p. 89.

(8) Ontario, Ministry of Health and Long-Term Care, Toronto-Peel Mental Health Implementation Task Force, The Time has Come: Make it Happen, A Mental Health Action Plan for Toronto and Peel. Final Report (Toronto: Queen's Printer, 2002), p. vi.

(9) Paula Goering, "Multisite Comparison of Case Management, Mobile Crisis and Self Help," Community Mental Health Evaluation Initiative 2004; http://www.ontario.cmha.ca/ cmhei/making_a_difference.asp

(10) See P.M. Baranek, R. Deber, A.P. Williams, "Policy trade-offs in 'home care': the Ontario example," CANADIAN PUBLIC ADMINISTRATION 42, no. 1 (Spring 1999), pp. 69-92.

(11) National Forum on Health, Striking a Balance: Health Care Systems in Canada and Elsewhere, Vol. 4 (Sainte-Foy, Quebec: Editions MultiMondes, 1998).

(12) Ontario, Metropolitan Toronto District Health Council, Metropolitan Toronto Mental Health Reform, System Design and Implementation Recommendations. Final Report (Toronto: Queen's Printer, 1996); Ontario, Thames Valley District Health Council, System Design for Mental Health Reform in the Thames Valley District: A Work in Progress (London: Queen's Printer, 1997); and Health Systems Research Unit, Clarke Institute of Psychiatry, 1997.

(13) See Monique Begin, Medicare: Canada's Right to Health, translated by David Homel and Lucille Nelson (Montreal: Optimum Publishing International, 1988).

(14) See Deborah A. Stone, Policy Paradox and Political Reason (Glenview, Ill.: Scott/Foresman, 1988); and Ellen Immergut, Health Politics: Interests and Institutions in Western Europe (Cambridge, England: Cambridge University Press, 1992).

(15) William D. Coleman and Grace Skogstad, eds., "Policy communities and policy networks: A structural approach" and "Conclusion," in Policy Communities and Public Policy in Canada: A Structural Approach (Mississauga: Copp Clark Pitman Ltd., 1990), pp. 14-33, 312-27.

(16) See Evelyn Vingilis and Ted Schrecker, Population and Community Health Unit, Faculty of Medicine, University of Western Ontario, Second Colloquia on Psychiatric De-institutionalization in Southwest Ontario, Synthesis Report (London: University of Western Ontario, 2001).

(17) See Harvey Simmons, Unbalanced: Mental Health Policy in Ontario, 1930-1989. Toronto: Wall & Thomson, 1990).

(18) See Ontario, Ministry of Health, Towards a Blueprint for Change: A Mental Health Program and Policy Perspective, Heseltine Report (Toronto: Queen's Printer, 1983); Ontario, Ministry of Health, Putting People First, Graham Report (Toronto: Queen's Printer, 1993).

(19) Ontario, Ministry of Health, The Road to Reform (Toronto: Queen's Printer, 1991).

(20) Interview with a Ministry of Health and Long-Term Care manager, 27 June 2000; Ontario, Ministry of Health, Putting People First (Toronto: Queen's Printer, 1993).

(21) Interview with a former executive of the Ontario Federation of Community Mental Health and Addiction Programs, 19 November 2001.

(22) Ontario, Thames Valley District Health Council, Multi-year Mental Health Implementation Plans for Thames Valley, 1999-2001 (London: Queen's Printer, 1999).

(23) Interview with a DHC mental health program coordinator, 10 April 2000. See also Simmons, Unbalanced, p. 184, and Ontario, Ontario Council of Health, Committee on Mental Health Services in Ontario, Agenda for Action (Toronto: Queen's Printer, 1979).

(24) Interview with a former executive of the Ontario Federation of Community Mental Health and Addiction Programs, 19 November 2001.

(25) Interview with a DHC mental health program coordinator, 10 April 2000.

(26) Ontario, Metropolitan Toronto District Health Council, A Strategy for TDHC/MOH Partnership to Implement the Toronto Mental Health System (Toronto: Queen's Printer, 1998).

(27) In Alberta and New Brunswick, a provincial board and commission, respectively, were responsible for overseeing mental health care planning as an interim step; responsibility was transferred to the regional health authorities in 2004.

(28) Interview with Ministry of Health mental health program coordinator, 27 November 2000. See also J. Durbin, J. Rogers, D. Macfarlane, P. Baranek, P. Goering, Strategies for Mental Health System Integration, Prepared for the Health Systems Research and Consulting Unit (Toronto: Centre for Addiction and Mental Health, 2001).

(29) See A. Holt, A. Neufeld and R.B. Deber, "The merger that wasn't: Lessons for senior administrators," Healthcare Management FORUM 6 no. 4 (Winter 1993), pp. 33-37.

