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10.1192/bjp.179.5.381

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2001, 179:381-383.

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JULIAN LEFF

Why is care in the community perceived as a failure?

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Ask any gathering of people who are not Ask any gathering of people who are not members of the psychiatric profession what members of the psychiatric profession what they think of care in the community and they think of care in the community and most, if not all of them, will reply that it most, if not all of them, will reply that it has failed. The phrase `in the community' has failed. The phrase `in the community' has even entered common parlance to has even entered common parlance to indicate that a person is `off his head' or indicate that a person is `off his head' or

`barmy' (Leff, 2000). The media almost

`barmy' (Leff, 2000). The media almost universally hold to this conviction, and universally hold to this conviction, and judging from their intention to introduce a judging from their intention to introduce a more restrictive Mental Health Act, the more restrictive Mental Health Act, the Government of England and Wales is of Government of England and Wales is of the same mind. How has this come about the same mind. How has this come about when there is substantial evidence of when there is substantial evidence of considerable success resulting from the considerable success resulting from the revolution in psychiatric care that has revolution in psychiatric care that has occurred over the past 50years? Few lay occurred over the past 50years? Few lay people are aware that of the 130psychiatric people are aware that of the 130psychiatric hospitals functioning in England and Wales hospitals functioning in England and Wales in 1975, only 14 remain open, with in 1975, only 14 remain open, with fewerfewer than 200 patients in each. The fact that this than 200 patients in each. The fact that this is not better publicised is an indication of is not better publicised is an indication of the Government's reservations about the Government's reservations about thethe outcome of the policy of deinstitution- outcome of the policy of deinstitution- alisation endorsed by their predecessors, alisation endorsed by their predecessors, both of the left and of the right.

both of the left and of the right.

THE INVISIBILITYOF A THE INVISIBILITYOF A COMMUNITY SERVICE COMMUNITY SERVICE

A number of sources of this general mis- A number of sources of this general mis- perception can be identified. Perhaps the perception can be identified. Perhaps the most potent is the term `care in the com- most potent is the term `care in the com- munity'

munity' itself. What image of success coulditself. What image of success could it conjure

it conjure up? The community as a conceptup? The community as a concept is nebulous and often evokes scepticism is nebulous and often evokes scepticism regarding its existence. A good community regarding its existence. A good community psychiatric service is virtually invisible.

psychiatric service is virtually invisible.

The residences for patients needing sheltered The residences for patients needing sheltered accommodation are intentionally indistin- accommodation are intentionally indistin- guishable from

guishable from neighbouring homes, inneighbouring homes, in accordance with the philosophy of normal- accordance with the philosophy of normal- isation. The network of professionals needs isation. The network of professionals needs to be based in a building in the catchment to be based in a building in the catchment area, but this often is a converted house area, but this often is a converted house with nothing identifiable about its exterior.

with nothing identifiable about its exterior.

Community psychiatric staff do not wear Community psychiatric staff do not wear distinctive uniforms: even those who are distinctive uniforms: even those who are medically

medically qualified do not carry black bagsqualified do not carry black bags and stetho

and stethoscopes. Psychiatric admissionscopes. Psychiatric admission wards often are an integral part of the wards often are an integral part of the general hospital and not evident to the general hospital and not evident to the casual passer-by. Thus the dramatic archi- casual passer-by. Thus the dramatic archi- tectural presence of the asylums has been tectural presence of the asylums has been replaced by an apparent absence.

replaced by an apparent absence.

HOMELESSNESS HOMELESSNESS

What is conspicuous to the public is the What is conspicuous to the public is the increase in homeless people on the streets, increase in homeless people on the streets, many of whom obviously are mentally ill.

many of whom obviously are mentally ill.

