Mental Health History 1975 Better Services for the Mentally Ill

"We believe that the philosophy of integration rather than isolation which, has been the underlying theme of development still holds good" (Better Services 1975 par 2.17).

Better Services for the Mentally Ill, a 91 page 'White Paper' was presented "by Barbara Castle, as Secretary of State at the DHSS, in October 1975. It was nick-named "Castles in the Air" by one radical group (COPE) because this long-term strategic document, pointing out the general direction the Government "wanted services to take, was prefaced with the statement that little progress could be made until the economic situation improved (p iv).

The Paper placed its emphasis on the provision of a comprehensive range of local services (described later) rather than the closure of asylums:-

"...our main aim is not the closure or rundown of the mental illness hospitals as such? but rather to replace them with a local and better range of facilities. It will not normally be possible for a mental hospital to be closed until the full range of facilities described" (in the paper) "has been provided throughout its catchment area and has shown itself capable of providing for newly arising patients a comprehensive service independent of the mental hospital. Moreover, even then, it will not be possible to close the hospital until I it is no longer required for the long stay patients admitted to its care before the local services came into operation" (par 11.5).

Given the economic situation the White Paper was exceptionally hazy about time scales. Providing the local services it proposed required (at November 1974 prices) an average annual capital expenditure of £30 million by the NHS and £8 million by councils over a 20 to 30 year period (par 11.8). Councils had actually spent only about £3 million in this field in 1974/1975 and although the NHS figure was about that actually spent in 1972/1973, less bad been spent since the health cuts (Priorities 1976 introduction and pars 8.9 + 8.10).

The White Paper said investment on the scale needed would not be possible "over the next three or four years" (par 11.5) but in 1976, by giving 'deprived sectors' 'priority' over general and acute hospital provision, a rate of development was proposed which "if maintained" would enable the 'Better Services' aims to be achieved over most of the country within 25 years (Priorities 1976 introduction and pars 8.9 + 8.10).

Although perhaps not as clear as it might have been, one could deduce from Better Services that many asylums were to maintain an active life well into the 21st century, and the White Paper said (p 88, par l) that they would contain the majority of patients "for many years to come".

The House of Commons was later told (*) that at the end. of 1975 only 8.1% of mental illness beds were in general hospitals so, presumably, over 90% of in-patients were still in the old asylums. 30% of admissions, however, were in District General Hospital units, so mental hospitals clearly contained a disproportionate percentage of long stay patients.

During the (now long) transitional period to local services the health authorities were to continue with a 1971 memorandum recommendation to split asylums into "divisions" each serving the district in which local facilities were being developed to replace it.

"In this way it is hoped that staff will increasingly think...in terms of a district service which, wherever it is provided, whether from a mental hospital "division", a general hospital psychiatric unit, a community hospital, or in...supportive work in the community itself, is all part of the same district service." (PP 88-9, pars 3-5. See also HM(71)97, par 14)

The "Old Long-Stay" Patients

A 1961 forecast of how many hospital places would be needed in the mid 1970s was based on a belief that the 110,000 long-stay patients in 1954 would have died or been re-habilitated by about 1970 (Tooth + Brooke, 1961, section on "Rate of Reduction of Long-Stay Population")

In 1971, 30,000 of them were still in hospital, their numbers were only slowly declining and as almost half were under 65 years old the veteran residents of the old asylums were unlikely to fade away for several years (pars 2.4 + 2.15).

In 1971 patients who had been in hospital for five years or more occupied 50% of the beds (England and Vales) and 30% had been in hospital for more than 20 years (WHO 1976, pp 8 + 57; Lader, M. in Meacher, M. 1979, p.37)

The White Paper referred to some, or all, of these patients as old long-stay, as distinct from new long-stay

New long-stay patients are those who:

"despite advances in treatment or staffing" are still becoming chronic in-patients in "significant numbers" (par 4.52).

The exact distinction between new and old is not clear. At least four definitions - each involving a different concept - appear to me explicit or implicit in the White Paper and its associated literature. For old long-stay these are:-

• Pragmatic Definition: Long-stay patients admitted, to a mental hospital "before a comprehensive district psychiatric service is established - a definition implicit in Better Services.

• Historical Definition: Patients "who became long-stay before the recent acceleration in discharge rates" (Wing, J.K. 1973, P 28) or, "whose need for long-stay hospital treatment is the result of past and less advanced patterns of treatment" (Better Services 1975 par 4.51).

• Humanitarian Definition: Patients so 'institutionalised' that it would be 'inhuman' to discharge them. (See below)

• Statistical Definition: People who have been in-patients for over 5 (or whatever) years. (WH0 1978, pp 8 + 57)

According to the 'White Paper a great deal of effort in the 1950s and 1960s had been put into rehabilitation work with long-stay patients - but in practice it had rarely proved possible to discharge to the community and hospitals had lost interest in rehabilitating chronic patients (par 2.12).

