MANAGING CHANGE:
THE DEVELOPMENT OF MENTAL HANDICAP SERVICES
IN SOUTH EAST THAMES REGIONAL HEALTH AUTHORITY, 1 9 7 8 -8 8
s u b m i t t e d by Nancy L i n c o l n Korman f o r t h e d e g re e o f D o c t o r o f P h i l o s o p h y
UMI Number: U0428B0
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T h i s d i s s e r t a t i o n i s an e x a m i n a t i o n o f t h e p l a n n i n g and management is s u e s i n v o l v e d i n t h e i m p l e m e n t a t i o n o f a r e g i o n a l h e a l t h a u t h o r i t y d e c i s i o n t o c l o s e a m e n ta l h a n d ic a p h o s p i t a l and r e p r o v i d e s e r v i c e s i n seve n d i s t r i c t s w h ic h had used t h e h o s p i t a l .
S e v e r a l f e a t u r e s made t h i s p r o j e c t w o r t h y o f a t t e n t i o n : i t was among t h e e a r l i e s t h o s p i t a l c l o s u r e s ;
i t i n v o l v e d a v e r y l a r g e number o f d i s t r i c t s and t h e r e f o r e was a c o m plex s i t u a t i o n w h ic h n o n e t h e l e s s was f a i r l y t y p i c a l o f l o n g - s t a y h o s p i t a l s i n t h e London a r e a ;
a l l r e s i d e n t s , r e g a r d l e s s o f d e g re e o f d i s a b i l i t y , w ere t o be g iv e n t h e chance o f l i v i n g i n t h e c o m m u n ity :
l o c a l a u t h o r i t i e s w ere a l s o i n v o l v e d a lo n g w i t h h e a l t h a u t h o r i t i e s , and t h i s p r o j e c t c o u l d i l l u s t r a t e new p r i n c i p l e s o f j o i n t p l a n n i n g .
The p r o j e c t f u r t h e r l e n t i t s e l f t o a c o n s i d e r a t i o n o f t h e adequacy and a c c u r a c y o f t h e a ca d e m ic l i t e r a t u r e on p l a n n i n g and r e l a t e d a c t i v i t i e s .
p r o j e c t t h r o u g h t o c o m p l e t i o n . The D a r e n th p r o j e c t t e s t e d t h e new NHS p l a n n i n g s y s te m w h ic h was based on a r a t i o n a l p l a n n i n g m o d e l, and fo u n d t h a t i t c o u l d n o t d e l i v e r w h a t was w a n te d fr o m i t . R e g io n a l o f f i c e r s c r e a t e d new t y p e s o f w o r k i n g r e l a t i o n s h i p s w i t h d i s t r i c t s w h ic h a l l o w e d p r o g r e s s t o be made.
The second s e t o f i s s u e s c o n c e rn e d t h e management o f t h e rundown o f t h e h o s p i t a l . A s p e c ts o f t h e rundown d is c u s s e d a r e : r e t e n t i o n and r e d e p lo y m e n t o f s t a f f ; p h y s i c a l c o n t r a c t i o n o f t h e h o s p i t a l ; im p a c t on r e s i d e n t s ; f i n a n c i n g t h e rundow n.
The t h i r d s e t o f is s u e s r e l a t e d t o j o i n t p l a n n i n g . One o f t h e p u rp o s e s b e h in d t h e i n t r o d u c t i o n o f j o i n t p l a n n i n g i n t o t h e NHS was c r e a t i o n o f a mechanism t o b r i n g a b o u t a more a p p r o p r i a t e b a la n c e o f s o c i a l and h e a l t h c a r e f o r p e o p le who w ere c u r r e n t l y l o n g - s t a y p a t i e n t s . B u t i t was n o t j o i n t p l a n n i n g w i t h l o c a l a u t h o r i t i e s w h ic h g o t t h e s e r e s i d e n t s o u t i n t o t h e c o m m u n ity . T h i s s t u d y docum ents some o f t h e re a s o n s why g o v e rn m e n t p o l i c y
i n t e n t i o n s c o u l d n o t be m e t.
T a b le o f C ontents
L i s t o f T a b le s I n t r o d u c t i o n C h a p te r 1
The P o l i c y Scene C h a p te r 2
A rg u m e n ts A g a i n s t I n s t i t u t i o n s C h a p te r 3
B r i n g i n g Change i n t o t h e System C h a p te r 4
M e th o d o lo g y C h a p te r 5
O v e rv ie w o f t h e D a r e n th P r o j e c t C h a p te r 6
R o le o f t h e R e g io n C h a p te r 7
G e t t i n g S e r v i c e s Ready f o r P e o p le C h a p te r 8
G e t t i n g P e o p le Ready f o r S e r v i c e s C h a p te r 9
J o i n t P l a n n in g C h a p te r 10
Rundown o f t h e H o s p i t a l C h a p te r 11
New Homes, New L i v e s C h a p te r 12
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T a b le 5.1 T a b le 7.1 T a b le 8.1 T a b le 8 . 2
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T a b le 1 0 .4 T a b le 1 0 .5
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T a b le 1 0 .7 T a b le 1 0 .8
T a b le 1 0 .9 T a b le 1 0 .1 0
H o u s in g S to c k i n t h e c a tc h m e n t b o ro u g h s 133 S t a f f i n D a r t f o r d and i n n e r London 189 Age and sex o f r e s i d e n t s , 1980 218 R e s id e n t s and t h e i r t y p e o f d i s a b i l i t y
219 T a b le 8 . 3 B e h a v io u r p a t t e r n s o f r e s i d e n t s 220 T a b le 8 . 4 R e s i d e n t s ’ l e n g t h o f s t a y 221 T a b le 8 . 5 Numbers o f p l a c e s and o f r e s i d e n t s 222 T a b le 9.1 L o c a l a u t h o r i t y d e v e lo p m e n ts i n d e t a i l
255 P la n n e d r e d u c t i o n , numbers o f r e s i d e n t s 288 The pace o f d i s c h a r g e , 1983-89 289 R e s id e n t s r e m a in in g i n h o s p i t a l l a s t day
o f each month 290
Ward c l o s u r e s , 1983-89 291
Ward c l o s u r e s and movements o f r e s i d e n t s
1 9 8 6 /6 7 292
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d e n t s 293
R e s id e n t s * moves b e f o r e d i s c h a r g e 295 D a r e n th P a rk H o s p i t a l s t a f f , March 1983 296 S t a f f i n g a t D a r e n th P a r k , 1985-88 297
T a b le 11.1 Age o f r e s i d e n t s , 1988 330 T a b le 1 1 .2 P h y s i c a l and s e n s o r y h a n d ic a p s 331
T a b le 1 1 .3 P la c e o f d i s c h a r g e 332
T a b le 1 1 .4 R e s i d e n t s ’ p l a c e s i n l o c a l a u t h o r i t y
homes 334
L i s t o f F ig u r e s
F i g u r e 5.1
F i g u r e 7.1
F i g u r e 10.
C a tc h m e n t a r e a f o r D a r e n th P a rk and o t h e r r e s i d e n t i a l f a c i l i t i e s f o r m e n t a l l y h a n d ic a p p e d a d u l t s , 1978
R e s i d e n t i a l f a c i l i t i e s f o r m e n t a l l y h a n d ic a p p e d a d u l t s , 1988
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I n t r o d u c t i o n
T h i s d i s s e r t a t i o n e x a m in e s t h e p l a n n i n g and management i s s u e s i n v o l v e d i n t h e i m p l e m e n t a t i o n o f a r e g i o n a l h e a l t h a u t h o r i t y d e c i s i o n t o c l o s e a m e n ta l h a n d ic a p h o s p i t a l and r e p r o v i d e s e r v i c e s i n t h e seven d i s t r i c t s w h ic h t h e h o s p i t a l s e r v e d . The r e s e a r c h was s u p e r v i s e d by P r o f e s s o r G l e n n e r s t e r and c a r r i e d o u t u n d e r a g r a n t fr o m t h e t h e n D e p a rtm e n t o f H e a l t h and S o c i a l S e c u r i t y (DHSS) betw een 1981 and 1988. The p r o j e c t r e p o r t has a p p e a re d i n a book p u b l i s h e d by t h e Open U n i v e r s i t y P re s s i n 1990 (Korman and G l e n n e r s t e r , 1 9 9 0 ). T h i s d i s s e r t a t i o n p r e s e n t s a r e v i s e d v e r s i o n o f th o s e a s p e c t s o f t h e p r o j e c t f o r w h ic h t h e a u t h o r was d i r e c t l y r e s p o n s i b l e u n d e r P r o f e s s o r G l e n n e r s t e r ’ s s u p e r v i s i o n .
The r e s e a r c h p r o c e s s i t s e l f had some u n u s u a l f e a t u r e s . F i r s t , i t began because o f l o c a l i n t e r e s t i n g e t t i n g r e s e a r c h done on t h e D a r e n th p r o j e c t , b u t i t became o f much g r e a t e r i n t e r e s t as t i m e w e n t o n , because o f t h e in c r e a s e d a t t e n t i o n b e in g p a id t o t h e h o s p i t a l c l o s u r e movement. M ost r e s e a r c h has t h e o p p o s i t e e x p e r i e n c e .
y e a r s o r so p r o d u c in g a s n a p s h o t o f a p a r t i c u l a r p a r t o f t h e change p r o c e s s . The e x p e r i e n c e o f w o r k in g c o n t i n u o u s l y on a p r o j e c t i n t h i s c a s e e n a b le d t h e r e s e a r c h t o i d e n t i f y t h e change p r o c e s s and t h e .end r e s u l t s , t h e im p a c t o f p e r s o n a l i t i e s , p o l i c i e s and e x t e r n a l e v e n t s . I t made p o s s i b l e t h e p r o d u c t i o n o f a c o h e r e n t and c o m p re h e n s iv e n a r r a t i v e o f e v e n t s w h ic h was c o m p r e h e n s ib le t o p a r t i c i p a n t s and t o a w i d e r a u d ie n c e o f p r a c t i t i o n e r s , m anagers and a c a d e m ic s .
