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Observations on the mental health act
PRESENT-DAY
OUTBREAK
OF DIPHTHERIA
303
REFERENCES BEACh,
M. W.. G A M B L E ,
W. B., Z E M P ,
C. H., & J E N K I N S ,
M. Q. (1955).
Pediat., 16, 335. B L U T E , J. F. (1954). New Engl. J. Med.. 2, 70. E LE ~<, S. D. (1948). Brit. 3Ied. J., 1,493. F o R n r ; s , J. A. {|948). ?tied. J. Austr., 2, 501. G R O A R K E , f . , A D A M S O N , M. I.. E~.~A s - J o , ~ r ~ s , T. F., & WHITTAKER, L. (1959), being published. !--1A I ~ H T, T, H., & F 1 N L n s o, M. (1952). 3@w EngL d. Med., 247, 227. L A L L, S., & K A R E L I T Z, S. (1953). dourn. Pedlar., 1, 35. M A v, H. B., & M A R R A ~:; K, J. R. (1951). " Panton and Marrack's Clinical P a t h o l o g y , " 6th ed. J. & A. Churchill, London, 375, P ^ r~ I s H, H. J. (1958). "Antisera, Toxoids, Vaccines and Tubcrculins in Prophyla×is and Treatment", 4th ed. Livingstone, E d i n b u r g h 50. ........... , L A u RE,~ ~t', L. J. M,, & M o Y N ~n AN, N. H. (1957). Brit. 3,led. J., 1, 639. W E IN ST E I Y, 1_ (1947). Amer. d. Meal. Sc., 213, 308.
OBSERVATIONS ON THE MENTAL HEALTH ACT* By W I L L I A M
NICOL,
M.r3., CH.B., D.P.H,
AdminLstration Q(licer of Health./'or Mental ttealth, Cio' of Birmingham As you know, the Mental Health Act implemented the recommendations made by the Royal Commission on the law relating to mental illness and mental deficiency and introduced new terminology, simplified procedure for admission to hospital, and placed on the local authority new responsibilities. One o f the most important principles of .the Report was the need for a general reorientation towards community care and some of us were perhaps a little disappointed ,~n reading the Bill that the essential role of t.he local authority in doing ~ ~ appeared to have been played down. However, in subsequent cireuk~r_, ~,ased on the Act it appears that the Minister has :~cccpled the spi: ";: of tbc Royal Conmfisd,~n. The following suggestions are based on Part !' :,i tlJe \ct but also take into consideration our experiences and expcrimcn f ,h,Z, fast and local conditions. PROV
ISIO7,~
EQUIPMENT
RESIDENTIAL
AND
MAINTENANCE
ACCOMMO1)
OF
ATION
There is bound to be a division o f opinion as to what hostel accommodation the local authorily should provide. The regional hospital board may wish us to go furthcr than we might want to, but I think local authorities will have to take a very firm line in this matter and in the early stages at least, pursue Address delivered to Midland Branch, 5th Novemtx, r, 1~59.
304
PUBLIC
HEALTH
VOL.
LXXIV
NO.
,~
a cautious policy. I intend to discuss primarily, accommodation for the following four types of patients :-(i) severely subnormal children; (ii) educationally subnormal or maladjusted young people; (iii) discharged mentally disordered patients: (iv) elderly mentally infirm. SEVERELY
SLrBNORM
It is requested that local health authorities should consider providing hostels where this type of child may be accommodated for short periods. There is no doubt that these would be of considerable benefit in relieving families experiencing temporary difficulties, in easing the lot of an overworked mother, or even in helping to stabilise the child who has become unmanageable. It is my contention that these can be organised in conjunction with the occupation centres. Our intention is to take children for short-term care to relieve parents, the ages of those admitted would be one and a half to 12 years. As a general rule, only ambulant cases would be admitted, while very difficult, noisy and very low-grade non-ambulant cases would be referred to hospital, but in emergencies they may be accepted. It is hoped that student h.vs. will help in the care of the children as part of their, training. Although the children's stay would be short it is intended that they attend local occupation centres during it. Medical attention will be carried out by general practitioners or local authority medical officers, with the agreement of the child's own practitioner. EDUCATIONALLY
SUBNORMAL YOUNG
OR
MALADJUSTED
PEOPLE
The view has always been held by Birmingham Health Committee that hostel accommodation for this type of case is inadvisable and a strong prefcrencc for private lodgings has been expressed. It is suggested that where these youths are handicapped only by intellectual capacity below the average then lodgings in home-like conditions would be more helpful, where, however, the problem is essentially serious maladjustment or subnormality complicated by it, then admission to hospital would be preferable. A hostel provided solely for such youths would, it is thought, not make a satisfactory contribution to their adjustment to the community, and is not recommended. Indeed, grouping this type of adolescent together is considered inadvisable, our experience has been that serious difficulties would occur. DISCHARGED MENTALLY DISORDERED PATIENTS The Minister recommends hostel provision for patients discharged from hospital who need some support on re-entering ,community life. One is to be
OBSERVATIONS
ON
Till,'.
