Care in the community is an “unfinished revolution,” says think tank

BMJ 2011; 343 doi: (Published 07 November 2011) Cite this as: BMJ 2011;343:d7219
  1. Jo Carlowe
  1. 1London

People with mental health problems are failing to receive the right care, despite huge amounts of money being spent on them, because of an “unfinished revolution” in mental healthcare. This is the conclusion of a new report from the independent think tank the Centre for Social Justice.

The report says that further reforms are urgently needed to achieve the goals set by the policymakers of the 1970s and 1980s who championed the cause of care in the community. And it urges the government to use the current health reforms to “make a quantum leap forward” and complete the revolution.

“We called this report Completing the Revolution because there is unfinished business dating from the closing of the asylums that began in the early 1960s,” said the centre’s executive director, Gavin Poole.

The report states that the decision to close big mental hospitals and treat patients in the community has failed the most vulnerable patients, despite the fact that, at £6bn (€7bn; $9.6bn) a year, mental illness constitutes the single biggest cost item to the NHS.

Mr Poole said, “The revolution that intended to give the mentally ill freedom from the high walls of the asylums and release, where possible, from the chains of their health conditions has stalled. Money is still concentrated in hospital care and only trickles into the community—yet hospitals are where inpatients report being fearful for their safety and do not consider they are being helped to make progress.”

The report makes policy recommendations across primary and secondary care and focuses on children, young people, elderly people, military veterans, and people from ethnic minority groups. It describes how patients are being neglected because the asylum closures were not accompanied by a parallel expansion of primary mental health services provided by GPs, psychiatrists, and nurses. The money for this, it says, is tied up in hospital care.

The knock-on cost to the country, says the report, is £105bn through higher general healthcare and social care costs, lost working days, and family breakdown. It recommends the move to clinical commissioning groups (as set out in the Health and Social Care Bill), to enable charities and other independent organisations to compete fairly with state run services for contracts to care for mentally ill people.

“Communities themselves need to become neighbourly and places where social isolation is the exception to the norm,” the report concludes.

The report has been welcomed by mental health organisations, but the Royal College of Psychiatrists has criticised its approach to secondary mental health services.

Jed Boardman, the college’s lead on social inclusion, described this as “disappointing” and “in need of further review.”

Meanwhile the Mental Health Foundation has criticised the media for portraying the report as reflecting a failure of care in the community. Simon Lawton-Smith, the foundation’s head of policy, said, “Good community support has allowed people who would have previously been unnecessarily detained in terrible long stay asylums to rebuild their lives and play a full role in the community. In order to complete that revolution of moving away from an institutionalised care model, the report advocates that better investment in community care services is needed—not a return to the asylums—and we agree.”


Cite this as: BMJ 2011;343:d7219


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