Shenley Hospital pulled down its shutters and bolted its doors for good last month after saying goodbye to its final patient. In its heyday it had housed more than 2,000 mentally ill residents.

When it was built in 1934 this Hertfordshire hospital was considered progressive compared with the previous generation of Victorian asylums. Its fate mirrors that of many other mental health institutions, which have closed as patients have benefited from new treatment and the trend towards care in the community has gathered pace.

But in the light of The New NHS white paper, managers and policy experts fear mental health patients could again become institutionalised and isolated.

They have urged extreme caution in mapping the way forward, saying an 'obsession' with structures could be damaging.

It is unclear from the white paper how far mental health services will be commissioned by primary care groups. But the paper does state that primary care trusts will not be expected to take responsibility for specialised mental health or learning disability services.

Where health and social care boundaries are not fixed, where joint working is particularly important and where an integrated range of services from community to hospital care is required, it says, specialist mental health trusts are likely to be the best mechanism for co-ordinating service delivery. This is all very well. But no one seems to know what is meant by a specialist mental health trust.

Tom McCarthy, director of the Mental Health Strategies consultancy, says it could mean either a trust providing a range of specialist services, such as child eating disorders; or a trust providing all mental health services within a locality.

If it means the locality, he thinks it is a good idea, arguing that district general hospitals, faced with competing pressures, are unable to give mental health the attention it needs.

Others are more sceptical. Fiona Wise, chief executive of Enfield Community Care trust, warns that specialist trusts could mean mental health services become stigmatised again.

And Matt Muijen, director of the Sainsbury Centre for Mental Health, argues there is a danger they could become over-large organisations under the pressure to merge if community services move into primary care groups.

This will particularly affect combined trusts, which are unlikely to survive if they lose a sizeable chunk of their income.

If mergers do happen, 'we will end up with what we are trying to avoid', Dr Muijen says. He is, however, not entirely negative about specialist trusts.

They could be a good thing, he ventures, if they attract resources and if boundaries are not erected between them and other health sectors.

Dr Muijen believes lack of clarity in the white paper hasn't helped. Firm decisions are needed if mental health services are not to become the 'orphan' of the NHS, he says.

Peter Clargke, chief executive of Mental Health Services of Salford trust, completely rejects the view that the creation of specialist trusts will result in care becoming institutionalised and mental health patients isolated.

'I am not saying specialist mental health trusts are the only option, but there is no reason why they should be seen as a return to institutionalised care,' he says. Mr Clarke believes there are 'massive opportunities to move mental health in the direction it aspires to go, but that direction requires careful thinking'. He adds: 'We will not do that thinking if people persist in arguing about structures.'

As the arguments rage on about the 'stand-alone' trust, so the jury is still out on what involvement GPs should have.

Some managers believe the white paper is carefully worded to avoid mental health being 'taken over' by primary care groups. That is the reason specialist trusts are mentioned at all, they argue.

Edward Peck, director of the centre for mental health services development at King's College, London, says: 'There were complaints that GP fundholders were destroying mental health services, but that is a myth. Even so, this rider was put in about specialist trusts. If we are cutting off mental health services from GPs, that seems a mistake. GPs are part of the solution, not the problem.'

The future of community trusts is clearer: in the long term, as primary care trusts emerge, they don't have one.

Mist opportunities?

Does the white paper's vagueness about mental health services mean they will once again be isolated and stigmatised, asks Dolly Chadda