Introduction

Until very recently, the history of mental health policy in Ontario, Canada, has been marked by frustrated attempts to move from a policy development path rooted in a hospital and physician-based tradition to one with significantly greater emphasis placed on community-based mental health care.Footnote ¹ Other countries have faced similar challenges in moving away from institution-based mental health care (Goldberg, Reference Goldberg1999; Grob, Reference Grob2005; Haug and Rossler, Reference Haug and Rossler1999; Monk-Jorgensen, Reference Monk-Jorgensen1999; The President's New Freedom Commission on Mental Health, 2003; Thornicroft and Tansella, Reference Thornicroft and Tansella2003; Turner, Reference Turner2004; Vazquez-Barquero and Garcia, Reference Vazquez-Barquero and Garcia1999; WHO Europe, 2005) but have approached mental health reform in various ways, with differing results (McDaid and Thornicroft, Reference McDaid and Thornicroft2005).

Some countries such as the UK and New Zealand have established national bodies to oversee long-term planning and to promote mental health reform (Kirby, Reference Kirby2004a, Reference Kirby2005b), with comprehensive national mental health polices and legislation as part of the solution (WHO Europe, 2004b). A Canadian Senate Standing CommitteeFootnote ²(the Kirby Committee) recommended the creation of a National Mental Health Commission following its review of the Canadian mental health system (Kirby, Reference Kirby2005b) and the commission is now being established (Government of Canada, 2007). This could have a profound impact on the mental health reform agenda, but to be successful, the dampening effect that past policies have had on mental health reform efforts must be considered (Altenstetter and Busse, Reference Altenstetter and Busse2005; Hacker, Reference Hacker1998; Pierson, Reference Pierson1993).

In the case of Ontario, the meaning of mental health reform has been reflected in numerous government study recommendations: (Health Services Restructuring Commission, 1999: 174–175; Ministry of Health and Long-Term Care, 1993, 1999a, 1999b, 2000a; Provincial Forum, 2002):

1. move care from psychiatric hospitals to community mental health services;

2. reduce the ratio of mental health spending for institutional vs. community-based services; and

3. create a seamless transition among the various services and settings (Canadian Mental Health Association, 2004; Ministry of Health and Long-Term Care, 1993).

Some change has been achieved since the mid-1960s. Seven of ten provincially owned psychiatric hospitals (PPHs) have been divested, spending on a number of community-based programs (Ministry of Health and Long-Term Care, 2004b) has increased substantially, and Assertive Community TreatmentFootnote ³(ACT) teams (Ministry of Health and Long-Term Care, 2004a) and Community Treatment OrdersFootnote ⁴(CTOs) (Government of Ontario Press Releases, 2000) have been introduced. However, the proportion of spending on institutional vs. community-based mental health care has not reached the policy target of 40:60 set in 1993 despite recent increases to community-based spending (Ministry of Health and Long Term Care, 2004b) and the system remains highly fragmented and difficult for consumers to navigate (Dewa, Rogers, Kates, and Goering, Reference Dewa Rogers, Kates and Goering2000; Health Services Restructuring Commission, 1999; Kirby, Reference Kirby2004b; Ministry of Health and Long-Term Care, 1993, 1999b). Moreover, the comprehensive recommendations of nine regional mental health implementation task forces have not been implemented.

The historical institutionalism literature suggests that during critical junctures, where there is significant policy change (such as the establishment of a publicly financed health care system), decisions will be taken the effects of which will result in policy legacies that impact on subsequent political development (Pierson, Reference Pierson1993). It is important, therefore, to examine the policy-making process within its historical context because the sequence of events can influence political outcomes (Hacker, Reference Hacker1998).

In this article, we examine how the legacies of two prior policies – (i) the introduction of provincial psychiatric hospitals (PPHs) (then asylums) in the mid 1800s, and (ii) the introduction of medicare to the province in the late 1950s and 1960s – have influenced repeated efforts to develop a coordinated, consumer-centred mental health system and achieve a significant rebalancing of spending from institutional to community-based care in Ontario through until at least the 1990s (Health Services Restructuring Commission, 1999; Ministry of Health and Long-Term Care, 1993, 1999a, 1999b, 2000a; Provincial Forum, 2002). We then assess current prospects for achieving stated mental health reform objectives in Ontario in light of these legacies and comment on the implications for other countries facing similar mental health reform challenges.

