12 February 1992

The Editors
Psychiatric Bulletin
Royal College of Psychiatrists
17 Belgrave Square
LONDON SW1X 8PG

Dear Sirs,

I appreciate the interest shown in our study in Sheffield, particularly by someone who works here (Dr Conway) and someone who used to work here (Dr Geddes). Perhaps the essential message is that, contrary to popular impression, long-stay patients are not being discharged to live in large numbers "on the streets".

I agree that it would be valuable to have information about the quality of life of patients, although this was not the point of our study, and I would maintain, as we did in our article, that it is not an easy question to answer because of methodological problems. It may be of interest to compare the results of our study with that of Professor Eve Johnstone (1991) (now in Edinburgh, of course, where Drs Newton and Geddes are) which traced 93.6% of 532 patients with schizophrenia discharged from Harrow services over 10 years. Almost all of them had permanent homes, and only one was in prison. Not all patients fared badly, but unemployment, social difficulties and a restricted lifeÄstyle were found to be common. Poor outcome is generally a defining characteristic of schizophrenia whether patients are in hospital or the community.

Dr Conway is rather sweeping in his condemnation of Part III homes. I do agree, though, with the implication of his argument that resettlement of long-stay patients should be for clinical reasons and not for the financial expediency that both health and local authorities gain because of the arrangements about "top-up". There is also a real problem about what registration authorities should do when homes do not meet adequate standards. It may be of benefit to inspect long-stay psychiatric wards by the same procedures.

I hope we did not seem complacent in our article. Sheffield Hostels (previously Sheffield hostel for homeless men) is a voluntary organization, supporting several people in houses belonging to South Yorkshire Housing Association, some of which are new properties. It is about six years since it was a night shelter.

There is a problem about the definition of homelessness. For example, the census in Sheffield by George et al (1991) did not include homeless people on the street, but I think did include Sheffield hostels. Nor am I saying that none of our sample have stayed at the Salvation Army or reception centres at some time, although we do not have the evidence.

Drs Newton and Geddes repeat an argument put forward by the Westminster Association of Mental Health (Hatch and Nissel 1989), which conceded that there was evidence that the resettlement of long-stay patients was working reasonably well, but suggested that the lack of long-stay provision was making the homelessness situation worse for acute psychiatric patients. It seems to me that there is a vested interest in proving that deinstitutionalization has been a mistake, however good the local facilities are, and the argument will change to fit the evidence. I am not sure if publication of a study that we have recently completed in Sheffield, following up a random sample of 100 out of 899 patients discharged from acute psychiatric wards during 1985, will change attitudes. We managed to trace all the sample and none were homeless.

A difficulty in interpreting the census in Sheffield by George et al (1991) is that detailed records of psychiatric admissions were not collected, although there is information on the year of discharge from hospital (George and Westlake 1991). Only 22 of 98 with a history of psychiatric admission had been discharged in the previous year.

Despite Drs Newton and Geddes, I do think it is important to correct the myths about deinstitutionalization. I believe more resources will be provided to meet mental health needs if the real situation is described.

Yours faithfully,

D B DOUBLE

References

George S L, Shanks N J, Westlake L (1991) Census of single homeless people in Sheffield. BMJ 302 1387-1389.

George S and Westlake L (1991) Homeless people and psychiatric care. BMJ 303 785.

Hatch S and Nissel C (1989) Is community care working? Report on a survey of psychiatric patients discharged into Westminster. London: Westminster Association of Mental Health.

Johnstone E C (1991) (ed) Disabilities and circumstances of schizophrenic patients - A follow-up study. British Journal of Psychiatry 159 Supplement 13