Select Committee on Health Appendices to the Minutes of Evidence


APPENDIX 23

Memorandum by South London and Maudsley NHS Trust (MH 57)

EXECUTIVE SUMMARY

We address separately the four questions put to us:

1.  CURRENT GOVERNMENT DEFINITIONS AND CATEGORISATION OF MENTAL ILLNESS

  The proposed category of "mental disorder" is largely satisfactory, although the exclusions are rather unusual [paras 1.1-1.2].

  The proposed category "dangerous people with severe personality disorders" (DSPD) is unsatisfactory in a number of important respects [paras 1.3-1.6].

2.  THE ABILITY OF CARE IN THE COMMUNITY TO CATER FOR PEOPLE WITH ACUTE MENTAL ILLNESS

  We agree with the view that community care is at present both under-funded and under-staffed, but do not agree that "community care has failed" [paras 2.1-2.3].

  Studies are quoted showing that community care produces better outcomes than hospital based care, and these results have been shown to apply to standard community services. Research that has suggested that dramatic reductions in bed numbers could be made has always excluded from the studies many people requiring acute hospital care [paras 2.4-2.7].

  Some patients will continue to need admission to hospital-based facilities or equivalent, however well community facilities are developed. If the numbers of hospital beds are to be reduced still further, then a range of alternative accommodation is necessary in the community, community mental health teams must be adequately staffed, and crisis houses and intensive home treatment should be more widely available [paras 2.8-2.10].

  With additional funds, we suggest improvements that are needed to increase satisfaction of users and carers with the service [paras 2.11-2.15].

  We explain how existing funds could be distributed more equitably, and so raise standards of care in deprived inner city areas. The costs of secure care need to be taken into account separately in the resource allocation formula [paras 2.16-2.17].

3.  THE TRANSITION BETWEEN ACUTE AND SECURE MENTAL HEALTH SECTORS

  The funding and organisation of forensic care must not be considered in isolation from general mental health services; the boundary between them is a flexible one and changes in one will affect the other directly [paras 3.1-3.2].

  Although it is desirable to provide beds or equivalent care as close to people's homes as possible, it should be borne in mind that improvements to general adult services are likely to lead to a reduction in numbers of expensive forensic beds [paras 3.3-3.4].

  We agree that those with a severe mental illness and a history of violent behaviour should have an enhanced level of the CPA. The majority of patients are not violent, and the evidence base to predict future dangerousness is not yet strong: services should therefore continue to be focused on clinical needs [para 3.5].

  If our recommendations for taking forensic needs into separate account in calculating a new resource allocation formula are heeded, resources will be available for providing a liaison forensic services to prisons—and these are greatly needed [para 3.6].

4.  THE TRANSITION BETWEEN ADOLESCENT AND ADULT MENTAL HEALTH SERVICES

  We commend the proposed interventions aimed at preventing the development of severe personality disorders, but observe that most of them are outwith the responsibilities of an NHS Trust, and there is a need for an improved knowledge base [para 4.1].

  In many places, adolescents with psychotic illness continue to be admitted to adult wards, where the milieu is quite unsuitable and they are unlikely to receive optimal treatment [paras 4.2-4.3].

  It is especially important that cases of early psychotic illness receive the best treatment possible, as future health costs are likely to be high, and recent research evidence suggests that morbidity can be prevented with earlier, more effective intervention. We describe steps taken in the South London & Maudsley Trust to improve co-ordination between the two services [paras 4.4-4.5].

  We draw attention to poor liaison between adolescent services and schools, and the need for better care for adolescents with drug problems [para 4.6].

5.  WE PRESENT OUR RECOMMENDATIONS ON THESE POINTS

  1.  The proposed term "DSPD" is unsatisfactory in several important respects, and we prefer the Scottish approach—"serious and violent sexual offenders who present danger to the public".

  2.  We are of the opinion that community care can succeed, and that hospital bed numbers could be reduced further—but only if considerable additional investment is made in community based residential facilities, in the provision of extra staff salaries, and additional staff training.

  Where intensive home treatment teams are being established, they should be properly evaluated so that the NHS can benefit from a developing evidence base in this area.

  We further recommend an important modification to the "Resource Allocation Formula" by making separate provision for forensic needs, and also making the funding that has been allocated to Health Authorities for mental health explicit.