Many old long-stay patients, it said, were not in hospital because they needed specialist hospital services, but because:-

"they either need other forms of shelter and support which are at present not available outside hospital, or have become so accustomed to hospital life - in some cases so institutionalised - that it would be inhuman to discharge them from the hospital that has in fact become their home." (par 4.51)

The humanitarian argument was a superfluous gloss. Economic considerations were to determine that old long-stay residents remained in the asylums. The Government's Priorities paper in 1976 took pains to explain that the network of district services outlined in Better Services was only intended to take over from the mental hospitals the care and treatment of new patients. The scale of facilities would not enable it

"to take over responsibility for the diminishing group of 'old long-stay' patients". (Priorities 1976 par 8.4)

Money was, however, to be spent maintaining the physical structure and improving the standards of decoration, toilet and other facilities in mental hospitals because this was "essential" to maintain the "morale of the staff" and to ease the "burden of nursing an increasingly ageing in-patient population" (Better Services 1975 p 90 par 12).

The "New Long-Stay" Patients

It was the "new" long-stay - those who remained in hospital despite modern treatment methods - that the "new pattern" of comprehensive local services was intended, eventually, to benefit. Sir Keith Joseph had spoken optimistically of "the small proportion of patients who will require relatively longer stay" (EC Hansard 7/12/1971 col 280) but Better Services pointed, out that:-

"While this group may be relatively few...the implications in terms of resources are quite disproportionate to their numbers" (Better Services 1975 par 1.16)

If of 100 patients entering a hospital, one remains for 10 years and the others stay an average of only 5 weeks then the one long-stay patient will use the same amount of bed-space as all the 99 short-stay patients.

An article in the British Medical Journal (7/3/1972) estimated that if chronic patients represented only 1% of all acute hospital admissions, after only 7 years they would have silted up half the beds in District General Hospital Psychiatric Units. (Cited MIND/13, p 7)

Better Services quoted estimates (*) that about one in three of the newly arising long-stay patients not suffering from dementia needed 24 hour medical and nursing supervision.

* The estimates appear to have been based on Wing, J.K., 1973» but the 'White Paper also cited research the DHSS had commissioned by Dr Sheila Mann and Mrs Wendy Cree (Mann, S.A. + Cree, V., 1976).

They were, predominantly, patients diagnosed "chronic schizophrenic" - who were "particularly prone to be slow, -withdrawn and liable to neglect themselves" (pars 4.52 + 4.53). 'Hospital' had to be 'home' as well for such patients and a ward in a District General Hospital Psychiatric Unit could not provide a sufficiently domestic environment for patients who stayed more than a year (par 4.53).

The other two-thirds, with the exception of small numbers in special categories, did not need hospital care, but were in hospital because the long-term sheltered accommodation in the community they needed was virtually non-existent (par 4.52 + Wing, J.K. 1973, P 30).

The White Paper's Guidelines for council accommodation repeated guidelines issued in 1972 (DHSS 35/72 par 42) with the emphasis on long- term accommodation instead of hostels. But the value of such guidelines depended on councils taking note of them. As late as November 1979, my local borough, Hackney, recorded in its social services minutes that the difficulties of its new 20 bed hostel were due to consultants referring "long-stay clients".

Hospital Hostels A suggested approach to the needs of long-stay patients who needed residential accommodation with medical and nursing supervision was a "Hospital Hostel" - a large house, reasonably close to the psychiatric unit, in which residents could be cared for in a domestic atmosphere, but with night nursing supervision. By day they would go to the day hospital, to council day centres or, perhaps, to sheltered work (pars 4.52 - 4.54).

The first (experimental) hospital- hostel was established at the Maudsley Hospital, South London, in 1977 (Wing in Wing + Olsen, 1979, p.10).

The Elderly

Patients over 65 formed. 20-25% of admissions to mental illness hospitals and units in 1975 (par 4.l0) and, as at Whittingham, their care was mainly being left to the mental hospitals. Better Services suggested priority development of local services for the elderly to counter the emergence of this 'two-tier' system.

Assessment of elderly patients' needs should, wherever possible, take place at home or in out-patient clinics because

"the physical uprooting of an old person is in itself a traumatic experience" (par 4.10).

Where this was not possible in-patient assessment should take place in a local unit even where a District General Hospital psychiatric unit had not yet been established - small 'joint assessment' units could be provided in the geriatric department of the District General Hospital (par 4.11).

In its comments on the 1972 memorandum, MIND had stressed the importance of such units pointing out that in one area only 10% of those admitted to a local assessment unit were found to be in need of long term hospital care (MIND/9, p 4).

In the new pattern of services, hospital admission, where necessary, would usually be to a psychiatric unit. In some districts a psychiatrist with special responsibility for elderly people had been appointed and this could facilitate links with geriatric physicians, G.Ps and social services departments (par 4.10).

