'Problematising' Australian policy representations in responses to the physical health of people with mental health disorders.
Australia, like other jurisdictions, is recognising the poorer
physical health of people with mental health disorders. This paper
explores policy responses to this issue through discourse analysis of 22
Australian Federal and State Government policy documents published in
2006-2011. The paper utilises Bacchi's 'what's the
problem represented to be?' approach to explore policy solutions in
relation to the representation of the issue, enabling identification of
issues which are not problematised and policy solutions that have not
been considered. The poor physical health of people with mental health
disorders is attributed in policy to poor lifestyle habits and limited
access to monitoring of physical health care. Three policy solutions are
offered: collaborative care delivery involving Greater use of
fee-for-service primary care to manage physical health; the monitoring
of physical health status by mental health teams; and the promotion of
lifestyle change. These solutions fail to address ongoing issues with
collaboration between specialist mental health and primary care
services. Reliance upon fee-for-service primary mental health care may,
in fact, reduce rather than increase access to services. The strategies
are discussed in light of neoliberal ideals of governance and personhood
which are underpinned by informed consumer choice and personal
responsibility for health.
Keywords: mental health, policy, physical health, primary care, Australia
Mentally disabled persons (Health aspects)
Mentally disabled persons (Laws, regulations and rules)
Mental illness (Risk factors)
Mental illness (Care and treatment)
|Publication:||Name: Australian Journal of Social Issues Publisher: Australian Council of Social Service Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2011 Australian Council of Social Service ISSN: 0157-6321|
|Issue:||Date: Winter, 2011 Source Volume: 46 Source Issue: 2|
|Topic:||Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
This paper explores Australian policy responses to the poorer physical health of people with mental health disorders. It addresses representations of the causes of poorer physical health in mental health policy and the social implications of this representation. Discourse analysis is undertaken of 22 policy documents using Carol Bacchi's 'what's the problem represented to be?' approach (2009). Bacchi's approach explores policy solutions in relation to the representation of the policy issue, arguing that the issues that are problematised arise from and reflect existing policy directions. This approach, in turn, enables identification of issues which are not problematised and policy solutions that have not been considered. Three policy solutions are identified: collaborative care delivery involving greater use of primary care services, particularly GPs, to manage physical health; the monitoring of physical health status by mental health teams; and the promotion of lifestyle change. Policy responses are examined against the literature on the extent and causes of physical health problems among people with mental health disorders as well as consumer lobby groups' concerns with current policy approaches. These solutions are examined in light of neoliberal approaches to health policy.
Recent developments in mental health care in Australia
Australia, like many Western countries, has moved away from institutional care for people with mental health disorders towards community care over recent decades. The movement towards community care was hastened by the National Mental Health Strategy, launched by the Federal government in 1992 with the goal of mainstreaming mental health care and developing services to support people with low prevalence disorders, such as schizophrenia and bipolar affective disorder within the community (Australian Health Ministers 1992). By 1998, the release of the Second National Mental Health Plan refocussed community care towards early intervention delivered through primary care with a greater focus upon the management of high prevalence disorders such as depression and anxiety (Henderson 2005; Hickie & Groom 2002). This move was justified in part, by recognition of the incidence of untreated or poorly managed high prevalence disorders and reliance upon general practitioners to provide care for these people (Fletcher et al. 2009). A move towards primary care was supported by strategies to increase collaboration between primary care and specialist mental health services. The first of these, the Better Outcomes in Mental Health Care (BOiMHC) was launched in July 2001, with the expressed goal of improving access to primary mental health care (Fletcher et al. 2009). The first cycle of reforms allowed patients to claim through the universal health care scheme Medicare for psychological interventions and promoted referral to allied health professionals of people with high prevalence disorders through the Access to Psychological Services component of the scheme (Fletcher et al. 2009; Hickie & Groom 2002). This was supplemented in November 2006 through the Better Access program which enabled people receiving care to claim under the Medicare Benefits Scheme for services provided by psychologists, and some social workers and occupational therapists, upon referral by a GP (Fletcher et al. 2009). Medicare data for the financial year 2009-10 demonstrates that mental health related problems accounted for 11.4 per cent of GP consultations, with depression and anxiety the most commonly managed of these conditions (AIHW 2011). In addition, claims for allied mental health services have increased, accounting for 3.9 million claims in 2007-08 (AIHW 2009). More recently, support for this scheme has been reduced. Medicare Benefit Support (MBS) was withdrawn for social work and occupational therapy services from July 2010 (Medicare Australia 2010) and the 2011 Budget lowered the number of consultations available through the Better Access programs and reduced Medicare rebates for GP mental health care planning, opting instead to target resources through Medicare Locals and non-government organisations for populations viewed as having reduced access to other resources, such as those with 'severely debilitating, persistent mental illness with complex and multiagency needs' (Roxon et al. 2011: 5). The National and State governments have also supported mental health shared care schemes, initially between primary care (GPs) and specialist mental health services (psychiatrists) (Keleher 2006). Available data suggests however, that referral rates between GPs and psychiatrists are low, accounting for only 1.9 per cent of mental health problems managed by GPs (AIHW 2009).
