CARNAGE IN THE COMMUNITY

Murders by the insane are running at about one

a month. Alasdair Palmer argues that the Government's

own policies have ensured that the killings continue

BAD IDEAS never die. They just get adopted as government policy. No adminis- tration has been more critical of the ideo- logy of the Sixties than the present Government. That decade was certainly responsible for some very silly ideas — but the permissiveness that ministers are so eager to condemn in theory (if not in prac- tice) was not one of them. Far from being attacked by the Government, the Sixties' most lethal ideological legacy forms the backbone of one of its most treasured poli- cies: the closure of mental hospitals, and their replacement by care in the communi- ty for severely mentally ill people. Thomas Szasz, who published The Myth of Mental Illness in 1960, first popularised the idea that there weren't any mentally ill people — there were simply people whose behaviour didn't fit with the established social norms. Trying to treat mental illness, he argued, was like trying to repair a televi- sion when you disliked the programmes being broadcast. The problem with mental- ly ill people wasn't their condition. It was the way they were treated by us. If we changed the way we reacted to them, most of the problems associated with 'mental ill- ness' would disappear.

The view that mental illness was a social problem, not a medical one, fast attained the status of orthodoxy: in Britain, R.D. Laing was its most notorious expo- nent. It was taken up by Mind, the power- ful mental-health pressure group, which still peddles a watered-down version of the doctrine. It led directly to the idea that the first priority was to get the mentally ill out of asylums and on to the streets. In Italy, Dr F. Basaglia, a leader of the 'liberation psychiatry' movement, was so successful in propagating his ideas that in 1978 the Ital- ian government closed down Italy's mental hospitals overnight, releasing their inmates on to the streets. The result was a social catastrophe, a disaster for thousands of mentally ill people, who ended up home- less, abused and, all too quickly, dead. The fad for 'liberation psychiatry' is diminishing. It now belongs to the rubbish heap of discredited ideas. Most psychia- trists now recognise that schizophrenia, the

most common mental disorder — there are around 180,000 sufferers in the UK — is a medical problem, not merely one caused by an 'inappropriate family environment'. It has chemical and probably genetic roots. It can be treated, if not cured, by drugs, and further research into the brain may point the path to a cure. Many schizophrenics — perhaps as many as half — need 24-hour care. They are seriously ill, extremely vul- nerable and utterly unable to cope with the pressures of life 'in the community'. But, though it may have lost whatever feeble intellectual credentials it once had, a belief in 'liberation psychiatry' seems to shape the Government's policy on mental illness now being implemented by the Health Secretary Virginia Bottomley, How else can one explain the policy of throwing seriously ill people on to the streets with- out any help or support? What 'Care in the Community' amounts to is a slow-motion version of what the Italians did overnight in 1978. The effects are the same here as they were there: homelessness, squalor, abuse, an epidemic of suicides — roughly one schizophrenic in seven kills himself — and an increasing number of people murdered by seriously deranged patients who should be in hospital, but either have never been near one or have been discharged in accor- dance with official policy.

Homicides committed by mentally ill individuals are currently running at about one a month. The public first became aware of the problem when Christopher Clunis stabbed Jonathan Zito to death whilst he waited for a tube train on 12 December 1992. The murder resulted in a mass of publicity and an official inquiry, thanks partly to the persistence of Mr Zito's widow, Jayne. Clunis was a schizophrenic with a record of violence. His career is in many ways a memorial to everything that is wrong with community care. He had spent most of his adult life shuttling from one form of temporary accommodation to another. There was never any real evidence that he was suited to living in ordinary society. Every effort to make him live 'in the community' had ended in his committing a serious act of violence. He had stabbed at least two peo- ple, and hit several others, before he killed Jonathan Zito. Yet the inquiry found that `despite the fact that an accurate history is widely recognised to be invaluable in assessing a patient's dangerousness, time and again violent incidents were either minimised or omitted from records, or referred to in the most general of terms in discharge summaries'.

It takes time for the enormity of what is being said here to sink in. Psychiatrists and social workers are making decisions about whether or not to release a patient into the community — but without the facts about whether he has killed or maimed in the past. The failure seems to be systemic, not individual. All of the people involved are participating in a kind of conspiracy to pre- tend that a real and terrible danger does not exist.

The Department of Health, whilst expressing regret that Clunis managed to `slip through the net', stresses that the inci- dent should not be used to undermine the policy of community care, which, in the view of one of its spokesmen, is 'working pretty well'.

That seems a bizarrely complacent atti- tude to take when 17 men and women have been murdered by severely mentally dis- turbed people since Clunis forced a screw- driver through Jonathan Zito's eye into his brain. Hundreds more mentally ill people have committed suicide, or burnt or maimed themselves. Only someone blinded by ideology could see that as evidence of a policy which was 'working pretty well'.

