Jeremy Laurance: The truth about care in the community

Mental health may no longer be a Cinderella service, but it enjoys at best third-cousin status
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The Independent Online

A madman hacks a friend to death, fries his brains in butter and eats them. We are even told what brand of butter - a tub of Clover. As stories go, it is irresistible. "Who let out the cannibal?" screamed The Sun. "I ate his brains - lovely," cried the Daily Mirror.

A madman hacks a friend to death, fries his brains in butter and eats them. We are even told what brand of butter - a tub of Clover. As stories go, it is irresistible. "Who let out the cannibal?" screamed The Sun. "I ate his brains - lovely," cried the Daily Mirror.

The kneejerk response is utterly predictable. Community care has failed, say its detractors. Indeed it has failed repeatedly, they allege, citing the litany of killings by mentally ill people that have received similar prominence in the media over the past dozen years.

It is an easy target. Community care is portrayed as some crazy, liberal philosophy dreamed up in the 1960s, the psychiatric equivalent of using flower power to end global conflict, that has left mad axemen walking the streets.

The implication is that we have some alternative ready to hand if only we had the political will and financial clout to implement it. It is called hospital care. But what does this mean? Patients admitted to hospital have to be discharged when they are better - even those who may have committed violence in the past. Unless, that is, we are to return to the Victorian era of life-long mass incarceration in huge, monolithic institutions, which is what I suspect many of community care's most strident critics would secretly prefer.

No, the problem with community care is not that it has failed. It is that it has never been properly implemented. Mental health has come bottom of the league for NHS resources - neglected, forgotten, ignored. True, things have improved in recent years with a substantial real increase in resources and a big expansion of specialist community teams. But compared to a specialty like cancer or heart surgery, mental health does not register. As one professor of psychiatry put it to me, mental health may no longer be a Cinderella service, but it still enjoys at best third-cousin status.

Let us look at a few facts. The most widely repeated myth is that killings by mentally ill people have soared as a result of the community care policy. But there has been no increase in the 40 years that the mental hospitals have been emptying. The murder rate has soared in that time, as we now live in a more violent society, but fewer than one in 10 killings is by someone with a mental illness. As a proportion of all homicides they have diminished. Our view is distorted by the prominence they are given in the media.

But, I hear you protest, community care certainly failed Peter Bryan, the "cannibal" jailed for life on Tuesday, and his victims. Maybe it did - it certainly looks that way - but only the independent inquiry that is now to be held will tell.

Behind this protest, however, lies a more pernicious assumption - that were the mental health services working properly they would, in every case, be able to detect the psychotic state of mind of a person such as Peter Bryan, predict that it could lead to violence, and prompt the necessary intervention to protect him and the public.

This too is a myth. There are 600,000 people with severe mental illness in Britain of whom 1 per cent - 4,000 people - are judged at risk of harming themselves or others. Most are at risk of suicide. The risk of homicide in a person with psychosis is estimated at one in 15,000. No test is sensitive enough and no psychiatrist clever enough to pick up such extremely rare events in every case.

The right response to this is to work to improve the service. The wrong and unacceptable response is to falsely lock up scores of others in hospital, solely on the grounds of their mental illness, because they might commit violence in the future.

The crucial flaw here is to equate mental illness with dangerousness. Thousands of young people drink excessively at weekends and a small percentage commit acts of violence. Some even kill. But no one is suggesting that those arrested for being drunk and disorderly be incarcerated indefinitely in alcohol treatment clinics.

There is no alternative to caring for mentally ill people in the community. We are not going back to the dark ages of the Victorian era. One of the most depressing features of this debate is that those who most vigorously defend the human rights of asylum-seekers, refugees and victims of racial discrimination are quite happy to see mentally ill people locked up for life and their rights ignored.

Instead of attacking community care we should be using its failures to demand more professional and political support and more resources to see that it provides a proper service. We need better mental health care, not some quick-fix change of strategy that will allow us to forget about it again.

There is no other way of caring for people humanely in the modern age than by treating their illness, if necessary in hospital, and then keeping them well while they go about their normal lives. By repeatedly claiming that community care has failed and should be abandoned, we undermine the service and increase the risks to ourselves and our communities.

j.laurance@independent.co.uk

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