  3.  Although there should be a separate assessment of forensic needs, HAs should retain their discretion over expenditure.

  No realistic risk assessments can be made for people who do not have a previous history of violent behaviour; we argue that risk assessments should be based on a full range of needs of the patients, with careful monitoring of quality of care.

  Our financial recommendations, if accepted, would support Trusts to set up and resource NHS forensic liaison services with prisons across the country.

  4.  Health Authorities should be instructed to provide facilities for severely ill adolescent patients to be treated in specialised adolescent beds and day places, and the practice of admitting adolescents to adult wards should cease.

1.  CURRENT GOVERNMENT DEFINITIONS AND CATEGORISATION OF MENTAL ILLNESS

  1.1  There has never been a precise correspondence between legal and medical definitions of mental disorder. The 1983 Mental Health Act recognised four categories: "mental disorder" was an inclusive category which embraced chapters 290-318 of the International Classifications of Disease, 9th Edition (ICD-9); "severe mental impairment" roughly corresponded to disorders described in Chapter 318.2; "mental impairment" was the same in milder degree—so chapter 317; while "psychopathic disorder" referred to chapter 301. These categories were similar to those in the previous Mental Health Act (1959).

  1.2  The "Reform of the Mental Health Act 1983" consultation document put out in November 1999 proposes "mental disorder", to correspond to chapter F, sections 00-09 of ICD-10, and further defined as "any disability or disorder of brain or mind, whether permanent or temporary, which results in an impairment or disturbance of mental functioning". This seems an acceptable definition. However, the paper proposes to exclude conditions such as disorders of sexual preference (F65) and drug and alcohol misuse (F10-F19) from the category. It is not clear why these particular disorders are excluded (such as paedophilia and sadomasochism), while others (for example tic disorders F95; homosexuality F66 x1) are left in. These decisions appear to us to be rather usual.

  1.3  The Home Office Consultation paper proposes the creation of a new category "dangerous people with severe personality disorders" (DSPD). In spite of its apparent medical flavour, this is not a recognised diagnosis: the law should classify offences; leaving medicine to classify disorders.

  1.4  Those who commit these offences should be referred to as "serious violent and sexual offenders who may present a continuing danger to the public", as they are in Scotland. Those who commit such offences are not a homogeneous group, but may have various combinations of psychosis, drug dependence, learning disability, personality disorder, or even no mental disorder at all.

  1.5  Nor do scales of "standardised procedures" exist that can reliably recognise dangerous and severe personality disorder. The most reliable guide to future offending is past offending (Heilbrun et al 1999)—which is why it is of concern for there to be a civil way of entering preventative detention without a limit of time. The proposal in the Home Office document to remove the requirement that someone assigned to the new category should be "likely to benefit from medical treatment" (p 14, para 14d) is also of concern to the South London & Maudsley NHS Trust. The proper place for a serious repeat offender who is unlikely to benefit from medical treatment may be prison, and that decision must rest with the Courts. In a free society, there is no proper place for the confinement of those who have committed no offence and who are unlikely to benefit from medical treatment, whatever personality disorder they are deemed to have.

  1.6  The proposed term "DSPD" has all the overtones of moral judgement and social rejection that the term "psychopath" has carried for so many years. The developments envisaged by the Home Office as "Option B" [pp16-18] would only make sense if it had been shown that there were better ways of assessing future dangerousness on the basis of personality tests, than could be obtained from a consideration of past offences. However, the fact that there are some very dangerous people without personality disorders, as well as many with severe personality disorders who are not dangerous to others at all, leads one to suppose that the task may not be soluble in the current state of knowledge.

  1.7  We recommend that a programme of high quality scientific research is commissioned to investigate the outcomes of treatment and care for violent and sexual offenders who constitute a danger to the public.

2.  THE ABILITY OF CARE IN THE COMMUNITY TO CATER FOR PEOPLE WITH ACUTE MENTAL ILLNESS

  2.1  On 22 October 1998 the then Under-Secretary of State for Health announced that "care in the community care has failed for three reasons: it was under-funded, under-staffed and lacked a clear and appropriate legislative framework to support it . . ." We would agree with his assessment of the causes of problems associated with community care, but we consider that in overall terms community care has not failed most patients.

