Care in the community: Ben Silcock's mauling by a lion at London Zoo has highlighted the plight of the mentally ill. Judy Jones examines the theory and practice behind closing psychiatric hospitals

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Why aren't people such as Ben Silcock in hospital?

Some are, but an ever- declining number under the 'care in the community' philosophy that now holds sway among the social and health policy- makers. The philosophy is that mentally ill people should spend as little time as possible incarcerated in hospitals. Only a few will be in hospital as long-term patients; others, the so-called 'revolving door' patients, will be there for short spells when their illness is particularly severe. Much depends on the severity of the illness in the judgement of individual psychiatrists, how easily a hospital bed can be found and what alternative services exist locally. To some extent it hinges on the clout of individual doctors, haggling with fellow health or social services professionals on a patient's behalf.

Can such people be compulsorily detained?

Yes. Under the 1983 Mental Health Act, a person can be detained (or 'sectioned') for varying periods of up to six months before the case has to be reviewed and a detention order renewed. Two doctors must certify that, in their opinion, a person is so ill as to be a danger to themselves or to others. Before 1983, a doctor had virtually unlimited freedoms to detain and treat someone, as mental patients were not considered in law to be capable of giving or withholding their consent.

What proportion of mentally ill people are in hospital?

A small and diminishing proportion of voluntary patients. Probably under 7 per cent of schizophrenics are cared for permanently in hospital.

According to the organisation Sane (Schizophrenia A National Emergency), one in 10 people suffer from a mental illness; one in 100, such as Ben Silcock, have schizophrenia; one in 200, manic depression. In theory, all those who are a danger to themselves or others are compulsorily detained. Detained patients number around 7,200 in England and Wales. About one-third are accommodated in Ashworth, Broadmoor, and Rampton, the top-security special hospitals.

So where are the other mentally ill people?

In the community. A nice homely word, much-loved by politicians. It evokes faded images of responsible folk popping in and out of each other's houses, being neighbourly and supportive, while the kids play hopscotch in traffic-free streets. In reality, 'community' means virtually anywhere that is neither a hospital nor a prison.

Some sufferers can continue to live relatively independently with their illness, either in their own homes or in group homes or hostels, of variable quality, and under some supervision. (Some group homes or hostels are privately run, some are provided by councils or by voluntary organisations, with local authority funding.) For others, 'community' means living a completely isolated existence in a filthy bedsit, or stumbling around the streets, and eating out of dustbins, with no one actually caring how or whether they live. They either cannot get any help or perhaps they reject the only treatment offered. Sometimes it is not so much a case of people falling through the net, as punching a whacking great hole in it with their own fists, in rage, despair or simple confusion.

Who is responsible for them?

The scope for professional buck-passing is almost infinite, given the variety of professionals who are supposed to play a role in their care and, more seriously, the inadequate resources at their disposal.

At present, if someone is living out of hospital but attending psychiatric outpatients' clinics, he or she is under the care of a psychiatrist. Other professionals who may help include GPs, community psychiatric nurses, local authority social workers, voluntary sector social workers and counsellors. But anyone getting useful, long-term and regular support or treatment from two or more of these sources should count themselves lucky.

In many areas, the organisation of services in the community has not kept pace with changes in the philosophy driving central government policy. New legislation, due for implementation in April, is supposed to change this (see below).

How did this situation come about?

Some people never accepted the case for building 'lunatic asylums', as they were called, in the first place. The shift towards more humane, community-based care away from institutional custody had been the dream of some doctors since the big, oppressive Victorian asylums first opened. The opportunity to realise their dream came in the 1950s with the advent of new drug treatments, involving tranquillisers particularly, which could control disruptive behaviour and enable mentally ill people to live normal, or near-normal, lives. In 1957, a Royal Commission concluded that the mentally ill, as well as the elderly, frail and handicapped, should be cared for in their own homes as far as possible. Three years later, Enoch Powell, then the health minister, spoke of his vision of the asylum wards being unlocked and more civilised ways found to accommodate the people they contained. 'For the great majority of these establishments, there is no appropriate future use,' he told the annual conference of the National Association of Mental Health. Although it was another two decades before a single mental hospital closed, large numbers of patients ceased to be permanent residents. The resident population of mental institutions, which peaked at 148,000 in 1954, had dropped to 59,000 by 1990.

