Leading Article: Mental illness needs a broader treatment

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The Independent Online
"Mental illness" doesn't exist. No, that is not to recycle some fashionable Sixties nostrum. It is to say we use the phrase to cover a variety of quite different medical conditions responding to no single set of therapies.

Mental illness demands the attention of no one set of professionals. In seven years the schizophrenic Christopher Clunis was seen by four teaching hospitals, three local psychiatric services, one probation hostel, two prisons, five social services departments, one sheltered housing scheme and five bed-and-breakfast placements. Bad enough: but manic depression is as prevalent as schizophrenia; it is just less visible. Up to 30 per cent of those aged 80-plus suffer from dementia, while up to one in five young people suffers from some kind of severe mental problem or disorder. And most mentally ill people spend most of their lives in our midst, in "the community", albeit often out of sight.

All that is to make the point that there can never be a definitive national scheme or system for the treatment of mental illness or the care of the mentally ill. Much more can and should be done to co-ordinate the flow of funds into general health and social services budgets intended to provide for the mentally ill. The care of the mentally ill demonstrates a pathology of government in the UK - "departmentalism" and the refusal of professionals and specialised policy-makers to surrender turf.

Some of that professional rivalry is based on genuine differences of view. In some case histories, there is no single "right answer". What that implies is that the space for experimentation needs to be as broad as possible, so that we can all learn what works. That inevitably means a degree of administrative untidiness. The trick - and cases such as Clunis and Zito demonstrate the human cost of failure - is to preserve space for innovation while ensuring that needy people do not fall through it; to patch together the medical and social services agencies into a seamless whole.

So: community care is dead - long live community care! The high hopes of a decade and a half ago for closing the hospitals and accommodating the mentally ill down the street have evaporated. Realism has dawned. We probably now have too few beds in dedicated psychiatric units and hospitals. But we also know that what matters as much as bed numbers is throughput - that is to say, not allowing patients who do not need residential care to block beds.

Stephen Dorrell's Green Paper is the Whitehall equivalent of wetting a finger and sticking it in the air to see which way the wind is blowing. The Health Secretary's good intentions are not in doubt; a decent and serious man, as well as an ambitious one, he deserves credit for giving the care of the mentally ill his attention - there are few votes in it.

He certainly deserves a more considered response than his shadow was prepared to give him yesterday. Chris Smith has fallen into the trap of reflex reactions to government announcements, always of a carping and critical nature. (Since Gordon Brown's announcement banning additional spending by Labour, Mr Smith really will have to start singing a more convincing tune than the archaic melody that says spend, spend, spend.)

The problem with the Green Paper yesterday was obvious on page one. It was signed by a single secretary of state - yet the core of the problem is that responsibility has to be shared between the domains of government. It ought to have been co-written with the Environment, Employment and Social Security Secretaries as well as the Health Secretary. At least it should have recognised that lack of co-ordination at the centre is part of the reason why "community care" has not lived up to the expectations of struggling families, worried neighbours and angry health professionals. Government passes money to local authorities through a support grant manipulated by the Environment Department, which has too little contact with the Department of Health. Some new arrangement is needed, perhaps a dedicated ministerial task force or a policy agency with a mission to deliver across departmental boundaries.

Those who present themselves to the state as mentally ill need a single and enduring reference in the system, a case worker who stays on the case - who persists. The mentally ill won't worry about whether they are being entered into a Care Programme (what the NHS offers the mentally ill) or receiving Managed Care (how local authority social services define things): what matters is that there is a path that can lead out of medical treatment into a Benefits Agency office and a housing association.

The Green Paper, hedging its bets, offers options for remaking the local commissioning agency for mental illness. One of them - the creation of new ad hoc authorities - is said to be a brainchild of Number 10. Whoever its author, it is a still-born solution. Such an agency would be a creature of central government, but provision for the mentally ill is predominantly a local service, depending as it does on variations in jobs, housing, demography and (not to be forgotten) public attitudes towards mentally ill neighbours.

This is a ferociously complicated subject, which requires sharper government thinking and clearer lines of communication. It is not a popular subject; you will hear few, if any, speeches about it during the election campaign. But it is hugely important to tens of thousands of our fellow citizens and their families. "Mental illness" may not exist as a single category. But the pain, fear and confusion is widespread and under-discussed; and these sufferers have had a rotten deal from the rest of us.