In the current issue of EBMH John Markowitz makes an impassioned plea for the revival of inpatient psychiatry – which if trends in the US continue may soon become a thing of the past. He pours scorn on the idea that bed days and numbers have been cut because of increased clinical effectiveness and is convinced that the primary motivating factor is reduced costs. This is a view that will be shared, I’m sure, by many mental health professionals in the UK.

Psychiatric beds in England have been cut to about one fifth of the number available in the 1960s. Social and political pressures originally drove the reduction, with perhaps some help from the introduction of chlorpromazine. A principal aim of course was to close the asylums. As a junior doctor I worked in one of these forbidding institutions on the outskirts of London, shortly before its closure. I have to say my abiding memory of working there is one of plentiful space, greenery, and a fairly easy workload. A singular perspective though and anyone looking for a less nostalgic view should take a look at the recently published “Bedlam: London and It’s Mad” by Catherine Arnold. This richly anecdotal social history chronicles the development of the asylum to the Victorian institutions: with as many as 3000 beds these were warehouses where brutality and neglect were commonplace.

Care in the community, to use that rather trite label, is now widely regarded as the ideal model but what remains of inpatient psychiatry? With the development of community services and more stringent criteria for admission, only the most unwell and often most difficult patients get into hospital, an environment that you might struggle to call therapeutic. Unsafe, understaffed, and unsanitary: not surprisingly, newly trained nursing staff are keen to abandon ship as soon as possible and join the specialist community teams. Is ‘the patient experience’ on an inpatient ward really any better than what was provided 40 years ago? Cost, as Markowitz argues, is important and it remains the case that mental health struggles to attract funding, but we also have to ask what we want of inpatient services? Are psychiatric wards simply holding cells for the topping up of antipsychotics, or do we have more to offer?