In our latest feature marking the NHS’s 60th anniversary, Mark Gould charts the journey from Victorian asylums to the national service framework and recent backward steps
In 1948 the infant NHS got something of a shock on realising it was responsible for 100 asylums, each with its own rules, regulations and treatment practices.
The asylums had an average population of nearly 1,500 patients. Some, the iconic Victorian gothic “bins” whose names still send evocative shudders, such as Colney Hatch in Middlesex, Claybury in Essex and the Whittingham in Lancashire, housed 3,000-4,000 souls.
Before 1948, with minor exceptions, care of the mentally ill often meant containment in institutions, padded cells and even straitjackets. Therapy consisted of strict routines and manual work. But there was also kindness, brass bands, sports and amateur dramatics, fresh air and tranquility. Treatments were of their time and often rudimentary or useless. Direct operations to remove sections of the brain - lobotomies - were seen as a way of treating mental disorder. Electro-convulsive therapy was widespread and aversion therapy was until the late 1950s used to “treat” homosexuality.
Len Smith, an approved social worker who has worked in community mental health services since 1973, is a historian at Birmingham University’s centre for medical history.
He says it did not take long for ministers to realise major change was overdue. In 1953 almost half of NHS beds were used for “mentally ill or mentally deficient” patients and spending on them was spiralling. In the West Yorkshire region it took 37 per cent of the total budget.
It was also realised the Victorian and Edwardian mental health mega-hospitals were crumbling and would cost too much to repair.
Mr Smith says another persuasive reason the was money could be made.
“Some of the big old institutions such as Cornwall county asylum, Colney Hatch or Gloucester asylum had lots of valuable land attached to them. Money from land sales was supposed to follow the patients who would be transferred into new community hospitals. [That money] did not match the sums made by property developers.”
In 1954 Winston Churchill’s Conservative government set up the Percy Commission, which set the course for a move by mental health services into the community. Its 1957 report called for mental illness to be regarded in the same way as a physical illness or disability and that psychiatric hospitals should be run as nearly as possible on the lines of “normal” hospitals.
It was followed by the 1959 Mental Health Act, which enshrined the commission’s principles and excluded “promiscuity alone” as grounds for incarceration.
Unmistakable and daunting
But the biggest milestone on the road to the therapeutic revolution occurred in Brighton in 1961 at the National Association for Mental Health (now Mind) annual conference. It was there that then health minister Enoch Powell signalled the end of the old asylums with his historic “water-tower” speech. He described the institutions thus: “There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside.”
Mr Smith says from then on psychiatric hospitals were demonised. While patients were often far from home doing manual work for little or no pay, “a lot of the good things got overlooked, that they were therapeutic communities, with a great emphasis on work and that patients had a lot of space and could look out onto green fields”, he says.
By the mid 1950s many institutions had open-door policies and academics were acknowledging that most people experience some degree of mental illness at some time.
As the historian Roy Porter commented in his book Madness: a brief history, “mental abnormality began to be seen as part of normal variability”.
The pace of change was also being led by new and effective drugs. Psychiatry was resolving some of its most punishing schisms and establishing itself as a therapeutic specialism. In 1961 US sociologist Erving Goffman published Asylums, a devastating and hugely influential demolition job on institutions, and the 1962 Hospital Plan built on the sentiments eloquently expressed by Enoch Powell, paving the way for the move to smaller urban hospitals.
Mr Smith feels the move left patients “more hemmed in and staff probably felt the same; [these places] felt a lot less therapeutic”.
All this meant that by 1975 the population of mental hospitals was massively reduced. But Mr Smith says standards of care were suffering as staff levels were low.
“Male staff were still called attendants and there were just one or two to a ward.”
As an NHS manager in north London, Angela Greatley - now chief executive of the Sainsbury Centre for Mental Health - was involved in the closure of Friern (formerly Colney Hatch asylum) and Claybury hospitals.
As a member of her local community health council she was also aware of what was going wrong in local services.
“We were hearing about some pretty scandalous conditions and treatment; poor food, poor conditions, poor clothing, lack of privacy; all of which set up momentum for change.”
Ms Greatley cites two milestones, the 1971 DHSS document Hospital Services for the Mentally Ill and 1975 white paper Better Services for the Mentally Ill, as driving forward innovation in treatment and care. Psychiatry was also developing new medical and psychological tools for treatment.
“Psychiatrists believed psychiatry was part of the medical family. That raised standards of care and treatment,” she says.
The late 1960s and 1970s also saw the rise of the anti-psychiatry movement led by psychiatrist RD Laing, who said mental illness, although sometimes debilitating, could be transcendent and was a normal reaction of the mind to the irrational experiences of life. “While Laing and others weren’t right, it made us realise that a whole range of mental health difficulties have a bio-psychosocial element,” adds Ms Greatley.
Wandering the streets
Meanwhile, as TV documentaries such as Man Alive and films such as One Flew Over the Cuckoo’s Nest raised awareness of the faults of psychiatric hospitals, scandals continued to emerge.
In 1971 the Payne inquiry into Whittingham Hospital near Preston uncovered patient neglect, fraud and maladministration as if “the therapeutic revolution of the 1950s never happened”. Five years later Daily Mirror investigative reporter John Pilger revealed 5,000 former asylum patients in Birmingham had been dumped in the community to wander the streets. An array of guesthouses, hotels and boarding houses flourished on the trade in ex-patients who paid for their keep in benefits.
One landlady told Pilger: “We pick them off the streets or the hospital rings us up and says ‘can you take a few?’” She had “a cupboard filled with prescribed tablets to keep them quiet”.
