Background: Open Minds, Healthy Minds, Ontario's Comprehensive Mental Health and Addictions Strategy commits to the transformation of mental health and addictions services for all Ontarians.
Objective: We analyzed the formulation and implementation of this Strategy to address the question: What are the prospects for transformative change in Ontario's current approach to mental health and addictions?
Methods: Qualitative policy analysis using interpretive description of key documents of the policy process, drawing on policy network and horizontal governance theory.
Results: Three features set this policy process apart from previous reform efforts: (1) expansion of the state pluralist network to those outside of health, (2) extension of the policy network approach into the Strategy's implementation stage and (3) the combined presence of political and policy leadership.
Conclusions: There is reason for optimism that the approach of the Strategy has increased the prospects for the transformation of Ontario's mental health and addictions system.
Ontario has had a long and challenging history of addressing its populations' mental health and addictions problems. The move towards deinstitutionalization beginning in the 1960s and continuing for over 40 years (Hartford et al. 2003) has increased governments' and communities' awareness of the need to address these problems. However, the provincial government has been slow to respond to this shift, leaving communities poorly resourced and with a community-based mental health system that is fragmented and difficult to navigate (Hartford et al. 2003; Mulvale et al. 2007).
Several authors have examined this lack of progress by analyzing reform efforts and various commissioned reports, task force documents and provincial government policies. Notably, Wiktorowicz (2005) sought to understand why the shift to a community-based system in Ontario has not kept pace with institutional downsizing, with particular focus on the years 2000–2004. Their analysis found that a lack of political will to reallocate funds to the community and to delegate control for them was the largest barrier to reform. Additional challenges identified were arm's-length and internal government policy processes with varying degrees of authority, a lack of consistent engagement with the policy community and the complexity of intersectoral coordination. Mulvale and colleagues (2007) also identified challenges to reform in their analysis of the role of legacies produced by psychiatric hospital policies stemming from the introduction of psychiatric hospitals in the 1850s and public health insurance in the 1960s.
While some incremental gains have been achieved in terms of investments in community mental health and addictions services since that time, programs still lack capacity to serve all those in need and clients still lack access to a broad range of supports and services (SEEI Coordinating Centre 2009). This may be partly attributable to insufficient funding levels. In 2013–2014, there was an estimated $3.5-billion direct investment from the Ministry of Health and Long-Term Care (MOHLTC) and the Ministry of Child and Youth Services (MCYS) as well as investments from other sectors such as education, justice and housing (Brien et al. 2015). This investment equates to approximately 6.5% of Ontario's health budget, markedly lower than many other countries and lower than the 9% target in Changing Directions, Changing Lives: The Mental Health Strategy for Canada (MHCC 2012).
In 2008, the Ontario government once again embarked on a reform process targeting mental health and addictions, this time with the goal of developing a 10-year mental health and addictions strategy. Open Minds, Healthy Minds, Ontario's Comprehensive Mental Health and Addictions Strategy (the Strategy) was released in June 2011 (Government of Ontario 2011). The Strategy commits to the "transformation" of mental health and addiction services for all Ontarians. It includes four goals: (1) improve mental health and well-being for all Ontarians; (2) create healthy, resilient, inclusive communities; (3) identify mental health and addictions problems early and intervene; and (4) provide timely, high-quality, integrated, person-directed health and other human services. It has been seven years since the release of the Strategy, so it seems reasonable to take stock of whether Ontario is any further along in realizing the transformation it promised and to assess whether this attempt at reform has been any different from the "frustrated" attempts of the past.
This paper traces the formulation and implementation of the Strategy guided by the question of whether there is something specific about this policy process that increases its prospects for leading to transformative change. We approach this research with two specific objectives in mind: (1) to describe the policy process; and (2) to identify key features that distinguish it from past policy efforts in this area. We draw on relevant policy theory to advance our core argument in the paper that the current Strategy has reasonable prospects for achieving its goals because of the approaches taken for its development and implementation.
We undertook a qualitative policy analysis using interpretive description (Thorne et al. 2004), which allows the researcher, through reflexive and critical examination, to extend the descriptive account to one that is also explanatory (Thorne 2016). In this case, interpretive description was particularly useful because it allowed us to critically examine a wide range of documents to create a descriptive account of the policy process, which we then interpreted through the lens of our research question and the theory we drew upon for our analysis.
