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Aims and MethodsTo calculate the prevalence of metabolic syndrome in patients receiving clozapine in community and long-stay in-patient settings. Patients were assessed using measures specified by the Expert Panel of the US National Cholesterol Education Program.ResultsThe prevalence of the metabolic syndrome was calculated as 53% in the community groups and 11% in the in-patient group, although both sample sizes (particularly the in-patient group) were small. Women were more frequently affected than men in the community population.Clinical ImplicationsThe higher percentage of metabolic syndrome in the community patients receiving clozapine has implications with respect to physical health. The reasons for the lower percentage in the in-patient group are unclear. Our findings point to a possible difference in the physical health of long-stay psychiatric in-patients and patients in the community.

We are old age psychiatrists; T.A. based in Britain, J.S. in Australia. A return visit by T.A. to Australia allowed us to focus attention on differences between the two countries in their provision of long-term care for old people with mental disabilities. What works well? What constrains development?

Aims and methodA retrospective review of the activity of a general practitioner employed specifically to provide a primary health care service to the residents of an ‘old long-stay’ psychiatric ward was undertaken.ResultsAll but one patient had a chronic physical health problem requiring active management. Presenting pathology covered all organ systems. The review indicated that these health problems had not previously been satisfactorily managed by psychiatrists. This service was acceptable to and valued by patients.Clinical implicationsThe success of the service was only achieved by dedicating specific resources to meet primary health care needs. The extent to which this model could be extended to ‘new long-stay’ populations located in dispersed hospital hostels is less certain.

This study, assessed 63 older, long-stay, learning disabled patients, the Health of the Nation Outcome Scales (HoNOS) highlighted the expected problems in areas of cognition, physical illnesses or disabilities, relationships and activities of daily living. No significant changes were observed in the problems assessed using the HoNOS over a six-month period in this group of patients with relatively stable health problems and needs. HoNOS proved to be useful in identifying some expected problems. However, further studies are needed to assess its sensitivity to changes secondary to improvement or worsening of problems along with wider use to see if its brevity allows it to give sufficient detail on the problems of persons with learning disabilities.

The outcome of 19 long-stay patients discharged from a large psychiatric hospital to staffed group homes managed by a voluntary organisation were compared with 11 patients discharged to a hostel ward managed by an NHS Trust. The former were found to have a higher rate of police involvement, readmission and threatened eviction. The study highlights the need for an integrated range of different residential facilities and the necessity for close monitoring of long stay patients discharged to more independent community settings.

It is important to ensure that the financial provision received by the long-stay psychiatric population is maintained as their care is relocated from hospitals to the community. A survey of the provision made by the 20 community homes to which Horton Hospital patients have been resettled was conducted. Comparison with the provision received by patients prior to resettlement revealed that the clothing allowance provided for patients without savings in Horton is often not maintained in the community and that resettled patients receive widely differing and frequently much smaller provision for clothing.

As part of the shift towards community care, a number of the large mental hospitals throughout the United Kingdom have now closed and many more are due for closure. In a review of deinstitutionalisation, Thornicroft & Bebbington (1989) concluded that the run-down of hospitals was outstripping the provision of new community facilities. Between 1974 and 1984 the mental hospital population fell by 25,000. However, the increase in residential places provided by local authorities and by the private and voluntary sectors totalled only 3,000. Inadequate planning and provision could give rise to discharged patients facing the prospect of isolated, segregated and impoverished lives with a high likelihood of homelessness and recurrent admission.

Studies have shown that significant physical morbidity exist within psychiatric units (Honig et al, 1989), yet general medical care is often left in the hands of psychiatrists who may not always be the most appropriate people to deliver it (Colenda et al, 1988). The new general practice contract places certain obligations on the general practitioner (GP) with regard to his or her patients, especially the elderly, yet these provisions do not extend to many of our patients. Our study looks at four areas of health care and examines how they are delivered to long-stay patients in a district pyschiatric unit with no GP input.

In recent years there has been increasing interest in long-stay psychogeriatric patients. Hilton et al (1989) and Anderson (1990) have described the profile and characteristics of this population, confirming clinical impressions of the severe degree of cognitive impairment and high dependency levels among such patients. At the same time, there has been a trend towards more active intervention in the type of care provided, moving away from the traditional custodial approach and towards more supportive continuing care models.