MENTAL
HEAL'itt
ACT
305
provided immediately in Birmingt~am accommodating about 12 males and opening on 1st January, 1960. The policy of this hostel will bc essentially short-term, this would appear to conform with the suggestion contained in Circular 9/59. Further, it is thought that following a period of perhaps six months' stay the ex-patienr, should :.... (i) have rc-cntercd thc commun'~:y, working ar:d living in lodging., or
(it) have re-entered lhc community, living in lodgings but m~t in remunerative employment but supported by National Assistance, psychiatric social services. Diversional therapy in liaison with the welfare depart. mcnt would bc arranged at welfare centres or (iii) be transferred to a welfare home. (Section 8 of the Mental Health Act makcs this possible) or
(iv) re-admitted to hospital. Bearing in mind these conditions and discussion with medical superintendents of the local hospitals, it is felt that the needs of such a class of ex-patient could be met by the provisions t'~f two hostels, ofle I\3r males and the other for females. It is not recommended that these should be established immediately, bul at a later date after experience has been gained from the first one. The above figures refer only to patients from mental hospitals. The numbers that could be discharged from mental deficiency hospitals have not been obtained as yet, but they are considered to be comparable with the above. It is ~uggested thai a home could be utilised in the course of time for patients predominantly from this type of hospital, or for subnormal, in need of support in the community only. Their stay would be rather long-term because they: take rather a longer time to adjust themsclvc, to community life. b L D E R L Y MENTALI..Y I N F I R M This is the last type of patient for whom the Minister suggests hostel accommodation and for whom the services and resources of a hospital are not required, The numbers already in the four large mental hospitals are approximately 6z'k and in addition to these there are a group of patients between the ages of 50 and 70, who are receiving little treatment beyond, custodial care who do not come within any of the categories already mentioned, Their exact number is not known, but is probably in the region of 200 from the mental hospitals and about the same number from mental deficiency hospitals. The Minister does not appear to request hostel accommodation for these two types at the moment, but does refer in the circular to Sections 613-.636 of the Royal Corn-
306
PUBLIC
HEALTH
VOl_.
LXX1V
NO.
8
mission Report, which recommend that local health authorities should provide long-stay hostels for the latter. It is felt that provision of such accommodation should be developed slowly, as it could create a considerable financial and administrative problem. In providing for the elderly mentally infilTn, it is suggested that in general the best policy would be to prevent the admission of this type of patient in the l'ulurc rather than lake them out of hospital. To discharge them precipitately because they are not receiving treatment would not: be in their best interests. Many old people are quite happy in their established surroundings and it would do them a disservice to remove them after many years, especially as no real therapeutic contribution would be made. With this approach the problem of the elderly mentally infirm in mental hospitals would gradually diminish and the local health authority would be given time to build up an organisation u~ deal with them adequately. The numbers supplied by the medical superintendents suggest that oac home accommodating 75 such patients of both sexes, with day centre and social club facilities attached, would meet the demand for the near future. All the patients in the above category present problems that make them unacceptable in normal welfare homes. There is another category which could, however, be accommodated in the latter. Discussions with the medical superintendents suggest that the number is not great and the deputy welfare officer felt that they could be absorbed by the existing welfare homes.
THE
PROVISION
OF
TRAINING
CENTRES
There is very little need be said on the provision of training centres because most authorities have been very busy building new ones, I would only say that my own particular preference is for the small centre which would accommodate about 50~ but this is motivated by conditions in Birmingham. I think in the past we have underestimated the capabilities of such children and that a more ambitious programme should be developed, certainly in building our centres provision should be made for the physically handicapped and fo; ~the incontinent to attend. I think that one of the difficulties tha • arise if local education authorities have too much to do with occupation centres is that they place undue emphasis on formal academic teaching for children who are only capable of limited success in the three Rs. We in Bii~ingham have been somewhat backward in providing new occupation centres and industrial centres, so we have the advantage now of starting from scratch and are determined to make our industrial centres places where proper and useful training methods can be applied. I think any industrial centres must present different types of work, so that all types can be catered for, those who are potentially employable and those who are essentially receiving diversional therapy, i.e. training would be divided into stages as follows--
OBSERVATIONS
ON
1HE
MENTAL
HEALTH
ACT
307
(a) simple for ::'~.:wentrants; (?,) intermediate .....many may remain at this level; (c) advanced. ORG
A N ISA
I ION
OF
T H I~ S T A
t:F
Ot:
THE
SER V ICfi
AI! local health authorities have had mental welfare officers and their organisalion has been influenced by local requirements. Here in Birmingham we have a rather rigid division of responsibility following our responsibilities under the Lunacy and Mental Treatment Acts, Mental Deficiency Acts and the National Health Service Act. This is largely unavoidable in a large city. but with the new Act there will be less need for so rigid a division and so the old terminology has already gone and the new term "mental welfare officer" introduced, but the officer's duties will largely be determined by his experience and training. As 1 see it, our obligations under the new Act are broadly preventive and community care support. The department has been organised bearing this in mind. P R E V E N T I V E SI-RV i C E S Many might consider this term too hopeful and one which suggests that wc know much more about the fundamental causes of mental illness, neurotic and psychopathic behaviour than we do and that we can influence them considerably. Certainly, to make such claims would be extravagant and would indicate an overestimation of the contribution we could make. Nevertheless, the written work of others and one's own experience suggests that mental ilh~ess and maladjusted behaviour take root in early life and that the orientation of services towards the family and tF~e parent/child relationship can have real preventive value, but if they are to have a significant effect they must be available to all families who need them. ]'he preventive services of the mental health section then has meant the orientation of the psychiatric social services towards the family, in co-operation principally with the h.vs. and has taken the form of discussions and counselling at certain welfare centres, active case work and intensive investigations at the parent guidance clinic. By counselling is meant the p.s.w, or trained case worker acting as adviser and consultant to the h.~,,s, on social work problems and case work methods. FAMILY
PROBLEMS
SECTION
Those families which have such intense problems are cared t\'~r ~ , the family problems sections of the psychiatric s ~ i a l service. Here 48 out o f lOi were referred by h.vs. during the year, ~he other main source of referral being the housing management department. The type of problem covered by this section is probably somewhat wider than that covered by the Family Service Unit. However, the linethat separates problem families from families with problems is vague and, in fact~ some would say non-existent, Neverthetes~, it can be said that a fair
308
PUBLIC
HEALTH
VOL.
