Public policy, and specifically national public policy, is one of the key factors that affects the practice of psychiatry, the shape of mental health services, and the environment within which mental health services work. The specific content of public policy varies greatly across the world and often even across neighbouring countries. It is therefore impossible within the space of this chapter to undertake systematic international comparisons. This chapter gives an overview of:

Koontz and Weihrich⁽¹⁾ define policy or policies as ‘General statements or understandings which guide thinking on decision making.’ This definition implies that:

1 policy may be stated in writing (statute, guidance, or statement) or may be unwritten and disseminated through management or political chains of command only;

2 policies may exist at various organizational levels albeit here we are mainly concerned with national policies;

3 policy is only one factor in any final management or clinical decision. Other factors will often be more important, and clinical behaviour is notoriously resistant to policy influence except where certain behaviour is directly prohibited.⁽²⁾

Therefore, the policy needs to be understood as just one of the factors which determine the nature and state of mental health services and mental health promotion or public mental health within a society.

In many developed countries, the management of the public sector has seen major changes over the last two decades, shifting from a hierarchical and bureaucratic administration to a model of ‘managerialism’.⁽³⁾ In the old model policy making and administration was separated, and governments were responsible for the provision of services often via related public sector agencies. The new model, inspired by business,⁽⁴⁾ is characterized by governments introducing competition and market principles and involving the private sector in providing services, setting measurable objectives, and introducing performance management with the aim of delivering higher efficiency. This has affected professionals such as psychiatrists by shifting accountability for good medical practice as judged by peers to reporting on outputs to managers as specified by contracts and practice guidelines. Nevertheless, in most cases strong professional accountability remains, creating a dual accountability that may be appropriate but is always challenging and sometimes conflicting.

Public policy in mental health is driven by a range of influences and interests which policy makers will attempt to balance. Positive drivers, that is factors that encourage the development of progressive mental health policies, include:

The strong interface between mental health issues and human rights explains the importance of human rights conventions and declarations in the shaping of policies and legislation, especially in countries where mental health policy and practice are less developed historically. Negative drivers, that is, factors that limit the commitment of policy makers, include budget limitations,
competition from other priority areas, discrimination, and the perception that mental health is not a fruitful area for investment.

Whilst policy on mental health services per se is likely to be the concern of the health ministry, the impact of other public policy on both mentally ill people, and the practical application of psychiatry may be even bigger. People with severe or persistent common mental health problems often face social exclusion and face difficulties with issues including housing/shelter, employment, education, and welfare or welfare benefits. All mental health professionals in all countries of the world will be aware of how much these issues can affect the lives of people with mental illness and indeed clinical outcomes. Box 7.1.1 summarizes some of the main relevant policy areas which will impact on mental health services.

It should be clear from only brief examination of this table that achieving a totally coherent mental health policy presents huge challenges:

It can be argued that mental health policies in most countries fall within four broad groupings:

1 Provision for the basic protection of human rights of people with mental illness or those lacking mental capacity;

2 As one together with a simple health care policy to provide for the health care needs of people with serious mental illnesses;

3 The above but with a more comprehensive health and social care policy which addresses primary and specialist care needs for various groups of disorders;

4 A comprehensive cross-sectoral mental health policy that addresses care, public mental health, and broader issues such as housing.

No country in the world has a fully comprehensive policy although developed countries such as New Zealand, Australia, several
European countries, and states of Canada and the United States have advanced policies. This reflects the nature and resources of these societies, and does not necessarily result in differences in prevalence or outcomes.⁽⁸⁾

Human rights have historically been a fundamental driver for the development of mental health policy in most countries of the world. The current Human Rights conventions derive from the United Nations, and are binding once they are ratified by member states following adoption by the United Nations General Assembly. The Universal Declaration of Human Rights was adopted in 1948. This was followed in 1966 by the International Covenant on Political and Civil Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR), in combination known as the International Bill of Rights. None of the conventions directly addresses issues related to mental health care, although the right to the highest attainable standard of physical and mental health is included in Article 12 of the ICESCR. In non-binding general comments, the committee on Economic, Social and Cultural Rights specified that right to health covers availability, accessibility with a strong emphasis on equality and non-discrimination, and acceptability including cultural sensitivity and quality. The obligation of signatories to provide information on detentions and measures taken to prevent abuse for people admitted to mental hospitals is important.⁽⁹⁾

In 1991, the United Nations General Assembly adopted ‘the principles for the protection of persons with mental illness and the improvement of mental healthcare’, better known as the MI principles, which remains a key reference document for national mental health legislation. The document outlines 25 principles, stressing the importance of non-discriminatory practice within the health care system. The rights to which patients with mental health problems are entitled, according to the MI principles, include the right to live and work as far as possible in the community, and the right to the best available treatment and care in the least restrictive settings in conditions suited to the cultural background of the patient. The principles also set out expectations for confidentiality, the protection of autonomy, and the conditions for involuntary detention. In combination the principles offer a good foundation for modern mental health policies and legislation. Although the document is not legally binding, it is clearly stated that member states are expected to implement these principles fully.