At the outset it is useful to define what is meant by theterm policy. This is not easy as the term has a certainconceptual fuzziness and has been used to describegovernment action, government programmes and/or thepolitical process [1]. In this article the following defini-tion is used: ‘public policy is deciding at any time andplace what objectives and substantive measures shouldbe chosen in order to deal with a particular problem,issue or innovation’ [2].

In free markets consumers and suppliers are to be leftalone to interact and balance supply and demand forservices. Much activity in society takes place in suchmarkets, especially with increasing deregulation andglobalization [3]. It is outside the scope of this paper todiscuss market failure in health, however, it is generally

accepted that governments need to intervene to providecertain services and regulate the market [4]. This inter-vention occurs in the form of specific policy action.Private sector organizations as well as governments havepolicies to guide their operations, however, this paperlimits its discussion to government policy.

In Australia, responsibility for the health system isshared between the Commonwealth, State and Territorygovernments and the private sector. Section 51 of theConstitution does not specifically allocate a role forthe Commonwealth in health apart from quarantine powersto prevent disease entering the country. However, it hasgradually assumed a prominent role following the central-ization of income taxation collection which occurredduring World War II. The fiscal dominance of theCommonwealth has resulted in it raising more revenuethan it spends in directly delivering services, with theStates spending more on their services than they raise instate taxes. This is referred to as vertical fiscal imbal-ance. It is therefore necessary for the Commonwealth totransfer money to the states and territories for areas suchas health, allowing the Commonwealth to influence oreven dictate the direction of reforms. The AustralianHealth Care Agreements are an example of such a trans-fer and understanding these arrangements is importantwhen considering national health policy.

Can research influence mental health policy?*

Harvey Whiteford

Objective: This paper describes the processes involved in policy development and imple-mentation with examples of how this can be influenced by the outcomes of research.Method: The author draws on his experience in the development and implementation ofAustralia’s National Mental Health Policy and on the literature describing public policyanalysis.Results: A five-step process of problem identification, policy development, political deci-sion, policy implementation and evaluation is described. This process identifies how issuesare considered, adopted and implemented by governments.Conclusion: An understanding of this process can inform mechanisms by which scientificresearch can impact on the issues considered and the decisions made in each step ofpolicy analysis and development.Key words: mental health policy, policy analysis, research.

Australian and New Zealand Journal of Psychiatry 2001; 35:428–434

*An earlier version of this paper was presented at the Australian Academyof Science Symposium, Schizophrenia and other Psychoses: TranslatingResearch into Policy and Action, Canberra, October 2000. The author wasthe Queensland representative in the drafting of the National Mental HealthPolicy and Plan between 1989 and 1992, was Chair of the Australian HealthMinister’s National Mental Health Working Group from 1993 to 1997, andCommonwealth Director of Mental Health from 1997 to 1999.

Harvey Whiteford, Kratzmann Professor of Psychiatry

The University of Queensland, P.O. Box 822, Toowong, Brisbane,Queensland 4066, Australia. Email: hwhiteford@worldbank.org

Received 20 November 2000; revised 21 February 2001; accepted 27February 2001.

Commonwealth and State governments fund the publichealth system and contribute most of the funding forprivate non-inpatient services. With the recent decisionto subsidize private health insurance, the Commonwealthgovernment now has an even greater stake in the provi-sion of care in what is supposed to be the private sector.In deciding how to spend this money, politicians arewary of the disproportionate influence of vested interestsand know that modern health programmes can offermore than the health budget will be able to pay for.

This paper identifies from the public policy and healthpolicy literature [3–8] a five-step process of policydevelopment and implementation. Examples from healthand mental health are used to highlight how issues reachthe threshold for being considered for policy attentionand the factors which will shape the policy and itsimplementation. Understanding this process shouldassist mental health researchers to use the outcomes oftheir research to exert greater influence on the policyprocess. Research is understood in this paper in thebroad sense of the generation or identification of newknowledge, and is not limited to biomedical research.

