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Social Work in Health Care

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Mental Health System Reform

Wes Shera PhD , Uri Aviram PhD , Bill Healy MA & Shula Ramon PhD

To cite this article: Wes Shera PhD , Uri Aviram PhD , Bill Healy MA & Shula Ramon PhD (2002)Mental Health System Reform, Social Work in Health Care, 35:1-2, 547-575, DOI: 10.1300/J010v35n01_11

To link to this article: http://dx.doi.org/10.1300/J010v35n01_11

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THE WORKINGS OF THE SYSTEMAND SYSTEM CHANGE

Mental Health System Reform:A Multi Country Comparison

Wes Shera, PhDUri Aviram, PhDBill Healy, MA

Shula Ramon, PhD

SUMMARY. In recent years many countries have embarked on varioustypes of health and mental health reform. These reforms have in largepart been driven by governments’ concerns for cost containment which

Wes Shera is Dean, Faculty of Social Work, University of Toronto, Canada. UriAviram is Zena Harman Professor, Paul Baerwald School of Social Work, The HebrewUniversity of Jerusalem. Bill Healy is Head, Department of Social Work and SocialPolicy, Faculty of Health Sciences, La Trobe University, Bundoora, Australia. ShulaRamon is Professor of Interprofessional Health and Social Studies, Division of SocialWork, School of Community Health and Social Studies, Anglia Polytechnic Univer-sity, Cambridge, England.

This paper was presented at the Second International Conference on Health andMental Health, Melbourne, Australia, January 12-16, 1998.

Since the presentations dealt with policy developments at that time, readers shouldbe aware that changes have occurred since this paper was presented.

[Haworth co-indexing entry note]: “Mental Health System Reform: A Multi Country Comparison.”Shera, Wes et al. Co-published simultaneously in Social Work in Health Care (The Haworth Social WorkPractice Press, an imprint of The Haworth Press, Inc.) Vol. 35, No. 1/2, 2002, pp. 547-575; and: Social WorkHealth and Mental Health: Practice, Research and Programs (ed: Alun C. Jackson, and Steven P. Segal) TheHaworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2002, pp. 547-575. Single or mul-tiple copies of this article are available for a fee from The Haworth Document Delivery Service[1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: getinfo@haworthpressinc.com].

2002 by The Haworth Press, Inc. All rights reserved. 547

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has, in turn, been driven by an increasing process of global marketizationand the need to control national deficits. A critical issue in these reformsis the increased emphasis on the use of “market mechanisms” in the de-livery of health and mental health services.

This paper uses a policy analysis framework to compare recent devel-opments in the mental health sector in Canada, the United States, Britainand Australia. The common framework to be used for this will focus on:the defining characteristics of the society; legislative mandate; sectoriallocation (within or separate from health sector); funding streams; organ-ising values of the system; locus of service delivery; service technologies;the role of social work; interprofessional dynamics; the role of consumers;and evaluation of outcomes at multiple levels. This analysis provides anopportunity to explore similarities and differences in mental system re-form and in particular identify the challenges for social work in the field ofmental health in the 21st century. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<getinfo@haworthpressinc.com> Website: <http://www.HaworthPress.com> © 2002by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Comparative, mental health, policy, service system, pro-grams, practice, multi country

INTRODUCTION

In recent years many countries have embarked on various types ofhealth and mental health reform. These reforms have in large part beendriven by governments’ concerns for cost containment that has, in turn,been driven by an increasing process of global marketization and theneed to control national deficits. A critical issue in these reforms is theincreased emphasis on the use of “market mechanisms” in the deliveryof health and mental health services. Managed care, managed competi-tion, and mixed service economies are but a few of the terms being usedto describe these reforms (Shera, 1996).

Mechanic and Rochefort (1996) observe that national health sys-tems, throughout the world, experience a number of pressures in com-mon related to demographic and epidemiological factors, developmentsin science technology, medical demand, and rising public expectations.They argue that these pressures are producing convergence in the objec-tives and outcomes of these systems in several key areas including

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cost-containment, health promotion, expansion of access, primaryhealth care, patient choice, and the linkage between health and socialservices. Chernichovsky (1995) argues that the reforms being made inresponse to these pressures differ according to the culture, social, his-torical and political circumstances of each country and typically musttake into account the advantages offered by existing institutions and po-litical realities.

Key differences can be seen between mental health care and generalmedical care but these differences have not been the focus of as muchscholarly work as in the area of health. Some helpful work in this area,however, includes: Rochefort’s (1992) comparison of the United Statesand Canada; Huxley’s (1990) comparison of the United States and Eng-land; Hollingsworth’s (1992) analysis of mental health services in theUnited States, Germany and the United Kingdom; Ramon and Mangen’s(1994) cross-national comparison of community care; and Goodwin’s(1997) comparative mental health policy in Western Europe and NorthAmerica.

This article intends to use a comparative policy framework to com-pare recent developments in the mental health sector in Britain, Israel,Canada and Australia. The framework used for this comparison focuseson: the defining characteristics of the society; legislative mandate; sec-torial location (within or separate from health sector); funding streams;organizing values of the system; locus of service delivery; service tech-nologies; the role of social work; interprofessional dynamics; the role ofconsumers; and evaluation of outcomes at multiple levels.

Given the length of this article, it is not possible to provide a signifi-cant amount of detail on each country’s mental health system. We havesimply included major highlights of their mental health reforms. Hav-ing provided these snapshots the authors will then use the comparativeframework to identify several emerging themes.

THE BRITISH MENTAL HEALTH SYSTEM:RECENT TRENDS

Three legislative acts relevant to the mental health system werepassed in the 1990s:

1. The Community Care Act 1990.2. The Patients in the Community Act 1995.3. The Carers Act, 1996.

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Implemented since 1993, the impact of the Community Care Act hasdominated the mental health system much more than the existing 1982Mental Health Amendments Act (of the 1959 Act) or the two newpieces of legislation from 1995 and 1996, even though it was not fo-cused on mental health services.

