Planning the transition from asylumbased care

In terms of translating this conceptual approach to actual planning decisions, we shall use as an illustration the question common in many economically developed countries of how to plan the transition from a pattern of services largely dependent upon a traditional mental hospital, to one that encompasses an array of more local provisions, including inpatient beds. The need to plan this transition is usually based on a mixture of political, social, and clinical reasons, although the local variations on this theme and the pace of change vary a great deal. In fact, as Table...6. shows, this is usually a twofold transition from a service component to a system approach, and from an institutional to a community orientation.

Table 6 Paths from traditional and segmental services to community-based care systems

Two illustrations can be given to show such transition planning. In Italy the approach chosen in 1978 was 'to close the front door', so that no more patients were admitted to the asylums/29' The disadvantage of this approach is that it incurs double-running costs for a prolonged period. It is notable that while this decision to stop further admissions was made at the country level in a matter of weeks in 1978, the responsibility for constructing a replacement community system was left to the regional levels without sufficient policy guidance. In essence, these changes were based upon a diagnosis of a dysfunctional system, and no detailed recommendations were made about how to construct an adequate alternative system, and so heterogeneous responses were produced. This has been implemented in a partial and inconsistent way across the different regions of Italy.(30)

In contrast, England offers an example of an alternative route, in that asylums have more often completely closed, but this has been achieved usually within a component- rather than a system-planning context. Service integration has most often been addressed as a subsequent issue. Two adverse consequences have accrued from this lack of integrated planning. First, the planning of places for long-term patients has only been applied to previously long-term inpatients, and not to the accumulating generations of their successors. Second, no allowance was made in the calculations of acute-bed requirements for the occasional need for readmission to hospital of former long-term inpatients discharged to homes and hostels in the community. These two shortcomings have contributed towards the current inappropriate use of about 30 per cent of acute inpatient beds by long-term patients in most parts of England. (31> In part, this is a consequence of the compartmentalization of planning that reprovides for each service component one at a time, and which cannot take into account the interrelationships within the whole service system.

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