As usual, there is one, very simple, expla- nation for the Government's failure to see the obvious: money. `Community care' promises big savings. Hospitals are expen- sive. They involve large capital and running costs. That is why Mrs Bottomley is attempting to 'rationalise' London's health service by closing institutions such as Bart's. But whereas the closure of a general hospital will produce an outcry and a cam- paign to save it, shutting down a mental institution can be completed without any- thing so embarrassing taking place. The mentally ill are not as telegenic as, say, a sick child called Jennifer. Yet the closure of a single large asylum can save many mil- lions of pounds per year. When expendi- ture in every other area of health care is rising relentlessly, the temptation to cut care for the mentally ill — who don't, gen- erally, vote, don't complain and aren't exactly sympathetic characters — is over- whelming, particularly when you can quote psychiatrists who say that mental illness isn't a medical problem anyway.

It is hard to know exactly how much money has been saved. The Department of Health is cagey about the figures. This may be because it is ignorant. The Government has stopped keeping national records on the number of hospital beds, on the grounds that, in accordance with the policy of community care, monitoring beds is now a local, not a national, responsibility. The Department of Health claims that any money saved from hospital closures goes straight into providing facilities for 'care in the community'. I can find not one psychia- trist who believes that. The Government's own Audit Commission recently attempted to find out whether it was true. It gave up. In the absence of national statistics, deter- mining the fate of the money gathered from the closure of mental hospitals turned out to be an impossible task.

The replacement for hospital beds is `care in the community'. Most communi- ties, of course, do not want to share their facilities with the insane, still less to care for them. Like the Holy Roman Empire, which was neither holy, nor Roman, nor an empire, community care provides neither care nor community for the seriously men- tally ill. The theory is that no bed for the seriously mentally ill is closed without alternative provision which is at least as good or better. That was what Enoch Pow- ell claimed when as health minister he initi- ated the policy of closing long-stay mental hospitals in 1961. As usual with govern- ment initiatives, nothing much happened for about 20 years. It is only since 1988 that hospital provision has started to collapse.

The most profound effect of closures is not on people who have spent a lifetime in mental hospitals; it is on younger disturbed individuals who should be placed in hospi- tals now, but who cannot be because there is no space for them. If Virginia Bottom- ley's promise of replacing hospital beds with 'as good or better' care in the commu- nity were to be kept, what would it involve? For the seriously schizophrenic, it would mean a trained psychiatric nurse 24 hours a day, in sheltered accommodation. It would mean organising activities, social events, work and education. And it would require someone to supervise drug treat- ment and psychotherapy.

That package would certainly provide care, though it is not obvious that it would consist of care in the community. But the most startling thing about it would be the cost. It is not possible to provide such facil- ities for 180,000 people without spending a great deal of money. If it costs a lot to pro- vide them in a hospital — and it does, which is why hospitals are being closed it costs even more outside one, where the economies of scale cannot be applied.

The Government's failure to provide the facilities Mrs Bottomley has promised is distressingly predictable. The easiest way to see it — apart from counting the number of corpses — is to look at the number of psychiatric nurses. Assuming one psychi- atric nurse can look after a maximum of 10 mentally ill patients without having a ner- vous breakdown herself, around 18,000 would be needed to care for the schizophrenics alone. The total number of community psychiatric nurses is actually 3,600. There are no plans to increase that number significantly, let alone by the factor of six which would be needed if the Gov- ernment was to keep its promises. The result is the large numbers of severely mentally ill people now out on the streets, untreated, with no one to care for them or to prevent them from harming either themselves or others. Places in secure units are as short as community nurses. In 1972 the Butler Report recom- mended that there should be at least 1,000 secure beds available for people who were so ill they were likely to be a danger both to themselves and to others. That was accepted as the absolute minimum, the lowest figure possible. Twenty-five years later, there are only 850 secure beds. It represents, at best, half the number actual- ly needed today. Every secure unit has a waiting list. For many, the waiting list is double the number of beds available in the unit. Dr Christopher Thompson, registrar at the Royal College of Psychiatrists, told me that there was enormous pressure on psychiatrists to release patients as a result; `Psychiatrists are being pushed into releas- ing people against their better judgment in order to make way for individuals who have proved themselves to be dangerous by killing or maiming someone.'

The result of that policy is frequently horrific. Paul Butterworth (not his real name), a man in his mid-twenties, is a severe schizophrenic. He was discharged from a secure ward before Christmas, largely because the psychiatrist in charge of his ward desperately needed the bed. Paul seemed to be better, so the doctor made the decision to release him, despite the fact that he was still hearing voices and halluci- nating, and was frightened about what might happen if he was free. It made no difference. The psychiatrist decreed that the community would care for him. The `community' into which he was discharged was his 60-year-old mother, who knew next to nothing about her son's recently devel- oped schizophrenia. None of the medical staff was prepared to tell her about the delusions he had been having. 'Medical confidentiality forbids it,' the psychiatrist explained. It took Paul a matter of days to decide that his mother was the devil. He stabbed her 40 times. She died before any- one knew what had happened.

