Annex B
THE ABILITY OF "CARE IN THE COMMUNITY"
TO CATER FOR PEOPLE WITH ACUTE MENTAL ILLNESS
BACKGROUND
B1. "Care in the Community" has
its roots in the philosophy of "moral treatment" evolved
during the first part of the 19th century in reaction against
the conditions which existed in workhouses and private "madhouses".
Reform accelerated during the 1950s as mental hospitals were incorporated
into the NHS.
B2. Pioneering work in line with the developing
"welfare state" and the discovery of new forms of psychotropic
drugs during the 1950s made care outside psychiatric hospital
a realistic possibility. Supporters of the "open door movement"
as it was called, shared a belief that such treatment was both
more ethical and more effective.
B3. Care in the community was presumed to
prevent the "institutional syndrome" from occurring.
This was the pattern of apathy, dependence and social withdrawal
almost universally present amongst long-term in-patients, making
it difficult for patients to return to an ordinary life. In addition
to the increasing growth of mental health services outside hospital,
the key components of community care were:
— the development of informal admissions
to psychiatric hospital (ie without legal restriction) and the
publication of the Mental Health Act 1959;
— the concept of the "therapeutic
community";
— the concept of psychiatric rehabilitation;
— the development of day hospitals;
and
— the advent of "talking treatments"
and more progressive social and psychiatric practice.
B4. Evidence for the effectiveness of "care
in the community" has come from large-scale randomised controlled
trials in this country and the USA. They showed that even acutely
ill patients treated in the community were likely to recover just
as quickly as in hospital, more likely to retain social and occupational
links, less likely to be readmitted and more satisfied with their
treatment.
B5. In practice, care in the community did
work for many, and began to tackle the problems of the old Victorian
asylums, which had been the source of a number of scandals and
inquiries. With the dedication of staff, it did bring many beneficial
changes to the care and treatment of people with severe mental
illness. The "old long stay" patients were discharged
in large numbers to group homes, hostels or other accommodation.
Bed numbers began to decline from the mid-fifties and Government
plans looked forward to a time when the large hospitals would
disappear altogether.
WHY CARE
IN THE
COMMUNITY FAILED
B6. Over the years the failures of "care
in the community" have become more apparent. Some people
were left vulnerable, others a threat to themselves or a nuisance
to others, with a small minority a danger to the public. This
latter group has been the focus of media attention with the publication
of inquiry reports indicating that community care did not provide
adequately from some acutely ill people.
B7. The initial policy was always over-optimistic
and the failures were perhaps inevitable because of a range of
issues:
— a group of people with severe mental
illness—most typically schizophrenia—who are socially
isolated, difficult to engage with services and in need of care
in the long term, has begun to emerge. Care in the community has
often failed to deliver the treatment and support they need;
— families who contributed willingly
to the care of people with mental illness, have found they are
overburdened;
— inadequate systems, poor management
of resources and underfunding have resulted in widespread and
unacceptable variation in standards;
— there are significant problems of
recruitment, retention and poor staff morale, particularly in
the inner cities;
— services have failed to provide adequately
for a group of patients known as the new long stay. These are
people with severe mental illness who cannot be returned to the
community, who remain severely ill for long periods of time as
in-patients in units where the expectation is that people will
return home in a matter of weeks;
— it is clear that advances in treatments
for mental health problems, such as effective new drug treatments
for depression and pyschosis as well as physological therapies
for people with severe mental illness are not reaching those who
need them; and
— the increase in substance misuse
within society as a whole has also affected those with severe
mental illness. This makes mental illness more resistant to conventional
treatment approaches and requires particular attention.
B8. The legal framework, which supports
the provision of treatment and care of those with mental illness,
is outdated. It was drawn up in the 1950s and was not designed
in relation to the wide range of services now provided. The Mental
Health Act has also failed to provide an adequate framework for
dealing with a different group of people: those with severe anti-social
personality disorder who provide a risk to the public.
B9. The National Beds Inquiry (Shaping
the Future NHS: Long Term Planning for Hospitals and Related Services)
was published in February 2000. Its main focus is on general hospital
services and that is the basis of the current consultation exercise.
B10. Services for those with mental health
problems were also considered and it was concluded that there
is currently a significant mismatch of mental health services
and mental health needs. There is both a substantial shortfall
and an imbalance in the places available for adults of working
age, in supported accommodation in the community, medium secure
beds, and local intensive care beds.
THE NEW
SERVICE MODEL
B11. The Government has embarked on a radical
programme of modernisation to make services "safe, sound
and supportive":
|
| Safe | Sound
| Supportive |
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Good risk management
Early intervention
Enough beds
Better outreach
Integrated forensic and secure provision
A modern legislative framework
| 24 hour access
Needs assessment
Good primary care
Effective intervention
Effective care processes
| Involvement of patients, service users and carers
Access to employment, education and housing
Working in partnership
Better information
Promoting mental health and reducing stigma
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B12. This programme of work was set out in Modernising
Mental Health Services:
— New investment and systems to manage resources
more effectively, taken forward through the Comprehensive Spending
Review which has invested an additional £700 million in mental
health services over three years;
— Legislative powers which work with the grain of
comprehensive mental health services, taken forward through the
review of the 1983 Mental Health Act and consultation on services
for dangerous people with severe personality disorder;
— Properly integrated care processes, which cross
professional and organisational boundaries, taken forward through
the development and early implementation of the National Service
Framework.
