The purpose of this essay is to Critically examine an area of Community Care provision in mental health services. ideological, political and legislative frameworks will be taken into account, it will also examine the complex relationships between service user movements, professional bodies and the statutory, voluntary and independent sector services in the delivery of community care it will also identify and justify evidence of good practice in the provision of community care
The system of community care was aimed to maintain the stability of the social order and to address the disparities and inconsistencies within the existing community care discourse. Mental health services became a part of the community care system early in the 17th century. With time, mental health in community care became an effective element of regulating the state of mental health across different population groups. Today, mental health community care is a two-tier system of community services, comprising health care and mental care provided to vulnerable populations in need for treating and monitoring various types of mental health conditions.
The history of community care in the UK dates back to the beginning of the 17th century, when the Poor Law was adopted to make every parish responsible for supporting those who could not look after themselves (Mind 2010). Yet, it was not before the beginning of the 19th century (or 1808, to be more exact) that the County Asylums Act permitted county justices to build asylums supported by the local authorities to” replace psychiatric annexes to voluntary general hospitals” (Mind 2010). In 1879, the UK established the Mental Aftercare Association which worked on a comparatively small scale and focused on personal and residential care of the limited amount of mental ex-patients (Yip 2007). The association was further supplemented with three more voluntary associations that worked on a national scale and provided community care to mental outpatients (Yip 2007). Those organisations included the Central Association for Mental Welfare, the Child Guidance Council, and the National Council for Mental Hygiene (Yip 2007). Later in 1939 the Feversham Committee proposed amalgamation of all four voluntary organizations into “a single system of mental health community care” (Yip 2007). In 1890, the first general hospital clinic for psychiatric patients
Was created at St. Thomas Hospital, while the World War I became the turning point in the improvement of health care facilities in the UK, giving rise to an unprecedented number of asylums and hospital facilities for mentally ill people (Yip 2007).
It should be noted, that the first stages of mental health community care development was marked with the growing public commitment toward institutionalized care: throughout the 18th and the 19th centuries, cure and containment of mental illnesses in the U.K. and in Europe was provided in accordance with the principles of institutionalized care (Wright et al. 2008). The mental health care went in line in the development and proliferation of other institutional solutions, including houses of correction, schools, and prisons (Wight et al. 2008). “The asylums’ rationale, first and foremost, lay in the belief that separation was in the interests of dangerous lunatics, giving them security and maximizing the prospects for cure” (Wright et al 2008). Yet, those who ever appeared within such asylums had only one chance out of three to come out; the majority of mental health patients, regardless of the diagnosis, were destined to stay behind the asylum walls for the rest of their lives (Yip 2007). Medical professionals considered asylums as an effective means to isolate potentially dangerous patients from the rest of the community: asylums and isolation often served an effective way of investigating the reasons and consequences of mental health disturbances (Wright et al 2008). Many doctors viewed asylums and isolation as the sources of effective moral treatment for mentally ill (Wright et al 2008). Only by the beginning of the 19th century did professionals in medicine and social care come to recognize insanity as a mental illness and not as a product of sinful human nature; yet, years would pass before asylum residents would be given a slight hope to release themselves from the burden of isolation and torture (Wright et al. 2008).
With the development of psychoanalysis in the 19th century, mental health became one of the issues of the national concern – supported by the active development of psychopharmacology in the 20th century mental illness was finally explained in somatic terms (Wright et al. 2008). Psychopharmacology promised a relatively safe method of treating and alleviating mental health suffering, while the identity of psychiatry within the medical profession was finally restored (Wright et al 2008). Nevertheless, for many years and centuries, mental health community care remained a by-product of industrialized society development, which, under the pressure of the growing urban populations, sought effective means to maintain the stability of the social order. Because in conditions of the newly emerging economies lunatics and individuals with mental health disturbances were less able to conform to the labor market discipline and more apt to create disorder and disturbance in society, asylums were an effective response to the growing urban mass and the basic for maintain peace and stability in the new industrialized community (Goodwin 2007). The need for maintaining social order was an essential component of the community care ideology, with institutionalization and local provision support as the two basic elements of mental health care provision. Today, the provision of mental health community care services is associated with several issues and inconsistencies; many of the community care complexities that emerged early in the 19th century have not been resolved until today. Nevertheless, it would fair to say that under the influence of the social and scientific development, the provision of mental health community services has undergone a profound shift and currently represents a complex combination of health care and social care aimed to treat and support individuals with diagnosed mental health disturbances.
