You are welcome to print and photocopy this page of Mind’s website. Organisations are free to distribute copies to service users and colleagues, but must ensure they always use the latest version, as available on the website, at the time of distribution. 1601 The Poor Law was introduced and clearly defined the responsibility of every parish to support those who were incapable of looking after themselves. This responsibility was limited to people born or defined as being ‘settled’ in a parish. Other people who did not fit these categories could be expelled from the parish.
1808 The County Asylums Act 1808 gave permissive powers to the Justices of each county to build asylums, paid for by local rates, to replace the few psychiatric annexes to voluntary general hospitals. However, this development was very slow. 1834 The Poor Law Amendment Act 1834 required relief to be provided within institutions only. This led to the construction of a huge network of workhouses. 1845 The Lunacy Act 1845 required counties to provide asylums. The majority of Britain’s psychiatric hospitals were built during the next 25 years.
The growth of asylums was fuelled by funding arrangements that encouraged local parishes to move the parish poor into asylums, as these were funded by the county councils rather than the parishes. 1860s The workhouses were obliged to build ‘infirmary’ annexes – the first general hospitals (to be set up as a legal requirement). 1863 The Mental After-Care Association (MACA, later renamed Together) was established: a voluntary organisation providing short-stay residential homes for discharged psychiatric patients in the Greater London area.
1875 The Government began to pay a subsidy to Poor Law authorities of up to 25 per cent of the cost of supporting ‘pauper lunatics’ in asylums. This was the first central government financing of any health or social care service. 1880 The second wave of asylum building began. 1890 The Lunacy Act 1890 brought in laws regulating asylums and compulsory care. 1891 The Lunacy Act 1891 imposed rigid procedures and criteria so that only people with the most severe mental illnesses were likely to be admitted to hospitals.
1909 A report of the Poor Law Commission was published, based around two central principles: in terms of health care, that prevention is cheaper and more effective than cure in terms of social care, that charitable activity has its proper place in supporting a public service. The report also suggested that the Poor Law should be replaced by specialised social services dealing with separate categories of people.
The subsequent development of the National Health Service (NHS) in 1948 and local authority social services can be seen in terms of these principles. 1923 The Maudsley Hospital was opened by London County Council. It was the first psychiatric hospital to operate outside the restrictions of the Lunacy Act.
1923 The Tavistock Clinic was founded as a centre for psychotherapeutic training and treatment. 1926 The Report of the Royal Commission on lunacy and mental disorder suggested that outpatient clinics should be opened and aftercare services developed, as well as voluntary admission to psychiatric hospital. The emphasis was changed from detention to prevention and treatment. 1930 The Poor Law was reformed and terms such as ‘pauper lunatic’ were abolished. Outpatient work by the medical staff of public mental hospitals was permitted. Legislation brought the workhouse infirmaries under the control of local authorities.
More of these progressed towards becoming general hospitals. Many had observation wards where patients were admitted under the Lunacy Act, while others had long-stay wards for non-acute psychiatric patients. 1930 The Mental Treatment Act 1930 allowed for voluntary admission to psychiatric hospitals. 1930s The 1930s saw the introduction of physical treatments such as electroconvulsive therapy (ECT), lobotomy and insulin coma treatment, allowing the early discharge of some people back to the community. By 1936, 143 outpatient clinics were operating, some of which had social workers attached to them.
(Insulin coma therapy was abandoned in the 1960s, having been conclusively shown to be ineffective. ) 1939 The Feversham Committee on voluntary mental health associations (1936-39) recommended the amalgamation of three major mental health organisations: the Central Association for Mental Welfare, the Child Guidance Council and the National Council for Mental Hygiene. Although the formal merger did not occur until the end of World War II, the associations worked together during the war through the Provisional Council for Mental Health.
The Government asked the Council to provide a national aftercare service for people discharged from military service on psychiatric grounds. 1942 In December, the British Government published the watershed report on social insurance and allied services – better known as the Beveridge Report after its author, the journalist, academic and Government advisor, William Beveridge; this report shaped government social policy for the rest of the century. 1946 The National Association for Mental Health (NAMH, which later became Mind) was formed by the amalgamation of the three major mental health organisations (see 1939).
