POINT OF VIEW

Intersectoral policy reform is critical to the-National Mental Health Strategy The implementation of the National Mental Health Policy'.2 and the five-year National Mental Health PlanJ promises a better deal for people with mental illness. The parts of the policy and the plan address- ing the structural reform of Australia's mental health services have focused heavily on two key policies- mainstreaming and integration.

Mainstreaming requires mental health services to be delivered within the same administrative structure as other health services and for acute psychiatric care to be delivered in general hospitals alongside other acute health services.4 Integration requires the hospi- tal and community components of the mental health service to become a single functionally integrated service to provide, among other things, continuity of care for people with more long-term mental illness.g

The national policy and plan clearly identify, as a priority, the development of the community-based component of the integrated service. However, the public policy implications of caring for people with mental illness and psychiatric disability in the com- munity have not been fully addressed."'

Historical context for national mental health reform The asylum era of the nineteenth and early twentieth centuries was a major effort of its time to reform the care of people with mental illness. Mentally ill people were segregated into small, pastoral asylums where it was expected they could receive humane care." How- ever, with few effective treatments available, and funding not keeping pace with the growing size of the institutions, the therapeutic environment originally envisaged became increasingly

The asylum era contributed substantially to the marginalisation of mental health from both general health and from other social reforms. Asylums assumed almost total responsibility for the lives of their patients-'whole of life' care. This included treatment, accommodation, clothing, food, and vocational and recreation experiences, all provided within a designated social network. The cost of this, however, was confinement, exclusion from main- stream community life, restrictions on civil liberties and increasingly substandard, overcrowded living conditions and a poorer quality of life."'

With growing social, medical, and human rights and economic criticisms of the asylums, service deliv- ery began to move from the institution to a more community-based system of care."." These forces shaped an administrative policy that became known as deinstitutionalisation. l 3 In response, Australia's psychiatric hospitals declined in capacity from 28 1 beds per 100 000 population in the early 1960s to 40 beds per 100 000 by 1992.'

However, being out of hospital did not mean that the symptoms and disability associated with serious mental illness ceased to exist. These individuals can experience significant disability, sometimes intermit- tently or continuously, over an extended period and possibly for life.14 The degree of disability is usually

not static and can fluctuate considerably, even over a short time. The nature of chronic mental illness is such that these people are among those most in need of both mental health and disability support services, but they are least able to obtain them independently.

Some psychiatric hospitals did develop aftercare or outreach services for patients discharged to their families, or into hostel or other accommodation facilities. Aftercare staff attempted to provide visit- ing services to these people, actively working with outpatient clinics and helping with readmission as required. These programs were limited and funded through the health system. Many continued the orientation toward providing some of the 'whole of life' services, including buying houses for aftercare accommodation, and delivering social and rec- reational programs.

During the 1970s and 1980s. new policy frameworks endorsed community-based mental health services as the preferred alternative to long- term hospitalisation and asylum.I5 With the trend to area or regonal health service administration, men- tal health services started to move toward an inte- grated system of care for discrete geographic populations. These area-based services could offer specialised treatment and rehabilitation which could include assessment, crisis intervention, acute inpatient services, community outpatient clinics, mobile treatment teams, domiciliary services, and liv- ing skills

However, the provision of non-health services, such as housing, vocational training, recreation and social and disability supports, was still not addressed in any organised way. In fact, social and disability ser- vices were simply not accessible in community set- tings for people with psychiatric disability as they were for people with other disabilities. The funding and management of the psychiatric hospitals were a state responsibility, and people with psychiatric dis- ability were also seen as a state responsibility and excluded from access to Commonwealth-funded dis- ability reforms.Ix This was translated into almost all health, aged care, welfare, housing and disability sup- port services provided or supported through the Commonwealth. Consequently, people with chronic mental illness and associated disability have been his- torically denied eligibility for a broad range of social and disability services.'

In this void, state mental health authorities began providing (or funding the nongovernment sector to provide) social and disability support services €or people with mental illness and psychiatric disability. This generally arose from necessity rather than as a deliberate policy choice. However, the services were poorly funded, partly from the lack of transfer of hospital-based resources to the community-based services, but also from the traditionally low overall expenditure on mental health. These developments have often congregated mentally ill people in resi- dential settings, which often mirror hospital ward environments, so called 'trans-institutionalisation'.

The attempts to address the 'whole of life' needs of people with mental illness living in the community have seen a plethora of different agencies, including generic support and mental health services, provid- ing existing services. This fragmentation of responsi-

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POINT OF VIEW

bility for delivering different services has resulted in serious breaches of care.Iti

Disability semce reform While these developments were under way in mental health care, the Commonwealth Government was reforming services for people with disability. Funding had been provided under the Common- wealth Handicapped Persons Assistance Act 1974, and social, income support and labour market programs underwent a major overhaul to meet the socialjustice requirements of people with disabilities. However, this focused mainly on people with physical, sensory and intellectual disability.

It was only after significant community pressure that the Commonwealth Disability Services Act I986 rec- ognised psychiatric disability. Even then it was officially afforded a low priority.' This has changed only in the past few years, with the Commonwealth/ State Disability Agreement 1991 (CSDA), and the Mental Health Statement of Rights and Responsi- bilities 1991 .Ip Under the CSDA, the Commonwealth has administrative responsibility for employment- related services, the states have responsibility for accommodation and support services (including accommodation support, respite, recreation, inde- pendent living skills training and community access services, information and print disability services), whereas advocacy services and research and develop- ment are a joint responsibility.

