1. Housing for people with a psychiatric disability; problems, partnerships and politics
Sam Battams, Dept of Public Health, Flinders University
DoH presentation, Adelaide, May 2008

2. Outline Background, Methods Findings – Intersectoral Linkages
– Policy agenda setting
for housing/support
resources
Summary and Interpretation
Recommendations

3. Background - Rationale
Association between people with mental illness and homeless -high rates in marginal accommodation in Australia (42%) (Jablensky et al 1999) and South Australia (54%) (Doyle et al 2003)
Previous research on maintaining housing stability of people with mental illness -the need for better intersectoral linkages and additional housing and support resources (O'Brien, Inglis et al. 2002).
Evaluation of the 2nd NMHP (2003) recognised that: 'inter-sectoral collaboration has been evident in some pilot areas, but not developed in a systematic or coordinated way'
& a lack of meaningful input into policy processes by service users & families.

4. Background - Research questions
Intersectoral Linkages: To what extent have inter-sectoral links between mental health services and the housing sector been developed through the implementation plan of the South Australian Mental Health Reform ? To what extent have these links been effective in improving housing options for people with a psychiatric disability?
Policy agenda setting: Is there evidence of the issue of providing adequate housing for people with a psychiatric disability making it to the policy agenda in the mental health sector? To what extent have community participation mechanisms contributed to the development of policy or programmes on housing provision for people with a psychiatric disability?
The reform period is taken as the start of the Brennan review in 2000 and the implementation and action plan documents covering the 5 year period after this.
I was interested broadly in users of mental health services, but particularly people deemed to have a psychiatric disability.

5. Background - Methods
Stage 1: Review of key national and state mental health, housing (& disability) policies & thematic analysis
91 participants:
52 professionals in Participant Observation of NGOs & 10 NGOs in Interviews & Focus Group
Stage 2: Explore what NGO advocacy groups & State level Consumer/Carer groups have input into & advocated for and progress/challenges.
Interviews and focus groups with 7 Consumer & Carer Reps and 2 Professionals working with state level groups
Stage 3: Public servants’ perceptions on collaboration & participation & housing, examples of successful collaboration efforts.
Interviews (20) X Sectors

6. Findings
Neo-liberal policy context & privatisation strategies across sectors reflected in key problems in housing identified as ‘resources’
accommodation and support for people with psychiatric disability (examples of families exploring private options or providing or seeking housing/support)
Housing instability - Turnover in public housing & SRFs
SRFs a form of tertiary homelessness that was a ‘last resort’ due to failure of public housing tenancies.
Intersectoral linkages raised as an important issue – across policy, programme and service levels
impacting upon housing outcomes e.g. Clients actually losing accommodation or their homelessness status overlooked.
1) The broad neo-liberal policy context has seen a decline in public housing resources through the CSHA and focus on private and NGO services. Funding for the CSHA has reduced in real terms by 31% from 1991/1992 to 2001/2002 (DFC 2005). Also across the first ten years of the NMHS private hospital sector expenditure increased by over 80% – this has been paralleled by reductions in the public sector.
Across groups, the most common problems cited with regard to housing for people with psychiatric disability was a shortage of accommodation and support for people with psychiatric disability. Although at least one senior bureaucrat highlighted the need for better intersectoral linkages rather than an increase in resources.
2) High turnover in public housing for ‘high needs’ clients, and examples of people living in SRFs where public tenancies had failed.
3) Intersectoral linkages also raised as an important issue and there were many examples provided where a lack of intersectoral linkages had actually led to poor housing outcomes.

7. Intersectoral collaboration can be seen from a number of multidimensional factors across national, state and regional levels. National state policies and programmes, politics (responsibilities) across levels of government, state governance arrangements and processes of reform, regional service delivery networks and service cultures, individuals’ commitment and skills for collaboration.

8. Findings – Intersectoral Linkages
Lack of strategic policy coordination & planning between the mental health, housing (and disability) sectors
Separate policy sectors – tied to bilateral agreements (CSHA, CSTDA), funded sectors, funding tied to departments, program guidelines, goals and ‘responsibilities’ of bureaucrats.
Some examples of regional X sector networks (SMHHA) unconnected to strategic networks
2) E.g. SA one of the few states not to allocate CSTDA funding to psych disability when it was introduced – notion that these funds had to be ‘advocated for’ by MH and weren’t as psych disability not on agenda in MH and funding for NGOs was slow to develop. CSTDA funds which were not used for psychiatric disability in SA until This ‘silo’ situation continued through separate bidding arrangements for funds (temp psych social disability vs ongoing disability) and separate planning regarding ‘housing’ or ‘disability sector’ funds
3) Government silos related to observations that there were problems in the recognition of the connection between problems –Emergency Demand, corrections system, turnover in public housing, deinstitutionalisation and housing shortages.

