Deficiencies in community-based mental health care and possible remedies

Thornicroft and Tansella have produced a clear account of the transition in psychiatric care from a hospital- based to a community-based system. During the second half of the last century this change progressed at different rates in the UK, North America, Western Europe and Australasia. The UK is now at the forefront of the development of community-based care, having closed almost all of the mental hospitals in England and Wales. While this change has benefitted most of the former residents of the mental hospitals, patients requiring hospital admission are now disadvantaged by conditions on many of Britain's admission wards. There are insufficient beds in National Health Service (NHS) wards for the number needing admission, resulting in the use of private hospitals by the NHS, a costly solution. While some psychiatrists call for more beds to be provided, other professionals advocate the development of more alternatives to acute hospital admission, such as those mentioned by Thornicroft and Tansella - crisis houses and home based treatment - as well as acute day hospitals (1). Many service users and carers express a preference for solutions which do not involve full time admission to hospital, and as a result, the boundary between hospital and community is likely to become less distinct and the use of hospital beds to decline.

A number of the functions of tradi- tional hospital care have not been adequately replaced by the modern style of service. The old mental hospitals contained populations of patients that formed a social community. While many patients were social isolates, at least they shared the same communal space with those who were more socially active (2). Life in the community can be very lonely for those with few social skills. Even the more outgoing patients tend to be trapped within the social world of users and professionals. This is partly due to the stigma attached to mental illness and the stereotypes held by the public. These include the characteristics of unpredictability, aggressiveness and difficulty in communication, all of which would deter members of the public from making social approaches (3). The problem of social isolation from neighbours can be tackled successfully by locally based education campaigns for the public (4).

Thornicroft and Tansella recommend that specialist services should focus on the treatment of people with the most severe symptoms. These patients accumulate in traditional mental hospitals since they are too demanding for most relatives to care for and cannot survive on their own in the community. Known as the difficult-to-place (DTP), they are usually left until the end of a psychiatric hospital closure programme (5). A high proportion has been aggressive in the past or is currently so. They show a variety of behaviours which are disturbing to the public, such as stealing, sexually provocative behaviour, and urinating in public. They tend to be on high doses of multiple neuroleptics since they respond poorly to medication. The planners' dilemma is where to care for them. They obviously need a high level of supervision and skilled interventions of a psychosocial nature. At the closure of Friern psychiatric hospital, most of the 68 DTP patients were transferred to highly staffed (1.7 staff: 1 patient) facilities mostly in the grounds of hospitals. However, one group of 28 were cared for in an open facility newly built on the site of a small psychiatric hospital. These DTP patients gradually lost their difficult behaviours over the course of five years, during which 40% were discharged to community homes.

An experimental rehabilitation programme for DTP patients in another traditional psychiatric hospital has shown that the combination of the use of novel antipsychotic medication with staff training and individualised cognitive behavioural programmes has enabled the discharge of 40% of the patients in two years (6). This experience highlights the need for medium term rehabilitation facilities for the most severely affected patients with psychoses. There is no need for these to be located on hospital sites, indeed there are advantages to their being sited in the community close to local amenities such as public transport and shops, so that patients can practise their newly developed skills. Unfortunately, in the UK rehabilitation has been overshadowed by the demands of acutely ill patients, yet those with long-term disabilities are the most costly to society in terms of lost work and burden on the carers. In the move to community based services, the rehabilitation function of the traditional mental hospital must not be neglected.