The search for seamless care

Thornicroft and Tansella make it clear from the beginning of their article that they are promoting the integration of hospital and community care rather than acting as advocates of one versus the other, an outmoded adversarial position adopted by several commentators on the subject (1,2). The most important task of those involved in planning psychiatric services is to ensure that the hospital and community services interact successfully and this will not be achieved by pitting one against the other.

Thornicroft and Tansella propose a sensible balance in which the level of care given to each patient is determined by his/her level of need and availability of the relevant services. They provide a clear structure of evidence to show that most care in mental health can be given at the community level, provided that there is quick and ready access to hospital care when it is needed, and in order for this to be achieved there needs to be excellent communication between different parts of the service. Some years ago the adjective 'seamless' crept into the managerial terminology of mental health services. It is a useful word, because it emphasises the natural discontinuity between hospital and community services and introduces the artificial notion of creating a close link between the two, which, if completely successful, would give the impression to everybody that no discontinuity existed.

For seamless care to exist we need excellent communication between all parts of the service, with preferably at least some staff working in both community and hospital components, sufficient skilled resources (a major problem in many countries), agreed measures of need (an area where Thornicroft and his colleagues have made a major contribution), and willingness to reform. Thornicroft and Tansella have illustrated graphically the fundamental differences in philosophy between the old and modern approaches and in some case this requires a sea change in attitudes. It is sad to reflect that this is often easier to achieve with patients than with staff, particularly in the old established mental hospitals, where consolidation often takes precedence over change.

The resource issue is more easily addressed. It has been shown universally that the most expensive component of mental health care is the provision of hospital beds. If bed usage can be reduced, and it is consistently found that community care provided from a dedicated team achieves this (3), then the claim that there is no money to introduce reform can be rebutted. It sometimes needs short-term funding to act as a bridge to get new services started, but this is quickly reclaimed (4). There is another reason why the balanced approach suggested by Thornicroft and Tansella is bound to prosper: it is preferred by patients to the older models of care and, for the first time in the history of psychiatry, patients are being asked to play a major part in planning their treatment.

There is only one possible barrier to progress, summarised by the words 'public protection'. If the public perceives that it is dangerous to have people with mental illness in their midst, then it makes it extremely difficult to promote integration. Stigma against the mentally ill is reinforced and, even if ten people are inappropriately detained to every one that poses a real danger, politicians and the public are likely to choose that option. 'Function vulnerable', as Thornicroft and Tansella put it; we must do everything we can to reduce this threat to a minimum.