This is linked in the minds of the public This is linked in the minds of the public and of some professionals with the closure and of some professionals with the closure of the asylums. The number of homeless of the asylums. The number of homeless people in England doubled during the people in England doubled during the decade of the 1980s but has since remained decade of the 1980s but has since remained at about 400 000 according to Shelter at about 400 000 according to Shelter (2001). The earlier rise was partly a result (2001). The earlier rise was partly a result of a reduction in the availability of low-cost of a reduction in the availability of low-cost accommodation and partly due to the clo- accommodation and partly due to the clo- sure of direct-access hostels, which ``since sure of direct-access hostels, which ``since the mid-1950s have served as unacknowl- the mid-1950s have served as unacknowl- edged asylums for large numbers of men- edged asylums for large numbers of men- tally ill people''

tally ill people'' (Craig & Timms, 1992).(Craig & Timms, 1992).

The proportion of

The proportion of homeless people with se-homeless people with se- vere mental illness

vere mental illness has remained steady athas remained steady at between a quarter and a half (Craig &

between a quarter and a half (Craig &

Timms, 1992; Fisher

Timms, 1992; Fisher et alet al, 1994; Hamid, 1994; Hamid etet al

al, 1995; Adams, 1995; Adams et alet al,, 1996). Thus, the pub-1996). Thus, the pub- lic were correct in

lic were correct in perceiving an increase inperceiving an increase in the absolute number

the absolute number of conspicuously men-of conspicuously men- tally ill people on

tally ill people on the streets during thethe streets during the 1980s, but where have

1980s, but where have they come from?they come from?

A number of surveys have shown that A number of surveys have shown that very few homeless men with mental illness very few homeless men with mental illness have spent any length of time in a psy- have spent any length of time in a psy- chiatric hospital (Timms & Fry, 1989;

chiatric hospital (Timms & Fry, 1989;

Craig & Timms, 1992; Hamid Craig & Timms, 1992; Hamid et alet al,, 1995). The situation may be different for 1995). The situation may be different for homeless women with mental illness homeless women with mental illness (Marshall & Reed, 1992; Adams (Marshall & Reed, 1992; Adams et alet al,, 1996) and homeless people in Belfast 1996) and homeless people in Belfast

(McCauley & MacKenna, 1995). Selection (McCauley & MacKenna, 1995). Selection biases may account for these conflicting biases may account for these conflicting findings but are avoided by prospective findings but are avoided by prospective follow-up studies of long-stay patients follow-up studies of long-stay patients resettled in the community. Pickard resettled in the community. Pickard et alet al (1991) followed up 103 such patients dis- (1991) followed up 103 such patients dis- charged from Cane Hill Hospital and found charged from Cane Hill Hospital and found that none became homeless in the first year.

that none became homeless in the first year.

A similar picture emerged from a follow-up A similar picture emerged from a follow-up of 150patients discharged from Tooting Bec of 150patients discharged from Tooting Bec Hospital (Craig & Timms, 1992), whereas Hospital (Craig & Timms, 1992), whereas the Team for the Assessment of Psychiatric the Team for the Assessment of Psychiatric Services (TAPS) study of a cohort of 670 Services (TAPS) study of a cohort of 670 long-stay patients found that a maximum long-stay patients found that a maximum of four became homeless over 5 years of four became homeless over 5 years following discharge (Leff & Trieman, following discharge (Leff & Trieman, 2000). The problem of homeless people 2000). The problem of homeless people with men

with mental illness is a blight on communitytal illness is a blight on community care but is

care but is not a consequence of the failurenot a consequence of the failure of planned resettlement of patients from of planned resettlement of patients from psychiatric hospitals.

psychiatric hospitals.

VIOLENCE VIOLENCE

The other overriding issue for the public and The other overriding issue for the public and the media is that of violence by people with the media is that of violence by people with mental illness. In fact, the staff in the closing mental illness. In fact, the staff in the closing psychiatric hospitals strove to prevent psychiatric hospitals strove to prevent patients with a history of violence, or a patients with a history of violence, or a propensity to it, from being discharged into propensity to it, from being discharged into the community,

the community, and such patients formed aand such patients formed a large part of the difficult-to-place group large part of the difficult-to-place group who were cared for in highly staffed and who were cared for in highly staffed and specialised facilities

specialised facilities (Trieman & Leff,(Trieman & Leff, 1996). Furthermore, care

1996). Furthermore, careful analysis of theful analysis of the figures for violent crime has revealed that figures for violent crime has revealed that people with mental illness are not especially people with mental illness are not especially prone to violent acts and that, if anything, prone to violent acts and that, if anything, there has been a decrease in violent crimes there has been a decrease in violent crimes committed by people with mental illness committed by people with mental illness in recent years (Taylor & Gunn, 1999).

in recent years (Taylor & Gunn, 1999).

