problematising' australian policy representations in responses to the physical health of people with...

8/12/2019 'Problematising' Australian policy representations in responses to the physical health of people with mental health

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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 Medicare Benefit Support (MBS) was withdrawn for social work and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 usealcohol 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 thatpeople 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


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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 Walesand 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


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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 wasmapped 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 mentalhealth 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


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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:

... 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).

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 associatedwith 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:

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


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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)

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 ofcare 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 healthservices (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


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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:

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)

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 mentalhealth 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 orservices 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 aboutphysical 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


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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 forcommunity 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 bulkbills. 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-fo-

-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' asa means of increasing access and choice of service deliverer (AGPN 2011, n.p.).

Discussion


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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-fo-

-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 mentalhealth 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


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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, governmentalsponsorship 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


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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

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


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(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


13/24

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


14/24

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


15/24

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


16/24

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


17/24

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


18/24

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


19/24

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


20/24

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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