Introduction

The move to community care

In the United Kingdom, as in other European countries and the United States, there has been a progressive move away from extended mental hospital inpatient care since the 1950s, so that nowadays most people with long-term mental illnesses spend nearly all their lives in the community (Chapter 14). More than 100 000 people disabled by long-term mental illnesses were estimated to be living in the community in England by 1986 (Department of Health and Social Security (DHSS), 1987) and the number is likely to have increased since then with further hospital closures.

Despite advances in treatment however, many mentally ill people still require support on a long-term basis (Chapters 16 and 18). For all their faults, the old asylums did at least provide patients with reliable food and shelter and the immediate support of trained nursing staff and psychiatrists. Outside hospitals such support is more difficult to deliver and by the 1990s there was serious concern in the UK that long-term mentally ill people might not get the continuing care they needed in the community. Researchers found that many disabled former residents of long-stay wards, with active symptoms, were living in hostels unsupported by psychiatrically trained staff (Marshall, 1989); a third of destitute men on the streets of inner London were found to be suffering from hallucinations and delusions (Weller et al., 1989); and a disproportionately high percentage of men with schizophrenia was found among those in remand prisons (Taylor & Gunn, 1984).