The r e s e a r c h r e p o r t e d i n t h i s d i s s e r t a t i o n e x c lu d e s t h a t s e c t i o n o f t h e r e p o r t t o t h e DHSS and t h e book w h ic h d e a l t w i t h an a n a l y s i s o f t h e c o s t s o f co m m u n ity c a r e , as t h a t a n a l y s i s was t h e w o rk o f P r o f e s s o r G l e n n e r s t e r .
A c kn o w le d g e m e n ts
I w is h t o e x p r e s s my th a n k s t o t h e many members o f s t a f f a t D a r e n th P a rk h o s p i t a l , w i t h i n t h e h e a l t h a u t h o r i t i e s and l o c a l a u t h o r i t i e s and a t t h e r e g i o n a l o f f i c e o f S o u th E a s t Thames R e g io n a l H e a l t h A u t h o r i t y f o r h a v in g a c c e p te d t h e p r e s e n c e o f an o u t s i d e r i n t h e i r m i d s t f o r j u s t o v e r seven y e a r s . They showed e v e r y c o u r t e s y t o me and gave f r e e l y o f t h e i r t i m e t o t h e r e s e a r c h p r o j e c t .
management s y s te m a t t h e DHSS, I can say t h a t f o r my p r o j e c t , t h e s y s te m w o rke d e x a c t l y as i n t e n d e d .
C h a p te r 1
The P o l i c y Scene
T h i s s t u d y c o n c e rn s t h e c l o s u r e o f a l o n g - s t a y h o s p i t a l f o r p e o p le w i t h m e n ta l h a n d ic a p , one o f t h e f i r s t t o be b u i l t s p e c i f i c a l l y f o r p e o p le w i t h m e n ta l h a n d ic a p and one o f t h e f i r s t t o c l o s e . The c l o s u r e was made p o s s i b l e by t h e d e v e lo p m e n t o f new s e r v i c e s i n t h e c o m m u n ity . H o s p i t a l c l o s u r e was t h u s n o t a p o l i c y o b j e c t i v e ; i t was e x p e c te d t o o c c u r as a b y - p r o d u c t o f t h e d e v e lo p m e n t o f c o m m u n ity -b a s e d s e r v i c e s . H o s p i t a l c l o s u r e s have come t o assume a s i g n i f i c a n c e , h o w e v e r, because o f t h e r e s o u r c e s t i e d up i n h o s p i t a l s w h ic h a r e e s s e n t i a l f o r t h e d e v e lo p m e n t o f c o m m u n ity -b a s e d s e r v i c e s - c a p i t a l as r e p r e s e n t e d by t h e b u i l d i n g s and la n d , re v e n u e as r e p r e s e n t e d by t h e r u n n i n g c o s t s and e x p e r t i s e o f s t a f f i n c a r i n g f o r p e o p le w i t h a m e n ta l h a n d ic a p .
g e n e r i c f a c i l i t i e s used by a l l c i t i z e n s . T h i s c h a p t e r d i s c u s s e s t h e p o l i c y c o n t e x t i n w h ic h t h e c l o s u r e o f D a r e n th P a rk h o s p i t a l t o o k p l a c e , w i t h a b r i e f r e v ie w o f e a r l i e r h i s t o r y .
C r e a t i n g i n s t i t u t i o n s
I n s t i t u t i o n s w ere c r e a t e d v e r y much more r a p i d l y th a n we a r e now a b l e t o c l o s e th e m . An e a r l y la n d m a rk i n t h e h i s t o r y o f i n s t i t u t i o n s was t h e 1845 L u n a t i c s A c t w h ic h made t h e e s t a b l i s h m e n t o f a s y lu m s by c o u n t y a u t h o r i t i e s c o m p u ls o r y , and w h ic h had i m p l i c a t i o n s f o r p e o p le w i t h m e n ta l h a n d ic a p as w e l l as t h o s e w i t h m e n ta l i l l n e s s , as t h e tw o w ere o f t e n c o n fu s e d and t r e a t e d s i m i l a r l y . Jon e s and S c u l l p r o v i d e c o n t r a s t i n g i n t e r p r e t a t i o n s as t o why a s y lu m s became a s t a t u t o r y o b l i g a t i o n .
K a t h le e n Jones (1 9 6 0 ) g i v e s w h a t m i g h t be te rm e d a c o n v e n t i o n a l i n t e r p r e t a t i o n o f t h e h i s t o r y o f m e n ta l
t h a t ’ A s h le y and h i s c o l l e a g u e s had ro u s e d t h e c o n s c ie n c e o f m i d - V i c t o r i a n s o c i e t y , and had s e t a new s t a n d a r d o f p u b l i c m o r a l i t y by w h ic h t h e c a r e o f t h e h e l p l e s s and de g ra d e d c l a s s e s o f t h e co m m u n ity was t o be seen as a s o c i a l r e s p o n s i b i l i t y ' ( i b i d , p . 1 4 9 ).
An a c c o u n t w i t h a d i f f e r e n t e m p h a s is i s p r o v i d e d by Andrew S c u l l (1 9 7 9 ) i n Museums o f Madness. I n t h i s book he a rg u e s t h a t t h e c r e a t i o n o f i n s t i t u t i o n s was t h e outcom e o f u r b a n i s a t i o n and i n d u s t r i a l i s a t i o n o f t h e economy w h ic h d e v e lo p e d d u r i n g t h e f i r s t h a l f o f t h e n i n e t e e n t h c e n t u r y . An economy based on wages r e q u i r e d t h o s e who c o u l d w o rk t o do s o , and t h u s a s e p a r a t i o n o f t h e a b l e - b o d i e d f r o m th o s e n o t c a p a b le o f w o rk f o r t h e r e l i e f o f p o v e r t y .
h o w e v e r, was n o t a p a r t i c u l a r l y m e d ic a l o n e . I t was t h e ’ m o ra l t r e a t m e n t ’ d e v is e d by Tuke w h ic h , d o c t o r s a r g u e d , w o u ld a l l o w them t o manage m e n t a l l y i l l p e o p le i n l a r g e n u m b e rs, w h i l s t a v o i d i n g t h e b r u t a l i t y and h o r r i f y i n g m e c h a n ic a l r e s t r a i n t s w h ic h had been t h e s o u r c e o f p u b l i c d i s q u i e t . W ith an o p t i m i s t i c f a i t h i n m o ra l t r e a t m e n t , i t was a c o m p a r a t i v e l y s h o r t s t e p f o r t h e m e d ic a l p r o f e s s i o n t o e n c o u ra g e t h e p u b l i c t o t r a n s f e r a c c e p ta n c e o f w o rk h o u s e i n s t i t u t i o n s t o s e p a r a t e i n s t i t u t i o n s f o r
l u n a t i c s .
Thus i n s t i t u t i o n s came t o be seen as t h e a c c e p t a b l e way o f c o p in g w i t h p e o p le seen as n e e d in g t o be c o n t r o l l e d o r t o have t h e i r b e h a v io u r m o d i f i e d . I n s t i t u t i o n a l c a r e was e x te n d e d fro m c o n t r o l l i n g t h e p o o r t o c a r i n g f o r p e o p le w i t h m e n ta l i l l n e s s o r m e n ta l h a n d ic a p , p h y s i c a l d i s a b i l i t i e s , c h i l d r e n w i t h o u t p a r e n t s and e l d e r l y p e o p le u n a b le t o l o o k a f t e r t h e m s e lv e s . W h i l s t much o f t h e e a r l y l i t e r a t u r e on i n s t i t u t i o n s was c o n c e rn e d t h o s e d e a l i n g w i t h m e n ta l i l l n e s s , many o f t h e f e a t u r e s o f t h e s e i n s t i t u t i o n s w ere common t o i n s t i t u t i o n s p r o v i d i n g c a r e f o r o t h e r g r o u p s , and t h e r e f o r e c r i t i q u e s o f m e n ta l i l l n e s s h o s p i t a l s a p p l y e q u a l l y t o o t h e r t y p e s o f l o n g - s t a y h o s p i t a l s .