NAMH lobbied for better services for people with mental health problems, set up day centres and hostels and provided training services for social workers and residential care staff. 1948 The National Health Service was established. A full history of the NHS can be found on Geoffrey Rivett’s website, www. nhshistory. net 1948 The National Assistance Act 1948 stated that, ‘it shall be the duty of every local authority to provide residential accommodation for persons who, by reason of age, illness, disability or any other circumstances, are in need of care and attention which is not otherwise available to them’.
This, together with the recent introduction of welfare benefits, encouraged the beginning of the move from institutional to community-based care. 1950s Day hospitals began to be established, providing greater flexibility in psychiatric services and reducing the use of hospital beds. Hostels and therapeutic social clubs were set up to provide support for discharged patients. The introduction of neuroleptic drugs helped to shorten the time that newly admitted patients spent in hospitals and encouraged the discharge of many into the community.
Some new district psychiatric services were developed in general hospitals, so that beds in regional mental hospitals were no longer needed; this provided a model for future service changes. 1954 The first outpatient nurses were appointed at Warlingham Park Hospital, Croydon. Their duties included visiting outpatients, supporting inpatients who had been discharged and helping them to find jobs and accommodation, and being available to give advice at outpatient clinics and therapeutic social clubs.
1954 After rising steadily throughout the first half of the century, the resident population of psychiatric hospital beds reached a peak of 152,000. Many of the hospitals were extremely overcrowded; for example, Friern Barnet hospital was built in 1851 to accommodate 1000 patients but by 1950 it accommodated over 2000. 1955 From 1955 onwards, psychiatric inpatient numbers began to decrease slowly, following the introduction of social methods of rehabilitation and resettlement in the community, the availability of welfare benefits and the introduction of antipsychotic medication.
1957 The Report of the 1954-57 Royal Commission on the law relating to mental illness and mental deficiency (the Percy Report) was published. The report marked a turning point in official policy from hospital-based to community-based systems of care. The Commission recommended that, ‘the law should be altered so that whenever possible suitable care may be provided for mentally disordered patients with no more restriction of liberty or legal formality than is applied to people who need care because of other types of illness, disability or social difficulty.
The Commission also recommended that, ‘the majority of mentally ill patients do not need to be admitted to hospital as inpatients. Patients may receive medical treatment from general practitioners or as hospital outpatients and other care from community health and welfare services. ‘ 1959 The Mental Health Act 1959 reinforced the Mental Treatment Act 1930, allowing most psychiatric admissions to occur voluntarily. Following the recommendations of the Percy Report, the procedure for deciding whether a person should be compulsorily detained in hospital changed from a judicial to an administrative process.
At the same time, procedures and safeguards around compulsory detention and treatment were tightened. 1960s It became commonplace for psychiatric nurses to work with patients outside of hospitals. Locked doors were beginning to disappear as a feature of psychiatric wards. 1961 Enoch Powell, then Health Minister, made his famous ‘Water Tower’ speech to the annual conference of NAMH. He envisaged that psychiatric hospitals would be phased out and replaced by care provided in the community. Powell’s plan was for ‘nothing less than the elimination of by far the greater part of this country’s mental hospitals as they stand today’.
1962 The Hospital plan for England and Wales stated that large psychiatric hospitals should close and that local authorities should develop community services. Inpatient numbers continued to fall, but many local services were not yet in place. A new group of ‘long-stay’ patients began to accumulate in the hospitals. The era of community care had begun and has remained official policy ever since. 1968 The Health Minister, Kenneth Robinson, stated that progress in modernising the organisation of mental health services was lagging behind progress in applying modern methods of treatment.
Robinson proposed the ‘Worcester development project’ to demonstrate how the problems of transition from the old psychiatric hospitals to modern community-based mental health services could be identified and solved in a cooperative exercise between local health authorities and local authorities. 1970s Debate focused on reviewing the Mental Health Act 1959. Limited progress was made towards the aims of the 1975 White Paper (see below). Social security benefits for board and lodging charges became available to individual claimants.