Methodology

Effects on government elites

The introduction of insane asylums had resource/incentive and interpretive effects on government elites. First, the sheer size of the investment in psychiatric hospitals required a large bureaucracy to support them. Across the country, more was spent on asylums over the period 1845–1902 than on prisons and other hospitals (Wright, Moran, and Gouglas, Reference Wright, Moran, Gouglas, Porter and Wright2003).

Governments focused on managing the construction and operation of very large facilities to house the mentally ill over the long-term rather than on clinical aspects of policy-making, which was left to the local asylum superintendents (Simmons, 1989). A resulting legacy was limited government capacity for internal strategic mental health policy-making and for many years the government relied heavily on external advice from the psychiatric profession.

Asylum policy also meant mental health policy decisions were divided across government departments, such as health and public works, with often competing objectives. Two legacies were (i) clinical mental health policy was a relatively low priority and (ii) an institutional focus for mental health policy became entrenched in government.

Over time, the psychiatric hospitals were used as a tool for regional development, often located in underdeveloped areas, which would benefit from the injection of funds and jobs. Politicians learned that asylum location decisions could be a powerful tool for generating votes (Simmons, Reference Simmons1989). The public did not develop meaningful involvement with local psychiatric hospitals in the same way as they did for general hospitals (Abelson, Reference Abelson2001: 787), so it was easy to choose politically expedient locations.

Effects on interests

The asylums had important resource/incentive effects on professional interests. First, they lead to the development of psychiatry as a profession, which did not exist before the end of the eighteenth century (Shorter, Reference Shorter1997). As Wright (Reference Wright2004) stated in a speech on the history of mental health policy in Ontario: ‘The asylum created the profession.’

Second, public ownership gave substantial power and authority to psychiatrists in policy-making in Ontario. The superintendent was in charge of each asylum and reported directly to the Ontario Department of Health (Simmons, Reference Simmons1989). Further, the geographic remoteness of many asylums meant the public was generally not familiar with their workings:

For consumers and family members, the asylums contributed to the stigma of mental illness by removing individuals with mental illness from the community (Arboleda-Florez, Reference Arboleda-Florez2003; WHO Europe, 2005). Patients residing in an often distant asylum, away from the support of family and friends were unable to come together to develop an effective lobby, and the stigma of a mentally ill family member kept families from forming a lobby on behalf of patients [PUB 1]. This meant that from the early days, no consumer- or family-based mental health interest group developed:

The Canadian National Committee for Mental HygieneFootnote ⁹ was a professionally based interest group that lobbied on behalf of the rights of the mentally ill. Founded by a progressive psychiatrist (Dr. Clarence Hinks), it was comprised of a small number of psychiatrists, physicians and a few nurses (Canadian Mental Health Association) (CMHA), but did not have the support of the majority of the profession:

Other interests emerged over time, and were vocal whenever there was discussion of closing psychiatric hospitals. These included the affected communities, which would lobby to keep the institutions and associated jobs; and the Ontario Public Service Employees Union (OPSEU), which lobbied on behalf of its members (Simmons, 1989) (National Union of Public and General Employees, 2002; Ontario Public Service Employees Union, 1998a, 1998b, 2002).

Effects on mass publics

The asylums ‘took the problem away’ from citizens in the community and relieved a major burden for family members who had struggled with caring for someone with mental illness.

The needs of the mentally ill in far-away asylums were much less visible to the public than other local needs.

There were also important interpretive effects. Since only those with more severe disorders were sent to asylums, the public came to recognize mental illness only at its most extreme. Although those with more moderate illness remained in the community, they were not necessarily recognized as having a mental illness.

Lack of familiarity meant the public became less comfortable around people with mental illness (Arboleda-Florez, Reference Arboleda-Florez2003). This prevented mental health from developing ‘the same sort of base of public consumer support’ [INT 3] needed for community-based mental health reform.

