Abstract
For better or for worse, we now practise psychiatry in a post deinstitutionalised era. Nowhere has deinstitutionalisation been more thorough than in Australia. The process is irreversible and we are now left with the task of dealing with the consequences, good and bad. As I commenced this review I had just read two items in Melbourne newspapers. The first reported on an inquiry into homelessness. Neil Buhrich was reported as stating that, in Sydney, 75% of the homeless were mentally ill and 29% had schizophrenia. The second item described an incident at the Flinders Street intersection in central Melbourne where a psychotic man, with a sword, held up traffic for a couple of hours. He believed he was the Highlander, a character from a recent film. Police finally overwhelmed him using pellets, capsicum spray and a dog. A jeering crowd of over 2000 was vastly entertained. I added the clippings to my bulging file of reports of similar incidents and turned to the book with some hope that it would address the problems that current psychiatric services have operating with minimal numbers of acute beds and almost no long-term beds.
Instead, I found myself in something of a time warp. The book focuses on the closure of two large English mental hospitals over a period of 10 years starting in 1985. The Hospitals were Friern and Claybury and were two of six psychiatric hospitals run by the North-east Thames Regional Authority in the London area. The hospitals had large, long-term populations and the preoccupation was on finding appropriate community placement and care for these chronically disabled people. Many had been in hospital for decades. It seemed to me to be describing a process which, in many parts of Australia, was largely undertaken in the 1970s. A few years ago there were approximately 100 beds per 100 000 of the population in the UK. At that time, I was running a Victorian service with around 18 beds per 100 000. I had not had meaningful access to long-term beds for about 15 years. This illustrates how dubiously relevant the experiences of other countries are to our own situation. Incidentally, this has not deterred local health bureaucrats from inviting ‘experts’ from the UK to come to lecture us on how to carry out deinstitutionalization as though it was a task still in front of us.
Nonetheless, the papers collected in this book are not without interest and some relevance. While numbers of hospital beds have declined dramatically in Australia, and whole hospitals have been closed, the process still continues. It was commendable that TAPS (Team for the Assessment of Psychiatric Services) was established to research the exercise. It was also praiseworthy that there were considerable efforts devoted to finding appropriate care for the patients who were discharged. In Australia, discharge planning has varied from good to neglectful. What were their findings?
Around 80% of patients discharged went off to staffed sheltered accommodation. Only 4% lived independently. A range of accommodation options was used providing a spectrum of supervision and support.
By a number of criteria the process was successful. The move from hospital was almost universally popular with patients. The patients achieved real gains in personal autonomy, although these proved difficult to maintain. Quality of life improved on a number of measures. Vagrancy and crime was not a major problem and the death rate was not significantly increased. The patients’ social networks increased in many cases.
Interestingly, the cost of care in the community was ‘marginally but significantly greater than hospital care’. It would appear that there have been considerable savings to state health budgets in Australia from the closure of hospital beds. There has been considerable cost shifting from state to federal budgets, which might result in any savings being illusory. Another good way of saving money on community care is of course to provide very little of it and Australian services have shown considerable expertise in the use of this strategy.
None of these findings are very surprising. It is a comparatively easy task to relocate long-term hospital patients to mini institutions in the community. The problem we in Australia face is how to care for large numbers of chronic patients with persisting active symptoms in the community when they have never had the opportunity to spend more than 3 weeks in hospital. At least long-term patients have had the opportunity to become socialised to one environment: that of the hospital. The new chronic patients have never had that chance. This problem is recognised by some of the authors. There is an understanding expressed that at least some patients cannot be adequately cared for in the community and a consensus that there was, in the UK, a serious shortage of acute hospital beds. The need for an adequate number of long- and short-term beds was one of the six lessons of deinstitutionalization noted by Leona Bachrach in her excellent chapter in which she comments on the American experience of emptying hospitals. Fuller Torrey describes the dark side of this in his book. Out of the Shadows.
This thoughtful book will be of interest to anyone wishing to keep in touch with developments in the UK. It is very much a story of their local experience and, with its focus on local issues such as funding arrangements, of limited relevance to Australia. The research described is careful, thorough and admirable. It is to be regretted that we have missed the chance to research our experience in a similar way.