Many long-stay patients who were formerly a charge on the NHS were discharged to the community, where they were to become a charge on local authorities but the charge was moved to the Department of Social Services. The Government introduced a small joint finance fund to encourage the transfer of services from the NHS to local authorities to foster community-based developments. 1970 The Chronically Sick and Disabled Person’s Act 1970 required local authorities to determine the needs of people in their local populations and to provide certain services for them. They also had a duty to publicise the availability of these services.
1970 The Local Authority Social Services Act 1970 created social services departments as we now know them. With effect from 1972, all personal social services were to be brought together in one department. 1972 NAMH changed its name to Mind. The Mind office in Wales was opened. (It was renamed Mind Cymru in 1997. ) 1975 The White Paper, Better services for the mentally ill, looked at developments since the 1962 Hospital plan. It set out a blueprint for an integrated local approach to mental health care involving the NHS, local authorities and the voluntary sector.
The White Paper set out the facilities that were required and set numerical targets for achieving better and more appropriate services. However, this White Paper came at a time of recession and pessimism about public services; it had little impact on the haphazard dissolution of the hospitals and the almost total failure of statutory authorities to provide adequate community-based care. 1977 The NHS Act 1977 was introduced. Section 28a of the Act gave health authorities the power to transfer money to support local authority services.
Section 28a was introduced primarily to assist with the re-provision of mental health services from NHS long-stay psychiatric hospitals to newly developed services in the community. 1981 The Department of Health published a consultation document entitled Care in the community. 1982 The Barclay Report was published. This was essentially a government prospectus for the future planning of social work. It recommended that people in need should no longer be seen as isolated individuals, but in terms of their relationships with family, friends, local community, etc. The report stated that social services should be organised on a local patch basis.
1983 The Mental Health Act 1983 provided safeguards for people in hospital. Section 117 of the Act imposed a duty on district health authorities and social services departments (in cooperation with voluntary agencies) to provide after-care services for people discharged from hospital. 1985 The Social Services Select Committee report Community care with special reference to adult mentally ill and mentally handicapped people stated that hospital closures had outrun community-care provisions, particularly in relation to people with mental health problems. There were calls for government action and increased spending.
In the Committee’s own words, ‘A decent community-based service for mentally ill or mentally handicapped people cannot be provided at the same overall cost as present services. The proposition that community care should be cost neutral is untenable… Any fool can close a long-stay hospital: it takes more time and trouble to do it properly and compassionately. ‘ 1986 Even though the psychiatric hospital population had halved between the mid-1950s and the mid-1980s, it was 1986 before the first psychiatric hospital was fully closed down. Many of the large old hospitals closed in the late 1980s and early 1990s.
1986 The report of the Audit Commission for Local Authorities in England and Wales Making a reality of community care pointed out that despite the reduction in the number of hospital beds, local authorities had not been allocated the resources necessary to provide alternative forms of care. Leading businessman Sir Roy Griffiths was given responsibility for reporting on this (see 1988). 1986 The Disabled Persons (Services, Consultation and Representation) Act 1986 was introduced to strengthen the legislation laid down in the Chronically Sick and Disabled Persons Act 1970.
Section 4 of the new Act gave local authorities the duty to assess people for services if asked to do so by the individual or their representative or carer. 1987 The Mind Consumer Network was set up to inform and advise on the experiences, views and opinions of service users, and to have a direct route into policy development. (The following year it was renamed Mind Link. ) 1988 The Griffiths report was published, its recommendations including the appointment of a Minister of State for Community Care and the transfer of all community care to local authorities.
The report recommended giving ‘earmarked’ grants, partly funded by central government, to local authorities. It also recommended that local authorities be allowed to purchase services from other agencies. 1989 The White Paper Caring for people was published in response to the Griffiths report. It set out a framework for changes to community care, which included a new funding structure for social care. This would mark the beginning of the purchaser/provider split whereby social services departments were encouraged to purchase services provided by the independent sector.
The report promoted the development of domiciliary, day care and respite services to enable people to live as independently as possible in their own homes. Other objectives included quality initiatives around assessment of need and case management. Carers’ needs were addressed by prioritising practical support initiatives for them. The next decade saw a dramatic increase in the number of voluntary and private sector service providers. 1989 The launch of the 1989 All Wales mental illness strategy (Welsh Office 1989) provided an impetus to develop mental health services in Wales.
