The data are only as good as contemporary methods of collection and aggregation. Increases in the complexity of data collected across the NHS in recent decades, accompanied by a growth in the number and type of reporting entities, have improved the validity of some measures but reduced the reliability of national aggregates. Increasing use of data for performance management has increased the probability of manipulation both at the point of collection at the patient interface and at the point of reporting Strategic Health Authorities or Trusts , and thus reduced the reliability of aggregates; this uncertainty applies particularly to admissions, length of stay and outpatient activity in and Patient data and nursing workforce data are rounded, partly to reflect the possible inaccuracies and inconsistencies in official statistics.
Except where indicated, staff numbers are headcounts. Changing reporting conventions make it impossible to present whole-time equivalents on a consistent basis across the period. Until , patients would have been referred by GPs to psychiatrists working in hospitals and certified, if needed, under the Mental Treatment Act.
Their treatment would have been determined by the Physician Superintendent of the hospital.
[Full text] Violence within mental health services: how to enhance risk management | RMHP
From then until , the route from the GP would have been to a consultant psychiatrist at an outpatient clinic, or sometimes directly to a clinical psychologist; the clinical process would have been controlled by the consultant or the psychologist. Between and , GPs would increasingly refer to multi-disciplinary Community Mental Health Teams, where other professionals, or GPs themselves, might assume responsibility for the clinical process. Under this scheme, key workers from either the NHS or local authority social services would be charged with coordinating the delivery of individual patient care.
Under the Increasing Access to Psychological Therapies IAPT programme after , people experiencing mental distress could also refer themselves to some services without GP intervention. For many, though, the patient journey never started, and for most it was very short.
The prevalence of mental disorder not dealt with by specialist services became a topic of discussion in the s. At least for the earlier years a broad consensus emerged about the main characteristics of the mental health services. The s were acknowledged as a period of slow but necessary change.
Services were dominated institutionally and intellectually by psychiatrists, who began to establish a more distinct professional identity and formal training under the Royal College of Psychiatry chartered in For this reason, long-serving psychiatrists saw Enoch Powell as a progressive figure in mental health reform.
Dissatisfaction with the status quo, as recollected by contributors, was manifested in a number of ways. The earliest service user movements appeared in the early s, demanding civil and economic rights for patients in the community, and, in parallel, pressure groups such as MIND began to agitate for changes to the Act. Yet the s also saw significant innovations in treatment and service delivery, led by clinicians responding to these challenges. There was increasing use of psychological treatments with an evidence base and widespread acceptance that the services needed to acknowledge and counteract the social devaluation of their users.
So the standard of nursing care was going up. And there was, in most cases, enough to make the old accommodation certainly tolerable, if not quite satisfactory. Clinicians remembered this process as doubling the number of managers in the NHS, 26 though some of these were undoubtedly existing senior clinicians rebadged as managers. This is private medicine of course. Thus for the last two decades of the twentieth century a consensus memory was superseded by multiple, interlocked narratives. Professionals divided into negative and positive camps, with the division cutting across professional boundaries.
From this perspective, public policy was at fault, because ministers would not fund or direct community care but pandered to public prejudice by imposing greater restrictions on patients and professionals, especially in the s and after, when politicians renewed their interest in mental health policy. Witnesses argued that a renewed emphasis on control and confinement was a bad policy and that it grew from a political reaction to scandal: specifically, homicides by psychiatric outpatients, such as the killing of Jonathan Zito by Christopher Clunis in These included assertive outreach teams and crisis resolution and home treatment teams created under the NHS plan, which were associated by some clinicians with fragmentation of care.
A more optimistic professional perspective saw a set of positive developments in the same period. On the one hand, closure of the long-stay hospitals was associated with significant advances in psychiatric rehabilitation, involving multi-disciplinary teams working in the community. The same years furnished wholly different insights from and about the users of services. Notwithstanding innovation, goodwill and improvement on the part of providers, mental disorder for the service user continued to be associated with social exclusion and the denial of civil rights.
