Journal of Mental Health,

February 2010; 19(1): 1–7

EDITORIAL

Rehabilitation psychiatry in an era of austerity

FRANK HOLLOWAY

Croydon Integrated Adult Mental Health Services, South London and Maudsley NHS Foundation
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Trust, Bethlem Royal Hospital, Beckenham, Kent, UK

The credit crunch is putting strain on personal and Governmental finances worldwide. The
UK has been the hardest hit of the G20 countries and the outlook for public finances is, to
say the least, bleak. So after a decade of investment and expansion of mental health services,
which has left them ‘‘the best in Europe’’ (Appleby, 2007), we face an era of ever greater
‘‘cost-improvements’’, ‘‘cash releasing efficiency savings’’ and perhaps more honestly cuts in
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services.
During the fat years the English Department of Health (DH) was hyperactive in
producing policy documents on mental health care, many of which were published under
the rubric of a Mental Health Policy Implementation Guide (PIG). The most influential PIG
was the first (DH, 2001) which set out a vision for adult mental health services based on a
‘‘functional’’ model of multiple specialist community teams that replaced the 1990s
consensus of the all-singing all-dancing Community Mental Health Team (CMHT) relating
to a local inpatient unit. This ‘‘functional’’ model consists of a number of community teams
in addition to the CMHT that provide Crisis Resolution/Home Treatment Teams (CRT/
HTT) as an alternative to admission, Assertive Outreach Teams (AOT) for difficult to
engage patients with severe mental illness and Early Intervention in Psychosis (EIP).
Subsequent PIGs addressed a range of topics which included services for people with a
personality disorder, women’s services, inpatient services and Psychiatric Intensive Care
Units and Low Secure care (the latter two perhaps unfortunately conflated in a single
document)(DH, 2003a, 2003b, 2002a; 2002b).
The DH has developed policies for almost every aspect of adult mental health services. It
has been very active in managing the implementation of these policies through a reporting
framework that was enormously detailed (to the extent that the numbers of patient contacts
by CRT/HTTs had to be reported and variances explained and the size of the AOT and EIP
caseloads were centrally determined whatever the local demand and epidemiology identified
as the need). However there is one area that has never received policy attention:
rehabilitation and continuing care services.

Correspondence: Frank Holloway, Consultant Psychiatrist and Clincial Director, Croydon Integrated Adult Mental Health
Services, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent
BR3 3BX, UK. E-mail: Frank.holloway@slam.nhs.uk

ISSN 0963-8237 print/ISSN 1360-0567 online Ó Informa UK Ltd.

DOI: 10.3109/09638230903555919
 2 F. Holloway

Why is rehabilitation psychiatry unfashionable?

Rehabilitation and continuing care services have become marginalized in the discourse
surrounding mental health care (Holloway, 2005). This is at odds with trends in general
medical practice, where rehabilitative inputs are seen as increasingly important in reducing
the burden of chronic disease. There are many reasons why this marginalization has
occurred.

(1) Health economies in England have disinvested in specialist community rehabilitation

teams and units in order to implement the policy requirements outlined in the initial
PIG document (DH, 2001). Some effective community rehabilitation teams have been
rebadged as AOTs (Killaspy et al., 2005; Mountain et al., 2009). This has resulted in
discharging their existing caseloads to the care of the local CMHT or merging two
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rather different client groups, one characterized primarily by difficulties of engagement

and the other by severe social disability requiring intensive support to maintain
independent living.
(2) The ‘‘virtual asylum’’ that has replaced the traditional mental hospital has grown in a
largely unplanned fashion (Poole, Ryan, & Pearsall, 2002), lying at least until recently
below the radar of policy-makers and local service commissioners. Both health and
social care placements have tended to be spot-purchased from independent sector
providers, allowing local services to avoid the necessity to make strategic decisions
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surrounding the treatment and support of those individuals who require the highest
levels of care. Huge sums of health service money have been spent in Out of Area
Treatments (OATs) that have often not been thought out, may not be effectively
monitored and may be of poor quality (Ryan et al.,2004; 2007): OATs cost the NHS
£222m in 2005.
(3) Inpatient facilities offering rehabilitation, which will generally seek purposefully to have
extended lengths of stay, fit badly with a managerial ethos focused on admission-
avoidance, ever-shortening length of stay in hospital and bed reductions. There are
technical difficulties in defining appropriate care episodes for inpatient rehabilitation
and Forensic spells, which will become an urgent necessity should mental health
services move from their current block funding into the Payment by Results (actually
payment by activity) regime that has funded mainstream health care in recent years (as
is due to happen from 2010; Howitt, 2009).
(4) More fundamentally, throughout the era of community care there has been a
consistent tendency to ignore the disability and social exclusion of people with the
most severe disorders. There has been a repeated assumption that advances in service
provision and treatment technology have abolished poor social and clinical outcomes
for people with psychotic illness. The NICE Schizophrenia Guideline (NICE, 2009)
effectively stops when a rather simple menu of treatments and interventions, including
Cognitive Behavior Therapy, clozapine and access to work rehabilitation, is exhausted.
In fact the evidence suggests that some important outcomes, such as achieving
employment, have got very much worse over the past 40 years (Marwaha & Johnson,
2004; Royal College of Psychiatrists, 2002). Failure to respond to treatment remains
common amongst people with schizophrenia (see, for example, Robinson et al., 2004)
and, even in the short term, a significant proportion of individuals presenting with
psychosis fare very badly indeed (Craig et al., 2004).
(5) Psychiatric rehabilitation, as a discipline, emerged within the traditional mental
hospital. Having served, through the hospital reprovision programmes of the 1980s and
 Editorial 3

