Mental health care policy in England: objectives, failures and reforms

For thirty years it has been government policy to shift the balance of mental health care from institutional to community care. But progress towards the objectives of ‘normalisation’ and integration of individuals with a mental health problem in the wider community has been slow. The fragmentation of responsibility and resources for the provision of care in the community has been a major deterrent to the development of services. For this reason, establishing a budget holder with clearly defined responsibility for meeting the needs of individuals with a mental health problem is necessary for more efficient and equitable service delivery. Sir Roy Griffiths (1988) and the Audit Commissions (1986) have suggested that this reform be accompanied by greater competition between the suppliers of services, however, the nature of mental health care rules out significant efficiency improvements from such competition. The evidence presented in this paper shows that the decline in the psychiatric in-patient population, 1976-86, exceeded the development of services in the community. More individuals with a mental health problem now spend a greater part of their life in the community, but for many the quality of life in the community is likely to be poor, given the lack of services available to give these individuals the support they require. Assessing whether the development of community care has been stifled by a lack of resources is difficult because there is no budget for community care that can be examined and data on the expenditure on mental health care are incomplete. Figures presented in this paper show that, so far, resources have not been diverted from in-patient care. Consequently, additional funds must be relied upon to develop new services in the community. The growth of real expenditure on mental health care at £137.5m (13%) 1976/77-1986/87 has probably been insufficient to develop a comprehensive community care service. As savings made by the hospitals lag behind the discharge of patients, there is a strong case for bridging finance in the short term to facilitate the transition to community care. Given the fragmentation of responsibility and resources for the provision of community care, the disincentives inhibiting the development of the service are such that, even if additional resources were available, there is no guarantee that this would result in the development of the appropriate services. The proposal of both the Audit Commission (1986) and Sir Roy Griffiths (1988) to make one authority responsible for meeting all the community care needs of individuals with a mental health problem is essential to the success of the policy. But at present no authority possesses the skills to arrange for both the ‘medical’ and ‘social’ needs of individuals to be met. One solution is to invest in training NHS staff to meet the ‘social’ needs of individuals with a mental health problem, which would enable the NHS to assume the lead agency role. The Audit Commission and the Griffiths Report both advocate the introduction of competition to the provision of care in the community, insisting that the lead agency purchases services from a number of providers and does not act as a monopoly service provider. The expectation is that competition will improve efficiency but it is demonstrated in this paper that a number of the characteristics of mental health care provision are likely to limit efficiency gains from competition.