Asylum sought

Luminaries as diverse as Enoch Powell and Albert Einstein are quoted in Mental Health Policy and Practice, a critique of how the UK continues to fail patients and carers. Einstein's definition of insanity appears on the very last page: "Doing the same thing over and over again, and expecting different results." Which is how successive British governments behave in their dealings with mental health, according to the authors, Helen Lester and Jon Glasby, from Birmingham University.

Care in the community, for instance, was not entirely a Thatcherite innovation. As the authors make clear, the policy of closing down what used to be known as asylums or mental hospitals was proposed by Powell as long ago as 1961. In characteristically apocalyptic terms, he warned: "There they stand, isolated, majestic, imperious, brooded over by the gigantic water tower and chimney combined, rising unmistakable and daunting out of the countryside - the asylums which our forefathers built with such immense solidity to express the notions of their day."

It's fair to say that care in the community has not had a good press. The killing of a pregnant woman by Benjamin Holiday, a paranoid schizophrenic, two months after his release from a secure unit was just one horror story to hit the headlines. Glasby chooses his words carefully when discussing what the tabloids routinely refer to as "loonies" putting innocent lives at risk. "One murder is clearly a murder too many," he says, "but the homicide rate for people with mental health problems has been falling, despite the closure of institutions. Although these are terrible and traumatic events, they are high profile because they're so rare."

Glasby is a social worker and also senior lecturer at the university's health services management centre; Lester is a GP. "She breaks the mould by being a mental health expert as well," Glasby says. "Most doctors in general practice are not confident enough in this field, yet one in four of us seeks help at one time or another. Problems with mental health are as common as asthma and the cost to the economy is greater than ischaemic heart disease, breast cancer and diabetes combined."

The authors concede that the government has given mental health services a higher priority. "Since 1997, there has been new funding and an emphasis on tackling the stigma," says Glasby. "That commitment is to be commended. But the government's record has been patchy and ambivalent. Its key report in 1998 was subtitled Safe, Sound and Supportive, reverting to fears of public safety as the number one priority. Are they seen as supportive by people with mental health problems? I suspect not."

Lester says: "There's still a significant gap between government rhetoric and reality."

In Glasby's opinion, mental health would benefit from joined-up government. "People don't live their lives according to structures laid down from the top," he says. "If care in the community means sending people home to poor housing, unemployment and family difficulties, we shouldn't be surprised when mental health problems recur." More liaison between health, social services, housing departments and other agencies would help, he says.

As well as researching a new book on community care services, he is running a master's course called partnerships in health and social care as a way of bringing health managers and social services managers together. "It's unusual within the context of higher education, where the divisions are just as entrenched," he says. "Medical schools don't talk to social work departments or nursing schools. The fact that Helen and I wrote a book together is an indication that Birmingham is at least making an effort."