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NO.
8
proportion of the families supervised are typical problem families of the large¢ disorderly and messy type with living standards well below the neighbourhood average and an income which at times is insufficient for the immediate needs of tile family. Others, less messy in appearance, have chronic problems that undernfine the stability and happiness of the home, which may be in grave danger of disruption either through eviction or desertion or separation of one or other parent. Most of these families have young children and have been a problem that has caused concern to the h.v. This type of service affords valuable help either directly or indirectly by general counselling. The services of selected home helps under an experienced p.s.w, has also been most useful in this work. Although the counselling activities and case work of the family problems section is done mainly in conjunction with the h.vs. it is not limited to them. Case conferences take place regularly with representatives of all organisations and the counselling service has been extended to the National Assistance Board field workers. The parent guidance clinic has been mentioned, it is similar to a child guidance clinic but deals with the problems of parents with children under five years of age, I feel that such clinics have preventive value if they are closely associated with the maternity and child welfare centres, t envisage development along the following lines : ~ The establishment of at least one clinic in one of the welfare centres, the staff to include part!time consultant psychiatrist, p.s.w, and/or a s.w. and a h.v. attached; from this centre is organised a peripatetic service with the p,s.w. visiting centres to discuss cases with h.vs., and i f necessary referring them for more intensive therapy to the main clinic. Part o f the functions o f this clinic would include in,service training of medical officers &health and h.vs. and health education among the adolescent COMMUNITY
CARE
SUPPORT
Although there is a general desire for the care of the mentally sick in the com, munity, it must not be forgotten that medical treatment plays an essential part i n i t and this in a specialised form is, i n t h e main. only obtainable in hospital o r out-patient clinics. Community care then can be narrowly conceived:and must be seen as an integrated :whole and developed in harmonious relationship with the hospitaiservice, Admission to hospital is n o t a n end in itself, but a phase in the patient's illness and as in any other the continuity should be preserved. Only close liaison between the hospital and local authority staffsand joint use Wherever possible can achieve this. Otherwise, the local :authority service tends to stand outside file hospital service and receives referrals in a ather haphazard, .... arbztrary and unsattsfa,~tory way. My o w n particularpreference would be the recommendation of theRoyal Comm3ssion that the local health authority should be solely responsible for this service and should be implemented, our experience in Birmingham illustrates this, e.g. at one of the
OBSERVATIONS
ON
THE
MENTAL
HEALTH
ACT
309
four city mental hospitals where the psychiatric social service undertakes the social casework, after-care referrals have been around 50 a year, whereas at another only two have been referred in two years. As regards the other two mental hospitals, referrals have started to rise steeply immediateJy a closer liaison was established between the hospital and the local authority mental health service. It is now planned to form the p.s.ws, and m.w.os, into teams of two p.s.ws, and two n.w.os, for each hospital reception area, and also a health visitor, as soon as staff numbers will permit. They will work as a team closely associated wi~h the hospital and concentrating on its catchment area, the team to be under the psychiatric direction o f a psychiatrist in each hospital while they remain administratively responsible to the medical officer o f health. As regards after-care, there is little doubt that for this to be eff~tive the after-care service must start long before discharge, tt sho~fld, in fact, start with admission, when the family should be told that the patient has been taken into hospital for treatment and that there is every" reason to hope that he will be returning home when treatment is completed. Further, the relatives should be helped to understand how they can help constructively in the treatment by visiting and reassuring the patient that there is a place waiting for him at his home as st.on as he is well enough to return. With the increased turnover of patients entering and leaving hospital it is not possible So provide after-care for all, nor is it necessary, and so careful selection of those eases that need this service has to be done and should be done while the patient is in hospital. Although our plans have principally taken into consideration working with hospitals, obviously it is intended that they should develop services with the general practitioner. As I see it tile general practitioner more and more will c ~ l in consultants for domiciliary visits. This will result° I think, in a considerable use o f m.w.os, and I would suggest that the Ioca] authority could set up mental health clinics in the welfare centres, one that was conveniently placed in the reception area of the hospital. T h e team c3f m : v ~ . o s , could operate from this centre and in co-operation with the g.p. refer special cases to the consultant. who is also part:of the team: The g.p, also could take part in the weekly discussions which would certainly :take place either at the hospital or at the welfare centre, but the idea o f the wdfare centre suggests itsetf because it is rather more informal a n d rather closer to the community. The idea o f speciali~d clinics is already well developed so yet another should be acceptable. Similar clinics for the diagnosis ofsevere abnornmlity are already in operation at welfare ~ntres. Alternatively, t h e hostels could b e developed along similar l i n ~ , using them as the toczd centre ~[or the mentally handicapped m t h e community. STAFFING
CONSIDERATtONS
~qmre addifion~l staff, w h i c h o f ~ e d t u a f i o m Ceru~i~y : ~ p e x i e n ~ t p~s.wsi and s,ws. are hard Io find; .p~rhaps
310
PUBLIC
HEALTH
VOL.
