In the last days of its bicentenary year The Times has this week received some of the most moving responses that we can ever recall to a series of feature articles. Schizophrenia is a disease that comes and goes without warning. It attacks promising teenagers and those fulfilled in middle-age. To the one per cent of the population who suffer its affliction the disease often denies insight into their own conditions. But to judge from what we have heard and published in the past three days it is almost as if it were the other 99 per cent which lacked the insight into schizophrenia. It has indeed been the forgotten illness.
To put a continuing tragedy to the forefront of our readers' minds is one thing. To suggest how it may be alleviated is much harder. Schizophrenia is on one level simply a disease with causes that are generally accepted to be biochemical and effects that are as cruelly clear to those close to the sufferer as they are so often consciously concealed from everyone else. But on another level schizophrenia is a dark mystery. Its sufferers are sometimes able to live what we know as normal lives, sometimes violently ill, uncontrollably ill, unrecognizably ill.
The duality of the condition has excited artists and writers who have seen it as a paradigm of the human condition itself. It has also excited intellectuals - most notably R.D. Laing and his followers who have used it as a stick to beat the western organization of family life. To those who examine it closely the world of schizophrenia is like a battlefield of fear and elation, of blood and courage and of sometimes warring ideologies each with their own vision of the right on their side.
Behind this fog of confusion it is clear that public policy towards schizophrenia is also in a mess; and it is the very alteration between sickness and health that is at the heart of the problem. Schizophrenia requires two distinct varieties of care: specialized care inside institutions and specialized facilities outside in the community. It needs the consent and understanding of the public both to pay for such care and, when the care takes place in the community, to co-operate in it too.
That consent " never as strong as it should have been " is now under threat from the very execution of policies that were designed to improve it. Schizophrenia " like all forms of mental illness " is less of an utter taboo than it was. The efforts of charities like MIND, the National Schizophrenia Fellowship (NSF), the Richmond Fellowship and others, have shifted public perceptions of mental illness. So has the commitment of every government since the early 1960s to community care for the mentally ill, after Enoch Powell as Minister for Health first eloquently condemned Britain's isolated, Victorian lunatic asylums to eventual extinction.
But Conservative ministers and organizations like MIND are not natural allies. Despite the apparent similarity of their commitments against institutionalization and in favour of community care both have forces behind them that would need little encouragement to be at each others' throats. MIND, at its recent conference, passed a resolution that talked of its opposition to 'involuntary incarceration' and the use of 'brain damaging and addictive drugs', representing as they do in MIND's view 'an unacceptable form of institutionalized violence' language that suggests a barely restrained rejection of any state medicine. Behind the Conservative Party there are always supporters who would prefer the State to lock away the mentally ill and throw away the keys.
Public confidence in the policy of running down and eventually closing Britain's long-stay hospitals and substituting instead care in the community is becoming increasingly fragile. Despite its honest denials, the Government is widely perceived to see community care as a money-saving exercise - a means of closing and selling off long-stay hospitals while providing care on the cheap in the community. The re-emergence on the streets of highly disturbed individuals visibly ill-cared for and incapable of enjoying a decent life not only offends the public's sensibilities, but also its sense of justice.
The message is beginning to come through - even from charities such as the NSF - that while the mentally ill may not be the best cared for in hospitals, they are better cared for there than in the absence of facilities outside. The demand to return the mentally ill back to the bins 'out of sight, and out of mind' could grow. Such a development would itself be a tragedy. The policy of making care in the community available is the right one. It is the execution which is proving weak. The running-down of mental hospitals is clearly happening more quickly than the provision of psychiatric support facilities in the community.
The problem is twofold. It is not just what to do with discharged long-stay patients. It is also about the standard of services for those who would have gone into long-stay hospitals but are now in some cases refused admission to keep the rundown on target. Parents and families too often receive little or no support. And the mess that has been made of the plans for regional secure units means that many psychiatric patients are ending up in prison not in hospitals.
What therefore is to be done? The first thing is a clear admission from the Government that care in the community is not a cheap option, but one that will cost more. The idea, after all, is not just to shift the location of care, but to improve it. Mental illness services are chronically underfunded. Although in recent years there have been marked improvements in mental illness spending and staffing, the resources needed to provide decent community care are almost certainly larger than the cost of running the old mental hospitals. They may not be very much larger. What evidence there is, in an area where comparisons are hard and figures unreliable, is that the less dependent mentally-ill patients may well be cheaper to care for in the community, but that heavily dependent chronically-ill patients are appreciably more expensive.
The second is that bridging finance must be provided to ease the transition from hospital to community care. Here imagination as well as hard cash is needed. Despite the fact that the policy of closing mental hospitals is almost a quarter of a century old, not one of the large old hospitals has actually shut down. The harsh economics of running down a mental hospital is that cutting the number of patients by a half cuts the cost of keeping the place open only marginally, and that until it closes the often considerable sums of capital from sale of buildings and land are not realized.
As the hospitals run down health authorities are faced with trying to run two services at once. In addition, capital is crucial to community care. It is needed to provide the housing association places, day centres, hostels, day hospitals, workshops and all the necessary elements of a proper community programme.
Some regional health authorities have set up bridging funds. But with health authority budgets under pressure the sums are insufficient. At least a three-pronged approach is needed. Some of the long-stay hospitals and their grounds, particularly if planning permission could be attached to them, are commercially attractive. Allowing health authorities to borrow against them, or to mortgage them against a firm closure date could in some cases release capital and revenue to develop community care now.
Regions which have not set up regional reserves need to be pressed by ministers through the annual review system to do so. But most importantly the government has to set up a substantial bridging fund of its own in the knowledge that much of it will be temporary extra expenditure. Once the closures take place, the savings will be realized. The money would be an investment in a future and better service, not an open-ended commitment to higher public expenditure.
With better central funding available the mechanism for developing community care programmes could be improved. Local authorities vary greatly in their willingness to take on more services for the mentally ill and some are wary of taking over health service spending for fear of the rate penalties such growth in services could eventually imply.
The channelling of bridging money through the joint consultative committees of local and health authorities plus local voluntary organizations which already exist could help ensure that it is spent only on well-developed plans where all three bodies agree the programme and objectives. In addition health authorities could be encouraged to contract with local authorities and voluntary organizations to provide services needed. Anomalies in the present funding system also need ironing out. Social security, for example, will pay the board and lodging costs of discharged mentally-ill patients in private accommodation and voluntary homes, but not in local authority homes or NHS-run residential facilities.
Anyone who has studied the problem of schizophrenia knows that the picture is not all gloom. A third of sufferers have a single attack, recover and never have a relapse. A further third go through a steady cycle of recovery and relapse. They may need many times to go through the so-called 'revolving door' between institutions and the outside world. But as long as the facilities on each side of it are improved there is a chance that many of these will have the opportunity to live fulfilling lives for themselves and safer lives for their families. Only the final third of sufferers are condemned to permanent reliance on the health and social services.
The responsibility for alleviating schizophrenia has to fall on individuals, on families, on charities, on voluntary organizations, on local and on central authorities. It has to be shared more widely and more fairly than it has been up to now.
It ought not to be beyond the capabilities of British society to recognize the different needs of those who need to make only the one return trip through the revolving door, those who make many return trips and those for whom the journey is one-way for ever. Without such a determined recognition today's tragedy of mental illness will become tomorrow's public scandal.
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