COMMUNITY CARE

For centuries, the care of mentally ill people was largely behind what are now thought of as the “forbidding gates” of asylums. This is somewhat ironic since the advent of the Asylums (providing a place of sanctuary) was initially a major advance in the humane care of the mentally ill. They relieved the community of the burden of patient care; nursing, protecting and maintaining the survival of the mentally ill.

For the latter part of the last century in particular, changes in ideology have placed mental hospitals under tremendous pressure. Ongoing criticism, together with financial and other measures, has moved the focus of care back to the concept of community-based services. In spite of the enthusiasm behind the concept, care in the community has taken over 30 years to establish and still has to fully prove its place as an effective approach to the care of the mentally ill. An urgent re-evaluation of the mental health-care system is necessary, to ensure suitable care of the mentally ill.

Asylums - an Historical Review

Decline in popularity of mental hospitals, and the growing scandals of sub-standard care provided in these institutions, started in the 1930s. A number of factors contributed towards this normous change:

1. Treatment innovations:

The introduction of pharmacological treatments, like phenothiazines in 1957, is believed to have profoundly influenced the role of the institutions. The bed occupancy in both the United Kingdom and the United States peaked in the mid 1950s, and has consistently fallen subsequently. Attributing the down turn of bed occupancy entirely to the advent of effective anti-psychotic medication is an oversimplification, particularly since the rates began to fall in the early 1950s.

2. Disenchantment with the mental hospitals:

The growing concern was that the mental hospitals were prolonging and adding to the disabilities caused by mental disorders. The most influential work came from Irving Goffman who criticised the pathological features of institutions and introduced the concept of Total Institutions characterised by:

  • Batch living: described as the antithesis of domestic living: in institutional living the three spheres of home, work and play are collapsed into one.
  • Binary management: means that staff and inmates live in different worlds. Staff tend to feel “superior and righteous”, while inmates are made to feel “weak, inferior and guilty”.
  • Inmate role: this role is taught starting with a highly ritualised admissions procedure to shape and code the person into the patient role.
  • Institutional perspective: a view of life which validates the institution’s existence to create an artificial sense of community and deny individual experiences. Russell Barton suggested that the “defect state” in chronic schizophrenia was caused by the mental hospitals.

3. Conceptual developments:

In the 1960s the mental hospitals came under increasing pressure by a series of scandals, revealing cruel and degrading treatments in long-stay mental hospitals. The anti-psychiatry movement (e.g. Thomas Szasz, R.D.Laing) challenged the validity and utility of psychiatric diagnosis. At the same time, publicity surrounding treatments such as psychosurgery and electroconvulsive therapy added to the society’s distaste for the then standard practice.

4. Social policy changes:

The policy of deinstitutionalisation continued, and the change in the Government’s approach was highlighted by the Member of Parliament Enoch Powell’s much-noted speech in 1961, when he foresaw the “demolition of brooding mental hospitals and their replacement by modern and acceptable services”.

5. Research findings:

Wing and Brown illustrated that an under-stimulating environment might actually be harmful by contributing to the social handicaps of the chronic patients. Their well-known three hospitals study compared the outcome results of three different hospitals which had very different styles of patient care.

International developments

The developments in the United Kingdom (e.g. incorporation of mental health services into the National Health Service (1948) and Mental Health Act (1959)), emphasised the integration of social and health provision. These were paralleled with similar changes in the rest of Europe and the United States:

The American Community Mental movement launched by President J. Kennedy arrived at similar policy changes. Italian Reforms - Law 180 (1978) stimulated massive shift of emphasis in mental care in the north of Italy. The radical decision to completely close all asylums has led to a highly controversial outcome.

The Concept of Community Care

The first official use of the term community care was in the Annual Report of the Board of Control (of mental hospitals) in 1930. The concept developed with the decline of the mental hospital population, and has recently gained further momentum. The term is imprecise, however, and controversial.