B13. The early focus is on:
— 24 hour access to services;
— New assertive outreach teams;
— More 24 hour staffed beds in the community;
— More beds in secure settings;
— Integrating health and social care teams to co-ordinate
services;
— Increases in staff education and training;
— Better access round the clock;
— A better quality of care for people with severe
mental illness through integration of the Care Programme Approach
and Care Management.
B14. The Government's new vision for mental health services
is elaborated in the National Service Framework for Mental
Health. This sets out seven standards for the modernisation
of mental health services, alongside the evidence from the literature,
examples of good practice, and performance indicators and milestones
to guide those with responsibility for implementation. Local implementation
will be underpinned by five national programmes (paragraphs 18
to 39 of the main section).
B15. There is clear evidence that a comprehensive range
of services must be provided to meet the needs of people with
severe and enduring mental illness, and that appropriate services
must be available when needed.
B16. There is evidence that early intervention is important
(Birchwood, 1997) in reducing the rate of relapse in certain severe
mental illnesses, and that psycho-social treatments ("talking
therapies" such as family therapy) are an important component
of effective treatment for this group (Roth and Fonagy, 1997).
There is also new evidence concerning the effectiveness of new
anti-psychotic drugs and of new antidepressants, and good preliminary
evidence of the effectiveness of assertive outreach for those
with the most complex needs.
B17. One or two localities have also explored the feasibility
of delivering these components of effective mental health care
in a real-life setting with acute as well as moderately ill patients.
In North Birmingham the total package (community based assertive
outreach, early intervention, newer anti-psychotic medication,
psycho-social interventions, multidisciplinary approach, emergency
cover, home treatment, integration with occupation and education
services, ethnic minorities team) has been made available. The
outcomes look very promising indeed.
B18. The Mental Health National Service Framework, supported
by additional investment, begins to address these problems. Standard
Five states that every service user who is assessed as requiring
a period of care away from home should have timely access to an
appropriate hospital bed or place. This should be in the least
restrictive environment consistent with the need to protect them
and the public, and should be as close to home as possible. However,
although beds will continue to be necessary, there are disadvantages
to hospital admission, such as loss of ties with friends and families,
the potential for "institutionalisation" and increased
stigma. In addition, some groups (particularly women) may feel
unsafe in an acute psychiatric ward. Proper community treatment
and care—through initiatives such as crisis resolution teams
and home treatment—enable service users to avoid unnecessary
admission, and to receive safe, sound and supportive care in a
community setting (Open All Hours: 24 hour response for people
with mental health emergencies. Sainsbury Centre for Mental Health
1998).
B19. The developments in services will only be successful
if there is a sufficient, motivated, appropriately trained workforce
to deliver them. Continuity of care is important. Where staff
remain in post and know service users and their carers over a
prolonged period of time, assessment of risk is likely to be better
and more appropriate packages of care to be offered, delivered
and accepted by users of services.
B20. The proposals in the Green Paper Reform of the
Mental Health Act 1983 will for the first time enable compulsory
treatment to take place in the community, through new Community
Treatment Orders. The Green Paper makes clear that:
— modern legislation must reflect modern patterns
of care and treatment. Many people with a serious mental disorder
now receive the care and treatment they need outside hospital.
For those who are admitted to hospital, most are treated on exactly
the same basis as those with physical health problems—voluntarily
and with consent. Many patients can be discharged quite quickly
with appropriate care and follow up in the community. But some
patients have a history of failing to follow their treatment plans
and this can mean that their condition deteriorates so that they
pose a real risk to themselves or to other people—occasionally
with tragic results. The new compulsory orders will mean that
such patients can be cared for within a clear management and supervisory
framework so that this is much less likely to happen;
— compulsory orders will be specific to each patient.
If the patient is not in hospital the order will, as necessary,
stipulate the place of residence, define the care and treatment
plan, oblige the patient to allow visits by caseworkers, impose
a duty on services to comply with the arrangements and the consequences
of non-compliance;
— patients who do not comply with an order in the
community would, if necessary, be taken to a hospital or other
health setting where they would be treated by trained healthcare
staff. They would not be compulsorily medicated at home against
their will. If a patient persistently failed to comply with a
care plan then the care team would, if necessary, arrange admission
to hospital so that their needs could be re-assessed and the care
plan reviewed.
B21. This is a 10 year agenda. There are improvements
that can and are being made immediately, others will require investment
and cultural change. The National Service Framework, plus proposals
to reform mental health legislation, underpinned by new investment,
provide the integrated approach needed.
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