  2.2  The Government were concerned about the number of incidents involving homicides by schizophrenic patients, as well as those with severe personality disorders who were in the community but clearly were not receiving adequate care in the community. The numerous deficiencies of the mental illness service in London were documented in the King's Fund Report (Johnson et al 1997), but there are similar problems in other large cities in the United Kingdom. These defects are not confined to community services: hospital facilities are too often overcrowded, understaffed and violent, and services for those with chronic disability have too often been curtailed or relatively neglected.

  2.3  Yet the King's Fund Report did not conclude that community care had failed, as it described numerous positive features of the present system, and made positive recommendations for the future. However, it agreed with him that community care was both under-funded and understaffed, and that further reform of the Mental Health Act would be helpful.

  2.4  There have been numerous papers showing that community-based services give a better service to users and carers than the hospital-based services that they replace, showing that there are both health and social gains that are replicable in ordinary clinical settings (Thornicroft et al 1998). These gains are less marked than those reported in earlier cost-efficacy studies, but they are there—and seen in a range of outcome measures, including more users receiving services, an improved quality of life, and better social networks.

  2.5  Earlier studies, reviewed in Thornicroft and Goldberg (1998) had shown that services based on modern acute units are more cost effective than those based upon a large mental hospital, in that they produce better social and clinical outcomes at no greater cost. This paper showed that community care can prevent the accumulation of long-term damaging effects of institutional care, can produce better social adjustment of patients, and is greatly preferred by both users and their carers.

  2.6  The early studies of the cost efficacy of community care gave some commentators the impression that hospital beds could be dispensed with entirely. It was perhaps not appreciated that all these studies excluded numerous patients from entry to the study [for example, those with homicidal or suicidal tendencies; those with drug dependency in addition to their psychotic illnesses, those who were homeless, or those with organic brain syndromes complicating their management]. Also, nearly all these studies did admit most patients to hospital, but discharged them after a few days to intensively staffed care in a community setting. Thus, a more cautious conclusion from them would be that length of stay can be drastically shortened for many users, providing that community services are well staffed, and that there is a readily available range of alternative residential placements in the community.

  2.7  For these large and important groups of patients who were often excluded from the randomised controlled trials, there continues to be a need for some form of in-patient care or intensively staffed equivalent. There are indeed other groups as well: those needing complex brain imaging techniques need to be in hospital, as do those mentally ill people with violently disturbed behaviour. In each area, there should be access to at least one ward for more behaviourally disturbed patients, and another for less disturbed patients.

  2.8  A reduction in the number of hospital beds could be made if two important conditions were to be met: first, there should be a full range of residential facilities to the required capacity available in the community—some staffed mainly by the NHS, others by social services or the voluntary sector—and secondly, there should be adequate numbers of community staff available to look after them.

  2.9  Many patients with established illnesses need re-admission from time to time to deal with a relapse in their illness, or to re-establish treatment. Many such admissions need not be to hospital premises, and can take place in facilities called "crisis houses" (Sledge et al 1995). In the South London & Maudsley Trust we have opened in Croydon a "women's crisis house", that provides such care outside the hospital, for women who are at least as unwell as those who are voluntarily admitted, and a further crisis house for women is planned in Lambeth as well. However, very important additional measures should be made by social services, housing departments and the voluntary sector, working in partnership with Health Authorities, to provide intermediate care, a range of residential accommodation, some of it staffed 24 hours a day, some staffed only during the daytime, and yet others with low staffing levels.

  2.10  There is evidence from randomised controlled trials that offering intensive treatment at home to people with severe mental illness during crises can result in less use of hospital beds. Though up to half the patients in these trials require at least a short admission, the overall reduction in bed use may be up to 60 per cent (Joy et al 1999; Smyth and Hoult 2000). However, attempts are now being made to introduce intensive home treatment into areas where community care is already functioning, and to combine it with other community treatment approaches such as assertive outreach (AO). While early reports of services such as those in Birmingham (Minghella et al, 1998) and in Islington suggest that savings in bed use can be made, there is a need for randomised controlled trials. The South London & Maudsley Trust is planning to introduce a home treatment service in North Southwark, and will be evaluating its impact on bed use.

