1. health and fitness

Starting Today - Background Paper 1: History of specialist mental health services
A brief history of specialist mental health services
Authors: Simon Lawton-Smith, Dr Andrew McCulloch, Mental Health Foundation
Many historians such as Roy Porter (2002) and Charles Webster (2002) have written
in detail about the development of specialist mental health services in the western
world The following background note attempts to summarise just some of the main
trends in how modern mental health policy and practice has evolved in the UK with a
view to informing the Inquiry Panel’s analysis. This note focuses mainly on the period
from the second world war to the present day, and specialist rather than primary
mental health care services.
Prior to Victorian times
There is evidence that people with major mental health problems have been
segregated either for care or containment for centuries. There are various accounts
of the development of the psychiatric hospital in the “dark” ages. For example,
Howells (Howells,J. 1975) refers to psychiatric care developing as part of general
hospitals in Islamic countries from the 8th century, and in India from the 10th
century. Dedicated hospitals for people with mental health problems and other
conditions in England go back at least as far as the Middle Ages (The Bethlem
Hospital was founded in 1247). Treatments offered included milieu therapy in
therapeutic communities and counselling as well as more archaic approaches.
Charitable provision developed as society and the economy developed, and further
asylums were opened, but generally most people with mental illness received no
organised systematic care until the 19th century. However, there was a strong
tradition of documenting and describing mental illness by the likes of Burton
(Burton,R. 1621, 2001). There were also some prototypical attempts at community
care such as boarding out from 1750 onwards (Bartlett,P. and Wright,D. 1999). Early
asylum treatments were primitive, usually involving sedative drugs like laudanum,
which were administered orally, and baths in various forms as a method of calming
agitated patients (Bewley, 2008). The asylums provided long term residential care
for a wide mixture of people including people with severe mental health problems,
dementias such as those resulting from tertiary syphilis, learning disabilities, epilepsy
and “moral defectiveness” (e.g. having an illegitimate child out of wedlock).
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Starting Today - Background Paper 1: History of specialist mental health services
Porter (2002) writes how the end of the 18th century saw 'the first wave of public
asylums', institutions that sprang up following the growth of the charitable hospital
movement. The last years of 18th century and the beginning of 19th century saw 'a
move away from unregulated and ad hoc local arrangements to a system which was
increasingly segregative, centralised and managed' (Rogers, A. & Pilgrim, D. 2001).
Barnes and Bowl argue that it was during the Victorian period that Enlightenment
ideas formed in the previous century were cemented, rational science replacing
religious belief and culminating in the emergence of psychiatry as a new and distinct
discipline (Barnes, M & Bowl, R, 2001).
The era of the asylums
The story of modern psychiatric care is relatively well documented. Modern mental
health policy could be said to have started with the introduction of legislation to
control the governance of lunatic asylums in early Victorian times and has evolved
from there. The central pieces of legislation were the 1845 Lunacy Act and County
Asylums Act, which made compulsory the provision of public asylums for all pauper
lunatics by local authorities. A few decades later, the 1890 Lunacy Act gave asylums
a wider role, and patients with means began to be admitted. The emergence of the
Victorian asylum in England was paralleled in most, if not all, developed countries to
a greater or lesser extent, including France, Italy, the United States and the countries
of the former Soviet Union.
After the first world war more modern approaches such as psychotherapy started to
evolve, in response to the effects of thousands of shell shock cases, which Stone
(Stone, M 1985) argues put an end to 'the monolithic theory of hereditary
degeneration upon which Victorian psychiatry had based its social and scientific
vision’. Another milestone came in 1926 with the publication of a report by The Royal
Commission on Lunacy and Mental Disorder which stated that 'mental and physical
illness should now be seen as overlapping and not as distinct' (Rogers & Pilgrim op
cit). After the second world war charitable and local authority mental health services,
mainly still asylum based, were mostly incorporated into the NHS. Numbers of
patients in asylums peaked in the mid-1950s. The 1959 Mental Health Act abolished
the distinction between psychiatric and other hospitals and encouraged the
development of community care. At its height – in the mid-1950s - asylums in
England accommodated 150,000 people (0.4% of the total population).
