From hospital to community
In the early 1970s there was an imprudent urge to plan the creation of enormous district general hospitals where all the services, including psychiatry, would be centred. This policy was later abandoned in favour of smaller units. At present the structure preferred is the 'nucleus', low rise, flexible, relatively cheap and adaptable. Already, throughout the country fifty are in the planning stages.
Contemporaneously, gross underfunding has led to an incredible decline in the maintenance of Britain's 2300 hospitals and Health Service buildings. Most of Britain's hospitals are outdated in any event; half of their floor space was provided before 1914. Conceivably these considerations have contributed to the trend in recent years which concentrates medical care and, in particular, psychiatric management in the community rather than the hospital.
In pursuance of this policy, on 16 July 1981, the Under Secretary of State for Health and Social Security announced proposals to close 30 of the country's mental hospitals and transfer 20000 mentally ill and mentally handicapped persons to community care (Care in the Community 1981). The Local Authority Services would be funded to provide the support required by transfer to them of financial resources from the National Health Service. Does community care mean new and exciting therapeutic methods of which the community has a monopoly? Can we speak about social curability? What contribution does community care make to the solution of elusive clinical problems? What hard evidence is there that hospital treatment hinders the patient's progress? The cause of half the cases of severe mental handicap is unknown (British Medical Journal 1981) and this surely requires research on an unprecedented scale; but the advocates of community care are inclined to frown upon the medical model. Dementia is becoming a problem of the first magnitude. Its enormity is reflected in the fact that one in six aged over 65 suffer from it. Half are due to Alzheimer's disease where research indicates the need for urgent biological studies. A geographical shift from hospital to community will do nothing to resolve these and similar clinical problems; it may even conceal them. The overriding responsibility of psychiatrists is to ensure that patients' needs and not administrative and political expediency determine basic policy in the National Health Service.
Restructuring and the doctors' role
A commendable provision of the restructured National Health Service which will have been introduced by April 1982 is the decentralization of decision making and budgetary control to the interface with clients in the hospital and- the community, and the elimination of superfluous administrative tiers. In this reorganization the doctors' responsibilities are crucial. During the 1 960s the doctors' role in management and administration became less significant. This trend, noteworthy in psychiatry, has persisted. It resulted from the profession's folly in failing to anticipate the course of administrative events despite the clearest signs, and organize themselves to meet the challenging changes of 1974. We were to witness the transfer of power and authority from the hospital, where it properly belonged, to a more remote and less effectual administrative tier. Yet another reorganized service will have taken over in April 1982 in which the doctors' role requires the clearest possible definition. There have been some disquieting references to the doctor as a subcontractor, a term which conjures up a remote figure to be consulted on specific medical or scientific problems only. He must steadfastly refuse to be inveigled into some limited function; rather his activities should encompass, without restriction, all areas which concern his patient in sickness and in health. The reorganized service should have medical leadership: not by resurrecting the office of Physician Superintendent, despite the clearest indications that he discharged his onerous responsibilities to much greater effect than his successors have done; not through a chief of service as has recently been recommended by the National Health Service Health Advisory Service; and not by altering the consultant's contract to include a corporate responsibility for a comprehensive mental illness service (Dick 1981). (These last two proposals suggest the possibility of unnecessary accountability, direction and control.) Rather, doctors should exert their influence by their activities at District and Unit levels where, after April 1982, there should be ample scope for dealing with key issues. In this connection they should represent the views of a medical profession united behind well defined principles and positive, forwardlooking policies with single-minded determination not to be deflected from their leadership responsibilities by the kind of controversial content of the Reith lectures (Kennedy 1981). The doctors' function in management is critical: first, because of their specialized knowledge of medical issues; and second, because as professional members of the community they approach the general problems of a non-medical nature with educated and dispassionate minds. Some of their fellow managers by the very nature of their civic responsibilities may find it difficult on certain issues to disentangle their local political allegiancies from the needs of the Health Authority. In these circumstances the doctors' contribution can exert a vital corrective influence.
Management and administration of the National Health Service have one purpose only. It is to enable medical practice both curative and preventive to proceed with expedition in order that the best interests of patients may be served. For the medical profession today to accept as inevitable the pronouncements of politicians, managers and administrators, whether it agrees with them or not, is to fail in its responsibilities to succeeding generations of doctors.
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