Hazel Croft

Past caring

From Socialist Review, No. 174, April 1994.
Copyright © Socialist Review.
Copied with thanks from the Socialist Review Archive.
Marked up by Einde O’Callaghan for ETOL.

Mental illness is increasing dramatically and is connected to other social problems: poverty, unemployment, homelessness. Hazel Croft looks at the provision for care in the community and finds it can often make the problem worse

‘The result is people have been living in degradation and poverty and people like Christopher Clunis are on the streets and they kill people. I am holding Virginia Bottomley accountable for the murder of Jonathan ... It is not enough to make a market out of mental health. These people need care and supervision. You cannot compete when you are dealing with people’s lives.’

Thus Jayne Zito pinned the blame for her husband’s death directly on health secretary Virginia Bottomley’s shoulders. Jonathan Zito was stabbed to death by Christopher Clunis, a diagnosed schizophrenic, in Finsbury Park station in 1992. The case has become symbolic of the scant provision for the mentally ill – just one year on from the introduction of the Tories’ latest inaptly named ‘community care’ policies.

The crisis in mental health provision has reached epidemic proportions. The results of the official inquiry into the Clunis case identified a combination of a shortage of hospital beds, too few doctors, psychiatrists and social workers, inadequate provision of sheltered housing, day centres and other services as the major elements in the tragedy.

The case is just the tip of an expanding iceberg. The Clunis report came within 24 hours of the results of another inquiry which found overcrowding of psychiatric wards in north west London a key factor in the unnecessary deaths of 14 patients. Hospital managers, the report found, were so busy gearing up for trust status, and planning £700,000 cuts in preparation, that they neglected anything other than financial matters. Severe understaffing also meant increasingly inadequate care for the patients. The report stated:

‘We believe that transfer of patients to locked wards, locking of normally open wards, and seclusion of patients are all related to nursing level and would be less frequent if more trained nurses were constantly available ...’

The bed shortage has become chronic. There are currently between 20 and 40 percent more patients than beds in psychiatric wards.

Often patients are shipped to hospitals far away from their homes, friends or families. The Royal College of Psychiatry found cases of severely mentally ill patients being sent to Yorkshire for treatment because no beds were available in London. One patient, transferred between hospitals in London because of ward closures, spent four hours handcuffed in an ambulance waiting to be admitted.

Virginia Bottomley’s measly offer of an extra £10 million for community based mental health provision in London does not come anywhere near addressing the crisis. MIND, the mental health pressure group, estimates that the care in the community programme needs a boost of £300 million at least.

Bottomley’s only answer has been to turn to more repressive measures. Following the case of Ben Silcock – the young schizophrenic man who was mauled by a lion at the zoo last year – Bottomley’s knee jerk response was to push for the introduction of compulsory treatment orders. Even the House of Commons health committee found the idea ‘fundamentally flawed’ and liable to contravene the European Convention on Human Rights. This April Bottomley plans to introduce registers of the most severely mentally ill.

This is a measure which MIND describes as ‘a purely cosmetic exercise ... People are at risk because the current community care system is a sham ... Registers will not stop people becoming desperate when they are attempting to recover from sometimes serious mental health problems with virtually no support.’

Why has the community care programme been such a shambles? Many socialists and workers in mental health welcomed the initial moves to close the big psychiatric hospitals. For many, looking after the mentally ill in the community offers a much more humane option than vast, impersonalised institutions.

Both Tory and Labour governments have advocated community care over the last 30 years. In 1961 Enoch Powell, then minister of health, first mooted plans to phase out the mental hospitals. Partly this was in response to a continuous stream of scandals about the often brutal treatment of patients in the hospitals and partly because of the advent of new drugs. The mass production of these tranquillisers and anti-depressants modified the behaviour of those suffering from schizophrenia and severe depression (although creating a wide range of often quite debilitating side effects).

The old psychiatric hospitals had a deservedly bad reputation. They had the stench of a 19th century Bedlam. Most of them were built between 1811 and 1914 – to take those deemed most insane off of the streets and out of the workhouses. By the turn of this century 83,304 beds existed in such institutions. Often built on the outskirts of towns – out of view of the city populations – these buildings resembled the prisons built in the same era and treatment was more about control and restraint than cure and caring.

By 1955 there were 150,000 people crammed in the hospitals. Conditions were horrific. Beds had almost no space between them and offered little respite or privacy for those who needed it. Many who were not mentally ill were incarcerated there – single mothers, epileptics, people with learning disabilities. Others were there for years and had become so institutionalised they had little chance of coping on the outside.

