ABSTRACT
Traditionally, mental health services have been institutionally led but, more recently, there has been a major shift towards the provision of care outside the walls of large institutions. The reasons are numerous and include the beliefs that people are better served in their own homes and that it is more humane to keep people in familiar surroundings that are non-institutional. Institutions are faceless, heartless and careless, and large institutions have contributed to the disabilities experienced by patients with long-term psychiatric problems. Political opinion has also swung in favour of care in the community, largely driven by economics. It was believed that the money tied up in the large Victorian institutions on prime sites would be released easily to provide better care, more cheaply, in the community. While most clinicians believe that community-based care is the best way of providing care, it is government policy that has determined the rapid shift into the community-often without sufficient resources to ensure adequate reprovision. As the quality of a service is as important as, if not more important than, its location, particular care needs to be taken to ensure that the quality of service is not compromised in the process of relocation. Provision in the community has meant the creation of smaller, local units, people being looked after in their own homes for longer periods, and the closure of hospital beds. The reduction in the number of available beds has made people think more about those patients who are heavy users of beds. One such group comprises the ‘revolving-door’ patients. These are people, usually with long-term and severe mental health problems, who come in and out of services usually in crisis. These may be people who, in the past, would have spent long periods in institutions. In the inner cities the majority of these appear to be black.
