Mental handicap-thirty years on? RODNEY WILKINS, Principal Medical Officer,

Department of Health & Social Security, Alexander Fleming House, Elephant and Castle, London, SE16BY.

This is a very short account of some of the develop- ments, past and present, in the field of mental handicap. I have neither the years nor the experience to begin at the beginning but to pick the story up in 1948 allows a moderately eventful 30 years to be covered. Also it should be made clear at the outset that much of this account will be concerned with health services. This reflects both my own perspective as a psychiatrist now working with the Department of Health and Social Security and perhaps also the more controversial ideolo- gical issues that seem to be involved in comparison with the generally accepted contribution to be made by social service and educational agencies. The effects of the NHS Act

In 1948 - as for the preceding 170 years or so - the care of the mentally disordered was largely influenced and managed by the medical profession who had been selected for this task following the “madness” of George I11 in what was seen as an enlightened and humane act but which is now often seen less warmly as the “medical model”.

At that time the great majority of services for the mentally handicapped were centralised and were located in the mental deficiency colonies provided by local authorities. Thesc were largely self-supporting com- munities, the more able looked after the less able to some extent and many residents and most staff members within this system had a reasonably clear understanding of their role and what was expected of them. To many this seemed to be an ordered secure world, with clear understanding of expectations and responsibilities and perfectly geared to the life tempo of mentally defective people.

In 1948 however, after long and careful consideration. a decision was taken to incorporate these colonies within the NHS. At a stroke they became hospitals and were thus exposed to all the resources and newly emerging practices, disciplines and traditions of the Health Service. A similar decision had been taken with the local authority lunatic asylums, of course, and they became hospitals also. These, were fortunate to benefit within a short while from the psychiatric and in particular the pharmacological innovations of the mid 1950s and over the ensuing years their resident numbers fell and even- tually a policy decision was taken that the mental hospitals should be allowed to run down their patient numbers and eventually close. This decision took account of the belief that psychiatry was clearly estab- lished as a specialty within medicine and could be expected to continue to develop more successful treatments for mental illness. Thus it was believed that the hospital needs for general psychiatry would be relatively small and that new services for the mentally ill should be closely associated with the general hospital services. Institutional to community care :

In 1957, ten years after their induction into the NHS and during the time of rapid change within the psy-

chiatric services the future of mental subnormality hospital services was foreshadowed by the report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency. That Commission recommended a move away from institutional care to care in the community and opened up a discussion concerning the future of the mental handicap hospital which has continued ever since.

The controversy ranges from the belief that large specialised mental handicap hospitals alone offer the range of facilities, placements and staff that the mentally handicapped require to the conviction that with good planning and supporting services no special hospital services for the mentally handicapped need be provided - although without denying that special medical services for some of them would always be needed. Meanwhile, a number of new mental handicap hospitals were built and local authorities continued to expand their provision for the mentally handicapped particularly in the sphere of education services and day services for adults.

The economy of the Country waxed and waned and no dramatic changes in the pattern of services for the mentally handicappcd seemed in the offing. But within the different parts of the service many rapid develop- ments in the field of professional practice with much innovation were taking place - for example in special education, in genetics and in the application of psycho- logical theory. On the sociological front too there was much new thinking and many new ideas. The concept of normalisatioit had been greeted by many with the same enthusiasm that had the notion of institutionul- imtioiz some years beforc. Stimulated by the writings of Goffman, and thosc who followed, and firm in the belief that the “small-group principle” was the greatest discovery made in the care of the mentally handicapped, the large mental handicap hospitals were seen as clear targets for change.

Concern for the mental handicap hospital In the late 1960s, the beginning of a further decade,

the scene was lit up brightly by the “spotlight of concern” turned on by a series of published enquiries into the problems of long-stay hospitals and in particular mental handicap hospitals. Mr. Crossman, then Secre- tary of State, seized the issue and a state of emergency in the mental handicap hospitals was recognised by the DHSS, hospital authorities and many who worked in the service. Some quick and practical form of relief was urgently sought for the overcrowded, under-financed and under-staffed hospitals. The situation was not unlike that in the mental illness hospitals in the early 1950’s when, with rising admission rates, an urgent programme of new psychiatric hospital building was being con- sidered. But whilst phenothiazines and new methods of psychiatric practice dramatically changed the course of events over the next few years for the mental illness services no similar remedy seemed likely to emerge for mental handicap. Perhaps the simplest and quickest

4

solution would have been to add new buildings to the existing mental handicap hospitals in order to relieve overcrowding in a quick and economical way. However, not only would this have consolidated the nature of those hospitals but it might also have inhibited alter- native capital investment in a different pattern of service a t a later date.

