The 13 steps to community care

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7035.913a (Published 06 April 1996) Cite this as: BMJ 1996;312:913
  1. Doris Hollander,
  2. Robin B Powell
  1. Consultant psychiatrist Camden and Islington Community Trust, Whittington Hospital, London N19 5NF
  2. Consultant psychiatrist North West London Mental Health Trust, London NW10 0JQ

    EDITOR,—Social services departments and community projects have erected bureaucratic procedures that impede the process of discharging mentally ill people from hospital. For example, in one district the following steps must be fulfilled (this process is typical of the problem throughout London).

    1. Refer patient for community living assessment (4 pages).

    2. Allocate worker to complete community living assessment.

    3. Complete community living assessment form (50 pages).

    4. Prepare summary and statement of need (3 pages).

    5. Pass statement of need to community living action group for approval. It may be challenged at this point, and if it is rejected it will need to be rewritten and presented again.

    6. Identify appropriate accommodation. If there is no vacancy the client may be placed on the waiting list and the process arrested.

    7. Complete application form (10 pages) and, once medical and social work reports are available, submit them to residential project.

    8. Succeed at one or more selection interviews at the prospective home. If the interview fails, the process must start again at step 6.

    9. If patient is accepted, refer to community living action group to agree funding. Placement may be rejected on grounds of cost.

    10. Complete finance forms, care plan forms, and public service agreements (totalling some 30 pages).

    11. Make arrangements for moving in (including referrals to community nurse and general practitioner, arrangements for benefits and other personal finances, bus pass, etc).

    12. Trial period of three months.

    13. Find social services care manager for case.

    This exercise entails over 100 pages of forms and reports and, if there are no mishaps (there always are), takes three months. If no appropriate home can be identified the procedure is of indefinite duration. This protracted process has the effect of delaying moves, thereby causing patients to “silt up” in admission wards. This in turn leads to difficulties in admitting acutely ill patients to wards and to overoccupancy1 as well as stoking the burgeoning industry in extracontractual referrals at growing cost to the health service.


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