Large mental hospitals are gradually being emptied. Patients return to the community. But often their prospective carers have little idea of what to expect when they arrive. Hospital staff often cannot give information regarding how disturbed patients might be.

The provision of care for patients with chronic mental illness is changing with the gradual closure of mental hospitals and the expectation that this group will be largely cared for in the community. In Scotland the process is only beginning. A recent Scottish survey examined the demographic, social and clinical characteristics of 2605 “old long-stay” in-patients, defined as those in hospital more than six years and under 65 years of age at the time of last admission (McCreadie et al, 1991). Patients in 18 psychiatric hospitals serving 83% of the Scottish population were studied. Results showed the population was elderly, 70% being over 60 years of age, and nearly 40% over 70 years. The aim of the present study was to look at the physical health of the old long-stay population in one hospital, namely Crichton Royal, Dumfries, because of the implications of physical health care needs for the management of this group in the community.

In 1973 a survey was carried out of male schizophrenic patients who had become long-stay residents in Leverndale Hospital, Glasgow, ‘long-stay’ being defined as having been continuously in hospital for more than three years (Todd et al, 1976). The patients were recruited from a four year cohort of admissions in the years 1967 to 1970 inclusive. In the following years there have been many changes in the provision of facilities and in clinical practice. In some countries, such as Italy, the USA and England, there has been a strong drive to reduce long-stay populations along with the closure of some mental hospitals. In Scotland the process has been much more gradual, possibly reflecting the differences in preexisting provisions and patterns of care.

Closing old psychiatric and learning disability hospitals was promoted in the interest of patients' quality of life and normalisation. However, it was also hoped that re-using (or selling) the sites could help the development of a span of good mental health services in the community, which could ease the pressure on acute hospital beds. We identified the 206 large psychiatric and learning disability hospitals with over 100 beds in 1962 and 1986 respectively. In August 1996 National Health Service regional executives were sent questionnaires, one per site, asking for summary information on closure dates, current use of hospital sites and difficulties relating to the sale of sites. Half of the land on sites no longer in use was vacant. Each vacant site generates maintenance costs, but these pale in comparison to the likely opportunity costs measured in terms of the health and community care services that could be provided with the resources released by selling or reusing vacant sites. If the future development of community mental health care is even partly dependent on the release of resources from asylum sites, we could be in for a long wait.

I was interested to read Dr Cormac et al ’s article regarding physical health and health risk factors in a population of long-stay psychiatric patients ( Psychiatric Bulletin , January 2005, 29 , 18–20). In my own service I am responsible for two long-stay units. Local general practitioners (GPs

Benbow et al 1994). New guidance from the Department of Health makes it very clear that the NHS has a respon sibility to provide a reasonable number of longstay beds for this patient group. Authorities are required to agree and to publish criteria for admission to such facilities and a mechanism is envisaged which will allow investigation of ap peals (Department of Health, 1995). How common is it for Authorities to have written criteria available now? What are the criteria identified, are they likely to meet the requirements of the new guidance and can they be useful to others who are only now addressing this exercise?

The asylum movement was developed in the 19th century to provide care and cure for people with mental disorders. In the 20th century the old vision of asylum was abandoned, but no new alternative vision of community mental health care has taken its place. A divide between acute psychiatric services and provision for the social aspects of care has been described by Murphy (1991).

Evidence bearing on the issue of what happens to patients from long-stay psychiatric wards in Britain is scarce. The results of a particularly well-planned resettlement programme may not be representative of the outcome from general policies of discharge from all psychiatric hospitals. The present study was undertaken in Sheffield to find the whereabouts of patients from long-stay wards after eight years, a longer period than usually studied previously. The expectation was that difficulties in tracing patients could be overcome with sufficient time and effort.

Tardive dyskinesia (TD) is an involuntary movement disorder associated with long term neuroleptic exposure. Gerlach & Casey (1988) reported a 15% prevalence rate of TD among patients on neuroleptics, the rate increasing to 54% in patients over 60 years old. Early diagnosis of TD is important because it is estimated (Marsden, 1985)that if neuroleptic medi cation can be stopped, 60% of TD cases will resolve within five years. Continuing medication has been shown to cause a worsening of TD in a proportion of cases. To date no effective long term treatment for established TD has been demonstrated. In this study we screened long stay psychiatric patients for signs of movement disorder. We sought to establish the level of awareness of the presence of TD among the medical and nursing staff caring for the patients. We also wanted to examine whether any relationship existed between the clinical features of movement disorder and staff awareness.