  • The term community has no defining boundaries and tends to be taken as “everything except the hospital”.
  • The process of deinstitutionalisation means “leaving the hospital”, for care in the “community”. The provision of care in the community has not progressed as fast as the move to discharge patients, and therefore some patients experience significant difficulties when they leave hospital.
  • The exact number of hospital beds for people with long-term mental illness is not known. The hospital closure program began in 1954, when the number of psychiatric beds peaked at 148 000, and it aimed at reducing beds to a target of 47 900.
  • By 1990, 64000 remained. The Government document, Caring for People9 (based on the work of Sir Roy Griffiths) implied that there is a wide range of voluntary services for people with mental illness, and that one key to effective care is the organisation and mobilisation of these resources. Provision in the private sector is certainly growing, and can be very effective, yet care is still patchily distributed.
  • There is evidence that many of those discharged have been lost to follow-up. Nearly 100000 long-stay patients have been discharged from British mental hospitals in the last 35 years, yet only 4000 places had been provided in local authority hostels by 1990.
  • There has been an increase in the number of cases of mental illness in the prison system that seems to have paralleled the number of patients discharged from the asylums. There is clearly still a need for asylums with a range of acute and chronic wards. Young people with relapsing psychotic illnesses and disabilities have been left behind in the move to the community setting. They now make up the new long-stay population. The patients that seem to be losing out in the allocation of community resources are those with chronic psychiatric difficulties. This group create a revolving door effect, being admitted and re-admitted again and again, sometimes for short periods of time. This may partly be due to self-discharge or a refusal to take medication such as depots.
  • Community care seems to work best for those with a mild degree of disability, good communication skills, an active social network and stable and predictable behaviour. In practice, however, community resources such as day hospitals and community psychiatric clinics may be used up by those who are not suffering from serious mental disorder; and yet demand help. In practice, this may include those with personality difficulties and those with milder psychiatric disorders.
  • Community care is also reasonably successful for people with learning disability, the infirm elderly and physically handicapped, where the effective targeting of community resources such as Community Psychiatric Nurses, District Nurses and the use of day hospitals may be very effective.

Evaluation and follow-up studies of discharged long-stay patients

The traditional functions of mental hospitals have not and cannot be totally replicated in the community. Treatment of patients in the community is certainly possible, and the emphasis has been on rehabilitation, developing after-care programmes, and shifting the resources towards services in the community (reprovision). The Team for the Assessment of Psychiatric Services (TAPS Project) is the most carefully researched reprovision exercise the United Kingdom. Using cohorts of “leavers” and “stayers”, the progress of 278 chronic patients with serious mental illness in Friern, Barnet and Claybury Hospitals has been studied. Those who were discharged into the community after extensive stays in hospital (movers), were meticulously monitored and compared with matched patients who remained in hospital (stayers). Most patients had schizophrenia. While a substantial proportion were re-admitted for brief periods, very few were lost to follow-up or became homeless. Patients demonstrated a modest increase in their level of social interaction and a marked improvement in satisfaction with their lives and treatment.

At 1-year follow-up, movers and stayers had the same death rate. Movers showed no significant improvement in psychiatric symptoms, but preferred their accommodation and the ability to be able to choose what to do with their time. The costs were about 10% less than that of in-patient care. After 2 years there was also a suggestion of improvement in aspects of their clinical functioning.

Alternatives to hospitalisation studies

There are a number of well conducted studies offering patients community support as an alternative to hospital admission (reviewed by Braun et al.). Important problems with these studies include:

  • Charismatic leaders (product champions) who enthusiastically ensure that the approach works. Thus findings cannot easily be generalised to other settings.
  • Studies examining only the early stages of practice.
  • Hawthorn effect of a major study (i.e. the very action of offering any intervention creates a therapeutic impact).
  • Enhanced or better resourced or informed clinical teams and restricted entry of patients which skew the results.
  • Poor quality control groups. Despite these reservations, there is accumulating evidence in favour of community psychiatry. The most influential studies are:
  • Stein and Test (1980). This study carried out in Australia demonstrated clinical, social and financial benefits, but also showed that withdrawal of the special team led to loss of all the gains. They introduced the importance of assertive outreach - the need to actively seek out those patients who default from treatment .
  • Dean and Gadd (1990). This is a study of intensive home treatment for acute mental illness Again benefits were found in social, clinical, financial and satisfaction ratings. Drawbacks of this study are a very special catchment area and the demands on the clinical teams.
  • Muijen et al (1992).This replicated the Stein and Test study at the Maudsley Hospital and confirmed the same findings.

