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Mental health—the shape of things to come
MENTAL HEALTH THE SHAPE OF THINGS TO COME* By D. T H O M S O N,
M.D., D.P.H.,
Deputy Chief Medical Officer, Ministo' of Health IT is with a certain diffidence that I talk of mental health, being no clinician let alone psychiatrist. My diffidence is increased in assuming the role of prophet, although I take comfort in the advice of Mark Twain the American humorist "that it is always dangerous to prophesy unless one happens to know". For, in the field of mental health we have two clear indications of the likely shape of things to come in the blue books published by the Ministry of Health, the first in January 1962, and the second in April 1963. These set out, the first for the hospitat services and the second for the local authority services, the plan of development over the next ten years. These plans will be reviewed annually and are primarily intended to stimulate discussion, study and experimentation. It is hoped that in the field of mental health, as well as in that of other subjects, there will be an increasing integration between the hospital and local authority services. I shall try to cover very briefly planning over the whole field of psychiatry but, although the main principles on which such planning is based are unlikely to change, much of the detail is not yet in focus and will be modified as need becomes clear. I will start by stating the principles that underlie thinking about the general pattern of the psychiatric services, and then give separate outlines of what is planned for the mentally ill, the elderly mentally infirm and the mentally subnormal, including the provision of services in the community. The two main changes in the practice of psychiatry that have developed during the past twenty years or so are first, that the range and effectiveness of treatment have greatly increased and second, that there has been a growing understanding of the social components of prevention, treatment, and after Gate.
Although treatment is still largely empirical its manifest success has led to a greatly increased demand with which the in-patient services alone could not possibly cope. It should be remembered that before 1930, there was virtually no treatment available for the mentally disordered except under certification in the designated mental or mental deficiency hospitals. Since then, the extra mural hospital services have been greatly expanded to meet the demand and the series of changes in the law have made it possible for hospital care to be reserved for those who really need it. It has been and still is the boast of psychiatrists that they treat the patient •
t,lJl
i
i
ii
J
i
ii
_
_
i
i
i
.,i
i
i
*Based on Dr. Thomson's opening address to the Refresher Course organized by the Mental Health Group of the Society, June, 1963. 94
MENTAL
HEALTH
95
and not just the disease, and by extension the patient as a member of society and not as an isolated being. But, an effective recognition of the social aspects of mental disorder is even now in its beginning. Even though a causal relationship between mental disorder and social conditions remains to be proved there is no doubt that conditions at work, in the home, and in society generally should be the c0nccm of those who wish to prevent mental disorder and so enable those disabled b y it to adapt or overcome their disabilities. The two general principles affecting planning for the mental health services of the future that emerge from these changes are: (a) The treatnaent in hospital, which is only an incidence in the course of mental disorder, should be reserved for those who cannot be.tter be treated outside. (b) The hospital and community services should be designed to facilitate the re-acceptance of mentally disordered persons as useful members of society. SERVICES
FOR
THE
MENTALLY
ILL
A. Hospital services The principles underlying the planning of services for the mentally ill are as follows: 1. Accessibility. A psychiatric hospital or unit should be readily accessible to the community it serves. This is the basis of future planning and is dictated by the vital need for bringing the resources of the community to the help of the patient, before, during and after the spell in hospital. Put in another way, it means that the psychiatric hospital should be conveniently sited in relation to its catchment area. Many of our existing mental hospitals are so geographically remote from the homes of the patients they serve that visiting by friends and relations is discouraged. Problems of liaison between hospital and local authority are greatly increased. This may not matter so much in the case of short stay patients, but it increases the danger of "institutionalization" of those who need longer periods of hospital care. 2. Size. The hospital should be large enough to allow for the proper classification of its patients, but not so large that it cannot keep in touch with community services. Size is therefore related to the number of people in the catchment area and their geographical distribution. It seems likely that a population of about 250,000 would be the maximum that a hospital could conveniently manage. Depending on the density of population, the siting of the hospital in relation to it and the transport facilities within the area, a unit of about 200 beds should on our present estimates be sufficient to meet the needs of such a population for short stay purposes. 3. The association with general medicine. The general desirability of this can hardly be questioned and one of the obstacles of its fulfilment has been
96
PUBLIC
HEALTH
VOL.
