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HomeNewsNiall McCrae: Fix care in the community or face backlash

Niall McCrae: Fix care in the community or face backlash


With a spring in his step, lecturer Jeroen Ensink left his house to deliver cards to neighbours, announcing the birth of his lovely daughter. Seconds later, his life was over. Femi Nandap, a young Nigerian man in a state of frenzy, had pounced, finding a random victim for a savage knife attack. As another psychiatric patient begins detention in a secure unit, think of Jeroen’s wife, and his only child. Take a few seconds, if you will, before reading on.

Two weeks later, I am at a mental health conference. As usual, there are positive messages about hope, empowerment and eschewal of restrictive practice. Patrick Callaghan of the University of Nottingham, in his abstract ‘myth of mental illness’, asserts: ‘by classifying individuals as risky we are giving the stamp of scientific approval to society’s prejudices and fear.’ Radical scholars and activists have tunnel vision; in their good intentions they deny the danger of severe mental disorder, and overlook the trauma caused by psychotic violence.

Qualifying as a psychiatric nurse in the early 1990s, I was a keen proponent of community care. As author of a history of British mental hospitals, I have no rose-tinted image of those institutions. Unlike the sylvan life suggested by the large grounds and well-tended flowerbeds, many patients languished in gloomy ‘back wards’, where neglect and abuse were allowed to fester. A high proportion of residents were no longer mentally unstable but institutionalised, having lost the will to retain their rightful place in society. A can of worms was opened by a series of scandals in the 1960s and 70s, and patients’ campaign groups identified themselves as ‘survivors’.

Myths around mental health policy persist. In ignorance of the valuable work of community practitioners and support services, a simplistic notion persists: the mental hospitals were closed to save money, and patients have been cruelly abandoned to wander the streets. Sometimes this has a political tone: blame Thatcher. But much of the impetus for care in the community was from the left of the spectrum, as a libertarian claim for rights, freedom and citizenship. Furthermore, with their economy of scale, mental hospitals were cheaper to run.

Community care policy had bad press in the early years, but opposition has declined over the last ten to fifteen years, partly because stigma and sensationalised media reporting have been challenged. However, this success has led to a censorial tendency. Recently a front page of The Sun declared ‘1200 killed by mental patients: shock 10-year toll exposes care crisis’. Cue enragement to this tabloid prejudice. But the figure was real, and each fatality was a mother, father, son or daughter who could be alive today. Professor Simon Wessely of the Royal College of Psychiatrists stated on an ITV documentary last week that the number of incidents is decreasing. But the data suggest the message is managed better than the hazard.

‘Lessons will be learned’ is the usual PR response by health service managers to an inquiry showing the missed opportunities of their services to intervene. Julian Hendy, after the unprovoked killing of his dad in Bristol in 2007, is leading a mission for safer care of the mentally volatile. Examining details of almost a thousand homicides by psychiatric patients, Hendy found the same failings repeated again and again. His words on Jeroen Ensink display his zeal for reform: –

Jeroen was a force for good in the world and was struck down after the birth of a much cherished baby girl. This is another deeply distressing case of an innocent man and young family destroyed by the violent actions of a seriously mentally ill offender.

From a historical perspective, the development of mental health care is not a straightforward linear trajectory from ‘dark ages’ to enlightenment; instead, it is cyclical. In my view, we are approaching ‘peak community care’. Inevitably, the dramatic decline of inpatient facilities will begin to reverse, because evidence is mounting against excessive reliance on community services. At the cutting edge of psychiatry are home treatment teams, which conduct several visits to each patient daily, checking first that he is still alive, and secondly that he takes his medication. But many on these caseloads should be in a safe environment with 24-hour care. This replacement of hospital is a bridge too far.

The bête noire of community care progressives is Marjorie Wallace, who has been fighting a losing battle against hospital closures. In the 1990s, after every adverse incident involving a psychiatric patient, Wallace was on the television news, decrying the policy as a big mistake. While I previously recoiled from her paternalistic attitude, recently I have come some way towards Wallace’s ardent stance. She has not relented, and her argument for more psychiatric beds is becoming more persuasive. The threshold for admission is now so high that only the most disturbed cases get into psychiatric wards; the turnover is so rapid that patients are discharged before they are well enough. Treatment is simply tranquillising medication, with insufficient time or resources for meaningful therapeutic engagement. More dangerously, patients on the cusp of psychotic relapse do not always receive the attention they or their families seek.

Mental health workers argue that money is the problem, yet treating an acutely disturbed patient at home rather than in hospital is an ideological option. This could become another example of counterproductive liberalism: by pushing an idea too far, the ultimate outcome is the opposite of that intended. If fighting stigma is prioritised over safety, a backlash will surely arise. It would be better for policy-makers to turn the corner now, before they are forced to act by a resurgence of public hostility. Tragic incidents cannot always be predicted, but a more robust system is needed. Lives matter.

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