9. Quote
“There is no planning we are aware of. We've raised this issue many times in appropriate forums e.g. SACOSS meetings with DHS Executive. Deinstitutionalisation has been done without key stakeholders in housing - it is just cost-shifting. It wasn't properly planned. Support has not materialised as promised. This issue has been raised with the authorities since the 1980's, as far as back as Emergency Housing Office Days.”
Housing sector NGO professional

10. Findings - Intersectoral links
Integrating Structures - DHS had enabled some pooling of resources coming from different programmes (Supported Housing).
Trouble for state level SIU drawing together separate sectors & interests, with attempts to develop ownership through SA strategic plan.
1) DHS enabled the supported accommodation projects which were not rolled out or progressed and its break-up resulted in difficulty working across sectors.
2) The SIU as a new ‘integrating structure’ had some trouble drawing together separate interests ‘which went right up to Ministers’ (Interview 6). Even following the SIU, it was unclear how the health sector was involved in Homelessness Strategy plans, or after the reform period, the housing sector involved in Stepping Up.

11. Findings – Intersectoral Linkages
Political context
Development of special housing projects and short-term solutions ‘within sectors’
Political commitment
Examples included Common Ground, the Supported Tenancies projects and the Supported Housing projects, temporary rehab funds released through the mental health unit. This was rather than ongoing X sector programmes – contrasted with the planning through reform & SIU.These short-term strategies affected the ability to develop intersectoral linkages
In 2006 former Director of Mental Health Services Jonathan Phillips declared the SA mental health system unbalanced, with a lack of political commitment and interest shown to it & kneejerk responses.

12. Intersectoral Linkages & Reform
Political context
‘Reform over resources’
State level - Changes in government leading to within sector governance reform making cross sector networks unstable, impacting upon collaboration
Ongoing reviews of MHS in 1993, 1998, 2000 and 2002.
Reform impacted on intersectoral linkages and within sector reform made links across sectors difficult to establish.

13. Intersectoral linkages
At a programme/service delivery level, the development and Implementation of programmes- Interrelated Processes, Commitment and Skills for collaboration important.
Pre-existing intersectoral networks facilitated commitment/relationships for cross sectoral projects.
Skills of negotiation and collaboration necessary for ‘within sector’ reform and cross-sectoral projects, but not necessarily compatible with clinical ‘doer’ role (Callan 1995).
Professional cultural issues - Housing sector workers reported some concerns with level of respect for non-clinical expertise and expectation of ‘working for’ clinicians.
Mixed views on usefulness of MOUs –Either considered relatively unimportant due to skills/commitment being crucial for collaboration – or important due to turnover of staff.
2) The importance of developing stake-holder trust was emphasised with regard to within sector reform. Resistance in the mental health sector related to resistance from staff at the stand-alone institution & lack of consultation in early stages of reform period.
3) Expectations for ‘medical authority’ (Lewis 2005) in some regions where supported housing projects were introduced.
4) A number of MOUs which had not been maintained or implemented.

14. Policy agenda setting -NGOs
Policy networks in health dominated by private sector (e.g. SRFs) and professional interests; situation influenced by undeveloped NGO sector
NGOs were sometimes involved in networks ‘within sectors’ & lobbied funded sectors
No cross sectoral policy & planning networks involving govt & NGOs (changed with SIU?)
Little advocacy or X sectoral policy targeting housing for people with psych. disability.
$57 million went to SRF funding in 2004, more than double the amount that went into social rehab funds in 2005.

15. Policy agenda setting - NGOs
Partnerships between govt & NGOs differed X sectors – e.g. Community Housing NGOs vs Mental Health NGOs (related to political environment)
Tension between advocacy and service provision role - As a result of their increased role in service provision, NGOs using networks as main source of influence - Smaller NGOs disadvantaged.
NGOs advocating for NGO services in alignment with neo-liberal trends.
Political environment also seen to influence NGO and consumer lobbying by NGOs in the health sector
1) Community housing NGOs were more involved in negotiations regarding affordable housing and contracts for service delivery. Claims of less transparent methods for tendering out in MH sector. Examples of groups being tapped on the shoulder in 2005 when social rehabilitation funds were released as a result of these funds being released quickly.
2) However, close relationships between NGOs and politicians/bureaucrats could also compromise lobbying activity, especially for smaller groups who have less access to networks.
4) Political environment, both nationally and at a state level, was seen to effect lobbying activity.

