WHY WERE LARGE MENTAL HOSPITALS CLOSED IN THE UK? DISCUSS THE REASONS FOR AND THE OUTCOMES OF SUCH POLICIES.
Historically the function of large mental hospitals was to provide shelter and asylum to a large group of people with a mental illness. More recently changes in care philosophy, care in the community is the accepted norm.
The 19th century witnessed a large growth in the number and size of large mental hospitals which were referred to as asylums. Grant et al states that there has been a revolution over the last 150 years and in particular the last 30 years in the way that public agencies have provided care and support for people with mental health problems and learning difficulties.
“The loss of basic personal rights is not a new experience for the mentally ill. Probably no other group has been so consistently prosecuted and deprived of basic human rights as those who suffer from psychiatric illness. Many of the problems arise from the dehumanisation that comes from the increasing size and complexity of our health care system. Whatever difficulties exist generally are magnified by the underfunding of the facilities and programs for the mentally ill. Added to this are the consequences of suspicion and fear of those whose behaviour is seen as deviant.” (Gibson, 1976).
Fraick comments that mental hospitals are places which are to be avoided unless that is absolutely impossible. They are in out of the way places where “they and their inmates were known to be there and also ignored.” He also makes the point about staffing and levels of care. “..too often patients are held without treatment plans and without treatment. Too often staffing is haphazard at best; the deterioration of patients is predictable rather than the other way round. The personnel they attract are often underpaid and lack the motivation and skill to resist the depersonalising experiences that both patients and staff meet. At worst there occurs physical abuse of patients. Few until recently have asked whether these hospitals should be improved or perhaps abolished?”
Baldock tells us that it was during the 1950s and 1960s that the use of large Victorian asylums began to decline. These huge imposing buildings were then considered to be inappropriate for the long term care of mentally ill people. The physical structure of the institutions was seen as custodial and put the patient in isolation. During this time it was increasingly believed that the stigma of committing a person with a mental health illness to such a regime of treatment was no longer the best policy.
Means et al stresses that the introduction of the National Health Service meant that the provision of care for people with mental health problems and learning difficulties came more under the provision of mainstream health care policies. There was a redesignation of asylums as hospitals and subsequently became the responsibility of regional health boards.
“Local authorities became responsible for the following range of services under Section 28 of the National Health Service Act 1946:
- the initial care and removal to hospital of persons dealt with under the Lunacy and Mental Treatment Acts
- the ascertainment and (where necessary) removal to institutions of mental defectives, and the supervision, guardianship, training and occupation of those in the community, under the Mental Deficiency Acts
- the prevention, care and after-care of all types of patients, so far as this was not otherwise provided for.” (Means et al, 2003).
The first two points were met more successfully than the third. In 1958/59, local authorities spend a mere £4.1 million on people with mental health problems. Goodwin goes on to show that hospital based provision was similar. During the early 1950s mental and mental deficiency hospitals contained 40% of in-patient beds in the NHS. However, they received only 20% of the budget. Costings of patient care led Goodwin to claim “these figures clearly underline why the mental health services have earned the tag of a “Cinderella” service.”
The Royal Commission on Mental Illness and Mental Deficiency sat from 1954 to 1957. The Mental Health Act of 1959 reformed the legislative framework of constraint and gave an infrastructure of local authority provided services such as hostels, day care, social work support and sheltered employment schemes. Unfortunately, these services failed to materialise. Murphy (1991) describes 1962-1990 as “the disaster years” for people with mental health problems. In 1974 there were 60,000 fewer people residing in large mental hospitals than there was in 1954 but despite this decline it was not reflected in the services available to these people in the community. Provision did not exist. It became practice for patients with long term mental health problems to be admitted, discharged and consequently readmitted. Provision remained based on hospitals.
“Institutional and treatment regimes remained controversial. For people with mental health problems, the emphasis was now on treatment not custody. However, the introduction of anti-psychotic drugs and new treatments such as ECT were seen to raise major issues about civil liberties. There were also numerous exposes of physical and mental cruelty by staff over patients.” (Means, p31).
Baggott tells us that the governmental policy on community care can be traced to the speech made by the then Health Minister, Enoch Powell in 1961. In this speech he put forward the proposal to run down large mental health hospitals. Thinking has been progressing in this direction since 1956.
“Throughout the 1960s a broad consensus developed, and care in the community was seen as being a more appropriate and more effective form of care. The poor standards of care for many long-term patients became increasingly evident. This was confirmed by a series of cases which came to light during the late 1960s involving the maltreatment of patients in long-stay hospitals.” (Baggott, 1994,p220)
Institutional care was seen as being substandard and the notion was reinforced that community care was a more humane policy. The supporters of community care argued the point that it allowed the patients to avoid dependency which was a major factor of experience in institutions. If the patients were integrated into the community it was thought that there was a much greater chance that the individuals would have a much greater chance of realising their own personal potential and independence. It was also felt that if mentally ill people were living in the community then it would highlight the condition to members of the general public. This was considered to be a positive end to them being hidden from public view. Institutional care was also considered to be expensive.
The notion of having patients as long stay clients in hospitals came to be considered as expensive and oppressive. Although the idea of slowly running down the large hospitals was becoming dominant in the 1950s and 1960s it was until into the 1980s that the process took pace.
“Between 1980 and 1990 thirty-five long-stay hospitals were closed, and the process accelerated in the nineties” (Rogers and Pilgrim 1996)
Baldock comments that the policy is now the use of community care but the shift in the provision is not always as complete as might be imagined. A lot of the new community services are based on the sites of the old hospitals.