We used two recognized theories from the political science field to guide our analysis: (1) policy networks; and (2) horizontal governance. These theories were selected based on a preliminary review of the Strategy and selected policy documents that suggested differences in the size and scale of engagement in both the development and implementation phases of the Strategy. When compared to previous reform efforts, the Strategy gave greater emphasis to the broad and inclusive engagement of stakeholders within and across sectors, as well as across government ministries. It also extended this engagement beyond the policy formulation stage and into the implementation stage. Recognizing these differences, we hypothesized that two key structural features in the Strategy – the mobilization of policy networks and the horizontal coordination of public policies – might increase the prospects for the Strategy to lead to more transformative change of Ontario's mental health system.
Policy networks can be simply described as the links that join state and societal actors together in a policy process (Katzenstein 1977). According to Kenis and Schneider (1991), policy networks can "be understood as those webs of relatively stable and ongoing relationships which mobilize dispersed resources so that collective (or parallel) action can be orchestrated towards the solution of a common policy problem" (p. 36). These networks vary according to the number of members and whether the state or the societal actors are perceived as dominant (Howlett and Ramesh 1998). Interest in policy networks continues to grow in part because it reflects important shifts in our forms of governance based on societal changes, including increases in the complexity of society and government, the emerging importance of information and technologies and a better understanding that policy objectives often require implementation support from non-government actors (Pal 2014). For most healthcare issues, a policy network of actors in government and society already exists, but network activation to realize policy goals is more haphazard. The draw of a network approach, Pal suggests, is the thinking that the wider the networks and the more competition among actors, the better the policy outcomes.
Horizontal coordination of public policies (or horizontal governance) refers to efforts made within government to coordinate across existing bureaucratic boundaries to solve problems that span bureaucratic jurisdictions. As Pal (2014) notes, horizontal governance is not new in the sense that it has traditionally occurred at high levels of government such as cabinet. However, he points to a growing interest in horizontality extending to all levels of the government bureaucracy and an increased expectation that departments work together. Hopkins and colleagues (2001) identify the key dimensions of horizontal management as: mobilizing teams and networks, developing shared frameworks, building supportive structures and maintaining momentum. There is some conceptual overlap between the horizontal governance and policy network literatures; however, for the purposes of this study, the former will refer to actors and interactions within government structures and the latter will refer to actors and interactions across government and societal boundaries. Both of these approaches have been described elsewhere in varying forms as either "joined-up government" or "whole-of-government" approaches (Christensen and Laegreid 2007; Davies 2009; Hunt 2005).
We searched for publicly available documents using the search engine Google and academic documents using PubMed, EBSCOhost and Google Scholar using the key words: mental health, addictions, "Open Minds Healthy Minds," "mental health addictions strategy Ontario," "minister's advisory group," "select committee" and "every door is the right door," in various combinations to identify publicly available documents related to the Strategy. We also reviewed the websites of the Ontario government and key organized interests across sectors, including mental health and addictions (such as Children's Mental Health Ontario), health (such as the Ontario Medical Association), education (such as the Ontario Public School Boards' Association), justice (such as the Ontario Association of Chiefs of Police) and child welfare (such as the Ontario Association of Children's Aid Societies), and we searched the Canadian Newswire for press releases from organized interests. All searches covered the period from 2009 (two years prior to the release of the Strategy) to 2016 (five years after the release of the Strategy). These sources were supplemented with additional documents from the authors' personal files.
The search resulted in 43 documents that included: (1) publicly available government documents and presentations by government officials on the Strategy and related policy formulation and implementation activities; (2) hearing transcripts from the Select Committee on Mental Health and Addictions; (3) academic articles focused on the policy process or outcomes; 4) Canadian Newswire press releases from organized interests; and (5) reports from the Mental Health and Addictions Leadership Advisory Council.
To describe the policy process, documents were read in their entirety, sorted and classified as either being related to policy formulation or implementation. A timeline was created to identify key activities and documents according to policy stage (Figure 1). The documents were then analyzed with the goal of identifying key features drawing from relevant theory and using the analytic procedures of interpretive description (Thorne 2016).
Description of the policy process
We identified three key government actions taken to inform the Strategy development that illustrate a policy network and horizontal governance approach to policy formulation: (1) the appointment of an all-political-party Select Committee; (2) the convening of a group of stakeholders to advise the Minister of Health on strategy development; and (3) the striking of an interministerial working group at the assistant deputy minister (ADM) level across multiple government ministries.