De-institutionalisation
Asylum-based care was the main model of psychiatric care for people with a mental
illness until the 1960s when a combination of advances in psychiatry and drug
treatment, greater emphasis on human rights, and advances in social science and
philosophy including labelling and institutionalisation theory, combined to start the
de-institutionalisation movement. In England this became explicit Government policy
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Starting Today - Background Paper 1: History of specialist mental health services
in the 1960s and this was paralleled in other countries which used administrative
policy to gradually close institutions. Some countries such as Italy took stronger
action through legislation (in this case Nuova Legge 180) to abolish the mental
asylum.
Deinstitutionalisation has therefore been one of the primary drivers behind the
development of modern care. It has been defined as “the process of moving patients
from large scale psychiatric institutions towards the community, where alternative
psychiatric services strive to provide care and support in the client’s community,
together with more modern and appropriate treatment with better outcomes. Its main
goal is to empower and emancipate people with psychiatric and social problems,
enabling them to be fully participating members of society.” (Bauduin,D.,
McCulloch,A. and Liegeois,A. 2002). Deinstitutionalisation and community care are
also at the heart of international policy development (WHO 2001, WHO 2005).
The development of modern care
Since the 1960s Governments, municipalities and health care systems across the
developing world have worked to a greater or lesser extent towards the goal of
implementing community based mental health services. Reform started early in a
number of countries including the United States, Italy, England, Australia, New
Zealand and the Scandinavian countries. Some of the most comprehensive models
have been developed in countries like Australia where complex sets of teams
interact to provide treatment and support for different groups of people with different
age and need profiles, supported by some inpatient and residential care and housing
and welfare benefits packages. This “comprehensive model of care” is necessary to
support de-institutionalisation, because of the complexity of need among people with
more severe mental health problems.. The many functions provided in the traditional
asylums - including health care, housing, food, occupation and leisure, arguably
none very satisfactorily (Goffman, A. 1959) - had to be unpacked, and rearranged on
an individual basis after individual assessments by many different agencies in
community settings.
In most European countries, including within the United Kingdom, the initial aim has
been to develop a model of care based on a combination of some long term
provision, often still based in the old mental hospitals, with acute psychiatric units in
District General Hospitals and community mental health teams within the community
(McCulloch, A., Muijen and Harper. 2000). Across the UK the asylums started to
decline in size in the 1950s and this policy direction was explicitly acknowledged in
Enoch Powell's ‘water tower’ speech in 1961 (http://studymore.org.uk/xpowell.htm).
Almost all of the old asylums are now closed, depending on how closure is defined.
During the 1970s more detailed and explicit mental health policies began to emerge
dealing with the establishment of acute psychiatric units in general hospitals and the
beginnings of community care. However, many would argue that during the initial
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period of the decline of asylums the needs of people with severe and enduring
mental illness, especially those with deteriorating conditions, were not well
addressed in policy. There was an erroneous view that, once the asylums were
closed, a new generation of damaged people who had not been institutionalised
would not develop schizophrenia with concurrent cognitive decline, perhaps because
the cognitive decline was seen as a consequence of institutionalisation. Initially this
group was not well provided for but in the early 1990s it was realised they needed
particular support. This happened through a mixture of assertive outreach, 24 hour
nursed care or residential provision depending on severity. So a comprehensive
model had to be adopted instead, closing the mental hospitals and creating a range
of community facilities teams, each with complementary functions. This process is
described in more detail below.
The development of modern treatments and care
In terms of treatments over the least 50 or so years, the first were primarily of a
somatic type. These included insulin coma treatment which involved patients being
injected with increasing doses of insulin to induce short hypoglaecemic comas,
which were then terminated using doses of intravenous glucose. The aim of the
treatment was to make changes to the adrenal system which was thought to be the
physiological root of schizophrenic illnesses (Shives, 2008). The decline of the
therapy was signalled by a 1953 Lancet paper by Dr Harold Bourne, who claimed
that the treatment had no real effect on schizophrenic illnesses (Bewley, 2008).