“Furthermore, in a critical report in the 1994 Audit Commission pointed out that two-thirds of the £1.8 billion spent on mental health in 1992/3 still went on in-patient facilities, despite the clear evidence of the cost-effectiveness of community provision and its popularity with users and relatives.” (Audit Commission, 1994)
The major financial gains of hospital closures came once it was no longer necessary to run a parallel service – the final stage of the process. It should also be noted that the old hospitals provided accommodation for mentally ill patients whereas the new community services did not provide this.
Faick comments that planning is frequently left out when there are discussions on institutional and social change. When de hospitalisation became popular and patients were returned to the community. With lack of planning community merely represented drift, poverty and no psychiatric or medical services. Many of the patients were from communities or families who might have been the root cause or location of the difficulties in the initial stages.
There “was a well-meant effort to lighten the burdens of people who had been mistreated in institutions for years; but in the absence of systematic long-range planning, their misery only changed location, while the “community” remained as cold and rejecting as ever.”(Fraick 1984).
McDonald points out the the services for people with mental illness problems shows two sides to community care: preventive care for those people who are in the community with an aim of keeping them in the community and the legacy of the movement to discharge people for the large mental health hospitals into the community. The lead authorities for care of the mentally ill are the Health authorities. The leads to anomalies in the system. The government became concerned that reports were coming to light of inadequate care being provided for patients being discharged from long stay hospitals. The government therefore provided guidelines to health authorities on the care programme approach (CPA) 1990 on the care of those people referred to specialist psychiatric services. A system of care management was also introduced in the wake of the NHSCCA 1990. Both systems ran parallel; one health authority run, the other local authority run but both often concentrated on the same people. The two systems were based on the same principles and are capable of being integrated to try to ensure the best use of professional skills.
There was modernisation of the CPA in 1999 and the focus was put on people with severe and long term mental illnesses. A Department of Health document put forward that all health and social services authorities would be required to appoint a lead officer to make sure that the development of an integrated approach be established between all agencies and services.
“The CPA was widened to include ‘all those people who are under the care of the secondary mental health services regardless of setting’, not just those about to be discharged from hospital, and was streamlined into
- standard CPA – for individuals who require the support or intervention of only one agency or discipline, or pose no danger to themselves or others, and who will not be at high risk if they lose contact with services.
- Enhanced CPA – for individuals who have multiple needs, including those who also have a drugs/alcohol problem. This category includes those at risk and those hard to engage and requires crisis and contingency plans.” (McDonald, 2006, p151)
Baldock shows that the CPA rests on four stages: assessment, care plan, appointment of a key worker, and review of the plan. There was new funding to support the development of social care facilities in the community provided by the Mental Illness Specific Grant, introduced in 1991.
“It is a revenue grant and paid to the local authorities, who have to find matching funds to those provided by central government to the extent of 30 per cent. Unlike the other monies transferred under the community care legislation, it is ring-fenced for mental illness – itself a measure of the sensitivity of the issue.” (Baldock, 1999, p364)
Baldock says that when there was a transfer of patients to care in the community new issues were raised about treatment. When a patient is in hospital it is relatively easy to keep in control of given medication. This was true even in cases of non compulsory detention and patients did have the right to refuse medication. The hospital was also able to monitor movements of the patients. Once the patients were taken out of the hospital environments and put in community care projects surveillance and control became difficult. The community frequently lose contact with patients who drift away from the community mental health services. Sometimes it is patients who have negative experience of psychiatric services. Sometimes it is due to sheer overload of work on the community service providers. The negative perception of psychiatric care can result as a consequence of the significant and unpleasant side effects of treatments. Long term prescription drugs can brain damage which induces involuntary body movements which stigmatise the user. Many severely mentally ill people refuse medication for these reasons and there have been some fairly high profile cases reported in the media. In 1994 the Government introduced a supervisory register to identify and try to keep track of mentally ill people who are at risk to themselves and/or others. In 1996 supervised discharge was introduced for people who had been compulsory detained at some point. There is however no provision for compulsory treatment.
Means and Smith (2003) claim that the reforms:
- introduced a system that is no better than the previous more bureaucratic system of resource allocation
- were an excellent idea, but received little understanding or commitment from social services as the lead agency in community care
- the enthusiasm of local authorities was undermined by vested professional interests, or the service legacy of the last forty years
- health services and social services workers have not worked well together and there have been few “multidisciplinary” assessments carried out
- in reality little collaboration took place except at senior management level
- the reforms have been undermined by chronic underfunding by central governmental the voluntary sector was the main beneficiary of this attempt to develop a “mixed economy of care”.
In conclusion, de institutionalisation or care in the community involves treating mentally ill people in their own homes rather than in the large asylum style building which grew up 150 years ago. When the large hospitals were established it was considered that they would provide the most appropriate and humane care for patients. However, pressure during the 1950s and 1960s brought this form of care into disrepute. The care in the community strategy was thought to be more humane and also be cheaper. It is now been shown that although there are many short and long term advantages to care in the community there are also many disadvantages such as the lack of continuity of care and the very real possibilities of patients becoming lost in the system.
Audit Commission (1994), Finding a Place, London.
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Means, R., Richards, S., Smith, R., (2003) – Community and Care. Policy and Practice (3rd edition), Palgrave McMillan, Basingstoke.
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