In 1991, the Government published a Green Paper which stated its intention to close many of the remaining 90 large mental hospitals in England and Wales by the year 2000. That specific commitment had disappeared by the time the proposals had become a White Paper. But the Government restated its faith in the 'development of locally based services'.

What are these locally based services?

About 5,500 places in private, voluntary or public sector homes or hostels have been made available for mentally ill people in England and Wales since 1980 - a fraction of the places lost in the mental hospitals. The people who fill the gap are mostly relatives. So the vast bulk of community care is not carried out by medical or social care professionals at all. It is done quietly, almost invisibly, by the spouses, daughters or sons of people who are mentally ill.

So have the new policies failed?

It is too early to make sweeping judgements, because so much of the evidence is a mixture of anecdote and estimate.

Some academic studies suggest that patients have benefited. In his recent book, Closing the Asylum, Peter Barham described the encouraging experiences in the late 1980s of 161 former residents of Friern Hospital in north London a year after discharge into supervised group homes in the community. 'Contrary to what some had feared,' he wrote, 'there were no suicides, no one was imprisoned; only three people became homeless. Four were readmitted to hospital because they were dissatisfied with their placements in the community.' The research team recorded a marked increase in the proportion of people who expressed satisfaction with their accommodation one year on - 74 per cent, compared with 17 per cent just before discharge. Within the space of a year, these patients seemed to have developed 'a more independent view of themselves, and demonstrated a reluctance to take medical authority for granted'.

But Barham also quotes studies that have had far more disturbing results. Seventy-four former patients of Tooting Bec Hospital in south London, many of them schizophrenics, were questioned about the support they had received. A year after they were discharged from formal care, half were neither employed nor attending any sort of day services, two-thirds had not seen a social worker in the previous three months, and one-third had seen neither a psychiatrist nor a community psychiatric nurse.

What difference will Virginia Bottomley make?

Any Secretary of State for Health who can get coverage on mental health (not a sexy subject, to use journalists' jargon) in both the tabloid and broadsheet press, and provoke debates on prime-time television and radio about schizophrenia deserves credit. Ben Silcock's mauling in the lions' enclosure at London Zoo was a tragedy for him, but the incident gave resonance to Mrs Bottomley's call for a review of mental health law and practice.

She is questioning whether the law is adequate to deal with people who are not considered ill enough to warrant a hospital bed, who are somewhere in 'the community' and who are refusing to accept treatment that, in a doctor's judgement, they need.

Specifically, she is considering amending the Mental Health Act to enable courts to make compulsory treatment orders for people living outside hospitals. Such treatment would be given in the hope of averting further serious relapses that might otherwise require admission to hospital. This idea has been kicked around by psychiatrists since the mid-1980s, and has already been implemented in America and New Zealand.

But only a few hundred individuals in the UK are thought to be likely candidates for such treatment orders. Consequently, some mental health campaigners say the initiative is a red herring, to divert attention from the paucity of local services for the majority. This may be uncharitable.

But implementation of the Government's new community care legislation is less than three months away. Many predict it will be a disastrous muddle, and say that panic stations have already been activated at the Department of Health.

So what changes in the law will occur in April? ?

Local authorities in England and Wales will be given prime responsibility for arranging care in the community for vulnerable groups. These are not just the ill. They also include the elderly, frail, disabled, mentally handicapped and people with drug and alcohol problems.