Failed reform efforts and psychiatric hospital legacies

Over time the PPHs became increasingly overcrowded and the original intent of providing moral treatment was lost (Kirby, Reference Kirby2004b; Simmons, Reference Simmons1989). Several attempts were made to adopt a community-based public health approach to preventing and treating mental illness, but these had limited success (Simmons, Reference Simmons1989). For example, in 1930, mobile mental health units in the community were introduced, but they were under-funded and soon overwhelmed by the demand and discontinued. Again, in 1946, the Deputy Minister of Health (McGhee) tried unsuccessfully to put forward a comprehensive community care plan that would create ambulatory mental health care in community public health units.

The difficulty of moving to community-based care can be understood in light of the policy legacies of PPHs. First, government elites had developed considerable bureaucratic capacity and expertise in running large institutions and had far less experience in community-based programming. The Ministry became dependent on the psychiatric community in policy-making and without a consumer- or family-based mental health interest group, the psychiatric profession was the dominant interest. Most psychiatrists were reluctant to switch to an unproven, less prestigious and potentially less-lucrative community-based system (Simmons, Reference Simmons1989). Further, there was more to be gained politically by building large institutions in disadvantaged areas, than by smaller investments in community-based programs across many municipalities. There was also a risk of public backlash if the community-based programs did not perform. In light of these legacies, it was not surprising that attempts at community-based reforms had limited success.

A second legacy and its effects: the introduction of medicare

Soon after McGhee’s attempt at widespread reform, the federal government introduced a series of incentives to support a public health insurance system (commonly referred to as medicare). In 1948, the federal government introduced the Dominion Health Grants to assist the provinces in developing and extending health facilities in specific areas. For mental health, $5 million of federal funding could be matched with provincial funds to support the development of general hospital psychiatric units (Hastings, Reference Hastings1999). This was followed by the Hospital Insurance and Diagnostic Services (HIDS) Act in 1957 and the Medical Care Act in 1966 (Health Canada, 2004) which offered federal cost-sharing for provinces and territories that operated a universal insurance program for hospital and physician services respectively. In Ontario, public hospital insurance came into effect in 1959 and medical care insurance for physician services in 1969. The combined health insurance program in the province was called the Ontario Health Insurance Program (OHIP).

During the federal-provincial negotiations which preceded the introduction of HIDS, the Ontario government pushed ‘to remove, as far as possible, any artificial financial or administrative distinctions between acute, convalescent, or chronic care, or care for mental illness and tuberculosis’ (Taylor, Reference Taylor1978: 135). However, the federal government indicated that its ‘contribution would not be made in respect of care in mental hospitals or tuberculosis sanatoria’ because PPH patients were already covered by provincial general revenues (Kirby, Reference Kirby2004b; Simmons, Reference Simmons1989). The discovery in the late 1950s of new medications that showed promise in the treatment of mental illness increased acceptance of community-based care (Kirby, Reference Kirby2004b), but also reinforced physicians and general hospitals in its delivery, rather than community support programs.

Effects on government elites

The matched federal funding for general hospital psychiatric units under the Dominion Mental Health Grants and OHIP encouraged provincial governments to move care from psychiatric hospitals to general hospital psychiatric units (Simmons, Reference Simmons1989).

Inpatient units expanded, and many community-based services were developed in general hospital psychiatric outpatient clinics, instead of local public health units or community agencies:

Since provincial psychiatric hospitals were excluded from OHIP, there was split responsibility within the Ministry of Health for policies pertaining to psychiatric and general hospitals. Separate bureaucratic structures posed a challenge to coherent policy-making (Rochefort and Portz, Reference Rochefort and Portz1993; Simmons, Reference Simmons1989).

Today there remains a marked split between child/youth and adult mental health services which are the responsibility of different government Ministries:

Separate funding streams meant publicly owned psychiatric hospitals were subject to government cost control measures during periods of fiscal restraint that did not apply to the general hospitals. Without a public mental health lobby, governments gave lower priority and reduced funding to mental health care spending.

Even within hospitals, funds intended for psychiatric units would frequently end up being allocated to acute care services because:

Effects on interests

OHIP covered hospital services regardless of provider type, and physician services regardless of delivery setting. This divided the mental health professional interest and privileged physicians over other mental health providers. For psychiatrists, OHIP offered the prospect of open-ended fee-for-service billing and professional autonomy in private practice rather than salaried employment in a government-run institution or community-based mental health organization. It placed few restrictions on the type or amount of mental health care that could be provided (Goering, Wasylenki, and Durbin, Reference Goering, Wasylenki and Durbin2000).

