Appendix A: The British context

The majority of mental health services are offered by the statutory sector, followed by the voluntary sector (Table 1). To date, the commercial sector provides relatively few services, and is concentrated in the provision of individual specialist consultation, housing and a small number of hospitals

Table Al. The structure of mental health services in Britaina

Statutory sector

Primary care (NHS)

Specialist out-patients service (psychiatrists, psychologists, ot, CPNs) (NHS) Social Services

MH teams (PSS)

Income support (SS through PSS) Mental health centres (multi- or uni-disciplinary (NHS and PSS)

Crisis service (NHS, PSS) Home treatment (NHS) Psychiatric wards in general hospital (NHS) Psychiatric hospital (NHS) (PSS -sw input)

Sheltered housing (PSS)

Day care (NHS and Social Services) Employment schemes (PSS) Resettlement teams (PSS)

Users' groups

Relatives' groups (PSS) Outreach projects (PSS and NHS)

Voluntary

Welfare advice Legal advice

Self-help

Drop-in centres MHcentres (ethnic minorities)

Beginnings of sanctuaries

Commercial

Private p.c.

Private Specialists

Psychiatric hospitals

Housing Housing Day care

Employment schemes

Users' groups

Relatives' groups Outreach projects Pressure groups

aNHS: National Health Service; PSS; Personal Social Services

The policy context 185

(which cater either for people with minor mental health problems or those with extremely severe difficulties). However, the table does not tell us about the availability, accessibility, content, quality and variability of these services across the country.

At present (1991) there are 110 Psychiatric Hospitals in the UK, with 190510 admissions in 1987-8 in England (i.e. excluding Scotland and Wales). (This number for admissions should not be confused with the number of people admitted, as some people have been admitted more than once.) There are also psychiatric beds in general hospitals. Out of all admissions, 63% do not last for more than one month and a further 24% are completed within a month (HPSSS, 1990).

Some of the basic social inequalities are reflected in these statistics, namely that proportionally more women and more members of the Afro­Caribbean ethnic minority are admitted across all categories of admission. Of particular concern is the finding that Afro-Caribbean young men are admitted to hospital through the initiative of the police (Rogers and Faulkner, 1987; Barnes et al., 1990; Bean et al. 1991), as this may reflect on the use of admission to deflect assumed but unproven aggression. The more general issue of services meeting the needs and wishes of women and of ethnic minorities will be looked at in the concluding section of the book.

There were 1 603 300 out-patient appointments in 1989-9, and 41 000 Day Hospital attenders. Thus the majority of the British population with mental health problems live outside hospitals for most of the time. Nevertheless two-thirds of the NHS mental health budget (about two billion pounds) is spent on hospitals, and only 2.5% of the personal social services departments is spent directly on mental health services (HPSSS, 1990).

Furthermore, although the number of mental health centres has increased considerably in the last five years, from 20 in 1986 to 150 in 1990 (Sayee, 1990), there are only 150 such centres in the whole country. This provides a rough indication as to the continuing gap between an over-developed hospital sector and an under-developed community service sector.

THE POLICY CONTEXT

Although hospital closure was mentioned in 1963 by Mr E. Powell, the then Minister of Health, as part of the future vision, it was not until1975 that the Ministry decided to fund one pilot project of such a closure. This has become known as the Worcester project (Hall, 1990). It took between 1975 and 1989 to resettle all of the 198 residents of two hospitals (St Wulstan and Powick) into alternative settings, even though new admissions to these hospitals stopped in 1978; this compared with 1000 residents resettled over ten years in Trieste, or 3000 in Turin over a similar period (Del Giudice et al., 1991; Pirella, 1987). The new settings consisted of sheltered accom­modation (primarily hostels), rehabilitation units, day care (in day hospitals and day centres), a new psychogeriatric unit, and an acute intervention unit in the general hospital. A considerable increase in home visiting by nurses

186 Appendix: The British context

took place. The accompanying evaluation has illustrated that ex-patients were satisfied with the change, as were the local GPs. Surprisingly no community mental health centres, or multidisciplinary teams, seem to have been planned as part of the alternatives to hospital care.

