Letters

Failure in community care Inpatient care is part of the integrated approach

Despite Coid's protestations about "professional dogma," not one of the research studies he quotes suggests that community services can exist without admission beds or that "mental hospitals can close and that seriously mentally ill people can be conveniently and easily managed in the community." All of these studies report inpatient spells as part of an integrated approach to their patients' needs. What they do show is that admission is less often needed and discharge more prompt when community services are adequately developed.

Coid suggests that community services research has sinned by either excluding too many patients² or by including too many.³ Early studies excluded patients judged at severe risk when these approaches were new and untested. With increasing confidence these exclusion criteria have been dropped.^3,4 Our study indicated major benefits for moderately to severely ill patients, rather than those with milder, transient disorders. Coid suggests that community developments rely on unrealistic staffing levels obtained through "generous development grants," often at the cost of hospital services. This comment sits uncomfortably directly after work is quoted that clearly states that no extra resources were made available.³ Indeed, community care research has generally been characterised by a remarkable detail and frankness about resource implications.

Research into community psychiatry has been more extensive than that on any other shift in psychiatric service delivery.^5,6 How many carefully controlled studies were there of the establishment of day hospitals or the move to district general hospitals? Resistance within the profession has ensured that community psychiatry has been carefully evaluated (as well it should be).

Coid is quite wrong to ask "whether community based services can safely replace inpatient beds in deprived ... catchment areas." Community psychiatry practice aims to ease the pressure on these much needed beds by more appropriate provision for patients who can be supported out of hospital. He might find purchasers and managers more receptive to demands for adequate inpatient resources (which we all support) by showing that despite best practice they are still needed. Caricaturing community approaches as a stand alone alternative to hospital psychiatry is as damaging to sensible mental health planning as any "simplistic criteria" used by purchasers.

The difficulty of providing comprehensive, community based services in the inner city does not prove that such approaches are wrong. Rather it demonstrates, once again, the disproportionate disadvantage suffered by severely mentally ill people in these areas and the need to sustain the pressure for them to get services as good as those in more settled areas.

T Burns, A Kent

1. Coid J. Failure in community care: psychiatry's dilemma. BMJ 1994;308:805-6. (26 March.) [Free Full Text]
2. Stein LI, Test MA. Alterntive to mental hospital treatment. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980;37:392-7. [Abstract]
3. Burns T, Beadsmoore A, Bhat AV, Oliver A, Mathers C. A controlled trial of home-based acute psychiatric services. I. Clinical and social outcomes. Br J Psychiatry 1993;163:49-54. [Abstract/Free Full Text]
4. Muijen M, Marks I, Connolly J, Audini B. Home based care and standard hospital care for patients with severe mental illness: a randomised controlled trial. BMJ 1992;304:749-54.
5. Braun P, Kochansky G, Shapiro R, Greenberg S, Gudeman JE, Johnson S, et al. Overview: deinstitutionalisation of psychiatric patients: a critical review of outcome studies. Am J Psychiatry 1981;138:736-49. [Abstract/Free Full Text]
6. Solomon P. The efficacy of case management services for severely mentally disabled clients. Community Ment Health J 1992;28:163-80. [Medline]

Psychiatrists fear care in the community

EDITOR, - Far from making a case for failure in community care, the editorial by Jeremy Coid confirms the continuing failure of psychiatrists to come to terms with the fundamental changes that are taking place in mental health care and the increasing research evidence that points to the feasibility and success of alternatives to institutional care in the treatment of severely mentally ill people.¹ Any unbiased and dispassionate appraisal of the available literature would have confirmed this - instead, Coid's editorial is a rather predictable response to the current moral panic created around "madness in the community," and it reasserts psychiatry's historical preoccupation with segregating mentally ill people and the continuing plea for more resources to achieve that.

None of the studies of home treatment for severe mental disorders cited in the editorial has come out in favour of the traditional method of institutional care, while all of them attest to the safety, efficacy, and - most importantly - acceptability to both clients and relatives of home treatment compared with hospital treatment.² Without providing any substantive evidence, Coid asserts that the results of these studies should not be accepted at face value, and he implies that the researchers may not have been objective in their evaluation because they stand to gain most from community based approaches. Such a claim, like the rest of the editorial, reveals the anxiety experienced by many psychiatrists when faced with any challenge to the "traditional hegemony" of hospital based psychiatry,³ such as the advantages of domiciliary care, which is not exclusively dependent on traditional psychiatric skills or knowledge. Evaluations of acute domiciliary care have shown consistently positive results; why have they not been fully integrated into existing services?³

The failure of institutional psychiatry, with its reliance on custody, compulsion, and control of patients, is what is most evident in contemporary psychiatric practice, especially in our inner city areas. Coid's plea for "more of the same," either in the form of more beds (a convenient euphemism for locking up more people) or greater control of mentally ill people in the community, ignores the available evidence that such conventional methods of psychiatric care have failed over the years to address the needs of substantial client groups - namely, black people, women, homeless people, and socially disadvantaged people. It is this crisis in relation to hospital psychiatry, especially in inner city areas, that has been most evident from the cases that have been highlighted recently; the issues here cannot be addressed without recognising that in many instances the nature of psychiatric treatment continues to be determined by notions of control and custody rather than the need for cure or care. By seeking alternatives to institutional models, we are also engaged in shifting the ideological balance away from custodial aspects of psychiatry, something that may not be acceptable to many psychiatrists, especially forensic psychiatrists.

