Compulsion can be caring, too: A review of provision for the mentally ill is announced today. Margaret Mervis doubts that it will tackle the key questions

SEVEN months ago Virginia Bottomley, the Secretary of State for Health, promised an urgent review of mental health law following the mauling of Ben Silcock in the lions' den at London Zoo. The resulting legislative proposals, to be published today, were widely leaked last week. They are an attempt to contain public, professional and political disquiet about the tragic and very obvious failures of the community care system in dealing with the seriously mentally ill.

The suggested changes - as reported so far - are, in my view, timid, based on flawed assumptions, costly and probably unworkable. They are fiddling at the edges instead of addressing a major issue with major - and immediate - changes.

The policy of care in the community I wholeheartedly support and actively implement. My argument is with the widely held assumption that almost everyone who suffers from serious mental illness is curable, or at least containable, by medication or therapy, or both. The consequence has become a universal expectation of provision in the community, which is explicit in the NHS and Community Care Act 1990.

This demonstrates the supremacy of the civil liberties lobby, which has strong support in the Royal College of Psychiatrists, some of the charitable support groups, notably Mind, and in the social work profession. This lobby defeated, via the House of Commons Health Select Committee, moves to introduce a Community Supervision Order, which would have allowed the enforced administering of medication when a patient failed to comply with treatment. This would not have been the complete answer, but it would have been an extra useful tool in a pitifully small range of options. I hope Mrs Bottomley will override the select committee's recommendations.

It is regularly said that there are not sufficient resources in the community. Whichever party is in power, there will never be sufficient resources. Mental illness has always been unfashionable for the NHS and councils to spend money on - it will always lose out to more glamorous or high-profile spending demands. But government funding can be effective - if conditions are placed on where and how it is spent.

The suggestion to provide a 'key worker' and a care plan to patients on discharge from hospital sounds attractive. Yet it has no chance of working. The patient's compliance with their plan, which should include being able to make choices about treatment, lifestyle, etc, relies upon the assumption of their continuing mental competence. Add to this the difficulty that lay people have in challenging the decisions of professionals and you have the present unholy mess that is community care for the mentally ill.

I want to propose a different way of delivering community care to the seriously mentally ill. It requires politicians of all parties to accept publicly that there are people with such severe disorders they must never live outside an institution. Into that category fall the criminally insane. You might think there is no argument about this, and yet just two weeks ago we were forcibly reminded that a multiple rapist released, not from prison, but from a top security hospital, had raped and murdered again.

Policy should reflect the reasonable public expectation that we can protect potential future victims, and a recognition that some disorders are incurable and untreatable. The numbers of criminally insane are small, relatively predictable and are not difficult to define. The institutions already exist.

My proposals also relate, however, to two other groups, which are more problematic. They include those whose behaviour can be violent and likely to inflict harm, unpredictably and at random, such as in recent noteworthy cases. Closely allied are sufferers whose behaviour harms themselves, such as Ben Silcock.

I would not argue with present arrangements and plans for community living for the remainder, whose illnesses are containable and who pose no threat to others. Into the latter category would be former patients released from long-stay institutions in supported hostels or small group units and others who need temporary support - medical and social - on their way back to independent living.

The closure programme of old long-

stay mental hospitals must continue. Many are crumbling, isolated, expensive to maintain, and offend all modern principles and expectations for institutional care. No one, least of all the Department of Health, knows how many institutional beds are needed. That is why it is essential to have systematic and public monitoring of psychiatric referrals by local authorities.

Currently, patients are in psychiatric wards either by voluntary admission or by virtue of orders under sections 2 or 3 of the Mental Health Act 1983. When the order ceases, a care plan covering future treatment, together with housing and other requirements, has to be agreed and implemented. Housing is usually provided in council flats. This often creates problems of noise and antisocial behaviour for neighbours and loneliness and social isolation for the person placed there. In some cases, obviously mentally ill people are placed without reference to social services colleagues.

Homelessness is a major problem for those people who cannot observe the normal expectations of community living. We should learn from the experience of 20 years of community care in the United States, where homeless mentally ill people on the streets is commonly cited as proof of the policy's failure.

The current Mental Illness Specific Grant arrangements are due to end in March 1995. I hope these are replaced by a different specific grant available only on a combined application by a local authority and district health authority for jointly commissioned or jointly purchased care arrangements.

Psychiatric patients do not, generally, need hi-tech, medically intensive and expensive hospital beds. Nor could the state ever afford the kind of intensive 'tracking' or 'minding' of individuals by guardians that reports suggest may be proposed today. Guardianship of adults, under the present Mental Health Act 1983, has three basic elements: first, a power of the guardian to direct where the person should live; second, a power to direct treatment; and third, an obligation to be accessible to the guardian.

The system has not been widely used, for good reasons. It requires a continuing recognition of the guardian's authority and a will to co-operate. Unless those drafting additional powers come up with a simple and swift sanction of enforced treatment this regime will remain a toothless tiger. It is 'sectioning' by another name.

It is cheaper, and more humane, to keep people in smaller community- based provision. Such establishments could combine on the same or adjoining sites hospital-type care, some of it secure, hostels, day hospital and day centre provision.

I would like to see these provided and run by the private sector and community trusts - with places purchased by either local or health authorities, GP fundholders or families. The increasingly blurred division between health and social care should be recognised and ended now.

I think this is the best quality, most personalised care in the community we can offer many people with severe mental illness. It requires difficult decisions about loss of choice, and legally sanctioned coercion. These decisions have not been made. The solutions civil servants have come up with are the emperor's new clothes. Those who carry the professional and political responsibility of implementing them should say so.

The writer is chairman of the Social Services Committee, London Borough of Wandsworth.