Mental disorders and physical ill health: the prevalence of co-morbidity
There is an emerging literature which demonstrates a link between mental health disorders and poor physical health. People with low prevalence mental health disorders such as bi-polar affective disorder and schizophrenia have higher rates of diabetes; heart disease, stroke, chronic obstructive pulmonary disease, breast cancer and bowel cancer than the general population, while people with depression have higher rates of stroke, diabetes and respiratory disease (Iosifescu 2007; Iacovidis & Siamouli 2008; Sayce 2009; Disability Rights Commission 2006). Iacovidis and Siamouli (2008) found that 50 per cent of people with mental health disorders have physical co-morbidities. This is particularly evident for people with low prevalence disorders. The Australian Institute of Health and Welfare estimates that approximately one-third of people with schizophrenia have coronary heart disease (Baker et al. 2009) while the Office of Statistics in the United Kingdom found that 62 per cent of people with psychosis experience physical health problems, compared with 42 per cent of those without psychosis (Roberts et al. 2007). Mood disorders are also related to physical illness, with Fenton and Stover (2006: 421) reporting a disproportionate prevalence amongst people with depression of type II diabetes (Odds Ratio=2.2), myocardial infarction (OR=4.5); stroke (OR=2.7) and arthritis (OR=1.3).
Causes of poorer physical health among those with mental disorders
Research has identified both individual and structural factors that explain the poorer physical health of people with mental health disorders. Among the individual causes identified are greater exposure to lifestyle risk factors, poorer self care of physical illness and medication side effects. An Australian study found that people with mental illness had higher smoking rates, were more likely to use alcohol in excess and had greater rates of obesity than the general population (Lambert 2003). The National Survey of Mental Health and Wellbeing found that 32 per cent of current smokers and 21 per cent of people drinking daily reported experiencing one or more mental health disorders in the previous 12 months (ABS 2008). Smoking is particularly evident among people with psychotic disorder, with 73 per cent of men and 56 per cent of women smoking (Jablensky et al. 1999) and is most evident for those in inpatient facilities. Warner (2009) estimates that approximately 50 per cent of people in inpatient facilities in the United Kingdom are heavy smokers, with almost 30 per cent of people with mental health disorders in the community smoking heavily.
Mental illness is also associated with poorer self-care skills. Lin and colleagues (2004) found that people with diabetes and co-morbid major depression were less likely to undertake physical exercise; had unhealthier diets; and lower medication adherence, while Evan and colleagues (2005) note that depression is associated with poorer adherence to dietary changes, smoking cessation and medication adherence for people with cardiac disease. In addition, many of the newer antipsychotic medications have side effects that result in weight gain (Leucht & Fountroulakis 2006).
With regards to structural causes, poor quality of health services provided to people with mental illness has been reported. Access to physical health services is inconsistent, and some clinical staff have inadequate skills and negative attitudes (Maj 2009; Canaway & Merke 2010). While Australia has policies for comprehensive mental and physical health services based on partnership between public and private sector providers, a review of stakeholder submissions to the Senate Select Committee on Mental Health found under-servicing due to poor continuity of care and limited success of intersectoral partnerships in delivering a comprehensive service (Townsend et al. 2006). A review by Canaway and Merke (2010) of barriers to treatment for mental health and alcohol co-morbidities found that siloing between sectors results in insufficient shared knowledge to manage co-concurrence of these disorders. The same is true of physical health needs. Lambert and colleagues (2003: $69) note that there is a perception by specialist psychiatrists that physical health matters should be the province of referring doctors, leading to infrequent physical examination by psychiatrists. In addition, the limited numbers of psychiatrists working within the public sector has undermined attempts to establish shared care schemes (Keleher 2006), while non-psychiatrists are reluctant to treat people with mental health disorders (Lambert 2003). Data on current government schemes suggests that they primarily increase referrals by GPs to allied health mental health services rather than create greater links between community mental health services and primary care (Fletcher et al. 2009). Further, when people with mental health disorders attend primary care services they are less likely to be monitored for physical health problems. Roberts and colleagues (2007) found that people with schizophrenia attending general practice in the United Kingdom were less likely to have their blood pressure, cholesterol levels and smoking status checked, when compared with a paired group of patients with asthma, and were less likely to have their blood pressure and cholesterol checked than the general population. Poorer monitoring of these patients has been associated with the misdiagnosis of physical symptoms (Henderson & Battams 2011), but also with lack of continuity in GP attendance (Lambert 2003).