Although the Worcester project was researched, the research component did not look at the staff's perspective, that of the community, or the relatives. No mention of the process of closure beyond the different stages has been made, and only the cost of the new services is mentioned, without the calculation of what it would cost to continue with the psychiatric hospital as the core of the services. It remains unclear why it took 14 years to close the two, rather small, hospitals. Tellingly, at the conference convened to mark the final closure this issue was not even raised. Ex­patients were not invited to present their experience of leaving the hospital and their new life in the community. Likewise the voluntary sector was not mentioned. The whole project seems to have been conducted with the intent to supplement hospitalization, rather than search and establish for alternatives to it.

In 1982, the then Minister of Health, Mr N. Fowler, announced that the Government was calling on Regional Health Authorities to decide and plan the closure of large psychiatric hospitals. It was recognized that this would require additional financial resources - especially in the period in which hospital services would continue to operate while those in the community were being established. Joint funding between the health and social ser­vices, and later a 'dowry' system of financing the resettlement of individual long-term residents of the psychiatric hospitals, was made available to meet these needs. The debate as to the feasibility of the funding system, the strings attached, and whether the sums included were/are sufficient continues. An indication of the degree of variability of funding available in different parts of the country is provided by the range of 'dowry' sums, from £11 000 to £22 000 per person.

It was also assumed that Health Authorities would sell closed hospitals sites and re-use the income in community services. With the current slump in the value of such sites, several authorities have been unable to do so, thus closure plans were curtailed accordingly. Nevertheless, from 1991, Health Authorities have to pay a capital tax on buildings that they own. This is assumed to establish a 'dis-incentive' to own buildings.

To date, the closure programmes relate only to people who have been in hospital for more than two years, the so-called 'long-stay' patients, and not to the majority that enters psychiatric hospitals for a short period (the 'acute' patients), even though it is well known that many in this group return to hospital for subsequent admissions and constitute a high-risk group and are likely to become long-term users of mental health services.

It would therefore seem that the Government intended to encourage the closure of large psychiatric hospitals, rather than that of all hospitals,

The legislative context 187

and/ or a restructure of the mental health system. As a direct result of the Government's pressure, 40 hospitals have been earmarked for closure throughout England and Wales, and none in Scotland. Out of these 40 hospitals, only five have already closed. Of the three hospitals described in detail in this book, two are due for their final closure within 12-18 months. It seems unlikely now that the third hospital will close down, even though it is already half empty. Formally the Regional Health Authority argues that it has run out of the money with which to finance the final closure; opposition of senior clinical staff must have contributed to this state of affairs. The situation in the other hospitals due for closure varies too, from those about to close, those in the process and those unlikely to close even though the process began a few years ago. Thus, although each of the hospitals in our study has unique features, the process they share has more similarities than is usually acknowledged by those involved in it.

THE LEGISLATIVE CONTEXT

The closure of psychiatric hospitals does not form a part of the British legislation concerning health and welfare. Likewise, the structure of the mental health services in the community is left to the understanding of each Health District and Social Services department. This state of affairs contrasts with the American legislation on mental health centres in 1963 and the right to treatment in 1980, as well as with the Italian 1978 legis­lation, which allowed the closure of hospitals and the establishment of mental health centres.

There are advantages and disadvantages to an unlegislated system. We need to ask ourselves whether a changing system is helped or hindered by legislation that takes on board the desired direction of change. Legislation provides a stamp of approval and a reinforcement of specific directions, and can prevent or limit the development of other directions. In this case, legislation could potentially encourage or discourage the closure of hos­pitals, the creation of comprehensive services in the community, limit or enhance the power of any of the stake holders in the field of mental health (e.g. administrators, professionals, unqualified care staff, service users, relatives or the general public). There has been no professional or public pressure to legislate in full the change of the mental health service system, but there has been a recent attempt to legislate the right to assessment and a planned package of care prior to discharge. This now forms a part of the new NHS and Community Care Act of 1990, and has been included at the insistence of the relatives, pressure group (the National Schizophrenia Fellowship, NSF) and its supporters in the House of Lords and the House of Commons. It is most doubtful whether this piece of legislation would lead to fundamental changes, as the law is unspecific as to the nature of the

188 Appendix: The British context

assessment, care package, and whose responsibility it is to see the package through and resource it.