The Community Care Act (Dimond, 1997) led to the introductionwithin the NHS (National Health Service) and to a lesser extent also inthe SSD (social services departments, which form part of local authori-ties) of commissioning and providing sections, in which the first is re-sponsible for planning and purchasing services, whereas the second–inwhich most health professionals are located–delivers the service. Fur-thermore, health units, such as hospitals, were allowed to become inde-pendent trusts within the NHS, with its own capital and revenue, and inreturn had to balance their books without reliance on the area or re-gional health authority. General Practitioners (GPs, family doctors)who are usually the first port of call for health problems, could becomefundholders, if they so choose. About half of them did choose to godown this route.

The Act also introduced Care Management, or CPA (care programapproach) within both health and social care (DoH, 1990; Carpenter &Sbaraini 1997). This has meant that people with serious mental healthproblems were assessed and offered an individualized plan of action.The focus was to be need rather than service led, but a ruling that unmetneeds would only be recorded and that meeting needs depends on finan-cial availability has meant that the change in orientation is too small tolead to a real shift within the service culture.

Some authorities are attempting to improve their care managementarrangements and are involving users as trainers of staff; too few au-thorities and services have taken up the strengths approach, while themajority continues to focus on problems and weaknesses. In particular,the reviewing system of both CM and CPA tends to be merely mechani-cal and tokenistic. Those who became commissioners were usually ini-tially enthusiastic about the potential for positive change in the act;those who became providers were the doubters and the cynics. Serviceusers and their relatives (a growing lobby group) were initially cau-tiously optimistic about care management and GP fundholding.

In a minority of cases commissioners involved users in an advisorycapacity in the planning process, although usually it is the rhetoricaround the desirability of such involvement which is in abundance.Formally each health area has representatives from the CHC (Commu-nity Health Council) on its planning committees. Although the CHCs

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have representatives of local voluntary groups they rarely engage directusers of mental health services or their relatives. Providers felt–andcontinue to feel–humiliated by these changes, overwhelmed by theamount of paperwork, and by the decrease in services they could offerto their clients. Housing and day care became more difficult to secure,as well as hospital beds. It soon became clear that the available budgetfor the implementation of the act is far less than was/is needed forproper individualized plans. In fact, budgets were cut in real terms ev-ery year from both the NHS and the SSDs, as part of a policy aimed atcurtailing public sector expenditure and existence. Yet it is interestingto note that the general public did not support these cuts, even thoughmany thought that the public sector was not cost-effective and the gen-eral public did not wish to see the health and social care services privat-ized, despite incentives offered by the government to those opting forprivate health care and to private corporations themselves. It is gener-ally accepted now that the health policy of the previous government wasone of the major issues leading to its resounding rejection by the elec-torate on May 1st 1997, when the Labour government came to powerwith a huge majority.

The scarcity of psychiatric hospital beds was/is due to a national pol-icy of closing psychiatric hospitals, which got off the ground aftertwenty years of lip service in the early 80s, as well as due to cuts in thebudgets of general hospitals (which affected not only beds for mentalillness). However, it is also due to reluctance to consider seriously alter-native asylum facilities in the community until the beginning of the 90s.The new government has just published a White Paper on its proposedchanges to the NHS structure (9th December 1997). GPs fundholdingwill be stopped, but GPs and nurses will form local purchasing consor-tia. The internal market will be also formally abolished, though it is un-clear from the paper whether this is going to happen or only appear to behappening. Thus the importance of primary care is confirmed, on the as-sumption that this is the tier nearer to the patients, yet the patients them-selves are mostly kept out of the planning and purchasing process.Service contracts will be allowed to run longer than the current limit ofone year (Ham, 1998). The provisional verdict is that the new adminis-trative change is too superficial to lead to the more radical changeswhich are necessary for a health NHS at more than one level.

The Patients in the Community 1995 Act introduced supervision reg-isters and supervision discharge orders which apply specifically to peo-ple deemed to suffer from serious mental illness who are not complyingwith taking their medication on a regular basis. These people are as-

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sumed to be in danger of relapse and thus likely to be harmful to them-selves or to others. Although the number of self-harm acts far outstripsharm to others and there has been no increase in harm to others by pa-tients since the closure of the psychiatric hospitals, this act was pro-duced due to the pressure of the media, relatives, and some psychiatristsunhappy with the closure of the psychiatric hospitals. The lack of evi-dence of any significant increase in the number of homicides carried outby seriously mentally ill people was masked by the few killings whichthey did, and which–understandably–felt as disasters that could havebeen avoided. Huge sums have been spent on inquiry committees whichinvariably highlighted unsatisfactory collaboration between and withinhealth and social care services each engaging in passing the buck exer-cises (Sheppard, 1996). Two years after its introduction, it continues tobe unclear what the benefits of this act (which does not give a preferen-tial right to treatment or to services) and even how many people it af-fects, as figures tend to fluctuate considerably from one area to another.

The fact that the media campaign focused on highlighting killings byblack men has only added to the sense of discrimination felt by blackservice users and their families, demonstrated by the higher rate of com-pulsory admission and hospitalization within closed facilities for blackmen than for the rest of the population (Fernando, 1993). The combinedeffect of the Community Care Act and this Act has led to greater focusthan before on people with serious mental health difficulties, side byside with severe reductions in work with those deemed as sufferingfrom mild mental illness and in any preventative work, highlighting theshort-sightedness of the legislators and the lobbyists.

The Carers Act of 1996 gives carers, including those of mental healthservice users, the right to ask for an assessment of their own needs.While in principle this is an important step in giving carers their due, inreality it amounts to very little. A potentially useful legislation, that ofthe Direct Payment Act, 1997, which enables service users to hire peo-ple in accordance with an agreed care plan, does not apply for the timebeing to people with mental health problems, seen as incapable of suchan undertaking.