Given moves to community-based models of mental health care and the involvement of mainstream primary care services in mental health, it is timely to examine the assumptions that underpin policy about how to meet the physical health needs of people with mental health disorders. This examination will consider how these policies articulate explicit and implicit understanding of the problem and hence the basis upon which these solutions are proposed.
This paper examines mental health policy documents published by the Australian, New South Wales and South Australian Governments between 2006 and 2011 (see Appendix Table 1, pp. 201-203). Both Federal and State government documents were examined. The constitutional division of labour in Australia is between the Federal Government, which manages the health budget and indirectly supports primary care through Medicare rebates, and the State governments, which are responsible for with services other than primary care. South Australia was chosen because it had until recently retained a strong focus upon institutional rather than community care for people with mental illness (South Australian Social Inclusion Board 2007). New South Wales, by contrast, has a strong community mental health sector and has developed specific policies for meeting the physical health care needs of people with mental illness (NSW Department of Health 2009a; 2009b).
The documents selected were all general policy statements, all publically available service plans and evaluation documents and service guidelines that made direct reference to physical health. All were available online and were obtained through searching the Department of Health and Ageing and Department of Families, Housing, Community Services and Indigenous Affairs websites for Commonwealth policy; and the New South Wales and South Australian Departments of Health websites for State policy. Further policy documents were obtained through a Google search for 'mental health policy'. This search elicited additional service plans but also policy statements and commentaries from mental health advocacy groups and other non-governmental organisations. Additional documents from these groups were obtained through a systematic search of websites of key organisations such as: the Mental Health Council of Australia; Mental Health Coalition of South Australia; National Mental Health Consumer and Carer Forum; SANE and Mental Illness Fellowship of Australia for commentaries on policy relating to physical health issues.
The methodology adopted to analyse the policy documents was discourse analysis. Bacchi (2009: 35) argues that policy documents can be examined to reveal the 'social knowledges' or discourses upon which they rely through asking 'what's the problem represented to be?' In this approach, policy is not considered simply a response to existing social problems: rather, postulated solutions are seen to frame 'problems' in such a manner that the recommended interventions become self-evident. The dominant representation of the problem reflects power relations, where power is viewed as a productive force that shapes who we are and how we live, rather than a negative force that restricts people's activities (Bacchi 2009: 37-38). Policy creates the discursive framework for understanding a social problem through producing that problem in a certain manner, excluding alternate representations of the issue and limiting the range of possible interventions to those following from that framework. The goal of discourse analysis of policy documents from this perspective, is to examine how social issues are represented; who stands to gain and lose from particular representations of the 'problem'; the subjectivities created by the way in which the 'problem' is represented; as well as the power evident in these representations (Bacchi 2000; 2009; Silverman 2000).
The policy documents were examined for discussion of the physical health of people with mental health disorders in the first instance. Following Armstrong (2009), citation of physical health was mapped across the five years to determine when it emerged as a problem within health policy. This time frame was adopted as preliminary perusal of Federal policy documents demonstrated that the physical health of people with mental health disorders was not 'problematised' prior to 2006. Policy was also examined to identify how physical health was represented, with a particular focus upon the factors identified as causing and perpetuating poor physical health. The causes of poor physical health were explored for the implications of this representation, particularly related to the subjectivities created for people with mental health disorders. The offered solutions to poor physical health were also canvassed and again explored alongside of the implications of these solutions for people with mental health disorders and service users. Documents from consumer and lobby groups were used to identify omissions within policy and provide an alternate view.
The emergence of physical health as a problem
Despite growing recognition of morbidity and mortality rates of people with mental disorders in the professional literature, there is limited discussion of the physical health of people with mental health disorders within Australian mental health policy. Federal policy first identified the physical health of people with mental disorders as a policy issue in 2009 when the National Mental Policy 2008 and The Fourth National Mental Health Plan were released. Physical health appeared in State mental health policy in both New South Wales and South Australia prior to 2009 (see Table 1). In New South Wales it was initially identified as an issue for at-risk groups such as the elderly or Indigenous populations who have higher rates of physical co-morbidities. Thus the NSW Service Plan for Specialist Mental Health Services for Older People 2005-2015 states that 'older people with mental health disorders may have complex care needs, including physical health needs'(2006: 4). By 2008, both the New South Wales and South Australian governments had identified the physical health care needs of the mentally ill population as a whole as problematic, but physical health was initially constructed as a risk factor for mental health rather than as a problem to be addressed in its own right. The NSW Community Mental Health Strategy 2007-2012 states, for example, that 'some physical illnesses also increase the risk of developing a mental illness or disorder' (2008: 2), while the National Mental Health Policy 2008 considers physical health problems as a risk for mental health disorders and mental health disorders a risk factor for physical health. By 2009, all three jurisdictions had identified the physical health care needs of the mentally ill as an issue to be addressed in policy. The New South Wales policy directive on the Provision of Physical Health Care Within Mental Health Services commits mental health services to the provision of physical health care, while South Australia's Mental Health and Wellbeing Policy 2010-2015 prioritises 'the physical health and wellbeing of people with severe mental illness' (2010: 17).