16. Policy agenda setting Consumer Participation in Policy
“We could talk about the shortcomings in mental health services and how it was failed and the need for funding, but actually consumers and carers had never sat at a decision making table”
Consumer Representative
Recognition of consumers in the theme "Count me in" is excellent. However we are in danger of looking at the micro level of service delivery and not directing our attention to the larger picture of public policy towards the mentally ill.
Justice Action Australia 2007
State level consumer groups not part of policy networks or involving in policy and planning.
One professional believed that when consumer groups were involved they were overly focused on ‘processes’ for participation and that consumers were missing the boat when it came to contributing to mental health reform. There was little challenge to consumerist discourses on participation where consumers were expected to input into health services and treatment environments.
However, groups were deflected from contributing to the content of policy through a high turnover of state level consumer groups over , connected to changes in government and personnel in bureaucracy, and changing Terms of Reference - One groups sole purpose was to determine processes for participation, not participation itself – groups were thus and end in themselves.
Eventually NGOs were established for generic ‘health service user’ consumer participation and mental health NGO representation. – HCA & MHCSA.

17. Policy agenda setting
What was being advocated for & solutions in separate sectors – influenced by discourses on health, disability in sectors
(& neo-liberal discourses X sectors).
Bio-medical model of health & disability (Baum 2002, Lewis 2005, Fulcher 1989) related to health policy sector
Discourses associated with ‘within sector’ solutions in health & housing (ED, affordable housing, disruptive tenants) and overlooking connections between problems
Medical discourse - focus on individual needs, deficit, linking impairment with disability, and focused on strategies such as rehabilitation where professionals play a central role– associated with the mental health sector, and failure consider ongoing needs such as housing and disability support and the overlap between policy problems.
Also in the housing sector, discourses on affordable housing and housing stress had overlooked particular population groups such as people with a psych disability.

18. Quote
“I came from a clinical background and just assumed because in the clinical framework the flow through and the pushing people through is the current mantra and so when I came in and started supervising assumed that that case load or that group of people would move on and what I quickly realised is that was an incorrect assumption of that group of 7 or 8 people, many of them had been there for the 14 years with her.”
Former mental health professional
“Well, I think it’s about the public private partnership, it’s the stuff about, in every new development there’s a percentage that goes to affordable housing. So, I just think that there might be some opportunities through those sorts of programmes –but who puts the flag up of mental illness?”
NGO Housing professional
Services becoming increasingly clinical in focus – focus on temporary solutions and turnover in services. Housing had not been a major focus for

19. Different notions of ‘ideal housing’
Fragmentation of the policy network tied was reflected in different perceptions of the policy problem and ideal housing solutions e.g.
24 hr supervised care tied to housing vs no need for high level care (carers and NGOs)
‘Citizenship’ approach & social participation highlighted vs ‘integrated services’
Shared living/cluster models vs independent living models (no need for disability specific housing)
General agreement on need to balance ‘independence’ and ‘isolation’
Carers made these comments in the context of people with very high needs receiving little support. The majority of people are in public housing & supported housing models involving public housing have proved to be been successful.

20. Policy agenda setting
What was successfully being advocated for within sectors – success influenced by general public debates and the social-political acceptability of proposals
e.g. NGO advocacy on supported accommodation which involved public housing competed with public debates on ‘Disruptive Tenants’ & expert recommendations.
E.g. Private sector solutions involving SRFs more compatible with overarching neo-liberal context & strategies of govt.
There was a strong debate on disruptive tenants in public housing, which were equated with people with mental illness, when supported housing inquiry was being held – the supported housing inquiry was advocated for more supported housing which included public housing, whilst the inquiry into the housing trust, referred to as the disruptive tenants inquiry, concluded that public housing was inappropriate for people with mental illness. The housing inquiry was influenced by Psychiatric expert advice recommending medically supervised housing.

21. Stigma influencing the policy environment
Stigma – reflected in political responses across levels of government, bureaucracy, public opinion - an important part of the policy context.
This media article was lobbying against a community rehab centres by a politician and nurse.