The growth of the service user movement provided a forum in which these concerns and complaints could be articulated. From this viewpoint, the Labour government offered a particular moment of political clarity, a model for implementation built on a target culture, a belief not shared by previous administrations in the value of national leadership on social policy issues, and above all the availability of money, all of which led to large positive changes.
There was also a desire to modernise mental health legislation by superseding the Act. Policy innovation was traced to leaps of faith and changing values as well as to the evidence base. Witnesses acknowledged that New Labour delivered large expenditure in mental health, but contested the effectiveness of that expenditure.
For many user groups, notably black and minority ethnic groups, it was argued that there had been little change for the better despite broadly good intentions. For clinicians, the development of clinical governance, which by implication made clinicians accountable to managers, and thus ultimately to the state and to the community at large, as well as to their patients, was a significant change. Strikingly, the different narratives of recent developments in mental health services describe the fragmentation of a system which was regarded arguably wrongly as relatively homogeneous in an earlier period.
Responsibility for providing these services, which had previously rested with the NHS and local authorities, had been extended to include the third sector and, increasingly, profit-making contractors. Psychiatric hegemony was challenged by new professions, by new conceptions of mental distress, and by a new assertiveness on the part of service users, as well as by the incursions of public policy and policymakers into clinical autonomy. The four voices in these discussions — professionals both approving and disenchanted , service users and policymakers — shared a number of common preoccupations which we argue should be central to future study of recent mental health services in England and probably elsewhere in the United Kingdom.
From Community to Meta-Community Mental Health Care
The most important of these were the rise of the service user, the risk agenda, the allocation of resources, changing and contested definitions of mental health and psychiatric need, and the impact of changing professional values on the delivery of services. Any articulated narrative of change since must be informed by these concerns. There was consensus among witnesses that one of the most important and striking changes in the history of post-war British mental health care has been the rise of the service user perspective. Discussion of the later period was much less definite.
The optimistic professional view of developments since the s was that the civilising influence of campaigning organisations such as MIND and other groups had successfully engaged professionals in collaboration with service users in the design and delivery of the services, and indeed that this was a relatively unusual and advanced aspect of British practice.
This generous and present-centred 56 perspective was contested from a number of directions. Contributors, including departmental officials, noted the lack of progress in addressing health inequalities in general, and in particular the disproportionately bad experience of service users from black and minority ethnic groups. The service user objections to the restrictions of liberty contained in mental health legislation are clearly alive and well after the Act, alongside a more consumerist critique of the inadequacy of resources to meet treatment needs.
Nor have professionals and service users reached an easy consensus on treatment methods or service design. Research led by service users on electro-convulsive therapy, for example, met with considerable hostility from the Royal College of Psychiatrists before being acknowledged in the NICE guidelines on risk and consent. A consistent theme in discussion was the distorting influence of a focus on risk, and the perception that this was a characteristic of recent policy and legislation.
And the big risk that all the psychiatrists worry about is violence. But the political salience of risk was recognised as being neither new nor confined to mental health. Psychiatrists acknowledged that. In the seminars, the risk agenda excited passions of two sorts. Clinicians tended to interpret it as an excuse for inappropriate bureaucratic interference in their clinical judgement:. This echoes the views of Rose and Castel, who see the risk agenda as diminishing the standing of psychiatrists.
By contrast, service users argued that consideration of risk, and especially new categories of risk, strengthened the control of clinicians over patients:. The question remains as to whether recent attitudes to risk in mental health policy are different in kind, or just different in degree and in consequences, from earlier perceptions. Additionally, Harvey Gordon has noted that the specific risk of re-offending was a consideration in the discharge of criminal lunatics from Broadmoor.
Much of the substance of any public policy lies in decisions about the allocation of resources. Seminar members were greatly exercised by the cost of services, but discussion threw up as many questions as answers. A starting point was that for at least a century before the inauguration of the post-war welfare state, mental health was one of the better-funded public welfare services, with large capital investments in asylums and a national regulatory system in the Board of Control.
