Community-Based Mental Health Care in Britain

Community mental health care in the UK was established by two influential mental health acts (MHAs). The 1930 MHA legislated for voluntary admissions and outpatient clinics. The 1959 MHA required hospitals to provide local follow- up after discharge, required them to work closely with local social services and obliged social services to help with accommodation and support. An effect of this was to establish highly sectorized services for populations of about 50,000. These were served by multidisciplinary teams (generic CMHTs), which accepted all local referrals from family doctors. Sector CMHTs evolved a pragmatic approach with an emphasis on skill-sharing and outreach, depending heavily on community psychiatric nurses. The NHS is funded by central taxation, with no distortion of clinical practice by per-item service fees. It is highly centrally regulated, with a strong emphasis on evidence-based treatments. Since 2000, generic sector teams have gradually been replaced or enhanced by Crisis Resolution Home Treatment teams, Assertive Outreach Teams and Early Intervention Teams. Assertive Outreach Teams were resorbed into CMHTs, based on outcome evidence. The last decade has seen a major expansion in outpatient psychotherapy (Improving Access to Psychological Treatments (IAPT) services) and in specialist teams for personality disorders and perinatal psychiatry. The traditional continuity of care across the inpatient-outpatient divide has recently been broken. During the last decade of austerity, day care services have been decimated, and (along with the reduction in availability of beds) compulsory admission rates have risen sharply. Mental health care is still disadvantaged, receiving 11% of the NHS spend while accounting for 23% of the burden of disease.


ESTABLISHED?
The United Kingdom of Great Britain and Northern Ireland (hereafter referred to as the UK) was in the vanguard of the asylum movement in the early 19 th century.   The extent of role-blurring may also be a consequence of the NHS funding system, with the absence of any 'fee for service' or targeted payments. NHS MH services are funded by a relatively simple block grant. This is based on a capitation formula, plus sophisticated adjustments for levels of deprivations. In recent years, commissioning of services has become more localized, with specific targets for individual services.

SPECIALIST AND FUNCTIONAL TEAMS
CMHTs have always been stratified by age group. called Increased Access to Psychological Treatments (IAPT). 11 This programme provided advice and self-care but also trained CBT therapists to provide more intensive treatment, initially from primary care. Once established, the service was absorbed into secondary MH care and is now routine. It has ensured much greater access to psychotherapy, with an estimated additional 3000 staff nationally. However, it has been criticized by some for its restriction to CBT, its rather rigid format and the quality of therapist training.

FINANCING AND LEGAL STRUCTURE
UK mental health care is funded by general taxation via the NHS and is totally free at the point of service. There are no patient-level payments (no itemized payments), although some service-level targets may affect funding.

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Consortium Psychiatricum | 2020 | Volume 1 | Issue 2 Currently, it accounts for 11% of the total NHS spend (9.8% of GDP, in line with the EU average of 9.7% in 2014).
In 2012, the Health and Social Care Act committed to 'parity of esteem' between physical and mental health care by 2020. As mental disorders account for 23% of the burden of disease, there is clearly quite some way to go. The rate of compulsory admissions in the UK is 114 per 100,000. This is in the mid-range for Europe, with Austria highest at 282 and Italy lowest at 14.5. 14 However, there are two significant issues of concern. The first is that the rate is rising faster than that of most comparable countries, and the second is the persistently high rate of detention among black patients. The number of compulsory admissions has risen from 43,364 in 2007 to 63,048 in 2015, an increase of 45%. This rise has settled at about 4.0% per annum and is in line with France (4.7%) and Australia (3.4%). However, in most other comparable countries, the rate of compulsory admissions has been steady or has declined slightly. This recent rapid rise in the UK has been associated with a substantial reduction in available beds. 15 Currently, one third of all admissions are compulsory, and a further third are converted to compulsory while the patients are in hospital. In many inner-city areas, virtually all inpatients are compulsory.
It has been suggested that the current rapid rise reflects not only the risk-averse nature of UK society but also that it may be the only way to secure a bed.
The second area of concern has long been expressed and relates to the very high rates of admission (including compulsory admission) for black patients (Afro-Caribbean men in particular). This was initially attributed to stigmatizing discrimination and over diagnosis. 16 Despite careful epidemiological work to contradict this and demonstrate a genuinely high rate of psychosis in these groups, 17,18 the failure of services to engage with this vulnerable group generates constant criticism.

RESOURCES
The UK lies in the mid-range in terms of the numbers of both psychiatrists and psychiatric beds in Europe. 19 The UK has 19 psychiatrists per 100,000 population, and day centre places (provided by local authorities) are difficult to obtain with any accuracy. The strong clinical impression, however, is that these are also being closed, even more so during the last decade of austerity. Substantially increased funding has been promised, and a review of the mental health act is underway. It would be foolish, however, to make predictions about anything in the UK currently.

Conflict of interest:
The author declares no conflict of interest.
Funding: The author declares that there was no funding for this work.