Framing the causes of poor physical health
For Bacchi (2000) the policy solutions adopted to address problems actually reveal how specific 'problems' are framed or represented. Postulated solutions draw upon taken-for-granted assumptions about the social world which, if accepted, make these solutions seem self-evident (Bacchi 2009). The proposed solutions to poor physical health for example, contain representations of the cause/s of the problem. In this case, the causes of poor physical health are found in both individual and structural factors. The primary individual factor identified is unhealthy lifestyle choice. A focus upon the management of lifestyle risks is evident in many of the policy documents. A Mentally Healthy Future for All Australians for example, identifies:
Likewise the NSW Health Physical Health Care of Mental Health Consumers Guidelines identify smoking, alcohol and drug consumption, poor diet and lack of exercise as risk factors associated with poor physical health in people with mental health disorders (2009: 5). Both place responsibility for health with the individual through focussing upon individual health behaviours.
The side effects of psychiatric medications are also identified as a factor. Concern with drug side effects is most evident within the South Australian mental health policy documents where it is associated with the health service quality and safety agenda. Thus the South Australian Mental Health and Wellbeing Policy 2010-2015 states that:
Structural issues are also identified. The issue most commonly discussed in these documents is access to health services. The National Mental Health policy 2008 states that '[p]eople with mental problems and mental illness should be able to access a necessary range of mental and general health services ...' (2009a: 12). Access is often associated in policy with rights, in line with the UN Convention of the Rights of Persons with Disabilities, which Australia ratified in 2008. The NSW Health Policy Directive on the Provision of Physical Health Care within Mental Health Services (2009: 3), for example, states at the outset that '[a]ll consumers of mental health services have the right to expect health care that is responsive and in line with the care provided to the general population'.
Poor physical health is related to access through 'insufficient medical assessment and treatment', which is viewed as a function of a lack of monitoring of physical health by mental health services and poor integration between mental health and primary health care services (NSW Department of Health 2009a: 3). A lack of monitoring is related to a failure to identify or to recognise physical illness and/or risk factors. Underpinning this is an assumption that mental health services are responsible for 'the initiation of preventative health measures for consumers' and for referring people with physical illnesses to GPs (NSW Department of Health 2009b: 3). GPs, in turn, are viewed as playing 'a vital role in maintaining the on-going physical health of mental health consumers', leading to calls for greater integration between community mental health and primary health services (SA Health 2010a: 14).
'Addressing' poor physical health
The three central policy solutions include: increased monitoring of physical health; the development of integrated care strategies with a focus upon primary care; and referral to or provision of programs which promote change in health behaviours. By asking how the 'problem' is represented in each of these solutions, it is possible to identify gaps and silences in current policy approaches.
The screening for physical health problems by community mental health teams and referral to primary health services are identified as key strategies for improving physical health. The model of care developed for the South Australian adult metropolitan mental health service (2010a: 17) requires that 'regular physical health screening must occur throughout the consumer's time with mental health services.' The same is true in New South Wales. The guidelines for Physical Health Care of Mental Health Consumers developed by NSW Health (2009a) recommend regular screening of blood pressure, weight, waist-hip ratio measurement, blood glucose and other blood tests as well as monitoring of smoking cessation, level of exercise and diet.
