Bottomley plans new controls on mentally ill: Government proposals to counter community care problems contain no offer of additional resources. Rosie Waterhouse reports

THE GOVERNMENT'S 10-point plan to improve the supervision, control and care of severely mentally ill patients when they are discharged from hospital into the community is a combination of new measures and the reinforcement of existing policy, with no new resources or facilities.

The most important new legal power of supervised discharge orders is similar to proposals for community supervision orders, which were suggested by the Royal College of Psychiatrists in January after Ben Silcock was mauled when he climbed into the lion's den at London Zoo.

Those orders, which would have forced patients to return to hospital for treatment, were rejected by the Commons health select committee last month after lobby groups argued that they were a breach of civil liberties and relied too much on enforcing medication as the only treatment.

However, similar powers are provided by the new supervised discharge orders. The key differences between these and community supervision orders are that the patient will not be compelled to take medication while in the community and will not be automatically sent back to hospital. Instead, if the patient refuses to co-operate with the agreed treatment programme an urgent review will be held, at which doctors, social workers and community psychiatric nurses will decide whether a recall to hospital, where the patient can be compelled to take medication, is the best outcome.

Under supervised discharge, patients would be subject to conditions, including a treatment plan negotiated with them and their carers, and a requirement to attend for treatment.

A named worker would be immediately responsible for the patient's care. He or she must ensure that procedures agreed in advance are followed, and that decisive action is taken if the patient does not co-operate.

Patients will have the right to appeal against the conditions of their discharge to a Mental Health Review Tribunal. Failure to comply with the conditions would lead to an immediate review of the case and, if necessary, the patient could be recalled to hospital by being committed or 'sectioned' under the Mental Health Act.

The supervised discharge orders can only be used for patients detained under the 1983 Mental Health Act, who are a small minority of the estimated 250,000 schizophrenia sufferers and 5 million others who will suffer from manic depressive illness at some time. In 1989-90, 235,100 admissions were made to NHS hospitals under the Act, but only 3,873 (1 to 2 per cent) were compulsorily detained.

Details of how supervised discharge will work in practice and how patients will be forced to return to hospital have not been worked out; the Department of Health is asking for comments by the end of October.

Launching the new package Virginia Bottomley, Secretary of State for Health, said: 'We must not ignore the problem presented by a very small minority of patients whose condition can deteriorate so that they present a risk to themselves or to other people . . . These positive proposals will bring added protection to the public and to mentally ill people, as well as bolstering confidence in the policy . . .'

The package of proposals include:

Strengthened powers to supervise the care of patients detained under the Mental Health Act who need special support when they leave hospital - consisting of the new power of supervised discharge and extending from 6 to 12 months the period when patients given extended leave under existing arrangements can be recalled to hospital - both require legislation.

Publication of the Department of Health team's report of its review of the 1983 Mental Health Act.

Immediate publication of an improved version of the Code of Practice, which spells out clearly the criteria for compulsory admission under the 1983 Act.

Fresh guidance to be published in the autumn to ensure that psychiatric patients are not discharged from hospital inappropriately, and that those who leave get the right support from the different agencies.

Better training for key workers in their duties under the (existing) care programme approach. This will cover the new code of practice and guidance and will take account of the lessons from the cases which have gone wrong, and from the Royal College of Psychiatrists' confidential inquiry into homicides and suicides by the mentally ill.

Other proposals cover better information systems, including supervision registers of patients who may be most at risk and need most support; a review by the Clinical Standards Advisory Group of standards of care for schizophrenics in hospital and in the community; and an agreed programme for the Government's Mental Health Task Force to support moves towards locally based care.

The remaining two points relate to ensuring that the health authority and GP fund-holder purchasing plans cover the essential needs for mental health services; and that the London Implementation Group devises an action programme to help improve mental health services in the capital, identifying and spreading best practice.

Leading article, page 17