Part of the misperception of the situation Part of the misperception of the situation is a confusion in the mind of the public is a confusion in the mind of the public between schizophrenia and personality dis- between schizophrenia and personality dis- order, engendered by the false equivalence order, engendered by the false equivalence of schizophrenia with split personality. A of schizophrenia with split personality. A single homicide by a person with mental single homicide by a person with mental illness or personality disorder, emblazoned illness or personality disorder, emblazoned by the media, is sufficient to reinforce the by the media, is sufficient to reinforce the public association of violence with mental public association of violence with mental ill health and the assumption that `care in ill health and the assumption that `care in the community' is responsible.

the community' is responsible.

COMPLEXITY COMPLEXITY

Another influential factor is the dispersed Another influential factor is the dispersed nature of a modern psychiatric service.

nature of a modern psychiatric service.

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B R I T I S H J O UR N A L O F P SYC HI AT RY

B R I T I S H J O UR N A L O F P S YC HI AT RY ( 2 0 0 1 ) , 1 7 9, 3 8 1 ^ 3 8 3( 2 0 0 1 ) , 1 7 9, 3 8 1 ^ 3 8 3

E D I T O R I A L E D I T O R I A L

Why is care in the community perceived as a failure?

Why is care in the community perceived as a failure?

JULIAN LEFF JULIAN LEFF

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L E F F L E F F

The psychiatric hospital was an extreme The psychiatric hospital was an extreme exemplar of centralisation. A comprehensive exemplar of centralisation. A comprehensive community psychiatric service is a complex community psychiatric service is a complex network of interlinked facilities and profes- network of interlinked facilities and profes- sionals encompassing multiple disciplines sionals encompassing multiple disciplines and agencies. The latter often include and agencies. The latter often include National Health Service (NHS) trusts, National Health Service (NHS) trusts, local authorities, social services, voluntary local authorities, social services, voluntary organisations and private facilities, making organisations and private facilities, making up a `mixed economy of care'. Even well- up a `mixed economy of care'. Even well- informed journalists find it difficult to informed journalists find it difficult to grasp the entirety of a community service grasp the entirety of a community service and the fact that some needs of patients and the fact that some needs of patients may be well served but others unmet. It is may be well served but others unmet. It is hardly surprising, then, that members of hardly surprising, then, that members of the public generally make an all-or-nothing the public generally make an all-or-nothing judgement concerning success or failure.

judgement concerning success or failure.

Psychiatric professionals are well aware Psychiatric professionals are well aware of the problems within their own ambit of of the problems within their own ambit of responsibility, and where a service is in responsibility, and where a service is in dire trouble, as are many admission wards, dire trouble, as are many admission wards, it becomes common knowledge within the it becomes common knowledge within the profession. However few members of the profession. However few members of the public are aware of this particular problem public are aware of this particular problem unless they have a relative with psychiatric unless they have a relative with psychiatric illness

illness who has needed admission. It iswho has needed admission. It is curious that journalists view waiting lists curious that journalists view waiting lists for medical and surgical emergencies as hot for medical and surgical emergencies as hot news, whereas

news, whereas the same problem affectingthe same problem affecting psychiatric patients does not seem to merit psychiatric patients does not seem to merit exposure. The disadvantage of a low or exposure. The disadvantage of a low or invisible profile in the media is that govern- invisible profile in the media is that govern- ments feel little pressure to find a solution.

ments feel little pressure to find a solution.