Physicians became a powerful force in health policy-making through the Ontario Medical Association’s interaction with government during the OHIP fee negotiation process (Hutchison, Abelson, and Lavis, Reference Hutchison, Abelson and Lavis2001; Tuohy, Reference Tuohy1999). Physicians became direct participants in health policy-making through joint management committees (Hutchison, Abelson, and Lavis, Reference Hutchison, Abelson and Lavis2001).

Other mental health providers did not have the same access to policy-makers, which was a major problem during times of fiscal restraint.

Psychologists were hit particularly hard during periods of hospital budget cuts. Unlike physicians, whose services were paid for by OHIP, psychologists’ salaries were paid from the hospital budget [INT 3, INT 4, INT 8, INT 11]. They were typically the first group to be let go from hospitals.

Medicare produced powerful interpretive effects for the various mental health provider interests. Physicians learned to protect the OHIP funds from encroachment by other provider groups [INT 1] and to lobby against any reforms that might reduce existing privileges.

Psychologists learned to operate in private practice [INT 2, INT 3] outside the public system. Some focused on private patients, and patients covered under private insurance through worker’s compensation or automobile accident insurance.

OHIP coverage for psychotherapy delivered by family physicians, but not by psychologists (who typically had more extensive training in these techniques) was a point of conflict between the mental health professions [INT 3].

Without a unified interest across professions, the mental health system became more fragmented. Although there were enlightened community psychiatrists who lead the development of new programs, for the most part, physicians focused on hospital and primary mental health care in private practice and had less interaction with public health units or community-based services.

Effects on mass publics

First dollar coverage under medicare gave the public a strong financial incentive to see their family physician for mental health problems rather than pay out of pocket to see a psychologist or social worker in the private setting. Family physicians found a growing demand for provision of psychotherapy. In fiscal year 2001/2 psychotherapy was the fourth most commonly billed OHIP fee code (Cree, Reference Cree2004). With their clinical autonomy, some family physicians chose to specialize in psychotherapy and became known as ‘GP psychotherapists’:

The public came to rely on family physicians for mental health care. OHIP billing data suggest that 84–93% of mental health services are provided by family physicians (Lin and Goering, Reference Lin and Goering1999). Self-reported survey data indicate that 68% of Ontarians see a family physician for a mental health problem, compared with 27% a psychiatrist, 28% a social worker or other counsellor, 14% a psychologist and 6% a nurse (Rhodes, Bethell, and Schultz, Reference Rhodes, Bethell and Schultz2007). Politicians have learned that the public will strongly resist any attempts to de-list family physician psychotherapy (Rochefort and Portz, Reference Rochefort and Portz1993).

Medicare also led to a two-tier system of psychiatry, as the public found general hospital care to be less stigmatizing than care in a psychiatric hospital.

The number of psychiatric units increased rapidly from seven in 1944 to 42 by 1970 (Simmons, Reference Simmons1989). Instead of providing alternatives to the psychiatric hospitals, the psychiatric units were meeting new and different categories of psychiatric need, including patients with less serious mental illness (Simmons, Reference Simmons1989).

Later, with downsizing of psychiatric hospitals and shortages of psychiatrists, those with the most serious mental illness primarily used those community-based services that were available (Kirby, Reference Kirby2004b; Simmons, Reference Simmons1989).

Community care since the introduction of medicare

The introduction of medicare meant a shifting of services to the general hospital setting and to physicians in primary care. During the 1960s and early 1970s, many chronic patients were also shifted from psychiatric hospitals to other long-term care facilities. Without community support services, many were discharged to the community and suffered frequent relapse and readmission to psychiatric units in the general hospitals, and some ended up homeless or in jail. By the late 1980s there were increasing calls for greater spending on community services and some incremental change was achieved. By the early 1980s a mixture of about 400 community-based small non-profit agencies and others organized under the Canadian Mental Health Association (CMHA) had developed (Graham, Reference Graham1988) that offered residential services, vocational rehabilitation, income support, and case management programs (Kirby, Reference Kirby2004b). However, only 3% of provincial mental health budgets in Canada were allocated to community support by 1990 (Goering, Wasylenki, and Durbin, Reference Goering, Wasylenki and Durbin2000).

