Introduction

Studies of home care as an alternative to inpatient treatment take place within the context of a long-term decline in psychiatric bed numbers, which began in the UK in 1955. Although much of this decline has been contributed to by the discharge and death of long-stay patients it has also been associated with a steady shortening of inpatient stays for ‘acute’ patients. Until the mid-1970s total admission rates increased, with a particularly dramatic increase in re-admissions. Subsequently admission rates have declined, a decline that has been more marked where sectorised services have been introduced (Tyrer et al., 1989). Psychiatric practice in the UK moved from the era of the locked mental hospital door via the ‘open door’ movement to the present revolving door of the District General Hospital psychiatric unit (Ramon, 1988).

More recently there has been a sustained effort to close the large psychiatric hospitals, replacing long-stay beds with local community provision and accommodation in private sector residential and nursing homes (Pickard et al., 1992; Leff, 1993). Carefully executed reprovision programmes do not result in an excessive rate of re-admission of former long-stay patients (Dayson et al., 1992; Pickard et al., 1992), although it is the heirs of this group (people with severe chronic and recurrent mental illnesses) who make the greatest demands on contemporary inpatient services.

It is interesting to speculate why these changes in bed utilisation have occurred. The initial impetus seems to have been changes in professional attitudes and practices within the psychiatric hospital rather than the implementation of government policy (Ramon, 1988).