Background
Services for people with mental health problems have seen some of the biggest changes over the lifespan of the NHS. Today the majority of care is provided in community settings. This is a far cry from the early years of the NHS, when mental health services were based largely in Victorian-era asylums with a focus on containment rather than treatment or support.
The asylums reached their peak in terms of bed occupancy in the 1950s. In 1957, the Percy Report marked a turning point in official policy from hospital-based to community-based systems of care. It recommended that the majority of people with mental health problems did not need to be admitted to hospital and could instead receive care from GPs or other community-based services.
The Mental Health Act followed in 1959, seeking to allow admissions for psychiatric reasons to be, wherever possible, as informal as those for physical reasons. In 1962, The Hospital Plan for England and Wales stated that large psychiatric hospitals should be closed and local authorities should develop community services.
A series of scandals about practices in some of the old mental health hospitals were exposed in the 1960s and 1970s and many public inquiries took place. One such inquiry dealt with the Whittingham Hospital, in Lancashire, which was one of England's largest mental health hospitals, where there were allegations of ill-treatment and the conviction of a male nurse for the manslaughter of a patient.
One reaction to these scandals was the publication of the white paper Better Services for the Mentally Ill in 1975 which said an alternative had to be found to hospitalisation and laid a foundation for care in the community. The idea was to gradually phase out the large mental hospitals and replace them with psychiatric units within district general hospitals. But it was not until 1986 that the first psychiatric hospital was fully closed, and many remained open until the early 1990s.
The Conservative government’s 1981 Green Paper Care in the Community went further and suggested ways of moving money and care from the NHS to local councils and voluntary associations to enable people with severe and ongoing mental health problems to live as independently as possible.
In 1983, The Mental Health Act for England and Wales introduced new legislation describing when and how a person could be detained or ‘sectioned’ for compulsorily treatment in a psychiatric unit. The Act placed legal controls on the use of certain treatments, particularly surgery and electro-convulsive therapy. It also imposed a duty on local health and social services authorities to provide appropriate care for people with mental health problems after discharge from hospital.
In 1997, the Labour government made mental heath one of their three clinical priorities, alongside cancer and heart disease. The National Service Framework (NSF) for mental health, published in 1999, set standards for mental health and how these should be achieved. This was backed by additional funding – £700 million over three years. An additional £300 million announced in The NHS Plan in 2000 was intended to ‘fast forward’ the NSF and help secure the introduction of new service types designed to better meet the needs of people with mental health problems living in the community – such as community mental health teams, early intervention in psychosis teams, and crisis resolution teams.
The Labour government also made it their ambition to reform the 1983 Mental Health Act, for a number of reasons. In part, there was a perception of a ‘revolving-door’ problem in that people would be detained under the Mental Health Act but then after recovering and being discharged into the community would stop taking their medication, deteriorate, and end up back on inpatient wards. This was the logic behind Community Treatment Orders, which compel a person to take their medication in the community – something that previously could only be done when a person was sectioned and in a hospital setting. The reforms were also driven by concerns around public safety.
The proposed reforms to the Mental Health Act were strongly opposed by the Mental Health Alliance – a group of over 50 voluntary organisations, service users groups, and professional organisations and trade unions all concerned that the proposals would tip the balance too far in favour of coercive treatment and control of people with mental health problems, as opposed to care and support.
The 2007 Mental Health Act was passed by parliament after certain concessions were made, including tighter controls over the use of compulsory treatment orders, and granting people the right to an independent advocate when they are detained under the Act. Further details on the Act can be found in a briefing by The King’s Fund.
The previous government launched a new mental health strategy in 2009, known as 'New Horizons'. This marked a shift in direction, with greater emphasis being placed on promoting positive mental health and well-being across the whole population, and preventing mental health problems from developing. The current government has not yet released details on whether this focus will remain in place.
