1834 Poor Law (Amendment) Act

RISK AND CONTROL:
• high profile homicides led to Care Programme Approach (1990) to co-ordinate support, provide full needs assessment and care plan
• supervision registers (1994) and Mental Health (Patients in the Community) Act 1995 tightened co-ordination and control over patients
• Mental Health Act 2007: supervised community treatment and wider role for mental health professionals

CARE AND RIGHTS
• National Service Framework 1998, 2009: set national standards and guidelines and targets for developing services
• recovery approach represents shift from medical focus on cure to individual capacity, regardless of diagnosis and symptoms
• measures to protect rights of people with mental illness in Mental Capacity Act 2005 and Mental Health Act 2007

PERSONALISATION:
• mental health service users’ limited access to direct payments the result of professional paternalism and fears about risk
• personal budget studies showed most positive outcomes for mental health service users in terms of overall wellbeing and quality of life
• Pathways to Personalisation, Putting Us First and New Horizons designed to increase access e.g. through risk management strategies
ASS007-3 DEPENDENCY AND CARE: CRITICAL PERSPECTIVES ON POLICY AND PRACTICE

Week 20 Mental health service users

1. Facts and figures
How many, what and why An estimated one in four people experience some form of mental illness during their lives which makes it one of the most common causes of disability. Common mental disorders are more likely to affect women than men, and the rates amongst women aged 45-64 have risen by about a fifth over the past fifteen years. People aged 75 and over are least likely to have a common mental disorder. More than half with a common mental disorder present with a mixed anxiety and depressive disorder. Whilst serious mental illnesses such as psychotic disorders (e.g. schizophrenia), anti-social personality disorder and borderline personality disorders receive considerable publicity they each affect one percent or less of the adult population. There are slightly higher rates of psychotic disorder amongst women than men but little difference in relation to personality disorders. The highest prevalence rates are amongst the 35-44 age group, with a significantly higher diagnosis of psychotic disorder amongst black men than men from other ethnic groups. Psychosis is also more prevalent amongst adults in the lowest income groups. A relatively high percentage of adult psychiatric patients, particularly amongst urban populations, have a co-diagnosis of substance misuse. The mental health disorders discussed so far may be transient, recurrent or chronic but degenerative brain disorders, commonly collectively known as dementia, are permanent and terminal. Because they affect one in twenty people over the age of 65, and one in five over the age of 80, an ageing population means that its prevalence will continue to increase.
Need for social care The stigma attached to mental illness continues to affect service users, their families and carers. Although there are some encouraging signs of a shift in public attitudes, surveys show that a high proportion still believe that people with a mental illness should be kept in a psychiatric hospital. Stigma affects the lives of people with mental disorders in a number of dimensions, such as relationships, paid employment, housing and quality of life. This makes mental illness an issue for social care as well as health policy, whilst the growing prevalence of dementia will place increasing demands on both health and social care providers.

2. From institutionalisation to community care
Institutionalisation In the 18C and 19C, as discussed in previous sessions, people regarded as dangerous were commonly confined to institutions under harsh and degrading conditions – initially in private madhouses and later in publicly-funded asylums. Successive Lunacy Acts passed during the 19C increased the number of medically-run asylums reflecting an increasing recognition that mental illness was a disease and the mind a function of the brain. Doctors played a central role in these institutions, certifying lunatics, diagnosing and treating them, running the asylums, and inspecting and supervising private madhouses. Nevertheless, only a minority of people with a mental disorder were confined to a specialist institution; the majority were looked after by their families or confined to workhouses or prisons.
Welfare state and community care The asylums were absorbed into the National Health Service when it was formed in 1948, representing over half of all in-patient beds. From the 1950s onwards, however, there was a policy of closing these hospitals down, a policy shift underpinned by a number of key factors including the discovery of medications to treat the symptoms of psychosis which made custodial care less necessary for risk management. A powerful medical lobby pressed for doctors to be allowed to practise ‘real’, that is acute, medicine in hospitals rather than using them for chronic care. In terms of grassroots pressure, the anti-psychiatry/mental health survivor movement emerged in the early 1970s alongside the disability movement. Academics gave rise to the idea that mental illness was a social construct rather than medical fact (e.g. such as Szasz, Laing, Foucault) as well as critiquing the inhumane treatment of patients in long-stay hospitals (e.g. Goffman). Arguments supporting hospital closure were developed against a backdrop of wider civil rights movements across Western society, exploited by pressure groups such as MIND in the UK. In Italy, radical psychiatrists successfully campaigned for the passing of Law 180 in 1978 which prevented new admissions to existing mental hospitals. As discussed previously, though, in the UK, deinstitutionalisation was also influenced by the belief that community-based care would be cheaper. The 1959 Mental Health Act was a significant landmark in the development of care in the community, that is, the provision of a network of state-run, professionally-delivered services outside hospital, such as hostels, day care, social work support and sheltered employment schemes. The 1975 White Paper Better Services for the Mentally Ill re-emphasised the need to provide a comprehensive range of community services, followed by the 1976 White Paper Priorities for Health and Personal Social Services which encouraged health and local authorities to prioritise chronic care. Joint planning and joint finance arrangements introduced over the 1970s were designed to improve co-ordination between health and local authorities in the development of community-based services. Some NHS responsibilities were transferred to local authorities, such as psychiatric social work; and multidisciplinary community mental health teams were formed, comprising community psychiatric nurses, social workers, occupational therapists, psychologists and psychiatrists. Despite these measures, economic crisis and public spending cuts over the 1970s slowed the growth of community-based provision