We have been providing a home treatment service in inner city Birmingham for nearly four years, and what has emerged in the context of this development in our local area is a greater recognition of the need for alternatives to hospital care in the local community and an increasing acceptance by psychiatrists that the inpatient service can be managed more efficiently and flexibly when there is easy access to acute domiciliary care. Unless we are prepared to consider such alternatives (and rigorously evaluate them, especially against criteria other than those derived from failed institutional models), most of our inpatient units will become indistinguishable from forensic secure units, something which even the most ardent advocates of hospital care would consider unacceptable.

S P Sashidharan

1. Coid J. Failure in community care: psychiatry's dilemma. BMJ 1994;308:805-6. (26 March.)
2. Reynolds I, Hoult JE. The relatives of the mentally ill: a comparative trial of community oriented and hospital oriented psychiatric care. J Nerv Ment Dis 1984;172:480-9. [Medline]
3. Tantam D. Alternatives to psychiatric hospitalisation. Br J Psychiatry 1985;146:1-4. [Free Full Text]
4. Mosher LR. Alternatives to psychiatric hospitalization: why has research failed to be translated into practice? N Engl J Med 1983;309:1579-80.

Community environment is stressful

EDITOR, - Jeremy Coid's timely editorial¹ about community care is a welcome contribution at a time when rapid changes are taking place in mental health care provision. Many questions still remain unanswered. How do we balance the civil liberties of individuals against the rights of society to protect itself? How far should society go in protecting mentally ill people from the consequences of their own actions committed under the influence of their illness? What should take precedence: an individual's right to freedom or the right to effective treatment?

The notion of "normalisation" disregards the fact that living in the community is not inherently therapeutic; people become ill in the first place while living in the community. It also underestimates the profound loneliness and alienation of mentally ill people in the community, and society's deep rooted prejudice against them. Experience from the United States shows that many "new chronic patients," who have never been institutionalised, are receiving inadequate care and pose the most difficult management problems in the community.² Many have severe mental illness, associated substance abuse, and constitute a large proportion of homeless and mentally ill people in jail. For this group the loss of asylum function of the old institutions has meant a loss of care, support, and protection. They are constantly exposed to the stresses of living alone in a sometimes uncaring and hostile environment. Denial of mental illness, misinformation about psychotropic drugs, and scare stories about the exploitative or abusive nature of psychiatry further alienate them from mental health services. A similar picture has emerged about homeless mentally ill people in Britain.³

Despite evidence of a bedrock of mental illness that requires inpatient care regardless of increases in community provision,⁴ the number of psychiatric beds is being reduced drastically. The division of opinion among psychiatrists that Coid mentions and the muted responses of the royal college are therefore worrying. We shouldn't have to wait for an increasing number of well publicised tragedies before these issues are discussed; that would swing the pendulum back, with demands for a harsh and punitive institutional care. An uncritical commitment to community care that does not address these questions may bring home the truth behind the saying "to err is human, to really cock things up requires an ideology."

S P Singh

1. Coid J. Failure in community care: psychiatry's dilemma. BMJ 1994;308:805-6. (26 March.)
2. Lamb HR. Lessons learned from deinstitutionalisation in the US. Br J Psychiatry 1993;162:587-92. [Abstract/Free Full Text]
3. Scott J. Homelessness and mental illness. Br J Psychiatry 1993;162:314-24. [Abstract/Free Full Text]
4. Lawrence RE, Copas JB, Cooper PW. Community care: does it reduce the need for psychiatric beds? Br J Psychiatry 1991;159:334-40.

Supervision register needs rethinking

EDITOR, - Jeremy Coid highlights many of the difficulties in psychiatric care that we are experiencing in Bristol.¹ The inner city area with its large homeless population (the second largest in England), has high psychiatric morbidity,² and the number of compulsory admissions under the Mental Health Act has risen in the past few years. Inpatient units are full, and we also have a shortage of forensic beds. Where community developments continue, we are concerned these may uncover further hidden morbidity.

In this climate we have been directed to implement the supervision register with no extra powers or resources to help manage patients in the community. It has been suggested that a supervision register might be developed in conjunction with the care programme approach.

Most mental health professionals support the principles of the care programme approach. They would also agree that its implementation has been patchy as its enormous resource implications have not been fully acknowledged. At a recent meeting medical, nursing, and other colleagues expressed their serious concerns about the introduction of the supervision register. Some of the most important concerns are that there is no clear benefit to patients; that the criteria for inclusion in the register are too broad; how patients should be informed of their inclusion on the register and how this may affect them; that there has been very little consultation; that there is no extra resource; that not all suicides, and certainly not all violent behaviour, are associated with psychiatric disorder; and how patients can come off the register.

It is important to follow up patients with serious psychiatric illness who are at risk of suicide or of harming others. Good follow up can be organised through the care programme approach if it is given sufficient resources.

People with serious psychiatric illness need good community provision, housing, employment, and easy access to well funded psychiatric services. We believe that we are being asked by the government to collude in an exercise designed to shift accountability and disguise poor psychiatric provision. The supervision register is of no proved benefit to patients. Indeed it may be harmful, both directly by the official labelling of some people as potentially at risk and indirectly by obscuring the real underlying problems for some of our more seriously ill patients.

S O'Connor, P Birkett, J Parker, P Dedman, D Mumford, R Brown, D A Cook, J Short, D Kingham, S Arnott, P J A Willems, A Moore 

1. Coid J. Failure in community care: psychiatry's dilemma. BMJ 1994;308:805-6. (26 March.)
2. Kammerling M, O'Connor S. Unemployment rate as predictor of rate of psychiatric admission. BMJ 1993;307:1536-9.

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