as we need t o j u s t i f y why i n s t i t u t i o n s g a in e d o r l o s t s u p p o r t as re m e d ie s f o r s o c i a l i l l s we need t o i d e n t i f y t h e re a s o n s why, once e s t a b l i s h e d , some s u r v i v e d i n t h e f a c e o f t h e i r o b j e c t i v e f a i l u r e t o m eet t h e i r a i m s . "
P e o p le w i t h m e n ta l h a n d ic a p s w ere i n c a r c e r a t e d w i t h p e o p le w i t h m e n ta l i l l n e s s e s ; t h e r e was l i t t l e u n d e r s t a n d i n g o f t h e d i f f e r e n c e s i n t h e s e c o n d i t i o n s by t h e p u b l i c . An e a r l y a t t e m p t t o i d e n t i f y i s s u e s p a r t i c u l a r t o t h e c o n d i t i o n o f m e n ta l d e f i c i e n c y , as i t was th e n c a l l e d , was t h e s e t t i n g up o f a R oyal C o m m issio n on t h e C are and C o n t r o l o f t h e F e e b le - M in d e d ( 1 9 0 4 - 1 9 0 8 ) . T h i s was l a r g e l y i n r e s p o n s e t o p u b l i c c o n c e r n s a b o u t a l l e g e d p r o m i s c u i t y and d e l i n q u e n c y o f p e o p le w i t h m i l d m e n ta l h a n d ic a p , c o n c e r n s w h ic h had been s t i r r e d up by s e v e r a l s t u d i e s p u r p o r t i n g t o t r a c e how m e n ta l d e f i c i e n c y had been passed f r o m one g e n e r a t i o n t o a n o t h e r w i t h i n f a m i l i e s , w i t h each g e n e r a t i o n h a v in g many f a m i l y members who had become p u b l i c b u rd e n s t h r o u g h c r i m e , p r o s t i t u t i o n o r p a u p e r is m ( J o n e s , o p . c i t , p . 1 8 9 ) . The C om m ission r e j e c t e d t h i s v ie w o f p e o p le w i t h m e n ta l d e f i c i e n c y , and i n s t e a d f a v o u r e d a more s t r i n g e n t s y s te m o f a s c e r t a i n m e n t and s u p e r v i s i o n w h ic h w o u ld p r o t e c t t h e m e n t a l l y d e f i c i e n t p e r s o n , r e j e c t i n g a p o l i c y o f s t e r i l i z a t i o n . T h i s r e p o r t l a i d t h e f o u n d a t i o n s f o r t h e 1913 M e n ta l D e f i c i e n c y A c t , w h ic h recommended t h a t each l o c a l a u t h o r i t y e s t a b l i s h a
t h e c o n s t r u c t i o n o f s u ch ’ c o l o n i e s ’ u n t i l t h e 1920s and 1930s. T h us, many o f t h e a rg u m e n ts used t o j u s t i f y t h e e s t a b l i s h m e n t o f m e n ta l i n s t i t u t i o n s i n t h e m id n i n e t e e n t h c e n t u r y w ere used a g a in t o j u s t i f y t h e e s t a b l i s h m e n t o f s e p a r a t e i n s t i t u t i o n s f o r p e o p le w i t h m e n ta l h a n d ic a p s - t h e need f o r s p e c i a l i s t f a c i l i t i e s t o c o n t r o l and c a r e f o r t h o s e seen as a d a n g e r t o th e m s e lv e s and t h e c o m m u n ity .
The p e r i o d betw een t h e tw o w a rs saw t h e r a p i d e x p e n s io n o f s p e c i a l i s e d i n s t i t u t i o n s f o r t h e m e n t a l l y h a n d ic a p p e d . S t a r t i n g w i t h 2 ,0 4 0 su ch p e o p le i n s p e c i a l i n s t i t u t i o n s i n
1914, t h e numbers r o l e t o 4 6 ,0 5 4 i n 1939 ( A l a s z e w s k i , 1986, pp 1 4 - 1 5 ) . By 1961, t h e r e w ere a b o u t 6 1 ,0 0 0 p e o p le i n m e n ta l h a n d ic a p h o s p i t a l s . The numbers peaked d u r i n g t h e m id 1960s t o a b o u t 6 4 ,6 0 0 (B one, S p a in & Fox, 1 9 7 2 ).
I n 1948, m e n ta l h a n d ic a p h o s p i t a l s came i n t o t h e new N a t i o n a l H e a l t h S e r v i c e fr o m management by l o c a l a u t h o r i t i e s . Under t h e 1959 M e n ta l H e a l t h A c t , p e o p le were a b l e t o e n t e r m e n ta l h a n d ic a p h o s p i t a l s as v o l u n t a r y p a t i e n t s . H o s p i t a l r e c o r d s show t h a t as t h i s new s t a t u s became u n d e r s t o o d , many in m a te s s i m p l y w a lk e d t h r o u g h t h e g a t e s ; s e l f - d i s c h a r g e was n o t uncommon.
p s y c h i a t r i s t s who w ere d e v e l o p i n g new fo r m s o f t r e a t m e n t f o r m e n ta l i l l n e s s e s (Ramon, 1 9 8 6 ). C o n d i t i o n s i n s e v e r a l
l a r g e h o s p i t a l s w ere expo se d i n t h e n a t i o n a l p r e s s t o be o f v e r y low s t a n d a r d s and le d t o a s e r i e s o f p u b l i c i n q u i r i e s ( e . g . Cm nd.3975, 1969, M a r t i n , 1 9 8 4 ). The g o v e rn m e n t’ s re s p o n s e t o t h i s s i t u a t i o n was t o p ro d u c e a p o l i c y s t a t e m e n t , B e t t e r S e r v i c e s f o r t h e M e n t a l l y H a n d i c a p p e d (Cmnd 4 6 8 3 , 1 9 7 1 ).
The B e g in n in g o f Change
t y p e s o f p r o v i s i o n ) . H o s p i t a l p la c e s f o r a d u l t s w ere t o d e c re a s e by h a l f b u t o n l y by o n e - s e v e n t h f o r c h i l d r e n . T h a t t h e s e t a r g e t s w o u ld be d i f f i c u l t t o re a c h c o u ld have been r e a l i s e d by c o m p a r in g w h a t l o c a l a u t h o r i t i e s t h o u g h t t h e y w o u ld be p r o v i d i n g i n 1972, as f o r c a s t i n t h e 1963 H e a l t h and w e l f a r e p l a n s : 9907 h o s t e l p l a c e s as compared w i t h 4300 a c t u a l p l a c e s i n 1969 ( i n c l u d i n g p r i v a t e and v o l u n t a r y ) , and 2 7 ,7 9 5 ATC p la c e s as com pared w i t h 2 4 ,5 0 0 a c t u a l p l a c e s i n 1969 (Cmnd 1973, 1 9 6 3 ).
D e s p it e t h e f o r w a r d l o o k i t gave t o c h a n g e s i n s e r v i c e s , t h e W h ite P a p e r n o n e t h e l e s s d i s a p p o i n t e d some o f i t s a u d ie n c e . I t gave l i t t l e j u s t i f i c a t i o n * f o r r e t a i n i n g t h e l e v e l o f h o s p i t a l c a r e i t recommended, f o r a d u l t s o r c h i l d r e n , and ig n o r e d some o f t h e e a r l y e v id e n c e w h ic h i n d i c a t e d t h a t even t h o s e w i t h s e v e r e h a n d ic a p s c o u ld a t t a i n h i g h e r l e v e l s o f a c h ie v e m e n t i n e n v ir o n m e n t s w h ic h e m ph a size d g r o w th and d e v e lo p m e n t r a t h e r t h a n t h o s e w h ic h w ere more c u s t o d i a l o r p a s s i v e i n s t y l e .
These c o u l d be fu n d e d on a t a p e r i n g b a s i s f o r a maximum p e r i o d o f seve n y e a r s by t h e NHS (DHSS, 19 7 7 a ) . J o i n t f i n a n c e was in t e n d e d t o e n c o u ra g e l o c a l a u t h o r i t i e s t o do more f o r t h e p r i o r i t y g ro u p s who w e re a l s o r e l a t i v e l y n e g l e c t e d i n te r m s o f c o m m u n ity s e r v i c e s . S e r v i c e s f o r p e o p le w i t h m e n ta l h a n d ic a p s a l s o w ere one o f t h e g ro u p s h i g h l i g h t e d i n t h e new p l a n n i n g s y s te m o f t h e NHS begun i n 1977 (DHSS, 1976b) w h ic h w i t h i n t h e DHSS i t s e l f was based on a programme b u d g e t u s i n g c l i e n t g r o u p s as one method o f o r d e r i n g e x p e n d i t u r e . P l a n n in g g u id a n c e f o r p r i o r i t y s e r v i c e s was c o n t a i n e d w i t h i n tw o e l a b o r a t e p l a n n i n g d o cum ents (DHSS, 1976b, 1 9 7 7 b ).
d is b a n d e d , i t s f i n a l p u b l i c a t i o n a p p e a re d , e n t i t l e d
S e r v i c e s f o r t h e M e n t a l l y H a n d i c a p p e d - U n f i n i s h e d
B u s i n e s s w h ic h was c r i t i c a l b o th o f p o l i c y d e v e lo p m e n t and r e s o u r c e a l l o c a t i o n as u n d e r t a k e n by c e n t r a l g o v e rn m e n t and l o c a l a u t h o r i t i e s . The N a t i o n a l D e v e lo p m e n t Group was d is b a n d e d because i t s demands f o r s e r v i c e d e v e lo p m e n t w ere b e g i n i n i n g t o e m b a rra s s t h e new C o n s e r v a t i v e g o v e rn m e n t w h ic h had a d i f f e r e n t s e t o f p r i o r i t i e s .
