We’re standing in front of Jamie’s* door for the second time today. It’s been 10 minutes but at least it’s stopped raining. This could be any one of the hundreds of crumbling red brick terraced houses in Leeds.



It’s not a surprise that there’s no sign of Jamie, beyond the sounds of his dogs barking and the bass music reverberating inside. The door still hasn’t been fixed since it was forced by the police prior to his last admission three months ago. Just as we’re about to leave, Jamie opens the door.

Our focus on therapeutic relationships is often​ ​usurped by a short-term approach to long-term mental illness

It’s never certain what reception we will get. Sometimes Jamie thinks that we are one of the government agencies trying to harm him, and threatens us. But today he is eager to see us. It’s obvious why. His face is a mess. A fresh black eye, dried blood around his nose and painful looking scratches to his arms and knuckles. He is shirtless and painfully thin.

He explains that his newfound friends took his money, his food and even his trainers. He wanted to call us but had sold his phone to buy food for the dogs. He hasn’t dared take them out since the assault.

“Sorry, you can’t come in. I’ve not tidied up yet,” he adds.

Through the crack in the door I can see it’s worse than the last time I visited. The floor is littered with old food, empty cider bottles, threatening brown envelopes about bills and benefits, and unopened medication boxes. The dogs have had no choice but to relieve themselves inside among the detritus.

Jamie struggles to manage at home but he refused the offer of a spell in a rehabilitation unit after his last admission. He desperately wanted to be back with his dogs and was rejected for funding for self-directed support. The council are refusing to go inside to make badly needed repairs as are the cleaners we enlisted. Sadly the massing summer flies show no such aversion to Jamie’s property.

Jamie is frightened. “I know I said no before but I want to talk to the police this time.”

We agree to take him and we start to help him secure his broken door. Before we can leave, Jamie’s friends appear around the corner. They nod to him and without a word he shrugs his submission, opens the door and gestures them inside.

“See you later,” he says to us as he closes it behind them.

I work as a consultant psychiatrist in an assertive outreach team. It was once the next big thing but these teams have been discarded in many areas due to their perceived failure to reduce hospital admissions. Our focus on continuity and therapeutic relationships is often usurped by a short-term approach to long-term mental illness.

Jamie is one of many people I see who have complex issues. A psychotic illness compounded by substance use, a rejection of psychiatric services both statutory and otherwise, all compounded by the serious risks he faces – most significantly – from others. It’s a combination that has led to numerous detained admissions. Other than his friends, we are the only people Jamie regularly sees. We’ve hung in there over the years and he has come to trust us, at least some of the time.

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He has been accused of failing to engage by much-changed health and social care systems that have failed to engage with him. Apart from the times that Jamie becomes disturbed in public due to his intense psychotic experiences, he and people like him, remain largely hidden from society.

We work hard to support Jamie’s wish to remain in the community but there are many barriers. Without access to the right health and social support, yet another admission, most likely under the Mental Health Act, feels sadly inevitable. As this vicious circle continues to turn, and the stigmatising perception of him as a danger to society grows, he becomes increasingly likely to join the thousands of people currently in expensive, locked, often out-of-area psychiatric units. Even the support from teams like ours is something that has been myopically stolen from many people like Jamie across the country.

The Care Quality Commission’s report into the state of mental health services has shown a worrying expansion of institutional care, with increasing numbers of people spending long periods in locked rehabilitation units. Maybe it is time to consider whether we may have made the wrong decisions about how we provide health and social support for Jamie and those like him. Maybe it is time we started instead to re-invest in better and more accessible community care. We have a duty to assist this group in staying well, out of hospital and protected from the harm of long-term institutional care, which costs us all so dearly.

*Jamie is a pseudonym for an amalgam of Dr Nuwan Dissanayka’s experiences of patient care.

Dr Nuwan Dissanayaka is consultant psychiatrist at Leeds and York partnership NHS foundation trust

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