The necessary funding arrangements to improve the quality of care

  2.11  The National Service Framework for Mental Health refers to a number of current challenges that need to be met if we are to improve the quality of mental health services. We need to employ more staff providing evidence based psychological treatments than we have at present; we should routinely provide prompt care after discharge to reduce the suicide rate; we should provide training to the majority of CPNs who have not yet had training in family interventions for schizophrenic patients; we should offer therapy aimed at improving acceptance of treatment generally available—since it has been shown to improve symptoms and reduce admissions (Kemp & David 1997); we should provide adequate numbers of permanent, trained nursing staff on our in-patient units; and we should provide intensive home treatment and assertive outreach—since these cause increased user satisfaction, and can also reduce admission rates.

  2.12  Resources are allocated to Health Authorities (HAs) using the "York formula", which contains a psychiatric component based upon census data. This results in a three-fold variation between HAs in the psychiatric component of their allocations. However, HAs have discretion over the way they spend their allocated resources, and actual expenditure varies widely, not always proportionately to the needs implied by the formula.

  2.13  When one compares the amount allocated to HAs per capita for mental illness with the amount spent, there is enormous variation—with some spending very much less than their notional allocation, and others rather more. In practice, per capita expenditure on all mental illness has a five-fold variation between HAs, and expenditure on mental disordered offenders (MDOs) has a 20-fold variation (Glover et all 1999).

  2.14  Since deprived inner city areas inevitably have the highest forensic expenditures, this often has the effect of starving other parts of local health services on funds.

  2.15  Outside London, secure costs impinge on the resources available for other forms of mental health care. Within London, secure care costs are exceptionally high, but expenditure on other forms of mental health care is also higher than predicted by the resource allocation formula, and the demand for secure care is therefore drawing resources away from other parts of the health service. There are strong reasons why inner London HAs are obliged to spend more than their allocation on mental health, due to the extent of the drug problem in London, the needs of refugees, the large immigrant populations with higher rates of illness and specific needs, and the particularly high rate of single person households compared with other deprived inner cities.

  2.16  If the implications of the resource allocation formula for mental health spending were to be made explicit to Health Authorities, while leaving them with discretion over their expenditure, under-funding of mental health services in the most deprived areas might be corrected over time.

  2.17  These problems could be addressed by revising the resource allocation formula to take account of the highly variable needs for forensic services, and other relevant factors such as the size of the local prison population, and the number of high support hostels in each local area. This would result in a shift in resources towards those areas where needs for forensic services are greatest. HAs should have the option of spending mental health resources directly on forensic services, or on other forms of service aimed at reducing the total need for beds. The current review of the resource allocation formula needs to take these issues into account.

3.  THE TRANSITION BETWEEN ACUTE AND SECURE MENTAL HEALTH SECTORS

  3.1  The interface between general and secure mental health services may be of two types:

    integrated, in which individuals requiring secure in-patient care are cared for by forensic services but return to general services as soon as secure care in no longer required (transition between the two therefore depending on the nature of the care required), and

    parallel, in which mentally disordered offenders (MDOs) are cared for by forensic services in a range of settings including the community (transition being dependent on the offending history or perceived risk characteristics of the patient). In practice, local services tend to contain elements of both integrated and parallel services in varying proportions.

  3.2  No systematic evidence favours the adoption of one or other model. Whichever model is adopted, it is important to consider the fact that most patients of forensic services will at times be in need of services provided by acute mental health services, as well as by social services and the voluntary sector.

  3.3  Although forensic needs must be included in a future allocation formula, forensic services should not be provided with funds in isolation from acute services. General services provided effectively at an earlier stage in a patient's illness may help prevent later offending and the need for acute care.

  3.4  At present, many patients in need of secure care are placed in private facilities at great distances from their homes. Standard 5 of the National Service Framework for Mental Health states that hospital care should be provided as close to home as possible, is not met. During long admissions, vital links with family and the local community are lost, and this complicates attempts at rehabilitation through community services. Current programmes such as those funded from the NHS Modernisation Fund to build more secure units may go some way to addressing this problem. However, a more efficient way of containing the demand for secure beds is to improve the quality and comprehensiveness of acute general services.

  3.5  It is reasonable that those with a severe mental disorder and a history of violent behaviour should receive an "enhanced level of the Care Programme Approach", as has been suggested. However the majority of patients are not violent, and the evidence base to predict future dangerousness is not strong, and is likely to produce far too many "false positives". Standard adult mental illness services should continue to be focused on the patient's needs, and the quality of care that is being received.

