Tom's addition; history, mental health sector's move to community model

Arguments confirming the move from hospital care to community care in the mental health sector – and related issues

Potted History related to mental health

• Since the early 1950s, psychiatric hospitals in Europe have been running down. It has been estimated hat over half a million long-stay patients have been discharged from psychiatric hospitals in the US and UK combined. This massive change in care has been endorsed by successive British governments since 19671, when then health minister Enoch Powell predicted the closure of 75 000 beds in asylums over the next 15 years.

Potted history related to general health care

• After 1945, successive governments became increasingly sympathetic towards shifting the balance of personal social services from residential settings to the community. The publication of Care in Action put community care high on the Conservative government’s priorities, 1979-97. The Conservative policy was driven by financial factors linked with cutting back the high cost of publicly funded residential care and by commitment to encouraging enterprise outside the public sector. The Thatcher government was turning away from universal state residential and daycare services and making these services increasingly subject to means testing and private and voluntary provisions.

Problems related to move to community care in mental health:

• Before 1984, problems in hospitals dominated the public agenda. Since then, attention and blame have shifted almost completely to community care. Even when incidents occurred in hospitals, care in the community seemed suddenly to play a significant part. This raises several important questions. Did hospital care before the 1980s prevent community scandals? Has mental health care deteriorated since then? Are people with mental health problems dangerous in the community? In 1996, when 1200 000 beds were available for mentally ill people in the UK, compared to 57 000 in 1990, a study in east London followed up people discharged from hospitals. Only 54 per cent of patients with schizophrenia discharged to known addresses could be traced after a year. Only about one third of these lived in satisfactory circumstances and a third neglected themselves. In the early 1990s, several studies give an idea of the state of community services. A survey in west Lambeth followed up 140 patients with schizophrenia after discharge from an acute unit. After a year, only one patient was lost to the services, but four had died, 3 from probable suicide.

• Frank Dobson’s statement in the House of Commons in 1998 that community care in mental health had failed heralded a series of papers and consultation documents on the revision of the 1983 Mental Health Act.

Public fear in the community

• Until 1981, inquiries into psychiatric care hade addressed scandals in hospital on behalf of an angry public, almost invariably showing patients as helpless vicvtims and staff as abusers. In 1981, when the first green shoots of community care could be seen, one shocking event had major repercussions for mental health care and public attitudes. Sharon Campbell, a former in patient, killed Isabel Schwarz, her former social worker, at Bexley Hospital. From then on, community care became associaterd with danger.