Care in the community

  ‘Any fool can close a mental hospital’ remarked a senior UK health official in the 1980s. He quickly added that the skill was not in closing the hospital but providing alternative care. Recognizable forms of modern community care have been developing since the 1930s – psychiatric day hospitals in Russia, outpatient departments in both the US and the UK, mobile clinics in the Netherlands. However from the 1960s onwards real effort went into community services as an alternative to mental hospitals rather than simply as a complement.

District general hospital units and day hospitals

  The building of small inpatient units either in or alongside local general hospitals stood for the destigmatizing of the mentally ill and the move away from the mental hospital. These units were small, usually 40–100 beds. They catered for acute, short-term patients and could usually rely on the mental hospital for back up. They are an international phenomenon but practice reflects local customs. In the US they embody a strong tradition of general hospital liaison psychiatry; in Germany an academic psychosomatic tradition of psychotherapeutic treatment of physical illnesses; in the UK a mental hospital tradition adapted to more rapid discharge. The Italian reforms insisted on a complete break, substituting tiny, very short-term admission units.

  It is sobering to reflect, however, that in the new expanded Europe over half of psychiatric inpatients are still cared for in traditional mental hospitals with little, if any, real community provision. US practice varies enormously between states, from highly communitybased services to extensive reliance on old mental hospitals. Locating psychiatric units in general hospitals and keeping them small guards against many of the problems of asylums, but they have their own problems, such as being cramped and less tolerant. They may also have difficulties with very difficult patients and usually cannot offer the breadth of activities and treatments of larger units. They are, however, a first essential step out from the asylum into the community.

Community mental health teams (cmhTs) and community mental health centres (cmhCs)

  Breaking the dominance of mental hospitals involved moving services closer to patients. Services needed to be accessible and not too frightening so that patients and families would approach them early for help. ‘Sector psychiatry’ arose to meet the challenge. Asylums took all the patients from a defined catchment area (often a whole county or a city). The sector approach divided this into small manageable areas (40,000–100,000 population) to provide easily accessible, fairly comprehensive care.

  France and the UK led the way in this development. The French ‘secteur’ arose from sociological theory and emphasized crisis intervention. The service was restricted to psychotic patients and remains patchy. The UK approach was more comprehensive but entirely pragmatic, much less theoretical. Local care followed 1950s legislation requiring compulsory detained patients to be offered outpatient follow-up and requiring the involvement of social services. Collaboration was not feasible from distant mental hospitals; linking with social workers and family doctors was only realistic in small neighbourhoods. The sector approach meant psychiatrists and nurses and social workers started working together in teams.

  In the UK this development was made possible by ‘community psychiatric nurses’ (CPNs). These are nurses who work almost exclusively outside hospital, most often visiting psychotic patients in their homes to ensure they carry on with their medicine but also helping to solve day-to-day practical problems. Starting from two in 1953 there are now more CPNs than psychiatrists in the UK. CPNs and psychiatrists working together established multidisciplinary team practice, gradually incorporating social workers, clinical psychologists, and occupational therapists.

  Community mental health teams assess the broad range of mental health problems (from depression to psychosis) and offer treatment in clinics, patients’ homes, day hospitals, and (when needed) as inpatients. They have become the norm throughout Europe and many parts of the world. The Italian reforms most clearly encapsulated this model of care, emphasizing informality, local knowledge, and flexible access.

  Most CMHTs are broadly similar. In Italy and the UK the same team usually looks after patients both in and out of the hospital, but in much of Europe and the US these responsibilities are separate. In some services CMHTs see the whole range of mental health problems; in others they may restrict themselves to severe psychoses. There has been a recent move to replace CMHTs with a range of specialized teams (e.g. for crisis, for long-term support, for first onset patients). While the focus of these teams differs, their practice (staffing, assessment, reviews, etc.) is surprisingly similar.

  CMHTs are not the only model for provision of local services. In the US President Kennedy’s 1963 ‘Community Mental Health Centers Construction Act’ established community mental health centres. These were ambitious, relatively large units aiming to reduce fragmentation of care and provide a range of services including day care, assessment, treatment, outreach, and preventative and educational services for mental health. They were over-ambitious and proved impossible to staff and run and soon contracted to focus on day care and clinics. The model has functioned well in the Netherlands and in some parts of Europe.