Restructuring mental health policy in Ontario: Deconstructing the evolving welfare state

Ontario's mental health sector offers an insightful case study of the welfare state restructuring in which governments have engaged, having recently undergone turbulent reform involving the divestment, closure or amalgamation of nine psychiatric hospitals and a fifty per cent reduction in psychiatric beds. While premised on a shift to community-based care, investment in the community sector has been slow to occur, increasing the risk of off-loading vulnerable members of society to the community without appropriate supports, as occurred in previous movements of deinstitutionalization. To understand why community sector reforms have not kept pace with institutional downsizing, we analyse the process of health system restructuring to clarify the obstacles contributing to delay. These include successive arm's-length governance processes with varying bases of authority, an absence of political will to allocate funds to the community and devolve the coordination of care to local networks, and insufficient engagement of the policy community in policy implementation. Finally, complexity - including the cross-jurisdictional nature and coordination of services on which community care relies - remains an important challenge. Not only have such obstacles diminished the pace of reform and led to regional disparities in Ontario, they reflect common barriers to effective reform across most provinces.