Community-orientated and locally based services were developed to include the establishment of multidisciplinary community mental health teams (CMHTs) throughout Wales. A wealth of voluntary sector facilities has since been developed, including drop-in facilities, self-help groups and employment training. These changes enabled some of the large older institutions to be closed, including North Wales, Parc, Mid-Wales and Pen-y-fal hospitals. 1990 The NHS and Community Care Act 1990 made all the legal changes necessary for the implementation of the Caring for people White Paper.
Local authorities, in collaboration with health-service and independent-sector agencies, now became responsible for assessing need, designing care packages and ensuring their delivery. 1991 The ‘mental health specific grant’ was introduced for mental health services in the community. This grant could only be spent with the joint agreement of local health authorities and social services departments. It was designed to encourage authorities to plan together so that a broad spectrum of services would be developed.
1991 Local authorities were made responsible, under the NHS and Community Care Act 1990, for the registration and inspection of homes and other community services either purchased or provided by them. 1991 The ‘care programme approach’ (CPA) was introduced in an attempt to improve and standardise the delivery of community care services. The CPA set out a practice framework for health authorities in England, giving guidance on how they should fulfil their duties as laid out in the NHS and Community Care Act 1990.
The CPA relied on liaison between health and social care agencies to ensure that people with mental health problems received appropriate levels of support in the community. 1992 Report of the All Wales Advisory Group on Forensic Psychiatry. 1992 Under the NHS and Community Care Act 1990, local authorities were expected to publish community care plans outlining the development of community-based services. They were also expected to show that they were making the best possible use of the independent sector. 1993 The Protocol for investment in health gain (mental health) – Welsh Office NHS directorate planning forum was published.
The protocol complemented the All Wales mental illness strategy (1989) and identified a range of health-gain targets for people with mental health problems. The forum was addressed mainly to the board members of health authorities and family health service authorities to assist them to develop their local strategies for health. The protocol identified where further investment could bring worthwhile health gain, and indicated where reinvestment might be considered. 1993 Local authorities were given the responsibility for making community care assessments.
However, the NHS and Community Care Act 1990 stated that health authorities would retain their responsibility for providing long-term health care for those in need. 1993 The Secretary of State for Health issued Guidance on the introduction of supervision registers. People considered to be ‘at risk of harming themselves or other people’ could be placed on a supervision register, with the aim of ensuring that they remain in contact with mental health services and that their care was monitored on a regular basis, embracing the principles of the CPA. 1994 The Department of Health set out its Framework for local community care charters in England.
The framework stated that local authorities should consult users and carers, voluntary organisations, independent service providers and others to ensure that their charters reflected local priorities and concerns. The charters would give service users and those involved in providing their care with better opportunities to influence service delivery. Charters would give people clear information about what they could expect from local authorities, and provide local authorities with criteria against which they could measure and improve their services.
1995 The Mental Health (Patients in the Community) Bill proposed new powers regarding the aftercare of people discharged from hospital. Under this bill, some service users could be required to live at a specified address and to attend certain places for treatment, occupation, education or training. The aftercare arrangements for each individual would be kept under review. A ‘supervisor’ could convey the service user to a place where they were to receive aftercare, but they could not force the person to have treatment against his or her will.
The ‘supervisor’ could also authorise another person to use the power to ‘take and convey’ the service user. No requirement was placed on health authorities and trusts in Wales to establish and maintain supervision registers. 1995 The Disability Discrimination Act 1995 was passed, making it illegal to discriminate against people on the grounds of physical disability, and placing an obligation on employers to make reasonable adjustments to working conditions to enable people with disabilities to accept employment. The application of the Act to people with mental health problems was initially quite restricted.
1996 The Welsh Office published Guidance on the care of people in the community with a mental illness, which addressed: the continuing role of CMHTs within the specialist mental health services the provision of care and support, including the assessment process, management of risk, discharge and aftercare arrangements the use and disclosure of patient information and immediate arrangements for improving communication and continuity of care across agencies. 1996 The Mental Health (Patients in the Community) Act 1995 came into force. The Act worked by creating a new section of the Mental Health Act 1983, section 25, which contained new powers.