In present day community care environments, mental health care provision exemplifies a complex combination of health care and social care. The former is the responsibility of the NHS, while the latter is arranged by local authority social services (Mind 2010). It should be noted, that the division of duties between medical establishments, local authorities, and social care professionals has always been one of the basic complexities in the development of mental health care in the U.K. (Wright et al. 2008). In 1954, the House of Commons was the first to emphasis inadequate resorting of mental health community services and to vote for the development of a community-based rather than a closed system of mental health institutions (Wright et al. 2008). Community services proposed by the House of Commons had to be available to everyone who could potentially benefit from them (Wright et al. 2008). As a result, deinstitutionalization became and remains one of the central policy debates within the mental health service provision discourse. “Central to the argument for deinstitutionalization and the development of community-based services is the contention that the prognosis of patients is likely to improve as a result of discharge from mental hospitals, and that people with mental health problems already in community will benefit from remaining there rather than being institutionalized” (Goodwin 2007). Social care providers in England claim that deinstitutionalization represents a new style of service provision and approach to mental illness which is better and more acceptable than traditional remote mental hospitals (Goodwin 2007). Since the beginning of the 1970s, mental health community care was associated with the treatment of mentally ill patients outside the asylums but, unfortunately, deinstitutionalization did not always lead to the anticipated results and is still one of the major policy debates.
The ideology of deinstitutionalization in mental health community care failed and did not improve the provision of mental health services for several reasons. First, deinstitutionalization does not provide mental health patients with an opportunity to reintegrate with their community: being discharged from asylums, many mentally ill patients were transferred to general medical establishments and other facilities, including residential homes – as a result, instead of community living, deinstitutionalization for these patients turned out to be a complex form of deinstitutionalization, while adequate funding of community services was constantly lacking (Wright et al. 2008). For this reason, the practical side of the deinstitutionalization policy proved to be less advantageous for the prevailing majority of asylums residents than it was claimed to be (Goodwin 2007).
Second, the ideology of deinstitutionalization does not improve health outcomes for patients with mental problems. The current state of research suggests that the process of transferring mental health patients from one hospital to another results in negative health consequences and adverse mental health reactions, including significant deterioration of behaviors and greater problems with social activity (Goodwin 2007). The more complex are the issues with transferring mentally ill patients from and into prisons – according to Fawcett and Karban (2007) the process, later called transinstitutionalisation, results in prison overcrowding and the loss of effective psychiatric care for those who are imprisoned. Today, deinstitutionalization as the ideological underpinning of mental health delivery does not work for patients but works against them. It does not improve the state of care provision and reflects in additional costs and adverse health outcomes. Nevertheless, the prevention of unwanted institutionalization is acknowledged as one of the basic principles of care provision (Gladman et al. 2007) and must become one of the basic elements of policy development and provision in community mental health.
The third problem is the lack of outpatient monitoring: the ideology of deinstitutionalization in mental health delivery will not be effective and productive, unless policymakers and social workers have a possibility to monitor the destination of the discharged patients and their live in communities. Throughout the period between 1954 and 1994, the number of mental health hospital beds in the U.K. was reduced from 152000 to 43000 which, according to Wright et al. (2008) did not result in a reduction in the number of people treated. Not with standing that since 1997 the Government is the one solely responsible for the development and implementation of programmes of supervision and control regarding mentally ill patients, the quality of their discharge and monitoring leaves much room for improvement (Lehman 2007). The discharge process itself and the destination of the discharged patients represent the two most problematic areas of community care provision: the discharge process is often poorly planned, while a very little effort is put into monitoring their quality of life beyond asylums (Goodwin 2007). Discharged patients are believed to live and operate in the community, with their families and friends, but the real outcomes of the discharge into community is highly variable (Ritchie & Spencer 2007). Of all patients discharged from mental hospitals, over 45 percent find themselves in residential homes, 7 percent are in locked facilities, and only 22 percent live independently or with their families (Goodwin 2007). The remainder are either homeless or untreated (Morse et al 2007).