A l o n g s i d e t h e NDG, a D e v e lo p m e n t Team f o r t h e M e n t a l l y H a n d ic a p p e d (NDT) was e s t a b l i s h e d . T h i s team s t i l l e x i s t s , a l t h o u g h i t i s now c a l l e d t h e N a t i o n a l D e v e lo p m e n t Team. T h i s i s a m u l t i d i s c i p l i n a r y g ro u p o f p e o p le , b o th p r o f e s s i o n a l s and g e n e r a l m a nagers, who v i s i t and a d v i s e on t h e d e v e lo p m e n t o f s e r v i c e s b e in g p r o v i d e d by h e a l t h and l o c a l a u t h o r i t i e s . T h i s q u a s i - i n s p e c t o r i a l f u n c t i o n was ta k e n o v e r fr o m t h e H o s p i t a l (now H e a l t h ) A d v i s o r y S e r v i c e , a body s e t up i n 1969 by t h e S e c r e t a r y o f S t a t e t o r e p o r t d i r e c t l y t o h im on v i s i t s t o lo n g s t a y h o s p i t a l s f o r e l d e r l y p e o p le , p e o p le w i t h a m e n ta l i l l n e s s o r a m e n ta l h a n d ic a p , a n o t h e r a s p e c t o f t h e g o v e r n m e n t’ s re s p o n s e t h e t h e r e v e l a t i o n s a b o u t c o n d i t i o n s a t E ly h o s p i t a l (Kogan e t a l , 1 9 8 9 ).
A new i d e o l o g y
c o m m itte e o f e n q u i r y i n t o m e n ta l h a n d ic a p n u r s i n g and c a r e (Cmnd 7648, 1 9 7 9 ). T h i s c o m m itte e c o n s i d e r e d i n d e t a i l t h e s k i l l s r e q u i r e d t o p r o v i d e r e s i d e n t i a l c a r e s e r v i c e s t o p e o p le w i t h a m e n ta l h a n d ic a p . The. r e p o r t began w i t h a s t a t e m e n t o f p r i n c i p l e s : p e o p le w i t h m e n ta l h a n d ic a p , even t h o s e w i t h s e v e r e m e n ta l h a n d ic a p , s h o u ld use o r d i n a r y c o m m u n ity s e r v i c e s u n l e s s t h e r e was a c l e a r r e c o g n i t i o n t h a t g e n e r a l s e r v i c e s c o u l d n o t cope w i t h a s p e c i a l n eed; t h e w o rk o f p r o f e s s i o n a l s s h o u ld s t r e n g t h e n e x i s t i n g co m m u n ity n e t w o r k s o f s u p p o r t r a t h e r t h a n s u p p l a n t them ; maximum d e g re e o f c o o r d i n a t i o n o f s e r v i c e s s h o u ld be p r o v i d e d w i t h i n and betw een a g e n c ie s ; p e o p le w i t h a m e n ta l h a n d ic a p had a r i g h t f o r someone t o i n t e r c e d e on t h e i r b e h a l f t o e n s u re t h e y r e c e i v e d t h e s e r v i c e s r e q u i r e d . The C o m m itte e f i r m l y r e j e c t e d t h e n e c e s s i t y o f h o s p i t a l c a r e f o r t h e numbers e n v is a g e d i n B e t t e r S e r v i c e s and a rg u e d f o r o r d i n a r y c o m m u n ity h o u s in g s t o c k as t h e m ost a p p r o p r i a t e f o r m o f a cc o m m o d a tio n . E q u a l l y c o n t r o v e r s i a l l y , i t u rg e d t h a t a l l r e s i d e n t i a l s t a f f r e g a r d l e s s o f t h e i r e m p lo y in g a u t h o r i t y , s h o u ld have a common t r a i n i n g and c a r e e r s t r u c t u r e .
came i n a r e p o r t p ro d u c e d by DHSS o f f i c i a l s and t h e f o r m e r c h a ir m a n o f t h e NDG, P e t e r M i t t l e r (DHSS, 1 9 8 0 ). T h i s r e p o r t r e v ie w e d p r o g r e s s to w a r d s t h e B e t t e r S e r v i c e s
t a r g e t s o f s e r v i c e p r o v i s i o n by b o th l o c a l and h e a l t h a u t h o r i t i e s . I t v e r y c l e a r l y c o u n t e r e d t h e re c o m m e n d a tio n s o f t h e W h ite P a p e r f o r c h i l d r e n ’ s r e s i d e n t i a l a c c o m m o d a tio n , s t a t i n g t h a t h o s p i t a l s d i d n o t p r o v i d e t h e c o r r e c t e n v ir o n m e n t f o r c h i l d r e n t o grow up i n and t h a t t h e t a r g e t s o f r e s i d e n t i a l p r o v i s i o n f o r c h i l d r e n by b o t h a u t h o r i t i e s w ere t o o h i g h . F o r a d u l t s , i t t h o u g h t t h a t t h e t o t a l l e v e l s o f p r o v i s i o n p ro p o s e d was s t i l l a p p r o p r i a t e a l t h o u g h i t u rg e d more c o n s i d e r a t i o n t o be g iv e n t o t h e b a la n c e o f p r o v i s i o n betw een h o s p i t a l and c o m m u n ity , and t o a g r e a t e r ra n g e o f ty p e s , o f h o u s in g such as g ro u p homes, s a t e l l i t e homes, l o d g i n g s and o r d i n a r y h o u s in g s t o c k . I t s t r o n g l y s u p p o r t e d t h e W h ite P aper t a r g e t f o r ATC p l a c e s and e x p re s s e d c o n c e r n t h a t th e s e m ig h t n o t be m e t.
im p ro v e m e n ts i n h o s p i t a l c a r e w o u ld depend on f a l l i n g numbers o f i n - p a t i e n t s . I t u rg e d t h a t more a t t e n t i o n be p a id t o t h e d e c l i n i n g r o l e o f t h e l a r g e h o s p i t a l s and t o ways o f g e t t i n g new s e r v i c e s i n t o t h e c o m m u n ity .
The new i d e o l o g y p u t f o r w a r d i n t h e Ja y r e p o r t was g iv e n f u r t h e r im p e tu s by t h e p u b l i c a t i o n o f An O r d i n a r y L i f e
( K i n g ’ s Fund C e n t r e , 1980) w h ic h drew on t h e e x p e r i e n c e o f t h e e x p e r im e n t s i n t h e use o f com m u n ity f a c i l i t i e s t o p r o v i d e a l l s e r v i c e s needed by p e o p le w i t h m e n ta l h a n d ic a p i n t h e ENCOR program m e, e a s t e r n N e b ra s k a . By b r i n g i n g t o g e t h e r t h e e x p e r i e n c e o f o t h e r s and p u t t i n g f o r w a r d p r i n c i p l e s o f s e r v i c e d e v e lo p m e n t t h a t c o u l d be e a s i l y u n d e r s to o d by p l a n n e r s and managers and members o f v o l u n t a r y o r g a n i s a t i o n s c o n c e rn e d w i t h p e o p le w i t h m e n ta l h a n d ic a p , t h i s p u b l i c a t i o n soon e s t a b l i s h e d i t s e l f as t h e s t a n d a r d t e x t f o r s e r v i c e d e v e lo p m e n t, and i t s t i t l e as t h e s h o r t h a n d e x p r e s s i o n f o r t h e new p h i l o s o p h y o f c a r e .
o f t h e d i f f i c u l t i e s i n d e v e l o p i n g co m m u n ity c a r e , m a kin g i t i n c r e a s i n g l y d i f f i c u l t f o r c e n t r a l g o v e rn m e n t t o a v o i d t a k i n g a r o l e i n s o r t i n g o u t some o f t h e s e i s s u e s .
R e s o u rc e s
I f t h e p o l i c y o b j e c t i v e was t o d e v e lo p s e r v i c e s i n t h e co m m u n ity t h e n r e s o u r c e s hiad t o be c h a n n e le d t h e r e . I n t h e f i r s t h a l f o f t h e 1970s t h e new s o c i a l s e r v i c e s d e p a r t m e n t m a i n t a i n e d v e r y h ig h r a t e s o f g r o w t h , o v e r 17%
p . a . i n c u r r e n t e x p e n d i t u r e f o r 1 9 7 2 /3 and 1 9 7 3 /4 , and j u s t o v e r 13X i n t h e f o l l o w i n g y e a r (Webb & W is to w , 1986, p . 3 2 ) . These r e a l r a t e s o f g r o w th w ere c o n s i d e r a b l y h i g h e r th a n c e n t r a l g o v e rn m e n t had p la n n e d and d e m o n s tr a te d a t t e m p t s t o d e v e lo p new s e r v i c e s i m m e d ia t e ly a f t e r t h e e s t a b l i s h m e n t o f t h e Seebohm s o c i a l s e r v i c e s d e p a r t m e n t . A t l e a s t one p r e v i o u s s t u d y has shown how d i f f i c u l t s o c i a l s e r v i c e s d e p a r t m e n ts fo u n d i t t o p l a n and manage g r o w th on t h i s s c a l e ( G l e n n e r s t e r e t a l , 1 9 8 3 ).