Discussion

Our analysis suggests that psychiatric hospital policy resulted in four legacies that have prohibited widespread mental health reform: (i) it set the treatment of mental illness ‘apart’ from the treatment of physical illness and gave it a generally lower priority in policy-making; (ii) it entrenched a hospital-based focus for mental health treatment, which (iii) led to the development of psychiatry as a profession and gave psychiatrists a privileged position in mental health policy; and (iv) it inhibited public interest in reform.

Medicare reinforced separate treatment and lower priority for mental health policy by excluding PPHs. It split decision-making across administrative units within governments, which weakened the capacity of mental health administrators to press for sweeping reform (Rochefort and Portz, Reference Rochefort and Portz1993). Medicare also emphasized hospital rather than community care, with coverage for hospital and physician services only. Finally, medicare divided the provider interest and continued to privilege psychiatrists and physicians over other mental health providers, through clinical autonomy, guaranteed public payment for services and access to government during fee negotiations (Simmons, 1989), and encouraged public support for physician-based mental health care. With some notable exceptions, physicians were unlikely to support community-based services that could threaten their existing privileges. Without a broadly based consumer or family lobby until the 1980s, community and union protests over hospital closures prevailed over community care advocates. These effects have sustained the fragmented mental health care system in the province.

Conclusion

Policy legacies can prevent widespread change from occurring when policy windows open. Nonetheless, changing ideas can lead to incremental change, which can support reform at a later critical juncture. Our examination of policy legacies suggests four important legacies of psychiatric and medicare policy: (i) the separation of mental and physical health policy-making in government and the lower priority given to mental health; (ii) the entrenched emphasis placed on hospital- and physician-based mental health care; (iii) the strength of physicians in policy-making compared with other mental health providers; and (iv) the limited public interest in mental health policy. Together these have resulted in the current fragmented delivery system and the difficulty in shifting the proportions of spending from hospitals and physicians toward more community-based care.

While widespread reform has proved elusive, below-the-surface changes have occurred that may support mental health reform as part of ongoing general health system transformation. It will be important to monitor whether a regionalized system promotes public interest in mental health policy, and, if not, to find ways to protect mental health funding in each region. Coordinating funding for LHINs and primary care is critical to achieve a coordinated, balanced mix of mental health services across settings. This calls for integrated LHIN/FHT planning at the provincial level, and a mental health system liaison function within each LHIN and delivery site. Paying attention to these issues now will promote long-sought mental health reform objectives. Failure to do so will reinforce policy legacies dating back to the 1850s and 1950s that have kept mental health reform ‘beneath the radar screen’ of policy-makers (Rochefort, Reference Rochefort1999) and once again thwart the development of a coordinated, consumer-centred and rebalanced mental health system in Ontario.

While the analysis presented here is specific to the case of Ontario, there are lessons to be learned from applying the Pierson framework to the mental health reform experience in other countries with a psychiatric hospital-based tradition. For example, similar legacies such as the weak and fragmented government capacity for mental health policy-making, the division of mental and physical health policy, the relative strength of physician interests compared to a weaker consumer interest and lack of public support for mental health policy may have resulted from caring for the mentally ill in large, geographically remote asylums. However, the subsequent path of policy development in each country during deinstitutionalization may differ from Ontario’s because of the unique legacies associated with the introduction of Canadian medicare. Differences in the deinstitutionalization experience of European countries include the degree of reliance on general hospitals, transinistitutionalisation, and in some countries, recent signs of reinstitutionalisation (Goldberg, Reference Goldberg1999; Haug and Rossler, Reference Haug and Rossler1999; Monk-Jorgensen, Reference Monk-Jorgensen1999; Turner, Reference Turner2004; Vazquez-Barquero and Garcia, Reference Vazquez-Barquero and Garcia1999). Applying the Pierson framework through comparative analysis in future work will help to explain these observed differences. It may also identify opportunities to promote mental health reform in different countries.