In the past, many agencies have been involved in providing and funding services - the departments of social security, environment, and health to name but three. The division of responsibilities has been blurred. In future, the buck will stop with your local director of social services. If your mother needs to go into a nursing home after 1 April, and you think the family will need help with the fees, your family doctor or hospital consultant should still be able to advise on the best course of action, but no longer fix it. Since social services will hold the purse- strings, they will assess her needs and take the final decisions. The social care of the mentally ill will also be provided in this way.

The functions of social services departments will split into 'purchasing' and 'providing' arms, in much the same way as the NHS has been transformed into a managed market. Before, every branch of social services had its own budget. From April, the purchasing side will decide what services are needed and buy them, by making renewable contracts, with the providers of those services.

Where did these ideas come from?

Sir Roy Griffiths, Margaret Thatcher's health adviser, laid the foundations for the legislative shake-up in his report Community Care: An Agenda for Action, published in 1988. It was admired for attempting to reflect the viewpoint of the user, rather than the 'producer' of services. The principle recommendations, that local authorities should become the lead agencies in the provision of care, was enshrined in the 1990 NHS and Community Care Act. The main elements of the legislation, as far as councils were concerned, should have been implemented in 1991. But ministers ordered a postponement because of fears that the costs would push up the poll tax beyond politically acceptable bounds.

Will the change be more expensive?

That depends on how good it is, and what elements you build into the equation. Access to high quality services when you need them is certainly not a cheap option. In the long-term, what will determine the resources we devote to integrating the mentally ill with the supposedly sane majority boils down to political will. The political left, along with a number of mental health organisations, has long feared that once in the hands of Conservative politicians, community care would be transformed into a tool for cutting public spending. No one has seriously challenged the principles underpinning the community care changes, only the adequacy of the resources invested.

The Labour-controlled Association of Metropolitan Authorities says the settlements announced for 1992-93 fall short of the amount councils will need by about pounds 200m overall. Altogether councils will get about pounds 735m for social services, a rise of about 15 per cent over last year to reflect their new responsibilities. This includes a specific grant of pounds 34m for mental illness, a 9 per cent rise on last year's figure. The National Schizophrenia Fellowship says this is nothing like enough to ensure that the Care Programme Approach, which ministers have comprehensively endorsed, can be implemented everywhere. The programme envisages that every person entering the psychiatric support network has a named individual, such as a senior social worker, who will help them procure the services they need.

What happens in other countries?

Even the Government's critics agree that Britain is at the cutting edge of mental health reforms among EC nations and, with the possible exception of Italy, years ahead of others.

The United States began releasing mentally ill people from institutions some 10 or 15 years before Britain did. The results should be a warning. E Fuller Torrey, a research psychiatrist working for the US National Alliance for the Mentally Ill, has written: 'The release of literally hundreds of thousands of sick individuals from state mental hospitals without ensuring that these individuals continue to receive medication, rehabilitation and follow-up care has been one of the great social disasters of 20th- century America.'

He had visited jails in 15 states for a study published last September. He found that nearly one in three jails held seriously mentally ill individuals, who had no criminal charges against them. Most of those who had committed offences were convicted of minor offences such as disorderly conduct. Some people are stuck in prison cells for weeks or months waiting for a bed in a psychiatric institution.

The state of Wisconsin, on the other hand, is widely regarded as a model, which is being imitated in Australia. It practises a policy known as Assertive Outreach. This form of community care involves the Community Treatment Orders that Virginia Bottomley is considering, but much more besides. Hospital beds are available to those who need them but the thrust of the policy is the 'outreach' work carried out by social work and medical professionals. They go out of their way to keep in touch with known vulnerable individuals. Most mentally ill people co-operate with this heavily interventionist approach.

Quite probably, Ben Silcock would have co-operated, too. But, in the British system, it was left to him to decide when he needed treatment and when he should seek hospital admission. In his case - and there are many like him - the only reliable 'community care' came from his father.

(Photograph omitted)

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