Intended for healthcare professionals


Modernising mental health services

BMJ 1999; 318 doi: (Published 02 January 1999) Cite this as: BMJ 1999;318:3

Have psychiatrists failed community care?

EDITOR-The editorial by Marshall is a useful contribution to the
debate about mental health policy (1), apart from, as noted by Canning
(2), the betrayal of an apparent lack of understanding about the need for
integration of primary and mental health services (3). Debate about mental
health strategy continues at the Mental Health Policy website

Campaigning organisations opposed to the rundown of the traditional
psychiatric hospital, such as SANE
( have deliberately
exploited public anxieties. Initially this was the concern that
homelessness is being increased among the mentally ill, but their tack
changed when evidence accumulated against this view (4), to concern about
public safety due to homicides by psychiatric patients. The tragic killing
of Jonathan Zito on the London Underground led to the formation of the
Zito Trust, and Jayne Zito's motivation to improve mental health services
is understandable, as she has been unable to pursue a negligence claim in
relation to her husband's death, because courts are loth to rule that
public bodies, such as mental health services, owe a duty of care to third
parties. Campaigners against community care will presumably have to change
their theme again now that it has become clear that the proportion of
homicides due to mentally disordered people has decreased over the period
of deinstitutionalisation (5).

Unfortunately, SANE has already convinced the government that
community care has failed. The appointment of Graham Thornicroft as Chair
of the External Reference Group of the National Service Framework for
mental health, however, seems inconsistent with this conclusion, as he
thinks that community care has not failed because it has not yet been
fully tried (6). It is important to recognise the reactionary influences
which have brought the government to its position, not least many
psychiatrists themselves, who are opposed to community care, because of
their loss of power in the traditional psychiatric hospital.
Psychiatrists' attitudes to community care need to change before it can be
said to have been properly implemented. The review of the Mental Health
Act should provide further safeguards against the potential abuse of
medical power, reinforcing the motivation for the 1983 reforms (7).

1. Marshall M. Modernising mental health services. BMJ 1999;318:3-4

2. Canning J. Neurosis in primary care. eBMJ, 2 Jan 1999

3. Double DB. Staff in mental health services need clearer
guidelines. BMJ 1996;313:1208

4. Leff J. All the homeless people - where do they all come from? BMJ

5. Taylor PJ, Gunn J. Homicides by people with mental illness: myth
and reality. British Journal of Psychiatry 1999;174:9-14

6. Thornicroft G, Goldberg D. Has community care failed? Maudsley
discussion paper 5. London: Institute of Psychiatry, 1998

7. Gostin LO. A human condition. London: MIND, 1977

Competing interests: No competing interests

15 January 1999
D B Double
Consultant Psychiatrist
Norfolk Mental Health Care, Norwich NR6 5BE