Deinstitutionalization in its current form and in the way the government implements it does not make outpatients automatically eligible for social care. In present day community care environments, the four basic measures predetermine the quality of outpatients with mental illnesses lives: sufficient material support, emotional support, sufficient care, and the presence of a well-performing social network within which they must be accepted (Goodwin 2007). These are the basic prerequisites for the successful outpatient reintegration with their
Community. The only problem to be resolved is the need to develop a clear set of criteria, which will define and determine each patient’s right for social care services. Today, according to the basic provisions of the National Service Framework for Mental Health, all mentally ill individuals should have 24-hour access to local social and medical services to meet their needs (Mind 2009). These patients and individuals have the right for their needs to be assessed – based on the results of the needs assessment social care providers will decide whether an individual is eligible for this particular type of social services (Mind 2009).
Finally, deinstitutionalization of care does not provide any opportunity to properly and objectively assess the needs of patients. When developed, the deinstitutionalization ideology in mental health community care implied that all mental health patients would have similar community needs, but the idealistic interpretation of deinstitutionalization is far from reality. Today, needs assessment was and in one of the most problematic aspects of the social care provision for mentally ill. Despite the fact that needs assessment represents and reflects the major policy shift toward better quality of social care provision, social services do not always provide or have an opportunity to fully utilize their service potential and to meet the needs of the mentally ill individuals. According to Mind (2009), needs assessment compromise’s community care assessment, care programme approach assessment, mental health assessment, and carer’s assessment. Yet, there is still the lack of consensus on what constitutes need: social care providers tend to define need as “the requirement of individuals to enable them to achieve acceptable quality of life” and as “a problem which can benefit from an existing intervention” (Thornicroft 2007). It is not clear whether acceptable quality of life is the notion comprehensible to guarantee that all community needs of mentally ill patients are met (Barry & Crosby 2007). More importantly, it is not clear who, when, and in what conditions should engage in the process of needs assessment: do social care providers possess enough education, training, and knowledge to conduct regular assessments? These are the issues which must be resolved to enhance the quality and efficiency of community care in the context of mental health services.
Mental health and deinstitutionalization: still effective
Despite the problems and failures of deinstitutionalization, community care for mentally ill individuals is effective and reliable, given that it leads to reduced social withdrawal, better social functioning, and increased participation in various pro-social activities (McGuire et al 2007). That, however, does not mean that mentally ill outpatients have better opportunities to find a job; rather, they either participate in specially designed workshops or return to the function of a house wife (Prot-Klinger & Pawlowska 2009). Yet, some population groups require additional attention on the side of care providers. For example, in older populations, more than 55 percent of people with diagnosed schizophrenia were never offered appropriate psychological therapies and do not even have any out-of-hours contact number (Parish 2009). As a result, there must be a profound shift toward providing community care based on the need rather than based on the patient age (Parish 2009). People with learning disabilities represent the opposite end of the current problem continuum, and social care providers often either omit or neglect the needs of these patients (Thronicroft 2007). Several essential steps should be made to develop the quality of community care provision for the mentally ill.
First, community care providers must develop a single set of measures as a part of their needs assessment strategy – to make sure that all community care providers operate as one, and use the same criteria of needs assessment in different socioeconomic groups. Second, special attention must be paid to the vulnerable populations that are often overlooked by the community care system, including older patients with mental health problems. Third, the principles of deinstitutionalisation require detailed consideration:
more often than not, patients who are discharged from closed mental health facilities are transferred to other mental health hospitals or smaller mental health departments and wards, while the government’s striving to reduce the number of mental health beds and specialists do not leave these patients any single chance to meet their health and social needs. The groups of patients, who will benefit most from the closure of the mental health institutions, have in many cases fared worst (Goodwin 2007). Finally and, probably, the most important, is that patients who are discharged from mental health institutions should be closely monitored and constantly supported. One of the main goals of the community care is to help out patients successfully reintegrate with their community. The destination of the discharged patients must become one of the social care priorities, and community care providers must engage outpatients in their social network, to ensure that all social and health needs of these individuals are met.