In what sense has community care failed?
The Government has now confirmed that it will not apologise for its
emphasis on public safety in mental health policy (1). Its stance is
unsurprising as it has no wish to concede that it has been duped by
campaigning organisations such as SANE (2), and Frank Dobson has given
mental health services his personal priority as Health Secretary. Public
relations are central for this government and its position could at least
lead to reconciliation of sterile disputes about community care. In this
context, it does seem important to establish in what sense community care
can be said to have failed.
There will be general agreement with the statement in the
government's strategy document, Modernising Mental Health Services, that
the policy of community care has brought many benefits and that the
failures have been caused by underfunding, inadequate care and poor
management (3). The issue is, therefore, about standards of care, which
makes the work of the External Reference Group crucial. However, it is not
easy to create consensus. For example, most psychiatrists are still based
in psychiatric hospitals and probably should be based in community mental
health centres, but they will tend to resist such change.
Public outcry may have been counterproductive by encouraging
defensive rather than therapeutic practice. Over recent years, more people
have been locked up in secure beds as numbers of other adult mental health
beds have reduced (see figure at http://www.uea.ac.uk/~wp276/beds.htm) and
numbers of people detained under the Mental Health Act have increased.
Justifiable motivation for the revision of the Mental Health Act is
because of the changed circumstances of deinstitutionalisation (1).
Ideological issues cannot be avoided. The Government's view could
reinforce a simplistic model of mental illness, viewing it as caused by
biological deficits that can be corrected by medication. There are
consequences of treating people as though they are objects (4). The
efficacy of psychotropic medication and the methodology of clinical trials
are not certain (5). Attempts by psychiatrists to justify their authority
by biological approaches to mental illness, rather than attempts to
understand people's problems, have undermined community care (2).
Although the Government may need to be educated about the
complexities of mental health care, its intention to improve the quality
of care should be supported.
1. Department of Health. Radical changes needed to mental health
services, says minister. Press release 1999/0036, 21 January 1999.
2. Double DB. Have psychiatrists failed community care? eBMJ
http://www.bmj.com/cgi/eletters/318/7175/3#EL8 (15 January 1999)
3. Department of Health. Modernising mental health services: safe,
sound and supportive. London: Department of Health, 1998
4. Kaiser D. Against biologic psychiatry. Psychiatric Times.
http://www.mhsource.com/edu/psytimes/p961242.html (December 1996)
5. Fisher S, Greenberg RP. (eds) From placebo to panacea. Putting
psychiatric drugs to the test. New York: John Wiley, 1997
Competing interests: No competing interests