Although in 1948 it was not thought patients needed a voice, public exposure of scandalous care and treatment galvanised them. Since the mid 1980s patient councils have allowed service users to speak out about what they want and service users now play a central role in the work of mental health charities and national bodies such as the National Institute for Mental Health in England.
In 1946 the National Association for Mental Health formed from a group of mental health and welfare organisations to promote and provide good community care and be a patients’ voice. Mind policy director Sophie Corlett says much of the association’s early work was in supporting people coming out of Second World War military service, giving them a voice and a role in development of policy and services.
The charity played a major role in shaping the 1983 Mental Health Act, which set out the duty of post-discharge care and placed legal controls on the application of treatments, particularly surgery, ECT and mood-altering drugs. The act also created the Mental Health Act Commission, a body to protect detained patients.
Ms Corlett sees the introduction of the national service framework for mental health in 1999 as another important landmark, focused on ensuring higher levels of competence and good practice among professionals. She says the past 10-15 years have seen a greater understanding that people with mental illness can recover their social and mental health status.
Changing drug treatments was another step change. By 1955 Largactil, the first of the phenothiazines - drugs that could really control psychotic symptoms - was coming into general use. Dr Thomas Bewley, a former president of the Royal College of Psychiatrists who worked in hospitals across south London, says this was “a real revolution. Before that you just stuck people with schizophrenia in a padded cell. It really reduced paranoid symptoms”.
Life outside hospital
In 1970 fluphenazine, the first long-acting antipsychotic phenothiazine, marketed as Modecate, appeared. One injection every few weeks enabled people to live outside hospital. Patients needed to be readmitted only if they refused their injection. A psychiatric community nurse would then visit to see what was happening.
The changes introduced by the national service framework meant legislation no longer reflected modern services and work began to update it. Then in 1998 the conviction of Michael Stone for the murders of Lin Russell and her daughter Megan led the government to promise legislation to protect the public.
In 2000 a draft Mental Health Bill introduced compulsory treatment orders under community supervision. People deemed to be suffering from dangerous and severe personality disorder had been considered untreatable but were covered by the proposals. But it was not until 2007, after unprecedented opposition from mental health charities, lawyers and civil rights groups, that they became law.
The jury is out on how the changes will work in practice. Rethink director of public affairs Paul Corry says that instead of introducing legislation to deal with a very small number of persistent violent offenders, who could have been treated ad hoc, the government should have continued with the direction outlined in the framework.
“Putting public protection at the heart of it instead of emphasising a patient’s right to care and protection was a backward step,” he says.
Stigma is now a main campaign issue. Mr Corry says Winston Churchill — a 2006 Rethink campaign used a statue of him in a straitjacket - has been a major figure for raising awareness that people with mental illness can be productive and even carry out work of historic significance.
1948 The NHS is born.
1955 Chlorpromazine appears as the first antipsychotic drug.
1959 Mental Health Act begins a therapy revolution.
1961 Health minister Enoch Powell’s “water tower” speech.
1962 Hospital Plan brings in smaller, community-based hospitals.
1971 The Medico-Psychological Association becomes the Royal College of Psychiatrists.
1975 National Schizophrenia Fellowship (later Rethink) is founded.
1983 Mental Health Act.
1999 National Service Framework for Mental Health sets modern service models.
2001Valuing People white paper for people with learning disability.
2004 Blofeld inquiry into the death of David “Rocky” Bennett makes 22 recommendations to protect detained patients and tackle racism in the NHS.
2007 Mental Health Act includes powers for compulsory treatment in the community.
‘You can have it the easy way or the hard way’
Being ordered to call a psychiatric nurse “Mr B” is one of Anthony Voyce’s abiding memories of being a detained patient in the early in 1970s at Hellingly Hospital, a vast Edwardian-era asylum in East Sussex.
“He was a big man in a uniform. He had a Teddy boy haircut and had been trained at Broadmoor. When it was time for my injection he would say: ‘You can have it the easy way or the hard way’. I would say I always had it in my left arm, as I am right handed. He would say ‘you have to have it in the backside’ and if you didn’t co-operate he would get four or five nurses to hold you down.”
Mr Voyce became ill in 1973 just before his university finals and in 1975 he, or rather his parents, were told the diagnosis was schizophrenia.
“They told my parents that I had this diagnosis and told me to take the pills, have the injections, stay in an all- male dormitory and go to industrial therapy classes, which usually consisted of packing soap.”
Injections of antipsychotic drugs to control Mr Voyce’s paranoid delusions created a cycle of despair.
“They made me suffer from akathisia, which is a terrible sort of internal restlessness, you are agitated and fidgeting but at the same time you are tired. This would last seven or eight days and begin to wear off. Then it would be time for another injection and if you complained they would increase the dose.”
Mr Voyce fell into a cycle of release and readmission.
“I would stop taking my pills and go missing, drive off, sleep in my car and then be caught by the police stealing petrol and be back in hospital.”
He says access to therapy was almost non-existent. Typically there were two psychologists to 800 patients.
“The psychologists were of the ink-blot type. ‘What does this ink blot tell you?’”
But 1990 was a watershed year.
“And I have Mrs Thatcher to thank. She pushed forward with the closure of the asylums and for more care in the community.”
Mr Noyce is happy with his community care, having a session with a psychological therapist every week since 1992.
“My medication does cause weight gain so I go to the gym every day. I haven’t missed a pill. I don’t have any of the side-effects.”
A modern atypical antipsychotic, olanzapine frees Mr Noyce of tardive dyskinesia - the involuntary jerks, tics and grimaces that are a side-effect of older drugs. The “excellent” support of care workers means he completed a degree - in social policy - in 1994 and later an MA.
Read more articles and news about HSJ’s celebration of the NHS’s 60th anniversary at www.nhs60.co.uk