(30) See Joel Harden, "The rhetoric of community control in a neo-liberal era," in Daniel Drache and Terry Sullivan, eds., Health Reform: Public Success Private Failure (New York and London: Routledge, 1999).

(31) Section 2.10, c. 15, s. 11 (1), 1997.

(32) Interviews with a regional CMHA executive director, 26 May 2000, and a former executive of the Ontario Federation of Community Mental Health and Addiction Programs, 19 November 2001.

(33) Interview with an executive of the Ontario Federation of Community Mental Health and Addiction Programs, 19 November 2001.

(34) The Ontario Health Services Restructuring Commission (1996-2000), Looking Back, Looking Forward, A Legacy Report (Toronto: Longwoods Publishing Co., 2000).

(35) The Ontario Health Services Restructuring Commission, Advice to the Ministry of Health on Building a Community Mental Health System in Ontario (Toronto: Queen's Printer, 1999).

(36) See Health Services Restructuring Commission, Looking Back.

(37) See Simmons, Unblanced, p. 185.

(38) Interview with Ministry of Health mental health program coordinator, 27 November 2000. See Paula Goering, "Multisite Comparison."

(39) Facilities were divested, and reconfigured or closed in London, St. Thomas, Brockville, Hamilton, Whitby and Kingston. In Toronto, the Queen Street Mental Health Centre, the Clarke Institute of Psychiatry, the Donwood Institute and the Addiction Research Foundation were amalgamated into the Centre for Addiction and Mental Health. The ministry operates facilities in Penetanguishene, North Bay and Thunder Bay.

(40) Health Services Restructuring Commission, Advice to the Ministry of Health, p. 7.

(41) Interview with the executive director of the CMHA / Ontario, 14 October 2001.

(42) See Report of the Auditor General, 2002.

(43) Interview with a regional CMHA executive director, 26 May 2000.

(44) Ontario, Canadian Mental Health Association, ACCESS, A Framework for a Community Based Mental Health Service System (Toronto: Queen's Printer, 1998); Paula Goering, J. Cochrane and Janet Durbin, Best Practices (1997); Ontario, Ministry of Health and Long-Term Care, Integrated Policy and Planning Division, Making it Happen: Implementation Plan for the Reformed Mental Health System (Toronto: Queen's Printer, 1999).

(45) Interview with a representative of the Association of General Hospital Psychiatry Services (AGHPS), 31 January 2002.

(46) Interview with a manager in the Mental Health and Rehabilitation Reform Branch, Integrated Policy and Planning, 4 July 2002.

(47) See Durbin et al. Strategies for Mental Health; and P. Goering, et al., "Toward the development of improved access and coordination of the Niagara Region Community Mental Health and Addiction System," Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Toronto, Ontario, 2000.

(48) See Toronto-Peel Mental Health Implementation Task Force, 2002.

(49) Ontario, Provincial Forum of Mental Health Implementation Task Force Chairs, The Time is Now: Themes and Recommendations for Mental Health Reform in Ontario, Final Report (Toronto: Queen's Printer, 2002).

(50) Association of General Hospital Psychiatry Services. Unpublished survey, Toronto, Ontario, 2001.

(51) This subtitle is drawn from Aaron Wildavsky's book Speaking Truth to Power: The Art and Craft of Policy Analysis (New Brunswick, U.S.A.: Transaction Publishers, 1987).

(52) See Carolyn Hughes Tuohy, Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (New York: Oxford University Press, 1999); Ivy L. Bourgeault and M.T. Fynes, "Delivering midwifery in Ontario: How and why midwifery was integrated into the provincial health care system," Health and Canadian Society 4, no. 2 (1996/97), pp. 227-62.

(53) See F. Van Waarden, "Dimensions and types of policy networks," European Journal of Political Research 21 (1992), pp. 29-52.

(54) See R.A. Young, "Tectonic policies and political competition," in A. Breton et al., eds., The Competitive State (Dordrecht: Kluwer Academic Publishers, 1991), pp. 129-45.

(55) See Gilles Paquet and Robert Shepherd, "The program review process: A deconstruction," in Gene Swimmer, ed., How Ottawa Spends 1996-97, Life Under the Knife, Carleton Public Policy Series 18 (Ottawa: Carleton University Press, Inc., 1996), pp. 39-72; Paul Starr, "The new life of the Liberal state: Privatization and the restructuring of state-society relations," in John Waterbury and Ezra Suleiman, eds., Public Enterprise and Privatization (Boulder: Westview Press, 1990).

