Summary

In this discussion paper we weigh the evidence for and against community care for people who suffer from mental illness, and interpret what the scientific and clinical evidence means and what should be done next.
The case against community care is that across the country wards are overcrowded and 30% of acute beds are blocked by patients who do not need to be there; there are unacceptable delays for services that are especially marked in deprived inner city areas. Staff responsible for administering care in the community have high sickness rates and low morale. Homicides by those suffering from severe mental illnesses attract much media attention, with increasing pressure on Ministers to take action. A substantial proportion of the homeless and remand prisoners are mentally ill.

The case for community care is that it is preferred by service users, and is associated with better social adjustment and fewer chronic symptoms. For those discharged from the old mental hospitals the benefits far outweigh the disadvantages. Care of severely disabled patients in houses in the community is successful, and the results of "home based" rehabilitation are encouraging. Research shows that community care does not increase the burden on carers, and while the overall rate of homicides is rising, those committed by the mentally ill are fairly stable in recent years.

We conclude that care of the mentally ill in the community is a policy that has been only half tried: the complete range of services advocated by the Department of Health is not yet to be found anywhere. Despite setting up multidisciplinary teams and catchment areas in most parts of the country, the most notable changes in hospital use have been the reduction in long term care: the numbers of acute beds has hardly changed. We need to invest more as these services are severely under-resourced, and to focus on the special needs of particular subgroups. Community care has been only half-implemented: we should fully implement it before deciding whether it has failed or succeeded.