Missing points

In response to an editorial by George Lodge ¹ and a commentary by Helen Killaspy ² I feel, with respect, that the authors have missed two terribly important points. First, that our enthusiasm for community services overcame us and second, that we forgot that admission to hospital can be a very powerful intervention.

The 11th report of the now defunct Mental Health Commission wrote cogently in 2003: ³

‘The systemic relation between hospital and community elements of mental health care make it dicult to determine whether inpatient overcrowding should be addressed by increasing bed numbers or further concentration on community support.’

It also gave information about in-patient care:

‘the number of psychiatric beds has reduced dramatically from a highpoint in the early 1950s… The number of [National Health Service] mental illness beds available to services in England in the last twenty five years (up to 2002)… shows a 40% reduction since the [Mental Health Act] 1983… however, as these figures do not include beds in the independent sector… the available but incomplete data on NHS and independent bed provision [appear] to show that, while the numbers of available beds in NHS facilities fell by around 20% between 1994 and 2001, the overall decrease in bed availability during that period was approximately 5%, once the growth in the independent sector is taken into account… In our view it is appropriate to note that independent sector services, whether profit-based or not, will rise and fall according to the dictates of the market. Given our estimate… that the actual reduction in beds was 5% up to 2000/1… it could be that we have already attained the minimum number of psychiatric beds for a viable service.’

It seems that the road taken was to invest in community services over the following decade, quite commonly at the expense of in-patient care. Now some services are reducing the number of functional teams; few seem to be re-investing in acute in-patient care.

I remain to be convinced that developing community services across multiple functions (or specialisms, if you prefer) or putting these resources in catchment-based teams would solve the issue that most of us (clinicians and patients) have faced sometime painfully recently - where and when might we get a bed? Do not get me wrong, my threshold was high enough, but sometimes admission is the kindest thing.