Electroconvulsive Therapy (ECT) was used from the beginning of the 1940s, first in
an unmodified form but then in tandem with muscle relaxants, to prevent injuries
from seizures. The treatment took the form of electrically induced seizures that alter
brain chemistry to rectify mood or thought disorder. By the 1960s the use of ECT
declined but it is still used up to the present day in regulated circumstances, mainly
to treat severe depression which has not responded to other forms of treatment.
More radical treatments such as lobotomies, originating in 1936, involved severing
connections within the brain through invasive surgery and were designed to modify
disturbed behaviour and mood. This treatment became increasingly controversial
and its crudeness and inexact nature caused the practise be phased out towards the
end of the 1950s, at a time when new medications started to arrive. In the relatively
short period time in which they were used, at least 15,000 of these operations were
performed in Britain. (Bewley, 2008)
A major change in treatment came with the rise of new drugs in the 50s and 60s,
including the first antipsychotic Chlorpromazine, which was first synthesized in 1950,
and the mood stabliser lithium. The use of these drugs was a major factor in allowing
people to be treated in the community rather than in hospital. The 1960s also saw
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the rise of talking treatments, reflected in an increasing diversification of mental
health professional roles.
Mental health policy from 1979 to 1997
Mental health policy during the Conservative administration of this period was
primarily aimed at addressing the consequences of the closure of the old asylums
and expansion of community care. In 1983 a forward-looking Mental Health Act was
introduced which consisted essentially of a substantial update of the landmark 1959
Act. Reforms included the creation of a Mental Health Act Commission to defend the
rights of detained patients. However in the latter part of the 1980s it became
increasingly clear that the model of providing care via hospital beds and
undifferentiated community services would not succeed in meeting the needs of a
core group of people with severe and enduring mental illness.
To try to address this, the Care Programme Approach (CPA) was introduced in 1990
to provide a framework for effective mental health care for people with severe mental
health problems (Mental Health Law Online, 2013). Its four main elements were
systematic arrangements for assessing the health and social needs of people
accepted into specialist mental health services; the formation of a care plan which
identifies the health and social care required from a variety of providers; the
appointment of a key worker (care coordinator) to keep in close touch with the
service user, and to monitor and coordinate care; and regular review and, where
necessary, agreed changes to the care plan.
Much of policy from this point on was about addressing the needs of this group and
responding to inquiries into homicides by people with severe mental illness
(McCulloch and Parker, 2004). The inquiry into the killing of a social worker by a
patient at Bexley Hospital (Sharon Campbell) was one such event which led to the
introduction of obligatory care planning for people requiring secondary mental health
care. Other changes included the introduction of supervision registers, conditional
discharge from hospital and compulsory inquiries into serious incidents. This created
a new risk management industry some of it perhaps beneficial and some certainly
not.
Alongside this, there was also a healthy emphasis (if not always backed by financial
resources) on public mental health in documents such as the Mental Illness Key
Area handbook, part of the Health of the Nation initiative, and on developing
specialist services for groups such as children and homeless people. Some of this
activity set the scene for the major development programme which came under New
Labour.
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Starting Today - Background Paper 1: History of specialist mental health services
Policy under New Labour (1999-2010)
Scotland and Northern Ireland (since 1998) and Wales (since 1999) have been able
to develop their own mental health policies and service delivery systems under
devolved powers from Westminster. Each has published mental health strategies
and frameworks outlining these policies. There are many consistencies between the
policies developed across the UK, including reductions in inpatient bed numbers, the
development of a wider range community services, more involvement of mental
health service users and carers in decisions about care, suicide reduction, the
growth of advocacy and peer support services, and a greater emphasis on the
recovery model of care and provision of psychological therapy. However for the
purpose of this short background paper, we limit ourselves below to highlighting
some of the developments that took place in England.
