A significant interest in something called mental health, not just mental illness, can be dated back in Britain to the interwar years. In other words, it was not a product of the new National Health Service. Indeed, hope that the new service might provide the opportunity for a vigorous state programme directed at mental health met disappointment. Recognition of the importance of mental health had been reinforced by lessons about military and civilian health in the Second World War, but the new NHS provided little in the way of new initiative. It certainly didn’t put mental health on the same footing as physical health. What’s more, the mentally ill continued to be housed in the same largely isolated, Victorian institutions that had been built up and down Britain over the past century: out of sight, out of mind.
As well as questioning the idea of 1948 as a turning point when it comes to mental health, we should also appreciate that a wholly negative account of the pre-NHS system of care needs some modification. In terms of public effort and investment, the building of this vast system of public institutions now seems impressive. In a sense this was a ‘National Asylum System’, well before the state accepted responsibility to provide free hospital care for the physically ill under the NHS. The problem was that so little could be done to cure those who ended up needing care in such places. Faced by a growing population of seemingly incurable patients, pessimism became pervasive. It was exacerbated as broader eugenic fears led to a parallel system of institutional care for people with mental disabilities – the ‘mentally defective’ as the new legislation of 1913 described them in a language that reflects the harsh attitudes of the time and the stigma that resulted from this. However, it was partly because these institutions seemed to have failed as sites of cure that an interest in the treatment of milder and early stages of mental illness advanced away from the site of asylum in the interwar years. This was often supported by charities. But in addition, local authorities began providing supervision in the community – community care in embryo. General hospitals began to offer outpatient care. Progressive general practitioners increasingly recognised that a large part of the physical illnesses they encountered had a psychological component. And child guidance and psychological clinics sprung up across the country. What’s more, with a boom in self-help literature, the public began to appreciate that mental health was a concern for the whole population. In other words, many of the pieces were in place for something far more ambitious in relation to mental health than was delivered in 1948.
Instead, 1948 saw more of the same. The old Victorian lunacy legislation remained largely in place. It had been modified in 1930 to allow some voluntary treatment in what were now to be termed mental hospitals rather than asylums. But this still left the mentally ill as a class apart, and this is how they were handled in the establishment of the new National Health Service. So, rather than a reversal, the decade after 1948 saw continued growth in the numbers ending up in these institutions to reach a peak of over 150,000 by the mid 1950s (40% of all beds in the NHS).
Reform of the legislation around mental illness had to wait until the Mental Health Act of 1959. The title of this piece of legislation symbolised the aspiration for integration into the NHS. At its heart was the decision to make entry to mental hospital an issue of medical rather than legal judgement. However, this was never going to be enough on its own to remove the stigma that surrounded these ageing institutions. The Act also signalled the intention of a move towards community care. This was given further momentum by a speech from Minister of Health Enoch Powell in 1961, which talked of getting rid of the Victorian asylums ‘brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside’. The solution was to be twofold: on the one hand, moving the treatment of mental illness to the wards and wings of general hospitals; on the other, developing new services in the community supported by an expanding social work profession. This fundamental transformation was made much more feasible because of a new generation of drugs. However, in terms of bringing mental health care into the NHS, there was arguably a tension in this vision: at last there was a more hopeful medicine for mental illness; yet the vague talk of community care in fact signalled a future in which responsibility for the care of the mentally ill might largely lie elsewhere, in the field of social care.
In the long term, the vision of transformation was to be realised. Indeed, there has been perhaps no more fundamental shift in the whole history of NHS care than this move from hospital to community care for the mentally ill. In that sense, it provides a significant case study for those who have looked for a similar shift away from the centrality of the hospital in relation to physical health. But change was initially slow, and throughout the period there have been serious misgivings about the quality of the service that has resulted. In the late 1960s and early 1970s, the lack of dignity afforded to patients in some of the remaining large and overcrowded mental hospitals was publicised in several scathing public reports. Fashionable anti-psychiatric writing emerging out of the counter-culture added to the sense of unease. More significant still was the emerging service-user movement, which for the first time brought the experiences of those who suffered through the inadequacies of mental health care in the NHS to the fore.
Powell had talked of getting rid of the Victorian institutions, but although the bed numbers began to decline few hospitals were closed until the 1970s. From the 1980s the pace of change accelerated, with a dramatic 60% fall in mental hospital beds from 1987 to 2010. The challenge was ensuring that something more effective and humane was introduced in place of the asylum. However, there was a strong feeling from many at the time that such community care often proved hugely disappointing and an excuse for cuts in expenditure. From 1997, under New Labour, there was a significant increase in expenditure on mental health care, though this reflected a more general increase of expenditure on the NHS and in fact still fell behind the overall trend. One result of the closure of mental hospitals was a growing anxiety, sparked by a small number of well-publicised cases, about the danger of releasing seriously mentally ill patients into the community. In such a context, the residential settings that remained became targeted increasingly on patients deemed to be a ‘risk’ to the broader community. It also became clear that many such individuals were ending up in the country’s expanding prison system. What remained of the mental hospital system now offered no real solution to the demand for ‘asylum’ for those not deemed a danger, nor for the mounting problem of dementia which fell instead into the hands of families and an ailing system of social care.
The considerable challenges of the shift from hospital towards community care meant that it was the issue of mental illness rather than mental health that had remained central as a concern of policy through most of this period. However, it is tempting to argue that the 21st century is seeing something a new kind of transformation. Since the turn of the century, the issue of mental health finally began to come to the fore in debate about the future direction of the NHS. Influential research began to claim that there was a strong economic case for improving mental health, with problems of mental health a major cause of expenditure for the welfare state and of lost productivity. Politicians began to talk about improving happiness and about the neglect of mental health care within the NHS. And the Health and Social Care Act of 2012 made it a requirement for the NHS to place mental health on a par with physical health. A policy of IAPT – improving access to psychological therapy – provided the hope of a new kind of therapeutic armoury for the NHS which could be rolled out far beyond the population that had been the focus of psychiatric care for most of the period since 1948. Often deploying the tools of self-help, assisted by the revolution in communication brought about by the internet and by a greater openness in talking about mental health, the new approach was attractive as a way to overcome the dual problem that had always held back an expansion of mental health services: the inadequacy of both funding and expertise. However, these limitations continued to be exposed in the struggle to access professional services. At a time that the NHS was under so much pressure, putting mental health genuinely on a par with physical health was going to be a huge challenge.
Despite all its ongoing problems and limitations, it is tempting to conclude that the area of mental health care has nevertheless been one of the areas of most major transformation in the history of the NHS. This case rests firstly on the dramatic move from hospital to community care, and secondly on a belated but growing effort to address the mental health of the population as a whole. In 1948 the NHS was really a national physical health (and to a larger extent illness) service. It did inherit a national mental illness service (that huge population in the mental hospitals), but this was not well integrated and was largely hidden away from view. In subsequent efforts at integration, policy makers came to regard this decaying institutional system as having no place in a modern health service. Thereafter barriers were to some extent broken down, although the move from hospital to community care also saw responsibility to some extent passed on to the family, the social services, even eventually the penal system. More recently, there have been signs that the NHS is coming to see tackling mental health as just as much part of its responsibility as its longer term focus on physical health. Whether this is truly to be the case, and whether the developments in the relationship of the NHS towards mental illness and mental health are truly compatible, remains to be seen.