“Quality of life” (QOL) appears intrinsically important but difficult to measure. As a mental health professional, one might wish to know whether patients moving from the security of hospital to “the community” improve their QOL, or to evaluate their QOL against that of other groups in society. Simply looking at symptom change or economic cost-benefit misses much of the point behind innovations in psychiatric services. From previous QOL assessments (e.g. Lehman, 1983) one would focus upon positive aspects such as living situation, personal relationships, and general health and on negative aspects such as lack of money or being a victim of crime. Literature from the 1950s and 60s attests to the adverse effects of institutional care but more recently writers such as Kathleen Jones (Jones et al, 1986) have drawn attention to the benefits of living in such an environment. Also, various well-publicised “scandals” have suggested the pitfalls of inadequately thought-out discharge into the community.

It is known that in most traditional psychiatric hospitals a significant minority of patients can have a better quality of life in hospital-hostels. With ample hospital-hostel places it was decided to interview and/or review the notes of all the non-demented Gloucestershire patients under 75 years whose stay in psychiatric hospitals exceeded one year on a census date of 26 September 1990. The characteristics of these long stay or residual patients are described.

For almost 20 years planning for the mentally ill and mentally handicapped has focused on a shift of care from hospital to community, the advantages and difficulties of this process generating much discussion and interest. The hospital population of the mentally handicapped is currently at the forefront of this change, planning impetus now being propelled by alterations in funding with budgets being transferred from NHS to local and social services. One conse quence is the closure, or planned closure, of large mental handicap hospitals situated at the periphery of urban centres, with residents being moved to small group homes and hostels within the towns and cities the hospitals once served. The change should prove beneficial for a majority of residents although the process continues to generate debate. Community care isprobably not as cheap an option as was initially believed. Glennerster (1990) calculat ing the costs following closure of Darenth Park, found both NHS hostels and group homes more expensive to run than comparative hospital care. If Darenth Park is representative of other similar hos pitals it would seem that, unless there is central commitment to increase the budget assigned to the mentally handicapped, community care may become impossible to implement fully. In addition, there is evidence that the resettlement which has already taken place has involved the less disabled, with the possibility that full resettlement might become more expensive still (Farmer et al. 1990). There are other considerations. During the period of transition from hospital to community, residents who continue as in-patients may become progress ively more deprived both in real and comparative terms as budgets are diverted from institutions to the community. Possible consequences include over crowding and loss of services. There now seems to be a recognition of this occurring, although little hope for any solution. Also, in spite of planned closure, admissions continue to arrive at the hospitals, often staying for prolonged periods of time. The impli cation is of a service provision unmet elsewhere. Adult psychiatry is unlikely to provide comprehen sive alternatives, and may not be able to offer all the facilities and expertise these admissions require. Supra-district services have not been developed, and in the current financial climate are unlikely to be forthcoming. In view of the important bearing these admissions have for future planning, we designed a study to try to discover their recent extent, to examine if among these a new long-stay group could be identified, and if so, what factors which might help predict this outcome.

The need for severely disabled long-stay general psychiatric in-patients to be resettled within their own districts is likely to arise increasingly as area mental hospitals close. The White Paper, Caring for People, acknowledges that some of these patients will continue to require hospital care. Transfer between hospitals might be considered a major life event for these patients, some of whom will have spent many years in the area mental hospital. Conflicting results have been found in studies of mortality rate following relocation (Morriss et al, 1988). Pryce's (1977) study with long-stay chronic schizophrenic patients and other more recent studies with new long-stay patients yielded data suggesting optimal environmental factors in keeping with Wing & Brown's (1970) observations.

On 21 September 1977, the first British ‘hostel ward’ was opened. In this paper we review the thinking behind such a concept and evaluate its successes and failures. This is not simply of value as an introspective exercise since it is also crucial that service planners and providers who are moving towards the closure of mental hospitals should consider the value for their district of such a service.

It is now widely recognised that families represent a hidden and largely unacknowledged resource to the NHS in the day to day management of long-term disabilities, particularly severe mental problems like schizophrenia. It is most likely that 50–60% of first admission schizophrenic patients will return to some type of family environment and a significant number will remain with the family for a considerable time. The current trend towards community management of mental illness, hampered by the lack of community provision, almost inevitably means discharge to families and is likely to continue and increase further.