Can We Manage Without the Mental Hospital?

Objectives: Many developed countries, having invested massively in psychiatric hospitals in the past 150 years, are in the process of dismantling them. The central question is whether this change in the location of care from the psychiatric hospital to district-based services has benefited the patients. The objectives of this review are to examine the evidence on which an answer to the above question might be based. Method: Much of the relevant research comes from the 13-year programme of the Team for the Assessment of Psychiatric Services conducted in London, but other research will be reviewed as appropriate. Results and conclusions: Long-stay, non-demented patients, including the elderly, enjoy a better quality of life in the community homes compared with the psychiatric hospitals. Public attitudes constitute an obstacle to social integration into the healthy community, but can be ameliorated with local educational programmes. The provision of work has been unsatisfactory, but the development of social firms holds some promise. Patients with dementia receive better care in community nursing homes compared with hospital wards, according to their relatives' opinions, backed up by observational studies. The part of the service which is most unsatisfactory is the admission facilities. This is due to a variety of causes, including a failure to plan for the admission needs of discharged long-stay patients, the virtual absence of rehabilitation units in the community and an inadequate provision of a range of sheltered accommodation. However, these problems could be resolved with adequate investment in innovative facilities.