In February 2009, the legislative appointment of an all-party Select Committee on Mental Health and Addictions (Select Committee) to develop a comprehensive mental health and addictions strategy, in structure alone, improved the likelihood that the resulting strategy would be acceptable to and supported by each of the parties in the event of a change in political leadership at the provincial level. The Select Committee began its work in 2009 with three main goals: (1) to determine the mental health and addiction needs of children and young adults, First Nations, Inuit and Metis peoples and seniors; (2) to explore innovative approaches to delivering services in the community; and (3) to identify ways to leverage existing opportunities and initiatives within the current mental health and addictions system (Ontario Legislative Assembly 2010a). The committee held a series of 30 public hearings, toured sites and accepted written submissions from a wide array of organized interests and members of the public. In total, over 230 witnesses presented to the committee providing diverse perspectives from the health and mental health sectors, as well as education, human rights, justice, housing and social care. In addition, 300 written submissions were received. The Select Committee submitted an interim report to the Legislative Assembly of Ontario in 2010 (Ontario Legislative Assembly 2010b) followed by a final report outlining recommendations to the Government in advance of the Strategy six months later (Ontario Legislative Assembly 2010a). While a committee of elected officials alone could be considered an authoritative policy instrument, the committee's engagement with such a broad range of actors demonstrates the additional efforts taken to engage the policy or "issue" network (Mulvale et al. 2014) in the formulation of a policy direction.
The second action involved the identification and convening of a Minister's Advisory Group (MAG) in 2008, to provide overall direction and priorities for the Strategy. The MAG comprised stakeholders outside of government, representing a range of individual and organized interests including researchers, service providers, professional associations, consumer groups, the Mental Health Commission of Canada, social development organizations and immigrant services (Government of Ontario 2009). The MAG consulted over 100 Ontarians, held workshops, commissioned five background or "theme group" papers on different topics and then created a discussion paper Every Door is the Right Door, which presented a framework for the proposed strategy (Government of Ontario 2009). Shortly after the discussion paper's release, the Minister of Health and the MAG held a summit, inviting over 1,000 consumers and experts from across Ontario to contribute to the discussion paper. Additional feedback was solicited following the summit through round-table consultations and written submissions. The MAG's final task was to develop recommendations for Ontario's mental health and addictions strategy, which were presented in a 2010 report (Minister's Advisory Group on Mental Health and Addictions 2010). This action put actors with varying interests in a position of power and responsibility in the formulation of policy. It allowed the government access to a wide array of ideas, including research evidence, tacit knowledge of practitioners and stakeholder values.
The third action was the creation of an interministerial assistant deputy ministers (ADMs) group, which reflects a horizontal governance approach to policy making. Comprising 14 different ministry ADMs, this group was tasked with identifying and streamlining services, policies and initiatives that address mental health to foster coordination (Government of Ontario 2009). They were also tasked with including mental health as a standing item on existing interministerial meeting agendas.
All told, the policy formulation process took place over almost three years, culminating with the release of the Strategy in June 2011 (Government of Ontario 2011). The scale and scope of this process reflect a deliberate and concerted effort at engaging and mobilizing a very broad policy network for the purposes of policy formulation.
We identified five features of the implementation plan and its subsequent roll-out that illustrate the government's persistence in extending the policy network and horizontal governance approach into the policy implementation process: (1) the dispersion of leadership and accountability for Strategy initiatives across government ministries beyond health; (2) the development of a range of interministerial approaches for ongoing collaboration and coordination across the government ministries; (3) the engagement of actors outside the government structure to lead Strategy initiatives; (4) the appointment of the Mental Health and Addictions Leadership Advisory Council; and (5) the delegation of leadership to the policy network to determine what should be done to meet some of the Strategy goals.
The distribution of the leadership – a key feature of a horizontal governance approach – could be identified in the first wave of implementation of the 22 initiatives across government ministries. While one ministry (MCYS) had overall accountability for the first three years, each particular initiative had an identified program lead in government. In total, four government ministries (MCYS, Ministry of Education, MOHLTC and Ministry of Training, Colleges and Universities) with multiple divisions and programs within those ministries had direct accountability for the initiatives.
Another horizontal governance feature used to support their efforts was the government's articulation of a range of interministerial approaches (Government of Ontario 2013). These included both decision-making and coordination approaches, such as a Deputy Ministers Social Policy Committee that would meet quarterly to discuss priorities including the Strategy, bi-weekly and monthly meetings of interministerial working groups at staff/manager, director and ADM levels and a clear process vetting communications/memos, advisory committee activity, education/training and advisory committee activities through the working groups (Government of Ontario 2013).