Problem identification

A policy is usually developed in response to a real orperceived problem. The identification of this problemoccurs within a larger social, cultural, historical andpolitical environment. The intent of action in any ofthese broad areas may be unrelated to health but stillhave an impact on it. For example, a political decisionto address a macroeconomic problem, for example toreduce a budget deficit, will impact on the spendingdepartments (e.g. health and social security). In theAustralian States and Territories, health and educationaccount for nearly half of the government outlays andwill be confronted with budget cuts to reign in thedeficit.

Given that hundreds of variables impact on the healthof a population and the functioning of any health system,how does one or more of these become identified asneeding attention? Roberts and colleagues [8] highlighttwo mechanisms which determine this selective atten-tion. First, cultural norms and social attitudes provide aset of filters that selectively focus or divert public atten-tion. Some aspects of the functioning of the health sectorare taboo and not to be discussed in public. This was thecase with the plight of mentally ill individuals in largepsychiatric hospitals until the 1960s. A more recentexample is doctor-assisted suicide of patients with termi-nal illness. With a change in societal attitudes, previouslyneglected areas such as these can become a topical socialissue and a problem needing attention.

The second mechanism relates to the role of issueentrepreneurs. These individuals or groups act on issueswhich emerge from the filters to articulate (or create theperception of) a public problem. The entrepreneurs whotake up these issues may be politicians, bureaucrats orparticular interest groups within the community. All seekto put a particular issue on the public’s radar screen.Sudden infant death syndrome is an example of successin doing this. The motives of issue entrepreneurs can bevaried. Some act on the basis of their conviction of theneed to address a particular area. A coalition with suchconvictions, including the Australian National Associ-ation for Mental Health and the Royal Australian andNew Zealand College of Psychiatrists, acted as issueentrepreneurs between 1984 and 1989 to build the mom-entum for the National Mental Health Strategy.

Motives of political players can be similar but can alsobe political in the electoral sense. This may not be rec-ognized by others involved in the debate. The willing-ness to adopt and fund policies is influenced by theelectoral cycle, with unpopular policies avoided, andpotentially popular policies introduced, in an electionyear. Political and bureaucratic competition can emergebetween individual politicians or branches of govern-ment. The competition between government departmentsand between States and the Commonwealth often reflectpolitical rivalry when different political parties hold gov-ernment in different jurisdictions. Alternatively it canreflect the long-standing Commonwealth/State powerstruggle for influence in the health system.

To achieve a national (as opposed to a Commonwealth)policy requires at a minimum the formal agreement of theCommonwealth, State and Territory governments. Priorto the adoption of the National Mental Health Policy [9],the Commonwealth considered mental health to be theresponsibility of State and Territory governments and wasnot supportive of a national policy. A critical piece ofresearch helped change this. A report prepared in 1988for the Commonwealth by Peter Eisen and KevinWolfenden demonstrated that Commonwealth expendi-ture for people with mentally illness was far more thanthe total cost of all State mental health expenditure. Thiswas confirmed by the National Health Strategy [10]which showed the extent of the Commonwealth expendi-ture on people with mental illness was $2.58 billion in1991/1992 (e.g. on sickness benefits, pensions, the Medi-care Benefits and Pharmaceutical Benefits Schemes). Thecombined expenditure of the public mental health ser-vices run by States and Territories was only $871 millionin that year.

The research went further and highlighted the incon-sistencies in the existing social policy framework as itapplied to mental health and psychiatric disability services.

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For example, the Commonwealth spent $1.45 billion in1991/1992 on income security for people with mentalillness and psychiatric disability, but at the same timeexcluded them from the programmes designed to decreasedependence on welfare payments and help disabledpeople back into the workforce (e.g. in the Common-wealth Rehabilitation Service). Research such as thisbecame tools for the issue entrepreneurs and helpedestablish the need for a national approach to mentalhealth in which the Commonwealth became a key playerin terms of funding and national leadership.

The interaction of social filters and issue entrepreneur-ship tends to produce certain patterns in the process ofproblem definition. An issue/attention cycle develops inwhich issues fluctuate as a matter of public attention.One reason for this lies in the incentives and behaviourof modern mass media. The revenues of print, radio andtelevision media all depend on circulation or audience.Media outlets believe that readers, listeners and viewersconsume news, in part, for its entertainment value.Stories become stale after a time and media outlets haveincentives to move to new, interesting topics to attract orretain viewers and readers. Politicians have similarincentives. Voters tend to want new ideas and not thesame old programme.

