Leading Article: No cheer for the mentally ill

AFTER the killings, suicides, misery and destitution that have highlighted serious flaws in the care of mentally ill people, Virginia Bottomley yesterday offered two proposals. The Secretary of State for Health wants to make it easier to readmit problematic ex-patients to hospital. And she is demanding that professionals do a better job looking after those living in the community.

If words were solutions, Mrs Bottomley would have cracked the problem. But there is no extra money for her proposals. So mentally ill people living in bed-sits with little company and no one to care for them should not rejoice too quickly. Not much is going to change for them: no new resources or facilities are planned to meet their needs. Mrs Bottomley has rightly stressed the importance of good discharge, follow-up and supervision procedures, but the Government set out these requirements in 1991 and its calls have had precious little impact on services that cannot cope with demand.

The main development former psychiatric patients can expect is that they are more likely to be readmitted into hospital if they are not taking medication and consequently look as if they will become ill again. But even that is unclear: no more money has been set aside for extra beds and most of the existing ones are full. Perhaps the hospital revolving door will have to revolve a little faster.

So what is going on? Mrs Bottomley is no doubt sincere in her efforts to make community care work. As a former psychiatric social worker, she can appreciate the problems. As a politician, she must be seen to be doing something. But Mrs Bottomley is strapped for cash by the Treasury and can do little more than beg staff to squeeze more out of the system. She is having to 'crisis manage'.

Her crisis centres on how to keep the acutely ill out of harm's way, not to mention the newspapers'. The killing of Jonathan Zito by Christopher Clunis, a paranoid schizophrenic who slipped through the mental health system, is the type of incident Mrs Bottomley is trying to insure against. Less arduous mechanisms for detaining Mr Clunis in hospital might have prevented the tragedy.

To achieve this, she has plumped for 'supervised discharge orders', a new measure that treads a careful line between the demands of some doctors for stronger powers and the fears of civil libertarians. These orders would not sanction compulsory treatment in the community, nor would non-compliance with treatment automatically trigger readmission. But they would allow a doctor to review cases and to put patients back into hospital if they were not taking their medication. Mrs Bottomley, clarifying the 1983 Mental Health Act, has also encouraged psychiatrists to detain people who may be slipping into ill-health, even if they present no danger to others. So at least doctors have a way of keeping seriously ill people off the streets.

However, Mrs Bottomley's plan is unlikely to achieve a great deal more than this. The rest of her proposals, demanding better care in the community, are unlikely to improve anything unless fresh resources are allocated. That would demand more money, which requires a political will to spend in the unfashionable area of mental health. Mrs Bottomley's calculation seems to be that, if she keeps the seriously insane off the streets, the deprived lives of other psychiatric patients will not cause too much political outcry. Such a calculation bodes ill for thousands of mentally ill people who do not represent a threat or require legal detention. For them, Mrs Bottomley has yet to provide solutions.