'Problematising' Australian policy representations in responses to the physical health of people with mental health disorders.
Abstract: 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
Article Type: Report
Subject: Medical policy (Analysis)
Mentally disabled persons (Health aspects)
Mentally disabled persons (Laws, regulations and rules)
Mental illness (Risk factors)
Mental illness (Care and treatment)
Authors: Henderson, Julie
Fuller, Jeffrey
Pub Date: 12/22/2011
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
Accession Number: 276807856
Full Text: Introduction

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.

Methods

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.

Results

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.).

Discussion

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).

Limitations

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.

Conclusion

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.

Appendix

References

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Bacchi, C. (2000) 'Policy as discourse: What does it mean? Where does it get us?', Discourse: Studies in the Cultural Politics of Education, 21 (1), 45-57.

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Baum, E (2007) 'Health for All Now! Reviving the spirit of Alma Ata in the twenty-first century: an introduction to the Alma Ata Declaration', Social Medicine 2(1), 34-41.

Canaway, R. & Merkes, M. (2010) 'Barriers to comorbidity service delivery: the complexities of dual diagnosis and the need to agree on terminology and conceptual frameworks', Australian Health Review, 34 (3), 262-268.

COAG (Council of Australian Governments) (2006) National Action Plan on Mental Health 2006-2011, Canberra, Council of Australian Governments.

Commonwealth of Australia (2009a) National Mental Health Policy 2008, Canberra, Department of Health and Ageing.

--(2009b) The Fourth National Mental Health Plan: An agenda for collaborative government action in mental health 2009-2014, Canberra, Department of Health and Ageing.

Deans, C. & Soar, R. (2005) 'Caring for clients with dual diagnosis in rural communities in Australia: The experience of mental health professionals', Journal of Psychiatric and Mental Health Nursing, 12 (3), 268-274.

Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People With Learning Disabilities and/or Mental Health Problems, Stratford upon Avon, Disability Rights Commission.

Evans, D., Charney, D., Lewis, L., Golden, R. et al. (2005) 'Mood disorders in the medically ill: scientific review and recommendations', Biological Psychiatry, 58 (3): 175-189.

Fenton, W. & Stover, E. (2006) 'Mood disorders: cardiovascular and diabetes comorbidity', Current Opinions in Psychiatry, 19 (4), 421-427.

Fletcher, J., Pirkis, J., Kohn, F, Blashki, G & Burgess, P. (2009) 'Australian primary mental health care: improving access and outcomes', Australian Journal of Primary Health, 15 (3), 244-253.

Gibb, H., Livesey, L. & Zyla, W. (2003) 'At 3 am who the hell do you call?' Case management issues in sole practice as a rural community mental health nurse,' Australasian Psychiatry, 11 (s1), 127-130.

Gordon, C. (1991) 'Governmental rationality: an introduction', in G. Burchell, C. Gordon & P. Miller (eds.) The Foucault Effect: Studies in Governmentality, Chicago, University of Chicago Press.

Greco, M. (1993) 'Psychosomatic subjects and the 'duty to be well': personal agency within medical rationality', Economy and Society, 22 (3), 357-372.

Guthman, J. (2008) 'Neoliberalism and the making of food politics in California,' Geoforum, 39, 1171-1183.

Henderson, J. (2005), 'Neoliberalism, community care and Australian mental health policy', Health Sociological Review, 14 (3), 242-254.

--(2007) 'The National Mental Health Strategy: redefining promotion and prevention in mental health?', Australian Journal of Primary Health, 13 (3), 82-89.

Henderson, J. & Battams, S. (2011) 'Mental health and barriers to the achievement of the 'right to health", Australian Journal of Primary Health, 17 (3), 220-226.

Henderson, J., Willis, E., Walter, B. & Toffoli, L. (2008) 'Community mental health nursing: keeping pace with care delivery?', International Journal of Mental Health Nursing, 17 (3), 162-170.

Humphreys, J., Jones, M., Jones, J. & Mara, P. (2002), 'Workforce retention in rural and remote Australia: determining the factors that influence length of practice', Medical Journal of Australia, 176 (10), 472-476.

Hickie, I. (2010) 'The 2010 Rudd plan: will it actually deliver better health services?', Medical Journal of Australia, 192 (7), 1-2.

Hickie, I. & Groom, G. (2002) 'Primary care-led mental health service reform: an outline of the Better Outcomes in Mental Health Care initiative', Australasian Psychiatry, 10 (4), 376-382.

Iacovidis, A. & Siamouli, M. (2008) 'Comorbid mental and somatic disorders:

an epidemiological perspective', Current Opinion in Psychiatry, 21 (4), 417-421.

Iosifescu, D. (2007) 'Treating depression in the medically ill', Psychiatric Clinics of North America, 30 (1), 77-90.

Jablesnsky, A., McGrath, J, Herman, H., Castle, D., Gureje, O., Morgan, V. & Korten, A. (1999) People Living With Psychotic Illness. An Australian study 1997-98, Canberra, Commonwealth Department of Health and Aged Care.

Keleher, H. (2006) 'Community-based shared mental health care: a model of collaboration?', Australian Journal of Primary Health, 12 (2), 90-96.

Lambert, T., Velakoulis, D. & Pantelis, C. (2003) 'Medical comorbidity in schizophrenia', Medical Journal of Australia, 178 (9 Suppl), S67-S70.

Leucht, S. & Fountoulakis, K. (2006) 'Improvement of the physical health of people with mental illness', Current Opinions in Psychiatry, 19 (4): 411-412.

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Mental Health Coalition of South Australia (2009) 'Mental Health: Lets Make It Work Better', http://mhcsa.net/?catID=48.

MHCA (Mental Health Council of Australia) (2009) Access to health services by people with mental illness, Canberra, Mental Health Council of Australia.

--(2010) Community mental health and primary mental health care background paper, Canberra, Mental Health Council of Australia.

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New South Wales Department of Health (2008) NSW Community Mental Health Strategy 2007-2012, North Sydney, NSW Department of Health.

New South Wales Department of Health (2009a) Physical Health Care of Mental Health Consumers: Guidelines, North Sydney, NSW Department of Health.

New South Wales Department of Health (2009b) Provision of Physical Health Care within Mental Health Services: Policy directive, North Sydney, NSW Department of Health.

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SA Health (2010a) Adult Community Mental Health Services (Metropolitan Regions): Model of Care, Adelaide, Government of South Australia.

SA Health (2010b) South Australia's Mental Health and Wellbeing Policy 2010-2015, Adelaide, Government of South Australia.

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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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