[See Mental Health (Patients in the Community) Bill above]. 1996 The Carers (Recognition and Services) Act 1996 amended the NHS and Community Care Act 1990. It placed a duty on local authorities to carry out an assessment of the needs of carers for services such as respite care. 1996 The Community Care (Direct Payments) Act 1996 gave local authority social services departments power to make direct cash payments to some individuals in lieu of the community care services they had been assessed as needing, to enable them to secure the relevant services for themselves.
1996 The National Prescribing Centre was set up by the Department of Health to ‘promote and support high-quality cost-effective prescribing and medicines management across the NHS, to help improve patient care and service delivery’. www. npc. co. uk 1996 A survey carried out by the National Institute of Adult Continuing Education (NIACE) with further education colleges and local education authorities concluded that provision for people experiencing mental health difficulties was patchy in quantity and quality. 1997 The Prime Minister set up the Social Exclusion Unit.
Initially part of the Cabinet Office, the Unit moved to the Office of the Deputy Prime Minister in May 2002 and now works closely with other parts of the Office such as the Neighbourhood Renewal Unit and the Homelessness and Housing Support Directorate to tackle deprivation. 1997 The Department of Health and the Scottish Office published a White Paper, The new NHS: modern, dependable, which described how the ‘internal market’ in the NHS was to be abolished. It also announced the establishment of NHS Direct, a 24-hour telephone advice line on health matters, to be staffed by nurses.
1998 The Welsh Office brought out the equivalent paper to the above for the NHS in Wales, NHS Wales: putting patients first. 1998 The Health Secretary, Frank Dobson, stated that, ‘Care in the community has failed. Discharging people from institutions has brought benefits to some. But it has left many vulnerable patients to try and cope on their own. Others have been left to become a danger to themselves and a nuisance to others. A small but significant minority have become a danger to the public as well as themselves. ‘ Mind, along with many others, disagreed with the statement that community care had failed.
1999 The Government published the National Service Framework [NSF] for mental health -: modern standards and service models for England. The NSF spelled out national standards for mental health services, what they aimed to achieve, how they should be developed and delivered, and how performance would be measured in every part of the country.
1999 The Home Office and Department of Health produced a consultation paper, Managing dangerous people with severe personality disorder: proposals for policy development, which announced plans to introduce a new legal power of ‘indeterminate but review-able detention of dangerous personality-disordered individuals’ who present a grave risk to the public (for previous offenders and non-offenders).
1999 The Government published proposals on reform of the Mental Health Act in England and Wales. Before publishing these proposals the Government received a report from an expert committee, chaired by Genevra Richardson, which had spent 10 months reviewing the Act. Unfortunately, many of the more positive aspects of the Richardson report were not accepted by the Government. Mind warned the Government that plans to introduce compulsory treatment in the community would backfire and drive users away from services.
1999 The National Institute for Clinical Excellence (NICE) was set up as a Special Health Authority for England and Wales on 1 April. (Its name was changed to the National Institute for Health and Clinical Excellence in 2005 when the Institute took on the functions of the Health Development Agency (see below), but the acronym remained unchanged. ) Part of the NHS, NICE’s role is to provide patients, health professionals and the public with authoritative guidance on current ‘best practice’.
NICE guidance covers individual health technologies (including medicines, medical devices, diagnostic techniques and procedures) and the clinical management of specific conditions. NICE guidelines relating to mental health issues include: antenatal and postnatal mental health (February 2007) anxiety (December 2004) bipolar disorder (July 2006) dementia (November 2006) depression (December 2004) eating disorders (January 2004) obsessive-compulsive disorder (November 2005) post-traumatic stress disorder (March 2005) schizophrenia (December 2002) self-harm (July 2004) violence (February 2005).