l e v e l s ; t h a t o c c u r r e d o n l y i n t h e l a t e 1980s (E v a n d ro n e t a l , 1 9 9 0 ). Y e t , as Webb and W isto w p o i n t o u t , r e s o u r c i n g p o l i c i e s o f ' t h e 1970s u n d e rm in e d co m m u n ity c a r e . The re d u c e d r a t e o f re v e n u e g r o w th i n t h e se cond h a l f o f t h e decade was i n s u f f i c i e n t t o b o th meet t h e re v e n u e co n s e q u e n c e s o f e a r l i e r c a p i t a l schemes and s u s t a i n d e v e lo p m e n t o f new c o m m u n ity s e r v i c e s . The a l l o c a t i o n o f a g e n e r a l g r a n t t o l o c a l g o v e rn m e n t p r o v i d e d no g u a r a n t e e t h a t any i n c r e a s e i n t e n d e d t o p ro m o te co m m u n ity c a r e w o u ld i n f a c t re a c h s o c i a l s e r v i c e s d e p a r t m e n t; i t was l e f t t o each l o c a l a u t h o r i t y t o d e c id e i t s own p a t t e r n o f e x p e n d i t u r e . And, even i f e x t r a fu n d s re a c h e d t h e s o c i a l s e r v i c e s d e p a r t m e n t s , t h e r e was no g u a r a n t e e t h a t i t w o u ld be used f o r co m m u n ity c a r e s e r v i c e s o r f o r t h e c l i e n t g r o u p s f o r whom i t m ig h t be in t e n d e d (Webb & W is to w , 1986, p . 3 3 ) .
s u p p o r t , use o f a d u l t e d u c a t i o n p l a c e s . The i n a b i l i t y o f t h e NHS t o l e g a l l y t r a n s f e r f u n d s t o l o c a l a u t h o r i t i e s ( o t h e r t h a n j o i n t f i n a n c e f u n d s ) was p l a c i n g a m a jo r l i m i t a t i o n on t h e d e v e lo p m e n t o f co m m u n ity c a r e and became a s o u r c e o f c o m p l a i n t t o c e n t r a l g o v e rn m e n t.
The g o v e r n m e n t’ s re s p o n s e t o t h i s was a c o n s u l t a t i v e docum ent on d i f f e r e n t means o f e f f e c t i n g such t r a n s f e r s (DHSS,1981b ) , and tw o y e a r s l a t e r a new p o l i c y on re v e n u e t r a n s f e r s (DHSS, 1 9 8 3 ). The c o n s u l t a t i v e docum ent began w i t h tw o s e n te n c e s i n d i c a t i n g a much g r e a t e r com m itm ent t o co m m u n ity c a r e t h a n had been e x h i b i t e d b e f o r e :
M o st p e o p le who need l o n g - t e r m c a r e can and s h o u ld be lo o k e d a f t e r i n t h e c o m m u n ity . T h i s i s w h a t m ost o f them w a n t f o r t h e m s e lv e s and w h a t t h o s e r e s p o n s i b l e f o r t h e i r c a r e b e l i e v e t o be b e s t . ’ (DHSS, 1981b, p a r a . 1 . 1 )
w i t h e v a l u a t i o n by t h e P e r s o n a l S o c i a l S e r v i c e s R e se a rch U n i t o f K e n t U n i v e r s i t y , t o e x p e r im e n t w i t h ways o f d e v e l o p i n g new s t y l e s o f s e r v i c e s f o r p e o p le com ing o u t o f h o s p i t a l (Renshaw e t a l . 1 9 8 8 ).
a l t h o u g h m ost o f t h e h o u s in g b e in g p la n n e d and p r o v i d e d was f o r p e o p le com ing o u t o f h o s p i t a l .
E m erging P ro b le m s
The Care i n t h e Community c i r c u l a r r e s o l v e d a t l e a s t one o f t h e f i n a n c i a l p r o b le m s , how t o t r a n s f e r f u n d s f o r p e o p le com ing o u t o f h o s p i t a l i n t o t h e c o m m u n ity . B u t many o t h e r p r o b le m s r e m a in e d , and t h e second h a l f o f t h e 1980s saw s e v e r a l r e p o r t s o u t l i n i n g t h e v a r i o u s d i f f i c u l t i e s b e in g e x p e r ie n c e d w h ic h made p r o g r e s s i n d e v e l o p i n g c o m m u n ity c a r e much s l o w e r th a n e x p e c te d o r d e s i r e d .
A f u r t h e r v o i c e o f d i s q u i e t a b o u t t h e way com m u n ity c a r e was b e in g d e v e lo p e d came fr o m t h e S e l e c t C o m m itte e on S o c i a l S e r v i c e s o f t h e House o f Commons i n i t s r e p o r t on co m m u n ity c a r e (House o f Commons, 1 9 8 5 ). The S e l e c t C o m m itte e s u p p o r t e d c o m m u n ity c a r e b u t n o t *on t h e c h e a p * . I t a l s o a rg u e d t h a t co m m u n ity c a r e c o u l d n o t be p r o v i d e d o v e r n i g h t - t h e r e was a need f o r a s lo w and t h o u g h t f u l d e v e lo p m e n t o f a w id e ra n g e o f f a c i l i t i e s and s e r v i c e s and c o n s i d e r a b l e p r e p a r a t i o n o f t h e p u b l i c t o a c c e p t p e o p le w i t h d i f f e r i n g d e g re e s o f d i s a b i l i t i e s i n t h e i r m i d s t .
The c o m m itte e e x p re s s e d c o n c e rn a b o u t t h e e m p h a s is ( " o b s e s s i v e c o n c e n t r a t i o n " , p a r a . 2 4) b e in g p la c e d by g o v e rn m e n t on t h e d i s c h a r g e o f p a t i e n t s fro m h o s p i t a l s . I t a rg u e d t h a t no h o s p i t a l s h o u ld be c l o s e d b e f o r e a l l n e c e s s a r y co m m u n ity f a c i l i t i e s w ere i n p la c e f o r t h o s e b e in g d i s c h a r g e d and f o r t h o s e who w o u ld o t h e r w i s e have s o u g h t h o s p i t a l a d m i s s io n . A f u r t h e r re c o m m e n d a tio n was t h a t no p a t i e n t s h o u ld be d i s c h a r g e d w i t h o u t an i n d i v i d u a l c a r e programme c o v e r i n g a l l t h e needs t h a t i n d i v i d u a l ha d . ment on m e n ta l h e a l t h s e r v i c e s (DHSS, 1 9 8 9 ).
s e r v i c e s , i n t h e l o n g - t e r m , i t t h o u g h t l o c a l a u t h o r i t i e s s h o u ld t a k e on r e s p o n s i b i l i t y f o r a l l com m unity r e s i d e n t i a l c a r e . J o i n t f i n a n c e was ’ p la y e d o u t * as a means o f t r a n s f e r r i n g f u n d s fr o m h e a l t h t o l o c a l au t h o r i t i e s ; m e n ta l h a n d ic a p s e r v i c e s w e re seen i n g e n e r a l as u n d e rfu n d e d and u n d e r s t a f f e d .
An e x c e p t i o n t o t h e s e d i f f i c u l t i e s o c c u r e d i n W a le s , w i t h t h e p u b l i c a t i o n o f t h e a l l - W a l e s s t r a t e g y f o r m e n ta l h a n d ic a p s e r v i c e s (W e ls h O f f i c e , 1 9 8 2 ). The i n t e n t i o n b e h in d t h i s docum ent was t o e n s u re t h a t a l l l o c a l a u t h o r i t i e s i n W ales e v e n t u a l l y had c o m p re h e n s iv e s e r v i c e s f o r p e o p le w i t h m e n ta l h a n d ic a p . The W elsh O f f i c e t o o k a d i r e c t hand i n b r i n g i n g t o g e t h e r l o c a l and h e a l t h a u t h o r i t i e s t o p ro d u c e c o m m u n ity based s e r v i c e p l a n s and t o p r o v i d e t r a n s i t i o n a l f u n d i n g t o a l l o w new s e r v i c e s t o d e v e lo p l o c a l l y . No o t h e r p a r t o f G r e a t B r i t a i n had such a h e l p i n g and g u i d i n g hand fr o m c e n t r a l g o v e rn m e n t i n t h i s p o l i c y a r e a .
t h a t p ro b le m s l a y a t s t r u c t u r a l and f i n a n c i a l a l l o c a t i v e l e v e l s r a t h e r th a n l o c a l p o l i t i c a l and a d m i n i s t r a t i v e f u n c t i o n s . I n p a r t i c u l a r i t c i t e d t h e p e c u l i a r i t i e s o f t h e ways f u n d s w ere d i s t r i b u t e d t o t h e NHS and l o c a l a u t h o r i t i e s ; t h e r e s t r a i n t s p la c e d on l o c a l a u t h o r i t y e x p e n d i t u r e w h ic h p e n a l i s e d a u t h o r i t i e s f o r e x p a n d in g c o m m u n ity s e r v i c e s ; t h e l a c k o f b r i d g i n g f i n a n c e t o a l l o w s e r v i c e s t o be b u i l t u p ; and t h e p e r v e r s e e f f e c t s o f a s o c i a l s e c u r i t y s y s te m w h ic h a l l o w s b e n e f i t s on t h e b a s i s o f l o c a t i o n and t y p e o f s e r v i c e r a t h e r th a n needs o f c l i e n t s .
could be overcome.
The C o m m is s io n 's f i n a l re c o m m e n d a tio n was t h a t a f u r t h e r ' h i g h l e v e l ' r e v ie w o f t h e s e is s u e s be u n d e r t a k e n t o c o n s i d e r th e s e and o t h e r p o s s i b l e o p t i o n s and t o c o n s i d e r ways i n w h ic h co m m u n ity c a r e c o u l d be d e l i v e r e d t o i n d i v i d u a l c l i e n t s . The C om m ission p ro d u c e d a n o t h e r r e p o r t e x c l u s i v e l y on s e r v i c e s f o r p e o p le w i t h m e n ta l h a n d ic a p , w h ic h more o r l e s s lo o k e d t o a more i n t e g r a t e d s e r v i c e a p p ro a c h ( A u d i t C o m m issio n , 1 9 8 7 ).
