The community and asylum care: plus ça change

current process of blind competitive contracting,and bilateral negotiation with favoured sons. The real test of this strategy will be whether it can influence the research undertaken within teaching hospitals using NHS funds. The Rothschild arrange ments for directing R & D in the Department during the 1970s failed for two reasons-the research com munity did not want to do the research directed at them, and the Department was always too poorly staffed to give critical leadership to researchers. Peckham's strategy will devolve much of the assess


management division, Professor Peckham's remit is
to control all the research and development activities funded through the NHS-estimated at over Â£200 million.
Is "control" too severe a word? Committees at national level will "identify research and develop ment (R & D) priorities", while regions "will be required to publish and implement" an R & D plan and be held accountable for it. Regional programmes will include regionally funded research of both local and national concern, and also R & D of national concern funded through the central committee through a bidding process with peer review. This structure will at least be more transparent for research workers than the Department of Health's current process of blind competitive contracting,and bilateral negotiation with favoured sons.
The real test of this strategy will be whether it can influence the research undertaken within teaching hospitals using NHS funds. The Rothschild arrange ments for directing R & D in the Department during the 1970s failed for two reasons-the research com munity did not want to do the research directed at them, and the Department was always too poorly staffed to give critical leadership to researchers. Peckham's strategy will devolve much of the assess ment of research to regions, not previously noted for their ability to handle R & D imaginatively or to provide expert advice on research priorities. Will those who get on the committees, or their friends, seek to ensure the status quo?
Yet psychiatric research could profit from these developments. Regions have community psychiatric care, dependency services and medium secure units high on their service agendas: the arrangements offer an open door for evaluating new patterns of care. Much basic work needs to be done in improving measures of mental health status and outcomes. And Professor Peckham specifically points to the need for partnership between epidemiological and health services research and biological psychiatry.
As a health services researcher I welcome Pro fessor Peckham's broad strategy, although there will surely be difficulties in its effective implementation. However I disagree with his view, argued here once again, that randomised trials are the "best way to evaluate competing forms of care". I sometimes think that Archie Cochrane's panegyric to the RCT, in his book Effectiveness and Efficiency, blighted outcome research in Britain for the past 20 years. In my own experience, most health care cannot be evaluated by RCTs, yet we still need to know whether it is effective. Much more attention needs be given to high quality, collaborative, observational research. Unless research commissioners advance from the logical purity of the RCT into the real world, this strategy for R & D in the NHS will fail, MARKMCCARTHY Director of Public Health, Bloomsbury and Islington and Hampstead Health Authorities 110 Hampstead Road, London NW1 2U Psychiatric Bulletin ( 1991 ), 15, 740-741 The community and asylum care: plus Ã §a change Is it reasonable for mentally ill people to "do nothing"? At a recent meeting of the Social, Com munity and Rehabilitation Section of the College, there was some discussion of this in the context of the influential Three Hospitals' study. The assumption of those researchers had been to view such nonactivity in a pejorative light. Some members of the audience considered this simply reflected the "class norms and value preferences of the professionals", a phrase used by Jones et al in relation to modern attitudes towards community care. Developing a thoughtful and historical perspective, based on their own continuing work in the Friern/Claybury TAPS (Team for Assessment of Psychiatric Services) research project, these authors have highlighted several key weaknesses of the modern non-asylum movement. Their criticisms focus on the dominance of man agement and organisational changes, changes that avoid dealing with the key issues of "professional and social conflicts". Noting the problems of selec tion bias and the new long-stay in their own research, they suggest that the "big questions" about the meaning of mental illness, the nature of society and our responses to deviant behaviours remain unaddressed. In particular they express doubts as to the expectations of rehabilitation. Although a little clumsy in their language, especially in their concluding paragraph, they do expose how super ficial are many of the so-called "changes". Their concerns will certainly strike a chord in those clini cally involved in the deinstitutionalisation process, for who has not spent endless chunks of time in liaison, planning and facilitation meetings that are in themselves a version of "doing nothing"? . Who has not wept at the assumptions of normalisation implicit in the callow phrase-so often heard from inexperienced community-orientated aficionadosthat patients should "take responsibility for them selves"? Yet in a cruel way the less the stigma, the less society may accept the mentally ill as "deserving poor". Does this cold paradox mean that neglect will accrue?
While sympathetic to most of the ideas expressed, I think Jones et al have under-estimated some optimistic uncertainties. We certainly need a new 741 and positive view of mental illness, a post-Laingian reassertion of the truths that schizophrenia may have to tell us. The continuing and public displays of community care do generate reactions, debate and concern. While the asylum did, and still does, provide acknowledgement and sanctioning of the needs of its inmates, its partial loss -and transformation into a research-orientated unit perhaps? -could lead to useful changes in the caring personnel. Tuke's exper iment at the Retreat, so fundamental to the asylum era, was first and foremost an experiment in staff attitudes. In other words, we can do something about allowing people to do nothing.