In July 1983 the Regional Medical Officer of the North East Thames Regional Health Authority (NETRHA) appeared on television to announce the closure of Claybury Hospital and much of Friern Hospital over a ten-year period.

When NETRHA announced its decision, the policy to be pursued was innovative because it involved psychiatric hospitals serving inner-city populations, and because there was apparently no intention to achieve its aim by decanting patients into other psychiatric hospitals, as had been done with the closures of St Wulstan's and Banstead Hospitals. Although the run-down of psychiatric hospitals had been occurring at a steady rate in the United States and in England and Wales since the early 1950s, there had been few attempts to evaluate the policy, and none had been in any sense comprehensive (this supplement, paper 7). Clinicians and research workers in the field of social psychiatry were well aware of the need for large-scale evaluative studies, since protagonists and opponents of the policy of deinstitutionalisation were locked in a polemical argument which was pursued with increasing stridency through lack of reliable information.

Various techniques have been used to assess the results of ‘deinstitutionalisation’. This paper reviews these outcome studies, most of which have concluded that a new long-stay group will replace the old long-stay patients, and that a residual group of ageing patients, mostly with organic syndromes, is difficult to accommodate in the community.

This paper describes the origins of the TAPS project and the design of the prospective study of the long-stay patient populations of Friern and Claybury hospitals, two large mental hospitals in north-east London scheduled for reprovision and closure by the regional health authority.

The development of the hospital and community versions of the Patient Attitude Questionnaire is described. The instrument rates the attitudes of psychiatric patients towards their treatment settings and staff, and is framed specifically to assess attitudinal change during the transfer of patients from hospital. For the items rated using the kappa coefficient of agreement, the mean test-retest reliability value was 0.51, and the average inter-rater value was 0.82. This study shows that long-term psychiatric patients are able to give clear and consistent views about their living arrangements - views that should be sought and respected by staff.

As part of the TAPS project, the baseline long-stay populations of Friern and Claybury Hospitals were compared using the TAPS assessment schedules. Each hospital has reduced bed numbers by two-thirds, and although the two have been subjected to different influences, their remaining long-stay patients were similar, and characterised by severe problems with hygiene, florid psychotic symptoms, a high prevalence of negative symptoms, and impoverished social networks.

The selection of patients for community reprovision during the first three years of an active closure programme at two large mental hospitals in the North East Thames Regional Health Authority was studied. It was found that a strong selection bias was operating: the patients selected were significantly younger, had spent less time in full-time psychiatric care, were less likely to have a diagnosis of schizophrenia, had larger social networks, and were more likely to want to leave hospital.

The extent of crime, vagrancy, death, and readmission in a prospective cohort of long-term mentally ill patients was measured during their first year out of hospital. All 278 long-stay psychiatric patients discharged during the first three years (1985-1988) of the closure of Friern and Claybury Hospitals were included. One patient was imprisoned, one committed suicide, and one became vagrant; five others may also have become vagrant. The mortality rate was similar for the leavers and their matched controls, who remained in hospital. There was one suicide among the matches. Mental deterioration most often caused readmission. On recovery, most patients returned to their community home. Six per cent of the cohort were readmitted and have remained in hospital for a year or more. With careful planning and a financial ‘dowry’ for each patient, the closure of large mental hospitals does not lead to a marked increase in vagrancy, crime, and mortality for the long-term mentally ill. However, the patients who have yet to leave have more problems of social behaviour and are likely to be more difficult to resettle.

The first prospective, controlled study of a large, long-stay, in-patient population as their hospital services were reprovided in the community is reported. Two-hundred-and-seventy-eight patients were matched individually with similar patients who remained in hospital. Clinical and social outcomes over a one-year follow-up are presented for the first three years of the reprovision process. Compared with matches, the leavers at follow-up had more diverse social networks that contained a higher proportion of contacts named as friends. The care facilities in the community allowed more opportunities for patient autonomy than the hospitals across all aspects of the environments measured. At follow-up, more leavers than matches wanted to remain in their current placement, while fewer leavers than matches said there was nothing they liked about their current placement. More leavers than matches found their medication helpful.