GPs are also identified as having an important role to play in 'early identification of and treatment for the physical health problems of mental health consumers' (NSW Department of Health 2009a: 8). The role of GPs is supported by calls for greater integration of mental health and primary health services (Commonwealth of Australia 2009b), with 'multidisciplinary collaborative practice' viewed as a means of overcoming clinical siloing and improving access to care (National Advisory Council on Mental Health 2009: 6). An interest in the development of integrated care, and in particular, greater use of GPs to provide care, precedes policy concerns with the physical health of people with mental health disorders. The National Action Plan on Mental Health 2006-2011 for example, views better co-ordination between services as a mechanism for 'prevent[ing] people who are experiencing acute mental illness from slipping through the care 'net" (COAG 2006: 3). While initially framed as a solution to service gaps, integrated care is now presented as a means to addressing poor physical health through enhancing consumer choice via provision of a range of services. Thus, the National Mental Health Plan (2009: 28) states:
A privileging of consumer choice and association of choice with access is also evident in an 'any door is the right door' approach to service delivery (SA Health 2010a: 15). The Federal government in 2011 budget documents promises 'one point of contact for all care needs ... [so that] no door is the wrong door' (Roxon et al. 2011: 5). This approach is seen as facilitating a 'comprehensive multidisciplinary assessment of their health and non-health needs' (Roxon et al. 2011: 5). The use of Medicare Locals and non-government organisations to perform this function is proposed. Use of Medicare Locals and NGOs is seen as increasing access but also increases reliance upon private over public service provision.
The policy documents present a range of strategies to strengthen collaboration between mental health and primary health services including better referral pathways, co-location of services, shared access to case records, attachment of GPs or practice nurses to mental health clinics, and joint consultation and planning sessions (NSW Department of Health 2006: 2009a: 2009b; SA Health 2010a; 2010b).
A final strategy adopted by both State governments to address physical health is health promotion through education about healthy lifestyles. The Adult Community Mental Health Services (Metropolitan Regions): Model of care states, for example, that:
Consumers and carers should receive education about lifestyle, and links to appropriate groups or services and physical health monitoring, focusing upon areas of known high risks to people with a mental illness. Interventions should focus on assisting the consumer to make choice regarding their own physical health and wellbeing (SA Health 2010a: 23, emphasis added).
This is in line with SA Health's Strategic Plan 2008-2010, which has a strong focus upon primary health care and health promotion, particularly around smoking and healthy weight. The NSW guidelines for the Physical Health Care of Mental Health Consumers associate health promotion with empowerment, noting that consumers 'need to be active participants in their own physical health care to determine their own health outcomes ...' (2009a: 10). Health promotion strategies recommended in these guidelines include development of readily available information about physical health, access and referral to dentists, podiatrists and health promotion activities, presentation of healthy living information in inpatient units, and support for attendance at GPs. This support might involve making appointments with or recommending GPs with mental health experience and organising transport to appointments.
A critical view: consumer and lobby groups
Bacchi (2009: 12) argues that discourse analysis of policy should also explore 'what fails to be problematised': that is, whose voices are omitted and where there are silences within policy. Analysis of policy documents and briefing papers arising from non-government organisations and consumer and lobby groups enables the identification of discrepancies between public policy and consumer concerns in relation to care delivery. Physical health is an issue that has been identified by these groups, evident in the number of websites which include consumer information about management of physical health issues. The specific causes of poor physical health are identified as lack of access to GPs and health promotion activities, adoption of risky lifestyle behaviours, siloing of services (MHCA 2009), a focus on high prevalence disorders (MHCA 2010), medication side effects, lack of health screening, and poverty and neglect (National Mental Health Consumer and Cater Forum 2010). The causes offered for poor physical health overlap with those evident in policy documents, however consumer and lobby groups place greater emphasis on the impact of structural factors, especially access to physical heath care. A focus on structural factors is also evident in commentary upon proposed policy solutions. While moves towards integrated care are generally viewed as a means of 'improv[ing] the health outcomes of people with co-morbid mental and physical disorder', there is more caution about dependence upon primary health care services (Mental Health
Coalition of South Australia 2009: 4). Concerns centre on two issues: the promotion of primary care to the detriment of secondary and tertiary mental health services and barriers to access to GPs.
Recent changes towards greater use of Medicare Locals flagged in the 2011 Budget are viewed with caution as there is no explicit mention of the physical health needs of people with mental health disorders. The Mental Health Council of Australia background paper of July 2010 notes that the use of primary care services may increase access and reduce stigma, but there is a potential for community care to be associated exclusively with primary care when 'not all community-based or 'non-hospital' mental health services provide primary care' (MHCA 2010: 3). Community mental health services traditionally service the needs of those with serious and disabling mental illness. A focus upon primary care is viewed as a threat to the specialist focus of community mental health services, potentially shifting care 'to people with less severe conditions, who would be the majority of people attending primary health care services' (MHCA 2010: 11).