Absence of any investment exacerbated the problems of dilapidated buildings, poor facilities and low staffing levels. Even in the 1990s horror stories are still emerging with patients on one psychiatric ward reported as having to share toothbrushes and underwear. Since the mid-1950s the hospitals have been emptied at a rapid rate. The closure programme has gathered pace under the Tories. It clearly fits in with Tory attempts to slash health spending. By 1992 the number of people in psychiatric hospitals had shrivelled to 45,100 – more than a 30 percent decrease since 1979. Only 7,000 places in day hospital facilities replaced that loss. In 1991 the Tories saved over £2,000 million through the closure of beds in psychiatric hospitals – more than half of all savings from the whole NHS bed closure programme.

By April 1993 just 89 psychiatric hospitals remained open. Of these there are only 22 for which there are no plans for closure or partial closure this century. Of the hospitals that have been closed only 12 of the sites have yet been sold. Many lie derelict and unused. The BMA reports that the fall in property values has severely upset plans:

‘The NHS capital loans fund, which commenced in 1991, enabled £28 million in the form of bridging loans to be distributed to six regional health authority projects for 1992, allowing them to close down and sell psychiatric hospitals and provide community places for resettled patients. However, a total of 60 applications to fund projects were made.’

The result has been a chasm where there should be alternative care. According to a report published in the Independent:

‘It costs £72 a day to keep a patient in hospital. But there are an estimated 5 million people suffering various forms of mental illness outside the hospitals: we spend just 29p a day on each of them.’

That’s £2.03 a week – massively less than the £390 a week a team from Essex University reckoned would cover comprehensive provision of community care.

The Tories’ real motives are clear. Community care equals cost cutting under a progressive veneer.

The knock-on effects reverberate at every level. MIND estimates that some 15,000 mentally ill people are homeless, living on the streets or in run down bed and breakfast accommodation. One third to one half of people sleeping in direct access hostels have mental health problems. In 1990 the number of people accepted as homeless in London because of vulnerability due to mental distress increased by a massive 75 percent.

The whole premise of the Tory version of community care assumes that relatives and friends can provide a range of services previously offered by the state. But many of these people have no support system, are not in contact with or have no family.

Many discharged into the community are left to fend for themselves. They are released into a community where cash comes before caring and where health, social service and benefit provision are near breaking point.

And it is not just patients released from long stay institutions who are suffering. Many of those who fall through the net are some of the 200,000 patients discharged each year from short stay units. According to a report in Westminster, more than a quarter of those released from short term psychiatric treatment will become homeless.

These are the people, like Christopher Clunis and before him Ben Silcock, caught up in the so called ‘revolving door’ policy, where patients are admitted to hospital for short spells and then speedily discharged. Of those released from short term admissions, one survey in London in 1992 found over 50 percent were unemployed and did not receive any form of day care. The survey found one man who lived in a flat with no electricity, gas or telephone because he couldn’t afford to pay the bills. Most lived on their own rather than with their family.

For those who do care for relatives the burden has become unbearable. Britain has an estimated six million carers – 14 percent of the adult population. Respite is hard to come by. Some 57 percent of all carers who spend more than 20 hours a week caring for someone they live with find they can’t manage to take a break of two days. And 8 percent of carers report that they find it hard to take even two hours off. Half of all carers not surprisingly suffer from long term health problems themselves. According to MIND, ‘It has been estimated that even if only 5 percent of those currently caring for severely disabled relatives gave up, the government would be faced with an annual bill of £324 million.’

What is the solution? Would a return to the old psychiatric hospitals solve the problem – as some of the sensationalised coverage in the media has suggested? Even the Independent on Sunday attacked what it described as the ‘politically correct’ notion of ‘civil rights’ for schizophrenics.

The truth is rather different. The danger of most people diagnosed with schizophrenia isn’t of harming other people but of harming themselves. Some research suggests that people suffering from schizophrenia are 100 times more dangerous to themselves than to others. The suicide rate is as high as 15 percent among schizophrenics and 30 percent suffer serious self-inflicted injuries.

And those diagnosed as schizophrenic are only a small portion of the total number of people suffering from mental health problems, which are as common as heart disorder and three times more likely than cancer. MIND estimates that 20,000 people die every year as a result of such problems – that is four times as many as die in road accidents. Some 12 million people consult their GPs each year with some symptoms of mental illness.

Real help for these people not only requires a huge injection of cash for extra resources for day-centres, counselling and other care. It also means addressing much wider social questions – providing jobs, good cheap housing and the promise of a future.

Mental health problems are often directly related to social conditions. That is why far more workers, and specifically black and women workers, are treated through the psychiatric system. One study found that among those with children at home, working class women were four times more likely than women of other classes to suffer from depression. The poorest and most vulnerable in Tory Britain are suffering the sharp end of Tory cost cutting.

Poverty, bad housing, unemployment and the effects of living in run down inner city areas all effect the likelihood of sleep disorders, phobias, depression, anorexia and bulimia, chronic depression and schizophrenia.

No one wants to see a rerun of the days when those who suffered mental illness were stigmatised by society and cast aside in long-stay institutions. But the Tories’ alternatives have created what one commentator described as a ‘new Bedlam’ – every bit as harsh as the old institutions.

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