Media in market economies tends to focus on scandaland/or personalities, which at its worst is called tabloidjournalism. There is also a herd pattern or pack mental-ity found among the media. Competitive media outletsfeel compelled to cover a story simply because otheroutlets are doing so. This obviously reinforces theissue/attention cycle since massive coverage results inmore impact but also makes the stories ‘wear out’ faster.Issue entrepreneurs have to be patient as their issuecycles in and out of public attention. However this atten-tion cycle can also modify social attitudes and normsthereby influencing the social filters. In recent yearsthere has been concern about the plight, and alternativelythe dangerousness, of mentally ill people living in thecommunity. In Australia this has not escalated to a sus-tained demand for reinstitutionalization.

What is the role for the scientific community in prob-lem identification? The outcomes of scientific research,provided strategically and in a way that promotes readyconsumption, can focus selective attention in problemdefinition with a considerable impact. It can determinewhether the issue matters and what can be done toaddress the problem. The Global Burden of Diseasestudy [11] is an example of how quantitative summarymeasures of the research can demonstrate whether anissue matters. Using the disability adjusted life year(DALY) mental disorders were found to be responsible fornearly 30 per cent of the non-fatal disease burden [12].

The controversial technical issues surrounding the DALYdid not affect the impact of this data and the messagereceived by policy makers is that mental disorders aremuch more burdensome than previously thought.

Likewise epidemiological studies in the area of mentalhealth [13] have demonstrated that the majority of peoplewith mental health problems do not access health practi-tioners. Seventy-five per cent of those who do, accessgeneral practitioners. This has focused attention on theneed to increase access to services and, given the limitedsupply of providers, ensure the cost-effectiveness ofthose treatments being provided to individuals whoaccess care.

There is a further role for scientific data. Issue entre-preneurs are usually seen as less than objective withregard to the issue they are advocating for. Governmentsand the media often wish to gain an opinion independentof the issue entrepreneur, and turn to scientific expertsfor an assessment of whether a problem exists, its natureand extent. Research is immeasurably strengthened bybeing seen as independent [14]. However the policydebate can and does proceed in a data vacuum and sci-entific information is only one input. But without objec-tive information myth, prejudice and ideology willdominate the debate.

Development of a policy option

Once the problem has been identified there is a need tofind a way to address it. On occasions the option pro-posed to fix the problem is predetermined. This occurswhen a political party is elected with an explicit plank ofits platform to take certain action in an area. However,usually any political party’s pre-election mental healthcommitments are light on substance. Once elected it mustfind solutions to the problems confronting government.

How is a response in the form of policy developed?Governments often start with local or internationalexperience in similar areas. When the problem is at thesystems level, for example the need to increase equity orefficiency, health is considered an industry and thesolutions which are applied to other industries are oftenapplied to the health sector. In health and mental healthservices the implementation of routine outcome mea-sures is considered as essential in order to provide cus-tomer feedback on services. The first National MentalHealth Plan [15] identified consumer outcome measuresfor this purpose [16–18]. Competition among health ser-vice providers can also be promoted, as this is believedto bring greater efficiencies. The drive to achieve ‘valuefor money’, and not only cost containment, is an explicitimportation of market concepts into the Second NationalMental Health Plan [19].

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On occasion a local or international scientific discoveryprovides an option so clearly revolutionary that the argu-ment for adopting the findings of the research as policy isoverwhelming. However, most research findings addincrementally to the knowledge base. Their application topolicy and services is not always apparent. However,even when research repeatedly demonstrates that a par-ticular action is beneficial, it can take many years for thisto find its way into policy. It was not until 1970, 20 yearsafter its efficacy was established that lithium wasapproved by the Federal Drug Administration in the USA[20]. Despite the well-established efficacy of psychoedu-cation and rehabilitation in improving outcomes in schiz-ophrenia, these components of treatment are not yetwidespread in Australia [21].