The NHS and Community Care Act 1990

Although compulsory entry to hospitalization is legislated in the Mental Health Act 1959 and the Amendments of 1983, the 1990 Act is of greater relevance to 95% of the long-term users of the mental health services, as only 5% are the subject of a compulsory admission. The main components of the act concern:

Purchasing and service provision

Purchasing and providing services in the NHS are to be separate units within each Health Authority. This split is hailed by some as the most important opportunity for the purchasers to establish new mental health services, and by others as a recipe for chaos and a money-only led service.

NHS units as autonomous trusts

Units in the NHS can become autonomous trusts, which have the right to capital revenues, the right to decide on pay to its employees, the right to refuse or offer health intervention to people who live in the catchment area. It is unclear what, if any, obligations they have to the Health District that has established them in the first place.

Trusts are seen by some as a flexible innovation that will benefit all of us and by others as a fragmenting device aimed at the near future privatization of the NHS.

GP budgets GPs can have their own budget, within which they are free to buy services as they choose, but neither have the obligation to explain to their patients the reasons for their decisions, nor to offer equitable treatment to all patients. Until now, GPs could refer people to any specialist treatment, which was also financed by the NHS, and did not have to pay for it. GPs who would not become budget holders are afraid of being given a less preferential treatment within the NHS than those with such a budget.

Quality assurance mechanisms

Quality assurance mechanisms are to be introduced, which will include not only quality assurance officers (already in existing in Health Districts for the last two years) but also the need to consult service users in the evaluation of services, the need to establish a complaints procedure and autonomous inspection units. No one doubts the usefulness of such measures or the justification of emphasizing quality assurance. There are, however, serious doubts as to whether resources necessary for establishing

The legislative context 189

these mechanisms will become available (especially to local authorities) and whether users' views will be taken on board after being collected, as well as how thorough will be the effort to consult users.

Local authority co-ordination Local authorities are to have a lead role in the co-ordination of community care for people with disabilities, including mental distress. While this has been seen as finally accepting that community care is primarily about social care, rather than medical care, there are doubts as to the ability of Local Authorities' services as they are now to provide this care, and whether the resources will become available when the law will be fully implemented. A complicated formula for the resources per capita has appeared in the White Paper (Caring for People, 1988) that led to the legislation and which made it clear that Central Government had no intention of covering the cost in full. It is therefore unclear where the rest of the necessary funding will come from, how easy will be the transfer of resources from the Health Service to the Social Services, and if indeed such transfer is to take place or whether we are likely to see an amalgamation of health and social services in this field proposed in the near future.

Furthermore, although put in the lead role, Local Authorities are instructed to become enablers and overseers rather than direct providers of services.

Individual assessment and care packages People with a disability will have the right to assessment, and to the co­ordination of their individualized care package (known as 'care manage­ment'). However, the following remains unclear: (a) whether every person with a disability will have this right, or only those with a serious disability; (b) who will decide; (c) what redress will exist regarding such decisions; (d) who will be the care managers; and (e) whether they will have a devolved budget or not. Several care management projects have been piloted in Britain since the early 1980s, most of which focused on people with physical disability (Chesterman et al., 1988). A pilot project focused on mental health service users is currently implemented in five districts and is co-ordinated by Research and Development in Psychiatry (RDP). All of these projects have been sponsored by the Department of Health.

The American experience has been variable, and it would seem that everything can take place under the name of care management (Beardshaw and Towell, 1990).