LXXVlll
NO.
2
the physical separation of the hospital psychiatrists both from their colleagues at hospital and in general practice. The siting of the psychiatric units within the curtilage of general hospitals will lower physical and, one hopes, emotional barriers to a better understanding of psychiatry and make the hospital "'general" in fact as well as in name. It is perhaps worth mentioning here that one of the points made by those who prefer the comprehensive psychiatric hospital is that psychiatric patients in general hospitals would be forced to conform to what is generally called general hospital routine, which would be contrary to their interests. It is not felt that this is a serious objection. First, because all but the smallest psychiatric units would be detached from the main building of the hospital, just as many obstetric units are now. Second, general hospitals are already under pressure to reform just those restrictive practices to which psychiatrists rightly object and which give the impression that the hospital is being run for the convenience of doctors and nurses rather than the patients. B. Community services 1. Mentally ill. Here as in the hospital service, the need is for people rather than bricks and mortar. The number of patients admitted to, and discharged from, hospital has been increasing for many years, and the average length of stay has been failing. These trends, which reflect earlier detection and treatment of mental disorder, are likely to continue. This will increase the demands on local authority services. Already, during 1961, almost 90,000 mentally ill or psychopathic persons were referred to them by general practitioners, hospitals, local education authorities, courts, police etc., for some form of mental health service. At the end of 1961, local authorities were providing some form of mental health service for about 40,000 mentally ill persons, almost all over sixteen years of age. It is sometimes said that the present hospital discharge policy will simply result in patients deteriorating and regressing in their own homes instead of in mental hospitals and that if this happens it would put an intolerable burden on their families. Unless adequate help and supervision are provided for discharged patients, especially those with severe disability, this is admittedly a real danger. Much can, however, be done if those concerned with the welfare of individual patients understand the patient's problems and keep in touch with each other before, during and after the patient goes into hospital or is accepted for out-patient day hospital treatment. Those chiefly concerned are the general practitioner, the local authority social worker, and the psychiatrist. Between them these three people mobilize a wide variety of support both statutory and voluntary; the problem is one of understanding and communication. On the local authority side it is hoped to see considerable expansion in the number of trained social workers engaged in the mental health and other
MENTAL
HEALTH
97
community care services, probably from the present 3,000 to over 5,000. But their work in the mental health field cannot be fully effective until the geographical difficulties of communication between the hospitals and local authorities have been removed by the re-planning of hospital services. The value of local authority hostels for the mentally ill still remains to be proved. For certain types of patients, for example, unmarried schizophrenics, the need seems to have been established. But, more important still, is the need for regular employment which in many cases would have to be o f the sheltered workshop type. Under the TenYear Plan, the number of hostels for the mentally ill will increase from 41 to 314. The number of mental welfare workers planned is 2,000 and it is reckoned that 260 psychiatric social workers will be required. 2. Elderly mentally infirm. The proportion of patients aged 65 and over at present in mental hospilals varies from 30 per cent. to nearly 50 per cent. and about 20 per cent. o f admissions to mental hospitals are in this age group. Much has recently been written about the therapeutic needs of the elderly and there is little doubt that in most cases mental symptoms are only part of, and often secondary to, a variety of physical infirmities. The desirability of a closer link between general medicine and psychiatry in the treatment of mentally enfeebled old people has been recognized for many years during which the demand for geriatric beds has steadily increased with the ageing population. But so long as the mental hospitals are able and willing to look after them, a better solution to the problem of their treatment has not been given high priority. Ideally one would like to see a variety of facilities for treatment, rehabilitation and support both in the hospital service and in the community. Much can be done to anticipate and prevent mental disorder by support in the home and by rehousing when necessary. About half the purely psychiatric disorders o f old people respond well to intensive treatment. For this purpose, short term diagnostic and treatment units attached to the geriatric department of the chronic sick hospital and under the joint control of a psychiatrist and a geriatrician are the obvious solutions. Longer term treatment and rehabilitation shouId be provided as part of the general geriatric service and since the introduction of tranquillizers, there is far less need for skilled psychiatric nurses. Indeed, once the mental symptoms have been controlled by drugs, treatment and nursing are in most cases a general medical problem. At present there are many people in local authority hospitals and homes who require treatment in hospital and there are also m a n y old people in hospital who could better be treated and cared for outside. A detailed review of the position is much needed. In this sense the present position of the mental health services for the elderly is similar to those for the mentally ill and the retarded. And, the need for expert personnel to sort them out is as great as that for more suitable buildings. 3. Mentally subnormal. Any estimates of hospital bed needs for the mentally retarded are complicated by lack of basic information such as the incidence and
98
PUBLIC
HEALTH
VOL.