3. Care v control
Risk and control Beginning in the late 1980s, a series of high profile violent episodes involving mental health service users recreated fears about the safety of community care. Criticism about the lack of co-ordinated support for discharged mental health patients resulted in the Care Programme Approach (CPA), implemented in 1991, which required health authorities to collaborate with social services departments and family carers, a care co-ordinator for each patient and regular care planning review. A further homicide led to an inquiry to conclude that CPA was ineffective. In 1994 the government required people considered most at risk of harming themselves or others to be placed on supervision registers to ensure they remained under the control of mental health services. The 1995 Mental Health (Patients in the Community) Act then extended the scope of healthcare providers’ authority over people discharged from hospital. The process of reforming the 1983 Mental Health Act once again gave prominence to the debate about public safety versus patient rights. A draft Bill contained controls such as compulsory medication and the detention of people with severe personality disorders even if they had not committed a crime. The Royal College of Psychiatrists formed an alliance with mental health user/survivor groups to oppose this use of psychiatry as a means of social control. Despite government concessions, the Bill was defeated and a second met with opposition. Thus the 2007 Mental Health Act left the 1983 Act largely intact, but introduced Supervised Community Treatment including Community Treatment Orders. This new power replaced supervised discharge with the power to return a patient to hospital where, if the individual had not taken prescribed medication, s/he could be forcibly medicated. The 2007 Act also replaced the specialist Approved Social Worker role with that of the Approved Mental Health Professional, whilst broadening the scope of the latter to permit treatment without patient consent.
Care and rights There was also an emphasis on improving care and rights during this period. The 1998 National Service Framework established guidelines for developing and evidence-based national standards for services as well as time-limited targets for their achievement. This was updated in 2009 by the policy document New Horizons which had the twin aims of improving the mental health and wellbeing of the general population and improving the quality and accessibility of services for people with poor mental health. Greater recognition of stigmatising attitudes towards mental illness, amongst public and professionals alike, can be linked to the recovery approach to mental illness. Alongside clinical treatment, the recovery approach focuses on each individual’s capacity to build a meaningful life, find and maintain hope, re-establish a positive identity and take responsibility and control, regardless of diagnosis or symptoms. Rather like the social model of disability, curing the illness is less the emphasis than social inclusion, individual choice and control. In terms of rights, the 2005 Mental Capacity Act gave expression to the principle that people were capable of making a decision unless a systematic assessment proved that their mental functioning was too impaired. The Act also contained safeguards to ensure that all practicable steps were taken to support vulnerable people to make decisions in their best interests with the least restrictive outcome. The 2007 also contained some protective measures. It replaced the treatability test with criteria for involuntary commitment based on a requirement that someone couldn’t be detained unless appropriate treatment was available. It also introduced the Mental Health Review Tribunal to improve patient safeguards and independent mental health advocates.
Personalisation can be linked to the recovery approach but, historically, mental health service users have had limited access to direct payments and individual budgets. The evaluation of pilot studies indicated that only a low proportion of mental health service users relative to other service user groups received an individual budget. Those who did, however, reported the most positive outcomes in terms of overall wellbeing and a significantly higher quality of life. They benefited from the flexibility of individual budgets which gave them access to a wider range of support other than standard services. Guidance, such as Pathways to Personalisation and Putting Us First, attempted to address the reasons for low access by addressing the issue of risk and providing good practice guidance on risk management strategies, such as advance directives and crisis management plans to cope with fluctuations in mental health. Pathways to Personalisation is linked to the recommendations of New Horizons, the cross-governmental mental health strategy cited earlier.