(56) Psychiatry's authority first declined in the 1930s following its adoption of therapies later found unacceptable and because of its paternalism toward patients. The decline was further reinforced by psychiatrists' inability to reverse legal restrictions on the use of the lobotomy or to halt the trend toward enhanced patient rights concerning committal and treatment. See Simmons, Unbalanced, pp. 218-21.

(57) See Ontario, Ministry of Health, Community Mental Health Snapshot (Toronto: Queen's Printer, 1991).

(58) Interview with a representative of the Ontario Medical Association, Psychiatry Section, 29 January 2002.

(69) Interview with a manager in the Mental Health and Rehabilitation Reform Branch, Integrated Policy and Planning, 4 July 2002.

(60) See Simmons, Unbalanced, p. 202.

(61) Interview with a former executive of the Ontario Federation of Community Mental Health and Addiction Programs, 19 November 2001.

(62) Ibid.

(63) Interview with a manager in the Mental Health and Rehabilitation Reform Branch, Integrated Policy and Planning, 4 July 2002.

(64) See Provincial Forum of Mental Health Implementation Task Force Chairs, 2002, and the Toronto-Peel Mental Health Implementation Task Force, 2002.

(65) See Goering, et al., "Toward the development of improved access."

(66) Interview with the director of psychiatric services in a regional general teaching hospital, 23 October 2000.

(67) See Janet Hux, The Ontario Drug Benefit Program Co-payment: Its Impact on Access for Ontario Seniors, and Charges to the Program (Toronto: Institute for Clinical and Evaluative Sciences, 1997).

(68) See J.A. Fleishman, "Research Issues in Service Integration and Coordination," in AHCPR Conference, Proceedings. Community-Based Care for Persons with AIDS: Developing a Research Agenda. DHHS Publication No. (PHS) 90-3456 (Rockville, Md: U.S. Government Printing Office, 1990), pp. 167-87; T. Jones, "Some thoughts on coordination of services," Social Work 20, no. 5 (1975), pp. 375-78; F. Reburn, "On human services integration," Public Administration Review 37 (1977), pp. 264-69.

(69) R. Agranoff, "Human services integration: Past and present challenges in public administration," Public Administration Review 51, no. 6 (November/December 1991), pp. 533-42.

(70) Interview with an MOHLTC mental health program coordinator, 27 November 2000.

(71) Ty Turner and Alicia de Sorkin, "Sharing psychiatric care with primary care physicians: The Toronto Doctors Hospital experience (1991-1995)," Canadian Journal of Psychiatry 42, no. 9 (November 1997), pp. 950-54.

(72) An ACT team provides support for approximately sixty clients (six clients per staff member) at an annual cost of $900,000. By 2001, about sixty ACT teams were in place to enhance court diversion, psychogeriatric outreach, case management, crisis support services and CTOS.

(73) Mental health services are provided by 370 community programs and 346 special care homes. The Community Investment Fund made $23.5 million available for case management, twenty-four-hour crisis response, housing and consumer/survivor directed supports. The ministry announced $66 million in transitional ($39.6 million), and annualized ($26.4 million) funding for ACT teams, case management, family support and crisis services in 1998. Housing supports and mental health care services for homeless individuals received $45 million in 2000, and the homes for special care per diem was increased by twenty-five per cent. Additional resources have also been allocated for community treatment orders.

(74) Key informant interview with a community program manager in Toronto, 9 November 2004. See also Halton Peel District Health Council, Review of 2003/4 Mental Health and Addictions Operating Plans, Mississauga, Ontario, pp. 2-3. http://www.hpdhc.com/2003-04 MentalHealth-AddictionOpPlanReview.pdf

(75) Public expenditures in the mental health sector increased to $1.7 billion by 2000 (excluding long-term care for the elderly) (Table 2). Mental health rose to 8.8 per cent of health care spending, and to 3.0 per cent of government expenditures by 1997/98. Information obtained from the Ontario, Ministry of Health and Long-Term Care, Canadian Mental Health Association, Ontario Office, 1998; Mental Health, Finance & Information Management Branch, Toronto, Ontario, 2001.

(76) Interview with a CMHA regional director, 26 May 2000.

(77) Interview with the executive director of the CMHA / Ontario, 14 October 2001.

(78) Simmons, Unbalanced, p. 151.

(79) See Royal Commission on the Future of Health Care 2002 (Ottawa, Ontario).

(80) R.D. Putnam, Making Democracy Work (Princeton: Princeton University Press, 1993), p. 23.

(81) Interview with a representative of Association of General Hospital Psychiatry Services, 31 January 2002.

(82) Interview with a representative of Ontario Medical Association, Psychiatry Section, 29 January 2002.

(83) Interviews with the executive director of the CMHA / Ontario, 14 October 2001, and a former executive of the Ontario Federation of Community Mental Health and Addiction Programs, 19 November 2001.
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