C l a r i f y i n g r e s p o n s i b i l i t i e s
The h ig h l e v e l r e v ie w o f com m u n ity c a r e was u n d e r t a k e n by S i r Roy G r i f f i t h s , a s p e c i a l a d v i s e r t o t h e DHSS (DHSS, 1 9 8 8 ). He t o o k s e r i o u s l y t h e A u d i t C o m m is s io n ’ s w a r n in g t h a t i t was no l o n g e r t e n a b l e t o i g n o r e t h e p r e s e n t d i f f i c u l t i e s l e s t t h e e m e rg in g e m ph a s is on r e s i d e n t i a l as opposed t o com m u n ity c a r e become e n t r e n c h e d as t h e new model o f c a r e . H is te r m s o f r e f e r e n c e w e re :
"To r e v ie w t h e way i n w h ic h p u b l i c f u n d s a r e used t o s u p p o r t co m m u n ity c a r e p o l i c y and t o a d v i s e [ S e c r e t a r y o f S t a t e ] on t h e o p t i o n s f o r a c t i o n t h a t w o u ld im p ro v e t h e use o f t h o s e fu n d s as a c o n t r i b u t i o n t o more e f f i c i e n t co m m u n ity c a r e . "
( p a r a . 2)
" A t t h e c e n t r e , c o m m u n ity c a r e has been t a l k e d o f f o r 30 y e a r s and i n fe w a r e a s can t h e gap betw een p o l i t i c a l r h e t o r i c and p o l i c y on t h e one h and, o r between p o l i c y and r e a l i t y i n t h e f i e l d on t h e o t h e r hand bheen so g r e a t . To t a l k o f p o l i c y i n m a t t e r s o f c a r e e x c e p t i n t h e c o n t e x t o f a v a i l a b l e r e s o u r c e s and t i m e s c a l e s f o r a c t i o n owes more t o t h e o l o g y t h a n t o t h e p u r p o s e f u l d e l i v e r y o f a c a r i n g s e r v i c e . T h i s i s n o t an a rg u m e n t i n i t s e l f f o r more r e s o u r c e s . The i n t e n t i o n i s t h a t p o l i c y and r e s o u r c e s s h o u ld come i n t o r e a s o n a b le r e l a t i o n s h i p , so t h a t we a r e c l e a r a b o u t w h a t co m m u n ity c a r e s e r v i c e s a r e t r y i n g t o a c h ie v e and so t h a t l e a d e r s h i p and d i r e c t i o n t o t h o s e p r o v i d i n g s e r v i c e s can be g i v e n . "
d e v e lo p e d , so t h a t one p e rs o n w o u ld p r o v i d e t h e b a s i c ra n g e o f p e r s o n a l and p r a c t i c a l c a r e needed t o m a i n t a i n someone a t home.
T h i s r e p o r t r e c e i v e d m ixe d r e a c t i o n s . I t o b v i o u s l y a d d re s s e d w h a t had been seen as t h e m ain d i f f i c u l t i e s i n d e v e l o p i n g com m unity c a r e i n t h e p a s t - s p l i t r e s p o n s i b i l i t i e s , f u n d i n g fro m d i f f e r e n t s o u r c e s - b u t i t c l e a r l y u p s e t h e a l t h a u t h o r i t i e s i n t h a t i t f o c u s s e d v e r y much on s o c i a l c a r e i n t h e co m m u n ity b u t n o t on t h e d i f f i c u l t i e s o f p r o v i d i n g co m m u n ity h e a l t h s e r v i c e s o r o f c o o r d i n a t i n g th e s e w i t h s o c i a l c a r e . N o n e t h e le s s , w i t h some m o d i f i c a t i o n i n t h e m e n ta l h e a l t h a r e a , th e s e re c o m m e n d a tio n s were a c c e p te d by t h e g o v e rn m e n t i n a W h ite P aper C a r i n g f o r P e o p l e w h ic h was p u b l i s h e d i n November 1989 (Cm 8 4 9 ) .
C o n c lu s io n
T h i s b r i e f r e v ie w o f t h e n a t i o n a l p o l i c y e n v i ro n m e n t i n w h ic h t h e c l o s u r e o f D a r e n th P a rk h o s p i t a l t o o k p i ace i l l u s t r a t e s many o f t h e themes t o be d i s c u s s e d i n s u c c e e d i ng c h a p t e r s •
was c a r r i e d t h r o u g h by c r i t i c a l r e p o r t s by t h e HAS and NDT on h o s p i t a l s e r v i c e s and by t h e i n c r e a s i n g a c c e p ta n c e g iv e n t o p r i n c i p l e s o f n o r m a l i s a t i o n as t h e b a s i s o f s e r v i c e p r o v i s i o n , w h ic h e v e n t u a l l y l e d t o l o c a l a u t h o r i t i e s b e in g g iv e n t h e p r im e r e s p o n s i b i l i t y f o r s e r v i c e s f o r p e o p le w i t h l e a r n i n g d i s a b i l i t i e s i n C a r i n g f o r P e o p l e
i n 1989. The heme o f d e i n s t i t u t i o n a l i s a t i o n i s ta k e n up p r i n c i p a l l y i n c h a p t e r tw o .
A second theme r e l a t e s t o id e a s a b o u t p l a n n i n g . B e t t e r S e r v i c e s gave c e n t r a l g o v e rn m e n t a s t r a t e g i c r o l e o f i d e n t i f y i n g a model o f s e r v i c e and i s s u i n g g u id a n c e i n t h e fo r m o f n o r m a t iv e l e v e l s o f p r o v i s i o n f o r l o c a l h e a l t h and s o c i a l s e r v i c e s a u t h o r i t i e s t o f o l l o w . C o o r d i n a t i o n betw een s e r v i c e s p r o v i d e d by t h e s e b o d ie s was t o be a c h ie v e d by j o i n t p l a n n i n g m echanism s. The h i s t o r y o f t h i s p e r i o d shows th a r ^ n e i t h e r o f t h e s e a p p ro a c h e s a c h ie v e d t h e s h i f t i n t h e b a la n c e o f c a r e d e s i r e d by g o v e rn m e n t. I n t h e en d , t h e DHSS began t o g a in some o f i t s o b j e c t i v e s by p r o v i d i n g i n c e n t i v e s t o t h e s t a t u t o r y / a u t h o r i t i e s t o t a k e up i t s p r i o r i t i e s w h i l s t a c c e p t i n g t h a t ) t h e model o f c a r e i t had i d e n t i f i e d was no l o n g e r t h e o n e ^ w a n te d by f i e l d a u t h o r i t i e s . The theme o f p l a n n i n g a p p ro a c h e s i s ta k e n up i n c h a p t e r s 5, 6 and 8.
C h a p te r 2
A rg u m e n ts a g a i n s t i n s t i t u t i o n s
D u r in g t h e second h a l f o f t h e 1 9 th c e n t u r y , V i c t o r i a n B r i t a i n c r e a t e d a s e r i e s o f i n s t i t u t i o n s t o p r o v i d e c a r e f o r p e o p le s u f f e r i n g f r o m m e n ta l i l l n e s s and m e n ta l h a n d ic a p . The q u a l i t y o f c a r e fo u n d i n t h e s e i n s t i t u t i o n s may have been p o o r , b u t t h e y d i d r e p r e s e n t an im p ro v e m e n t o v e r t h e a r b i t r a r y and c r u e l t r e a t m e n t o f i n d i v i d u a l s i n p r i v a t e u n r e g i s t e r e d madhouses w h ic h p re c e d e d t h e p u b l i c i n s t i t u t i o n s .
Now, i n t h e se co n d h a l f o f t h e 2 0 th c e n t u r y , a l l t h i s i s t o be r e v e r s e d . I n s t i t u t i o n s a r e seen t o be bad p l a c e s , w h ic h harm r a t h e r th a n h e l p t h e i r in m a te s . D e i n s t i t u t i o n a l i s a t i o n i s b e in g ta k e n up w i t h t h e same f e r v o u r , r h e t o r i c a l c o n v i c t i o n and l a c k o f e v id e n c e t h a t one im a g in e s i n s t i t u t i o n a l i s a t i o n r e c e i v e d i n i t s t i m e .
w ere many e x a m p le s o f d i f f e r e n t t y p e s o f i n s t i t u t i o n s c l o s i n g ; even t h e p r i s o n s e r v i c e began t o d e v e lo p non c u s t o d i a l s e r v i c e s . T h i s c h a p t e r c o n s i d e r s some o f t h e a rg u m e n ts a g a i n s t m e n ta l i n s t i t u t i o n s and t h e b a c k la s h a g a i n s t th e s e a rg u m e n ts . The D a r e n th p r o j e c t e x h i b i t e d b o th th e s e t r e n d s .
L e g a l c r i t i c i s m
D i r e c t a s s a u l t s on i n s t i t u t i o n s , and m e n ta l h o s p i t a l s i n p a r t i c u l a r , began i n t h e e a r l y 1950s. One o f t h e e a r l i e s t was based on a l e g a l a rg u m e n t: 5 0 , 0 0 0 O u t s i d e t h e Law
(NCCL) r e k i n d l e d f e a r s a b o u t w r o n g f u l d e t e n t i o n w h ic h had i n t h e p r e v i o u s c e n t u r y le d t o a l e g a l p r o c e s s o f c e r t i f i c a t i o n f o r p e o p le w i t h m e n ta l i l l n e s s .