22. Quotes - Media
I think the biggest influences on the government and its policy is Leon Biner; it's the media, the media, the media, and then from the media, the public perception of what's going on. Like psychotropic, knife-stabbing schizophrenic; the media, the media, the media, the portrayal in the media.…People ring the radio to have a bitch and away you go. And the politicians listen, that's all tracked apparently and documented.
Consumer representative
I would think here in South Australia the political framework is so close, it’s a small state. I’m not from South Australia. And the proximity of the politics to the local community is tighter than any I’ve ever seen. And you add to that a one newspaper town where the media, the media voice runs the public opinion and, you know, that’s what the politicians all read because that’s their paper
Health sector professional
Role of media/political response to media important part of policy agenda setting – and associated with perceptions that govt had not made the political commitment to mental health.
However, the local messenger had a large volume of articles on issues pertaining to people with mental illness, so they may have seen themselves as a champion of their cause.
The media both a barrier and enabler to progressing this policy area.

23. Summary & Interpretation
Policy agenda setting influenced by a constellation of factors;
Broad neo-liberal values and strategies, discourses on health, disability & community care, policy level sectoral interests and the integration of policy networks, the connections of networks and the political timing of proposals, general public debates and social-political acceptability of proposals.

24. Summary & Interpretation
Lack of strategic policy coordination and shortage of accommodation & support resources linked to:
Broad neo-liberal policy context (Dean 1999) related to decline in public housing resources & focus on private (rental & SRF solutions) & NGO solutions
Political context - Proposals must also be social-politically acceptable (Fischer 2003) - community/govt stigma reflected in public opinion and the media influences social–acceptability of proposals and resourcing. Neo-liberal strategies were more likely to be accepted.
1) Affecting resources for housing, resources for coordination, and leading to a situation where there are a number of providers of services making coordination more difficult.

25. Summary & Interpretation
Separate policy networks across sectors & levels of government. The health and housing policy sectors could be seen as separate ‘policy subsystems’ with little integration – not competing advocacy coalitions (Sabatier & Jenkins Smith 1999) ‘within sectors’.
Different conceptions of health and disability (Fulcher 1989) tied to policy networks. How problems are being represented (Bacchi 1999) was crucial to understanding agendas as often ‘social determinants’ of health such as housing were overlooked.

26. Recommendations
1) Need for cross sectoral policy debates, forums & policy networks
Opportunities for experts X sectors, housing tenants and people with psych. disability/families to be involved in public forums and debates about housing
Economic arguments important in the neo-liberal context – cost savings that can be produced by providing supported accommodation (e.g. Culhane et al 2002)
2) Integrated X sectoral planning & policy solutions making connections between problems
- Mental health better coordinated with justice/corrections system & incorporating private sector in strategies
Pooling commonwealth-state resources.
Service networks facilitating relationships with other sectors (for implementation)
As policy agenda setting is not just about the integration of networks – challenging consumerist discourses of participation and biomedical view of health important to agenda setting on housing.
Current ‘within sector’ solutions of Affordable Housing (Housing Sector) or separate Supported Housing (Mental Health Sector) are unlikely to resolve issues pertaining to ‘disruptive tenants’ in public housing, ‘emergency department demand’ ‘housing instability’

27. Recommendations
3) Accountability mechanisms - Collect information on the housing within MH sector and monitor outcomes e.g. ‘housing stability’ rather than current focus government expenditure in NMHR. Housing performance measures considering safety net housing in the event of hospitalisation. Recognition where strategies are leading to cost savings to ‘other sector.’
4) Supported Housing models co-ordinating public housing, NGOs, private and public providers (disability sector) & Balancing ‘independence and isolation’. Developing housing worker skills and understanding of psych disability.

28. Recommendations
5) NGO leadership in housing advocacy & development of cross sectoral advocacy networks outside of government contracting arrangements, working with media.
6) Development of state-level mental health body where people with psych disability are members -currently no opportunities to directly consider interests of people with psych disability as a group outside of ‘health consumer’ concerns or NGO interests
2) Due to the conflict of interest between NGOs service provider and advocacy role, and the limits to smaller NGOs using networks of influence, appeared to be a need to develop networks outside of contracting arrangements and even outside of NGO arrangments.

29. Recommendations 7) Tackling community stigma
Local identification of stigmatising attitudes (i.e. media watch campaigns) & Developing relationships with media & community leaders to challenge stigma (relates to social/political acceptability of proposals)
8) Leadership
Developing leadership skills for negotiation and collaboration (intersectoral)
Engendering support of leaders across levels of govt when initiatives are introduced.
Political support for pursuing housing across levels of government – COAG funding.