Restructuring Mental Health Policy in Ontario: Deconstructing the Evolving Welfare State

Article excerpt

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. …