1990s, as the mechanism for closing the mental hospitals rehabilitation came to be seen
as a redundant concept, irrelevant in the era of deinstitutionalization. There was a
belief that after the successful hospital closure programme the issue of long term need
had somehow been dealt with, since these needs were so obviously an iatrogenic
phenomenon consequent on the effects of institutionalization.
(6) The evidence base for the practices of Rehabilitation Psychiatry is seen to be limited,
despite the publication in recent years of several major texts on the subject (Corrigan
et al., 2008; Liberman, 2008; Pratt et al., 2007; Roberts et al., 2006).
(7) The concept of psychiatric rehabilitation, which implies both long-term disability and
long-term commitment from services to address this disability, is simply unfashionable.
Historically psychiatric rehabilitation has been predicated on concepts of impairment,
disability and handicap (Wing, 1993) that appear to fit badly with a contemporary
discourse that embraces strengths, empowerment, involvement, social inclusion and,
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of course, that currently dominant paradigm, Recovery (Davidson, 2003; Roberts &
Wolfson, 2004; Shepherd, Boardman, & Slade, 2008).

Why is rehabilitation psychiatry important?

There are two broad arguments for the continuing importance of rehabilitation psychiatry.
One is humanistic: we know that despite advances that have occurred in mental health care
over the past few decades major mental illnesses continue to be a cause of enormous distress
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and social disability for a significant proportion of patients, even where the new service
models have been fully implemented.
In the face of this continuing disability and distress it makes sense to invest in
rehabilitation services which aspire to ‘‘provide a whole system approach to recovery from
mental ill health which maximizes an individual’s quality of life and social inclusion by
encouraging their skills, promoting independence and autonomy in order to give them hope
for the future and which leads to successful community living through appropriate support’’
(Killaspy et al., 2005). In practice people get referred to rehabilitation services once the
NICE Guideline algorithms for treatment have been exhausted and other approaches have
failed (Holloway, 2005). The high proportion of people receiving long-term care in OATs
results in people with the most severe and complex problems being excluded from their local
communities: quite literally out of sight, out of mind.
The second argument is pragmatic and relates to the scale of resources expended on
rehabilitation and long-term care, which may come as a surprise to many. Although the trend
in NHS psychiatric bed numbers has continued downwards throughout the past decade,
to a new low for England of 23,000 occupied beds in 2008 (National Health Service
Information Centre for Health and Social Care, 2009) there has been a massive expansion in
certain kinds of NHS provision – medium secure beds and (a rather new concept) low secure
beds – which largely lie within the domain of Forensic Psychiatry. In addition there is a large
and growing independent sector offering a wide range of longer-term provision including
secure care, rehabilitation and continuing care and some niche provision, for example for
people with acquired brain injury and co-morbid autistic spectrum disorder. It is surprisingly
difficult to be confident about inpatient psychiatric provision in England. Data sources
converge on their being approximately 16,000 adult mental health beds, of which 10,000 are
designated as acute or psychiatric intensive care, 1300 are low secure, 1700 medium secure
and 3000 rehabilitation and continuing care (this excludes people in high secure hospitals)
(Mental Health Strategies, 2008). To this need to be added independent sector beds
(Commission for Healthcare Audit and Inspection, 2008). Roughly 3000 of these beds are
 4 F. Holloway

purchased by the NHS to provide long term care, usually in settings that are many miles away
from the patient’s home and their families. Despite five decades of deinstitutionalization
there are therefore almost as many working-age adults in long-stay beds as there are in acute
facilities (which also contain a share of people who have become long stay, of course).
For some years the DH has commissioned a mapping exercise for mental health services
in England, which has included a financial mapping of expenditure on health and social
care. In 2008 some £5.5 bn was spent on adult mental health of which 52% went on budget
headings that are providing some form of rehabilitative or long-term care (e.g., secure care,
continuing care, housing and residential care, day care and assertive outreach) (Mental
Health Strategies, 2008). This is not just an English phenomenon. Contemporary evidence
suggests that throughout Western Europe, we are now entering an era of reinstitutionaliza-
tion. The expansion in secure care has already been noted and as mental hospital beds have
declined residential care has expanded to fill the gap (arguably along with the prison
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population) (Priebe et al., 2005). There are throughout Europe concerns over the quality of
long-term care, both within and outside the hospital sector (Taylor et al., 2009).