Working group on standards This doubt on how to proceed and the intensified

pressure for a move completely away from any new hospital provision caused the DHSS to set up a working party in 1968 to consider the problem. It consisted of about a dozen people representing the professions primarily concerned including nursing, paediatrics, psychiatry and social services and after a commendably brief series of meetings a report was produced which outlined the principles of their concept for modern services.

At about the same time another working group of professionals from both outside and inside the DHSS was given the task of identifying a number of deficien- cies within the hospital service which required urgent rectification. The group proposed the setting of certain minimum standards of care for such items as space by day and night, staffing levels, food and clothing. These standards were set in 1969 but in some instances still have yet to be met.

Who should be responsible for fulfilling the needs ? The 1968 working party’s report recognised (as did

the subsequent White Paper “Better Services for the Mentally Handicapped”) that there were some issues which seemed reasonably clear, such as the range of services which local authorities were required to provide, but controversy still continued over the shape and size of the heutth needs of mentally handicapped people. The controversy was confined to a relatively small group of people both within and without the Health Service although public outrage had been formally expressed at some of the unhappy aspects of the services which had been revealed.

The ‘Crossman’ working party At such times a Secretary of State comes under great

pressure and since it was known a Government state- ment on policy for mental handicap services was in the offing there were representations from professional organisations, voluntary organisations and parent groups, political party groups and from individual sociologists, psychiatrists and psychologists. At that time the Secretary of State (the late Mr. Richard Cross- man) - inaugurated a series of discussions ranging from weekend gatherings of 30 or more professional workers to meetings with just a few people. The Report of the working party was discussed in these settings and much of it was incorporated in the White Paper “Better services for the mentally handicapped” which was then being written and eventually published in June 1971.

Epidemiological audits We were fortunate in having a good deal of epidemio-

logical material both from the Registers at Wessex and Camberwell and from a survey that had been done in the Newcastle region, and it was believed that the number of mentally handicapped in the Country who were receiving a service was known. By looking a t a simple breakdown of their handicaps a tentative profes- sional judgement was made as to whether they required hospital or local authority care and a number of

provisional guidelines for service planning were drawn UP.

A plan for action There was a problem on the hospital side. We were

still not sure what course of action to recommend and the Government was bold enough to say so. A very flexible compromise position was decided on which gave some satisfaction to most participants in the hospital/ no hospital debate, Health authorities were told that “for the time being” no new large mental hospitals should be built and that none of 500 beds or more should be added to. New hospital building at district level was urged and “alternative lines of development” were encouraged. Additionally, planning authorities were urged to give a higher priority to mental handicap services, some additional funds were made available, and many began to see real physical improvements and an increase in the staff in the mental handicap hospitals. The Hospital Advisory Service was also created and commenced its unprecedented series of visits to mental illness and mental handicap hospitals.

The last ten years We are approaching the end of the third decade. I t

began in the late 1960s with the public awareness of hospital problems and the production of a Government policy. It saw too, in 1971, the assumption of a respon- sibility by education authorities for the education of all children and the newly created Social Services structure took both new tasks and a commitment to expand their existing roles with mentally handicapped people.

On the health side, too, as a result of the implemen- tation of the Salmon recommendations, nurses were given a new duty of professional care to organise and deliver their own special skills, psychologists began to offer new approaches in treatment and the psychiatrists moved more and more from the hospital into providing out-patient and domiciliary services and services for mentally handicapped people and staff in a variety of local authority premises - residential homes, ATC’s and special schools.

In many ways the decade began with the hope of better things to come since the White Paper offered a flexible and comprehensive plan which appeared afford- able at the time. However, the energy crisis and world recession meant that initial progress was slower than had been hoped at first. All experienced the bitter disappointment of unfulfilled expectations and, on the health side, the complex and often ill-understood process of reorganisation of the NHS was felt by many to be a bureaucratic affront calculated to inhibit if not extin- guish all willing enterprise. I t was a period too of social unrest and within the Hospital Service profes- sional groups sought to explore the limits of their new concepts of responsibility within a new pattern of hospital life in which a clearly understood system had been dissolved and replaced by an unformed and untried successor. But throughout these years there stretched an unbroken thread of many strands. There was the swelling recognition of the natural entitlement to equal rights that mentally handicapped men, women and children share with their fellow citizens. There was a growing awareness of their greater potential for develop- ment than had been thought possible. There was also the widening strand of advance in prevention of handicap, and the changing prospects as a result of new educational, residential, rehabilitative and therapeutic practices.