  3.6  There is a high level of psychiatric morbidity and suicide in prisons (ONS 1998). We are pleased that the government has recently responded to this and given the Department of Health a lead role in providing medical services to prisons. However, mental health services to prisoners remain poor (Birmingham et al 1998; Robertson et al 1994), and liaison between prisons and local mental health Trusts is highly variable. We accept in principle the responsibility of Trusts to take responsibility for improving liaison services to local prisons. However, given the failure of resource allocation to HAs to make adequate allowance for the need for forensic services in deprived areas (2.7 above) Trusts with large local prison populations are often constrained in their ability to offer an adequate liaison service. Improving mental health care for prisoners should be a priority. The changes to the resource allocation formula which we have proposed would to some extent help to achieve this.

4.  THE TRANSITION BETWEEN ADOLESCENT AND ADULT MENTAL HEALTH SERVICES

  4.1  The measures set out in "Managing Dangerous People with Severe Personality Disorders" aimed at preventing children and adolescents from developing severe abnormalities of personality are admirable in their intentions. Those aimed at supporting families, improving conditions in schools, preventing bullying and providing better education on parenting, are especially welcome. However, the research base for these various interventions requires improving, and many of the suggested improvements do not lie within the remit of an NHS Trust.

  4.2  There is considerable variation across the country concerning how well the interface between adolescent and adult services works, but we are unaware of any empirical data concerning the interface. However, adolescents are still admitted to adult wards in many parts of the country—and this is usually highly undesirable, depending upon how mature they are for their years. Figures exist in Wales in 1996-98 published by the Welsh Office show that a total of 69 adolescents were admitted to adult wards in South Wales, and 63 in North Wales. Some of these were admitted to paediatric wards, but these are also unsuitable, since they are unlikely to offer the patients the range of specialised services that are necessary.

  4.3  It has been estimated that about 4 per cent of schizophrenic episodes have their onset before the age of 17 (Cannon et al 1999), so this is a problem which requires a solution. There is also a lack of age-appropriate day care facilities for adolescents with severe mental disorders; since not all of these people need to be admitted to hospital for in-patient treatment. The newly established Lambeth Early Onset (LEO) project has been designed to offer optimum treatment and care to people who develop a first episode of psychosis, many of whom are teenagers. It will create a range of services acceptable to people who have traditionally found mental health services inappropriate to their needs, or culturally inappropriate. This service will also have a newly developed designated in-patient ward providing safe areas for women. It is especially important that adolescents with severe mental illness receive the best possible treatment, and do not have to take their chances on adult wards where the milieu may be quite unsuitable for them. There are at present insufficient numbers of in-patient adolescent beds and day places to allow this highly undesirable practice to cease.

  4.4  Not all adolescents who have been treated by specialist adolescent mental health services wish for or need to be seen by the adult services: it is often completely appropriate to promote resumption of development towards independent functioning, with social/educational support as necessary, but without the need for indefinite involvement from mental health services. However, it is important that those with complex and long-term needs (in particular those with severe psychotic illnesses) do receive continuity of care—up to 70 per cent of adolescents experiencing a psychotic episode will experience another episode within five years (Kraus & Muller-Thomsen 1993). Another recent European study showed that half of those developing psychosis before adult life had a severe, continuous course to their illness, with those developing the illness before the age of 12 often having an insidious onset (Eggers et al 1999). Birchwood (1999) has described the "critical period" early in the course of the illness, where it is desirable that in addition to optimal pharmacological management, the patient receives cognitive-behavioural treatment as well, and family interventions are tried in an attempt to reduce the [otherwise high] probability of relapse.

  4.5  In the South London & Maudsley NHS Trust, in the newly established Croydon Adolescent Community Service, for example, there are between five and eight referrals per year for psychotic adolescents, for a unit with approximately 120 referrals per year—the remainder being mainly conduct disorders, severe depression and deliberate self-harm. Our service in Croydon is arranged on multidisciplinary lines similar to an adult community mental health team, and the consultant psychiatrist and community psychiatric nurses devote regular time to liaison between their own team and the appropriate adult mental health team. Also within our Trust the work of Professor Hilton Davies indicates that early parenting assistance to families may help to reduce the occurrence of mental health problems in adolescents.

  4.6  Nationally, the interface between specialist Mental Health, Education and Social Services is poorly developed, and protracted hospital admissions are most likely for those with severe and complex needs, where policies for multi-agency co-ordination of assessment and provision are lacking and there is a lack of joint adolescent/adult services for those with drug dependence. As is well known, there is a considerable overlap between drug use and severe psychotic illness. Recent studies in London, for example, show that at least 30 per cent of patients with psychotic disorders also misuse drugs, or alcohol, or both.

