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Wednesday, July 29, 1998 Published at 01:02 GMT 02:02 UK

The origins of care in the community

Source of figures: Sane

The concept of care in the community has its foundations in the 1950s and 1960s.

At this time there was a shift in attitudes concerning how society should care for the mentally ill and some of the old Victorian asylums began to be closed.

The new philosophy said the asylums were no longer appropriate. Instead services and support should be provided in people's own homes, giving the person as much independence as possible.

The policy was backed up with legislation, the most extensive of which was introduced under the last Conservative government.

Problems with the policy

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But it has been beset by problems. Its flaws have been highlighted by a number of headline-grabbing killings by mentally ill people who were supposedly being 'cared for' in the community.

But there are other areas that have also caused concern:

  • The high number of suicides among mentally ill people who are under health service care. In 1996/7 nearly 500 committed suicide.

  • Lack of funding and bed shortages: The number of psychiatric beds has been halved over the past 15 years. The number of 24-hour nursed beds in residential care has been cut by one third.

  • Shortage of staff: 87% of NHS trusts have reported recruitment problems in mental health professions.

  • a falling investment in mental health, although mental health experts say community care is more expensive than hospital care. The proportion of the average hospital budget spent on mental health fell from 14.4% in 1988/9 to 12% in 1994/5.

  • Some health professionals suggest that social changes in society in the last 40 years mean the policy is no longer as achievable. The decline of local communities and extended family networks, combined with growing numbers of women working, have made unpaid community care increasingly hard to come by.

The birth of community care

The trend towards care in the community came from several sources, including changes in social attitudes to mental health.

The new wave of psychotropic drugs in the 1960s meant patients could be more easily treated outside of an institution.

This was combined with the philosophy of civil libertarians like former health minister Enoch Powell who argued that mental hospitals were effectively prisons, preventing a return to normal life.

It was also believed at the time that community care would be cheaper than hospital care, although mental health campaigners have consistently argued in recent years that it is more expensive, if properly funded.

Number of beds fall

During the 1970s large-scale psychiatric hospitals were steadily discredited.

The new district general hospitals which provided some psychiatric services contributed to the reduction in the number of beds in mental hospitals from 150,000 in the mid-1950s to 80,000 by 1975.

But by the 1980s people were already becoming wary of care in the community after a series of killings by people with mental health problems.

The murder in 1984 of social worker Isabel Schwarz, who was killed by a former client, prompted a government inquiry.

1990 Community Care Act

The inquiry, led by by Sir Roy Griffiths, resulted in the National Health Service and Community Care Act of 1990, which was phased in over a three-year period.

It established a system of assessing individuals' needs which involved setting out an agreed plan of care, assigning a key worker and a regular review of progress.

If a person is judged to represent a significant risk to themselves and others then they are placed on a Supervision Register. The aim of the register is to prevent those at risk from slipping through the net, but there have since been several notable cases where this has happened.

Recent legislation introduced in 1995 brought in a new power of "supervised discharge" for patients leaving hospital. This was meant to ensure patients received proper care on discharge.

However, there have continued to be problems with some mental health patients slipping through the net and getting no support on release.

Many have ended up homeless or in hostels and some have stopped taking the medication they need to keep on an even keel.

In some cases, this has led to high-profile attacks on members of the public.

There have also been money wrangles between health and social services over who should pay for care in the community.

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