Community Hospitals for patients with severe dementia needed to be developed in parallel with, if not ahead of, the District General Hospital Psychiatric Unit so that the mental hospitals were not

"left to care for patients who make heavy demands on nursing staff, often in unsatisfactory physical conditions" (par 11.19).

The community hospitals would, normally contain geriatric and psycho geriatric units for longer stay patients and the geriatric unit would care for all patients who were significantly physically ill including demented patients (par 4.15).

In such hospitals the "interest of friends and relations and local communities" could be more easily maintained, and the day to day care of patients could be entrusted to local GPs (pars 4.13 + 4.15).

Adjoining the psychogeriatric unit there should, be a day hospital for in-patients and patients living in the community (par 4.l6).

With respect to the care of the majority of the mentally infirm: those living at home (or sometimes in old people's homes) the 'White Paper had little to say. The DHSS was "examining the advantages and disadvantages" of various local authority support schemes, "and may issue guidance...in due course" (par 4.48).

The Future Pattern of Services.

The psychiatric scenario outlined in Better Services is illustrated by the table (*) and diagram below.

GUIDELINES FOR SERVICES AT DISTRICT LEVEL Rates per 100,000 population
Hospital Services	Beds	Day Places
District General Hospital Psychiatric Unit	50	65
Units for elderly severely mentally infirm patients	30-40	25-40
Units for new long-stay patients under 65	17
Local Authority Services	Beds	Day Places
Hostels	4-6
Long-Stay Accommodation	15-24
Day Centres		60

The old asylum, or mental hospital, is outside the community:

It is a self-contained world on its own, structuring every aspect of its inhabitants' existence day and night, day after day; and, "because of its location, separating those who reside there from the lives of families, friends and neighbours - what Goffman called, in Asylums, a Total Institution.

This is to be replaced by the range of local facilities shown, although even then the "old long-stay" residents would remain in the asylum.

In the future pattern of services, hospital facilities be local, and in-patient treatment avoided.

Where in-patient treatment was unavoidable, and care continued for any length of time, there would be a distinction between where the patient resided and where he or she spent the day.

The psychiatric unit, for example, was to have "two main functional components":

wards, "or rather residential units", and

a "day activity area".

The great majority of in-patients would

"spend the day on a planned programme in the day hospital...thus having the stimulation of... a pattern of living which more closely resembles normal everyday life" (par 4.3)

A range of day-time and evening facilities, including local authority day centres, sheltered employment schemes and social clubs, would be required for those living in community accommodation. These would assist people to maintain an independent life outside hospital and, in some cases, relieve the strain on families of their living at home. (par 4.28)

In addition to the District level facilities there would be required on a Regional basis: a 'Regional Secure Unit' (2 beds per 100,000 population) for patients too disruptive to be accommodated in a District General Hospital ward, and units for mentally disturbed children and adolescents (2.25 beds per 100,000 population for each). (Better Services 1975 par 4.63. Norms taken from other sources).

From Medical to Social Provision

The importance of the strategy outlined in Better Services 1975 was that it did not rely on an unrealistic belief in psychiatry's power to "cure" mental disability. The comprehensive provision it envisaged included long-term social care for the 'chronic' cases acute psychiatry had been sending to the mental hospitals.

Hospital staff, the paper noted, saw a hospital's role as an "active therapeutic one" and were increasingly unwilling to be "social care custodians" but facilities for social care outside hospital were "not generally available" (par 2.8). "For 16 years or more" Dr David Owen told MPs "we have all...paid lip service" to the concept of caring for most of the mentally ill in the community, but the White Paper showed that, whilst nearly £300 million (*) was spent on hospital services for the mentally ill, in 1973-4 only about £.15 million (*) was spent on Social Services (HC Hansard. 26/1/1976 col 35). The Government intended to see that, over a period of years, "the balance of health and social services" was "put right" (par 2.8).

The Government's four main objectives were to expand council services, to move specialist (hospital) services to local settings, to establish the right organisational links between sectors and to improve staffing levels (par 2.22). Alison Wertheimer commented in MIND's magazine that establishing the right links was the objective that "poses the greatest difficulties and the greatest hopes" :-

"The crucial factor in the achievement of the.. .service envisaged.... is going to be successful joint planning between health and social services coupled with a shift in resources from the health sector to ... social services." (Mind Out, December 1975 p.12).

JANUARY 1976: THE BIRMINGHAM SCANDAL.

Between 1970 and 1975 the population of mental illness hospitals was reduced from 107,977 to 87 .,321 and that of mental handicap hospitals from 55,434 to 49,683 (**).

But how had this been achieved? Some argued it was by discharging patients to families ill-equipped to cope with them, to private 'hotels' that exploited them, or onto the streets.

Better Services 1975 acknowledged such things happened, and. said;-

"the public...cannot be expected to tolerate under the name of community care the discharge of chronic patients without...after- care...who perhaps spend their days wandering the streets or become an unbearable burden on the lives of their relatives..• Such situations do not occur very frequently: but where they do, the whole concept of community care is placed at risk" (par 2.27)*

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