5

The National Development Group and the Development Team

In order to maintain momentum in the wake of the White Paper, to scrutinise the policy in it and to explore a bridging of the gap between new knowledge and existing practice the Secretary of State, then Mrs. Barbara Castle, set up the National Development Group for the Mentally Handicapped (NDG), the Development Team and a Committee of Enquiry into Mental Handi- cap Nursing and Care. Already the NDG has made its impact with a series of pamphlets and the Development Team has spent a busy eighteen months visiting and advising on services up and down the Country.

Despite the hard times of recent years there have taken place significant changes in our ideas and beliefs from thirty years before and yet some believe that traditional thinking on the sort of services we need continues to influence developments. Certainly in choosing to allot a shared responsibility for mental handicap services between health and local authority the most severely handicapped, dependent and disturbed people, have been assigned to health care - a formidable commitment. The commitment to provide local district based services raised the question of how should the Health Service provide for this group ? An attractive solution from the design, management and organisational viewpoint is the provision of hospitals on one site of 150-200 beds as part of a range of services provided by health and local authority. Many might consider this an ideal size allowing the possibility of compact organisation, personalised professionalism and yet allowing for some flexibility in the use of its space and providing a reasonable pool of staff to draw on for various purposes. Others might think that to create a hospital of this size invites institutional practices, encourages false economy by tempting such non domestic provision as central catering and laundry facilities and generally carries all the potential prob- lems, albeit on a smaller scale, to which large institutions

are prone. Such believers would consider there to be significant advantages in providing the necessary places in 10-20 quite discrete units each having a clear place in a carefully planned district organisational structure but each unit being able to operate in such a way as to promote individuality and homeliness as well as developing strong staff loyalties. Such a service might also be able to take account of the needs of special small groups such as deaf and blind people and those with severe behaviour disorders who require very individually planned care involving speciaI psycholo- gical, nursing and psychiatric skills. By definition such small hospital units would carry the most heavily handi- capped mentally handicapped people in the district served by them - and some of the units may also offer a regional or sub-regional service. We know, however, that there are problems in concentrating severely handi- capped people together, particularly adults, and in such circumstances there do seem to be disadvantages in having two authorities, health and local authority, responsible for residential care for separatc types of residents. But even such thinking is conditioned by experience of the sort of people a t present living in hospitals and it may well be that we shall not continue to see created new generations of severely handicapped people on the scale we have known in the past. Even with the increased survival rates of heavily handicapped people we would hope that the prospects for prevention or early detection and the institution of remedial measures will inexorably result in a decrease in the incidence and prevalence of severe mental handicap.

In any event, 30 years after joining the NHS we still lack a clear vision about the sort of hospital services we require for the mentally handicapped. But we are not dealing with an unchanging problem and perhaps the fourth decade will allow us to take full account of changing times, both philosophically and economically, and that a follow-up article in 1988 will see us with a service which represents the collective wisdom of pro- fessionals who are jointly agreed on what is needed.

IMS Mental Handicap Bulletin At the end of the King’s Fund Mental Handicap Project, production of the Mental Handicap Bulletin passed to the Institute of Mental Subnormality. The IMS Mental Handicap Bulletin is published quarterly, in June, September, December and March. Each issue will comprise a collection of articles reprinted from a wide variety of sources on many aspects of mental handicap, written in non-technical style and with a general appeal to anyone working, or otherwise involved, with the mentally handicapped, collated into a clear plastic folder together with additional booklets and pamphlets of topical interest. Bulletin is available by annual subscription of €4.00. Sample copies on request price f 1 .OO each.

To : The Subscription Manager, IMS Mental Handicap Bulletin, Institute of Mental Subnormality,

Either: I wish to subscribe to the lMS Mental Handicap Bulletin and enclose my annual subscription of

f .................. Please send me a sample copy of the lMS Mental Handicap Bulletin for which I enclose f..

Wolverhampton Road, Kidderminster, Worcs. DYIO 3PP.

or .. . . .

Name (Block capitals please)

Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

“Onlv last month, intermittent daudication ‘ made walking an uphill battle!’

In arterial iiisufficieiicy

keeps people in circulation

7