Professor Nick Bouras is a Professor Emeritus of Psychiatry at the Institute of Psychiatry, King’s College London and Honorary Consultant Psychiatrist at South London and the Maudsley Foundation NHS Trust. He is currently Programme Director of Maudsley International. Below, Nick gives a brief overview of the developments of community care, concluding with a consideration of ‘Where next?’.Reflections cover 

Deinstitutionalisation has been an essential step forward and community care has had its successes in mental health care. It is time however, to look more on to new ways of thinking, research, training and mental health services planning and delivery.

The process of deinstitutionalisation

The harmful effects of the long stay institutions and asylums were increasingly noted and strongly criticised during the early post Second World War years. Among the influential critics was Erving Goffman with his book on Asylums published in 1961. Goffman illustrated how total institutions strip individuals of their identity and then re-socialise them in the institution’s routines. The criticisms of asylums gained momentum during the 1960’s when American and Western European societies were stunned by the civil rights movement, the Vietnam anti-war demonstrations and the cultural and sexual revolutions. In this context, several policies were devised and relevant bills were enacted in the UK and the USA. Deinstitutionalisation has since progressed vigorously across the world, although more so in some countries than others.

In the UK, Enoch Powell, the then Minister of Health, in his famous “Water Tower Speech” addressed to the National Association of Mental Health Conference in 1961, advocated the reduction of the number of hospital beds and a move towards community care for people with mental health problems. Successive legislation and service planning in the UK reinforced deinstitutionalisation and promoted community care so that today there are almost no long stay state institutions in the country, except for the “High Security Mental Hospitals”.

Many people with poor mental health have had positive outcomes from the change in delivery of mental health care and have been enjoying a better quality of life. Regrettably, despite such positive experiences, the implementation of comprehensive community mental healthcare remains an ideal and not a current reality for all. Expectations that community care would lead to fuller social integration have not been fulfilled and many service users remain secluded in sheltered environments and have limited social contacts and no prospect of work.

The importance of social ideologies

Dominating mental health reforms that have driven deinstitutionalisation have been the social ideologies of normalisation principles, antipsychiatry, patient and carer advocacy, empowerment and more recently the recovery model. Overall, the impact they have had on mental health services and on the care of service users has been profound. One of the problems with social ideologies, however, is that they sometimes conflict with such other standards as evidence and objectivity and this can be a complex issue.

Fortunately, the process of deinstitutionalisation for people with intellectual and developmental disabilities has progressed well compared to that for those with poor mental health. It evolved more gradually and selectively and resulted in less recidivism. Perhaps the fact that it is more difficult to deny the presence of actual disability in this group, compared those with mental health problems, has made the crucial difference in this respect.

Yet challenges remain

Successes of community mental health care notwithstanding, the future development and growth of community mental health care continues to challenge mental health policy and practice. Complex issues have emerged that were not anticipated at the start of the community mental health care: the insufficient number of admission beds; the fact that some service users require a longer and intensive inpatient and rehabilitation treatment; the large numbers of service users sent out of area miles away from their residence and the increase of prison population are all new dimensions but are directly related to community care. All the above have been hampered by financial constraints, reduced budgets and untested management systems.

These are universal issues for mental health care across all countries. In today’s complex landscape of services for people with poor mental health the number of possible interfaces between other services is increasing. Together with existing uneven financing systems, these interfaces are becoming difficult to manage in terms of providing personalised care pathways adjusted to needs of service users, their carers and families.

On a conservative estimate, mental health and neurological problems contribute to 14% of the global burden of disease. The interaction of mental and physical health conditions confirms that there can be no health without mental health. In 2015, the United Nations General Assembly 193 world leaders adopted 17 Global Goals. They pledged to take action to end poverty and inequality and protect the planet, and agreed 169 targets to help them achieve those goals within 15 years. Mental health – Goal 3 is ‘good health and well-being’ – was included in the 2030 Agenda for Sustainable Development (SDG) and aims to ‘ensure healthy lives and promote well-being for all at all ages.’ Target 3.4 is particularly relevant: ‘By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.’ Here, the importance of focusing on mental health is demonstrated, but the challenges remain. We still have little information about either the effectiveness or the cost–effectiveness of many interventions and methods of delivering services in the community. In addition, we continue to lack established methodology for evaluating organisations of mental health systems as a whole.

What next?

Half a century after the introduction of community mental health care it is time to move from the idea of community mental health care to the concept of “meta community mental health care” a concept that I have developed in collaboration with my colleagues Professors George Ikkos and Tom Craig. This capitalises on the successes of community mental health care but equally acknowledges the limitations, including the wide range of complexities that have been experienced in the implementation of community care plans. It is of interest to look back at some of the roots of deinstitutionalisation and the beginning of community care and draw some lessons for the future.

Written by Professor Nick Bouras

Nick has recently released Reflections on the Challenges of Psychiatry in the UK and Beyond, a personal historical chronicle of the last 40 years in psychiatry. It covers the changes and developments modern psychiatry has faced, including deinstitutionalisation, with a particular focus on learning disabilities.
You can find out more about Reflections on the Challenges of Psychiatry in the UK and Beyond here.