LXXtV
NO.
8
within the department existing staffs can be used. I would like to consider the role that some of them might play. PSYCHIATRIC
SOCIAL
WORKERS
AND
SOCIAL
WORKERS
Although ] consider p.s.ws, as invaluable to a local health authority community care service I feel that not so many are required as might be imagined. In my experience p.s.ws, can be used as key members of a team to guide the others in case work and we have used them to maximum advantage in this respect in Birmingham. However, to m~: they seem to over-exaggerate the role of the environment and of supportive case work in the community and delay unnec~essarily admission to hospital. S,ws., their less highly trained brethren, are useful potential recruits to a Iocal mental health service, but initially, what they can contribute to the care of the psychotic patient is very little. There is no doubt in my mind that the experienced m.w.o, has few equals in spotting the psychotic patient, who is urgently in need of hospital care. In my opinion he must continue to play a major role in the local authority team. What he Iacks is experience in after-care and the necessary case work training to support patients in the community. This gap can be filled by providing training schemes and including p.s.ws, in the team. HEALTH
VISITORS
The h.v., although lacking perhaps the experience of the above workers in this speciatised field, has the basic training and experience which could be built upon to enable her to m a k e a valuable contribution" to a mental health team, and I see her inclusion in it as necessary and commendable. TRAINING
OF
MENT/~
L
WELFARE
OFFICERS
P.s.ws. with a me~:al2 health certificate are usually regarded as the most highly qualified workers in the mental health field, but it is not likely in the foreseeable future that there will be enough of them to meet future needs. A l t h o u ~ the courses arranged by Universities for their training are already full, only a relatively few become available annually. Therefore, because of this deficiency of the highly trained worker it will be necessary to recruit those who are either completely or relatively untrained. Although this wilt create the problem of instffuting training schemes it gives an opportuniW for us to draw upon people with a wide background of experience. Many people w h o have not had the opportunity of taking the training necessary to be a fully qualified p.s.w, would be able, because of their personality and background, to make a considerable contribution to psychiatric social work if they could be given the opportunity of emering this field and receiving the necessary training. A course has already begun in Birmingham with the help of the College of Commerce for those already working in mental health departments of the
OBSERVATIONS
ON
THE
MENTAL
H,EALTH
ACT
311
local health authority and who want systematic teaching in mental disorders, case work and case work training, Much has been learnt from this course and of the needs of those without previous academic training and the following proposals are based on them. Broadly, training programmes for the following three types of worker will be necessary : - 1. new entrants without any previous experience in social work in mental illness; 2. those with previous knowledge such as health visitors, mental hospital nurses, s.ws. with only the basic s.w. qualification and recently recruited inexperienced m.w.os; 3. refresher courses for experienced workers without recognised training or qualifications. NEW
!
ENFRANTS
WITHOUT
EXPERIENCE
suggest that workers entering this field should be attached to a large hority where they could accompany experienced p.s.ws, and m.w.os. i~. .,c~ld of mental illness and mental subnormality. I would suggest that they have three months with each group and they gain experience in day-to-day observation. As they would be attached to a hospital reception area and work closely with the hospital and the general practitioners they would also have the opportunity of attending the clinical conferences. Their progress and experience gained will be carefully recorded by the health of the mental health department & t h e local health authority and their suitability f ~ the next stage in the training assessed. If those undergoing training were employed by a smaller local authority then I would suggest that they are released to a larger local authority on a part-time basis for perhaps two days per week, where the)' could get the wider experience, more particularly with opportunities of seeing urgent admission and clinical work. This would be the essential first step of all new entrants without an)' previous experience. Having finished their nine-month attachment to the local authority the' would then be in a position to join the new course prepared for CIass 2 ~ p e of worker, who has some basic experience, and the suggested programme for this is as follows :.--
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PUBLIC
HEALTH
VOL,
LXXIV
NO.
8
mor:ning per week over 10 weeks with discussions and ~raining in casework and clinical psychiau~¢ continuing. The last term would consist of one morning per week for 10 weeks, when the workers would be introduced to all the different service.~, available to the handicapped, with perhaps a short series of: lectures summarising the work previously undertaken. For those in the third group requiring a refresher course, they should join the four-week period of fuU-time intensive study and also the last term, which of course is part time. It is suggested that the students: should sit an examination a't the end of this two-year course of training and that a diploma should be awarded. The lecturers to be obtained from the regional hospital board, University, local authority and otl~,er agencies interested in the handicapped. In the more distant future it is suggested that using the same course as a basis it could be adapted for a nationally recognised diploma obtained by nationally organised examinations. It is further recommended that steps should be taken now, e.g. by approaching the Minister of Health to set up such arrangements. That is an outline of our future plans, many difficulties no doubt wilt arim. The possibility of the co-operation of other services has to be investigated fully, but essentially the problem is one that the local health authority should be able to tackle.