S o c i o l o g i c a l s t u d i e s o f m e n ta l h o s p i t a l s
A cadem ic r e s e a r c h e r s began t o pay a t t e n t i o n t o t h e s t a t e m e n ta l i l l n e s s h o s p i t a l s fr o m a s o c i o l o g i c a l s t a n c e , s t a r t i n g w i t h s e v e r a l s t u d i e s c a r r i e d o u t i n A m e ric a
( S t a n t o n & S c h w a rz , 1954; B e lk n a p , 1956; Dunham & W e in b e rg , 1 9 6 0 ) . These s t u d i e s f o c u s s e d on t h e i n t e r p e r s o n a l r e l a t i o n s h i p s among t h e v a r i o u s s t a f f g r o u p s e m ploye d a t t h e h o s p i t a l s and between s t a f f and p a t i e n t s , and t h e ways i n w h ic h t h e s e a f f e c t e d t h e p r im e o b j e c t i v e o f t h e h o s p i t a l s - t h e c a r e o r r e h a b i l i t a t i o n o f p a t i e n t s . What t h e y f o u n d was an o r g a n i s a t i o n a l s t r u c t u r e w i t h i n t h e h o s p i t a l g e a re d to w a r d s c u s t o d i a l c a r e r a t h e r t h a n c u r e o r r e h a b i 1 i t a t i o n :
c o n s i d e r a b l e s h o r t a g e o f p r o f e s s i o n a l s t a f f o f a l l t y p e s w i t h i n h o s p i t a l s t o c a r r y o u t t r e a t m e n t program m es, w h ic h le d t o c y n i c i s m a b o u t t h e i r j o b s and t h e i r r o l e s w i t h i n h o s p i t a l s ;
because o f th e s e s h o r t a g e s o f s t a f f , t h e t r e a t m e n t and management o f p a t i e n t s was d e t e r m in e d by t h e w ard a t t e n d a n t s , t h e l e a s t w e l l - t r a i n e d o f a l l s t a f f ;
t h e e x tre m e s h o r t a g e o f t r a i n e d s o c i a l w o r k e r s r e s u l t e d i n p o o r l i n k s b e in g m a i n t a i n e d betw een t h e p a t i e n t and h i s f a m i l y , and among t h e f a m i l y , t h e c o m m u n ity and t h e h o s p i t a l , so t h a t p a t i e n t s who m ig h t have been a b l e t o be d i s c h a r g e d w e re l e f t i n h o s p i t a l ;
s t a f f , e s p e c i a l l y d o c t o r s and a t t e n d a n t s , l e d t o a t t i t u d e s o f s u s p i c i o n , a v o id a n c e and h o s t i l i t y , r e s u l t i n g i n c o n s i d e r a b l e b a r r i e r s t o c o m m u n ic a tio n ; t h e d i f f e r e n c e s betw een t h e f o r m a l and i n f o r m a l s t r u c t u r e s and o b j e c t i v e s o f h o s p i t a l s w ere d i s p l a y e d m ost c l e a r l y a t t h e w ard l e v e l . The o f f i c i a l d u t i e s o f w ard a t t e n d a n t s , f o r e xam ple i n S o u th e r n S t a t e H o s p i t a l ( B e l k n a p ) , w ere t o c l e a n t h e w a rd and a t t e n d t o t h e p h y s i c a l needs o f t h e p a t i e n t s ; w h a t t h e r e s e a r c h r e v e a le d was t h a t due t o u n d e r s t a f f i n g ( t h e h o s p i t a l had 4800 p a t i e n t s and 600 s t a f f ) t h e w a rd a t t e n d a n t s s p e n t t h e i r t im e s u p e r v i s i n g t h e w o rk done by p a t i e n t s who d i d t h e c l e a n i n g o f t h e w a rd , w a s h in g and f e e d i n g o f o t h e r p a t i e n t s and o t h e r t a s k s o f f i c i a l l y b e l o n g i n g t o t h e w ard a t t e n d a n t s . F o r t h i s r e a s o n , w h a t seemed t o be a c o n f u s e d m i x t u r e o f p a t i e n t s on t h e w a rd s was seen t o r e l a t e t o t h e need t o have an a d e q u a te number o f ’ m i l d * m e n ta l p a t i e n t s t o h e l p on w a rd s . The p r im e needs o f t h e a t t e n d a n t s were f o r o r d e r and c o n t r o l , and t h e s e te n d e d t o o v e r r i d e t h e needs o f p a t i e n t s .
p r e v i o u s l y p o i n t e d t o t h e im p o r t a n c e o f g a i n i n g t h e c o o p e r a t i o n o f t h e p a t i e n t i n a c h i e v i n g h i s own r e c o v e r y and o f m o d i f y i n g t h e h o s p i t a l e n v ir o n m e n t so t h a t i t was more r e s p o n s iv e t o c l i e n t needs th a n t o o r g a n i s a t i o n a l demands. These s t u d i e s a t t e m p t e d t o f i n d ways o f m aking h o s p i t a l c a r e more e f f e c t i v e ; o n l y one a u t h o r , B e lk n a p , c h a l l e n g e d t h e i d e o l o g y o f h o s p i t a l s : " t h e f a i l u r e o f r e f o r m was t o a sk w h e th e r a l a r g e - s c a l e , c e n t r a l i s e d and p a r t l y s e l f - s u f f i c i e n t i n s t i t u t i o n i s i n f a c t a b l e t o f u n c t i o n e f f e c t i v e l y i n t h e t r e a t m e n t o f t h e m e n t a l l y i l l " ( o p . c i t . , p . 2 0 5 ) .
C l i n i c a l c r i t i q u e s
S i m i l a r i s s u e s came t o be r a i s e d i n E n g la n d by B a r t o n (1 9 5 9 ) who was among t h e f i r s t t o see * i n s t i t u t i i o n a l n e u r o s i s ’ as an i l l n e s s , b r o u g h t a b o u t by a l e n g t h y s t a y i n a h o s p i t a l . The m ain symptoms o f t h i s i l l n e s s w ere an u n w i l l i n g n e s s t o t a k e r e s p o n s i b i l i t y f o r o n e s e l f and t o le a v e h o s p i t a l a t a l l . T h i s c o n c e p t was l a t e r ta k e n up by Wing & Brown i n t h e i r s t u d y o f i n s t i t u t i o n a l i s m ( 1 9 7 0 ) .
th a n t h e i l l n e s s ; t h e i r p e r s o n a l i t y and human needs re m a in e d and demanded r e s p e c t .
By t h e end o f t h e 1950s and e a r l y 1960s " p r o g r e s s i v e " t h o u g h t i n p s y c h i a t r i c s e r v i c e s was r a p i d l y m o vin g away f r o m t h e h o s p i t a l base to w a r d s t h e c o m m u n ity . T r e n d s i n
t h e M e n t a l H e a l t h S e r v i c e s (Freeman & F e r n d a l e , 1963) b r o u g h t t o g e t h e r many o f t h e l e a d i n g e x p o n e n ts o f com m u n ity m e n ta l h e a l t h s e r v i c e s and re p r o d u c e d some o f t h e more i n f l u e n t i a l a r t i c l e s . I n t h e i r i n t r o d u c t i o n , t h e e d i t o r s n o te d t h a t " t h e r e i s a t p r e s e n t a p e r i o d o f tre m e n d o u s u p h e a v a l, i n w h ic h a s y s te m o f c a r e w h ic h has grown up o v e r more th a n a c e n t u r y i s b e in g l a r g e l y d i s c a r d e d " ( i b i d , p . x ) .
O t h e r c l i n i c a l s t u d i e s w ere u n d e r t a k e n a t t h e MRC S o c i a l P s y c h i a t r y R e search U n i t , f o c u s s i n g on s e r v i c e s f o r p e o p le w i t h a m e n ta l h a n d ic a p b u t f o l l o w i n g t h e same t r e n d o f c o m m u n ity o r i e n t a t i o n fo u n d i n c o n te m p o r a r y t h o u g h t a b o u t m e n ta l i l l n e s s s e r v i c e s . These s t u d i e s te n d e d t o be c r i t i c a l o f h o s p i t a l s f o r w h a t t h e y d i d and f o r w h a t t h e y c o u l d do b u t d i d n ’ t .
t h o s e c u r r e n t l y p r o v i d e d . T h e i r comments on t r a i n i n g o p p o r t u n i t i e s i n h o s p i t a l s h i g h l i g h t e d how p o o r r e h a b i l i t a t i o n s e r v i c e s w e re :
" m o s t p a t i e n t s w ere g i v e n o c c u p a t i o n a l a c t i v i t y r a t h e r t h a n em ployed on w o rk o f v a l u e t o t h e c o m m u n ity ;
" t h e w o rk u n d e r t a k e n i n h o s p i t a l s had a lm o s t no r e l a t i o n t o t h e k i n d s o f j o b s done on l i c e n c e o u t s i d e t h e h o s p i t a l ; " e q u ip m e n t used i n w o rk s h o p s was o b s o l e t e ;
" l i t t l e c o n t a c t w i t h c o m m e rc ia l f i r m s , so i t was h a rd t o p l a c e t r a i n e d p a t i e n t s ;
" t r a i n i n g s i t u a t i o n s w ere d e v o id o f i n c e n t i v e s ;
" t o o l i t t l e a t t e n t i o n was p a id t o s e l e c t i o n and t r a i n i n g o f s u p e r v i s o r s and t r a i n i n g s t a f f ;
" in a d e q u a t e s u p e r v i s i o n o f p a t i e n t s on l i c e n c e o r i n d a i l y s e r v i c e .