Unlegislated Major Policy Shifts

a. Psychiatric Hospitals Closure

By 2000, 90 of the 120 hospitals Britain had in 1982 have beenclosed down. The pace of closure is uneven; more hospitals have been

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closed in England, and few in Scotland, more were closed since 1990than between 1982 and 1990 (Ramon, 1992). Most of the “long longstay” patients (i.e., those who were in hospital for more than two years)moved to small group homes, and the intensive follow-up research hasdemonstrated that (Leff, 1997):

1. There are few relapses and re-admissions to psychiatric hospitalsfrom this resettled population.

2. Less than 1% from this group has become homeless or committedoffenses.

3. Most of them are more satisfied than they were in hospital.4. There has been no change in psychiatric symptomatology; but

there has been an improvement in self-care and social interactionskills.

5. The most expensive item of this program is the cost of housing.6. The overall cost is cheaper than hospitalization, though for the

more needy end of this population the cost of living in the commu-nity becomes higher as they become more dependent on services(mainly for physical health needs, due to age and impact of yearsin institutions).

7. In many cases the group homes act as mini-institutions.

Thus in contrast to North America, this hospital closure program hasbeen by and large a success for the long stay population. However, thefocus of attention has now moved to the “new long stay,” namely thosewho stay less than two years, a much younger group, more articulateand assertive/aggressive, often with dual diagnosis of mental illness anddrug/alcohol misuse, who go in and out of hospital for varying periodsof time, from two-three weeks to one year. It would seem that the Brit-ish policy commissioners and the providers had no specific plans forthis group. The planners seemed to have been totally unprepared for thefact that this group does not conform to their expectations, based on thelong stay population, or even for the existence of the group (Ramon &Tallis, 1997). This population also moves in and out of their familyhomes, remains in erratic relations with relatives, does not like tradi-tional housing or day care solutions, complies less with medication, hasmore people who wish to work and study, is much more self-harmingand more seriously so than the older group. The response to this grouphas been the invention of the supervision register and discharge, the es-tablishment of a variety of secure units at astronomical cost (£80,000per year vs. £35,000 in an ordinary psychiatric hospital/ward) with no

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discernible benefit apart from being in a closed, prison-like facility(which some would see as a benefit, while others would see as a furtheruntherapeutic measure), and relatively too few educational and voca-tional initiatives.

Currently the closure of psychiatric hospitals is being halted, but psy-chiatric beds in the general hospital are vulnerable due to the generalcuts in bed numbers by hospital trusts, as hospitals are less used thanthey were before the introduction of the purchasing and providers splitand GPs fundholding.

b. Community Mental Health Teams

In 1985 there were only 20 multidisciplinary mental health teamsworking in the community. By 1987 there were 46, and by 1990 therewere 150. The number continues to increase, but teams vary fromclose-knit teams working together under the same roof to teams whichexist only on paper. Teams vary also in what they offer, but most ofthem offer out-patient appointments, home visiting (mainly by CPNs(community psychiatric nurses), medication, limited opportunities forpsychotherapy of any type, benefit advise, limited work with families,referrals to day and housing services (Onyett, Pillinger & Muijen,1995). Nearly all multidisciplinary teams are headed by psychiatrists,even though they are less used to work in the community, know locali-ties much less well at the informal level than other professions (notablysocial workers and increasingly CPNs), and have no proven track rec-ord of ability or training for leadership. Thus the move to the commu-nity from a hospital base has not led to a shift in the hegemony of themedical model within mental health services. Most such teams workduring weekdays; some have out of hours cover, or a locality will havean emergency cover by doctors and social workers.

c. Crisis Facilities

The loss of a large number of beds has not led to the creation of a par-allel structure of easy access to services when people are in crisis, withor without a residential component. This is incredible, as the need forsuch a component was highlighted by the protagonists of hospital clo-sure, service users and relatives throughout the 80s and the 90s. Some ex-emplary crisis services have existed since the 1970s, such as the BarnetIntensive Crisis Intervention which consists of a multidisciplinary teamresponding by home visits and focusing on preventing the need for hospi-

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talization (Mitchell, 1993). The work of this team has been systemati-cally evaluated and found to have indeed lead to considerable reductionin admissions rate as well as shorter periods of hospitalization. How-ever, there has been no rush to create similar services in other parts ofthe country, partly due to the fact that the Barnet team is committed to apsychodynamic family work orientation and is not that keen on the tra-ditional medical model.

Home treatment teams are in existence, in which most of the inter-ventions take place at home (Burns, 1993). In these areas too the reduc-tion in admission rates and length of hospitalization is noticeable. Yetagain, although home treatment schemes are in existence since the late80s, they have not been copied in other areas. Some self-referral crisisdrop-in and residential units exist, but these continue to be the excep-tion.

The Mental Health Foundation is currently running a crisis program,which consists of publicizing examples of good practice and sponsoringa small number of pioneering projects already receiving local support,as well as funding the evaluation of these initiatives. Some of these pro-jects are attempting to create safe houses, telephone help lines andmothers and children safe facilities. Some are run by the voluntary sec-tor, even by user-led groups. All suffer from visible and vocal lack of lo-cal support.

d. The Not-for-Profit and the For-Profit Private Sectorsin Mental Health Services

Britain had traditionally a viable not-for-profit sector, active more incampaigning than in service provision. With the Community Care Actcame the proviso that 85% of the budget allocated to the local authori-ties has to be spent on purchasing care in the private sector. This has ledto most not-for-profit organizations becoming service providers,mainly of housing, but also of day care and advice services. Currentlycontracts are awarded on a yearly basis, leading to considerable depend-ence of the voluntary sector on the purchasers, making it difficult to inno-vate. The move to service provision has also curtailed the campaigningcomponent, now left mainly to national head offices of the voluntary sec-tor organizations.

The for-profit sector has made inroads within the British systemsince 1980, with considerable encouragement by the previous govern-ment. Most of its activities are limited to nursing homes, some grouphomes, secure facilities, and a few psychiatric hospitals. This sub-sector

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moved to what it saw as the more profitable end of the services range.While the less secure housing facilities in the for-profit sector cost lessthan they do in the public sector, nursing homes, secure units and hospi-tals cost more.