It is necessary to build the political will and institu-tional capacity to make a success of a particular optionwhether it is being ‘imported’ or developed locally. Polit-ical will depends, in part, on the likely public support forany particular option and the vulnerability to which poli-ticians are exposed given the electoral cycle. Stakeholderanalysis is used to determine the position of relevantgroups and individuals both inside and outside govern-ment who are likely to influence the policy choice andthe success of its implementation. Policy developmentthreatens change and will therefore be resisted by groupswith certain vested interests.

Stakeholder analysis combines two distinct groups ofanalysis within political science. One is interest groupanalysis and the second group is bureaucratic analysis.The first consists of understanding those groups in thecommunity that are advocating for government action.The second is focused on competition among agenciesand organizations within government. Stakeholder analy-sis allows the opportunity for research data to be collatedand analysed to address the options being considered. Itmay even allow time for new research to be commis-sioned. When an option has to be chosen in a short timeframe there is little or no time for stakeholder analysisand only a small window of opportunity (often a fewmonths) for research to influence policy [22]. Here it isa case of advocating with information already available.Following the 1997 Port Arthur shootings there wereinaccurate media reports concerning Martin Bryant’smental state. The immediate debate in the bureaucracyand media turned on the issue of whether the problemneeding policy attention was that of dangerous mentallyill individuals in the community or gun control. Researchdata available at the right time helped swing the debate.Philip Alpers, a New Zealand gun policy researcher, hadpresented at a conference in Melbourne just before thePort Arthur tragedy. His paper reported that the majorityof mass civil homicides are not committed by persons

with known mental illness discharged from hospital andthat most held a licence for their firearm [23]. Mediacoverage and government consideration of this datahelped successfully turn the debate toward the option ofstricter licensing of firearms.

Overriding the stakeholder analysis is the question ofwhether a given option adopted as a policy position ispolitically feasible. Science and politics can clash whenthe two come to irreconcilable conclusions. The debateabout needle exchange programmes is an example [24].The scientific data supported the use of such pro-grammes but the political view was that they would beunpopular with the electorate. The likelihood of gettinga policy adopted depends on the situation, skill and com-mitment of its advocates in the political environment.

Political decision

The adoption of a particular option as policy is a polit-ical decision. The factors bearing on this are the relativepower of each player in the political game, the positionstaken by them and the intensity of commitment for oragainst the policy. Within the political sphere, theseplayers include not only the Health Minister, but also hisor her staff, other key Ministers (especially the Ministerfor Finance and/or the Treasurer) and their staff and thePremier or Prime Minister and his or her social policy orhealth policy adviser [7]. Senior government bureaucratsin each of these departments are often exceptionallyinfluential through the advice they give to the Minister’soffice. For each of these individuals and groups an analy-sis can be made of their interests, power and influence.Successfully negotiating a coalition of support usuallyinvolves bargaining and trade-offs. Throughout the pro-cess of negotiation, the content of a policy will be mod-ified, as compromise is usually necessary to achieveconsensus.

Decisions on health policy are characterized by levelsof complexity, which need to be specifically considered.Health is technically complex in both a clinical andsystems sense. Service policy often needs to change mul-tiple parts of the system at the same time, with failure inone area undermining the success of change in another.The failure of community accommodation for patientsdischarged from psychiatric hospitals (often the respon-sibility of the Housing Department) can seriously under-mine a policy of expanded community based mentalhealth care and the closure of hospital beds [25].

Another component of this complexity is the concen-trated costs on groups renowned for being well orga-nized and influential, for example the medical professionand the pharmaceutical industry. The beneficiaries (civilsociety and consumers) are less informed and often less

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organized. This can create significant political obstaclesto reform. The development of national and State con-sumer advisory groups under the National Mental HealthStrategy was in part to help address this imbalance [26].The benefits of reform are often dispersed and this, com-bined with the lack of political influence of some recipi-ents, makes it difficult to create significant politicalsupport for reform which will benefit them. The closureof a ward in a psychiatric hospital with the savings goingto community-based services is likely to bring a muchmore vigorous response from the staff who are to beaffected in the hospital than the potential beneficiaries ofthe community services.

