Since the 1950s, mental health services in England have gone from compulsorily detaining patients with mental illness for long periods in large asylums, to the majority of patients spending most of their lives without legal constraint, outside hospital with the support of a number of healthcare professionals. The journey is not complete. But the 1959 Mental Health Act was undoubtedly an important milestone.
NHS England’s National Clinical Director for Mental Health, a practicing mental health nurse 35 years ago, has spoken of her own memories as, of patients who had been admitted in their teens and were still there seven decades later. Mark Winstanley, Chief Executive of Rethink Mental Illness, has highlighted the fear many people felt of going into asylums “because you could be completely institutionalised and never get out”. He concludes “the fact that we see people as individuals now with the possibility of recovery is a huge advance.”
The 1959 Mental Health Act was a ground-breaking piece of legislation that kickstarted the change in attitudes and care for people with mental ill health. It aimed to remove the stigma of mental illness, stating that patients with mental ill health should not be considered different from patients with any other illness.
The Act also made new provisions for the treatment and care of people with mental ill health, establishing for the first time that community care should be prioritised. The Royal College of Psychiatrists lauded the provision of local authority facilities complementary to the NHS as “the most vital and progressive” part of the Act. Many argue that there has been no shift more fundamental than this move towards delivering mental healthcare in the community in the whole history of the NHS.
What of the Act’s impact? It’s a familiar story. Laudable aims, patchy delivery.
The consensus is that where community services were available and comprehensive, most patients significantly benefited from the shift from hospital to community care. But the quality of the new services has been a key concern raised through the years. The Royal College of Psychiatrists expressed its concerns in 1976 that many councils were still failing to deliver services to work alongside the NHS.
On the matter of public attitudes, the Royal College of Psychiatrists concluded that the Act was effective in bringing about some desired changes. They welcomed its role in promoting developments in the care and treatment of the mentally ill, pointing to the emergence of new therapeutic techniques within hospitals and the establishment of better doctor-patient relationships.
Other senior psychiatrists are also said to have seen the 1959 Act as benign in its impact on services and patient experience, allowing psychiatrists to implement improvements in treatment and care which had been foreshadowed in the 1950s. However, overall progress on tackling the stigma of severe mental illness has been limited. The rise in detentions, as recently as the last ten years, also continues to raise concerns.
What made such a sea change in attitudes and policy towards mental healthcare in Britain possible? A key agent for change was a growing moral agenda, based on a growing emphasis on human rights. Advances in social science and philosophy critiquing psychiatry and the boundaries of what constituted mental illness also reached its height in the 1950s and 60s.This meant a compelling narrative, driven by ethical and emotional arguments, could be communicated, going well beyond purely technical or clinical issues.
The political consensus amongst parties for psychiatric hospital reconstruction was also a key element. The left and right of British politics both supported the transformation – albeit for widely differing motivations.
There were also important clinical developments. Treating patients with mental illness in the community was only feasible because of the development of a new generation of medicines that demonstrated people with severe mental illness could be treated at home rather than in institutions.
In the NHS’s 70th year, mental health arguably has a higher priority than ever before. So learning the lessons from the fundamental transformation of mental healthcare provision in Britain since the 50s – from implementing complex system changes to transforming public attitudes couldn’t be more important.
We certainly have come a long way, but there remains a long way to go.
Ella Fuller, Account Manager