Consumer and lobby groups are also concerned that the policy focus on user pays services provided through the private sector has potential to reduce access to these services. While all Australians receive benefits under Medicare, this scheme does not meet all consultation costs unless the GP bulk bills. Further, reliance on Medicare, which is not a health workforce planning instrument, does not ensure equitable distribution of, and hence access to, GPs. The Mental Health Council of Australia notes that dependence upon GPs is problematic in rural and remote areas and the socially disadvantaged outer suburbs of major cities, both of which have relatively few GPs and long waiting times for appointments (MHCA 2009; 2010). Additionally, while most GP services pass the consultation cost onto the government through bulk billing, access to services may depend upon the level of disposable income when this does not occur (MHCA 2009; 2010). Reliance upon fee-for-service delivery of primary mental health care through GPs is challenged by the Chair of the Australian General Practice Network, who calls for '[b]roadening mental health services to multidisciplinary, team-based models of care, that are less reliant upon fee-for service programs' as a means of increasing access and choice of service deliverer (AGPN 2011, n.p.).
A review of Australian policy documents for solutions to the poorer physical health of people with mental health disorders reveals a focus upon three central strategies: increasing monitoring of physical health by mental health teams, greater use of primary care services to meet physical health care needs, and the adoption of healthier lifestyle choices by people with mental disorders. These are encompassed within the favoured service delivery model which is an integrated comprehensive care model. An integrated model is viewed as a means of increasing access to greater range of services, thereby enhancing 'consumer choice' and has come to be seen as a solution to poor management of physical health care needs. In practice, the introduction of integrated care has had little impact on access to services. Service use remains low with three-fifths of women (59.3 per cent) and three-quarters of men who experience mental health disorders within a 12 month period not seeking support (Saw et al. 2010). A focus on consumer choice is one of the underlying principles of neoliberal governance. For Guthman (2008), neoliberalism is associated with subjectivities in which market rationalities are employed in day-to-day behaviour; that is, consumer are assumed to make choices by weighing the costs and benefits of health services. It is clear from the documents from consumer and lobby groups, however, that enhanced choice through primary care and Medicare Locals is not viewed as a means of increasing access to physical health care for people with mental health disorders. These groups view reliance on privately provided fee-for-service primary care services as limiting choice through lack of access and affordability of these services. Hickie (2010) notes growing inequity in affordability and access to services for Indigenous and rural Australians and ineffective care delivery for people with chronic illness. People in outer metropolitan and rural areas face well publicised shortages of GPs alongside of reduced access to non-government organisations and other support services for people with mental health disorders (Humphries et al. 2002; Henderson et al. 2008). While the development of Medicare Locals is viewed in policy as a strategy to addresses service shortages, if GP services are in limited supply physical health issues are unlikely to be addressed. In addition, not all GPs have the necessary expertise or an interest in mental health clients. This is particularly problematic in rural areas where consumers may need to travel significant distances when they do not have a local GP with an interest in, and knowledge of, mental health (Deans & Soar 2005; Taylor et al. 2009).
In addition, a focus on integration between primary care and mental health services relies on overcoming ongoing structural barriers including clinical siloing, the narrow focus of specialist knowledge; and poor monitoring of the physical health of mental health clients. Reviews of mental health services have identified gaps in service delivery which are further confounded by management across multiple levels of government and multiple governmental departments (Townsend et al. 2006; Henderson & Battams 2011). Hickie (2010) highlights a lack of structural links between private and public mental health services and NGOs. Primary care services operate under different governance systems than tertiary mental health services. Responsibility for primary care services lies with the Federal Government while provision of secondary and tertiary mental health services is a State responsibility. This division of responsibility leads to difficulties in integration, contributing, in turn, to reliance on informal rather than formal collaborations and hence quality of care that depends upon the personal compatibility of health professionals (Gibb et al. 2003; Taylor et al. 2009). These factors, taken together, have the following implications for the first two strategy solutions to poor physical health. First, reliance upon mental health teams or Medicare Locals to monitor physical health may not be effective unless steps are taken to ensure referral to and follow up by GPs. This was an issue recognised in policy from New South Wales insofar as it calls for client support for GP attendance, through the making of appointments, the recommendation of GPs who are sympathetic to mental health clients and the organisation of transport. Second, current service collaborations were designed to address mental health co-morbidities (often depression) that are associated with physical conditions, such as diabetes or heart disease, or the treatment of the high prevalence disorders that were not being treated at all (depression or anxiety). However, without addressing structural barriers to access to GPs and other services, these existing collaborative arrangements may not have the capacity or be appropriate for treatment of people with (for example) a chronic psychotic disorder. The third consideration, which is largely silent in policy, relates to where care is managed. Given the specific nature and needs of some people with a chronic and severe psychosis, it could be that service is better managed in mental health services, with GP services contracted in. Phelan and colleagues (2001) note, for example, that primary care is largely reactive, with short consultation times that may preclude effective physical and mental assessment of reluctant clients.
