Failure in community care Inpatient care is part of the integrated approach

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Abstract
EDITOR, - Jeremy Coid's editorial1 contains sentiments about supervision registers and the government's response to proposals for community supervision orders, which will find broad agreement within the profession. It also contains misrepresentations of the research findings and aims of community psychiatry. Despite Coid's protestations about “professional dogma,” not one of the research studies he quotes suggests that community services can exist without admission beds or that “mental hospitals can close and that seriously mentally ill people can be conveniently and easily managed in the community.” All of these studies report inpatient spells as part of an integrated approach to their patients' needs. What they do show is that admission is less often needed and discharge more prompt when community services are adequately developed. Coid suggests that community services research has sinned by either excluding too many patients2 or by including too many.3 Early studies excluded patients judged at severe risk when these approaches were new and untested. With increasing confidence these exclusion criteria have been dropped.3,4 Our study indicated major benefits for moderately to severely ill patients, rather than those with milder, transient disorders. Coid suggests that community developments rely on unrealistic staffing levels obtained through “generous development grants,” often at the cost of hospital services. This comment sits uncomfortably directly after work is quoted that clearly states that no extra resources were made available.3 Indeed, community care research has generally been characterised by a remarkable detail and frankness about resource implications. Research into community psychiatry has been more extensive than that on any other shift in psychiatric service delivery.5,6 How many carefully controlled studies were there of the establishment of day hospitals or the move to district general hospitals? Resistance within the profession has ensured that community psychiatry has been carefully evaluated (as …