Commander & Disanyake (Psychiatric Bulletin, 30, 213–215) reported that the number of psychiatric in-patients in west Birmingham fell by one-third between 1992 and 2003 and attributed this change to functionalised community mental health teams. They have not discussed several other factors which I think are also relevant.

In 1992 there were about 5 consultant (adult) psychiatrists supported by about 10 junior doctors and a small number of nurses and social workers in the community, serving an inner-city population of about 250 000. By 2003 the number of mental health professionals, including doctors, had greatly increased (probably tripled) and west Birmingham had become part of the Birmingham and Solihull Mental Health Trust, covering a population of about 1.2 million. The large psychiatric hospital in west Birmingham had closed and was replaced by fewer admission wards and fewer continuing care wards. Several ‘ respite hostels’ were set up by the trust for patients who would have been admitted to hospital in the past, and residents may not have been counted as admissions. Beds were often full, and patients were sometimes moved to other psychiatric hospitals and occasionally to the private hospital in Birmingham.

With fewer beds, patients with depression and other psychiatric illnesses with less challenging behaviour who did not require admission under the Mental Health Act 1983 received out-patient care. This may explain the increase in the proportion of compulsorily detained patients. Wards were often full, with occupancy rates in excess of 100% most of the time.

I wonder if the fall in the number of people in hospital was not only due to the functionalised teams but also because there were fewer beds, more staff working in the community and other places for patient admission.