In recent years it has become fashionable to decry the policy, initiated in the 1960s and accelerating in the 1980s, of transferring people with long-term mental illness from institutions into various forms of care in the community. Now widely scorned as a policy driven by a convergence between radical anti-psychiatry and reactionary cost-cutting, community care has been blamed for pushing disturbed individuals onto the streets, where, in a number of highly publicised cases, they have killed themselves or other people.
‘Care in the community has failed’ the then health minister Frank Dobson told parliament in 1998, in an opportunist invocation of a popular prejudice. I recall thinking that this was a mean-spirited jibe at all those who, over the preceding decades, had striven to release the mentally ill from institutional confinement. Anybody who ever visited the back wards of the old asylums knows that, whatever the inadequacies of care in the community, it marked a historic advance in the treatment of people with serious mental illness. The glib global condemnation of community care fails to recognise the dramatic improvements in mental health services in recent years, and the range of imaginative initiatives that now exists.
As a GP in Hackney over the past two decades, I have witnessed a transformation in local mental health services. It is therefore a particular pleasure to find that two of Hackney's leading psychiatrists — Mark Salter and Trevor Turner — have produced A Practical Guide to Outdoor Psychiatry, which is informed by the experience of providing community mental health care in one of the country's most diverse and challenging neighbourhoods.1 ‘Keeping patients well’ they write, ‘requires a mix of money and therapeutic skills, a knowledge of social, welfare, cultural and housing arrangements, an awareness of basic medical and medication aspects, and a hard core of commonsense.’ Their book covers all these areas and more, with wit and passion, with a sense of history and a shrewd awareness of the role of politics and the media.
The prejudice that community care is a failure has been nurtured by one public ‘serious incident’ inquiry after another. As the authors acerbically put it, ‘assaults with swords always get the headlines’. The result is the culture of ‘risk management’ and ‘risk assessment’, which the authors regard as ‘the single most pernicious change in the delivery of mental health care in the last 20 years’. They blame ‘the lawyers and the hindsight junkies creaming a living from the random misfortunes that happen to mentally ill people in a complex individualistic and unrealistic society.’
The authors warn that when risk becomes the basic criterion of services, mental health workers ‘essentially become psychological dustcart drivers’. Major resources will be spent on a small number of people deemed (not necessarily accurately) to be a threat, while the vast majority of people who need help, but are not a danger, get overlooked. Furthermore, the risk agenda encourages a resort to coercive legislation (notably in the proposal to introduce preventive detention for those with ‘dangerously severe personality disorder’) and the return to diverse forms of institutionalisation.
Salter and Turner acknowledge that their handbook is written for somebody who does not yet exist — a professional community mental health worker. Still, it makes a valuable contribution by defining the skills, values, and training required by such a worker. I hope the book encourages the emergence of a generic mental health worker, who could give greater coherence to the work of struggling locality mental health teams.
Meanwhile, as GPs will continue to carry out a share of the tasks of community mental health care, Outdoor Psychiatry will be a useful guide, and the optimistic spirit expressed in its final sentence is an inspiration: ‘Our business is unique and wonderful and the journey never ends.’
- © British Journal of General Practice, 2008.
