community mental health programs. Often referred to as the three
solitudes, these components of what should be a mental health system have
historically not been well connected. The origins of each component were
historically quite different. Ontario's provincial asylums had their origins in
the 19th century, when confinement of the mentally ill and their separation
from community was the norm. General hospital psychiatric units were the
product of mainstreaming mental health services in the 1960's. Community
mental health programs first received funding in the late 1970's when it was
recognized that alternatives to inpatient care needed to be created.
While some interdependence developed, as provincial and general hospital
psychiatric programs needed access to community housing and case
management programs in order to discharge people, much of the debate
since 1988 has been about approaches to building a community-focused
mental health system.
The debate has focused on three elements:
Who has voice in decisions about the system?
What is the lens by which the system should be viewed, i.e. medical
model or something else?
How should the component parts be integrated?
In 1988, the government published The Graham Report: Building
Community Support for People, which for the first time identified a need for
partnerships between consumers, families and providers. The Graham
Report found that while community mental health spending was increasing,
as a proportion of health spending it was actually declining.
It proposed a whole-system view with comprehensive services. This
included psychiatric rehabilitation services, housing, as well as improved
access to treatment services close to home, leading to the development of
local and regional mental health systems that effectively linked provincial
psychiatric hospitals, general hospital and community services; in other
words, a community-focused mental health system. The report also called
for inter-ministerial collaboration on income, employment and housing.
The 1990 election of a new government with an interest in policy
frameworks led to the publication of Putting People First in 1993, which set
targets for a funding shift and focused on the core functions of crisis, case
management, housing, consumer and family supports. The funding targets
proposed shifting spending from 80% hospital and 20% community to 60%
community and 40% hospital services over a 10-year period.
District health councils were again asked to develop plans and a small
amount of transitional funding was injected into the system. It was thought
the Community Investment Fund, which totalled $23 million, would
facilitate the reallocation of funding from institutional to community
services over time.
The policy lens of the government and of many stakeholders focused on
community-based supports, rather than treatment services, and for the first
time the provision of supports by consumers and families themselves was
given legitimacy and funding.
