In 1983 the government wanted to speed up the rate of closure of long-stay hospitals. These old-style asylums and traditional institutions for people with mental health needs, learning disabilities, physical disabilities and older people had become widely discredited, offering sometimes appallingly poor care and denying thousands of individuals some fundamental human rights. Policy statements had been made previously about closing these institutions, but progress had been very slow. So funds were made available to support joint projects by local health and social care agencies to help move people out of long-stay hospitals. The Care in the Community Demonstration Programme covered 28 projects that between them relocated more than 900 people with a wide range of long-term care needs from long-stay hospitals to permanent residence in the community. As part of the programme, PSSRU was commissioned by the Department of Health and Social Security (as it then was) to support the local projects and to evaluate them. Professor Ken Judge led this for the first year at PSSRU, and when he left the Unit I took over, with a team that included Roger Hampson, Judy Renshaw and Corinne Thomason, and, later, Jeni Beecham, Paul Cambridge and Lesley Hayes.
We worked closely with the 28 projects, which were exploring several different approaches – building new facilities, converting facilities, helping people to return to their families, or moving individuals to independent flats. So in addition to evaluation, our role was to support the projects in devising local plans and implementation.
It was an enjoyable and interesting process because we had the opportunity to influence what was being done locally, and to evaluate the impact on the lives of many hundreds of people. For example, we recommended that the projects included some form of case management in their community care plans, an approach which David Challis and Bleddyn Davies had shown to be enormously effective and cost-effective in supporting older people already in the community. We were also able to help teams set up local information systems to monitor what they were doing.
The evaluation itself included interviews with people before they left hospital, and again about nine months after they had moved to the community. Further follow-up work with people with learning disabilities and mental health problems was carried out five and 12 years after the move. For the vast majority the move was a positive experience. After five years most people with learning disabilities who were followed up were still enjoying better lives in the community than in hospital; the average weekly cost of support was 16 per cent higher than hospital costs. After 12 years, those followed up with mental health problems were mostly satisfied with their lives and accommodation, with satisfactory long-term clinical and social outcomes; overall care costs were lower than when living in hospital.
PSSRU was also commissioned to contribute to a separate study on the closure of psychiatric hospitals, working as part of the Team for Assessment of Psychiatric Services (TAPS) project, led by Professor Julian Leff at the Institute of Psychiatry. The main task was to evaluate the closure of Friern and Claybury Hospitals in north London. Friern Hospital was a typical old Victorian asylum: at its peak it had more than 3,000 resident patients, its own farm and gardens, and by repute the longest corridor in Europe – 1km straight with no fire doors. (When it was finally closed part of the building – which was listed – was converted into luxury flats, and the old refectory became an indoor swimming pool.)
More than 1000 patients met selection criteria for participation in the study: these were the long-stay residents. Data were collected on each of them before closure and at one and five years after moving into the community. Our role in PSSRU was to carry out the economic evaluation: what was the cost of replacement community care, how did it compare with hospital cost, what was the link between individual characteristics and costs, and the crucial link between costs and outcomes? Friern is the most comprehensive study of a psychiatric hospital closure and the research team was very productive – it produced 30-40 journal papers, with PSSRU involved in perhaps a dozen. For these long-stay patients, the transition from care in the psychiatric hospital to community care was a qualified success and affordable. Many individuals still had continuing mental health needs and required support, but they did not wander the street creating mayhem, which was the (sometimes alarmist) image presented at the time in the media. Overall, the project was influential in helping central government and local commissioners plan community services in England and has endured in its influence internationally. Although these asylums no longer exist in the UK, or at least do not perform the role they played 30 years ago, they can still be found in many other countries, and so we get asked occasionally to talk about our findings, even though we have not published a paper in this area for more than a decade.
One of the important lessons from the Care in the Community and Friern studies was that both of those hospital closure initiatives were adequately funded, which was why the outcomes were broadly positive. If hospitals are closed in the expectation of saving money then insufficient funds will be allocated for developing the replacement community-based care. In some localities this has led to many individuals rapidly returning to hospital in crisis admissions, homelessness and other problems.
These two studies were also important in the development of PSSRU. They were the first times we had worked in the mainstream mental health field, I think, and they helped PSSRU build a good reputation particularly for economic evaluation. Since then, we’ve been involved in hundreds of mental health studies. Our work also resulted in my being asked to establish in 1993 the Centre for the Economics of Mental Health at the Institute of Psychiatry, King’s College London, with many positive crossover links with PSSRU staff and research.
PSSRU’s expertise in the social care field meant we could contribute something novel to mental health research, policy and practice. The production of welfare approach that we had developed for social care was very relevant for mental health, given the complexities of care arrangements and outcome generation, and the need for understanding resource implications. Secondly, many fundamental aspects of social care research – non-randomised trials, routinely collected data, more challenging outcome measurement – gave us a good platform for work in mental health. Thirdly, we were one of the first groups internationally to carry out economic evaluations of mental health interventions, an area in which we quickly became quite prominent. In the opposite direction, I think the opportunity to work so extensively in mental health helped greatly in developing PSSRU’s activities and reputation.
Interviewed by Teresa Poole
Martin Knapp joined PSSRU at the University of Kent in 1974 to work on the economics of social care. In 1996 he and Bleddyn Davies set up the PSSRU branch at the London School of Economics and Political Science, where he remains Director and Professor of Social Policy. In 2009, Martin was appointed as inaugural Director of the School for Social Care Research, funded by the National Institute of Health Research (NIHR) and continues in that role today. Until early 2014 he was Professor of Health Economics at the Institute of Psychiatry, King’s College London, having established the Centre for the Economics of Mental Health there in 1993. Here Professor Knapp explains how PSSRU first became involved in the area of mental health through its evaluations of the economic impact of closing old-style long-stay hospitals and asylums.