Criticism of the Concept of Community Care

Community care has been exposed to large amounts of press coverage and public criticism. The scandal were highlighted and dramatised where the services seem inadequate to provide effective care of the mentally ill in the community.

Sensational headlines like “One murder a Fortnight by mentally ill” (Daily Telegraph), called for immediate action after 34 murders by the mentally ill over 18 months. Many were recently discharged and had recent contact with the psychiatric services prior to the incidents.

  • An inquiry was held following the killing of 11-year-old Emma Broadie at Doncaster shopping centre in 1991 by Carol Barratt, who was discharged from a Section two days before the tragedy.
  • A case which highlighted similar failings to act on warning signs was that of Christopher Clunis a schizophrenic who stabbed and killed a complete stranger, Jonathan Zito, at a London underground station.
  • Ben Silcock was mauled by a lion at London Zoo.
  • The care worker Jonathon Newby was killed by a patient, Jonathon Rous. These various factors have contributed to a growing concern regarding the safety of the mentally ill in the community, within the setting of continued political debate about inadequate funding for community care. The political outcome was a demand for care by the Department of Health.
    Efforts to Improve Care in the Community

In response to mounting criticism during the 1980s, the Government produced a White Paper entitled Caring the People.

Community Care in the Next Decade and Beyond

There has been further legislation in the NHS and Community Care Act (1990). Local authorities are now required to produce and Publish community care plans for their area, to provide assessments of people likely to require community care services, and care management systems. The care programme approach (CPA) had its origins in the Spokes Inquiry into the care and aftercare of Sharon Campbell. Its recommendations led to the publication of a document by the Royal College of Psychiatrists. This document Provides a framework for good practice in delivering care to People accepted by psychiatric services. CPA involves:

  • Assessment of health and social care needs.
  • A key worker to co-ordinate care.
  • A written care plan.
  • Regular review.
  • Interprofessional collaboration.
  • Consultation with users and carers. In practice, the care programme approach tends to be forma applied in the following three situations:
  • Patients discharged from hospital after being detained under Section 2, 3 or 37 of the Mental Health Act (1983).
  • Patients who are discharged after being in hospital for 6 months or more.

  • Patients who have complex needs requiring multi-disciplinary management. Collaboration and regular review will be facilitated by a formal care programme.

A community supervision order was proposed by the Royal College of Psychiatrists to ensure that “at-risk” patients maintain their treatment outside hospital and would permit early compulsory readmission to re-establish treatment if necessary. This was rejected by the Government after objections from pressure groups such as MIND on the basis of whether such an approach would infringe the rights of patients to refuse treatment. It was argued that such statutory powers might encourage lazy clinical practice, create an overemphasis on drugs, increase ethnic discrimination and create problems with consent similar to those with Section 7 (guardianship) orders.

Supervised community treatment (SCT) was introduced into the MHA by the Mental Health Act 2007. It allows a person who has been detained under certain sections of the MHA to be discharged back into the community under a community treatment order (CTO). The person must comply with certain conditions or face being recalled (brought back) to hospital and being detained once again under their original section.

Other possibilities to enhance care in the community included extended leave of absence and guardianship.

The Clunis inquiry recommended special supervision to monitor high risk groups. The criteria proposed that certain patients be closely monitored:

  • Those detained several times under the Mental Health Act.
  • Those with a history of violence and persistent offending.
  • Those failing to respond to treatment.
  • The homeless.

Conclusions

Treatment has been transferred to the community but the traditional function of custodial care has not. The need to protect some people from their own actions when ill, and to protect the public from others, will always be there. “Special hospitals” and prisons are facing increasing demands, and it is likely that the community care debate will continue for many years.