The mental health specific grant For the first time in the history of the mental health services in Britain, a small amount of money has been 'ring-fenced' for the purpose of establishing innovations in this field, no doubt in recognition of the level of

190 Appendix: The British context

need to do so. The sums involved are very small (currently £20 million for the whole country - roughly £120 000 for a county). Projects are run by Local Authorities in agreement with the Health Authorities as from April 1991, and are closely monitored by the Social Services Inspectorate (SSI).

So far it has been heartening to observe the high degree of interest and commitment that this grant has generated, as well as the wide range of initiatives proposed (e.g. mental health services for ethnic minorities, user­run services, alternatives to hospitalization, crisis services, respite care, mental health resource centres). It is too early to know whether the grant will indeed generate the width and depth of innovation that is required for the transformation of the mental health services from a hospital-based core to a community-based core, or not.

While the NHS part of the Act has already been applied since April1991, only the mental health specific grant has been implemented out of the Community Care component of the Act. The rest of this element is to be implemented only from April1993, raising doubts concerning the degree of political commitment to this part of the Act.

THE EMERGING PARTNERS IN THE BRITISH SCENE

Service users During the 1980s, we have witnessed the considerable growth of user groups and user involvement in Britain, analysed by Rogers and Pilgrim (1991). In particular, the voluntary sector (with Mind in the lead role) has taken on board this involvement, encouraging the development of users' participation. Up to now social services trailed behind the voluntary sector, with some interesting and innovative initiatives (Hennelly, 1991). The Health Service seemed to have ignored this development until the application of the NHS part of the 1990 NHS and Community Care Act. Presently there are several examples of new initiatives taken by Health and Social Services authorities to utilize existing users' groups and encourage the formation of new ones, especially as partners to planning and evalu­ation (Barker, 1991; Perring, 1991). 'Top-down' and 'bottom-up' approaches can be discerned (Somekh, 1991). The cynics would doubt how genuine all of this is, arguing that only when power is divested from the formal authorities and the professionals to the users will this move be more than tokenistic.

Relatives

This group too has come to the fore in the 1980s much more than before. The NSF, the only well known relatives' organization, has more than 6000 members. Social services and Mind also have relatives' groups attached to local branches, which provide some support.

The emerging partners in the British scene 191

The NSF has campaigned publicly against the closure of the psychiatric hospitals, together with another pressure group, SANE (Schizophrenia Emergency Campaign). Although the latter has attempted to frighten the general public by a publicity campaign that portrayed people with schizophrenia as dangerous and menacing, there are no signs that the public has accepted these views. While the national newspapers and television continue to portray mostly the failures of community care, rather than its successes in relation to people with mental illness, the general public seems to assume that hospital closure is a reasonable step towards well-resourced community services, and would like the Government to invest more in these services (McKie, 1990). Thus at the political level and that of the general public relatives may get a sympathetic ear, although this does not seem to apply to policy decisions, unlike the situation in the USA.

Care staff

Although the number of care staff has increased considerably in Britain in the last decade as a direct result of hospital closure, the care staff are not a coherent, cohesive or 'heard' group. As suggested in the Introduction, this reflects on its internal and external ambiguous, almost marginalized, position. This, in turn, mirrors the process of being in change, which is where British society is vis-a-vis mental health issues, and people who suffer from mental illness.

The non-statutory sector

This sector has expanded considerably during the 1980s as a service provider, as a direct result of the Government's encouragement. The latter attempted to cut down the statutory sector and replace it by non-profit (voluntary) and for-profit services.

However, while the for-profit sector has expanded primarily in housing provision, the non-profit services have expanded in all directions. This has been the case because there is no profit to be made from most other services in the field of mental illness, with some exceptions such as consultations and hospitalization for people with private health insurance who, for the time being, are a minority in the population.

Yet, paradoxically, the continuation of the expansion of this sector is threatened by the same government that has enticed them to expand. Under the new regulations, the cost of housing is not fully covered by Central Government through its social security arm. Instead, the Government expects Local Authorities and/ or relatives to top up any addi­tions incurred due to inflation, in its attempt to cut down the expenditure on housing. As housing has been the most lucrative area for for-profit agencies, it is likely that a number of them will disappear from an insecure market. This latest twist illustrates nicely the degree of reliability of the for­profit subsector as a service provider for people with mental illness.

