Happy Birthday, NHS
In an article for the British Journal of Psychiatry on the 50th anniversary of the NHS, the then president of the Royal College of Psychiatrists Robert Kendell suggested that it was "easy to forget, in the face of our present difficulties and discontents, that psychiatric services have improved out of all recognition in the past 50 years".
On its 65th anniversary, this sentiment still rings true. The regimented tyranny of the old asylums is a thing of the past – what we have to offer people with mental health problems today is often (though sadly not always) world-class.
In 1948, mental healthcare for those with serious disorders was largely provided in more than 100 asylums dotted around the countryside or suburbs. These had 145,000 residents. Out of sight was out of mind. There was minimal independent supervision of standards of care, while treatments were limited and - to our modern sensibilities - pretty barbaric. The 1950 Ministry of Health report set out the various treatments available in hospital. It highlighted therapeutic convulsion treatment ("a potent weapon for cutting short depressive illness"), insulin shock treatment ("particularly valuable" in the treatment of schizophrenia) and prefrontal leucotomy – cutting out part of the brain (believed to have a "usefulness" in "properly selected cases"). Outpatient clinics or other forms of community support were few and far between. Those with less serious problems generally made do as best they could in family settings.
Yet mental health services nearly did not make it into the NHS. The chief medical officer's report of 1946 which looked forward to its creation made no mention of mental health, and some politicians argued that it should be the preserve of local authorities rather than the NHS. The eventual decision to include mental health services was hugely important in bringing psychiatry into the broader family of medical disciplines, legitimising its professional aspirations and establishing mental hospitals and staff within the same operational framework as other health services.
The most evident change in the provision of specialist mental health services over the past 60 years has been the move from treatment in hospital to treatment in the community. The mental hospital population has fallen from 145,779 in 1948 in England and Wales to some 33,000 today. The number of patients resident as certified or formally detained in hospital under the Mental Health Act has plummeted from 123,464 in 1948 to 17,500, in England, in 2012.
A range of factors has been cited for this change. New medication that better controlled symptoms of mental illness allowed many patients to be discharged. The increasing cost of inpatient care turned politicians' thoughts towards cheaper community care. The Percy Commission of 1957 highlighted concerns about hospital conditions and occasional hospital scandals hit the headlines through the 1960s, 1970s and 1980s. Social policy developed a more libertarian view of mental illness and new welfare benefits enabled people to survive in the community, even if they were not capable of work.
However, there were no overnight changes. For many years after 1948, life in mental hospitals continued much as before, with bed numbers peaking at over 150,000 in the mid-1950s. Asylums only started to close in any numbers in the late 1970s and early 1980s, although many had by then transferred some patients to general hospital psychiatric wards or to the community.
Alternative community services were prompted by new legislation setting out local authority responsibilities of care. The Mental Health Act 1959 gave impetus to local authorities to develop a range of community support such as group homes and day centres for those who did not need hospital care. In 1961, at a conference of the National Organisation for Mental Health (later Mind), the then health minister Enoch Powell spoke passionately against the grim isolated asylums "brooded over by the gigantic water-tower and chimney combined". This speech cemented the shift in focus from asylum to general hospital and community care and the 1975 white paper Better Services for the Mentally Ill led to more day hospitals, day centres, residential homes, hostels and community nursing provision.
Sadly, the rhetoric of community care was not backed up by adequate NHS or local authority resources. Progress was slow and public perceptions of its failings were formed by occasional high-profile incidents involving care in the community patients, which continue to this day. But community services were boosted by the NHS and Community Care Act 1990, which provided a backdrop for multidisciplinary community mental health teams and the care programme approach, which gave some patients an assessment, a care plan and a key worker. Despite this, implementation was inconsistent.
An attempt to address these inconsistencies was behind the Labour Government’s generally admirable programme for modernising mental health services between 2000 and 2010. This involved a national service framework for mental health and specific service provision targets overseen by a National Institute for Mental Health, all driven from the centre by a national director.
Importantly, all this was backed by significant new money. Those days may be over, now that we have had a recession that we are still struggling to get out of. It is hard to see much, if any, new money being put into mental health services for some time to come.
There have been radical improvements since 1948. There are clear mental health strategies in place across all four parts of the UK. Much is now accepted that would have seemed very strange to our predecessors in 1948 – personalisation, patient-centred care, the recovery model, talking therapies, peer support, best practice on effective interventions set out in national guidance from NICE. In addition the mental health workforce has expanded and achieved greater professional recognition. The patient voice is growing stronger, and is often properly represented and effective in influencing national and local levels of service. Treatments are more humane and care standards are better monitored.
We know the various factors that can lead to mental illness but diagnosis, and offering the right intervention, can be an inexact science. Prevalence rates remain obstinately high. Not enough resource is spent on improving public mental health and preventing mental disorders from arising. Too many people still wait too long for appropriate support, or fall between gaps in uncoordinated services. Many people with mental disorders also experience very poor mental health, which can be addressed, but often isn’t. Services are cash-strapped, many with limited access for patients. Reports of overcrowding, poor environment and staff shortages in hospitals are common to both 1948 and 2013.
Legislation remains focused on compulsion rather than rights. New Community Treatment Orders have increased the overall number of people under compulsory powers of the mental Health Act, at least in England. The stigma attached to mental illness remains and public attitudes and behaviour are often negative. And we are faced today and in the future with new challenges, such as the increasing numbers of patients with substance misuse problems, high levels of diagnosed disorders among some black and minority ethnic communities and refugee and asylum seeker communities, an increase in the numbers of young people recorded as self-harming, and an ageing population with significant levels of depression and, due to longevity, creating a dementia "time bomb".
A 65th birthday should be a time of celebration. We should rightly applaud the advances made in mental health services the past 65 years and recognise the contribution of the thousands of NHS, local authority and voluntary sector staff who have been - and remain - committed to caring for people with mental health needs.
But we still experience many of the "difficulties and discontents" that Robert Kendell spoke of 15 years ago. To progress, we must take public mental health more seriously; develop more effective interventions and new ways of integrated working across a range health, social care and other services; and, perhaps most importantly, listen harder to people who experience mental health difficulties to learn what they want in the way of support.