Viewpoint: Case highlights drawback to community care

Six weeks ago, I was asked to see an elderly patient who had become very depressed for the first time in her life. Some sorts of depression are varieties of ordinary human experience - understandable or existential misery - but this patient had the sort of delusional misery that comes out of the blue and seems to represent an illness rather than an experience or a reaction.

I left the National Health Service seven years ago. In the late 1970s, I had worked as an NHS psychiatrist. I can't imagine that the NHS hospital ordeal that this patient suffered could have occurred back then.

My patient had health insurance and was admitted to a private hospital. She made a slow response to anti-depressant drugs - so slow that at one stage I thought we might have to consider ECT (electro-convulsive therapy). After a month in hospital, she improved to a point where she was able to make her first short visit home, though the prospect terrified her. At this delicate stage in her recovery, it was discovered that due to a misunderstanding, her insurance, which normally covers up to three months of in-patient treatment, had run out.

As a retired couple, they could not afford to pay for further in-patient treatment and, although the hospital agreed to give them another four days for free, an NHS psychiatric bed had to be found.

I did not expect any difficulties, we had a good 72 hours to find one. It would surely be in her favour that she probably needed to be hospitalised for only another week or two and that she had already saved the NHS the cost of nearly five weeks' in-patient treatment.

I was wrong. Over the next three days I spent several hours on the telephone. No NHS psychiatric bed was available for a patient suffering from severe and unequivocal psychiatric illness. The need for her admission was not questioned. They simply said there were no beds - or rather, that the only bed available was in a ward which only took patients aged less than 65. She was over the limit by several years. Ironically, her local health authority had been using one of London's private psychiatric hospitals for more than a year on a contractual basis to alleviate its NHS bed- shortage problem. But such was the pressure on psychiatric facilities in London that even the private hospitals were full.

This also means that it is now often difficult to find a psychiatric bed in an emergency for a private patient - and that the private hospitals are increasingly populated with precisely the sort of foul-mouthed, chain-smoking, proletarian NHS schizophrenics and psychopaths that the BUPA classes pay heavily to avoid. I would not mind quite so much if the stated determination of Virginia Bottomley, Secretary of State for Health, to keep the streets clear of dangerous psychotics has not led to the bed shortages. If that were the case, there would not be an equally desperate shortage of places in properly supervised hostels for discharged psychiatric patients.

Like many metropolitan psychiatrists, I find it increasingly difficult to believe that the NHS in London is safe in Mrs Bottomley's hands. Community care of the mentally ill is a laudable and achievable aim in compact and stable communities, but it does not work well in large fragmented ones.

At least my patient's case had a happy ending. She improved sufficiently after spending the four extra days in hospital to risk her discharge to out-patient treatment. She should make a complete recovery.

However, an earlier discharge - even a few days - might have severely set back her recovery and cost the NHS, eventually, a lot of money.

Dr Brewer is a consultant

psychiatrist.