Enabling recovery for people with complex mental health needs. A template for
rehabilitation services
In an attempt to plug the policy gap that exists surrounding rehabilitation and complex care
the Faculty of Rehabilitation and Social Psychiatry of the Royal College of Psychiatrists has
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recently published a report that sets out in brief a template for a comprehensive psychiatric
rehabilitation and recovery service (Wolfson, Holloway, & Killaspy, 2009). Enabling recovery
for people with complex needs was developed after a consultation exercise involving
stakeholders that included users, carers, service commissioners and mental health
professionals (Wolfson & Mountain, 2008). This template is deliberately not prescriptive
in terms of the numbers of people who will require any particular kind of service in a
catchment area. This is because the precise figures will depend on particular local factors
relating to the epidemiology of severe mental disorder, local demography and social capital
and to an extent on the history of the local services.
The starting point is a simple definition of a psychiatric rehabilitation service as a
‘‘recovery-oriented service for people with disabilities associated with longer-term mental
health problems’’. The aim is to promote personal recovery ‘‘whilst accepting and
accounting for continuing difficulty and disability’’ (Roberts et al., 2006). The case is made
for proper access to rehabilitation services across the UK in terms of a set of principles that
the authors believe to be important: localization of care so that the service is close to its
clients, their families and the wider service system; personalization of a local service tailored
to the needs of individuals and capable of responding to a change in need; choice; social
inclusion and addressing stigma; and promoting mental health and safety. The current culture of
throughput that dominates in-patient care pathways can be too optimistic for some service
users who become trapped in an aversive and unsafe cycle of revolving door admissions:
long-term problems need a long-term strategic approach.
It must never be forgotten that services are not in themselves treatments – merely ways of
delivering treatment and care. The main function of a rehabilitation service is to provide
specialist treatment in a suitable setting that helps service users gain or regain the skills and
confidence to achieve their own goals, be that living independently, getting a job or starting a
family. Treatments and interventions will include optimal medication, psychosocial
interventions, healthy living, attention to self care and complex living skills and are often
but not invariably initiated in a therapeutic living environment.
 Editorial 5

The core components of a rehabilitation service will include a range of inpatient provision
(defined as hospital beds able to care for compulsorily detained patients) that can offer care
across a set of dimensions (e.g., site – on a campus or free-standing; expected length of
admission; the functional abilities of residents; the capacity of the settings to manage risk;
and the degree of specialization in terms of client group). A detailed typology of inpatient
settings is provided. This is sufficiently complex to mean that not all dimensions can be
provided at a truly local level and independent providers, regional and even national services
will form part of the functional network.
The inpatient provision needs to be complemented by a multidisciplinary community
rehabilitation team: this should be taking on a role of supporting people in placements and
receiving complex packages of care in their homes as well as offering consultation to more
generic community mental health teams. Much of the work will be in ensuring that their
clients are encouraged to maximize their independence (something that traditionally
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residential care providers have been poor at). The community rehabilitation team will form
part of a ‘‘family’’ of teams that support people with psychosis and other complex
conditions: AOT; EIP; community forensic teams; and community mental health teams
with a longer-term complex caseload.
The specialized rehabilitation services cannot operate in isolation and must work in
partnership with other essential resources that are funded out of mental health and social
care budgets, including a spectrum of locally available supported accommodation to meet
local needs, agencies working to foster social inclusion, advocacy services and peer support.
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It goes without saying that the principles of partnership working extend to the patient/client
and their carers: identifying goals that the person wants to attain is a core skill that the
recover-oriented practitioner needs to have (Davidson, 2003).

Rehabilitation in an era of austerity

It may seem quixotic to be putting forward plans for service development in the coming era
of austerity: rehabilitation services with their relatively slow pace of work and high costs per
case have long been a target for cost-improvements, service reviews and downsizing
(Mountain et al., 2009). In fact investment in ethical and effective rehabilitation
programmes set up within a coherent framework that seeks to minimize dependency and
maximize autonomy are a way, perhaps the only way, of managing mental health services
through the economic downturn.

Declaration of interest: Dr Holloway is a former Chair of the Faculty of Rehabilitation

and Social Psychiatry, Royal College of Psychiatrists and one of the authors of Enabling
recovery for people with complex mental health needs. A template for rehabilitation services.

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