OUTBREAK
OF DIPHTHERIA
303
REFERENCES BEACh,
M. W.. G A M B L E ,
W. B., Z E M P ,
C. H., & J E N K I N S ,
M. Q. (1955).
Pediat., 16, 335. B L U T E , J. F. (1954). New Engl. J. Med.. 2, 70. E LE ~<, S. D. (1948). Brit. 3Ied. J., 1,493. F o R n r ; s , J. A. {|948). ?tied. J. Austr., 2, 501. G R O A R K E , f . , A D A M S O N , M. I.. E~.~A s - J o , ~ r ~ s , T. F., & WHITTAKER, L. (1959), being published. !--1A I ~ H T, T, H., & F 1 N L n s o, M. (1952). 3@w EngL d. Med., 247, 227. L A L L, S., & K A R E L I T Z, S. (1953). dourn. Pedlar., 1, 35. M A v, H. B., & M A R R A ~:; K, J. R. (1951). " Panton and Marrack's Clinical P a t h o l o g y , " 6th ed. J. & A. Churchill, London, 375, P ^ r~ I s H, H. J. (1958). "Antisera, Toxoids, Vaccines and Tubcrculins in Prophyla×is and Treatment", 4th ed. Livingstone, E d i n b u r g h 50. ........... , L A u RE,~ ~t', L. J. M,, & M o Y N ~n AN, N. H. (1957). Brit. 3,led. J., 1, 639. W E IN ST E I Y, 1_ (1947). Amer. d. Meal. Sc., 213, 308.
OBSERVATIONS ON THE MENTAL HEALTH ACT* By W I L L I A M
NICOL,
M.r3., CH.B., D.P.H,
AdminLstration Q(licer of Health./'or Mental ttealth, Cio' of Birmingham As you know, the Mental Health Act implemented the recommendations made by the Royal Commission on the law relating to mental illness and mental deficiency and introduced new terminology, simplified procedure for admission to hospital, and placed on the local authority new responsibilities. One o f the most important principles of .the Report was the need for a general reorientation towards community care and some of us were perhaps a little disappointed ,~n reading the Bill that the essential role of t.he local authority in doing ~ ~ appeared to have been played down. However, in subsequent cireuk~r_, ~,ased on the Act it appears that the Minister has :~cccpled the spi: ";: of tbc Royal Conmfisd,~n. The following suggestions are based on Part !' :,i tlJe \ct but also take into consideration our experiences and expcrimcn f ,h,Z, fast and local conditions. PROV
ISIO7,~
EQUIPMENT
RESIDENTIAL
AND
MAINTENANCE
ACCOMMO1)
OF
ATION
There is bound to be a division o f opinion as to what hostel accommodation the local authorily should provide. The regional hospital board may wish us to go furthcr than we might want to, but I think local authorities will have to take a very firm line in this matter and in the early stages at least, pursue Address delivered to Midland Branch, 5th Novemtx, r, 1~59.
304
PUBLIC
HEALTH
VOL.
LXXIV
NO.
,~
a cautious policy. I intend to discuss primarily, accommodation for the following four types of patients :-(i) severely subnormal children; (ii) educationally subnormal or maladjusted young people; (iii) discharged mentally disordered patients: (iv) elderly mentally infirm. SEVERELY
SLrBNORM
It is requested that local health authorities should consider providing hostels where this type of child may be accommodated for short periods. There is no doubt that these would be of considerable benefit in relieving families experiencing temporary difficulties, in easing the lot of an overworked mother, or even in helping to stabilise the child who has become unmanageable. It is my contention that these can be organised in conjunction with the occupation centres. Our intention is to take children for short-term care to relieve parents, the ages of those admitted would be one and a half to 12 years. As a general rule, only ambulant cases would be admitted, while very difficult, noisy and very low-grade non-ambulant cases would be referred to hospital, but in emergencies they may be accepted. It is hoped that student h.vs. will help in the care of the children as part of their, training. Although the children's stay would be short it is intended that they attend local occupation centres during it. Medical attention will be carried out by general practitioners or local authority medical officers, with the agreement of the child's own practitioner. EDUCATIONALLY
SUBNORMAL YOUNG
OR
MALADJUSTED
PEOPLE
The view has always been held by Birmingham Health Committee that hostel accommodation for this type of case is inadvisable and a strong prefcrencc for private lodgings has been expressed. It is suggested that where these youths are handicapped only by intellectual capacity below the average then lodgings in home-like conditions would be more helpful, where, however, the problem is essentially serious maladjustment or subnormality complicated by it, then admission to hospital would be preferable. A hostel provided solely for such youths would, it is thought, not make a satisfactory contribution to their adjustment to the community, and is not recommended. Indeed, grouping this type of adolescent together is considered inadvisable, our experience has been that serious difficulties would occur. DISCHARGED MENTALLY DISORDERED PATIENTS The Minister recommends hostel provision for patients discharged from hospital who need some support on re-entering ,community life. One is to be
OBSERVATIONS
ON
Till,'.