To build support for the policy it is useful to align itwith symbols which are seen as ideologically unchal-lengeable. This can generate wide public support. Com-munity mental health care was aligned with ‘freedom’.Health is said to be a ‘human right’ and ‘equity’ is soughtin access to health care. All align a health issue with theuniversally supported symbols of freedom, human rightsand equality.

When an impasse is reached, reframing of the policycan often overcome differences between groups. Thepolicy position of allowing patients to be involuntarilydetained in private hospitals was initially seen as unsup-portable because of the perception that the private sec-tor would profit from patients being treated in hospitalagainst their will. This was reframed to state that aperson with mentally illness who had paid for theirprivate health insurance should be allowed to remainwith the psychiatrist (and hospital) of their choice evenwhen (or especially when) their illness was at its worst.The policy became politically acceptable and wasadopted. Perceptions of reform are matters of values aswell as facts. Political decision making is about emotionas well as data.

Policy implementation

It often seems as if the hard work is over once a polit-ical decision has been made to adopt a particular policy.However in reality the hard work has only just begun.Many policies are developed and never implemented.Governments are not omnipotent and in reality have onlyfour main levers available in formulating and imple-menting an option [5,8]. These are the financing systemwhich determines what resources are available, wherethese resources come from and who has access to them;the payment system which determines on what termsthese resources are made available to individuals andorganizations; the organization of the health system inboth the distribution of services and how they respond toconsumer demands; and the regulatory system which

imposes a set of constraints on services, for examplehow providers are trained and recognized, how the medi-cal and pharmaceutical benefit schemes operate and theregulations which cover the private health insurance andprivate hospital systems.

Assembling these levers into an implementation plan(in the case of Australia, the first and Second NationalMental Health Plans) requires the ongoing support of theprofessional and community organizations which cametogether to ensure the policy was adopted in the firstplace. Alignment with other organizations consolidatessupport and enhances implementation. Such an alignmenthas occurred between governments and the StrategicPlanning Group for Private Psychiatric Services. Theprivate sector had not been involved in the early imple-mentation of the National Mental Health Policy or Plans.The more broadly representative and independent MentalHealth Council of Australia has strengthened the role ofnon-bureaucrats in the ownership and implementationof the Second National Mental Health Plan.

The financing lever was used to help drive the imple-mentation of the National Mental Health Policy. The firstNational Mental Health Plan [15] detailed how thePolicy would be implemented and initially came with$135 million (over 5 years) of specific Commonwealthfunding. This was increased a year later as discussedbelow. The provision of this funding through Schedule Fof the 1993–1998 Commonwealth/State Medicare Agree-ments, was made to States on the basis that they not onlyimplement the Policy but maintain their own financialeffort in mental health care. Importantly, there was arequirement on all parties to provide data on their pro-gress in implementing the Policy. The data providedunder the Medicare Agreements was drawn from a set of49 national policy indicators adopted by the AustralianHealth Ministers Advisory Council (AHMAC) MentalHealth Working Group in July 1993 [27]. The indicatorswere first collected for the 1992/1993 years, publishedin March 1994, and provided a baseline of activity forfuture years. Published annually since that year in aNational Mental Health Report, the information becamea public benchmark for measuring progress and wasused by community groups and the media.

During the life of the first National Mental HealthPlan the political party in power in all governments(with the exception of the Northern Territory) changed.However the national reform agenda continued essen-tially unchanged. In part this was because substantialpublic expectation for change had been created andprogress toward meeting this was being reported onannually. Successful implementation was rewarded withpositive community reaction. Poor progress was metwith demands to do better. The other reason for sustained

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implementation was because the Commonwealth fund-ing for reform was locked into the 5-year Commonwealth/State (Medicare) financing agreement. Once both majorpolitical parties had, either at State or Commonwealthlevels, supported the National Mental Health Policy itwas seen to enjoy bipartisan political support.

Key players within and outside government do notoften remain in a position to see the policy implementa-tion through to conclusion. Institutional structures suchas the AHMAC National Mental Health Working Groupmet regularly even though the membership changedduring the life of the policy. Communicating both thesuccesses and failures of the policy implementationenhances credibility, institutionalizes the process andlegitimizes action to modify the implementation [28].