The government's implementation approach also included actors outside of the government structure. This is most apparent through the delegation of accountability for many of the Strategy initiatives from ministry programs to policy network actors. For example, the initiative "Provide Nurses in Schools to Support Mental Health Services" was delegated for implementation to the Registered Nurses Association of Ontario. Similarly, in education, the Hamilton Wentworth District School Board was designated lead for "Implement School Mental Health ASSIST Program and Mental Health Literacy Provincially." Within the health area, "Create 18 Service Collaboratives" was delegated to the Centre for Addiction and Mental Health. It should be noted that, in all cases, leads represented well-established institutions. This delegation continued in the second wave of implementation that began in the fourth year of implementation when lead accountability for the Strategy shifted from the MCYS to the MOHLTC. During this period, the government appointed a Mental Health and Addictions Leadership Advisory Council comprising 20 system stakeholders with a mandate to provide implementation advice for three years, from 2014 to 2017. The Council, in turn, identified a number of working groups, led by council members but comprising additional experts from the province on specific topics. This widened the engagement of the policy network even further during the second wave of implementation.
The government also took a networked approach to determine what should be done to meet some of the Strategy goals by creating a $27-million "Mental Health Innovation Fund" aimed at supporting innovative approaches to on-campus mental health service delivery for post-secondary students (Ontario Undergraduate Student Alliance 2014). In 2012, the Ministry of Training, Colleges and Universities solicited proposals from stakeholders based on the objectives of the fund. Thirty-two initiatives were supported as of 2015, led by a variety of actors (Ministry of Advanced Education and Skills Development 2015). Thus, leadership and engagement in the implementation of this particular policy objective was shared with actors who were selected during the process, thus diffusing the responsibility and accountability for improving campus mental health across the system.
Assessing the prospects for transformative change
Our findings identified a number of features of policy network and horizontal governance approaches visible in the Strategy that offer promising prospects for transformative change. First, in contrast to previous reform efforts that have focused on a narrower set of actors from the mental health and health sectors, the Strategy defined the policy network more broadly and intersectorally, an approach viewed as critical to successfully address wicked problems (Roberts 2000). Involving multiple actors and government ministries through horizontal governance distributes leadership in policy reform, but may also increase collective accountability, making the process less likely to stall at the implementation phase. It may also reduce resistance to implementation among organized interests (as noted by the series of news releases from organizations mainly applauding the release of the Strategy) (Canada Newswire 2011a–g).
A second distinguishing feature is the concerted effort to extend the engagement of the policy network and the horizontal governance approach beyond the policy formulation stage and into implementation. Continuing to mobilize policy network actors into the implementation stage significantly increases the prospects for reform by embedding changes across systems and developing shared ownership at the implementation level. Policy networks are important sinews for implementation and delivery (Pal 2014), so early and continued engagement of relevant actors lays the groundwork for success.
Finally, this process involved both political and policy leadership. The political leadership (the Select Committee) was a unique feature when compared with past policy activity in the mental health and addictions domain. Committee membership from all three main political parties increased the likelihood that the Strategy would be sustained through changes in government.
Our findings demonstrate that many of the features of the policy network and horizontal governance approach to policy making were present in the Government of Ontario's Strategy. Notably, our analysis revealed an expansion of the state pluralist network to include both governmental and non-governmental actors beyond those in the health sector. Second, we see examples of the various dimensions of horizontal governance as identified by Hopkins and colleagues (2001). The presence of these features reveals a deep commitment to responding to the challenges of the complex, multi-faceted problem of mental health policy in a comprehensive and collaborative way across multiple sectors and in both the policy formulation and policy implementation stages.
Although our findings offer an optimistic account regarding the potential for transformative change in mental health and addictions in Ontario, there are several limitations to policy network and horizontal governance approaches. One drawback is time. As this case illuminates, using a networked approach can be lengthy because of the coordination of inputs and consensus building required before decisions can be made. This approach may take longer than a centralized authoritative model of policy formulation, which places pressure on governments who want to be seen as "doing something" and making strides towards reform. This challenge is amplified by relatively short electoral cycles, which can increase the impetus for swift action and constrain the perceived options for implementation. A related challenge is the value conflicts that arise during the policy development and implementation process and the need to create effective resolutions to ethical dilemmas that are encountered, particularly when the policy development and implementation process involves the engagement of such a wide array of actors. Scholars have suggested that network and horizontal approaches can ignore important political value conflicts because of the focus on consensus and partnership, which creates only shallow goal consensus and can result in a replication of silo practices that were meant to be avoided by using these approaches (Davies 2009).
