The politicians take over the asylum

Nicholas Timmins examines whether the Government's new approach to care for the seriously mentally ill will work

"Care in the community" is no longer an accurate description of the Government's mental health policy, Stephen Dorrell, Secretary of State for Health, said yesterday. What we are talking about, he said, is "a spectrum of care".

Thus came the first political recognition of one of the main failings afflicting the care in the community programme: the way it fails to cope with schizophrenics and other seriously mentally-ill patients who need long-term, round-the-clock support. And buried amid the plethora of documents which Mr Dorrell released yesterday - from a hit list of 33 health authorities whose mental-illness plans are not up to scratch, to a proposed Patient's Charter - was the beginnings of an answer: a detailed specification of how to provide 24-hour nursed care in a new form of asylum.

These new asylums will house those who need "close attention day and night", who may, at times, "be a serious danger to themselves and others", and most of whom will remain "ill, dependent, vulnerable and at risk for 10 years or more".

This is a massive step in the right direction. But will it be enough?

Care in the community began its life as an idea almost 40 years ago. The policy was first enunciated by Derek Walker-Smith, a Conservative health minister, in 1959 as part of the changing attitude towards the mentally ill which led to mounting criticism of traditional asylums and the liberalising 1959 Mental Health Act.

New drugs, which allowed effective treatment and symptom suppression, made it possible to imagine that care in the community might work. To that was added a political push delivered by Enoch Powell in his famous "water towers" speech in 1963 in which he called for the torch to be put to the "funeral pyre" of the great Victorian lunatic asylums. These stood "isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside" - places of massed locked wards of more than 100 beds apiece, their air heavy with the stench of the powerful sedative paraldehyde, in a world of strait-jackets and even more straitened resources where, at Banstead in the 1950s, one consultant was responsible for 1,500 patients.

Powell launched a 10-year Health and Welfare Services plan to allow the transition - only for it to founder, unfulfilled, at the hands of successive Labour and Tory governments. None the less the beds in the traditional asylums closed, and at virtually the rate Powell predicted. What did not close, until the late 1980s, was the hospitals themselves. Instead they ran on, the numbers in them depleting and their costs per patient rising, as health authorities struggled to find the cash to create the new services. Repeated pleas for pump-priming funds fell on deaf ears. That was one of the main causes of the failure of parts of the policy in recent years.

The result was an extremely mixed record. Many of the less seriously mentally ill fared well from the closure policy. But among their other failings, the plans made virtually no allowance for the "new long stay" - younger patients, too ill, too dangerous, too vulnerable to survive at home, in a hostel, or with day care and other support.

As the report on Christopher Clunis's murder of Jonathan Zito put it - echoed by other recent inquiries - "if the needs of [this] small group are not met, care in the community will be discredited ... perceived as a policy which has failed. We do not think we can afford to let this happen ... we have no wish to return to the day of locked, impersonal, dehumanising and undignified institutional care."

Allied to the lack of new long-stay homes has been a crisis over secure units for the most disturbed mentally ill. Here cash was provided up-front. But in a little discussed scandal of the 1980s - and before the days of clear line management in the NHS - much of that cash was diverted by health authorities for other uses. Most of the new secure units did not get built. Then in 1992 the Government adopted a humane policy of attempting to place mentally ill offenders in hospital, not prison.

The result is that acute mental-illness beds in hospital, which are meant to treat those who need intensive care for a limited period only, have increasingly been occupied by people who in the past would have been in prison or by those new long-stay patients who really need long-term care. Their numbers have been swelled by the rising tide of mental illness triggered by persistent high unemployment. There has been cash for countless specific initiatives - the homeless mentally ill, for example - but not for these mainstream services.

As a result, many of the "new long-stay" are either blocking acute mental illness beds, living inadequately supported in hostels or stuck in secure facilities such as Broadmoor which their conditions do not warrant. Many others are trapped in a revolving door of admission, discharge and readmission.

Some seriously mentally-ill people have simply slipped through the net altogether. In desperation private secure beds in hospitals scores and sometimes hundreds of miles from patients' homes have been pressed into use. That makes planned care almost impossible. And the Mental Health Act Commission has voiced serious reservations about the quality of care in some of the private units.

Some action has been taken. A pounds 40m programme for which ministers have found the cash should mean a two-and-a-half fold increase in medium secure beds to 1,200 by the end of this year, with a further 300 planned. These will help. But they are not long-term beds for long-stay patients. The answer for them, according to yesterday's announcement, is 24-hour nursed care; small homes for eight to 20 people, and ideally for 12.

We have been here before. Such homes were recommended five years ago by the Department of Health. Relatively few have been provided. The NHS executive estimates 5,000 people in England alone, and maybe more, need such care. Among them, no doubt, will be the Christopher Clunises and John Rouses (see panel, above), but also many more who are a risk only to themselves. On the executive's own figures that implies 400-plus homes at a capital cost of between pounds 275m and pounds 350m - and running costs of between pounds 175m and pounds 250m a year.