MENTAL
HEAL'itt
ACT
305
provided immediately in Birmingt~am accommodating about 12 males and opening on 1st January, 1960. The policy of this hostel will bc essentially short-term, this would appear to conform with the suggestion contained in Circular 9/59. Further, it is thought that following a period of perhaps six months' stay the ex-patienr, should :.... (i) have rc-cntercd thc commun'~:y, working ar:d living in lodging., or
(it) have re-entered lhc community, living in lodgings but m~t in remunerative employment but supported by National Assistance, psychiatric social services. Diversional therapy in liaison with the welfare depart. mcnt would bc arranged at welfare centres or (iii) be transferred to a welfare home. (Section 8 of the Mental Health Act makcs this possible) or
(iv) re-admitted to hospital. Bearing in mind these conditions and discussion with medical superintendents of the local hospitals, it is felt that the needs of such a class of ex-patient could be met by the provisions t'~f two hostels, ofle I\3r males and the other for females. It is not recommended that these should be established immediately, bul at a later date after experience has been gained from the first one. The above figures refer only to patients from mental hospitals. The numbers that could be discharged from mental deficiency hospitals have not been obtained as yet, but they are considered to be comparable with the above. It is ~uggested thai a home could be utilised in the course of time for patients predominantly from this type of hospital, or for subnormal, in need of support in the community only. Their stay would be rather long-term because they: take rather a longer time to adjust themsclvc, to community life. b L D E R L Y MENTALI..Y I N F I R M This is the last type of patient for whom the Minister suggests hostel accommodation and for whom the services and resources of a hospital are not required, The numbers already in the four large mental hospitals are approximately 6z'k and in addition to these there are a group of patients between the ages of 50 and 70, who are receiving little treatment beyond, custodial care who do not come within any of the categories already mentioned, Their exact number is not known, but is probably in the region of 200 from the mental hospitals and about the same number from mental deficiency hospitals. The Minister does not appear to request hostel accommodation for these two types at the moment, but does refer in the circular to Sections 613-.636 of the Royal Corn-
306
PUBLIC
HEALTH
VOl_.
LXX1V
NO.
8
mission Report, which recommend that local health authorities should provide long-stay hostels for the latter. It is felt that provision of such accommodation should be developed slowly, as it could create a considerable financial and administrative problem. In providing for the elderly mentally infilTn, it is suggested that in general the best policy would be to prevent the admission of this type of patient in the l'ulurc rather than lake them out of hospital. To discharge them precipitately because they are not receiving treatment would not: be in their best interests. Many old people are quite happy in their established surroundings and it would do them a disservice to remove them after many years, especially as no real therapeutic contribution would be made. With this approach the problem of the elderly mentally infirm in mental hospitals would gradually diminish and the local health authority would be given time to build up an organisation u~ deal with them adequately. The numbers supplied by the medical superintendents suggest that oac home accommodating 75 such patients of both sexes, with day centre and social club facilities attached, would meet the demand for the near future. All the patients in the above category present problems that make them unacceptable in normal welfare homes. There is another category which could, however, be accommodated in the latter. Discussions with the medical superintendents suggest that the number is not great and the deputy welfare officer felt that they could be absorbed by the existing welfare homes.
THE
PROVISION
OF
TRAINING
CENTRES
There is very little need be said on the provision of training centres because most authorities have been very busy building new ones, I would only say that my own particular preference is for the small centre which would accommodate about 50~ but this is motivated by conditions in Birmingham. I think in the past we have underestimated the capabilities of such children and that a more ambitious programme should be developed, certainly in building our centres provision should be made for the physically handicapped and fo; ~the incontinent to attend. I think that one of the difficulties tha • arise if local education authorities have too much to do with occupation centres is that they place undue emphasis on formal academic teaching for children who are only capable of limited success in the three Rs. We in Bii~ingham have been somewhat backward in providing new occupation centres and industrial centres, so we have the advantage now of starting from scratch and are determined to make our industrial centres places where proper and useful training methods can be applied. I think any industrial centres must present different types of work, so that all types can be catered for, those who are potentially employable and those who are essentially receiving diversional therapy, i.e. training would be divided into stages as follows--
OBSERVATIONS
ON
1HE
MENTAL
HEALTH
ACT
307
(a) simple for ::'~.:wentrants; (?,) intermediate .....many may remain at this level; (c) advanced. ORG
A N ISA
I ION
OF
T H I~ S T A
t:F
Ot:
THE
SER V ICfi
AI! local health authorities have had mental welfare officers and their organisalion has been influenced by local requirements. Here in Birmingham we have a rather rigid division of responsibility following our responsibilities under the Lunacy and Mental Treatment Acts, Mental Deficiency Acts and the National Health Service Act. This is largely unavoidable in a large city. but with the new Act there will be less need for so rigid a division and so the old terminology has already gone and the new term "mental welfare officer" introduced, but the officer's duties will largely be determined by his experience and training. As 1 see it, our obligations under the new Act are broadly preventive and community care support. The department has been organised bearing this in mind. P R E V E N T I V E SI-RV i C E S Many might consider this term too hopeful and one which suggests that wc know much more about the fundamental causes of mental illness, neurotic and psychopathic behaviour than we do and that we can influence them considerably. Certainly, to make such claims would be extravagant and would indicate an overestimation of the contribution we could make. Nevertheless, the written work of others and one's own experience suggests that mental ilh~ess and maladjusted behaviour take root in early life and that the orientation of services towards the family and tF~e parent/child relationship can have real preventive value, but if they are to have a significant effect they must be available to all families who need them. ]'he preventive services of the mental health section then has meant the orientation of the psychiatric social services towards the family, in co-operation principally with the h.vs. and has taken the form of discussions and counselling at certain welfare centres, active case work and intensive investigations at the parent guidance clinic. By counselling is meant the p.s.w, or trained case worker acting as adviser and consultant to the h.~,,s, on social work problems and case work methods. FAMILY
PROBLEMS
SECTION
Those families which have such intense problems are cared t\'~r ~ , the family problems sections of the psychiatric s ~ i a l service. Here 48 out o f lOi were referred by h.vs. during the year, ~he other main source of referral being the housing management department. The type of problem covered by this section is probably somewhat wider than that covered by the Family Service Unit. However, the linethat separates problem families from families with problems is vague and, in fact~ some would say non-existent, Neverthetes~, it can be said that a fair
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HEALTH
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NO.
