It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.
The loss of Phase I gains were perhaps due to attenuation of home-based care quality and to benefits of Phase I home-based care lingering into Phase II in DLP-controls. The Phase II home-based care team suffered from low morale.
A survey of all admissions of patients under the age of 65 during the first 6 years of a District General Psychiatric Department without mental-hospital support is reported. Three high-uptake groups of in-patients were defined; the long-stay (12 months or more), the medium-stay (6-12 months), and the revolving-door group (more than three admissions in any period of 12 months). Identifying characteristics which distinguish between these groups were examined. During a 7-year period there was no accumulation of long-stay patients, and a striking lack of schizophrenic patients who remained in hospital for more than 6 months or who had more than three admissions in any twelve-month period. This was not accounted for by drift of the high-uptake groups out of contact with the service, but may be related both to the style of service provision and to the socially cohesive nature of the area under study. Local variation should be given due importance when community services are being developed.
A controlled study of community care in serious mental illness (SMI) was carried out. Patients with SMI were randomised to have hospital care or be looked after by a community psychiatric care team in a Daily Living Programme (DIP). The day-to-day work of a clinical team with the difficulties encountered in delivering community psychiatric care in an inner city is described. There were seven deaths from self-harm during the 45-month study. One DIP patient committed homicide. An ordeal by media following this and the suicides are described. Lessonsleamt include the need for the community care team to be responsible for discharge from any in-patient phases and for attention to team morale, especially during adversity, and to time spent working under pressure.
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