The states and territories received responsibility for administering the bulk of the non-employment- related disability services at a time when major impli- cations for these services were surfacing as a result of the mental health and psychiatric disability reforms.

The Commonwealth Disability Discrimination Act I992 makes it unlawful to discriminate against people with disability, including those with a psychi- atric disability. Legislative prohibitions against dis- crimination on the grounds of mental illness now also exist in Victoria; Queensland, Western Australia, the Australian Capital Territory and Northern Territory.

Nevertheless, there remains a substantial problem in providing equitable access for a group of people who have previously been denied access. Given the relatively small amount of growth dollars going into disability programs and the fact that many other dis- ability groups have influential lobbies for keeping (and increasing) their share of the allocation, the sub- stantial discrepancy referred to above will not be quickly addressed.

Intersectoral policy reform The National Mental Health Policy has advocated an intersectoral links Dolicv to:

L ,

eliminate any explicit or implicit discrimination against people with mental illness in programs and services within and outside the health sector develop formalised policy and planning arrange- ments at Commonwealth, state, territory and area or regional levels to ensure that all programs adequately meet the needs of the clients encourage interagency links and sewice delivery at the local and area/regional level to ensure access to services meets client needs. This policy was introduced because of the restric-

tive guidelines and informal barriers (promoted by resource scarcity) existing in all areas, including those which had been subject to reform. For example, a 1991 census which reviewed the then Commonwealth-funded disability services found that, although 26 per cent of people receiving dis- ability related income support had psychiatric dis- ability, people with psychiatric disability accounted for only 4 per cent of all long-term funded services and 2.2 per cent of all new services.2"

The first National Mental Health Report, released in 1994, estimates that 19 per cent of people granted the disability support pension and 20 per cent of those receiving sickness allowance suffer from men- tal illness.ln Following the CSDA demarcation of ser- vice responsibility between the states and the Commonwealth, it is difficult to aggregate state and territory data on access to programs by individuals with a particular disability type. Many senices do not collect data by disability type as they feel this 'labels' people. They claim it is more important to identify specific disability needs and respond to these. It is of concern that issues such as equity of access for a group, historically discriminated against, may be lost in this argument.

Some consumer profile data are available for the Commonwealth services and the data indicate that 6 per cent of clients accessing employment support under the Disability Support Program have a psychi- atric disability.Is People with mental illness represent 13 per cent of clients in the Supported Accommo- dation Assistance Program.lX

The states and territories have, or are in the pro- cess of establishing, mechanisms to facilitate the necessary intersectoral access and linkages for people with psychiatric disability to the necessary social and disability services. I n

This reform is critical for the success of the National Mental Health Policy and Plan. Health ser- vices are not, and should not, provide the full range of health, social and disability services necessary for people with mental illness and psychiatric disability t o live in the community. There are several reasons for this:

no one service, in this case the mental health ser- vice, should have control over the majority of ser- vices needed by a person. One of the aims of institutional reform was to break this 'whole of life' control; nondiscrimination means that access to those social and disability programs available to people with other forms of disability should be available t o people with psychiatric disability on an equitable basis; mental health professionals are trained to provide treatment and rehabilitation, not services such as disability housing, vocational training or general support. Some of these services (for example, vocational programs) may require special skills or alternatively can be performed by generic social agencies at a much reduced cost (for example, daily living support); mainstreaming the provision of social and disability services as much as possible decreases rnargin- alisation and stigmatisation which may be the greatest barrier people with mental illness have to face in the community. Broadening the range of

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POINT OF VIEW

available services to which mentally ill people have access makes their social environment as normal as possible. mental health services do not have sufficient funding to provide the necessary range of mental health, social and disability services needed by people with mental illness and psychiatric dis- ability. Past attempts to provide comprehensive mental health services in Australia have eventually (and in this context understandably) run into major resourcing problems. As a result, these reforms have often not been able to provide for all the needs of all their clients and have been blamed for this failure. The current reform of Australia’s mental health

services is at a crossroads. Not since the early days of deinstitutionalisation have there been such concur- rent forces for reform and never before has there been such a nationally coordinated approach to reform. Therefore, as a country, Australia is in a period of its history where there is a chance to make enduring changes to mental health service delivery.

To succeed, changes are necessary not only within the health system but also outside it. It is my view that one element which will be critical to the success of the national mental health policy and plan is the reform of the social and disability service sector to ensure access for people with mental illness and psychiatric disability. If mental health services are not going to provide these social and disability services, the out- come of mental health reform becomes, in large part, dependent on changes in departments outside health.

This, of course, causes considerable anxiety within health and mental health services. If the reforms necessary outside the health departments are not forthcoming, and the community tenure of people with mental illness and psychiatric disability fails, not only are the mental health services often held respon- sible, but the impact is felt on the mental health ser- vice structure. The most obvious example of this is the requirement to rehospitalise individuals who are not able to be treated and supported adequately in the community.

The National Mental Health Policy is a health pol- icy and was signed by health ministers. It was con- sidered that health portfolios could not determine policy for other portfolios. However, for mental health reform to succeed, cooperation and commit- ment are necessary. In recognition of this, meetings of health and community services ministers and meetings of housing ministers in early 1994 endorsed the formation of a national coordinating forum for the three key portfolio areas. These are health (men-

tal health services), community services (disability support) and housing (accommodation). Australia’s mental health reforms will depend on whether and how this critical tripod of services is implemented at the coalface.

Harvey Whiteford Queensland Health D+rtment, Brisbane

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