ABSTRACT
Introduction Mental health policy and programmes in Australia have over the past 50 years undergone an enormous range of changes. In essence they have moved from a system dominated by large congregate care institutions to one defined as being a set of essential community-based programmes. This pattern of change is typically presented as being a linear, progressive triumph of advances in biological-medical understandings of and responses to major mental illness and the result of caring and committed governments. It is our contention that the story is much more complex, messy and non-linear and the result of change happening in oftenturbulent environments. More often ‘progress’ has been disorganised, recursive and the product of enduring tensions between the competing interests (care, control, protection and treatment) and the underpinning ideological and theoretical paradigms (psychological, social, legal and biological-medical) of understanding and action in response to the social problem of mental health and mental illness (Bainbridge, 1999; Healy, 2002; Meadows and Singh, 2001). At some points in our local history these different interests and approaches to policy and service arrangements seem to have been in relative harmony. For instance some 50 years ago following very public exposure of appalling physical conditions and the almost total lack of treatment for patients in the mental hospitals in one Australian state, Victoria, a major reform was undertaken under the banner of social psychiatry (Dax, 1992). The resultant changes preceded the introduction of the modern psychotropic medications, were primarily focussed on improvements to the conditions of the old institutions so that patients had better accommodation, food, more privileges, less restrictions on their movements and significantly more connection with the wider community (Dax, 1961). At the same time the reforms also sensibly sought to greatly improve the range and quality of staff, especially medical and nursing, and placed faith in system improvement due to a major upgrade of education, training and research. At other times the nature and direction of change has been more the result of, or has led to, the exacerbation of the tensions between the identified range of interests and approaches to policy and programme development in the mental health field. Current conditions seem to represent a pattern of ‘progress’ which is
underpinned by a number of, more or less explicit, conflictual sets of circumstances on the one hand, around balancing out the competing interests of care and community concern, and on the other hand around the competing definitions of what constitutes the system’s preferred mode of intervention with identified consumers (the preferred – but contentious – Australian term for service users). In order to better understand this story it is necessary to go back to the first National Mental Health Plan, and its component parts, namely the Strategy and the Policy of 1992 (Australian Health Ministers, 1992). Until that time mental health services were virtually the sole responsibility of the Australian States and Territories with the Commonwealth Government playing only a minor role. This chapter focuses on the policy for services for adults between 18 and 65 which is probably the area that is most contested in Australia in relation to the competing paradigms of medical-biological approaches and psychosocial approaches. Current Policy Directions A mix of aims, interests and motives drove the first National Mental Health Plan of 1992. There was, for instance, considerable recognition that services were poorly funded, anachronistic in their reliance on institutional care and offering a type and quality of service, which was significantly poorer than was the case in general health. At the same time the process of deinstutionalisation, which had been a reality, albeit a slow moving one, for some years, was accelerating to such an extent that the imminent closures of institutions required additional resources to carry the massive shifts of the locus and focus to community settings. This policy outcome has been frequently represented as an agreement between the Commonwealth and the States that would precipitate a more rapid modernisation of services in return for increased funding from the Centre (Meadows and Singh, 2001). Thus the first national policy gave a central role to two key concepts, mainstreaming and integration (Healy and Varney, 1995). The former was the policy aim of moving mental health services from their isolated and separatist existence in the old institutions into the context of health policy and service provision. The latter was a recognition that services had to be vertically integrated across a range of mental health programmes which were to be based in both general hospital and community settings and which related to a notion of essential continuity of care. Thus improved inpatient services are proposed to be based in general hospitals and the range of other related services to be delivered primarily through redeployed public sector organisations but now with the emergence of some acknowledgement of other stakeholders, namely, consumers, the NGO or non-government sector and private agencies. In short the primary focus of this first national policy was upon building a better structure of services, which met the needs of consumers and the wider community in a post-institutional world (Whiteford et al., 2002). The implementation was overtaken by a variety of contextual issues. Most importantly it coincided with massive neo-liberal reform of government, which led
to extensive restructures of public organisations, significant reduction in budget commitments, a rush to contract out services and resultant major changes in work practices. In these contexts, the psychosocial interests embedded in the National Plan became diminished and at the same time, the seemingly more efficient medical interventions became more dominant. The second National Plan of 1998 identified further priority areas for reform and in particular identified promotion and prevention; the building of better partnerships across related service areas; and increased quality and effectiveness of services. To some extent this iteration of national policy made the psychosocial interests more explicit. The choice of these goals reflected a combination of the identification of continuing problems of quality; the WHO agenda that has focussed on the notion of burden of disease; and the recognition that outcomes ultimately relate far more to quality of life than they do to levels of symptomatology (Australian Health Ministers, 1998). The new emphasis on early intervention and primary prevention draws on a public health, population based approach that means that the second National Mental Health Strategy provides:
… a broader focus, with stronger emphasis on population health issues and interventions. To a large extent this is both inevitable and desirable. Stemming from the Strategy’s initial concern with the long-term mentally ill, it is necessary that any modern nation widen its concern to mental health issues in the community and the social, political and economic forces that produce mental health disorder. The emphasis on a ‘whole of community’ approach to building resilience and reducing future community morbidity is also consistent with World Bank projections of an increase over the next 20 years in the burden associated with mental illnesses (Commonwealth Department of Health and Aged Care, 2000: 14).