The verdict on the quality of service offered by the for-profit servicevaries. Although local authorities have the responsibility for inspection,the cuts in manpower in these authorities has meant that inspection vis-its are few and far between.

Users’ and Relatives’ Views and Voice

Relatives-led organizations, such as the NSF (National Schizophre-nia Fellowship) and SANE (Schizophrenia a national emergency) havebecome much more vocal in the 1990s than they have been before. Bothorganizations opposed hospital closure, and are pro-medical model.The NSF has a user component, has gone down the route of service pro-vision and has found itself opposing supervision registers. SANE has atelephone help line, has mounted a defamation campaign against peoplewith serious mental illness, opposes any research which is not focusedon biological premises of mental illness, and has been very effective ininfluencing the media and the Ministry of Health. Users have becomebetter organized locally and nationally. Many cities have user-rundrop-in services, and users express systematically their views on policymatters (Lindow & Morris, 1995). Some of the more articulate usershave become trainers on educational courses (for social workers andnurses, and not for other professions) and for specific issues withinhealth and social care public sector services.

Users are not a homogenous group any more than professionals orrelatives are. However, the majority of those who express their viewsare unhappy about the excessive use of medication (rather than againstthe use of medication per se), and want to see more counseling, advice,advocacy, income, housing, education and work opportunities madeavailable within the system. Above all, they wish to be respected byprofessionals and the public, and for their version of reality to be takenon equal footing to the professional version.

MENTAL HEALTH SYSTEM REFORM IN ISRAEL

On June 1, 1995, the reform of mental health service in Israel wentofficially into effect, and its implementation process began. However,

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the process of its implementation has been very turbulent, and it is un-known whether the planned reform will succeed at all. This reform,considered one of the major changes in the structure and the delivery ofservices (Mark & Shani, 1995), was brought about by the new legisla-tion of the national health insurance (National Health Insurance Act,1994). Whereas under the new legislation the services for physicalhealth care were based on what most of the population had already beengetting in the past, the reform in mental health services is a dramatic de-parture from the past.

The purpose of this paper is to discuss Israel’s mental health reform,its process and problems related to its implementation. After some hesi-tations, the Israeli government decided to include mental health ser-vices in the framework of health services that people were entitled tounder the new national health insurance scheme (Mark, Rabinowitz, &Feldman, 1996). This led to propose a reform in the mental health sys-tem.

The Proposed Mental Health Reform

Broadly speaking, this reform has been driven by political and eco-nomic considerations, namely, to transfer all direct health care provi-sion from government agencies to non-government organizations, toresolve the chronic financial crisis of the largest Sick Fund (GeneralSick Fund; in Hebrew: Kupat Holim Klalit), and to control the increasein the health care costs by introducing market considerations and man-aged care systems into the health service arena.

Mark and Shani (1995), representing the government view on the re-form, describe five major features of the mental health reform:

• The inclusion of inpatient and outpatient mental health servicesamong the basic health services that must be provided by the SickFunds under the new National Health Insurance Act.

• The transformation of all government and public mental healthservices to become independent economic units that must competefor Sick Fund contracts.

• The regionalization of mental health services within regionalhealth administrations.

• The establishment of a special fund, controlled and operated by thegovernment to insure and finance the care of long term psychiatricpatients.

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• The reorganization of the government Mental Health Services Di-vision. Accordingly, the Division would divest itself of the directoperation of the mental health services, assuming a supervisoryposition and becoming a regulatory policy making organization.

As one of the reasons for the reform was to control costs, a financialcap was put by the Ministry of Finance on the total expenditures formental health services. It was not to exceed the amount spent on mentalhealth services (adjusted for COL increases) prior to the implementa-tion of the reform.

As one can see, the mental health reform was driven also by an at-tempt towards managed care. The reformers expected that the move to-wards market based services would contain costs, reduce reliance oninpatient care, increase community care programs and, in general, im-prove services (Mark & Shani, 1995; Mark, Rabinowitz, & Feldman1995).

Changing Trends of the Israel Mental Health System

Like any other system of service delivery, Israel’s mental health ser-vice system reflects the political and social conditions of the country aswell as the historical and cultural background of its people. These in-clude factors such as1: the mass immigration into the country and thedramatic population growth of the country’s population; the strongmedical model approach and orientation toward curative medicine ofhealth care services; and, of course, security problems and existentialissues with which the country has been confronted since its establish-ment, fifty years ago.

A noticeable decline has occurred in the numbers and rates of inpa-tients in mental hospitals during the last thirty years (Popper &Horowitz, 1989; 1990; Central Bureau of Statistics, 1997). Since 1970,it declined by 60% from 2.7 to 1.1 per 1,000 of the general population in1997 (Popper & Horowitz, 1989; Central Bureau of Statistics, 1997;Ministry of Health, 1998). The rates of admissions declined by 36% be-tween 1973 to 1988, from 3.9 to 2.5 per 1000 of the population. An in-crease in the rates of admissions occurred after 1988. Between 1988 to1995 the rates of admission increased by about 15% from 2.5 during1988 to 2.8 during 1997 (Central Bureau of Statistics, 1997; Ministry ofHealth, 1998). The increase in admissions in the last several years hasbeen attributed mainly to higher rates of admission of new immigrantsfrom the former Soviet Union (Popper & Horowitz, 1992; Shemesh et

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al., 1993). In assessing this trend, the changes can be attributed to a con-figuration of factors–demographic, social, economic, clinical, as well aspolicy changes and the development of alternative care facilities (Pop-per & Horowitz, 1989, 1990; Aviram, 1996).

Analysis of the budgets of the Ministry of Health shows that inpatientservices take between 85 to 90 percent of the budget of Mental HealthServices (Aviram, 1996; Mark, 1995). The high proportion of mentalhealth service budgets which is allocated to inpatient services is in sharpcontrast to the distribution between inpatient and ambulatory care in thegeneral medical service budgets, contrary to needs of the recipients andpotential users of mental health services, and sharply differs from trendsin other modern mental health services (Aviram, 1996; Aviram et al.,1998; Mechanic, 1994).

