Overzealous efforts to move mental health care into the community?

Edmund Stubbs, 7 May 2015

There is absolutely no doubt that deinstitutionalising mental health care is the right thing to do. From the 1950s onwards, and especially following the development of psychotropic drugs, patients formerly isolated from the rest of society in psychiatric institutions were ever more regularly cared for and treated in the community, either at home with their families or in various types of supportive accommodation.

This transition, largely justified as a human rights issue, is now complete and has changed the way society cares for patients with severe, chronic mental illness as well as those with developmental cognitive disabilities.

Nowadays, we now strive whenever possible to treat all mental health issues in the community using hospitalisation only as a last resort. As is true for all types of illness, it is believed that the ideal treatment situation is to manage each patient’s condition well at home and thus avoid ‘crisis point’ interventions, which are both costly to our health system and often extremely distressing for the patients themselves.

Nevertheless, occasionally care in the community is not possible or even available, either through a lack of appropriate mental health services or due to the severity of an individual’s condition. In such cases hospitalisation is still appropriate. It is essential that we recognise the needs of these hospitalised patients even though we continue with our efforts to move mental health care back into the community as much as possible.

It should be remembered that of the 1.7 million people who have contact with specialist mental health services, 6% still require to spend time in hospital. There are also 21.7 million hospital outpatient and community contacts associated with mental health each year. This reveals that in spite of the success of community care, there are still around 102,000 people requiring hospital treatment in some form each year.

However, In the ten years between 2001 and 2011 the number of general psychiatric beds have fallen from a little over 3500 to around 2250 and since 2011 there has been a further reduction of 12% in all bed types (including geriatric) allocated to mental healthcare. It is a sobering consideration that since 2012 seven patients have ended their own lives after being told that there was no hospital bed available for them.

Currently, mentally ill individuals in crisis, including adolescents, are too frequently held in police cells until mental health beds become available. In terms of mental wellbeing it seems obvious that a police cell is perhaps the very worst possible place for someone experiencing an acute crisis (although it may keep them safe). Being held in this way, even if only temporarily also creates a stigma of association between mental health and criminal procedures.

Mental illness accounts for 23% of the disease burden in Britain though we currently spend only around 10% of our healthcare budget on this category, and in fact, have recently witnessed a real terms reduction of 1% in general mental health expenditure with a more severe 3.1% reduction in the allocation for older people.

When addressing the issue of mental health, it is worth highlighting the fact that investing in mental health treatment probably pays for itself by preventing the physical health issues that are often linked with or the result of a mental condition. Investment in mental healthcare also proves cost effective by thereby keeping people in work. Currently an estimated £100 million a year is lost through reductions in productivity largely caused by absences from work attributable to mental health issues.

In conclusion, by treating mental illness in the community, the stigma experienced by patients is being reduced, and it is becoming widely accepted as a disease in the same terms as the other illnesses treated by the NHS. Care in the community should not however become a dogma, and should never provide an excuse for the neglect of adequate hospital provision for those experiencing mental illness.

Edmund Stubbs, Healthcare Researcher, @edmundstubbs1