More information is available at www. nice. org. uk 1999 Section 31 of the Health Act 1999 outlined new powers to enable health and local authority partners to work together more effectively, to come into force on 1 April 2000. This included pooled funding and integrated provision and the creation of primary care trusts (PCTs). 1999 The Disability Rights Commission was set up under the Disability Rights Commission Act 1999.
2000 The Health Development Agency was established as a Special Health Authority to develop the evidence base to improve health and reduce health inequalities. (Its functions were transferred to NICE on 1 April 2005. ) 2000 Direct payments were extended to those aged 65 years and over. An easy guide to direct payments was published in April 2000 to promote direct payments for people with a learning disability. The Government expressed a wish that people who currently had preserved rights to income support for long-term care costs should also be offered direct payments if they wanted to leave residential care.
2000 The National Assembly for Wales published its draft adult mental health services strategy for Wales, entitled Equity, Empowerment, Effectiveness, Efficiency. The final strategy from the consultation process will provide the strategic background against which an NSF for Wales (NSFW) for adult mental health services will be developed. The draft strategy stated that it was right that an NSFW should ‘differ in some important respects from the English document as there are distinctive differences in emphasis that reflect particular circumstances in Wales.
The standards set should be at least as good as those set for England. ‘ 2000 The draft Child and adolescent mental health services strategy Everybody’s Business was published in June. 2000 The NHS plan, published in July, included the proposal to abolish Community Health Councils (CHCs) in England, replacing them with a range of bodies including Patient Advocacy and Liaison Services (PALS), patients’ forums in trusts and health authorities, and local authority scrutiny committees.
The NHS plan also set out plans for increased funding, and for reform of many sections of the NHS. This included the establishment of a National Care Standards Commission. The NHS plan promised hundreds of mental health teams to provide an immediate response to crises. 2000 The Mental Health Alliance, a group of over 50 major voluntary organisations, service-user groups, service providers, professional organisations and trade unions lobbied Parliament to press for changes to the Government’s plans for a new Mental Health Act.
The Alliance wanted a new Mental Health Act that would: include a legal right to care and treatment result in the reduced use of compulsory powers. www. mentalhealthalliance. org. uk 2000 The Home Affairs Select Committee’s report, Managing dangerous people with severe personality disorder, was published. 2000 Professor Louis Appleby was appointed as the National Director of Mental Health (widely known as the ‘mental health czar’).
He stated that key areas of the NSF would include: the phasing out of mixed-sex psychiatric accommodation over the next two years the elimination of out-of-area acute admissions as soon as possible 24-hour access to mental health services for patients and carers to be in place by April 2001 setting up of a website to enable patients/users, families/carers and staff to give their views directly to Professor Appleby new training and courses in ‘cultural awareness’ for psychiatrists a drive to encourage more nurse consultants in the mental health area, in particular to work with people with mental ill health and drug and alcohol problems.
More information 2000 The Care Standards Act 2000 set up the National Care Standards Commission for England. 2000 Nine regional public health observatories (PHOs) in England and Wales (and three others for Scotland, Northern Ireland and Eire) and the Association of Public Health Observatories (APHO) were set up as part of the Government’s strategy for improving health and reducing health inequalities, as set out in the White Paper Saving lives – our healthier nation. www. apho. org. uk 2001 NHS Direct covered the whole of England. NHS Direct Online was developed and re-launched in November 2001.
Public access was extended through NHS information points and digital TV. www. nhsdirect. nhs. uk 2001 The Mental health information strategy, prepared for the Department of Health by a team of people from Mental Health Strategies and the Sainsbury Centre for Mental Health, was published, setting out the way in which information systems would be developed to support modern mental health care delivery. 2001 The National Care Standards Commission was set up in April, and began regulating services in April 2002. It took on the four main roles suggested by the Royal Commission on Long Term Care:
monitoring representing the consumer providing national benchmarks encouraging the development of better services. The Commission established the General Social Care Council for England (www. gscc. org. uk) and the Care Council for Wales (www. ccwales. org. uk) to regulate social care workers (abolishing the training body CCETSW), and set up the ‘protection of vulnerable adults’ scheme, to ensure that unsuitable people are prevented from working with vulnerable adults. 2001 The National Assembly for Wales launched the adult mental health services strategy for Wales, which include.