Even the executive adds, in the dry words of the civil service, "it is hard to avoid the conclusion that an element of pump priming" - cash up- front to get the new homes built and running while the existing services cope with the present crisis - "will greatly facilitate the transition".

Yet precious little of that is being provided. Of the pounds 95m of "new money" Mr Dorrell announced, pounds 53m is health authorities' funds, some from growth in their budget but some diverted from elsewhere. Of the pounds 20m challenge fund, just pounds 10m is new central government money - the rest authorities themselves will have to find. And pounds 11m is specific grant to local authorities - which will go to mental-illness services, but not to 24-hour nursed care, which the executive says must remain an NHS responsibility and must not be part-funded by social security payments.

There will be other difficulties. Not least will be finding locations for the 400-plus homes needed, the executive's own report recording that "increasingly, it is likely there will be objections from local residents". That will require careful public education and reassurance - including a 24-hour contact number for local residents.

The design of homes must enable staff to keep a watchful eye on the residents. Converting existing houses could lead to compromises that could damage the initiative. So history is in danger of repeating itself. The policy is right, but the practice will fall short because too little is being invested to ensure it happens properly. The story since 1959.

Killings

An inquiry said the police, social workers, psychiatrists, the Crown Prosecution Service, hostel staff and probation service must share the blame for the death of Jonathan Zito, who was stabbed to death by paranoid schizophrenic Christopher Clunis in December 1992. The Clunis case was one of the most influential in forcing a government rethink on community care.

In 1993, John Rous, 49, telephoned police from the Oxford charity hostel where he was being cared for, to warn them that he was going to kill a voluntary care worker. The call was ignored, and Jonathan Newby was later stabbed through the heart by Rous.

Jason Mitchell, 24, was committed indefinitely to a secure mental institution in 1990 after he attacked a church cleaner with a baseball bat. Released after the community care scheme began, he was jailed for life in July 1995 after killing three people, including his father.

Wayne Hutchinson was convicted of manslaughter this February after killing two people and wounding three others. He had been released by mistake from a hospital near his home in Brixton.

Martin Murcell was jailed for life on 15 February after murdering his stepfather and almost killing his mother. The judge ordered an inquiry into the care he was receiving at the time of the murders.

Christopher Clunis: an influential case

Suicides and tragedies

Although murders by mental patients in the community have caused most controversy, there have been far more suicides, and patients coming to harm. In 1984, Ben Silcock was diagnosed schizophrenic. On New Year's Eve 1992 he was seriously mauled by a lion after jumping into its pen at London Zoo. The incident prompted Virginia Bottomley, then health secretary, to order a review of mental health policy.

Although the family of Lorraine Kelly, 31, had requested that she be placed in a secure unit, she was able to walk out of a Manchester hospital and commit suicide in 1993. Her body was found in a local canal six weeks later.

Stephen Hext, 21, was voluntarily admitted to Torbay Hospital as an in-patient in December 1993, and was later sectioned. On 15 December, he fell to his death from the roof of a local multi-storey car-park after being given permission to go out.

Graham Close's body was found at his home five weeks after he died of a drug overdose. Social services withdrew help from him in 1994 fearing that he was too dangerous to visit.

In 1995, Valerie Goldingay, 53, threw herself from a tower-block eight hours after being refused admission to a psychiatric hospital in Edgbaston. She had a history of attempted suicide.

Lorraine Kelly: her body was found in a canal

The sums that don't add up

The Government estimates England needs 5,000 places for 24-hour nursed care in homes, ideally of 12 places each. It needs 416 homes.

Based on a 20-place home outside London, the capital costs work out at about pounds 55,000 per place, including pounds 175,000 for land, pounds 675,000 for buildings, pounds 118,000 for fixtures and fittings and about pounds 140,000 for other costs. The costs would be higher inside London.

For 5,000 places, the capital cost would be at least pounds 275m, rising to perhaps pounds 350m to include homes in more expensive urban areas.

A home would need about 26 staff, with seven qualified nurses, 12 support workers and six housekeeping staff.

Salaries make up two-thirds of running costs, with the remainder made up by housekeeping, transport, utilities charges and sundries. Running costs work out at about pounds 35,000 to pounds 50,000 per place.

Number of places needed: 5,000

Total capital costs: pounds 275m-pounds 350m

Total running costs: pounds 175m-pounds 250m per annum.

Total start up costs : pounds 450m-pounds 600m

Extra funding available next year: less than pounds 100m

Hospital beds have closed by the thousand. But despite homicides rising, there is little evidence that the mentally ill - who can usually plead diminished responsibility - have caused more deaths in the community