Witnesses were able to point out that NHS expenditure had normally not kept pace with changes in need except, briefly, in the increased spending of the last Labour government , that it continued to fall behind growth in expenditure on physical medicine, and that within the mental health budget there have been contestable allocations with rapid recent increases as noted previously in spending on forensic and secure services, an emphasis on services for adults of working age at the expense of children and older people, and persistent large variations between regions.
The failure to recognise the resource demands of community-based care, from the very beginning of the de-institutionalisation programme, was taken as read. It was noted that ministers had demanded, and got, evidence of efficacy in minute detail before agreeing to fund, and then continue funding, the IAPT programme. Given this widespread preoccupation with cost and resource constraints, historians will find it necessary, but difficult, to go behind these words and selected indicative statistics to build a balanced and informative picture of changes over time in actual resource allocation and the policies which drove it.
Local authority expenditure is published in annual departmental reports but does not separate mental health from other social services expenditure after the establishment of generic social service teams. Where data from third sector and private providers is available it does not reliably distinguish mental health from other forms of social support. An even more elusive and fluid problem is the resourcing of care for people with dementia.
Successive acts of policy have moved patients away from NHS institutions and towards local authority provision or private or third sector institutions. As the number of patients in long-term residential care, or requiring care in the community, has increased, the share of the cost borne by public expenditure has dropped. On resource issues, as in many other perspectives on the mental health services, fragmentation of provision has led to fragmentation of evidence. Historians will also ask how the debate on the validity of psychiatric knowledge and practice — fascinating as it is to cultural historians — has been relevant to the development of services.
Anti-psychiatry of the s included three very distinct strands, represented totemically by R. Laing, Thomas Szasz and Erving Goffman. Laing, influenced by existentialism and psycho-analysis, saw schizophrenia as a sane response to an insane environment created, largely, by dysfunctional families and capitalism.
Szasz regarded mental illness as a construct misappropriating medical concepts in order to control people whose behaviour was regarded as alarming or offensive. At the time, British psychiatric commentators were ambivalent about Laing and generally hostile to Szasz. And their demand was to be put back on the map as regular, decent citizens. Psychiatry now faces two challenges it cannot ignore. First, a growing body of empirical evidence points to the primary importance of the non-technical aspects of mental healthcare …second, real collaboration with the service user movement can only happen when psychiatry is ready to move beyond the primacy of the technical paradigm…Substantive progress in our field will not come from neuroscience and pharmaceuticals important as these might be but from a fundamental re-examination of what mental healthcare is all about and a rethinking of how genuine knowledge and expertise can be developed in the field of mental health.
Within and beyond psychiatry, witnesses also emphasised the continuing controversy over the application of the paradigms of evidence-based medicine to mental health problems — a paradigm which was perhaps most prominent in the introduction of psychological therapies through IAPT, but one which discomfits many clinicians whose favoured therapies do not fit easily into randomised controlled trials.
The willingness of many service users and many non-users to challenge professional definitions of their distress as illness is an evident legacy of the anti-psychiatry movement, but debate about scope and definition has been just as intense within and between communities of service providers. Psychiatric diagnosis is denounced as an instrument of power by critics of the disease model of mental distress, and the major diagnostic schemas, DSM-IV and ICD, are attacked by critics because, inter alia , they have been seen to include more and more people in stigmatised categories, especially by defining behaviour disorders as illness.
On the other hand, the idea that mental illness is definable and treatable as a disease process like any other has been fundamental to many developments in service delivery in the period covered by these seminars. Diagnosis is hardwired into the logic of NICE guidelines. To the outsider the mental health professions appear notably tribal, even to the extent of identifying specific positions within clinical and scientific debates with loyalty to specific professional communities. Witnesses acknowledged that such tribalism existed, and associated it particularly with the separateness of training regimes, but raised further questions which clearly demand historical investigation.
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