192 Appendix: The British context

The non-profit organizations now face a new challenge with the split in purchasing and provision in the NHS and the move to a contract culture in both the NHS and the social services with the introduction of care management programmes. Central Government has also attempted to curtail the campaigning role of the non-profit organizations, arguing that their charitable status excludes campaigning. Such an attempt goes against the grain of the long-honoured tradition of the British non-profit sector, as well as against the interests of the people represented by these organizations.

REFERENCES

Barker, I. (1991) User Views in Purchasing and Contracts. Conference on Effective Consumer Feedback in Mental Health Services, 11th-12th June, RDP, London.

Barnes, M., Bowl, R. and Fisher, M. (1990) Sectioned: Social Services and the 1983 Mental Health Act. Routledge, London.

Bean, P., Bingley, W., Bynore, I., Faulkner, A., Rassaby, E. and Rogers, A. (1991) Out of Harm's Way. Mind Publications, London.

Beardshaw, V. and Towell, D. (1990) Case Management. King's Fund Publications, London.

Chesterman, J., Challis, D. and Davies, B. (1988) Long-term care at home for the elderly: a four-year follow-up, British Journal of Social Work, 18 (Suppl), 43-53.

Del Giudice, G., Evaristo, P. and Reali, M. (1991) How can Mental Hospitals be Phased Out? In: Ramon, S. (ed.) Psychiatry in Transition. Pluto Press, London.

Hall, P. (1990) Closure of the Worcestershire asylums and their replacement by a new community-based service. In: Hall, P. and Brockington, I. (eds.) The Closure of Mental Hospitals. Gaskell, London.

Hennelly, R. (1991) Mental health resource centres. In: Ramon, S. (ed.) Psychiatry in Transition. Pluto Press, London.

Health and Personal Social Services Statistics (1990). HMSO, London. McKie, D. (1990) Mentally Ill Aid Doubted, The Guardian, July 23rd. Perring, C. (1991) Issues from Consumer-Oriented Research, Caring in Homes Initiative,

Department of Government, Brunei University, Uxbridge. Pirella, A. (1987) The implementation of the Italian psychiatric reform in a large

conurbation, International Journal of Social Psychiatry, 33(2), 119-31. Rogers, A. and Faulkner, A. (1987) A Place of Safety. Mind Publications, London. Rogers, A. and Pilgrim, D. (1991) 'Pulling down churches': accounting for the British

mental health users' movement, Sociology of Health and Illness, 13(2), 129-47. Sayee, L. (1990) Community Mental Health Services in Britain: The Pace of Development.

Research and Development in Psychiatry, London. Somekh, D. (1991) A District Strategy. Conference on Effective Consumer Feedback

in Mental Health Services, 11th-12th June, RDP, London.

Index

Administrative culture and conflicts 71-5 dominance of 77-8

Advocacy schemes xxiii, 41-2, 178 Alternative asylums xix, 107, 172-3 Alternative services, constructing

105-9 Anthropological research 123-4 Architectural designs, model 70 Assessment, patients 32-4, 138-42 At-risk registers 176

Barclay Report 53 'Breaking the news' 97-8, 138 Brokerage xx, 178

Camberwell Health District, mental health services, history of 10-11

Camberwell Housing Partnership 25 Camberwell Resettlement Team

characteristics 15-21 establishment 11

obstacles to 12 involvement in other service

developments 41-2 progress review 42-7 Reduction Control Plan 28-9 relations with hospital staff 27-34 relations with medical staff 30 relations with nurses 29-30 relations with other departments