Continuing Problems of the Mental Health Service System

The Israeli mental health service system cannot escape the major is-sues faced by any modern mental health system. It has to tackle the ba-sic disagreements in society in general and among the mental healthprofessions in particular over values and priorities. The limited knowl-edge on etiology of most disorders and treatments has greatly affectedthe field of mental health. On top of these issues, the system has contin-uously been faced by scarce resources, as well as disagreements amongfactions, professions, and organizations about the distribution and useof these resources.

In addition to these common issues, the Israeli mental health servicesystem faces three specific interrelated problems (Aviram, 1994, 1996):

1. Limited development of community mental health services.2. Dominance of the mental hospital in the provision and administra-

tion of mental health services in the country.3. Medicalization of mental health services.

Contrary to official policy since the early 1970s, the development ofcommunity mental health services in the country was rather limited. It isa reflection and a consequence of the dominance of mental hospitals inthe mental health service system. The dominant position of the mentalhospital in the system has been attributed to several factors: organiza-tional and professional interests, the legal arrangements that affect theflow of patients into the system, the principles that determine the fi-nancing of hospitals by bed occupancy, the structure of the budgetary

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system that budget hospitals directly and not through the Mental HealthServices and personnel policies that give financial advantages to hospi-tal staff over community mental health workers, as well as historical tra-dition (Aviram, 1991, 1996; Aviram & Shnit, 1981; Elizur, 1994;Ginath, 1992; Shefler, 1995).

These two trends have been accompanied by a strong current ofmedicalization of mental health services that has been shaping the sys-tem. These medicalization trends have also been reflected in the law andregulations governing mental health services in the country (Aviram &Shnit, 1984; Levy, 1992; Aviram, 1990; Kanter & Aviram, 1995).

Advantages and Shortcomings of the Mental Health Reform

The reform in the mental health service system suffered a major set-back when the Israel Legislature did not meet its own deadline of Janu-ary 1, 1998 to integrate mental health services into the basket of healthservices according to the National Health Insurance Act. However,one can say that it is still in its early stages holding promises to im-prove the system of treatment and care. Integrating mental health ser-vices into the health care system, and giving an entitlement to everyresident in the country to receive mental health services as part of the“basket” of health services, is indeed a great achievement.

Introducing economic considerations, free market competition, andmanaged care principles into the mental health service system holdspromise of improving the system of care and treatment, and providingpolicymakers with a better grasp of setting up priorities. Transferringmental health services into independent economic entities would nodoubt increase productivity of mental health organizations in deliveringdirect services, services would become more client oriented, and createmechanisms by which these agencies would monitor the provision ofservices. The reformers hoped that through the introduction of eco-nomic considerations and competition, policymakers will be able tochange the direction of the system, converting the flow of patients frominpatient to the community and enhancing community care instead ofhospital care (Mark & Shani, 1995).

However, one must not ignore the dangers ahead. The basic tenetsand directions of the current mental health reform have strengthened themedicalization trends of the mental health service system. It seems thatin-spite of declared intentions, mental hospitals would retain their cen-tral role and strong position in the system. Organizational arrangementsand principles of financing the system put many community services

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under the administration and authority of mental hospitals, creating agreat deal of uncertainty for these services. This may further stifle theslow development process of community care programs. No one shouldminimize the central role of the medical profession in the treatment ofmental illnesses. However, many of the problems of the seriously men-tally ill are clearly related to other systems of care and services(Aviram, 1990; Mechanic, 1993, 1994), and interpreting them instrictly medical terms would be counterproductive to the social effortsto deal with the problem of mental illness.

Many fear that the reform will result in neglect of the chronicallymentally ill persons (Neumann, 1993). The low tariff set for the longterm mentally ill, and the heavy caseload planned for case managers, aswell as the social marginality of these patients, may lead the Sick Fundsinto providing care for this group of mentally ill persons at a minimumlevel either at the hospital or the community.

The reformers expected that economic considerations would createan incentive for the Sick Funds to discharge patients (Mark & Shani,1995). However, it does not assure that the money will follow the pa-tient into the community nor that the quality of care will be improved.Redistribution of the budget does not mean that it would be directed to-wards development of community services, and according to the Israeliexperience, redistribution might result, in fact, in shrinkage of the bud-get for mental health services (Levy, 1994).

There are strong organizational incentives to prolong hospitaliza-tions and maintain chronic patients permanently in the hospital. Thesize of these mental hospitals and, in fact, the very existence of some ofthem, depends on retaining patients in the hospital. The stigma still at-tached to mental illness along with communities’ reluctance to acceptchronically mentally ill persons into the community may further hinderefforts at discharging patients into the community. Faced with suchstrong currents working against discharge of patients, Sick Funds mightdecide not to be bothered with rehabilitation efforts and retain thechronically mentally ill in hospitals.

Two principles that were established for financing the reformed men-tal health services create uncertainty regarding the amount, level andquality of the services. The first principle was the restriction imposed bythe Ministry of Finance placing a cap on the amount that can be allo-cated by the government for mental health services. Admittedly, sav-ings resulting from a better managed system, as expected by thoseleading the reform efforts, can be transferred towards improving theservices. However, the likelihood of this action, which will require ei-

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ther to raise taxes or to transfer money to mental health services fromother branches of health care services, is slim.

The second principle should worry mental health policymakers evenmore that the first one. The proportional expenditure of the Sick Fundsfor mental health services has not been fixed at a certain level. In fact,Sick Funds are allowed to transfer resources, provided for their servicesand based on a capitation scheme, to other types of health services, aslong as they give the minimum basket of services required by law. In thecompetition for resources, psychiatry has not been doing well comparedto other branches of medicine.

The fact that the reform plan calls for the government Mental HealthServices to continue to provide direct services to long term mentally illthrough a special fund, jeopardizes the reorganization objective. TheMinistry of Health will continue to be a direct provider for about 70% ofthe current resident population of mental hospitals. One may expect thatstrong organizational interests would create incentives to retain themoney and power that goes along with it at the Ministry level ratherthan transferring it to the Sick Funds.