The final strategy, which focuses upon the promotion of healthier lifestyle choices, is indicative of a wider trend towards the management of lifestyle behaviours as a health goal in its own right (Armstrong 2009). Armstrong (2009) argues that lifestyle behaviours have become an object of study within the last 40 years, making the management of behaviour a health care goal in itself, in the process shifting focus from the structural factors which contribute to poor health behaviours to individual agency. This approach is indicative of neoliberalism, in which responsibility for health is increasingly placed upon the individual, through calls for greater self-management of lifestyle risk. The promotion of lifestyle change can be seen as an example of the 'responsibilisation' of people with mental health disorders. The essence of neoliberal government is self-governance, that is, governance through personal choice (Rose 1993). Personal autonomy is incorporated into the process of governance through encouraging individuals to take responsibility for making socially responsible choices. Personal responsibility for health is premised on a belief that health can be 'chosen' rather than something 'one simply enjoys or misses' creating an imperative to adopt lifestyle change (Greco 1993: 370).
For Warner (2009) this is problematic for two reasons. First, poor lifestyle habits are often associated with social disadvantage, as are low prevalence mental health disorders. The proposed strategies can be viewed as selective rather than comprehensive primary health care strategies as they apply externally developed rather than tailored strategies to the problem with the goal of preventing disease rather than promoting health (Baum 2007). In addition, governmental sponsorship of service delivery by GPs privileges prevention strategies focused on the individual over strategies that promote the health of the population as a whole (Henderson 2007). Funding decisions are informed by attribution of risk on the basis of epidemiological data (Baum 2007). This form of epidemiology expresses social inequalities as lifestyle factors and behaviors of the individual (McMichael 1999: 892), shifting attention away from structural aspects of inequality (Nettleton & Bunton 1995). Second, health promotion campaigns can, of themselves, be stigmatising. Through targeting at-risk populations the stigma accrues to the targeted population, in this case resulting in the mentally ill becoming 'multiply stigmatised' (Warner 2009: 277).
The data for this paper is drawn from three jurisdictions only and while there is a commonality in approach, it is evident that there are differences in emphasis between jurisdictions. Policy from New South Wales emphasises systemic solutions, while South Australia highlights lifestyle change. In addition, a consumer voice is represented by consumer and lobby groups. While, this is not problematic in relation to the methodology which seeks only to identify alternate means of representing the problem, caution must be exercised in viewing this as an authentic consumer voice.
This paper has explored policy representations of, and solutions to, the poorer physical health experienced by people with mental health disorders within Australian mental health policy. Utilising Bacchi's 'what's the problem represented to be?' approach to policy analysis, it has identified a policy focus upon lifestyle and lack of access to medical treatment as causes of poor physical health. Policy solutions target a greater reliance upon primary and collaborative care models; the monitoring of physical health and lifestyle factors by mental health teams, and the promotion of healthy lifestyles among people with mental disorders.
For Bacchi (2009), by examining how proposed 'solutions' create the 'problems' they purport to address, it becomes possible to identify those issues and voices which are marginalised. This paper argues that in subscribing to neoliberal conceptions of personhood, evident in the goals of informed consumer choice and personalised responsibility for health, some issues are overlooked. Specifically, the role of socio-economic inequity is not factored into suggestions that access to primary care services and the adoption of lifestyle behaviours will improve the poorer physical health of people with mental health disorders. In addition, in relying on comprehensive health services, there is uncritical acceptance that the delivery of physical health care services will not be hampered by the structural and attitudinal barriers that currently prevent effective integration between primary care and specialist mental health services. Consumer and lobby groups, by contrast, challenge a dependence upon primary health care services, arguing that primary care services may be less affordable and accessible and less able to meet the needs of people with low prevalence disorders. These changes may result in a widening rather than narrowing of inequities.
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... improved health [that] can be attributed to the improved living conditions many of us enjoy .... and reductions in preventable risk factors associated with what we eat, how much exercise we get, whether we smoke tobacco, how much alcohol we drink and so on (2009:14).
