The period of community care coincided with the initial stages of what came to be termed neoliberalism. These policies led to increased inequality, which has produced social and economic segregation (Savage, 2015). These developments have social, psychological and economic impacts (Wilkinson and Pickett, 2010). There are huge differences between the physical and mental health of the richest and poorest in society. The early development of these increasing divisions can be traced back to the 1980s. These differences are starkest in the most unequal societies. More equal societies with progressive welfare and health systems mitigate these potentially adverse outcomes (Marmot, 2015). There was a brief period under the first New Labour government where increased investment in social welfare halted some of these developments. However, they have been intensified during the austerity since 2010 (Cummins, 2018). In many ways, the progressive arguments for community care in the mental health sector assumed continued broader investment in social welfare provisions. There was an implicit view that a shift from spending money on institutionalised psychiatry to community mental health services would not only take place but also lead to better outcomes for service users.
From the late 1990s onwards, in the UK and across Europe, there has been an ongoing moral panic (Cohen, 2011) about the ‘ghettoisation’ of socially deprived urban areas. The term ghetto – in modern usage – suggests an area of poor housing, poverty, substance misuse problems, high crime and gang violence. It also has racist overtones.
More recently in the UK, governments of all political persuasions have been concerned with the issue of ‘sink’ estates. Slater (2018) demonstrates that the term ‘sink estate’, which is often presented as an academic or sociological term, was invented by journalists. Its use was then extended by free market think tanks before becoming a form of policy doxa. It was used as a shorthand for areas that allegedly create a range of social problems such as poverty, worklessness and welfare dependency. Slater (2009) argues that the ghetto is a social and psychological space with its boundaries created by ethnicity. Although these spaces were originally the result of discrimination, they also generate forms of community organisation.
Wacquant (2008a, 2008b, 2009a, 2009b) suggests that modern, urban, spatially concentrated forms of poverty have made it more difficult to sustain social and community institutions. Fordism had been associated with a range of previously strong civic institutions, ranging from political to social and from trade unions to sports and youth clubs. Changing patterns of employment and the increase in precarity have been a key factor here. It is very important to note that Wacquant is not suggesting that such social systems do not exist. For example, his Body and Soul (2000) examines the experience of young black men who use a gym in Chicago and considers the function of these informal structures in some detail. In a similar vein, McKenzie’s (2015) portrait of life on a Nottingham estate – Getting By – focuses not only on the economic and social pressures facing the residents but also the ways in which they overcome them.
Wacquant (2007) terms this ‘territorial stigmatization’ – the processes whereby areas are characterised by:
… forms of poverty that are neither residual, nor cyclical or transitional, but inscribed in the future of contemporary societies insofar as they are fed by the ongoing fragmentation of the wage labour relationship, the functional disconnection of dispossessed neighbourhoods from the national and global economies, and the reconfiguration of the welfare state in the polarizing city. (Wacquant, 2007: 66–7)
Media representations of community care as a failing policy focused on either the neglect of patients or an increased risk to the public. The longer the policy was in the public eye, the more the media focus was on the alleged increased risk that former psychiatric patients posed to their fellow citizens. There is a similar arc here to the asylum narratives outlined earlier. The failings of the policy in its later iterations acts as a prism through which the whole prism is viewed. This obscures not only positive aspects of earlier periods but also means that the narratives of those who might have spent their lives in institutions but did not are never examined or are lost. By 1984, there were 71,000 inpatients, roughly half the number when Powell made his Water Tower speech in 1961. Leff and Triemann (2000) argue that the first wave of community care was largely seen as a positive move. This period saw the resettlement of long-stay patients. These patients were, on the whole, better supported by mental health services. One key aspect of this was the fact that resettlement often involved the use of specific funding for that purpose. Later, community care services had to compete with others for access to increasingly squeezed funds.
As with deinstitutionalisation in the US, community care rather rapidly became associated with street homelessness or people living in very poor accommodation. Scull (1986), in criticising the impact of deinstitutionalisation, identifies what he terms a modern trade in lunacy. He notes that the irony of a policy developed to deal with the abuses of the asylum regime leading to concerns about vulnerable people being exploited by unscrupulous private landlords. Similar concerns in the early 19th century had been a driving force in the establishment of the original asylums. In 1976, John Pilger, then a campaigning journalist for the Daily Mirror, wrote an expose of the way that psychiatric patients were being discharged to bed and breakfast (B&B) accommodation with no support or follow up. Pilger report is based in Birmingham, which he describes as a ‘city of lost souls’. The article reports that former patients are living in crowded, often insanitary conditions. They are often not allowed