30-1 relations with other resettlement

teams 31-2 responsibilities 12-15 setting up houses 34-9 strategy

development 21-4 impact of complex service system

26-7 implementation 24-5

strengths and weaknesses 16-20 Cane Hill Hospital

decision to close 4-5 final phase of run-down 41 history 5-9 patient assessments 32-4 patient group 27 process of closure 42-3 Reduction Control Plan 28-9 rehabilitation programme 34 relationship with Camberwell HD

mental health services 10-11 staff development 29 strategy for replacement

development 21-4 implementation 24-5

see also Camberwell Resettlement Team

Care, definition 132 Care management 189 Care staff xxiv, 191

group homes 160 induction training 37-8 recruitment 37 relationship between qualified and

unqualified 91 Carers xix

see also Relatives Caring for people 128, 189 Case registers 176 Challenging behaviour 175-7

and placements 40 Change

and loss 145-7 resistance to 148-50 staff responses to 148-51

Chronic patients 57-9 Circles of support 178 Citizens charters 170 Claybury Hospital, see North East

Thames RHA, closure policy

194 Index

Closed facilities xiii, 106 Closure

as a challenge 99-101 doubts concerning xv-xvii fears concerning xv-xvii hopes concerning xviii-xix,

xix-xxii motives for proposing xiv-xv, 51-3,

128-9 objectives 101-4 problem recognition and resolution

162-3 Community, definition 131-2 Community care

coordination by local authorities 188-9

philosophy of 131-2 Community development workers 79 Community living questionnaire 63 Community meetings 32-3 Community mental health centres

70-1, 173-4 Community placements, as permanent

residences 56-7 Community psychiatric nursing 99 Community-based mental health

services 129-31 Compulsory treatment, in the

communty 177 Control 108-9 'Core and cluster' concept 75-6 Cost 43-4

indirect xvii Cost-effectiveness xvii-xviii Culture, definition 124 Cumberlege Report 53

Daycare 174 in group homes 158-60

Decision-making, and the 'administrative culture' 71-5

Defensive arguments 98 Defensive tactics 98-9 De-institutionalization xiv-xv Dependency 141 De-professionalization 171-2 Deviance, sociology of xv Deviant identity xiv

Ethics, professional 86-7 Evaluation of service, by users xxiii Evaluation of services 170--1

Flexibility of services 70--1 For-profit agencies xxv, 191 Friern Hospital, see North East Thames

RHA, closure policy

General practitioners budgets 188 communication with 38

Great Britain, see United Kingdom Griffiths Report 128, 189 Group homes 34, 122, 128, 152, 174-5

continuities with hospital life 157-60 design 35 development project team 35 everyday life in 152-7 high-support 19,40 models of life 161-2 moving in 38-9 purchase 35 residents' perceptions of 162 selecting the residents 35-6 staff recruitment 37 staff training 37-8 visits to 144-5

Grove Project 75-8

High-support house 19,40 Homelessness xvi, xvii Hospitalization, change in pattern of

xiii Hospitals, hierarchical structure 134 Hostels 40 Houses, see Group homes

Illness, as a social role 124-6 Institutionalism 126-7 Institutions, positive/negative aspects

58 Interdisciplinary work 94-6 Intervention

psychological 178 social strategies 178

Italy de-institutionalization policies 50

Index 195

Italy professional reactions to closures

99-101

Job satisfaction, in mental health work 94

Knowledge, professional 86-7

Labelling theory 125--6 Leave-taking 147-8 Legislation 109, 187-90 Life book 178 Life histories 164 Living accommodation, normalization

62-4 Local authorities, and coordination of

community care 188 Loss, and change 145-7

Management committees, users as members xxiii

Medication in group homes 158 use and misuse 177-8

Mental health professionals, sources of ambiguity and ambivalence 91--6

Mental health specific grant 189 Mental health work

attractions of 92-3 interdisciplinary 94-6 job satisfaction 94 and risk-taking 93

Mental illness, as a social role 124-6 Mutual help groups xxiii

National Health Service, reorganizations 53-4

Neighbours, informing 37 Networking 178 NHS and Community Care Act 1990 109,

188-90 NHS trusts 188 Non-compliant clients xvi Non-profit agencies, see Voluntary

organizations Non-statutory sector xxiv-xxv, 191

Normalization xvii, xix-xxii, 13, 21, 60-1,127-8

criticisms of xxii elements 59-60 in living accommodation 62-4 passing system 60-2