The c o n c l u s i o n o f t h i s s t u d y a rg u e d t h a t a f a r more e f f e c t i v e s e r v i c e c o u l d be p r o v i d e d f o r t h e g ro u p o f m e n t a l l y h a n d ic a p p e d p e o p le w h ic h w o u ld e n a b le them t o
le a d p r o d u c t i v e r a t h e r t h a n d e p e n d e n t l i v e s .
re m o te n e s s fr o m adva n ce s i n m e d i c i n e , e d u c a t i o n and p s y c h o lo g y ; t h e d i f f i c u l t i e s f o r f a m i l i e s i n k e e p in g i n to u c h w i t h t h e c h i l d i n h o s p i t a l , and o t h e r a rg u m e n ts . I n p a r t i c u l a r , T i z a r d s t r e s s e d t h e im p o r t a n c e o f s i z e and i t s r e l a t i o n t o t h e q u a l i t y o f s e r v i c e p r o v i d e d .
S t u d i e s o f i n s t i t u t i o n s by s o c i o l o g i s t s / s o c i a l a d m i n i s t r a t i o n
The f r o n t a l a s s a u l t on t h e ' u n d e r l y i n g i d e o l o g y o f i n s t i t u t i o n s was made by G offm an ( 1 9 6 1 ) . G o ffm a n ’ s w o r k , an a n a l y s i s o f t h e s o c i a l s t r u c t u r e o f i n s t i t u t i o n s and r e l a t i o n s betw een i n h a b i t a n t s and s t a f f , c r e a t e d a p r o t o t y p e o f a t o t a l i n s t i t u t i o n . T h i s was d e f i n e d as ’ a p l a c e o f r e s i d e n c e and w o rk where a l a r g e number o f l i k e s i t u a t e d i n d i v i d u a l s , c u t o f f fr o m t h e w i d e r s o c i e t y f o r an a p p r e c i a b l e p e r i o d o f t i m e , t o g e t h e r le a d an e n c lo s e d , f o r m a l l y a d m i n i s t e r e d ro u n d o f l i f e * ( p . 1 1 ) . The c e n t r a l f e a t u r e o f a t o t a l i n s t i t u t i o n was s a i d t o be *a breakdow n o f t h e b a r r i e r s * fo u n d i n o r d i n a r y l i f e n o r m a l l y s e p a r a t i n g t h e p l a c e t o l i v e , t h e p l a c e t o w ork and t h e p l a c e f o r r e c r e a t i o n . F u r t h e r , f o u r c h a r a c t e r i s t i c s o f t h e o p e r a t i o n o f a t o t a l i n s t i t u t i o n s was c i t e d :
a l l a s p e c t s o f l i f e f o r t h e in m a te s c a r r i e d on i n t h e same p la c e and u n d e r t h e same s i n g l e a u t h o r i t y ;
* a l 1 phases o f t h e d a y ’ s a c t i v i t y a r e t i g h t l y s c h e d u l e d ’ ;
’ t h e v a r i o u s e n f o r c e d a c t i v i t i e s a r e b r o u g h t t o g e t h e r i n t o a s i n g l e r a t i o n a l p la n p u r p o r t e d l y d e s ig n e d t o f u l f i l l t h e o f f i c i a l aim s o f t h e i n s t i t u t i o n ’ ( i b i d , P .1 7 ) .
Academ ic s o c i a l a d m i n i s t r a t o r s began a l s o t o t a k e an i n t e r e s t i n c o n d i t i o n s i n a w id e v a r i e t y o f i n s t i t u t i o n s and t h e i r e f f e c t s on t h e i n h a b i t a n t s . These s t u d i e s c o n c lu d e d t h a t t h e s e i n s t i t u t i o n s f a i l e d t o a c h ie v e t h e o b j e c t i v e s e s t a b l i s h e d f o r them and i n t h e p r o c e s s o f t h i s f a i l u r e dehum anised t h e i r i n h a b i t a n t s .
F i r s t was T o w n s e n d 's s u r v e y s o f l o c a l a u t h o r i t y , p r i v a t e and v o l u n t a r y i n s t i t u t i o n s f o r e l d e r l y p e o p le i n E n g la n d and W ales ( 1 9 6 2 ) . H i s p u rp o s e was t o d e s c r i b e t h e c o n d i t i o n s fo u n d i n i n s t i t u t i o n s , and how’ e l d e r l y p e o p le
l i v e d i n them . Townsend d i d n o t a rg u e t h a t no e l d e r l y p e rs o n needed i n s t i t u t i o n a l c a r e ; he d i d c l a i m t h a t a s i g n i f i c a n t p r o p o r t i o n o f e l d e r l y p e o p le th e n i n i n s t i t u t i o n s a l c a r e had been a d m i t t e d because o f s o c i a l f a c t o r s r a t h e r th a n p h y s i c a l n e e d s: h o m e le s s n e s s , u n a v a i l a b i l i t y o f d o m i c i l i a r y s u p p o r t s e r v i c e s , f i n a n c i a l
i n s e c u r i t y , g e n e r a l l a c k o f s o c i a l r e s o u r c e s , o f f r i e n d s o r f a m i l y n e t w o r k s . O ver h a l f o f new a d m i s s io n s , he s a i d , were p h y s i c a l l y and m e n t a l l y f i t t o le a d in d e p e n d e n t
What was so s t r i k i n g a b o u t h i s s t u d y w ere t h e d e s c r i p t i o n s o f c o n d i t i o n s i n t h e homes - t h e management r e g im e s , t h e s o c i a l i s o l a t i o n o f t h e in m a te s , t h e i r l o s s o f o c c u p a t i o n , t h e p h y s i c a l p o v e r t y o f t h e e n v i r o n m e n t , t h e l o s s o f d e c i s i o n m aking by t h e e l d e r l y p e rs o n a b o u t h i s o r h e r p r e s e n t l i f e o r f u t u r e . A l t h o u g h n o t a l l i n s t i t u t i o n s w ere r a t e d as p o o r , t h e o v e r a l l p o r t r a i t p r e s e n t e d was g r i m .
c o n t a c t , t h e l a c k o f a c t i v i t y f o r so many o f t h e p a t i e n t s , t h e crow ded l i v i n g c o n d i t i o n s , t h e t r e a t m e n t o f r e s i d e n t s by s t a f f as i f t h e y w ere c h i l d r e n . Even i n v o l u n t a r y homes, w h ic h w ere r a t e d more h i g h l y t h a n h o s p i t a l s on s t a n d a r d s o f p h y s i c a l e n v ir o n m e n t , t h e a u t h o r c la im e d t o have fo u n d fe w e x a m p le s o f r e h a b i l i t a t i o n o r t r a i n i n g .
i n c h i l d h o o d was hampered by i n s t i t u t i o n a l p r a c t i c e s and a t t i t u d e s .
S i m i l a r c r i t i c i s m s w ere made by Oswin ( 1 9 7 4 ) i n h e r s t u d y o f weekend a c t i v i t i e s o f f e r e d t o h a n d ic a p p e d c h i l d r e n l i v i n g i n t h r e e d i f f e r e n t t y p e s o f i n s t i t u t i o n s . These r e s e a r c h r e p o r t s were d e m o n s t r a t i n g t h a t i t was p o s s i b l e t o r a i s e s e v e r e l y m e n t a l l y h a n d ic a p p e d c h i l d r e n i n ways s i m i l a r t o th o s e f o r n o n -h a n d ic a p p e d c h i l d r e n o f t h e same m e n ta l age, and t h a t h a n d ic a p p e d c h i l d r e n b e n e f i t t e d fr o m o p p o r t u n i t i e s t o do ’ n o rm a l* a c t i v i t i e s .
A more r e c e n t s t u d y o f B o o th (1 9 8 5 ) e xam ined t h e e x t e n t t o w h ic h dependency o f r e s i d e n t s i n l o c a l a u t h o r i t y o l d p e o p l e ’ s homes was in d u c e d by t h e re g im e o f management o f t h e home. He a t t e m p t e d t o l o o k a t w h e th e r re g im e s in d u c e d dependency because o f p o o r p r a c t i c e o r w h e th e r an i n s t i t u t i o n a l s e t t i n g was n e c e s s a r i l y h a r m f u l t o p e o p le no m a t t e r w h a t t y p e o f management s t y l e was u s e d . The s t u d y he d i r e c t e d exam ined 175 homes i n f o u r l o c a l a u t h o r i t i e s o v e r a t w o - y e a r p e r i o d o f t i m e . D e s p i t e f i n d i n g d i f f e r e n c e s i n t h e ’ e t h o s o f r e g i m e s ’ ( l i b e r a l t o r e s t r i c t i v e ) , t h e outcom es f o r r e s i d e n t s seemed n o t t o v a r y a c c o r d i n g t o r e g im e ; he c o n c lu d e d t h a t
" s o c i o l o g i c a l l y , t h e d i f f e r e n c e s betw een re g im e s m u s t, i n l i g h t o f t h i s s t u d y , be seen as a v e n e e r t h a t d e c o r a t e s t h e m a s s iv e u n i f o r m i t y o f i n s t i t u t i o n a l l i f e ,
