Health: Care in the community: Was it really as bad as they claimed?

Though the current obsession with risk and danger now drives a more coercive agenda for people with severe mental illness, voices of wisdom and experience are calling for a more enlightened approach.

It has become fashionable to decry the policy, which accelerated in the 1980s, of transferring people with long-term mental illness from institutions into forms of care in the community.

“Care in the community has failed,” Frank Dobson, then health minister, told parliament in 1998, in an opportunist invocation of a popular prejudice. I recall thinking that this was a mean-spirited jibe at all those who had striven to release the mentally ill from institutional confinement. Anybody who ever visited the back wards of the old asylums knows that, whatever the inadequacies of care in the community, it marked a historic advance in the treatment of people with serious mental illness. The glib global condemnation of community care fails to recognise the dramatic improvements in mental health services in recent years.

As a GP in Hackney, east London, over the past two decades, I have seen local mental health services transform. Two of Hackney’s leading psychiatrists, Mark Salter and Trevor Turner, have produced “a practical guide to outdoor psychiatry” that is informed by the experience of providing community mental health care in such a diverse and challenging neighbourhood.

“Keeping patients well,” they write, “requires a mix of money and therapeutic skills, a knowledge of social, welfare, cultural and housing arrangements, an awareness of basic medical and medication aspects, and a hard core of commonsense.” Their book covers all these areas and more, with wit and passion, with a sense of history and a shrewd awareness of the role of politics and the media.

The prejudice that community care is a failure has been nurtured by one public “serious incident” inquiry after another. As the authors put it: “Assaults with swords always get the headlines.” The result is the culture of risk management and risk assessment, which the authors regard as “the single most pernicious change in the delivery of mental health care in the last 20 years”. They blame “the lawyers and the hindsight junkies creaming a living from the random misfortunes that happen to mentally ill people in a complex individualistic and unrealistic society”.

The authors warn that when risk becomes the basic criterion of services, mental health workers “essentially become psychological dustcart drivers”. Resources will be spent on a small number of people deemed (not necessarily accurately) to be a threat, while most people who need help, but are not a danger, are overlooked. Further, the risk agenda encourages a resort to coercive legislation and the return to forms of institutionalisation.

Ken McLaughlin, former approved social worker with a statutory mental health team and now senior lecturer in social work at Manchester Metropolitan University, shares many of the concerns of Salter and Turner. He writes that “an obsession with risk avoidance and harm reduction is inhibiting social workers from doing their job properly, leaving them open to public hostility, limiting their professional discretion and putting them at risk of being subject to an official inquiry if things go wrong”. McLaughlin criticises proposals for compulsory treatment orders under the Mental Health Act 2007, on the grounds of civil liberties and public safety.

Yet these specialists share an optimistic spirit. As Salter and Turner put it: “Our business is unique and wonderful and the journey never ends.”

Michael Fitzpatrick is a GP practising in Hackney, east London

This article is published in the 15 January issue under the heading Care in the Community: Was it really as bad as they claimed?