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proportion of the families supervised are typical problem families of the large¢ disorderly and messy type with living standards well below the neighbourhood average and an income which at times is insufficient for the immediate needs of tile family. Others, less messy in appearance, have chronic problems that undernfine the stability and happiness of the home, which may be in grave danger of disruption either through eviction or desertion or separation of one or other parent. Most of these families have young children and have been a problem that has caused concern to the h.v. This type of service affords valuable help either directly or indirectly by general counselling. The services of selected home helps under an experienced p.s.w, has also been most useful in this work. Although the counselling activities and case work of the family problems section is done mainly in conjunction with the h.vs. it is not limited to them. Case conferences take place regularly with representatives of all organisations and the counselling service has been extended to the National Assistance Board field workers. The parent guidance clinic has been mentioned, it is similar to a child guidance clinic but deals with the problems of parents with children under five years of age, I feel that such clinics have preventive value if they are closely associated with the maternity and child welfare centres, t envisage development along the following lines : ~ The establishment of at least one clinic in one of the welfare centres, the staff to include part!time consultant psychiatrist, p.s.w, and/or a s.w. and a h.v. attached; from this centre is organised a peripatetic service with the p,s.w. visiting centres to discuss cases with h.vs., and i f necessary referring them for more intensive therapy to the main clinic. Part o f the functions o f this clinic would include in,service training of medical officers &health and h.vs. and health education among the adolescent COMMUNITY
CARE
SUPPORT
Although there is a general desire for the care of the mentally sick in the com, munity, it must not be forgotten that medical treatment plays an essential part i n i t and this in a specialised form is, i n t h e main. only obtainable in hospital o r out-patient clinics. Community care then can be narrowly conceived:and must be seen as an integrated :whole and developed in harmonious relationship with the hospitaiservice, Admission to hospital is n o t a n end in itself, but a phase in the patient's illness and as in any other the continuity should be preserved. Only close liaison between the hospital and local authority staffsand joint use Wherever possible can achieve this. Otherwise, the local :authority service tends to stand outside file hospital service and receives referrals in a ather haphazard, .... arbztrary and unsattsfa,~tory way. My o w n particularpreference would be the recommendation of theRoyal Comm3ssion that the local health authority should be solely responsible for this service and should be implemented, our experience in Birmingham illustrates this, e.g. at one of the
OBSERVATIONS
ON
THE
MENTAL
HEALTH
ACT
309
four city mental hospitals where the psychiatric social service undertakes the social casework, after-care referrals have been around 50 a year, whereas at another only two have been referred in two years. As regards the other two mental hospitals, referrals have started to rise steeply immediateJy a closer liaison was established between the hospital and the local authority mental health service. It is now planned to form the p.s.ws, and m.w.os, into teams of two p.s.ws, and two n.w.os, for each hospital reception area, and also a health visitor, as soon as staff numbers will permit. They will work as a team closely associated wi~h the hospital and concentrating on its catchment area, the team to be under the psychiatric direction o f a psychiatrist in each hospital while they remain administratively responsible to the medical officer o f health. As regards after-care, there is little doubt that for this to be eff~tive the after-care service must start long before discharge, tt sho~fld, in fact, start with admission, when the family should be told that the patient has been taken into hospital for treatment and that there is every" reason to hope that he will be returning home when treatment is completed. Further, the relatives should be helped to understand how they can help constructively in the treatment by visiting and reassuring the patient that there is a place waiting for him at his home as st.on as he is well enough to return. With the increased turnover of patients entering and leaving hospital it is not possible So provide after-care for all, nor is it necessary, and so careful selection of those eases that need this service has to be done and should be done while the patient is in hospital. Although our plans have principally taken into consideration working with hospitals, obviously it is intended that they should develop services with the general practitioner. As I see it tile general practitioner more and more will c ~ l in consultants for domiciliary visits. This will result° I think, in a considerable use o f m.w.os, and I would suggest that the Ioca] authority could set up mental health clinics in the welfare centres, one that was conveniently placed in the reception area of the hospital. T h e team c3f m : v ~ . o s , could operate from this centre and in co-operation with the g.p. refer special cases to the consultant. who is also part:of the team: The g.p, also could take part in the weekly discussions which would certainly :take place either at the hospital or at the welfare centre, but the idea o f the wdfare centre suggests itsetf because it is rather more informal a n d rather closer to the community. The idea o f speciali~d clinics is already well developed so yet another should be acceptable. Similar clinics for the diagnosis ofsevere abnornmlity are already in operation at welfare ~ntres. Alternatively, t h e hostels could b e developed along similar l i n ~ , using them as the toczd centre ~[or the mentally handicapped m t h e community. STAFFING
CONSIDERATtONS
~qmre addifion~l staff, w h i c h o f ~ e d t u a f i o m Ceru~i~y : ~ p e x i e n ~ t p~s.wsi and s,ws. are hard Io find; .p~rhaps
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HEALTH
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NO.
