Community care
129. As has often been said, it is relatively
easy to close an institution but much harder to replace it with
community-based arrangements that deliver high quality services
of the kind that people actually want to use. As we have seen,
community care tends to be preferred to hospital-dominated approaches
on the grounds of human rights, relative effectiveness and social
inclusion, and is strongly preferred by most service users.
130. Today, a "balanced care" approach
is often recommended: front-line services should be based in the
community, but hospitals and other "congregate care"
settings would play important roles as specialist providers. Under
such an approach people would still be admitted to in-patient
psychiatric care, but hospital stays should be as brief as possible,
and should be offered in integrated facilities rather than in
specialised, isolated locations. As the Christian Council on Ageing
noted, "No-one likes to be in an institution, including those
with dementia or severe mental illness, but some aspects of the
institutions were beneficial. A sheltered environment with easy
access to recreation and useful activity may be the most satisfactory
way of preserving the rights and dignity of some individuals.
This does not have to be in an 'institution' but does need to
alleviate isolation fear and anxiety. Support should not mean
disempowerment" (pp 112-113). Their clear message was
that some people would sometimes need a place of "asylum"
in the proper sense of the word.
131. When all of the costs of delivering a comprehensive
community care system are taken into account, including the costs
that fall to non-health care agencies as well as those that fall
to families, community-based mental health care may not be less
costly than hospital provision. A worry often expressed is that
policy makers will make untested assumptions of lower cost and
then under-fund community provision, for example not investing
sufficiently in after care support or crisis services. There is
also the worry, alluded to earlier, that any resources released
by closing an institution would not be "protected" for
the mental health sector. Ring-fencing funds for mental health
can also have disadvantages, but in countries that have still
to make the transition away from care dominated by asylums, adequate
and (in the short-term at least) protected community mental health
budgets are needed.
132. Another worry is that staff are not always
recruited and trained, nor appropriate community facilities in
place, before the process of hospital closure commences. The rapid
decanting of people out of long-stay institutions into under-prepared
and under-resourced support systems in what are often very hostile
communities is a recipe for disaster. Even when services are apparently
in place, people with mental health problems may not use them
because they do not want to, or because they do not appreciate
the benefits of doing so, or because they feel stigmatised, or
because health care and other staff in "ordinary" community
services discriminate against them.
133. A well-planned community-based approach
to mental health care will involve a range of public and other
bodies. Perhaps more than any other health issue, mental health
requires a concerted, coordinated, multi-sectoral approach to
both policy development and implementation on the ground. Multiple
responsibilities mean multiple budgets, which in turn can easily
erect barriers in the way of appropriate systems of treatment
and support. As the locus of care shifts from hospital to community
so too must the balance of funding. Indeed, because of the organisational
structure of care systems in many countries, and the diverse funding
streams employed, the balance of funding often needs also to shift
from a system that is dominated by medical services to one that
represents a greater mixture of services and budgets, drawing
on social care, education, social housing and other community
resources. A major challenge across the EU is to ensure that the
right structures or incentives are in place to mobilise resources
from a range of service-providing and other bodies in order to
meet the multiple needs of people with mental health problems.
134. The Green Paper recognises these challenges
stating that: "… although medical interventions play
a central role in tackling challenges, they alone cannot address
and change social determinants. Therefore, in line with the WHO
strategy, a comprehensive approach is needed, covering the provision
of treatment and care for individuals, but also action for the
whole population in order to promote mental health, to prevent
mental ill health and to address the challenges associated with
stigma and human rights. Such an approach should involve many
actors, including health and non-health policy sectors and stakeholders
whose decisions impact on the mental health of the population.
Patient organisations and civil society should play a prominent
role in building solutions".[43]
135. The Open Society Mental Health Initiative
(MHI) welcomed the Green Paper's comprehensive approach, but wanted
to see this approach reflected more clearly in the suggested areas
of action. They particularly drew attention to the need for social
welfare reform for the development of community-based services,
and to involve service users in decision-making (pp 155-159).
136. The Northern Ireland Association for Mental
Health (pp 148-155) similarly argued for a cross-sectoral
approach and partnership working, rather than "silo-dominated"
modes of operation. They also urged the Commission to take social
capital into account, i.e. the collection of "networks, norms,
and social trust that facilitated coordination and cooperation
for mutual benefit". The Royal College of Psychiatrists (pp 161-164)
agreed that added value would flow most readily from initiatives
that were based on, or encouraged, inter-agency and inter-state
collaboration. Mind (pp 54-60) wanted the Commission to ensure
that its strategy to improve mental well-being was not isolated
from wider EU policy relating to risk factors such as poverty,
social exclusion, work-related stress, racial injustice, and drug
and alcohol misuse.
137. Arguing that the whole can be greater than
the sum of the parts, Mind (pp 54-60) had welcomed earlier
EU initiatives on mental health but noted that they had been restricted
to specific initiatives in separate policy areas. They would complement
each other more effectively if part of a coherent, strategic whole.
The example they gave was of initiatives to reduce the stigma
of mental illness which have to battle against government policies,
or at least government rhetoric, that portrayed people with mental
health problems as a threat to public safety. They saw this as
happening currently in England and Wales in the debate over reform
of the 1983 Mental Health Act.
138. Ms Rosie Winterton MP, Minister for
Health Services, described to us the efforts made within the National
Framework for Mental Health to improve community-based mental
health care. Some 700 community health teams had now been set
up in England to support people with mental ill health in the
community, including getting help at an early stage with both
early intervention and crisis resolution (Q 224). Dr Matt
Muijen took the view that a great deal had been achieved with
community care in England. He saw the provision of specialist
services at local level as a most impressive achievement equalling
anything elsewhere in the world, with the possible exception of
Australia. He did, however, mention the negative side of the NHS
system of centralised funding which could mean that insufficiently
good access was available in England in some cases for treatment
of conditions such as depression, which needs a short, sharp intervention
by a therapist on a one-to-one basis (Q 197).
139. Good community care requires coordinated
responses from a range of public and other bodies, the challenges
of which should never be under-estimated.
140. We recognise that the consensus among organisations
in the UK, representing both service providers and service users,
is that front-line services for the treatment of mental health
problems should primarily be based in the community, but that
hospitals still need to play an important role as specialist providers.
Our view is that Member States should pursue a balanced care approach,
using specialist hospital services within a system of care and
treatment that is primarily community-based, and that promotes
integration, inclusion and choice for the individual and appropriate
protection for the community.
TABLE 1
Human rights legislation of relevance
to mental health issues