The National Service Framework in England
When the National Service Framework for Mental Health (NSF) (Department of
Health, 1999) was launched, the Sainsbury Centre for Mental Health commented:
"For the first time, Government has set out a comprehensive agenda for
mental health services which acknowledges that the whole system of mental
health care must be made to work if we are to succeed in modernising care."
(SCMH, 1999)
Whilst the NSF was radically new in terms of its comprehensiveness and ambition it
can be located within a general attempt to develop health care policy on a more
comprehensive, evidence based way (McCulloch, Glover and St John, 2003). The
NSF set out seven Standards which were really key areas for service and practice
development, summarised in the box below. The NSFMH 1999 was for adults of
working age (16-65). Standards for the mental health of older people were set out in
the NSF for older people (2001) and for children in the NSF for children and young
people (2004).
The National Service Framework for Mental Health (1999) standards
Standard 1 aims to ensure health and social services promote mental health
and reduce the discrimination and social exclusion associated with mental
health problems.
Standards 2 and 3 aims to deliver better primary mental health care, and to
ensure consistent advice and help for people with mental health needs,
including primary care services for individuals with severe mental illness.
Standards 4 and 5 aims to ensure that each person with severe mental
illness receives the range of mental health services they need; that crises are
anticipated or prevented where possible; prompt and effective help if a crisis
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does occur; timely access to an appropriate and safe mental health place or
hospital bed, including a secure bed, as close to home as possible.
Standard 6 aims to ensure health and social services assess the needs of
carers who provide regular and substantial care for those with severe mental
illness, and provide care to meet their needs.
Standard 7 aims to ensure that health and social services play their full part
in the achievement of the target in set in a previous public health white paper
to reduce the suicide rate by at least one fifth by 2010.
Inevitably with such a wide-ranging document there were some confusions and
contradictions and there was a subsequent debate about differing emphases on
safety and compulsion as opposed to care and choice, for example. However, there
seem to be six readily definable core aims that can be deduced from the document
(McCulloch, Glover and St John, 2003):
1. Modernising primary, secondary and tertiary mental health care
2. Improving public mental health
3. Reducing suicide
4. Improving public safety
5. Improving the quality of care
6. Improving support for carers.
Of these 1, 4 and 5 were given the most emphasis in words and actions.
The NHS Plan
The year after the NSF was published the NHS Plan (Department of Health, 2000)
put in place the targets and money that made parts of the NSF a reality – specifically
improvements in forensic services and intensive community care teams. Three
critical targets were the focus of much management action within mental health
services:



50 early intervention teams to be in place by 2004
335 crisis resolution teams by 2004
220 assertive outreach teams by 2003.
Implementation of the NSF and NHS Plan/Achievements
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Starting Today - Background Paper 1: History of specialist mental health services
Supporters of mental health policy during the New Labour years tend to focus on
seven key areas of achievement:
1. The reform of community care to provide a much more intensive and
comprehensive service. This resulted in networks of intensive community
care teams in many areas (Early Intervention, Assertive Outreach and
Crisis Intervention) along Australian lines
2. Reductions in suicide rates nationally
3. Large investment in mental health services of perhaps £2bn in real terms
and staffing increases averaging about one third. There were large
increases in some groups such as clinical psychologists and unqualified
support workers and significant ones in psychiatrists and mental health
nurses
4. Improvements in in-patient care with around 70% of patients in private
rooms
5. Increased use of new drugs and therapies including psychotherapy
6. Higher patient satisfaction
7. Investment in older people's and children's services.
A more specific analysis by NSF standards tends to show a more mixed picture. In
relation to Standard 1 (Promotion and Prevention) there were very few achievements
and no evidence of improved public mental health in terms of reduced prevalence of
mental disorders. Prevalence rates of mental disorders have remained broadly
consistent over the past 15 to 20 years, although there has been some deterioration
of the mental health of middle aged women as shown by epidemiological surveys.
