Introduction

This short chapter provides a brief overview of the development of community care. It examines the way that the asylum became an obsolete institution – certainly one that had few defenders in the early 1980s. In giving a brief overview of the intellectual underpinnings of community care, the chapter introduces a series of issues – deinstitutionalisation and the penal state, community care inquiries and the asylum/ community binary – which are examined in depth in subsequent chapters. Community care is a complex and highly influential shift in mental health services. As with all policies, there were a series of drivers behind the policy. I would summarise these as a combination of progressive idealism that attacked the whole notion that institutions could ever provide humane, dignified care and fiscal conservatism. Progressive idealism and fiscal conservatism are unlikely and uneasy bedfellows. The result was a policy that was imbued with service user rights but was introduced at a time of welfare retrenchment. In the UK and the US, this major shift to a community oriented vision of mental health service provision was introduced by governments committed to a small state and convinced of the supremacy of the market.

Community care is a phrase that does not appear in many, if any, contemporary mental health policy documents. It has either been discarded or is so deeply embedded that it is not worth commenting on. One of the aims of this volume is to examine the reasons behind the disappearance of community care from official discourse. The closure of the large psychiatric hospitals that had been built in the 19th century is one of the most significant social policies of the last 50 years. The process of asylum closure is usually referred to as deinstitutionalisation. Estroff (1981) identified four groups of patients who were affected by the process of deinstitutionalisation:

• • long-term hospital patients who were discharged;

• • patients who experienced potentially multiple psychotic episodes and hospital admissions – this group was treated as outpatients or with short, crisis-oriented admissions;

• • patients who were treated on an outpatient basis;

• • those patients who experienced a first serious episode of mental distress and were not admitted to hospital or who were in hospital for a relatively brief period compared to asylum admissions.