LXXVIII
NO.
2
prevalence rates for the various types of disorder. Nor have we precise information about the composition of the present hospital population. It was presumably expected that the terms "idiot", "imbecile", and "feeble minded", which did ~ve some indication of the social viability of the individual would be replaced by an intelligence rating or some more precise classification. But this has not happened. In this class, too, there is little doubt that at present there are patients living in hospitals who need not be there if suitable training and support could be provided in the community. Also, local authority waiting lists include many urgent cases for whom hospital care is essential. In order to clarify these and other questions affecting the hospital community services for the mentally retarded, the Ministry of Health is financing a survey which is starting in the Wessex region. But, whatever basic information is obtained in this way, there remain a number of factors the influence of which will have to be evaluated over quite long periods of tirne. For example, it is probable that medical advances will reduce the infant mortality and enable severely handicapped children to survive. At the other end of the age range it is probable that the mentally retarded are living longer, particularly mongols who are prone to respiratory disease. Apart from these purely medical factors there are numerous social variables, the end results of which cannot at present be precisely assessed. The effects of intensive training on stable medium grade patients have not been fully explored. Training methods based on learning theory may well enable a high proportion of these persons to become socially viable and productive members of society. The estimate of bed needs for the mentally retarded is, therefore, particularly difficult, but it is given in the Hospital Plan as 1.3 per 1,000. In the absence of more precise information, t~fis figure was arrived at by adding •those at present in hospital to the number on local authority waiting lists and then making a suitable adjustment for population increase. Again, the optimum size of a hospital for the mentally retarded is a highly controversial question and ranges from small homes in converted private houses containing 20 beds or so, to communities of 1,000 beds and over. It is felt that the size of any unit should be governed by the principle of accessibility as it is for the mentally ill. On the basis of 1-3 beds per 1,000, a population of 250,000 would be served by about 350 beds and for urban areas this would probably be as large a population as could conveniently be catered for if home and local authority contacts are to be facilitated. But, as noted, this estimate of 1-3 beds per 1,000 is based in part on patients at present in hospital and includes a number of those who would be able to live at home when local authority training and supervision is available. It may well be that the number of low grade patients who must be cared for in hospital will be considerably smaller for a similar population. To ~:acilitate
POST
INFECTIOUS
ENCEPHALITIS
99
this, under the Ten Year Plan, the number of hostels for subnormals will increase from 47 to 464 in 1972. As it was, at the end of 1961, local authorities were providing some form of mental health services for about 80,000 mentally subnormal. Again, it is doubtful whether lowest grade, brain damaged and doubly handicapped children need psychiatric care and nursing. They might be better looked after in pa:diatric hospitals. Similarly, a proportion o f high grade patients need treatment for the relief of psychotic and neurotic symptoms and this night better be given in mental hospitals. It is clear, from these factors, that we are not yet in a position to give precise guidance on the form or scope of future services for the mentally retarded. But it seems likely that there will be a greater variety of types of accommodation and a greater specialization o f functions in the future than exist at present. As mentioned, the main object of the Ten Year Plan is to encourage experimentatior and already in Plymouth, Worttfing, Chichester and other places there is evidence that an adventurous and imaginative spirit is abroad. The success of this will inevitably bring about a degree of integration between the hospital and local authority services. This cannot be other than to the patient's advantage for thus, in the sphere of mental health, prevention will have at last an opportunity of coming into its own. This is surely as it should be in the organization of a National Health Service. For, in the realm of the mental as well as in that of the physical, the centuries old words of Aristotle are ever true "The end of the State is not life, it is rather good quality of life".
