BBC News Online: Health: Background Briefings: Politics of Health

The origins of care in the community

At this time there was a shift in attitudes concerning how society should care for the mentally ill.

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

Problems with the policy

But the policy 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.

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

This was combined philosophy of civil libertarians like 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 to the National Health Service and Community Care Act of 1990, which was phased in over a three-year period. It established the local authority as the lead agency in community care.

It also 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.

The 1996 Mental Health Act introduced a new power of "supervised discharge" for patients leaving hospital in an effort to ensure they receive the proper care.