As it looks now, it is doubtful whether one of the major features ofthe reform, namely, integrating mental health services into the frame-work of health services that people were entitled to under the nationalinsurance scheme, would be realized. It was not implemented by thedue date of January 1, 1998. However, attempts are made to implementother parts of the reform, so that it may be too early to eulogize it.

MENTAL HEALTH REFORM IN CANADA

Prior to the 1950s public mental hospitals were the mainstay in provid-ing mental health care in Canada. The 1950s saw a shift to communitymental health through deinstitutionalization. As has been experienced inmany jurisdictions there was a lack of appropriate community-based sup-ports and services during this period. The 1970s saw a growth in commu-nity mental health services but with little consumer involvement in theplanning and delivery of services. Trainor, Pape and Pomeroy (1997) de-scribe the current policy approach as “the community process approach”which focuses on the community context within which consumers strive tosurvive. This approach challenges the service paradigm and explores op-portunities for consumers to be in control of defining alternative modes ofmeeting needs within the community (Trainor, Shepherd, Boydell, Leff &Crawford, 1997).

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With our Federal Government struggling to reduce the deficit andpay down the national debt there has been a gradual decrease in Federalfinancial support for health and mental health services. This also servedto further accelerate provincial differences in organizing mental healthservices. Access to services tends to vary by severity of illness, commu-nity support is needed but provision has been limited and nationally,mental health expenditures still exhibit a strong institutional domi-nance. There have been numerous efforts at provincial reform and Nasir(1994) has identified five central themes in these efforts:

• correcting the imbalance between institutional and commu-nity-based care

• moving towards a more comprehensive array of services which in-clude treatment, rehabilitative, preventive and promotion

• devolving governance of mental health services at the regional andlocal levels to increase responsiveness

• the recognition that mental health care should not be limited to for-mal mental health supports

• the involvement of consumers and families as partners in plan-ning, delivering and evaluating mental health services

MacNaughton (1992), after reviewing the documentation on mentalhealth policy initiatives across the country, also identifies a set of policythemes. He articulates seven themes which include:

• the need to establish clear priorities as to whom the mental healthsystem should support

• the need for reallocation of resources (both fiscal and human)• the trend towards regionalization/decentralization of administra-

tion and service delivery• the move towards individualization of planning and service de-

livery• the need to promote opportunities for self-help• increased consumer and family participation in the mental health

system

In planning mental health initiatives, Wasyenki, Goering andMcNaughton (1992) take the view that the severely mental ill should bethe priority target, the relative use of general hospital and psychiatricunits and psychiatric hospitals should be clearly defined, communitysupport services should be expanded and continuity and integration of

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care should be emphasized. Working with co-morbidity and respondingto the new consumerism are also pivotal challenges in improving men-tal health care.

Goering, Cochrane and Dubin (1996) maintain that the mental healthsystem in Canada has a number of unique characteristics that are condu-cive to reform. They include:

• a growing body of evidence on the effectiveness of models of ser-vice delivery.

• numerous examples of horizontal and vertical linkages acrossagency and sector boundaries.

• mental health services for the severely ill are a more manageableset of providers and organizations.

• Canada’s single payer system of financing is a less administra-tively expensive system of financing.

• leaders and stakeholders are increasingly committed to collabora-tion to enhance the effectiveness of their work.

In an effort to move systematically and capture new developments inmental reform from across the country, the Health Systems ResearchUnit of the Clarke Institute of Psychiatry was commissioned by the Fed-eral/Provincial/Territorial Advisory Network in Mental Health to carryout a critical, evidenced-based review of the current state of knowledgeand a situational analysis of mental health reform policies, practices andinitiatives in Canada.

The project consisted of three phases, an evidence-based review ofthe current state of knowledge about best practices relevant to mentalhealth reform, a situational analysis of mental health reform policies,practices and initiatives in Canada, and the development of guidelinesfor the implementation of best practices across systems of care. The sit-uational analysis included 13 examples of best practices, four receivedintensive site visits and nine less intensive reviews. What emerged fromthese analyses were an important set of lessons about what facilitatesmental health reform. They include:

• Clearly articulated philosophy and principles typically underliethe specific innovations that have been implemented.

• A wide range of stakeholders were meaningfully involved in theplanning and operation of innovative programs.

• Political will is a special dimension of system change.

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• Infrastructure support is another essential element with powerfulconsequences.

• It is possible to successfully reallocate funds and personnel frominstitutional to community care.

• When support extends beyond health services to involve agenciesfrom other sectors, it becomes possible to better address the broadrange of needs among those with severe mental illness.

• With concerted action, stigmatizing attitudes can be changed andresistance to change overcome.

• The enthusiasm and dedication of skilled program directors, staffand volunteers is essential for making the programs work.

• The Canadian Mental Health Association-National Office is animportant force in promoting a common set of principles throughthe diverse provincial and territorial mental health reform efforts,especially in encouraging formation of partnerships between men-tal health and other health and social service agencies (in recogni-tion of the range of supports and resources that all citizens need)and in emphasizing consumer involvement in planning, manage-ment and evaluation of services and supports. (Health Systems Re-search Unit, Clarke Institute of Psychiatry, 1997, p. 15)

The authors argue that best practice checklists should be used asguidelines for mental health systems planning and assessment of per-formance. Regional service integration with authority to make changesis critical. They also feel that a separate, single funding envelope whichcombines funding streams for mental health services is essential. Ex-plicit operational goals, performance indicators and further research arealso seen as pivotal in demonstrating the effectiveness of mental healthservices.

What is encouraging about this important research is that it docu-ments that significant reform is achievable. Funds and personnel havebeen shifted to community care. Collaboration amongst health andnon-health agencies is possible. In many of these innovative reforms theCanadian Mental Health Association has played an influential role. Intheir recently released report, Access: A Framework for a CommunityBased Mental Health System, they provide an organizing framework forthe development of a continuous, integrated and seamless mental healthsystem. It is an approach which is person centered, strengths focused(Rapp, 1998) and embedded in a community resource base rather thanprofessional services.

