Does the community care?: Diverse provision for the mentally ill brings its own problems, argues Rosie Waterhouse

THE CALLER said she was tired and had had enough. Her counsellor is away. She has to go to a day centre in three days' time, but last time she went there she didn't manage to tell them how bad she was feeling. She needed help now but she had nowhere to turn. She has started to plan how to die. She has stockpiled a cocktail of drugs. She has cried all morning but she is past tears now.

This is an account of a typical call last week from the daily log book kept by staff and volunteers at Saneline, a telephone helpline operated by the charity Sane, which offers information and advice to people suffering from all forms of mental illness, and their families. Set up in April 1992, the helpline answered 45,287 calls in the year up to July 1994. Another 92,002 people tried but failed to get through because all the lines were busy.

The calls to Saneline, which is London- based but launching a nationwide number next month, illustrate graphically the problems facing the increasing numbers of mentally ill people who are being cared for - or not - in the community.

Judging by an analysis of 417 calls to Saneline over three consecutive nights recently, the plight of mentally ill people and their families is desperate. More than half the calls concerned serious psychotic illness such as schizophrenia and manic depressive illness. Almost a quarter of calls were from people suffering from depression. Nearly half talked of the unmet need of the sufferer for medical treatment; nearly 40 per cent concerned a sufferer who was exhibiting violent, aggressive, bizarre or embarrassing social behaviour; one in five callers talked of suicidal feeings.

Sane estimates that one in four people suffer from mental illness at some time in their lives and one in seven have to seek medical treatment. The most common form of serious mental illness - and the one that most frequently makes headlines - is schizophrenia, a disorder which typically develops in late adolescence or early adulthood and affects an estimated 250,000 people in the United Kingdom.

Since the Sixties, successive governments have pursued the policy of closing the old mental asylums and treating more mentally ill people in the community, with care supposedly provided by a combination of health and social services. This week that policy came under renewed fire after a report published by the Royal College of Psychiatrists revealed there had been 34 killings in three years by patients who had been in contact with psychiatric services in the previous 12 months. The researchers blamed lack of co-ordination of support and failure by carers to interact.

The report led to calls for a halt to the hospital closure programme, and demands for more government money to build additional accommodation and employ extra doctors, nurses and social workers to care for this most vulnerable group.

So how have services for the mentally ill changed since the mental hospital closure programme began, and what is going wrong with care in the community?

The decision to close all 130 of the large mental institutions in England by 2000 was announced in 1961 by Enoch Powell, then Minister for Health, in an evocative speech conjuring up menacing images of the asylums which he said had to close. 'There they stand, isolated, majestic, imperious, brooded over by the giant water tower and chimney combined, rising unmistakable and daunting out of the countryside . . .'

By March 1993 only 38 of the institutions had closed, according to a Department of Health study carried out by researchers at Birmingham University's Health Services Management Centre. But they were some of the largest, and the number of beds has dropped from 140,000 in 1960 to 28,000.

However, the survey showed that the number of hospital beds and places in the community for mentally ill people has remained about the same, falling from 92,234 in 1982 to 85,168 in 1992. The latest report, due next month from the Department of Health, shows a slight increase in total beds and places since last year.

What has changed dramatically is the mix of accommodation and level of supervision. As the graphic (above right) shows, the number of beds in the large mental hospitals has fallen from about 68,555 in 1982 to fewer than 28,448 in 1992. The number of psychiatric beds in district general and cottage hospitals has increased slightly from 15,145 to 21,830. Local authority nursing homes appear to have increased their accommodation for the mentally ill from 4,173 beds in 1982 to 7,552 in 1992. However, the researchers are not sure whether the sharp rise in 1986 is because local authorities simply reclassified what used to be beds for the elderly as a new category, the elderly mentally infirm.

By far the biggest expansion has been in the voluntary and private sector. Voluntary residential places have risen from 1,603 in 1982 to 4,303 in 1992 and private places from 764 to 10,382. The number of private hospital beds is up from 1,994 to 12,653.

It is this change in the type of accommodation, and quality and quantity of care for the mentally ill - particularly the more serious cases - which most concerns mental health pressure groups. No national data is available on the level of care or amount of supervision in voluntary and private places. They can vary from bed-and-breakfast hotels and hostels, in which the patients fend for themselves, to private hospitals with 24- hour care, which was provided in the old mental institutions.

The National Schizophrenia Fellowship is calling for an extra pounds 500m a year of government money to build new facilities and employ more staff. A report published by the group this week says that many acute urban psychiatric wards are operating at well above maximum occupancy levels and that at least another 350 medium-secure beds in regional units are needed to meet the Government's own targets.

Despite official figures that show beds and places remaining fairly static at about 85,000, the lack of accommodation has reached crisis point, according to the Institute of Psychiatrists. New guidelines for doctors on how to treat patients with schizophrenia, published this week, said: 'Accommodation, or the lack of it, is a source of anxiety to patients, carers and professionals alike. It underlies much of the breakdown in successful community care for people with schizophrenia and has contributed to some recent tragedies.'

The mental health charity Mind takes a significantly different stance from that of Sane. Mind puts first the rights of patients, and was one of the original campaigners in favour of caring for more people in the community. However, while supporting the principle of the hospital closure programme, Mind is also concerned that community care is not working in practice. It blames in part the professionals, for failing to follow guidelines on co-ordinating a 'care programme approach' for every discharged patient. Sane advocates far stricter controls on the seriously mentally ill who are a burden on their families or a danger. They believe more people need to be detained and treated in hospital. Mind objects to the Government's introduction of supervision registers - partly on civil liberties grounds. However, both would agree that better services in the community are needed.

Marjorie Wallace, a campaigning journalist who founded Sane, accuses the Government of turning the clock back 150 years. She argues: 'Community care can only work if services are available that actually replace those provided by a hospital, and if there is easy access to skilled medical care when a sufferer relapses and can no longer cope.'

Sane's helpline is 071-724 8000.

(Photograph omitted)