The cost consequences of changing the hospital-community balance: the mental health residential care study

Changing the locus of care from the psychiatric hospitals to the community is a key and often contentious component of mental health care policy in many countries. Implementation of this policy in the UK has been slowed by the apparent shortage of suitable community accommodation for people with long-term needs for care and support. Among the consequences could be the silting up of hospital beds by people who could more appropriately be supported elsewhere, in turn denying inpatient treatment to people with acute psychiatric problems and unnecessarily pushing up health service expenditure. Using data collected in a survey of hospital and residential accommodation services and their residents in eight areas of England and Wales, the cost components of today's balance of care were explored. It was found that on a like-with-like basis, the costs of providing hospital inpatient treatment far exceed the costs of providing community-based care for what appear to be inappropriately placed patients. This should not, however, fuel the closure of hospital beds. Given the unknown but potentially considerable extent of unmet demand, as well as the impact of previous inpatient bed reductions appparent in the services surveyed, resources for developing appropriate conimunity-based residential care probably cannot be derived from hospital closure programmes.