When there is nowhere else to go

We all know the dangers of returning the seriously mentally ill to the community. But what of those who are a danger only to thems elves? Liz Hunt reports

"SQUEEK [sic], squeek, squeek Drug trolley, ever closer Through pastel walls minds fragment Silent screams piercing cold bitter hearts Maybe peace of mind is heaven scent [sic] Not found in chemical never never land Nor achieved through current thinking Who can be shocked into reality?

Two-faced patronisation and thin tissues of lies The two-way mirror sneers behind curtains Who speaketh the truth for wretches like I."

Joanne, psychiatric patient.

Joanne arrives on the ward without warning, demanding to see a doctor. Her GP is on holiday, she is having a crisis and so she goes to the only place she knows for help: the acute psychiatric ward where she was once a patient. She is lucid but erratic, unable to sit still for more than a few moments.

She darts up and down the corridor, lighting cigarettes and stubbing them out seconds later. She jokes loudly with patients waiting at the drugs trolley for their morning doses of oblivion, but turns viciously on a nurse she doesn't like. He says there will be a delay while they find a doctor. "Don't bullshit me. I want to see a doctor now," she yells.

Joanne, who is in her thirties, says she used to be a nurse. She is sharp and eager to talk, describing in chilling detail her life as a manic depressive. "My grandmother had it and she brought me up. I think it runs in families. I'm hyper now, I know that, and I just need someone to talk me through it. I'm living on my own ..."

She turns away to continue her pacing about the ward but the need to talk is overwhelming. She comes back to tell me that she is HIV positive. "They think it's drugs. It's not. Look at my arms - there's nothing there. It was my partner. We were together a long time." Then she's gone again, returning minutes later to pull a few scraps of paper out of her bag and show me her poems.

Gail Bayes, nurse co-ordinator on Bewick, the acute psychiatric ward at the Hadrian Clinic (part of Newcastle General Hospital), is resigned to Joanne's appearance this grey winter morning. "Ex-patients often do this; they just turn up from nowhere, demanding to see the doctor because there is no one else. We're not funded to see them but morally we can't turn them away."

Joanne is now slumped in a chair in the smoke-filled sitting room, where a local radio station blares out its own mix of inane chatter. Her eyes are blank, her body still. For the moment she is no longer high.

Community care, that Utopian vision of support for all but the most seriously mentally ill away from dehumanising institutions, was rarely out of the headlines in 1994. Criticism of a policy that had closed down hospitals and homes before there was adequate replacement was widespread: from the agencies left to pick up the pieces to the psychiatrists unable to find places for patients they knew were a risk to themselves and others.

Sir William Utting, a former government adviser, attacked the reality of community care last September. His criticisms were soon echoed by the Royal College of Psychiatrists and the Mental Health Foundation.

Last month the Audit Commission criticised the lack of community-based services, reporting that very few areas have the "seamless service" of care from hospital to community for the mentally ill that was envisaged by the NHS and Community Care Act 1990.The concern is unlikely to diminsh this year.

So far attention has focused on the most seriously ill patients, who have made headlines after attacking or injuring others. But people like Joanne are also a cause for concern, when they fall through the gap between hospital and home.

At times Joanne is well and able to cope. At other times she needs support. It is not always there and the responsibility falls back on the acute ward. John O'Grady, a consultant psychiatrist and divisional manager for mental health services at NewcastleCity Health NHS Trust, would like to admit her for the weekend but cannot take the chance. "There is no flexibility in the system to allow that. Weekends are busy and there are people who may need a bed more urgently ..." The best on offer for Joanne is achat with a senior registrar.

Newcastle has all the problems of other inner cities when it comes to caring for mentally ill people. The Hadrian Clinic serves the west end of the city, where illness thrives on poor housing, unemployment, extensive drug problems and increasing homelessness. The pressure on the acute services is not as great as in London, where bed occupancy rates have hit 140 per cent; in Newcastle it ranges from 96 per cent to 104 per cent - and seriously sick patients are not yet being discharged to make way for thesicker still. But that chance remains.

The Bewick ward has 16 beds that are invariably full; 90 per cent of admissions are emergency referrals from GPs or the casualty department and the average stay is two months. At any one time there are two or three patients who stay on because they have nowhere else to go. Places in a hostel or supported accommodation are at a premium, and the limited day-care facilities are already over-subscribed in this area.

"The need is so great that any developments get swamped," says Dr O'Grady. "Mental health services should be approached from a different route than in-patients."

Newcastle is not short of new ideas in this field. There is the Grange, a pioneering example of community-based care praised by the Audit Commission in its report. A former family home, surrounded by gardens, the Grange provides in-patient care in a non-hospital setting, and home psychiatric care for up to 500 patients who are referred there each year. But the Grange, too, is under pressure and, in the Commission's words, in danger of "filling up with people who have nowhere appropriate to move to".

Then there is the Horticultural Project at The Dene, an old people's home. There gardening as therapy is helping 20 or more ex-psychiatric patients, or "clients" as they are known, to get back into a work environment. Working as volunteers, they have created a garden out of wasteland, and want to expand into a landscaping business and plant sales.

The project is, however, over-subscribed and its future uncertain, although it costs the trust less than £3,000 a year to run. The clients have already lost their share in the minibus. The old people's home that owned it had to sell it. They also need a greenhouse but the chance of getting that is slim.

James, aged 30 - "I'm a Guardian reader, by the way" - has suffered from schizophrenia. He was brought up in the west of Ireland and is full of articulate charm, which suggests an acute and aggressive intellect.

He has worked at The Dene five days a week for a year and now he is conducting his own research into how horticutural therapy can reduce hospital admissions and drug dosage. "Keep somebody's mind active, then there is less time for the psychotic episodes," he says.

Twenty years ago, says Dr O'Grady, a project such as The Dene would have lead to some form of permanent employment for James and the others like him. "My expectations in treating patients then were that we were trying to get them fit for gainful work of some kind. Now there is no chance of that." He believes community care is really very simple. "It is about having a home, something meaningful to do and having contact with someone."

Susan, a young single mother coming to the end of her nine-month stay on Bewick, agrees. She is schizophrenic and hypomanic but not ill enough for long-term care. She is about to step back into that community. The staff worry most about her vulnerabilityto men. "She'll sleep with anybody and often it's the wrong type of person who won't really care for her," says one. On the other hand, it is important for her to be with her child, who is four years old.

The plan is for Susan to move into a flat and live on her own with substantial supervision. It is a gamble but one that might provide Susan and her child with the best quality of life open to them.

Dr Suresh Joseph, a consultant psychiatrist at the Hadrian would be optimistic for their future if he were confident that the resources were there in the short and the long term: "Setting up community service is a major task, which we are only begining to address.

"In principle it would be difficult to find a psychiatrist opposed to it ..." In practice, as the Audit Commission pointed out, without adequate resources and proper allocation, vulnerable people like Susan and Joanne may end up the losers.