It is probably fair to state that a com- It is probably fair to state that a com- prehensive community psychiatric service prehensive community psychiatric service catering to all the needs of the catchment catering to all the needs of the catchment area population exists nowhere in the area population exists nowhere in the British Isles and will never be achieved.

British Isles and will never be achieved.

This is because health service provision is This is because health service provision is always chasing need in an ascending spiral.

always chasing need in an ascending spiral.

When basic needs are satisfied, a new level When basic needs are satisfied, a new level of need becomes apparent. This is another of need becomes apparent. This is another reason why the judgement of the success reason why the judgement of the success of a service cannot be absolute and must of a service cannot be absolute and must be relative.

be relative.

REMEDIES REMEDIES

What can be done to alter the perception of What can be done to alter the perception of the public, the media and the Government the public, the media and the Government that care in the community has failed?

that care in the community has failed?

Although the conspicuous presence of Although the conspicuous presence of mentally ill homeless people is not a direct mentally ill homeless people is not a direct consequence of closure of the psychiatric consequence of closure of the psychiatric hospitals, it represents a mass of human hospitals, it represents a mass of human misery for which our profession must take misery for which our profession must take responsibility. People admitted to a psychi- responsibility. People admitted to a psychi- atric ward from a hostel for the homeless atric ward from a hostel for the homeless

are ``discharged prematurely back to the are ``discharged prematurely back to the hostel, often with no warning and without hostel, often with no warning and without follow-

follow-up arrangements'' (Marshall & Reed,up arrangements'' (Marshall & Reed, 1992).

1992). My own experience of caring forMy own experience of caring for admitted patients, 20% of whom were admitted patients, 20% of whom were homeless or from out of the catchment homeless or from out of the catchment area, taught me that a period of rehabilita- area, taught me that a period of rehabilita- tion extending

tion extending over a year or more couldover a year or more could re-establish many of them in a settled re-establish many of them in a settled way of life.

way of life. Unfortunately, this is seen asUnfortunately, this is seen as an unattainable luxury under the condi- an unattainable luxury under the condi- tions of today's admission wards. Long- tions of today's admission wards. Long- term rehabilitation units are an essential term rehabilitation units are an essential component in any community service.

component in any community service.

In recent years a number of campaigns In recent years a number of campaigns have been launched with the aim of have been launched with the aim of combatting the stigma of mental illness.

combatting the stigma of mental illness.

These include the Mind campaign entitled These include the Mind campaign entitled

`Respect', the ongoing World Psychiatric

`Respect', the ongoing World Psychiatric Association Campaign Against the Stigma Association Campaign Against the Stigma of Schizophrenia Worldwide and the of Schizophrenia Worldwide and the Royal College of Psychiatrists' campaign Royal College of Psychiatrists' campaign

`Changing Minds: Every Family in the

`Changing Minds: Every Family in the Land'. Each of these aims to raise public Land'. Each of these aims to raise public awareness of the essential humanity of awareness of the essential humanity of people with psychiatric problems and the people with psychiatric problems and the need to integrate them into society instead need to integrate them into society instead of excluding them on account of their of excluding them on account of their

`otherness'. However, none of these

`otherness'. However, none of these campaigns focuses on educating the public campaigns focuses on educating the public and the media about the reality of and the media about the reality of community care.

community care.

Not all of our colleagues are convinced Not all of our colleagues are convinced that closing the psychiatric hospitals was that closing the psychiatric hospitals was the right policy to pursue. When the the right policy to pursue. When the proposed closure of Claybury Hospital proposed closure of Claybury Hospital was announced in 1983, the consultants was announced in 1983, the consultants resisted and refused to allow their patients resisted and refused to allow their patients to be assessed for possible discharge. This to be assessed for possible discharge. This