M.D., D.P.H.,
Deputy Chief Medical Officer, Ministo' of Health IT is with a certain diffidence that I talk of mental health, being no clinician let alone psychiatrist. My diffidence is increased in assuming the role of prophet, although I take comfort in the advice of Mark Twain the American humorist "that it is always dangerous to prophesy unless one happens to know". For, in the field of mental health we have two clear indications of the likely shape of things to come in the blue books published by the Ministry of Health, the first in January 1962, and the second in April 1963. These set out, the first for the hospitat services and the second for the local authority services, the plan of development over the next ten years. These plans will be reviewed annually and are primarily intended to stimulate discussion, study and experimentation. It is hoped that in the field of mental health, as well as in that of other subjects, there will be an increasing integration between the hospital and local authority services. I shall try to cover very briefly planning over the whole field of psychiatry but, although the main principles on which such planning is based are unlikely to change, much of the detail is not yet in focus and will be modified as need becomes clear. I will start by stating the principles that underlie thinking about the general pattern of the psychiatric services, and then give separate outlines of what is planned for the mentally ill, the elderly mentally infirm and the mentally subnormal, including the provision of services in the community. The two main changes in the practice of psychiatry that have developed during the past twenty years or so are first, that the range and effectiveness of treatment have greatly increased and second, that there has been a growing understanding of the social components of prevention, treatment, and after Gate.
Although treatment is still largely empirical its manifest success has led to a greatly increased demand with which the in-patient services alone could not possibly cope. It should be remembered that before 1930, there was virtually no treatment available for the mentally disordered except under certification in the designated mental or mental deficiency hospitals. Since then, the extra mural hospital services have been greatly expanded to meet the demand and the series of changes in the law have made it possible for hospital care to be reserved for those who really need it. It has been and still is the boast of psychiatrists that they treat the patient •
t,lJl
i
i
ii
J
i
ii
_
_
i
i
i
.,i
i
i
*Based on Dr. Thomson's opening address to the Refresher Course organized by the Mental Health Group of the Society, June, 1963. 94
MENTAL
HEALTH
95
and not just the disease, and by extension the patient as a member of society and not as an isolated being. But, an effective recognition of the social aspects of mental disorder is even now in its beginning. Even though a causal relationship between mental disorder and social conditions remains to be proved there is no doubt that conditions at work, in the home, and in society generally should be the c0nccm of those who wish to prevent mental disorder and so enable those disabled b y it to adapt or overcome their disabilities. The two general principles affecting planning for the mental health services of the future that emerge from these changes are: (a) The treatnaent in hospital, which is only an incidence in the course of mental disorder, should be reserved for those who cannot be.tter be treated outside. (b) The hospital and community services should be designed to facilitate the re-acceptance of mentally disordered persons as useful members of society. SERVICES
FOR
THE
MENTALLY
ILL
A. Hospital services The principles underlying the planning of services for the mentally ill are as follows: 1. Accessibility. A psychiatric hospital or unit should be readily accessible to the community it serves. This is the basis of future planning and is dictated by the vital need for bringing the resources of the community to the help of the patient, before, during and after the spell in hospital. Put in another way, it means that the psychiatric hospital should be conveniently sited in relation to its catchment area. Many of our existing mental hospitals are so geographically remote from the homes of the patients they serve that visiting by friends and relations is discouraged. Problems of liaison between hospital and local authority are greatly increased. This may not matter so much in the case of short stay patients, but it increases the danger of "institutionalization" of those who need longer periods of hospital care. 2. Size. The hospital should be large enough to allow for the proper classification of its patients, but not so large that it cannot keep in touch with community services. Size is therefore related to the number of people in the catchment area and their geographical distribution. It seems likely that a population of about 250,000 would be the maximum that a hospital could conveniently manage. Depending on the density of population, the siting of the hospital in relation to it and the transport facilities within the area, a unit of about 200 beds should on our present estimates be sufficient to meet the needs of such a population for short stay purposes. 3. The association with general medicine. The general desirability of this can hardly be questioned and one of the obstacles of its fulfilment has been
96
PUBLIC
HEALTH
VOL.