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While I have outlined what are promising developments in mentalhealth reform, it must be emphasized that these are the best examples ofpractice and not the norm. They do provide hope however that signifi-cant change can be achieved. It does however require a major collabora-tive effort on the part of those who are concerned about improving carefor the mentally ill.

MENTAL HEALTH REFORM IN AUSTRALIA

Australian Mental Health policies and services are, like those of ev-ery other country, products of historical time and place. Events, pro-cesses, ideas, people and places are among the forces that giveparticular shape and color to the specific policy and program outcomesthat evolve across time. For Australian mental health policy there are anumber of key identifiable factors which have been significant over thepast 200 years of European settlement: inheritances from Britain; thephysical scale of the country; the patterns of demographic growth; thecultural mix; the fluctuations over time in the nature of the social, politi-cal and economic conditions and more recently the impact of globaliza-tion. The system has evolved so that it contains both public and privateservices and a rapidly growing non-government (N.G.O.) sector andwith the former, at least until relatively recently, the main focus of men-tal health policy and legislation. Within the past decade there has beenthe first comprehensive effort to relate all of these sectors to each otherwithin an overall national policy (Whiteford, 1992).

The British inheritance included, at least in the first 20 years of settle-ment, the “care” and control of “lunatics” within prisons which wassoon followed by the opening of the first Asylum in the colony of NewSouth Wales in 1811. From that time until the Second World War the“asylum system” continued to expand in much the same ways as wasgenerally the case in most Western Industrialized countries. Thus thegeneral pattern of policies and services was, well into the 1950s, institu-tionally-based, primarily custodial in nature, isolated and separatedfrom both the wider world of social policy and the community (Lewis,1988).

Legislative and service provision were originally the responsibilityof each colony and since Federation in 1901 have been under the juris-diction of each of the six States and two Territories. Until very recenttime Commonwealth interest and involvement has been minimal apartfrom direct funding of specific services for armed forces personnel in

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war and postwar repatriation contexts and a brief though importantforay by the reformist Whitlam labor government into the funding ofcomprehensive Community Health and Mental Health from 1972-75.Indeed as recently as 1985 the then Federal Health Minister ruled thatpsychiatric patients were not to be eligible for support under the Na-tional Disability legislation and agreement! It was only in 1992(A.H.M., 1992; 1993) with the formulation of the first National MentalHealth Policy that the Federal government entered into an explicit andsubstantial participation in the funding of public psychiatric services.Thus any representation, like this, of trends in mental health policy inAustralia carries a caveat that acknowledges considerable variations inpractices across the States over time whilst still claiming that general di-rections and shape of change in policies and provisions remain largelythe same.

Like most comparable countries Australia’s mental health provisionfrom the late 19th century to the end of World War 2 was centeredaround the Asylum and its later manifestations as Mental Hospital andPsychiatric Hospital. The forces for change unleashed by the war andpostwar recovery impacted enormously on the system in ways whichwere obvious and in ways which only became apparent in later years.The most public changes were expressions of a movement to reform theAsylum and to improve the basic conditions of life for the inmates(Dax, 1961). Bars came off windows, doors were unlocked, food wasimproved, activities were introduced and a therapeutic rather than an es-sentially custodial ethos began to infiltrate the services.

As part of a modest beginning of a move from the asylum to the com-munity the first social workers were employed in the public mentalhealth programs. Yet the fundamental ideas about the nature of the taskremained largely unchanged despite the atmosphere of reform. Thusduring this period new Mental Health legislation introduced in someStates represented more of a privileging of professional medical inter-vention and control at the boundaries of the institutions than it did ofany fundamental change to the hospital-based system. There seems tohave been a belief that greater dependence on medical authority ratherthan administrative-legal would be to the greater benefit of the patient.Whilst this may well be a valid assumption it nevertheless leaves the ba-sic problem of the social isolation of the institution largely untouchedand perpetuates another version of paternalistic control and care. Fromthe late 1950s through almost the next two decades the numbers of pa-tients in psychiatric and mental hospitals steadily declined so that inmost States by the end of the 1970s the inpatient populations had at least

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halved in numbers (National Health Strategy, 1993; Whiteford, 1992),despite the absence of any explicit policy of deinstitutionalisation. Partof the explanation, it is frequently argued, lies with the introduction,early in this period, of modern psychotropic drugs. But many more sig-nificant factors were at work including changing attitudes to institu-tional care, higher expectations for treatment, improved economicconditions with generally low unemployment and the emergence fromabout 1975 of what has become a dominant factor in contemporary pol-icy processes, the wish of governments to cut costs, reduce services andto move the burden of care away from government and back onto thedomestic sector. The cold winds of economic rationalism gathered mo-mentum so that by the early 1980s their various axioms (or perhaps plat-itudes) about improving productivity and efficiency at lower cost andtheir “high priests” (generic managers) had come to dominate policythinking and direction.

Whilst that has brought many benefits, not least being the closures ofthe old institutions and their partial replacement by community-basedservices, it has also brought many mixed blessings for consumers,carers, professionals and the community at large. The first NationalMental Health policy in 1992 introduced the ideas of mainstreamingand integration as the two key organizing ideas for service location anddesign. The first placed psychiatric services into mainstream health andthe latter made specific the vertical integration of services so that therewould be the goal of a seamless set of relationships from inpatient wardto community support (Healy & Varney, 1995). The key assumptionswere that general medical services were more professional, better orga-nized, much closer to where people live and largely free of stigma. Amore implicit assumption was that medicine had the “answers,” at leastto acute conditions and such a shift of services into the mainstreamcould only bring benefit to sufferers previously isolated away from pub-lic scrutiny in second rate services. With it came also a reinforcing ofthe idea already in use in some States of a key organizing concept, bor-rowed from the commercial world, of a focus on core business whichmeant, in this context, the “seriously mentally ill.” Increasingly this hascome to mean those with a major psychosis, especially when in an acutephase and those longer term patients with “enduring disabilities.” Thusthe brief lived 1970s “romance” with comprehensive community men-tal health provision for all was finally put to rest to be replaced by aleaner and arguably a meaner set of programs. However the gains fromthe National Government involvement were considerable and includeda significant increase in Federal funding, a comprehensive policy