`strike' lasted for 6 months and then col-

`strike' lasted for 6 months and then col- lapsed, and Claybury closed in 1997. Active lapsed, and Claybury closed in 1997. Active resistance by psychiatrists has ceased but resistance by psychiatrists has ceased but there is a general passivity about community there is a general passivity about community care when what is needed is advocacy and care when what is needed is advocacy and positive action. Many patients in the positive action. Many patients in the community lead impoverished and aimless community lead impoverished and aimless lives, exacerbated by the lack of gainful lives, exacerbated by the lack of gainful employment and the difficulty of making employment and the difficulty of making friends outside of the circle of providers friends outside of the circle of providers and users of psychiatric services. These and users of psychiatric services. These problems can be solved: Pathfinder NHS problems can be solved: Pathfinder NHS Trust has implemented a policy of employ- Trust has implemented a policy of employ- ing people with

ing people with psychiatric illness, whopsychiatric illness, who

now constitute 10%

now constitute 10% of the Trust's work-of the Trust's work- force. An experimental campaign to educate force. An experimental campaign to educate neighbours about the problems and needs neighbours about the problems and needs of psychiatric patients moving into a of psychiatric patients moving into a sheltered home in their street was successful sheltered home in their street was successful in promoting social inter

in promoting social interaction and friend-action and friend- ships with the new residents

ships with the new residents (Wolff(Wolff et alet al,, 1996).

1996).

A new generation of psychiatrists is A new generation of psychiatrists is growing up who not only have never growing up who not only have never worked in a psychiatric hospital but have worked in a psychiatric hospital but have never seen one! All of us need to accept the never seen one! All of us need to accept the role of `product champions' for community role of `product champions' for community care and, by our actions, to promote the care and, by our actions, to promote the social and occupational integration of social and occupational integration of patients, become more visible in our local patients, become more visible in our local communities now that the protection of communities now that the protection of the asylum walls is no more. Few, if any, the asylum walls is no more. Few, if any, of us would wish to return to the era of of us would wish to return to the era of the asylums and, if we do not undertake the asylums and, if we do not undertake a public relations job of this kind, we a public relations job of this kind, we and our clients are likely to face increas- and our clients are likely to face increas- ingly restrictive mental health legislation ingly restrictive mental health legislation enacted by governments pandering to public enacted by governments pandering to public misperceptions.

misperceptions.

DECLARATION OF INTEREST DECLARATION OF INTEREST Funding for the Team for the Assessment of Funding for the Team for the Assessment of Psychiatric Services was received from the Psychiatric Services was received from the Department of Health and North East Department of Health and North East Thames Regional Health Authority.

Thames Regional Health Authority.

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Craig, T. K. J. & Timms, P.W. (1992)(1992)Out of theOut of the wards and onto thestreets? Deinstitutionalization wards and onto thestreets? Deinstitutionalization and homelessness in Britain.

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Fisher, N., Turner, S.W., Pugh, R.,

Fisher, N.,Turner, S.W., Pugh, R., et alet al (1994)(1994) Estimating numbers of homeless and homeless Estimating numbers of homeless and homeless mentally ill people in north east Westminster by using mentally ill people in north east Westminster by using capture^recapture analysis.

capture^recapture analysis. British Medical JournalBritish Medical Journal,, 308308,, 27^30.

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Hamid,W. A.,Wykes, T. & Stansfeld, S. (1995)(1995) The social disablement of men in hostels for homeless The social disablement of men in hostels for homeless people. II. A comparison with patients from long-stay people. II. A comparison with patients from long-stay wards.

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Leff, A.

Leff, A. (2000)(2000)Clean round the bend ^ theClean round the bend ^ the etymology of jargon and slang terms for madness.

etymology of jargon and slang terms for madness.

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3 8 2 3 8 2

JULIAN LEFF, FRCPsych, Social Psychiatry Section, Institute of Psychiatry, De Crespigny Park, Denmark Hill, JULIAN LEFF, FRCPsych, Social Psychiatry Section, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF,UK

London SE5 8AF,UK

(First received 16 January 2001, final revision 19 April 2001, accepted 23 April 2001) (First received 16 January 2001, final revision 19 April 2001, accepted 23 April 2001)

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3 8 3 3 8 3

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