Finally the implementation of policy is not linear andrarely occurs according to plan. Flexibility in adapting toemerging forces which can create barriers and opportu-nities is essential. The implementation of the NationalMental Health Plan provided a classic example of howan unplanned enhancing of the process can occur. Thenegotiations on, and drafting of, the National MentalHealth Policy commenced in 1989 and concluded withthe adoption of the Policy by all Health Ministers inApril 1992. A parallel process at the time was the HumanRights and Equal Opportunities Commission (HREOC)Inquiry into the Rights of Persons with Mental Illnesscarried out by Commissioner Brian Burdekin between1991 and 1993 [29]. The 1992 Federal Budget, withBrian Howe as Health Minister, contained $135 millionfor the National Mental Health Plan. When the HREOCreport was released in 1993 with extensive media cover-age, the Federal Health Minister was Graeme Richardson.Senator Richardson announced additional Commonwealthfunding in response to the deluge of adverse mediacoverage surrounding the issues Commissioner Burdekinraised. This amounted to a further $134 million overthe remaining 4 years of the National Plan, effectivelydoubling the budget for the National Mental HealthStrategy.

Evaluation

Evaluation is often the most neglected area of policydevelopment and implementation. By the time an evalu-ation of a policy is due to be conducted, most of the gov-ernment officials originally involved in its developmentwill have departed. During the implementation, organi-zations who support the policy may have wilted (orgrown), and those who oppose it may be stronger. Theenvironment will be different. For an evaluation to havecredibility it must be as transparent and independent as possible. It was difficult to find individuals within

Australia who had not been part of or impacted upon bythe National Mental Health Strategy. Several individualsfrom outside the country were recruited to help ensureobjectivity and this also provided an international pers-pective on the strengths and weaknesses of the policyand its implementation [30].

Feeding the evaluation into a revision of the policycompletes the cycle of policy development and imple-mentation. While the National Mental Health Strategydemonstrated success in promoting health sector reform,an objective evaluation demonstrated insufficient atten-tion to certain specific groups (for example, child andadolescent populations, aged care, forensic groups). Issuessuch as prevention, early intervention and primary healthcare were also identified as relatively neglected. Thesehave been incorporated into the Second National MentalHealth Plan [19].

However in revising the policy it is important to resistthe temptation to neglect those areas that have been suc-cessful and let the pendulum swing too far in the direc-tion of areas that have been less well addressed. InAustralia we run the risk of this under the Second Plan ifwe neglect service reform for those with establishedmental illness while trying to enhance mental healthpromotion and illness prevention. While we broaden thescope we must ensure that scarce resources remainfocused on key areas where the best outcomes can beachieved. If we spread our effort and resources too widely,effectiveness will be diluted with an eventual backlashfrom the core mental health constituency and a loss ofcredibility for the Policy.

Conclusion

Policy development, adoption and implementation isoften seen as a political and bureaucratic exercise. How-ever research can impact on all these levels by providingoptions which are scientifically validated and data whichallow decisions to be made more on the basis of fact andless on the basis of political expediency and ideology. Indoing this it is necessary for the information to be avail-able and communicated to the right people at the righttime. It must be communicated in a way which can beassimilated by individuals unfamiliar with the technicaldetail and yet able to understand the essence of the argu-ment or the information. It is often necessary to reframethe information or reduce it to what may seem to the sci-entist to be overly simplistic or inexact. Scientists mustbe able to tolerate imperfection in the use of their data asthe political process inevitably involves oversimplifica-tion, compromise and trade-off.

The debate about whether science and clinical practicecan be more proactive is important [31]. In their recent

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book on clinical futures, Marinker and Peckham [32]argue that anticipated breakthroughs in science and tech-nology, and their potential impact on prevention and treat-ment of disease, need to be incorporated into thinkingabout health policy. They rightly note that political con-sideration of economic and social futures dominate thehealth debate to the exclusion of what is coming down thehealth research pipeline. The likely scale of medicaladvances, including in psychiatry, presents opportunitiesfor researchers and clinicians to play a much more pro-active role in health policy. To do this they will have to better understand the complex environment of policydevelopment and implementation and be prepared to enteran arena many see as unfamiliar and disturbingly irrational.

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