LXXVlll
NO.
2
the physical separation of the hospital psychiatrists both from their colleagues at hospital and in general practice. The siting of the psychiatric units within the curtilage of general hospitals will lower physical and, one hopes, emotional barriers to a better understanding of psychiatry and make the hospital "'general" in fact as well as in name. It is perhaps worth mentioning here that one of the points made by those who prefer the comprehensive psychiatric hospital is that psychiatric patients in general hospitals would be forced to conform to what is generally called general hospital routine, which would be contrary to their interests. It is not felt that this is a serious objection. First, because all but the smallest psychiatric units would be detached from the main building of the hospital, just as many obstetric units are now. Second, general hospitals are already under pressure to reform just those restrictive practices to which psychiatrists rightly object and which give the impression that the hospital is being run for the convenience of doctors and nurses rather than the patients. B. Community services 1. Mentally ill. Here as in the hospital service, the need is for people rather than bricks and mortar. The number of patients admitted to, and discharged from, hospital has been increasing for many years, and the average length of stay has been failing. These trends, which reflect earlier detection and treatment of mental disorder, are likely to continue. This will increase the demands on local authority services. Already, during 1961, almost 90,000 mentally ill or psychopathic persons were referred to them by general practitioners, hospitals, local education authorities, courts, police etc., for some form of mental health service. At the end of 1961, local authorities were providing some form of mental health service for about 40,000 mentally ill persons, almost all over sixteen years of age. It is sometimes said that the present hospital discharge policy will simply result in patients deteriorating and regressing in their own homes instead of in mental hospitals and that if this happens it would put an intolerable burden on their families. Unless adequate help and supervision are provided for discharged patients, especially those with severe disability, this is admittedly a real danger. Much can, however, be done if those concerned with the welfare of individual patients understand the patient's problems and keep in touch with each other before, during and after the patient goes into hospital or is accepted for out-patient day hospital treatment. Those chiefly concerned are the general practitioner, the local authority social worker, and the psychiatrist. Between them these three people mobilize a wide variety of support both statutory and voluntary; the problem is one of understanding and communication. On the local authority side it is hoped to see considerable expansion in the number of trained social workers engaged in the mental health and other
MENTAL
HEALTH
97
community care services, probably from the present 3,000 to over 5,000. But their work in the mental health field cannot be fully effective until the geographical difficulties of communication between the hospitals and local authorities have been removed by the re-planning of hospital services. The value of local authority hostels for the mentally ill still remains to be proved. For certain types of patients, for example, unmarried schizophrenics, the need seems to have been established. But, more important still, is the need for regular employment which in many cases would have to be o f the sheltered workshop type. Under the TenYear Plan, the number of hostels for the mentally ill will increase from 41 to 314. The number of mental welfare workers planned is 2,000 and it is reckoned that 260 psychiatric social workers will be required. 2. Elderly mentally infirm. The proportion of patients aged 65 and over at present in mental hospilals varies from 30 per cent. to nearly 50 per cent. and about 20 per cent. o f admissions to mental hospitals are in this age group. Much has recently been written about the therapeutic needs of the elderly and there is little doubt that in most cases mental symptoms are only part of, and often secondary to, a variety of physical infirmities. The desirability of a closer link between general medicine and psychiatry in the treatment of mentally enfeebled old people has been recognized for many years during which the demand for geriatric beds has steadily increased with the ageing population. But so long as the mental hospitals are able and willing to look after them, a better solution to the problem of their treatment has not been given high priority. Ideally one would like to see a variety of facilities for treatment, rehabilitation and support both in the hospital service and in the community. Much can be done to anticipate and prevent mental disorder by support in the home and by rehousing when necessary. About half the purely psychiatric disorders o f old people respond well to intensive treatment. For this purpose, short term diagnostic and treatment units attached to the geriatric department of the chronic sick hospital and under the joint control of a psychiatrist and a geriatrician are the obvious solutions. Longer term treatment and rehabilitation shouId be provided as part of the general geriatric service and since the introduction of tranquillizers, there is far less need for skilled psychiatric nurses. Indeed, once the mental symptoms have been controlled by drugs, treatment and nursing are in most cases a general medical problem. At present there are many people in local authority hospitals and homes who require treatment in hospital and there are also m a n y old people in hospital who could better be treated and cared for outside. A detailed review of the position is much needed. In this sense the present position of the mental health services for the elderly is similar to those for the mentally ill and the retarded. And, the need for expert personnel to sort them out is as great as that for more suitable buildings. 3. Mentally subnormal. Any estimates of hospital bed needs for the mentally retarded are complicated by lack of basic information such as the incidence and
98
PUBLIC
HEALTH
VOL.