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model, greatly enhanced consumer rights, new emphases on carerneeds, new opportunities for the private sector with in particular a strat-egy to involve general practitioners as basic primary care providers anda determined attack on old separatist ways and accompanying stigma.Furthermore the seriously mentally ill were given priority within thepublic sector; a comprehensive set of key programs (crisis, outreach,mobile support and accommodation support teams) became the normfor quality service provision. The much sharper focus on core businessmeant in the first place that persons with sub-acute and non-psychoticdisorders had to seek out assistance from the private fee for service pro-fessionals and secondly it paradoxically ran the risk of increasingstigma by basing eligibility for service on a set of dubious dichotomousdistinctions between serious and non-serious. Perhaps the greatest gainof this new involvement by the Commonwealth government was thatthrough the injection of money, ideas and strategies it precipitated themass closure of most of the old psychiatric and mental hospitals in Aus-tralia and their replacement with community-based services.

A further key injection of ideas from the era of the 1980s was a ratherbelated but nevertheless welcome new emphasis on consumer rights fre-quently extended through legislation. Whilst some States, most notablySouth Australia, had rights oriented legislation in the previous decade ittook most jurisdictions until the first half of the 1980s to legislate for con-sumer rights and protection. For instance in the State of Victoria the 1986Mental Health Act introduced for the first time in that State the require-ment for several criteria to be met before an involuntary admission couldbe made. Essentially these codified a form of narrow civil commitmentrules based on established norms, largely from North American jurisdic-tions, which entrench notions like need for treatment, dangerousness,least restrictive environment as tests to be met before an involuntary ad-mission (Moynihan et al. 1996). In addition most Australian legislationfrom this time also included some form of review and appeal and for thefirst time made reference to the existence of community programs.

Despite this progress on consumer rights the Australian HumanRights and Equal Opportunity Commission Report of its Inquiry intothe Rights of the Mentally Ill published in 1993 (HREOC, 1993) con-tains an enormous litany of widespread rights violations not only in in-stitutions but also across a wide range of community locations. Clearlythere is much still to be done to alleviate neglect, exploitation and preju-dice towards the mentally ill.

The current patterns and emerging trends in public policy and provi-sion are increasingly being shaped by the next “logical” step in sup-

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ply-side economic theorizing about how to gain more for less. Thuswithin this decade there has been the dismantling of the old monolithicservice networks and their replacement with smaller, area-based ser-vices funded through contract, based in a purchaser-provider philoso-phy. To take one Australian example, in the State of Victoria, until 1995the model was a State wide one with some devolvement to regions butwith strong direct central control. Then, following one enormous ten-dering out process, the State dispersed the old unitary system into 23area-based services, funded by central government but on the basis ofspecific funding and service agreements with the new “owners,” usu-ally large general hospitals. Government sets the parameters of the ser-vice mix and the funding formula and the purchaser organizations thencontract with service providers. One result of this move to what somehave termed the “contract state” is a serious diminution in State ac-countability for services as government can and does say responsibilityfor any failures lies with the provider agency and not with them.

Social work, not surprisingly and like all professional groups, hasstruggled to keep up with the degree and pace of change. Much of whathas happened and is happening is congruent with most social workers’vision of what might constitute appropriate and effective mental healthpolicy and practice. For example the shift in the focus and locus of thesystem to a community-based one represents a long standing goal of theprofession. Ironically, despite the rhetoric, the social dimensions ofpeoples’ suffering and related ameliorative resources continue to bematters to be fought for rather than those which can be taken forgranted. Nevertheless for those with longer term memories of the oldsystem there is a sense of enormous progressive change, an almost totalabsence of nostalgia for the “old ways” and a sense of a platform fromwhich much greater things can be built.

CONCLUSION

In reviewing the experiences of these four countries, in the area ofmental health reform, one can identify several emerging themes:

• in all four countries these reforms were primarily driven by con-cerns regarding cost containment or cost reduction.

• market mechanisms have been introduced within the delivery ofmental health services in most of the countries but the evidence re-garding efficacy is still not solid.

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• the reforms in all countries espouse a progressive commu-nity-based philosophy of care but in most cases this is rhetori-cal–the real agenda is cost containment; there has been either verylittle or insufficient reallocation of resources to community care.

• in all countries we observe examples of deskilling andde-professionalization again driven by cost concerns.

• the mentally ill, in all of the countries reviewed, are a significantlymarginalized group. Consumer/user groups however, particularlyin Britain and Canada have had significant impacts on reform ef-forts including the design and delivery of services.

• in terms of interprofessional dynamics, medicine and psychiatry inparticular are playing more significant roles–greater emphasis isalso being placed on interprofessional teamwork in providing carebut sometimes at the cost of disciplinary identity.

• more emphasis is being placed on the need for families and the com-munity to take an increased role in caring for persons with mentalillness.

• public support for changes in mental health systems is not strong–po-litical will is a extremely critical component in promoting change.

• more progressive legislation and service system improvements arecritical, however the translation and implementation of policiesand plans into practice is not as effective as it should be. System-atic monitoring to improve performance is in its infancy.

The themes which emerge from this review of mental health reform re-quire further in-depth analysis beyond the scope of this paper. It has how-ever, even in a beginning fashion, been extremely informative to examinethe similarities and differences in the experiences of these countries in at-tempting to respond to the needs of their mentally ill citizens. Too oftenwe become trapped in our own context and unable to generate alternate orinnovative perspectives. Although much more comparative research isneeded, what has been done moves us in a more thoughtful direction.

NOTE1. For an extended discussion on the background of Israel mental health system, see,

for example, Aviram (1996); Yishai, (1993).

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