Paul Butterworth now has a permanent bed in a secure ward. But it took his moth- er's murder to achieve it. The shortage means that currently the only way to guar- antee a place in a secure unit is to kill someone.

Marjorie Wallace, who runs Sane, the charity which provides advice and help for schizophrenics, tells me that she has knowl- edge of scores of cases where severely ill people cannot get admitted to a hospital, even though they tell the psychiatrist that they are aware that they are deteriorating and are frightened that, as they slip further into madness, they may become violent. The Government likes to stress that whilst state-run provision for the mentally ill may have diminished, privately run hostels and homes have mushroomed. Private provi- sion has expanded sixfold in the last ten years, and now accounts for 40 per cent of all residential places for the mentally ill.

Privately run homes for the mentally ill have a chequered history. It was the dis- graceful abuse which took place in such places in the early 19th century — docu- mented with increasing outrage in succes- sive Select Committee Reports in 1807, 1815, 1816 and 1827 — which led to the Victorian state asylum-building pro- gramme. Even the most vigorous apostles of 19th-century free-market liberalism became convinced that lunatics could not be cared for properly by private operators, and that a civilised nation could not leave their welfare to market forces. Human nature has certainly not changed much since 1830, and neither have market forces. What makes the Governrrient think that private provision will be so much better this time round?

`Local authority social services operate a very rigorous inspection and registration process,' explained a jaunty spokesman from the Department of Health. Others do not share the same confidence in either the regulations or local authorities' ability to apply them. Sane called 28 local authorities to ask to see the register of accredited pri- vately owned homes for the mentally ill in their area. Only two authorities claimed both to have such a register, and to know where it was located. None was able to send a copy to Sane. Policing standards in an area in which there may be as many as 400 different homes is enormously difficult, even when the local authority is in the fortunate posi- tion of being aware of exactly where all its registered homes are. Some private care is excellent. But even the Department of Health recognises that not all of it is. 'It was difficult enough to maintain a consis- tent quality of care in the large hospitals,' explains John Mahoney, chief executive of North Birmingham's NHS Mental Trust.

`It's just about impossible to do it when you have patients dispersed in scores of small hostels and homes. The inspectorate can't know what's going on in them all. Even when they do know, it's damn hard to close anywhere down. I can count the num- ber of closures we've had on one hand. I wish that was a testament to the uniformly high quality of care. It isn't.'

Giovanni Ulleri and Katy Jones of Granada TV's World in Action uncovered a horrendous catalogue of abuse in a net- work of homes run by one John Holcroft in Birmingham. Mentally ill people were placed in derelict houses, looked after by totally unqualified staff, whilst Holcroft, who has a conviction for drug dealing, col- lected full benefits — more than £1,000 a week from one hostel alone — for provid- ing them with care. One 'care worker', paid £2 an hour, was in charge of dispensing night and morning medication. The closest he came to having a medical qualification was once having cleaned a hospital corri-

dor. Even when the abuses were brought to the attention of the inspecting authorities, Holcroft's homes were still not shut down.

One reason why the inspectorate is reluc- tant to close hostels is the lack of anywhere to put the people who would lose a roof over their head as a result. Almost anything is better than nothing. The complexity of the benefits system — difficult for any sane person to master, let alone someone suffer- ing from severe mental problems ensures that many mentally ill people are incapable of claiming what they are enti- tled to, living in abysmally deprived condi- tions as a consequence. From there, the downward spiral into more serious and more dangerous forms of madness is more or less inevitable: hence the high body count.

It is interesting to speculate about what would happen in any other area of health care if victims of a disease were deliberate- ly untreated; if there was a 15 per cent mortality rate from a condition where the bulk of the deaths could be prevented if the condition was treated; and if perfectly healthy citizens were being killed as a con- sequence of a failure to ensure that every- one with the illness was properly looked after. The outcry would be gigantic. Gov- ernment policy would be instantly reversed.

It is a testament to the prevalence of stupid prejudice amongst the rest of us that we have allowed the Government to get away with leaving the majority of seriously mentally ill people untreated, and with the idea that it could possibly be a solution to the problem to leave sufferers to fend for themselves. We too have been brainwashed by the ideology which denied that mental illness was a ^ edical problem. It has made it easier for us to ignore sufferers, and to deny that their care is our responsibility. The people who are paying the price for the silliest piece of Sixties libertarianism are the most vulnerable and helpless.

We should get back to the old idea that those with mental problems are ill, and need careful and serious medical attention. Unfortunately, this is not one of the basics to which the Government wants to get back. It would cost too much.