Better funding holds key to improved care: ANALYSIS

In the 1960s and 1970s it was hospitals that gave the names to scandals in the care of the mentally ill and handicapped: from Ely to South Ockenden, from St Augustine's to Normansfield.

In the 1990s, it is the names of the victims - both those killed and those who do the killing - that make the headlines: Jonathan Zito and Christopher Clunis, Jonathan Newby and John Rous, William Horsley and Paul Gordon, Bryan Bennett and Stephen Laudat. The list could go on. Thirty since 1991, according to the Zito Trust.

It was the awesome conditions and at times appalling treatment meted out on the closed wards of long-stay hospitals, and the development of new drugs for mental illness, that led to the essentially humane policy of community care. For too many, however, it is clear that it is not working.

Psychiatrists insist it can, but that it won't function effectively with too few resources.

"We all have people who have done violent things in the past, associated with being mentally ill," according to Dr Geoff Searle, a spokesman for the Royal College of Psychiatrists, who is now based in Bournemouth but who has worked in Hackney where Stephen Laudat was treated for a time. "But if we keep all these people in hospital indefinitely, then the hospitals would be jammed solid with people who would in fact be well from the mental health point of view."

But community care can work, even for the seriously mentally ill, Dr Searle said. There are model examples of part or all of a service, in Newcastle, North Birmingham and Peckham. "But many of these units work on staffing levels three and four times those that most people have. The best ones have perhaps 10 patients to each community psychiatric nurse. That allows very close supervision and follow-up. But most places have to cope with 50 patients to each nurse. At that level you simply cannot provide an intensive service"

Meanwhile, in inner cities, mental health service managers say the drift away of the better-off and the concentration of mentally ill patients among them, has left them seriously under-resourced.

In addition, an entirely admirable policy of ensuring that the mentally ill are treated in hospitals, and not prison, has put pressure on medium secure units - beds that provide longer term "asylum" at a level below Broadmoor, for example.

Dr Searle left Hackney seven years ago, "because it was so appallingly bad. You had to throw out people who were very mad in order to admit people who were very, very mad. They are still doing that, having to discharge people who down here I would be admitting. They have got no choice. They should have ten times the resources that I have, and they have probably got about double. It is hardly surprising that there is trouble."

Earlier this year, the chief executives of a dozen inner city mental illness trusts argued that community care, complete with intensive support 24 hours a day, seven days a week, could work. But a pounds 50m investment in pilot projects was needed to prove that - and then more to keep it going. "The problem with community care is not that it has gone too far," Chris Heginbotham, one of the dozen said. "It is that it hasn't gone far enough. To be made to work, it needs more"