Sir: John Snowden and Tom Arie (Psychiatric Bulletin, January 2002, 26, 24-26) covered a huge amount of ground, and inevitably omitted some features of service delivery in the two countries. One major difference is that hostel and nursing home care in Australia is accessed only after assessment by a geriatric medicine team, and the costs of care are largely met by the Commonwealth Government, which closely controls the number of beds it approves. Patients are funded on a sliding scale that can be viewed negatively as encouraging dependency, or positively as challenging nursing homes to tackle seriously ill patients. UK nursing homes seem not to attract additional funds for higher dependency care, which can lead to patients ‘blocking’ beds in acute general and psychiatric hospitals. The Australian systems of documentation of dependency can be a drain on nursing resources, directed at ensuring maximum funding rather than patient benefits.

Western Australian old age psychiatry services have suffered age based fiscal discrimination in recent years, and consequently limited community services. UK social services provide substantial support care in the home that is not available in Australia. The system of community based assessment is well developed in Western Australia and emphasises early response by assessment teams of a social worker and community mental health nurse, followed by consultant intervention as required. The UK model favours consultant assessment in the community in the first instance. My somewhat heretical view is that this is costly and inefficient. Statistics of bed numbers are notoriously unreliable. In the absence of any independent audit to establish that each state is providing honest and accurate figures, and that we are talking about units with the same operating characteristics, it is impossible to establish validity. The ‘throughput’ issue is critical if comparing service delivery. ‘Continuing care’ units in the UK provide much of the permanent care seen in nursing homes in Australia. I understand the units in Victoria are essentially continuing care facilities despite the intentions, as are the confused and disturbed elderly (CADE) units in New South Wales. Services in Western Australia have always followed a firm policy of discharge only when difficult behaviours are abated. Western Australia Health Department attempts to shift a minority of long-term but behaviourally challenging patients into the private sector are misguided and so far unsuccessful. Every psychiatric patient, whether long term or acute, needs professional multi-disciplinary care until the reasons for that specialist care are no longer present. Poorly resourced ‘continuing care’ in either country is simply an excuse for rebuilding the ‘back wards’ of mental hospitals.

I must also gently disagree with the implication that making long-term care facilities domestic was intended to ‘demedicalise’ care. The drive for more domestic character was part of a deliberate process using environmental design to help modify and manage behaviours with for example, less use of medication. It was pioneered in Western Australia by Lefroy and also in the state psychogeriatric services well before the Victorian psychogeriatric nursing homes. The CADE units in New South Wales are also similarly influenced by design and behavioural management concepts, unfortunately often ignored in later developments in many states, including Western Australia.