LXXVIII
NO.
2
prevalence rates for the various types of disorder. Nor have we precise information about the composition of the present hospital population. It was presumably expected that the terms "idiot", "imbecile", and "feeble minded", which did ~ve some indication of the social viability of the individual would be replaced by an intelligence rating or some more precise classification. But this has not happened. In this class, too, there is little doubt that at present there are patients living in hospitals who need not be there if suitable training and support could be provided in the community. Also, local authority waiting lists include many urgent cases for whom hospital care is essential. In order to clarify these and other questions affecting the hospital community services for the mentally retarded, the Ministry of Health is financing a survey which is starting in the Wessex region. But, whatever basic information is obtained in this way, there remain a number of factors the influence of which will have to be evaluated over quite long periods of tirne. For example, it is probable that medical advances will reduce the infant mortality and enable severely handicapped children to survive. At the other end of the age range it is probable that the mentally retarded are living longer, particularly mongols who are prone to respiratory disease. Apart from these purely medical factors there are numerous social variables, the end results of which cannot at present be precisely assessed. The effects of intensive training on stable medium grade patients have not been fully explored. Training methods based on learning theory may well enable a high proportion of these persons to become socially viable and productive members of society. The estimate of bed needs for the mentally retarded is, therefore, particularly difficult, but it is given in the Hospital Plan as 1.3 per 1,000. In the absence of more precise information, t~fis figure was arrived at by adding •those at present in hospital to the number on local authority waiting lists and then making a suitable adjustment for population increase. Again, the optimum size of a hospital for the mentally retarded is a highly controversial question and ranges from small homes in converted private houses containing 20 beds or so, to communities of 1,000 beds and over. It is felt that the size of any unit should be governed by the principle of accessibility as it is for the mentally ill. On the basis of 1-3 beds per 1,000, a population of 250,000 would be served by about 350 beds and for urban areas this would probably be as large a population as could conveniently be catered for if home and local authority contacts are to be facilitated. But, as noted, this estimate of 1-3 beds per 1,000 is based in part on patients at present in hospital and includes a number of those who would be able to live at home when local authority training and supervision is available. It may well be that the number of low grade patients who must be cared for in hospital will be considerably smaller for a similar population. To ~:acilitate
POST
INFECTIOUS
ENCEPHALITIS
99
this, under the Ten Year Plan, the number of hostels for subnormals will increase from 47 to 464 in 1972. As it was, at the end of 1961, local authorities were providing some form of mental health services for about 80,000 mentally subnormal. Again, it is doubtful whether lowest grade, brain damaged and doubly handicapped children need psychiatric care and nursing. They might be better looked after in pa:diatric hospitals. Similarly, a proportion o f high grade patients need treatment for the relief of psychotic and neurotic symptoms and this night better be given in mental hospitals. It is clear, from these factors, that we are not yet in a position to give precise guidance on the form or scope of future services for the mentally retarded. But it seems likely that there will be a greater variety of types of accommodation and a greater specialization o f functions in the future than exist at present. As mentioned, the main object of the Ten Year Plan is to encourage experimentatior and already in Plymouth, Worttfing, Chichester and other places there is evidence that an adventurous and imaginative spirit is abroad. The success of this will inevitably bring about a degree of integration between the hospital and local authority services. This cannot be other than to the patient's advantage for thus, in the sphere of mental health, prevention will have at last an opportunity of coming into its own. This is surely as it should be in the organization of a National Health Service. For, in the realm of the mental as well as in that of the physical, the centuries old words of Aristotle are ever true "The end of the State is not life, it is rather good quality of life".