REFERENCES

  Birmingham, L; Mason, D; Grubin, D. (1998) A follow-up study of mentally disordered men remanded to prison. Criminal Behaviour and Mental Health. 8(3), 202-213.

  Bindman J. (1999) Allocation and expenditure on mental health services in England: The implications for equity. MSc dissertation: London School of Hygiene and Tropical Medicine.

  Bindman J, Beck A, Thornicroft G, Knapp M, Szmukler G. Which psychiatric patients are at greatest risk and in greatest need? Impact of the Supervision Register Policy. British Journal of Psychiatry (in press).

  Bindman J, Beck A, Glover G, Thornicroft G, Knapp M, Leese M, Szmukler G. (1999) Evaluating mental health policy in England: The Care Programme Approach and Supervision Registers British Journal of Psychiatry 175 327-330.

  Birchwood M (1999) Early intervention in psychosis: the critical period. In Ed McGorry PD and Jackson HJ "The recognition and management of early psychosis. Cambridge: Cambridge University Press pp 226-264.

  Cannon M, Jones P, Huttunen MO, Tanskanen A, Huttunen T, Rabe-Hesketh S, Murray RM (1999) School performance in Finnish children and later development of schizophrenia: a population-based longitudinal study. Arch Gen Psychiatry 56(5):457-63.

  Eggers C, Bunk D, Volberg G, Ropcke B (1999) The ESSEN study of childhood-onset schizophrenia: selected results. Eur Child Adolesc Psychiatry 1999;8 Suppl 1:I21-8.

  Glover G (1999) Can we say how much English HAs are allocated for mental health? British Journal of Psychiatry 175 402-406.

  Gunn J, Maden A & Swinton M (1991) Treatment needs of prisoners with psychiatric disorders. British Medical Journal 303, 338-40.

  Heilbrun K, Ogloff JRP, Picarello K (1999) Dangerous Offender statutes in the USA and Canada: implications for risk assessment. Int J Law Psych: 22; 393-415.

  Joy C, Adams C, Rice K (1999) Crisis intervention for people with severe mental illnesses. Cochrane Library.

  Johnson S, Ramsay R, Thornicroft G, Brooks L, Lelliott P, Peck E, Smith H, Chisholm D, Audini B, Knapp M, Goldberg DP (1997) London's Mental Health. London: The King's Fund.

  Kemp R; Kirov G; Everitt B; Hayward P; David, A (1998). Randomised controlled trial of compliance therapy: 18-month follow-up. British Journal of Psychiatry. 172; 413-419.

  Kraus M, Muller-Thomsen T (1993) Schizophrenia with onset in adolescence—an 11 year follow-up period. Schizophrenia Bulletin 19; 831-834.

  Maden T; Swinton M; Gunn J (1994) Therapeutic community treatment: A survey of unmet need among sentenced prisoners. Therapeutic Communities: the International Journal for Therapeutic and Supportive Organizations. 15(4), 229-236.

  MILMIS Project Group (1995) Monitoring Inner London Mental Illness Service Psychiatric Bulletin 19: 276-280.

Minghella E, Ford R, Freeman T et al (1998) Open all hours: 24 hour response for people with mental health emergencies. London: Sainsbury Centre for Mental Health.

  Office of National Statistics (1998). Psychiatric Morbidity among prisoners in England and Wales—a survey carried out in 1997 on behalf of the Department of Health, London: The Stationery Office.

  Sledge W, Tebes J, Rakfeld J (1995) Acute crisis respite care. In ed Phelan P, Strathdee G, and Thornicroft G "Emergency mental health services" Cambridge: Cambridge University Press. pp 233-258.

  Smyth M, Hoult J (2000) The home treatment enigma. British Medical Journal 320 305-307.

  Thornicroft G, Goldberg DP (1998) Has community care failed? Maudsley Discussion Paper No.5. London: Institute of Psychiatry.

  Thornicroft G, Wykes T, Holloway F, Johnson S, Szmukler G (1998) From efficacy to effectiveness in community mental health services. Prism psychosis study 10. British Journal of Psychiatry 173; 423-427.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2000
Prepared 24 July 2000