In addition, actors who engage in horizontal and network approaches still must interact with and, to some degree, operate within the authoritative structures that exist in the system. Hierarchical organizations have not been designed for this mode of operation, which can have challenging consequences. For example, joint communications announcing the Strategy implementation initiatives were initially slow to surface. However, once these processes were established, they began to move more swiftly, and a subsequent memo with four ministry signatories was circulated to key actors in a timely way announcing a particular implementation initiative (Srinivasan 2012).
A further potential limitation of the network approach is the boundaries that networks create, resulting in some stakeholders being left out and therefore unable to contribute in a direct way. One example of stakeholders who were excluded from the network in this case was private sector service providers who continue to play a key role in delivering mental health and substance use services that are not covered by publicly funded health insurance plans.
Finally, networks require some form of governance and management. Applying a network approach requires both a different frame of thinking and a different way of acting. Network management has been acknowledged as no easy task (Klijn and Koppenjan 2000). When the government does not use horizontal governance and policy network approaches frequently, additional leadership and individuals with skills in brokering, communication and systems thinking are required. This is a particular challenge with high turnover in bureaucratic positions and leadership and will continue to be a challenge for the Ontario government as it manages the Strategy moving forward.
Underpinning any approach to reform is a need to resource the system appropriately to undertake the reforms and deliver services that meet the needs of citizens. As identified by Bartram and Lurie (2017), and as alluded to earlier, Canada has a long-standing gap in mental health funding relative to the disease burden of mental illnesses and addictions. Any reforms identified through this approach will require appropriate financial investments to ensure success.
Our study included a thorough document analysis but did not include other empirical strategies such as interviews or surveys with relevant actors, which would enrich the understanding of the intricacies of the policy process related to the Strategy. This analysis is therefore most helpful in identifying the features of the policy process that are salient for future investigation and hypothesis development.
Because the Strategy is only midway through its implementation, there are many avenues for additional exploration as it continues to unfold. Future research should examine and measure the policy outcomes of the Strategy with the aim of specifying the components of the policy network and horizontal governance approach most important in explaining the policy outcomes. Comparative studies that examine Ontario's approach to that of other provinces/states based on either the same subject area (mental health and addictions) or on other similar policy network and horizontal governance approaches would yield additional explanatory power. Furthermore, studies comparing the costs of such approaches with more traditional approaches to health policy development and implementation, and related trade-offs in efficiency and outcomes, would be of value to begin to understand when such approaches are warranted. Moreover, quantitative social network analysis of the policy network could offer important insights into how the structure of the network and the ties among actors affect the policy outcomes (Brandes et al. 1999; Rhodes 2006). Finally, evaluation activities should focus on the changes implemented as a result of the policy, whether those changes address the original problems and if they result in positive outcomes for citizens.
Our analysis suggests that there is reason to be optimistic that the policy formulation and implementation stages of the Strategy as currently constructed have increased the likelihood for transformative change. Further evaluation will be required to determine whether this was enough to improve outcomes for Ontarians.
Nouvelle fraîcheur dans la réforme ? Analyse des politiques liées au développement et à la mise en œuvre de la stratégie ontarienne de santé mentale et de lutte contre les dépendances
Contexte: Esprit ouvert, esprit sain – Stratégie ontarienne globale de santé mentale et de lutte contre les dépendances représente un engagement envers le changement profond des services de santé mentale et de lutte contre les dépendances pour tous les Ontariens.
Objectif: Nous avons analysé la formulation et la mise en œuvre de cette Stratégie afin de répondre à la question suivante : quelles sont les perspectives de changement profond dans la démarche ontarienne actuelle envers la santé mentale et la question des dépendances?
Méthode: Nous avons effectué une analyse qualitative des politiques, au moyen de la description interprétative de documents clés touchant au processus, en tirant profit du réseau politique et de la théorie de la gouvernance horizontale.
Résultats: Trois caractéristiques font que ce processus politique se démarque des efforts de réforme précédents : (1) l'expansion du réseau provincial multiple au-delà du milieu de la santé, (2) l'étendue de la démarche du réseau politique dans la phase de mise en œuvre de la Stratégie et (3) la présence combinée de leaderships politiques et administratifs.
Conclusion: Il y a des raisons de croire que la démarche adoptée pour la Stratégie a permis d'accroître les perspectives de changement au sein du système ontarien de santé mentale et de lutte contre les dépendances.
About the Author(s)
Heather L. Bullock, MSc, PhD Candidate, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
Julia Abelson, PhD, Professor, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
Correspondence may be directed to: Heather L. Bullock, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON; e-mail: email@example.com
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