Due to an increasingly ageing population, dementia is also increasing in line with
demography. Child mental health problems have remained steady at the high levels
of 1990s. This poor progress is reflected by very low levels of investment in public
mental health – arguably other Ministries such as Education have invested more in
emotional wellbeing than Health (between 2000 and 2009 only around 0.1% of
annual NHS adult mental health spend was spent on mental health promotion, the
subject of Standard One).
In terms of Standards 2 and 3 (Primary Mental Health Care) there have been some
ad hoc improvements, but these are hard to measure. GPs use interventions other
than medication sporadically - many wish to do so but face limited local availability or
a lack of knowledge about alternative provision. The development of psychological
therapies is making some progress but is struggling on the ground.
The greatest achievements seem to be in relation to Standards 4 and 5 (Secondary
Care) which appears to have improved in both quality and quantity and is regarded
as being amongst the best in the world for a public sector mental health service.
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However, large resources are being spent on secure care and some inpatient care
without clear beneficial outcomes. Services are still not fully user or recovery
oriented although some good progress has been made. The Mental Health Act 2007
introduced Community Treatment Orders as a mechanism by which more sectioned
patients could be treated in the community rather than in hospital, but the Orders
have been controversial and evidence of their effectiveness is lacking.
In relation to Standard 6 (Carers) little was achieved except to introduce carer's
assessments and there is little value in assessment in isolation. On Standard 7 a
good suicide prevention strategy was put in place and suicide reduced over the
decade, although a causal link between the two is hard to demonstrate.
Overall, it appears that major progress was made in mental health service
development during the new Labour years but with a number of key deficits:
(a) there were and are no plans to deal with ineffective services such as
unfocused day care and counselling for. Inpatient care also lacks an absolute
evidence base but progress has been made to reform this
(b) secure settings and prisons seem to be used as modern asylums at huge
financial and human cost
(c) services remains poorer and patchy for children and young adults, older
people, people from ethnic minorities and people with a learning disability
(d) there remains a lack of adequate investment in promotion and prevention
(e) services are still too medically focused and too downstream with not
enough early intervention, housing and employment services
(f) the workforce model is arguably too top heavy and lacking integration, for
example, between psychology and other services
(g) service user and carer input into policy has been poor although their input
into many local services has improved
(h) there was no clear hierarchy of priorities, giving the impression that policy
is unachievable as a whole.
However, the implementation of the NSF left a positive legacy as a whole leaving
England with arguably the most highly developed mental health services of any large
country in the world.
Since 2010
The current Government published a new mental health strategy for England in
2011. This has not substantively shifted the overall policy focus, although it has
reframed it under six ‘shared objectives’:
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Starting Today - Background Paper 1: History of specialist mental health services
i.
More people will have good mental health. Fewer people will develop mental
health problems – by starting well, developing well, working well, living well
and ageing well.
ii.
More people with mental health problems will recover. More people who
develop mental health problems will have a good quality of life – greater ability
to manage their own lives, stronger social relationships, a greater sense of
purpose, the skills they need for living and working, improved chances in
education, better employment rates and a suitable and stable place to live.
iii.
More people with mental health problems will have good physical health.
Fewer people with mental health problems will die prematurely, and more
people with physical ill health will have better mental health.
iv.
More people will have a positive experience of care and support. Care and
support, wherever it takes place, should offer access to timely, evidencebased interventions and approaches that give people the greatest choice and
control over their own lives, in the least restrictive environment, and should
ensure that people’s human rights are protected.
v.
Fewer people will suffer avoidable harm. People receiving care and support
should have confidence that the services they use are of the highest quality
and at least as safe as any other public service.
vi.
Fewer people will experience stigma and discrimination. Public understanding
of mental health will improve and, as a result, negative attitudes and
behaviours to people with mental health problems will decrease.
The strategy was widely welcomed, but the economic recession of the past three
years has led to significant extra pressures on parts of the population (including
threat of loss of job and housing, and increased levels of debt) that has led to an
increase in reported common mental disorders, and the suicide rate has risen. At the
same time public service spending restraints have led to cuts in NHS and local
authority services that are severely challenging the ability of the new strategy to
achieve its intended objectives.
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