8
within the department existing staffs can be used. I would like to consider the role that some of them might play. PSYCHIATRIC
SOCIAL
WORKERS
AND
SOCIAL
WORKERS
Although ] consider p.s.ws, as invaluable to a local health authority community care service I feel that not so many are required as might be imagined. In my experience p.s.ws, can be used as key members of a team to guide the others in case work and we have used them to maximum advantage in this respect in Birmingham. However, to m~: they seem to over-exaggerate the role of the environment and of supportive case work in the community and delay unnec~essarily admission to hospital. S,ws., their less highly trained brethren, are useful potential recruits to a Iocal mental health service, but initially, what they can contribute to the care of the psychotic patient is very little. There is no doubt in my mind that the experienced m.w.o, has few equals in spotting the psychotic patient, who is urgently in need of hospital care. In my opinion he must continue to play a major role in the local authority team. What he Iacks is experience in after-care and the necessary case work training to support patients in the community. This gap can be filled by providing training schemes and including p.s.ws, in the team. HEALTH
VISITORS
The h.v., although lacking perhaps the experience of the above workers in this speciatised field, has the basic training and experience which could be built upon to enable her to m a k e a valuable contribution" to a mental health team, and I see her inclusion in it as necessary and commendable. TRAINING
OF
MENT/~
L
WELFARE
OFFICERS
P.s.ws. with a me~:al2 health certificate are usually regarded as the most highly qualified workers in the mental health field, but it is not likely in the foreseeable future that there will be enough of them to meet future needs. A l t h o u ~ the courses arranged by Universities for their training are already full, only a relatively few become available annually. Therefore, because of this deficiency of the highly trained worker it will be necessary to recruit those who are either completely or relatively untrained. Although this wilt create the problem of instffuting training schemes it gives an opportuniW for us to draw upon people with a wide background of experience. Many people w h o have not had the opportunity of taking the training necessary to be a fully qualified p.s.w, would be able, because of their personality and background, to make a considerable contribution to psychiatric social work if they could be given the opportunity of emering this field and receiving the necessary training. A course has already begun in Birmingham with the help of the College of Commerce for those already working in mental health departments of the
OBSERVATIONS
ON
THE
MENTAL
H,EALTH
ACT
311
local health authority and who want systematic teaching in mental disorders, case work and case work training, Much has been learnt from this course and of the needs of those without previous academic training and the following proposals are based on them. Broadly, training programmes for the following three types of worker will be necessary : - 1. new entrants without any previous experience in social work in mental illness; 2. those with previous knowledge such as health visitors, mental hospital nurses, s.ws. with only the basic s.w. qualification and recently recruited inexperienced m.w.os; 3. refresher courses for experienced workers without recognised training or qualifications. NEW
!
ENFRANTS
WITHOUT
EXPERIENCE
suggest that workers entering this field should be attached to a large hority where they could accompany experienced p.s.ws, and m.w.os. i~. .,c~ld of mental illness and mental subnormality. I would suggest that they have three months with each group and they gain experience in day-to-day observation. As they would be attached to a hospital reception area and work closely with the hospital and the general practitioners they would also have the opportunity of attending the clinical conferences. Their progress and experience gained will be carefully recorded by the health of the mental health department & t h e local health authority and their suitability f ~ the next stage in the training assessed. If those undergoing training were employed by a smaller local authority then I would suggest that they are released to a larger local authority on a part-time basis for perhaps two days per week, where the)' could get the wider experience, more particularly with opportunities of seeing urgent admission and clinical work. This would be the essential first step of all new entrants without an)' previous experience. Having finished their nine-month attachment to the local authority the' would then be in a position to join the new course prepared for CIass 2 ~ p e of worker, who has some basic experience, and the suggested programme for this is as follows :.--
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HEALTH
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mor:ning per week over 10 weeks with discussions and ~raining in casework and clinical psychiau~¢ continuing. The last term would consist of one morning per week for 10 weeks, when the workers would be introduced to all the different service.~, available to the handicapped, with perhaps a short series of: lectures summarising the work previously undertaken. For those in the third group requiring a refresher course, they should join the four-week period of fuU-time intensive study and also the last term, which of course is part time. It is suggested that the students: should sit an examination a't the end of this two-year course of training and that a diploma should be awarded. The lecturers to be obtained from the regional hospital board, University, local authority and otl~,er agencies interested in the handicapped. In the more distant future it is suggested that using the same course as a basis it could be adapted for a nationally recognised diploma obtained by nationally organised examinations. It is further recommended that steps should be taken now, e.g. by approaching the Minister of Health to set up such arrangements. That is an outline of our future plans, many difficulties no doubt wilt arim. The possibility of the co-operation of other services has to be investigated fully, but essentially the problem is one that the local health authority should be able to tackle.