North East Thames RHA, closure policy 50-1

challenge of 55--6 and community placements 56-7 conflicts arising 64-81 humanity 54-5 motivation 53-4 reaffirmation of chronicity 57-9

NSF 190 Nursing

as a semi-profession 87 students failing to complete training

89 Nursing staff

conflicts arising out of closure policies 65-6

defence mechanisms 89-90 involvement 79-80 reservations about closures 66-7 responses to closures 99-101 training 137

Occupational therapy, as a semi­profession 87

Open Door policy xiv

Para-professionals 91 Participative model 169-71 Partners, emerging xxii-xxv Patients

assessment 32-4, 138-42 direct contact with 134-5 lack of choice 135 lack of facilities for self-care 136 lack of privacy 135 preparation for leaving hospital

136-8 selection for placement in houses

35-6, 142-3, 163-4 view of ward life 132-4 visits to group homes 144-5 see also Residents; Users

196 Index

Patients' councils xxiii, 104 Placements service 39-40 Politicians, motives for proposing

closure xiv Power, balancing 95-6 Privacy, lack of in wards 135 Private sector 44-5

placementin 39-40 Product champions 74--5 Professional associations, and

construction of alternative services 105-{)

Professional reactions to closure 96-109

available evidence 85-6 Professional staff

implied criticism in closure decision 98-9

learning of closure decision 97-8, 138

responses to change 148-51 Professionalism 86-8, 171-2 Professions

health-related 88-91 see also Semi-professions

Psichiatria Democratica 101, 105 Psychiatric institutions, critiques of

125 Psychiatric technician 106 Psychiatrists

conflicts arising out of closure policies 64--5

responses to closures 99-101 Psychopathy 175-6 Public backlash xix Public consultation 78-9

Quality assurance 188

Rehabilitation 33, 143-5 within the hospital 34

Relatives organizations xxiii-xxiv, 190-1 reactions of 34

Re-professionalization 171-2 Reprovision

facilities 130 planning 49-81

Researchers, users as xxiii Resettlement xiii

see also Camberwell Resettlement Team

Residents consequences of the move for 45-7 grouping 36 perceptions of group homes 162 preparation for re-entering ordinary

life 107-8 visits to houses 36-7 see also Patients; Users

Responsibility 132 Risk-taking

and mental health work 93 risk of 172

rite of passage, leaving hospital as 146-8

Sabotage 99 SANE 190 Secure facilities 173 Self help groups xxm Semi-professions 87-8 Service providers, users as xxm Service provision, models of 43 Sick role theory 125 Social clubs 41 Social control 108-9 Social devaluation 45-6 Social role valorization approach, see

Normalization Social work, as a semi-profession 87 Social work teams 109-12

closure work 112-13 lack of innovation 115-16 marginalization 115-16 members' views on closure 113-15 positive actions 118-19 relevance of closure work 116-17

Social workers, conflicts arising out of closure policies 67-9

Sociologists, motives for proposing closure xiv-xv

South East Thames Regional Health Authority, development of approach to hospital closure 4--5

Specialist units, asylum-type 65 Stigma xiv Support workers, See care staff

Team for Assessment of Psychiatric Services (TAPS) 51

Terminology 179 Total institution xiv, 126-7 Training 37-8, 179-80 Transinstitutionalization 57 Transitions 145-51, 164-5

United Kingdom emerging partners 190-1 legislation 109, 187-90 mental health services 184-5 policy on closures 185-7

United States alternative services 106-7 de-institutionalization policies 49

Index

User-managed services xxii-xxiii Users

collective participation 104 and evaluation of services 170-1 forums xxiii involvement xxii-xxiii, 190-1 see also Patients; Residents

Vision, overall 180-1 Voluntary organizations xxiv-xxv,

160,191 blurring or roles in 73--4 and service provision 130

Wards 172-3 lack of privacy 135 viewed by patients 132-4

Worcester Project 185 Workprogrammes 41

197