People with serious mental illness experience far poorer physical health than the general population and use of medications to treat psychosis can have significant adverse effects on an individual's physical health. We need to ensure that mental health services and professionals are able to actively identify, prevent and reduce harm to physical health associated with treatment for mental illness (2010: 16)
Development of partnerships and linkages between service types -both through co-location and service agreements--can promote coordination and continuity of care and enhance consumer choice, as well as ensuring physical and mental health care are considered jointly rather than separately (emphasis added)
Table 1: Policy documents examined, the representation of physical heath of people with mental illness and policy solutions offered Year Policy documents Representation of Policy solutions physical health (what's the problem represented to be?) National policy 2006 National Action Absent Plan on Mental Health 2006-2011 (COAG) 2007 Mental Health Absent Community Based Program: Program Guidelines (FaHCSIA) 2009 National Mental Physical health as Population health Health Policy 2008 a risk factor for approach to mental health Lack identify at-risk of knowledge of the groups Improved mix of services access to private needed providers through MBS Further mainstreaming of specialist mental health services 2009 A National Mental Prevalence of Collection of data Health Report Card physical about the rate of for Australia co-morbidities health assessment and lifestyle risks Burden of disease of mental health and economic costs consumers 2009 A Mentally Healthy Exposure to Collaborative and Future for all preventable risk multi-disciplinary Australians factors service delivery (National Advisory Council on Mental Siloing of service Health screening Health) delivery Education and healthy lifestyle programs 2009 The Fourth National Poor access to Role of GPs in Mental Health Plan services identifying co-morbidities Lack of continuity of care Development of partnerships for integrated and continuous care 2011 Budget: National Poor access to Use of Medicare Mental Health services Locals to provide Reform comprehensive Lack of continuity assessment of care Targeting of services towards underserviced communities New South Wales 2006 NSW: A New Absent Direction in Mental Health 2006 Specialist Mental Older people as a Partnerships Health Services for group at-risk of between mental Older People physical health services, (SMHSOP)--NSW co-morbidities aged care services Service Plan-- and GPs 2005-2015 Impact of physical health on mental Co-location of health services Joint planning Referral protocols 2007 NSW Aboriginal Aboriginal people Training of primary Mental Health and identified as being care workforce to Well being Policy at-risk of mental improve working 2006-2010 and physical relationships with co-morbidities aboriginal communities Lack of access to culturally Health screening appropriate services 2008 NSW Community Mental illness as a Co-location of Mental Health risk factor for services Strategy 2007-2012 physical co- morbidities and Address lifestyle physical illness as risk factors a risk factor for mental illness Assessment of physical health 2008 NSW Multicultural Absent Mental Health Plan 2008-2012 2009 Provision of Physical health Regular health Physical Health care as a right checks Care within Mental Health Services: Poor access to Protocols for Policy Directive healthcare referral of mental health clients to GPs Facilitation of access to health promotion activities 2009 Physical Health Poor access to Regular health Care of the Mental healthcare checks Health Consumer: Guidelines Cost and waiting Greater times for GPs collaboration between primary and Poor medical secondary services assessment and treatment Training of mental health staff to Exposure to support physical lifestyle risk health needs factors Referral to health promotion and prevention activities South Australia 2007 Stepping Up: A Absent Social Inclusion Action Plan for Mental Health Reform 2007-2012 (South Australian Social Inclusion Board) 2007 Country Health SA Absent Inc Mental Health Strategic Directions 2007- 2012 2007 Child, Youth and Absent Women's Health Service Division of Child and Adolescent Mental Health 2007-2010 2008 SA Health Strategic Risk of chronic Use of GP Plus Plan 2008-2010 disease clinics to provide co-morbidities integrated care for noted chronic illness Education and information for self-management of risk factors 2008 SA Health Absent Disability Action Plan 2008-2013 2009 Country Health SA Association of poor Regular health Mental Health physical health checks by GPs Services: Model of with capacity to care live independently Provision of lifestyle advice Education to facilitate self- managed care 2010 South Australia's Medication side Integration of Mental Health and effects Poor services Wellbeing policy assessment of 2010-2015 physical Collaboration with co-morbidities GPs and Divisions of General Practice Education of mental health service providers to identify medication side effects 2010 Adult Community Exposure to Role of GPs in Mental Health lifestyle risk maintaining Services physical health (Metropolitan Medication side Regions): Model of effects Regular physical care health screening Education about lifestyle risks and referral to groups or services Consumer and lobby groups 2009 Towards a National Reduced life Collection of Mental Health expectancy mortality data Report Card for Australia (MHCA) 2009 Access to Health Adoption of high Services by People risk behaviours with Mental Illness Less engagement in (MHCA) health promotion activities Access to and affordability of GPs GP waiting lists Siloing of services 2009 Mental Health: Degree of morbidity Intersectoral and Let's Make it Work interagency Better (Mental cooperation Health Coalition of South Australia) 2010 Community Mental Lack of provision Regular health Health Guiding of comprehensive checks Principles (MHCA) health care Shared care arrangements 2010 Community Mental Access to and Shared care Health and Primary affordability of arrangements Mental Health Care: GPs Background Paper (MHCA) Focus upon high prevalence disorders to the detriment of people with disabling mental health problems 2010 Physical Health Medication side Education on Impacts of Mental effects physical illness Illness (National Mental Health Poverty and neglect Responsible Consumer and Carer prescription of Forum Advocacy Lack of health medication brief) screening Monitoring of Lifestyle factors physical health Reporting and accountability for provision of health assessment
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